Causes for Exceeding LCD Maximum
The following are the pertinent laboratory tests for which frequency limitations will be specified, noting that lipid, thyroid, glycated hemoglobin/glycated protein, and glucose testing frequencies apply to analytes from the laboratory National Coverage Determination (NCD) via negotiated rulemaking:
| Type of Lab Test (CPT Code) | LCD Frequency Limit (Per Beneficiary Per Provider) | Acceptable Reasons for Exceeding the LCD Maximum |
|---|---|---|
Lipids:
| No more than every two months for any test (e.g., triglycerides, LDL cholesterol), whether in a panel or separately ordered | Inability to stabilize lipid-lowering drug dosing (Z79.899). Adverse reaction to lipid-lowering drug (Z79.899). Pancreatitis (B25.2, K85.00, K85.01, K85.02, K85.10, K85.11, K85.12, K85.20, K85.21, K85.22, K85.30, K85.31, K85.32, K85.80, K85.81, K85.82, K85.90, K85.91, K85.92, K86.0, K86.1). Monitoring of acitretin (i.e., Soriatane) therapy (Z79.899) |
Thyroid testing:
| Four times a year for most patients, except for selected endocrine presentations | Inability to stabilize thyroid medication dosing Thyrotoxicosis Concurrent endocrinopathies Hypothyroidism. (Codes pertaining to the above bullets: C73, D34, D51.0, D53.9, D64.9, D89.82, D89.89, E00.0-E00.2, E00.9, E01.8, E02, E03.0-E03.3, E03.8-E03.9, E05.00-E05.01, E05.10-E05.11, E05.20-E05.21, E05.30-E05.31, E05.40-E05.41, E05.80-E05.81, E05.90-E05.91, E06.0-E06.5, E06.9, E10.10-E10.11, E10.21-E10.22, E10.29, E10.311, E10.319, E10.3211, E10.3212, E10.3213, E10.3291, E10.3292, E10.3293, E10.3311, E10.3312, E10.3313, E10.3391, E10.3392, E10.3393, E10.3411, E10.3412, E10.3413, E10.3491, E10.3492, E10.3493, E10.3511, E10.3512, E10.3513, E10.3591, E10.3592, E10.3593, E10.36, E10.39-E10.44, E10.49, E10.51-E10.52, E10.59, E10.610, E10.618, E10.620-E10.622, E10.628, E10.630, E10.638, E10.641, E10.649-E10.65, E10.69, E10.8-E11.01, E11.10, E11.11, E11.21-E11.22, E11.29, E11.311, E11.319, E11.3211, E11.3212, E11.3213, E11.3291, E11.3292, E11.3293, E11.3311, E11.3312, E11.3313, E11.3391, E11.3392, E11.3393, E11.3411, E11.3412, E11.3413, E11.3491, E11.3492, E11.3493, E11.3511, E11.3512, E11.3513, E11.3591, E11.3592, E11.3593, E11.36, E11.39-E11.44, E11.49-E11.52, E11.59, E11.610, E11.618, E11.620-E11.622, E11.628-E11.630, E11.638, E11.641, E11.649-E11.65, E11.69, E11.8-E11.9, E13.00-E13.01, E13.10-E13.11, E13.21-E13.22, E13.29, E13.311, E13.319, E13.3211, E13.3212, E13.3213, E13.3291, E13.3292, E13.3293, E13.3311, E13.3312, E13.3313, E13.3391, E13.3392, E13.3393, E13.3411, E13.3412, E13.3413, E13.3491, E13.3492, E13.3493, E13.3511, E13.3512, E13.3513, E13.3591, E13.3592, E13.3593, E13.36, E13.39-E13.44, E13.49, E13.51-E13.52, E13.59, E13.610, E13.618, E13.620-E13.622, E13.628, E13.630, E13.638, E13.641, E13.649-E13.65, E13.69, E13.8-E13.9, E20.0-E20.1, E20.8-E20.9, E23.0, E23.6, E25.0, E25.8-E25.9, E27.1-E27.40, E27.49, E78.00, E78.2, E83.50-E83.52, E83.59, E87.0-E87.1, E89.0, E89.2, E89.6, F03.90, F05, F30.10-F30.13, F30.2-F30.4, F30.8-F31.0, F31.10-F31.13, F31.2, F31.30-F31.32, F31.4-F31.5, F31.60-F31.64, F31.70-F31.78, F31.81, F31.89-F32.5, F32.89-F33.3, F33.40-F33.42, F33.8-F33.9, F34.81, F34.89, F34.9, F39, F41.0-F41.1, F41.3, F41.8-F41.9, G73.7, H02.531-H02.536, H02.539, H02.841-H02.846, H02.849, H05.89, I47.1, I48.0, I48.2, I48.91, I49.2, I50.20-I50.23, I50.30-I50.33, I50.40-I50.43, I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84, I50.89, I50.9, J91.8, K56.0, K56.7, N94.4-N94.6, Q38.2, R00.0, R00.2, R07.0, R40.0-R40.1, R40.4, R63.4-R63.5, R94.6, Z79.899) |
Glycated hemoglobin / glycolated protein:
| Once per month as discussed in NCD 190.21 | No diagnoses are to exceed this frequency but unusual circumstances can be reviewed in the appeals process. |
Glucose testing:
| Once per month | Type I or Type II Diabetes with hyperglycemia/complications (E10.65, E10.8, E11.65, E11.8). |
Medicare is establishing the following limited coverage for CPT/HCPCS codes: 80061, 82465, 82948, 82962, 82985, 83036, 83718, 83721, 84436, 84439, 84443, 84478 and 84479:
Notice: The LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.