Diagnostic Cardiology Services: Medical Necessity Denials

• CO-50 - These are non-covered services because this is not deemed medically necessary by the payer.
• N-115 - This decision was based on a Local Coverage Determination (LCD).  An LCD provides a guide to assist in determining whether a particular item or service is covered.  A copy of the policy is available at www.cms.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD.  
• CPT codes: 93303-93308, 93320, 93325

• Refer to the 'Echocardiography' Local Coverage Determination
• If the service being performed is not covered under the LCD guidelines, we encourage you to provide your patients with an Advance Beneficiary Notice (ABN) prior to performing these tests

ABN Information

• 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 a copy 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. Access the revised ABN and other background information from the CMS website.
• If you have obtained a valid ABN, submit claims for this service with HCPCS modifier GA. Refer to the Palmetto GBA Modifier Lookup tool, which is located under Self Service tools, for information on HCPCS modifier GA.