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Myocardial Perfusion Imaging: Medical Necessity Denials
Denial Reason, Reason/Remark Code(s)
- CO-50, CO-57, CO-151, N-115 - Medical Necessity: An ICD-9 code(s) was submitted that is not covered under a LCD/NCD
- CPT codes 78465, 78478, 78480, 78481
Resolution/Resources
- Jurisdiction 1: Refer to the 'Cardiovascular Nuclear Medicine: Myocardial Perfusion Imaging and Cardiac Blood Pool Studies' Local Coverage Determination on the Palmetto GBA Web site:
- Jurisdiction 1: www.PalmettoGBA.com/j1b/LCD
- LCD Reconsideration Process: To request changes to any existing LCD, fax clinical evidence/documentation to Palmetto GBA
- Ohio and West Virginia: Refer to the 'Cardiac Radionuclide Imaging' Local Coverage Determination on the Palmetto GBA Web site:
- The patient's medical record must document the medical necessity of services performed for each date of service submitted on a claim, and documentation must be available to Medicare on request
- The medical record must document when significant resting ECG abnormalities are present, or a medication is being used and cannot be withdrawn, that would interfere with interpretation of a stress ECG, resulting in the selection of myocardial perfusion study
- The rationale for selecting pharmacologic stress rather than exercise stress must be indicated in the medical record
- Claims submitted for stress tests performed as preoperative evaluation of patients without symptoms of CAD who are deemed to be at moderate risk must document one of the following at-risk conditions in the medical record: diabetes mellitus with complications, peripheral vascular disease, aortic aneurysm or cerebrovascular disease
Advance Beneficiary Notice (ABN) Information
- If the service being performed is not covered under the LCD guidelines, we encourage you to provide your patients with an ABN prior to performing these tests
- ABNs allow patients to make an informed decision about whether to receive a service that is likely to be non-covered on the basis of 'not reasonable and medically necessary'
- If you utilize ABNs, they must be issued in advance. Maintain the original in the patient's medical record. Provide the patient with a copy of the signed notice.
- ABNs must be issued using the standard CMS form. For services provided on or after March 1, 2009, you may use either version of the CMS ABN form. For servics provided after on or after March 1, 2009, you must use the revised CMS ABN if you are providing advance beneficiary notice to a beneficiary. Access the revised ABN and other background information from the CMS Web site at www.cms.hhs.gov/BNI/01_overview.asp.
- If you have obtained a valid ABN, submit claims for this service with HCPCS modifier GA. Refer to the Palmetto GBA Modifier Lookup tool for information on HCPCS modifier GA.