Revised Policies

The following are revised policies. To view the new policies on the WPS Medicare website, use the left hand navigation to go to the Local Policies (LCD). Be sure to note the effective date of the revision, as the revision will not appear in the Active policy until the effective date. Prior to the effective date, the revision can be found by selecting the link "Display Future Effective Documents" within the CMS Medicare Coverage Database(external link) (MCD).

May 2012

POLICIES WILL BE AVAILABLE ON THE CMS WEBSITE 04/26/12 AND ON THE WPS MEDICARE WEBSITE 05/07/12.

Policy Title MCD Policy # WPS Policy # Effective Date
Application of Bioengineered Skin Substitutes L30135 GSURG-052 05/01/2012
Added coverage of HCPCS code Q4107 Graftjacket, per square centimeter for claims with dates of service on and after 05/01/2012.
Botulinum Toxin Type A & Type B L28555 INJ-018 05/01/2012
Added CPT code 64653 and ICD-9 codes: 438.20, 438.21, 438.22, 438.30, 438.50, and 438.51-438.53. In Billing and Coding Guidelines, updated number 4 - When billing for injections of Botulinum toxin for covered conditions/diagnosis, added ICD-9 codes 438.20, 438.21, 438.22, 438.30, 438.50, and 438.51-438.53.
Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) L29584 CV-016 05/01/2012
Addition of CPT codes 0295T, 0296T, 0297T and 0298T, effective 01/01/2012. Inclusion of Category III codes as payable when medically necessary and conditions of coverage have been met expands coverage. Thus no notice period applies.

The following statement has been added to the Indications and Limitations of Coverage section: The use of 0295T, 0296T, 0297T, and 0298T, external electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage, may be considered medically necessary in patients treated for reasons listed in the ICD-9-CM list to monitor for asymptomatic episodes in order to evaluate treatment response. The use of external electrocardiographic event monitors for more than 48 hours up to 21 days that are either patient-activated or auto-activated may be considered medically necessary as a diagnostic alternative to Holter monitoring in patients who experience infrequent symptoms (less frequently than every 48 hours) suggestive of cardiac arrhythmias (i.e., palpitations, dizziness, presyncope, or syncope).

Billing and Coding Guidelines
Added under Section B the following statement:
CPT Codes 0295T-0298T
External electrocardiographic recording for more than 48 hours up to 21 days (CPT codes 0295T, 0296T, 0297T, and 0298T) includes a coverage period greater than 48 hours up to 21 days. No other EKG monitoring codes can be billed simultaneously with these codes and services represented by these codes are non- covered for inpatient or outpatient observation care.
Podiatry Code List N/A N/A 05/01/2012
05/01/2012: Add HCPCS code Q4121, dates of service on and after 01/01/2012, and HCPCS code Q4107, dates of services on and after 05/01/2012.
Psychiatry and Psychology Services L30489 PSYCH-014 05/15/2012
Removed Psychological Testing and Neuropsychological Testing services 96116; is in LCD - L31990
Radiopharmaceutical Agents L31361 RAD-026 05/01/2012
New CPT codes 78579, 78582, 78597, 78598 have been added to this LCD. Removed deleted codes 78584-78496. This change is effective 01/01/2012. Resubmit any claims that may have been denied inappropriately.

Indications and Limitations of Coverage and/or Medical Necessity

A. Technetium (Tc) labeled radiopharmaceuticals:
    4. Technetium Tc-99m Pentetate, Diagnostic, per study dose, up to 25 mCi's, A9539 Lung ventilation (CPT 78579, 78580, 78582, 78597, 78598)
    5. Technetium Tc-99m Pentetate, Diagnostic, aerosol, per study dose, up to 75 mCi's, A9567 Lung ventilation (CPT 78579, 78580, 78582, 78597, 78598)
    11. Technetium Tc-99m Macroaggregated Albumin (MAA), Diagnostic, per study dose, up to 10 mCi's, A9540 Lung perfusion agent (CPT 78580, 78582, 78597, 78598)
B. Iodine labeled radiopharmaceuticals:
    3. I 131
      6. Iodinated I-131-Serum Albumin, diagnostic, per 5 microcuries, A9524 Pulmonary perfusion imaging (CPT 78580, 78582, 78597, 78598)
D. Miscellaneous Radiopharmaceuticals:
    8. Xenon Xe-133 Gas, Diagnostic, per 10 mCi's, A9558 Lung study (CPT 78579, 78580, 78582, 78597, 78598)
Removal of Benign Skin Lesions L30330 DERM-008 05/01/2012
Added ICD-9 codes: 078.11, 235.1, 236.6, 239.2, 374.84, 686.1, 701.1, 701.4, 709.3, 709.4, 709.9, 757.32, 757.33, 757.39

April 2012

POLICIES WILL BE AVAILABLE ON THE CMS WEBSITE 03/29/12 AND ON THE WPS MEDICARE WEBSITE 04/06/12.

Policy Title MCD Policy # WPS Policy # Effective Date
Application of Bioengineered Skin Substitutes L30135 GSURG-052 04/01/2012
Hospitals are reminded that HCPCS codes describing skin substitutes (Q4100 - Q4130) should only be reported when used with one of the CPT codes describing application of a skin substitute (15271 - 15278). These Q codes for skin substitutes should not be billed when used with any other procedure besides the skin substitute application procedures.

Only CPT codes Q4101, Q4102, Q4106, Q4110, and Q4121 are payable by Medicare Part B and only in POS inpatient hospital, outpatient hospital, ambulatory surgical center, or office setting.
Bone Mass Measurement L31620 MS-004 01/01/2012
CPT 2012 coding update; discontinued CPT code 77083. Effective 01/01/2012.
Botulinum Toxin Type A & Type B L28555 INJ-018 04/01/2012
Added ICD-9 788.31 to HCPCS codes J0585 - J0587 when billed with CPT code 53899.
Chemotherapy Drugs and their Adjuncts L28576 HONC-010 04/01/2012
Indications and Limitations of Coverage and/or Medical Necessity
C. The following drugs are covered for the following indications:
    2. Alemtuzumab 10 mg (Campath) (J9010)
    T-Cell prolymphocytic leukemia 204.80, 204.82

    31. Irinotecan (Camptosar) 20 mg (J9206)
    Carcinoma of unknown primary 199.0, 199.1
E. Monoclonal Antibodies that are useful in chemotherapeutic regimens:
    1. Rituximab (Rituxan) 100 mg, (J9310)
    Polymyositis 710.4
Computed Coronary Tomography Angiography L30288 RAD-034 01/01/2010
Prior to 01/01/2010, services described by CPT 75573 were coded as CPT 0150T and services described by CPT 75571 were coded as CPT 0144T. These two CPT codes (75571 and 75573) were inadvertently omitted from the 01/01/2010 revision of this LCD. The changes made with this revision merely correct typographical errors and now include information of coverage for CPT code 75573. Quantitative evaluation of coronary calcium by CCT (CPT code 75571) remains non-covered. Minor formatting changes. CPT code 75573 effective for dates of service 01/01/2010 and thereafter.
Low Vision Services L32007 OPHTH-026 02/15/2012
It is the intent of WPS Medicare to ensure access to all beneficiaries in need of low vision services. Therefore, the following revisions have been made to this LCD.
  1. Revised statement found in the Indications for Low Vision Service section that read: Occupational therapists are trained to observe for and manage cognitive deficits and they work under established regulations that dictate that when no progress is made in two consecutive visits, for any reason, therapy must be terminated.
            To now read;
    Occupational therapists are trained to observe for and manage cognitive deficits and based on this knowledge may determine after reasonable attempts that when no progress is made, for any reason, therapy must be terminated.
  2. Deleted from Documentation Requirements, paragraph number one (1) that referenced FIM.
  3. Removed from Documentation Requirements, former paragraph four (4) now paragraph three (3) all references to FIM.
  4. Removed from Documentation Requirements, former paragraph five (5) now paragraph four (4) the words "This may require five (5) or more days between visits."
  5. Removed for Documentation Requirements, former paragraph six (6) now paragraph five (5) from the first sentence the words "in two consecutive visits." Revised entire paragraph to better emphasize quantitative measurements.
Podiatry Code List N/A N/A 04/01/2012
The following procedure codes have been added, by the WPS medical director staff, to the list of HCPCS codes approved as payable for podiatrists: CPT codes 10021 and 10022.
Psychiatry and Psychology Services L30489 PSYCH-014 05/15/2012
Removed Psychological Testing and Neuropsychological Testing services and placed in New LCD - L31990
Vitamin D Assay Testing L31076 PATH-032 12/15/2010 (Retroactive)
Added code 278.4 to the policy, retroactive to 12/15/2010. Note: This date will not be on the policy itself.

March 2012

POLICIES WILL BE AVAILABLE ON THE CMS WEBSITE 02/24/12 AND ON THE WPS MEDICARE WEBSITE 03/06/12.

Policy Title MCD Policy # WPS Policy # Effective Date
Chemotherapy Drugs and their Adjuncts L28576 HONC-010 03/01/2012

Indications and Limitations of Coverage and/or Medical Necessity

9. Bortezomib (VelcadeTM) (J9041), 0.1mg Primary chemotherapy for progressive solitary plasmacytoma or smoldering myeloma (asymptomatic) that has progressed to active (symptomatic) myeloma (203.80 or 238.6) in:

-combination with dexamethasone with or without cyclophosphamide, doxorubicin, lenalidomide, or thalidomide for transplant candidates (all preferred regimens)

-combination with dexamethasone or in MPB (melphalan, prednisone, and bortezomib) regimen for nontransplant candidates (all preferred regimens)
11. Cetuximab (ErbituxTM) (J9055) 10 mg Squamous Cell Skin Cancer of the head and neck 173.02, 173.12, 173.22, 173.32, 173.42

Squamous Cell Skin Cancer for Regional Recurrences or Distal Metastases 239.2 or V10.83.
Mohs Micrographic Surgery L30713 DERM-004 03/01/2012
Add ICD-9 code 238.1, Neoplasm Uncertain behavior soft tissue (Atypical fibroxanthoma).
Radiopharmaceutical Agents L31361 RAD-026 03/01/2012
New CPT codes 78226 & 78227 have been added to this LCD. The new codes are effective 0/01/2012. Removed 78220 and 78221.

Indications and Limitations of Coverage and/or Medical Necessity

A. Technetium (Tc) labeled radiopharmaceuticals:

6. Technetium Tc-99m Disofenin (Hepatolite®, DISIDA) A9510, per study dose, up to 15 mCi's Hepatobiliary scan agent. (CPT 78226, 78227)
10. Technetium Tc-99m Iminodiacetic Acid (IDA) A4641 Usual Dosage 5-12 mCi Hepatobiliary scan agent. (CPT 78226, 78227)
12. Technetium Tc-99m Mebrofenin (Choletec®) Diagnostic, per study dose, up to 15 mCi's A9537 Hepatobiliary scan agent. (CPT 78226, 78227)


Page Last Updated: Friday, 27-Apr-2012 14:28:19 CDT