ultrasound diagnostic procedures (ncd 220.5) · that it can be considered essential to good patient...

Ultrasound Diagnostic Procedures (NCD 220.5) of 17 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/11/2020

Proprietary Information of UnitedHealthcare. Copyright 2020 United HealthCare Services, Inc.

ULTRASOUND DIAGNOSTIC PROCEDURES (NCD 220.5) Guideline Number: MPG336.07 Approval Date: March 11, 2020 Table of Contents Page POLICY SUMMARY .................................................... 1 APPLICABLE CODES ................................................. 2 PURPOSE ............................................................... 12 REFERENCES .......................................................... 13 GUIDELINE HISTORY/REVISION INFORMATION .......... 16 TERMS AND CONDITIONS ........................................ 16

POLICY SUMMARY Overview Ultrasound diagnostic procedures using low-energy sound waves are widely used to determine the composition and contours of almost all body tissues apart from bone and air filled spaces. This technique permits noninvasive

visualization of even the deepest structures in the body. The use of the ultrasound technique is sufficiently developed that it can be considered essential to good patient care in diagnosing a wide variety of conditions. Ultrasound diagnostic procedures are listed below and are seperated into two categories. Medicare coverage is

extended to the procedures listed in Category I. Periodic claims review by the A/Medicare Administrative Contractor (A/MAC) medical consultants should be conducted to ensure that the techniques are medically appropriate and the general indications specified in these categories are met. Techniques in Category II are considered experimental and

should not be covered at this time. Guidelines Nationally Covered Indications Category I - (Clinically effective, usually part of initial patient evaluation, may be an adjunct to radiologic and nuclear medicine diagnostic technique)

Echoencephalography, (Diencephalic Midline) (A-Mode) Echoencephalography, Complete (Diencephalic Midline and Ventricular Size) Ocular and Orbital Echography (A-Mode) Ocular and Orbital Sonography (B-Mode Covered procedures include efforts to determine the suitability of aphakic patients for implantation of an artificial

lens (pseudophakoi) following cataract surgery

Echocardiography, Pericardial Effusion (M-Mode)

Pericardiocentesis, by Ultrasonic Guidance Echocardiography, Cardiac Valve(s) (M-Mode) Echocardiography, Complete (M-Mode) Echocardiography, limited (e.g., follow-up or limited study) (M-Mode) Pleural Effusion Echography Thoracentesis, by Ultrasonic Guidance Abdominal Sonography, complete survey study (B-Scan)

Abdominal Sonography, limited (e.g., follow-up or limited study) (B-Scan) Abdominal Sonography is not synonymous with ultrasound examination of individual organs Renal Cyst Aspiration, by Ultrasonic Guidance Renal Biopsy, by Ultrasonic Guidance Pancreas Sonography (B-Scan)

Related Medicare Advantage Policy Guideline

Bone (Mineral) Density Studies (NCD 150.3)

Related Medicare Advantage Reimbursement Policies

Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging Policy, Professional

Multiple Procedure Payment Reduction (MPPR) on

Diagnostic Cardiovascular and Ophthalmology Procedures Policy, Professional

Related Medicare Advantage Coverage Summary

Radiologic Diagnostic Procedures

UnitedHealthcare® Medicare Advantage Policy Guideline

See Purpose

Terms and Conditions

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/b/bone-mineral-density-studies.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-reimbursement/COMM-MPPR-Diagnostic-Imaging-Policy.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-reimbursement/COMM-MPPR-Diagnostic-Imaging-Policy.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-reimbursement/COMM-MPPR-Cardiovascular-Ophthalmology-Procedures-Policy.pdf



https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-coverage-sum/radiologic-diagnostic-procedures.pdf



Pancreatic Sonography has proven effective in diagnosing pseudocysts Spleen Sonography (B-Scan) Abdominal Aorta Echography (A-Mode) Abdominal Aorta Sonography (B-Scan)

Retroperitoneal Sonography (B-Scan) Retroperitoneal Sonography does not include planning of fields for radiation therapy Urinary Bladder Sonography (B-Scan) Urinary bladder Sonography does not include staging of bladder tumors Pregnancy Diagnosis Sonography (B-Scan) Fetal Age Determination (Biparietal Diameter) Sonography (B-Scan) Fetal Growth Rate Sonography (B-Scan)

Placenta Localization Sonography (B-Scan) Pregnancy Sonography, Complete (B-Scan) Molar Pregnancy Diagnosis Sonography (B-Scan) Ectopic Pregnancy Diagnosis Sonography (B-Scan) Passive Testing (Antepartum Monitoring of Fetal Heart Rate In the Resting Fetus) Intrauterine Contraceptive Device Sonography (B-Scan)

Pelvic Mass Diagnosis Sonography (B-Scan) Amniocentesis, by Ultrasonic Guidance

Arterial Flow Study, Peripheral (Doppler) Venous Flow Study, Peripheral (Doppler) Arterial Aneurysm, Peripheral (B-Scan) Radiation Therapy Planning Sonography (B-Scan) Thyroid Echography (A-Mode)

Thyroid Sonography (B-Scan) Breast Echography (A-Mode) Breast Sonography (B-Scan) Hepatic Sonography (B-Scan) Gallbladder Sonography Renal Sonography Two-Dimensional Echocardiography (B-Mode)

Monitoring of cardiac output (Esophageal Doppler) for ventilated patients in the ICU and operative patients with a need for intra-operative fluid optimization

Nationally Non-Covered Indications

Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review. Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states " ...no Medicare

payment shall be made for items or services which are not reasonable and necessary for the diagnosis and treatment of illness or injury...". Furthermore, it has been longstanding CMS policy that "tests that are performed in the absence of signs, symptoms, complaints, or personal history of disease or injury are not covered unless explicitly authorized by statute".

Category II - (Unproven clinical reliability and effectiveness): B-Scan for atherosclerotic narrowing of peripheral arteries

APPLICABLE CODES The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws

that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or

guarantee claim payment. Other Policies and Guidelines may apply. Coding Clarification: Specific CPT code for non-covered service: B-scan for atherosclerotic narrowing of peripheral arteries not found.

CPT Code Description

76376

3D rendering with interpretation and reporting of computed tomography, magnetic

resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation




76377

3D rendering with interpretation and reporting of computed tomography, magnetic

resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation

76506

Echoencephalography, real time with image documentation (gray scale) (for

determination of ventricular size, delineation of cerebral contents, and detection of fluid masses or other intracranial abnormalities), including A-mode encephalography as secondary component where indicated

76510 Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during

the same patient encounter. (See the Medicare Advantage Policy Guideline for Use of Visual Tests Prior to and General Anesthesia during Cataract Surgery (NCD 10.1))

76511 Ophthalmic ultrasound, diagnostic; quantitative A-scan only. (See the Medicare Advantage Policy Guideline for Use of Visual Tests Prior to and General Anesthesia during Cataract Surgery (NCD 10.1))

76512

Ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed non-quantitative A-scan) (See the Medicare Advantage Policy Guideline for

Use of Visual Tests Prior to and General Anesthesia during Cataract Surgery (NCD 10.1))

76513

Ophthalmic ultrasound, diagnostic; anterior segment ultrasound, immersion (water bath) B-scan or high resolution biomiscroscopy. (See the Medicare Advantage Policy Guideline for Use of Visual Tests Prior to and General Anesthesia during Cataract Surgery (NCD 10.1))

76514 Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness)

76516 Ophthalmic biometry by ultrasound echography, A-scan. (See the Medicare Advantage Policy Guideline for Use of Visual Tests Prior to and General Anesthesia during Cataract Surgery (NCD 10.1))

76519

Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power

calculation. (See the Medicare Advantage Policy Guideline for Use of Visual Tests Prior to and General Anesthesia during Cataract Surgery (NCD 10.1))

76529 Ophthalmic ultrasonic foreign body localization

76536 Ultrasound, soft tissues of head and neck (e.g., thyroid, parathyroid, parotid), real time with image documentation

76604 Ultrasound, chest (includes mediastinum), real time with image documentation

76641 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete

76642 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited

76700 Ultrasound, abdominal, real time with image documentation; complete

76705 Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow-up)

76706 Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA)

76770 Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image

documentation; complete

76775 Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; limited

76776 Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation

76800 Ultrasound, spinal canal and contents

76801 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal

evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/u/visual-tests-prior-general-anesthesia-during-cataract-surgery.pdf















76802

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal

evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; each additional gestation (list separately in addition to code for primary procedure)


evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation

76810 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; each additional gestation (list separately in addition to code for primary procedure)


evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation


evaluation plus detailed fetal anatomic examination, transabdominal approach; each additional gestation (list separately in addition to code for primary procedure)

76813 Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation

76814 Ultrasound, pregnant uterus, real time with image documentation, first trimester

fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation (list separately in addition to code for primary procedure)

76815 Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., fetal heartbeat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses

76816

Ultrasound, pregnant uterus, real time with image documentation, follow-up (e.g.,

re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus

76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal

76818 Fetal biophysical profile; with non-stress testing

76819 Fetal biophysical profile; without non-stress testing

76820 Doppler velocimetry, fetal; umbilical artery

76821 Doppler velocimetry, fetal; middle cerebral artery

76825 Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording

76826 Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording; follow-up or repeat study

76827 Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete

76828 Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study

76830 Ultrasound, transvaginal

76831 Saline infusion sonohysterography (SIS), including color flow Doppler, when

performed

76856 Ultrasound, pelvic (nonobstetric), real time with image documentation; complete

76857 Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (e.g., for follicles)

76870 Ultrasound, scrotum and contents

76872 Ultrasound, transrectal

76873 Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure)

76881 Ultrasound, complete joint (e.g., joint space and peri-articular soft tissue structures) real-time with image documentation




76882

Ultrasound, limited, joint or other nonvascular extremity structure(s) (e.g., joint

space, peri-articular tendon[s], muscle[s], nerve[s], other soft tissue structure[s], or soft tissue mass[es]), real-time with image documentation

76885 Ultrasound, infant hips, real time with imaging documentation; dynamic (requiring physician manipulation or other qualified health care professional manipulation)

76886 Ultrasound, infant hips, real time with imaging documentation; limited, static (not requiring physician manipulation or other qualified health care professional manipulation)

76930 Ultrasonic guidance for pericardiocentesis, imaging supervision and interpretation

76932 Ultrasonic guidance for endomyocardial biopsy, imaging supervision and interpretation

76936 Ultrasound guided compression repair of arterial pseudoaneurysm or arteriovenous

fistulae (includes diagnostic ultrasound evaluation, compression of lesion and imaging)

76937

Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime

ultrasound visualization of vascular needle entry, with permanent recording and reporting (list separately in addition to code for primary procedure)

76940 Ultrasound guidance for, and monitoring of, parenchymal tissue ablation

76941 Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis, imaging supervision and interpretation

76942 Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation

76945 Ultrasonic guidance for chorionic villus sampling, imaging supervision and interpretation

76946 Ultrasonic guidance for amniocentesis, imaging supervision and interpretation

76948 Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation

76965 Ultrasonic guidance for interstitial radioelement application

76970 Ultrasound study follow-up (specify)

76975 Gastrointestinal endoscopic ultrasound, supervision and interpretation

76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method. (See the Medicare Advantage Policy Guideline for Bone (Mineral) Density Studies (NCD 150.3))

76978 Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac); initial lesion

76979 Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac); each additional lesion with separate injection (List separately in addition to code for primary procedure)

76981 Ultrasound, elastography; parenchyma (eg, organ)

76982 Ultrasound, elastography; first target lesion

76983 Ultrasound, elastography; each additional target lesion (List separately in addition to code for primary procedure)

76998 Ultrasonic guidance, intraoperative

76999 Unlisted ultrasound procedure (e.g., diagnostic, interventional)

93303 Transthoracic echocardiography for congenital cardiac anomalies; complete

93304 Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study

93306 Echocardiography, transthoracic, real-time with image documentation (2D), includes

M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography

93307

Echocardiography, transthoracic, real-time with image documentation (2D), includes

M-mode recording, when performed, complete, without spectral or color Doppler echocardiography






93308 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study

93312

Echocardiography, transesophageal, real-time with image documentation (2D) (with

or without M-mode recording); including probe placement, image acquisition, interpretation and report

93313 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only

93314 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); image acquisition, interpretation and report only

93315 Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report

93316 Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only

93317 Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only

93318

Echocardiography, transesophageal (TEE) for monitoring purposes, including probe

placement, real time 2-dimensional image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis

93320 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (list separately in addition to codes for echocardiographic imaging); complete

93321 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display

(list separately in addition to codes for echocardiographic imaging); follow-up or limited study (List separately in addition to codes for echocardiographic imaging)

93325 Doppler echocardiography color flow velocity mapping (list separately in addition to codes for echocardiography)

93350


M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report

93351


M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional

93571

Intravascular Doppler velocity and/or pressure derived coronary flow reserve

measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; initial vessel (List separately in addition to code for primary procedure) (See the Medicare Advantage Policy Guideline for Percutaneous Coronary Interventions)

93572

Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including

pharmacologically induced stress; each additional vessel (List separately in addition to code for primary procedure) (See the Medicare Advantage Policy Guideline for Percutaneous Coronary Interventions)

93880 Duplex scan of extracranial arteries; complete bilateral study (See the Medicare Advantage Policy Guideline for Noninvasive Tests of Carotid Function (20.17))

93882 Duplex scan of extracranial arteries; unilateral or limited study (See the Medicare Advantage Policy Guideline for Noninvasive Tests of Carotid Function (20.17))

93886 Transcranial Doppler study of the intracranial arteries; complete study (See the Medicare Advantage Policy Guideline for Noninvasive Tests of Carotid Function (20.17))

93888 Transcranial Doppler study of the intracranial arteries; limited study (See the

Medicare Advantage Policy Guideline for Noninvasive Tests of Carotid Function (20.17))

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/p/percutaneous-coronary-interventions.pdf



https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/n/noninvasive-tests-carotid-function.pdf









93890

Transcranial Doppler study of the intracranial arteries; vasoreactivity study (See the

Medicare Advantage Policy Guideline for Noninvasive Tests of Carotid Function (20.17))

93892 Transcranial Doppler study of the intracranial arteries; emboli detection without

intravenous microbubble injection (See the Medicare Advantage Policy Guideline for Noninvasive Tests of Carotid Function (20.17))

93893 Transcranial Doppler study of the intracranial arteries; emboli detection with intravenous microbubble injection (See the Medicare Advantage Policy Guideline for Noninvasive Tests of Carotid Function (20.17))

93925 Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study

93926 Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study

93930 Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study

93931 Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study

93970 Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study

93971 Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study

93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study

93976 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study

93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study

93979 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study

93980 Duplex scan of arterial inflow and venous outflow of penile vessels; complete study

(See the Medicare Advantage Policy Guideline for Diagnosis and Treatment of Impotence (NCD 230.4))

93981 Duplex scan of arterial inflow and venous outflow of penile vessels; follow-up or limited study (See the Medicare Advantage Policy Guideline for Diagnosis and Treatment of Impotence (NCD 230.4))

93990 Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow)

CPT® is a registered trademark of the American Medical Association

HCPCS Code Description

G9157 Transesophageal Doppler used for cardiac monitoring

Modifier Description

TC Technical component

26 Professional Component

Coding Clarification: This section lists codes that are never covered when given as the primary reason for the test. If a code from this section is given as the reason for the test and you know or have reason to believe the service may not be covered, call UnitedHealthcare to issue an Integrated Denial Notice (IDN) to the member and you. The

IDN informs the member of their liability for the non-covered service or item and appeal rights. You must make sure the member has received the IDN prior to rendering or referring for non-covered services or items in order to collect payment.





https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/d/diagnosis-treatment-impotence.pdf






ICD-10 Diagnosis Code Description

Non-Covered

R99 Ill-defined and unknown cause of mortality

Z00.00 Encounter for general adult medical examination without abnormal findings

Z00.01 Encounter for general adult medical examination with abnormal findings

Z00.110 Health examination for newborn under 8 days old

Z00.111 Health examination for newborn 8 to 28 days old

Z00.121 Encounter for routine child health examination with abnormal findings

Z00.129 Encounter for routine child health examination without abnormal findings

Z00.5 Encounter for examination of potential donor of organ and tissue

Z00.70 Encounter for examination for period of delayed growth in childhood without abnormal findings

Z00.71 Encounter for examination for period of delayed growth in childhood with abnormal findings

Z00.8 Encounter for other general examination

Z02.0 Encounter for examination for admission to educational institution

Z02.1 Encounter for pre-employment examination

Z02.2 Encounter for examination for admission to residential institution

Z02.3 Encounter for examination for recruitment to armed forces

Z02.4 Encounter for examination for driving license

Z02.5 Encounter for examination for participation in sport

Z02.6 Encounter for examination for insurance purposes

Z02.71 Encounter for disability determination

Z02.79 Encounter for issue of other medical certificate

Z02.81 Encounter for paternity testing

Z02.82 Encounter for adoption services

Z02.83 Encounter for blood-alcohol and blood-drug test

Z02.89 Encounter for other administrative examinations

Z02.9 Encounter for administrative examinations, unspecified

Z04.6 Encounter for general psychiatric examination, requested by authority

Z04.8 Encounter for examination and observation for other specified reasons (Removed 09/30/2018)

Z04.81 Encounter for examination and observation of victim following forced sexual exploitation (Effective 10/01/2018)

Z04.82 Encounter for examination and observation of victim following forced labor exploitation (Effective 10/01/2018)

Z04.89 Encounter for examination and observation for other specified reasons (Effective 10/01/2018)

Z04.9 Encounter for examination and observation for unspecified reason

Z11.0 Encounter for screening for intestinal infectious diseases

Z11.1 Encounter for screening for respiratory tuberculosis

Z11.2 Encounter for screening for other bacterial diseases

Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission

Z11.4 Encounter for screening for human immunodeficiency virus [HIV]

Z11.51 Encounter for screening for human papillomavirus (HPV)

Z11.59 Encounter for screening for other viral diseases

Z11.6 Encounter for screening for other protozoal diseases and helminthiases

Z11.7 Encounter for testing for latent tuberculosis infection (Effective 10/01/2019)

Z11.8 Encounter for screening for other infectious and parasitic diseases




Non-Covered

Z11.9 Encounter for screening for infectious and parasitic diseases, unspecified

Z12.0 Encounter for screening for malignant neoplasm of stomach

Z12.10 Encounter for screening for malignant neoplasm of intestinal tract, unspecified

Z12.13 Encounter for screening for malignant neoplasm of small intestine

Z12.2 Encounter for screening for malignant neoplasm of respiratory organs

Z12.6 Encounter for screening for malignant neoplasm of bladder

Z12.71 Encounter for screening for malignant neoplasm of testis

Z12.72 Encounter for screening for malignant neoplasm of vagina

Z12.73 Encounter for screening for malignant neoplasm of ovary

Z12.79 Encounter for screening for malignant neoplasm of other genitourinary organs

Z12.81 Encounter for screening for malignant neoplasm of oral cavity

Z12.82 Encounter for screening for malignant neoplasm of nervous system

Z12.83 Encounter for screening for malignant neoplasm of skin

Z12.89 Encounter for screening for malignant neoplasm of other sites

Z12.9 Encounter for screening for malignant neoplasm, site unspecified

Z13.0 Encounter for screening for diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism

Z13.21 Encounter for screening for nutritional disorder

Z13.220 Encounter for screening for lipoid disorders

Z13.228 Encounter for screening for other metabolic disorders

Z13.29 Encounter for screening for other suspected endocrine disorder

Z13.3 Encounter for screening examination for mental health and behavioral disorders (Removed 09/30/2018)

Z13.30 Encounter for screening examination for mental health and behavioral disorders, unspecified (Effective 10/01/2018)

Z13.31 Encounter for screening for depression (Effective 10/01/2018)

Z13.32 Encounter for screening for maternal depression (Effective 10/01/2018)

Z13.39 Encounter for screening examination for other mental health and behavioral disorders (Effective 10/01/2018)

Z13.4 Encounter for screening for certain developmental disorders in childhood (Removed 09/30/2018)

Z13.40 Encounter for screening for unspecified developmental delays (Effective 10/01/2018)

Z13.41 Encounter for autism screening (Effective 10/01/2018)

Z13.42 Encounter for screening for global developmental delays (milestones) (Effective 10/01/2018)

Z13.49 Encounter for screening for other developmental delays (Effective 10/01/2018)

Z13.5 Encounter for screening for eye and ear disorders

Z13.71 Encounter for nonprocreative screening for genetic disease carrier status

Z13.79 Encounter for other screening for genetic and chromosomal anomalies

Z13.810 Encounter for screening for upper gastrointestinal disorder

Z13.811 Encounter for screening for lower gastrointestinal disorder

Z13.818 Encounter for screening for other digestive system disorders

Z13.820 Encounter for screening for osteoporosis

Z13.828 Encounter for screening for other musculoskeletal disorder

Z13.83 Encounter for screening for respiratory disorder NEC

Z13.84 Encounter for screening for dental disorders

Z13.850 Encounter for screening for traumatic brain injury




Non-Covered

Z13.858 Encounter for screening for other nervous system disorders

Z13.88 Encounter for screening for disorder due to exposure to contaminants

Z13.89 Encounter for screening for other disorder

Z13.9 Encounter for screening, unspecified

Z36.0 Encounter for antenatal screening for chromosomal anomalies

Z36.1 Encounter for antenatal screening for raised alphafetoprotein level

Z36.2 Encounter for other antenatal screening follow-up

Z36.3 Encounter for antenatal screening for malformations

Z36.4 Encounter for antenatal screening for fetal growth retardation

Z36.5 Encounter for antenatal screening for isoimmunization

Z36.81 Encounter for antenatal screening for hydrops fetalis

Z36.82 Encounter for antenatal screening for nuchal translucency

Z36.83 Encounter for fetal screening for congenital cardiac abnormalities

Z36.84 Encounter for antenatal screening for fetal lung maturity

Z36.85 Encounter for antenatal screening for Streptococcus B

Z36.86 Encounter for antenatal screening for cervical length

Z36.87 Encounter for antenatal screening for uncertain dates

Z36.88 Encounter for antenatal screening for fetal macrosomia

Z36.89 Encounter for other specified antenatal screening

Z36.8A Encounter for antenatal screening for other genetic defects

Z36.9 Encounter for antenatal screening, unspecified

Z40.00 Encounter for prophylactic removal of unspecified organ

Z40.01 Encounter for prophylactic removal of breast

Z40.02 Encounter for prophylactic removal of ovary(s)

Z40.09 Encounter for prophylactic removal of other organ

Z40.8 Encounter for other prophylactic surgery

Z40.9 Encounter for prophylactic surgery, unspecified

Z41.1 Encounter for cosmetic surgery

Z41.2 Encounter for routine and ritual male circumcision

Z41.3 Encounter for ear piercing

Z41.8 Encounter for other procedures for purposes other than remedying health state

Z41.9 Encounter for procedure for purposes other than remedying health state, unspecified

Z46.1 Encounter for fitting and adjustment of hearing aid

Z56.0 Unemployment, unspecified

Z56.2 Threat of job loss

Z56.3 Stressful work schedule

Z56.4 Discord with boss and workmates

Z56.5 Uncongenial work environment

Z56.6 Other physical and mental strain related to work

Z56.81 Sexual harassment on the job

Z56.82 Military deployment status

Z56.89 Other problems related to employment

Z56.9 Unspecified problems related to employment

Z57.0 Occupational exposure to noise

Z57.1 Occupational exposure to radiation

Z57.2 Occupational exposure to dust




Non-Covered

Z57.31 Occupational exposure to environmental tobacco smoke

Z57.39 Occupational exposure to other air contaminants

Z57.4 Occupational exposure to toxic agents in agriculture

Z57.5 Occupational exposure to toxic agents in other industries

Z57.6 Occupational exposure to extreme temperature

Z57.7 Occupational exposure to vibration

Z57.8 Occupational exposure to other risk factors

Z57.9 Occupational exposure to unspecified risk factor

Z59.0 Homelessness

Z59.1 Inadequate housing

Z59.2 Discord with neighbors, lodgers and landlord

Z59.3 Problems related to living in residential institution

Z59.4 Lack of adequate food and safe drinking water

Z59.5 Extreme poverty

Z59.6 Low income

Z59.7 Insufficient social insurance and welfare support

Z59.8 Other problems related to housing and economic circumstances

Z59.9 Problem related to housing and economic circumstances, unspecified

Z60.2 Problems related to living alone

Z62.21 Child in welfare custody

Z71.0 Person encountering health services to consult on behalf of another person

Z74.1 Need for assistance with personal care

Z74.2 Need for assistance at home and no other household member able to render care

Z74.3 Need for continuous supervision

Z74.8 Other problems related to care provider dependency

Z74.9 Problem related to care provider dependency, unspecified

Z75.5 Holiday relief care

Z76.0 Encounter for issue of repeat prescription

Z76.1 Encounter for health supervision and care of foundling

Z76.2 Encounter for health supervision and care of other healthy infant and child

Z76.3 Healthy person accompanying sick person

Z76.4 Other boarder to healthcare facility

Z76.81 Expectant parent(s) prebirth pediatrician visit

Z80.1 Family history of malignant neoplasm of trachea, bronchus and lung

Z80.2 Family history of malignant neoplasm of other respiratory and intrathoracic organs

Z80.49 Family history of malignant neoplasm of other genital organs

Z80.51 Family history of malignant neoplasm of kidney

Z80.52 Family history of malignant neoplasm of bladder

Z80.59 Family history of malignant neoplasm of other urinary tract organ

Z80.6 Family history of leukemia

Z80.7 Family history of other malignant neoplasms of lymphoid, hematopoietic and related tissues

Z80.8 Family history of malignant neoplasm of other organs or systems

Z80.9 Family history of malignant neoplasm, unspecified

Z81.0 Family history of intellectual disabilities

Z81.1 Family history of alcohol abuse and dependence




Non-Covered

Z81.2 Family history of tobacco abuse and dependence

Z81.3 Family history of other psychoactive substance abuse and dependence

Z81.4 Family history of other substance abuse and dependence

Z81.8 Family history of other mental and behavioral disorders

Z82.0 Family history of epilepsy and other diseases of the nervous system

Z82.1 Family history of blindness and visual loss

Z82.2 Family history of deafness and hearing loss

Z82.3 Family history of stroke

Z82.41 Family history of sudden cardiac death

Z82.49 Family history of ischemic heart disease and other diseases of the circulatory system

Z82.5 Family history of asthma and other chronic lower respiratory diseases

Z82.61 Family history of arthritis

Z82.62 Family history of osteoporosis

Z82.69 Family history of other diseases of the musculoskeletal system and connective tissue

Z82.71 Family history of polycystic kidney

Z82.79 Family history of other congenital malformations, deformations and chromosomal abnormalities

Z82.8 Family history of other disabilities and chronic diseases leading to disablement, not elsewhere classified

Z83.0 Family history of human immunodeficiency virus [HIV] disease

Z83.1 Family history of other infectious and parasitic diseases

Z83.2 Family history of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism

Z83.3 Family history of diabetes mellitus

Z83.41 Family history of multiple endocrine neoplasia [MEN] syndrome

Z83.49 Family history of other endocrine, nutritional and metabolic diseases

Z83.511 Family history of glaucoma

Z83.518 Family history of other specified eye disorder

Z83.52 Family history of ear disorders

Z83.6 Family history of other diseases of the respiratory system

Z83.71 Family history of colonic polyps

Z83.79 Family history of other diseases of the digestive system

Z84.0 Family history of diseases of the skin and subcutaneous tissue

Z84.1 Family history of disorders of kidney and ureter

Z84.2 Family history of other diseases of the genitourinary system

Z84.3 Family history of consanguinity

Z84.81 Family history of carrier of genetic disease

Z84.89 Family history of other specified conditions

PURPOSE

The Medicare Advantage Policy Guideline documents are generally used to support UnitedHealthcare Medicare Advantage claims processing activities and facilitate providers’ submission of accurate claims for the specified services. The document can be used as a guide to help determine applicable: Medicare coding or billing requirements, and/or Medical necessity coverage guidelines; including documentation requirements.

UnitedHealthcare follows Medicare guidelines such as LCDs, NCDs, and other Medicare manuals for the purposes of determining coverage. It is expected providers retain or have access to appropriate documentation when requested to support coverage. Please utilize the links in the References section below to view the Medicare source materials used



to develop this resource document. This document is not a replacement for the Medicare source materials that outline Medicare coverage requirements. Where there is a conflict between this document and Medicare source materials, the Medicare source materials will apply.

REFERENCES CMS National Coverage Determination (NCD) NCD 220.5 Ultrasound Diagnostic Procedures

LCD Article Contractor Medicare Part A Medicare Part B

Breast Imaging

L33585 (Breast Imaging:

Breast Echography (Sonography)/Breast MRI/Ductography)

A52849 (Breast Imaging:

Breast Echography (Sonography)/Breast MRI/Ductography-Supplemental Instructions Article)

NGS CT, IL, MA, ME,

MN, NH, NY, RI, VT, WI

CT, IL, MA, ME,


L33950 (Breast Imaging

Mammography/Breast

Echography (Sonography)/Breast MRI/Ductography)

A56448 (Billing and Coding for

Breast Imaging

Mammography/Breast Echography (Sonography)/Breast MRI/Ductography)

CGS KY, OH KY, OH

Cardiac

L33577 (Transthoracic Echocardiography (TTE))

A56781 (Billing and Coding: Transthoracic Echocardiography (TTE))

NGS CT, IL, MA, ME, MN, NH, NY, RI, VT, WI

CT, IL, MA, ME, MN, NH, NY, RI, VT, WI

L33579 (Transesophageal Echocardiography (TEE)) NGS

A52868 (Billing and Coding:

Transesophageal Echocardiography (TEE) )

NGS CT, IL, MA, ME,


CT, IL, MA, ME,


L33756 (Transesophageal Echocardiogram (TEE))


Transesophageal Echocardiogram)

First Coast FL, PR, VI FL, PR, VI


A57182 (Billing and Coding: Transthoracic Echocardiography (TTE))


L34324 (Cardiovascular Stress

Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography)


Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography)

Noridian AS, CA, GU, HI, MP, NV

AS, CA, GU, HI, MP, NV

L34337 (Transesophageal Echocardiography (TEE))


Transesophageal Echocardiography (TEE))

CGS KY, OH KY, OH


A57306 (Billing and Coding: Transthoracic

Echocardiography (TTE))

CGS KY, OH KY, OH

L35016 (Transesophageal Echocardiography (TEE))


Transesophageal Echocardiography (TEE))

Novitas AR, CO, DC,

DE, LA, MD, MS, NJ, NM, OK, PA, TX

AR, CO, DC,


L36209 (Cardiology-Non-

emergent Outpatient Testing; Exercise Stress Test, Stress Echo, MPI SPECT, and Cardiac PET)


Cardiology – non-emergent outpatient testing: exercise stress test, stress echo, MPI SPECT, and cardiac PET)


http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=263&ncdver=3&DocID=220.5&bc=gAAAAAgAAAAAAA%3d%3d&

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33585&ver=33&Date=&DocID=L33585&bc=iAAAAAgAgAAA&




https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52849&ver=27&LCDId=33585&Date=&DocID=L33585&bc=iAAAAAgAQAAA&











https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=56448&ver=8&DocID=A56448&SearchType=Advanced&bc=IAAAABAAQAAA&






https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33577&ver=43&DocID=+L33577++&kq=true&bc=gAAAAAgAgAAA&

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33577&ver=43&DocID=+L33577++&kq=true&bc=gAAAAAgAgAAA&

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=56781&ver=9&Date=&DocID=A56781&bc=ggAAAAgAAAAA&










https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=57179&ver=5&DocID=A57179&bc=gAAAAAgAAAAA&



https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33768&ver=23&Date=&DocID=L33768&bc=hAAAAAgAAAAA&





























https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36209&ver=30&Date=&DocID=L36209&bc=iAAAABAAgAAA&













L36889 (Cardiovascular Stress

Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography)


Cardiovascular Stress Testing, Including Exercise and/or

Pharmacological Stress and Stress Echocardiography)

Noridian AK, AZ, ID, MT,

ND, OR, SD, UT, WA, WY

AK, AZ, ID, MT,

ND, OR, SD, UT, WA, WY

L37379 (Echocardiography) A56625 (Billing and Coding: Echocardiography)

Palmetto AL, GA, NC, SC, TN, VA, WV

AL, GA, NC, SC, TN, VA, WV

Extremity

L33619 (Nonvascular Extremity Ultrasound)


Nonvascular Extremity Ultrasound)

NGS CT, IL, MA, ME,


CT, IL, MA, ME,


L35409 (Non-Vascular Extremity Ultrasound)

A55037 (Billing and Coding: Non-Vascular Extremity Ultrasound)

Novitas AR, CO, DC, DE, LA, MD,

MS, NJ, NM, OK, PA, TX

AR, CO, DC, DE, LA, MD,


L33667 (Duplex Scan Of Lower Extremity Arteries)

A57064 (Billing and Coding: Duplex Scan Of Lower Extremity Arteries)


A56291 (Duplex scan of lower extremity arteries revision to the Part A and Part B LCD


L33674 (Duplex Scanning) A57636 (Billing and Coding: Duplex Scanning)


L35408 (3D Interpretation and Reporting of Imaging Studies)


3D Interpretation and Reporting of Imaging Studies)

Novitas AR, CO, DC,


AR, CO, DC,


L33256 (3D Interpretation and Reporting of Imaging Studies)

A56919 (3D interpretation and

reporting of imaging studies revision to the Part A and Part B LCD)


A56920 (Billing and Coding: 3D Interpretation and Reporting of Imaging Studies)


L33621 (Ophthalmic Biometry

for Intraocular Lens Power Calculation)


Ophthalmic Biometry for Intraocular Lens Power Calculation)

NGS CT, IL, MA, ME,


CT, IL, MA, ME,


L33630 (Corneal Pachymetry) A56548 (Billing and Coding: Corneal Pachymetry)

NGS CT, IL, MA, ME, MN, NH, NY, RI, VT, WI

CT, IL, MA, ME, MN, NH, NY, RI, VT, WI

L33999 (Corneal Pachymetry) A56457 (Billing and Coding:

Billing and Coding for Corneal Pachymetry)

CGS KY, OH KY, OH

L34181 (Ophthalmic Biometry

for Intraocular Lens Power Calculation)


Ophthalmic Biometry for Intraocular Lens Power Calculation)

CGS KY, OH KY, OH

L34512 (Corneal Pachymetry) A56611 (Billing and Coding: Corneal Pachymetry)

Palmetto AL, GA, TN NC, SC, TN, VA, WV


N/A A53131 (Ophthalmic Biometry

for Intraocular Lens (IOL) Power Calculation)

Novitas DC, DE, MD, NJ, PA

DC, DE, MD, NJ, PA

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36889&ver=24&Date=&DocID=L36889&SearchType=Advanced&bc=KAAAABAAgAAA&






























https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33674&ver=10&DocID=L33674&bc=gAAAAAgAAAAA&















































L33416 (3D Interpretation and

Reporting of Imaging Studies) Palmetto (Retired 08/23/2019)

A53268 (3D Interpretations

and Reporting of Imaging Studies) Palmetto (Retired 08/23/2019)



L33904 (B-Scan) First Coast

(Retired 12/15/2018)


N/A A52383 (Corneal Pachymetry-

Supplemental Instructions Article) (Retired 04/03/2019)

CGS KY, OH KY, OH


for Intraocular Lens Power Calculation-Supplemental Instructions Article) (Retired 11/26/2019)

CGS KY, OH KY, OH

Head and Neck

L34027 (Ultrasound, Soft tissues of Head and Neck)


Ultrasound, Soft Tissues of Head and Neck)


A57028 (Ultrasound soft tissues of head and neck revision to the Part A and Part B LCD)


L33977 (Transcranial Doppler Studies) First Coast

A57633 ( Billing and Coding: Transcranial Doppler Studies


A57493 (Transcranial Doppler

studies revision to the Part B LCD)


L35397 (Non-Invasive Cerebrovascular Arterial Studies)

A52992 (Billing and Coding: Non-Invasive Cerebrovascular Arterial Studies)

Novitas AR, CO, DC, DE, LA, MD,


AR, CO, DC, DE, LA, MD,


Pelvic

L33578 (Transrectal Ultrasound)

A57427 (Billing and Coding: Transrectal Ultrasound

NGS CT, IL, MA, ME,


CT, IL, MA, ME,


L34577 (Retroperitoneal Ultrasound)

A55336 (Billing and Coding: Retroperitoneal Ultrasound)



L37636 (Nonobstetric Pelvic Ultrasound)


Nonobstetric Pelvic Ultrasound)



Noncovered Services

L33777 (Noncovered Services) A57743 (Billing and Coding: Noncovered Services)


A57749 ( Noncovered

services – revision to the Part A and Part B LCD


L36954 (Noncovered Services

other than CPT® Category III Noncovered Services)


Noncovered Services other than CPT® Category III Noncovered Services)















































https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?arhttps://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=56506&ver=13&Date=&DocID=A56506&bc=ggAAAAgAAAAA&ticleId=56506&ver=13&Date=&DocID=A56506&bc=ggAAAAgAAAAA&







N/A A52383 (Corneal Pachymetry-

Supplemental Instructions Article) Retired 04/03/2019

CGS KY, OH KY, OH


for Intraocular Lens Power Calculation-Supplemental Instructions Article) (Retired 11/26/2019)

CGS KY, OH KY, OH

CMS Benefit Policy Manual

Chapter 15; § 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests

CMS Claims Processing Manual

Chapter 13; § 20 Payment Conditions for Radiology Services Chapter 18; § 110 Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) Chapter 32; § 310 Transesophageal Doppler Used for Cardiac Monitoring

MLN Matters

Article MM5235, Implementation of a One-Time Only Ultrasound Screening for Abdominal Aortic Aneurysms (AAA),

Resulting from a Referral from an Initial Preventive Physical Examination Article MM5608, Ultrasound Diagnostic Procedures

Article MM8330, Coding Changes to Ultrasound Diagnostic Procedures for Transesophageal Doppler Monitoring Article MM8881, Medicare Coverage of Ultrasound Screening for Abdominal Aortic Aneurysms (AAA) and Screening Fecal-Occult Blood Tests (FOBT) Article MM9888, HCPCS Code Update for Preventive Services Article SE1122, Important Reminders about Advanced Diagnostic Imaging (ADI) Accreditation Requirements (MIPPA Exclusion for Ultrasound)

CMS Transmittals

Transmittal 76, Change Request 5608, Dated 09/12/2007 Ultrasound Diagnositc Procedures Transmittal 2743, Change Request 8330, Dated 07/25/2013 Coding Changes to Ultrasound Diagnostic Procedures for

Transesophageal Doppler Monitoring

UnitedHealthcare Commercial Policies Breast Imaging for Screening and Diagnosing Cancer

Spinal Ultrasonography

GUIDELINE HISTORY/REVISION INFORMATION Revisions to this summary document do not in any way modify the requirement that services be provided and documented in accordance with the Medicare guidelines in effect on the date of service in question.

Date Action/Description

03/11/2020 Supporting Information Updated References section to reflect the most current information

TERMS AND CONDITIONS The Medicare Advantage Policy Guidelines are applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates.

These Policy Guidelines are provided for informational purposes, and do not constitute medical advice. Treating physicians and healthcare providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care. Benefit coverage for health services is determined by the member specific benefit plan document* and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific

benefit plan document supersedes the Medicare Advantage Policy Guidelines. Medicare Advantage Policy Guidelines are developed as needed, are regularly reviewed and updated, and are subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. UnitedHealthcare may modify these Policy Guidelines at any time by publishing a new version of the policy on this website. Medicare source materials used to develop these guidelines include, but are not limited to, CMS National

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c13.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c32.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5235.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5235.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5608.pdf

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/MM8330.pdf



https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9888.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1122.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1122.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R76NCD.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2743CP.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2743CP.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/breast-imaging-screening-diagnosing-cancer.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/spinal-ultrasonography.pdf



Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Medicare Benefit Policy Manual, Medicare Claims Processing Manual, Medicare Program Integrity Manual, Medicare Managed Care Manual, etc. The information presented in the Medicare Advantage Policy Guidelines is believed to be accurate and current as of the date of publication, and is provided on an "AS IS" basis. Where there is a conflict between this document and Medicare source

materials, the Medicare source materials will apply. You are responsible for submission of accurate claims. Medicare Advantage Policy Guidelines are intended to ensure that coverage decisions are made accurately based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Medicare Advantage Policy Guidelines use Current Procedural Terminology (CPT®), Centers for Medicare and Medicaid Services (CMS), or other coding guidelines. References to CPT® or other sources are for definitional purposes only and do not imply any right to reimbursement or guarantee claims payment.

Medicare Advantage Policy Guidelines are the property of UnitedHealthcare. Unauthorized copying, use and distribution of this information are strictly prohibited. *For more information on a specific member's benefit coverage, please call the customer service number on the back of the member ID card or refer to the Administrative Guide.

https://www.uhcprovider.com/en/admin-guides.html

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