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May 27, 2020

CGS is Retiring Policy L34370 Category III CPT Codes

CGS Administrators will be retiring policy L34370 Category III CPT Codes effective 6/29/2020.

We wanted to let the provider community know of this change before being implemented, as this is a change from how we currently handle Category III codes.

The codes associated with this policy may be subject to coverage determinations under other Medicare policies such as local coverage determinations (LCD) or national coverage determinations (NCD).

In the absence of policy, the Category III code must still meet the reasonable and necessary provisions of the act or be in an approved investigational trial to be covered.   Reasonable and necessary is defined in the IOM 100-08 Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2:  Reasonable and Necessary CriteriaExternal PDF.  CGS will review published medical literature regarding the Category III in making this determination.

Providers may be asked to submit records for review. If records are needed, they will be requested through the Additional Documentation Request (ADR) process.

This is not to be confused with prior authorization; the review will occur after the code has been billed. The determination cannot be made prior to submitting the claim.

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