License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

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CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

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The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

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Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association website.
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Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Alert

Prevent Denials

Before a PA request is submitted, ensure your facility understands the difference between cosmetic vs. reconstructive procedures. The medical record must also support that the services are medically reasonable and necessary. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). Items and services which are not reasonable and necessary for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member are not covered services.

Background

Title XVIII of the Social Security Act section 1862 (a)(1)(A) allows coverage and payment of those services that are medically reasonable and necessary. In the absence of a local coverage determination (LCD), CGS utilizes the Centers for Medicare & Medicaid Services (CMS) based regulatory guidance, national coverage determinations (NCDs), evidence-based specialty guidelines, and high quality published literature to establish medical necessity. See CMS Regulation Reference: Publication 100-08, Chapter 3, Section 3.6.2.2 for Reasonable and Necessary Criteria.

Coverage and Documentation Requirements

Meeting medical necessity requirements remain unchanged for certain hospital OPD services for dates of services (DOS) on or after July 1, 2020 in order to protect the Medicare Trust Fund from improper payments. The patient s medical record must contain documentation to fully support that services are medically reasonable and necessary. Reimbursement for a non-covered procedure performed during the same operative session as a covered surgical procedure will not be covered.

The patient s medical record should include but is not limited to:

Assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit
Relevant medical history
Results of pertinent tests/procedures
Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed)

Is the Service Being Performed Cosmetic or Reconstructive?

Reconstructive items and services are reasonable and necessary for the diagnosis or treatment of illness, injury, or to improve the functioning of a malformed body member are covered. Cosmetic procedures or expenses incurred in connection with such procedures (addressing aesthetic appearance alone) will not be covered.

Cosmetic Procedures

Cosmetic procedures include surgical procedures directed at improving appearance, except when required for the prompt repair of accidental injury or for the improvement of the functioning of a malformed body part. For example, procedures solely to improve or enhance the aesthetic appearance is not considered reasonable and necessary.

Indications for Cosmetic Procedures

Services performed to improve a patient's appearance in the absence of any signs or symptoms of functional impairment such as:
- Treatment of wrinkles using Botulinum toxins
- Corrective facial surgery in the absence of addressing a functional impairment
Panniculectomy is performed for the following indications:
- Removal of unwanted localized collections of fat in order to improve appearance
- Treatment of neck or back pain
- Treating psychological symptomatology or psychosocial complaints
- Hernia repair
- In conjunction with abdominal or gynecological procedures (e.g., abdominal hernia repair, hysterectomy, obesity surgery) unless criteria for panniculectomy and abdominoplasty are met separately
Nasal surgery performed solely to improve aesthetic appearance in the absence of any signs and/or symptoms of functional abnormalities
Interventional vein ablation treatments for the following indications:
- Treatment of spider veins (telangiectases)
- Interventional treatment of asymptomatic varicosities
- Sclerotherapy for cosmetic purposes

Reconstructive Procedures

Reconstructive procedures include surgical procedures to correct, repair, or restore bodily function of a deformity resulting from trauma/injury, infection, inflammation, degeneration (e.g., from aging), neoplasia, or developmental errors (e.g., congenital anomalies, defects). When the service performed is to improve necessary functioning of a malformed body part, the services are considered reasonable and necessary.

Indications for Reconstructive Procedures

Blepharoplasty is performed to correct visual impairment caused by drooping of the eyelids
- Repair defects caused by trauma or tumor-ablative surgery
- Treat periorbital sequelae of thyroid disease and nerve palsy
- Relieve painful symptoms of blepharospasm
Nasal surgery generally performed to improve:
- Respiratory function
- Repair defects caused by trauma
- Treatment of nasal deformity associated with congenital anomaly such as:
  - cleft lip or cleft palate
  - choanal atresia
  - oronasal or oromaxillary fistula
- Replace nasal tissue lost after tumor ablation
Panniculectomy to correct or relieve:
- Structural defects of the abdominal wall
- Improve skin health within the fold beneath the pannus
- Improve chronic low back pain due to functional incompetence of the anterior abdominal wall
Vein ablation treatments will be considered for the following indications:
- Interventional treatment of varicose veins (e.g., sclerotherapy, ligation with or without stripping)
- Endovenous radiofrequency or laser ablation
- Failure of conservative therapy severe enough to require daily pain medications and inability to complete activities of daily living (e.g., pain, swelling, itching, burning, or other symptoms associated with vein reflux)