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National Coverage Determination (NCD)

Surgery for Diabetes - RETIRED

100.14

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Tracking Information

Publication Number
100-3
Manual Section Number
100.14
Manual Section Title
Surgery for Diabetes - RETIRED
Version Number
3
Effective Date of this Version
04/10/2023
Ending Effective Date of this Version
Implementation Date
04/10/2023
Implementation QR Modifier Date

Description Information

Benefit Category
Physicians' Services


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description
Indications and Limitations of Coverage

100.14 – Surgery for Diabetes (RETIRED)
(Rev. 11892; Issued: 03-09-23; Effective: 04-10-23; Implementation: 04-10-23)

Please note section 100.14 has been removed from the NCD Manual and incorporated into NCD 100.1 effective September 24, 2013.
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
11892
Coverage Transmittal Link
https://www.cms.gov/files/document/r11892NCD.pdf
Revision History

12/2013 - Updated per TN158

03/2013 - CMS translated the information for this policy from ICD-9-CM/PCS to ICD-10-CM/PCS according to HIPAA standard medical data code set requirements and updated any necessary and related coding infrastructure. These updates do not expand, restrict, or alter existing coverage policy. Implementation date: 10/07/2013 Effective date: 10/1/2015. (TN 1199) (TN 1199) (CR 8197)

04/2009 - Effective for services performed on and after February 12, 2009, CMS determines that open and laparoscopic Roux-en-Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) in Medicare beneficiaries who have type 2 diabetes mellitus (T2DM) and a BMI less than 35 are not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act, and therefore are not covered. Additionally, effective for services performed on and after February 12, 2009, CMS determines that open and laparoscopic RYGBP, LAGB, and open and laparoscopic BPD/DS in Medicare beneficiaries who have T2DM and a BMI greater or equal to 35 improves health outcomes. Thus, type 2 diabetes mellitus is a comorbid condition related to obesity. Effective date: 02/12/2009 Implementation date: 05/18/2009. (TN 100) (CR6419)
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Surgery for Diabetes - RETIRED 3 04/10/2023 - N/A You are here
Surgery for Diabetes 2 09/24/2013 - 04/10/2023 View
Surgery for Diabetes 1 02/12/2009 - 09/24/2013 View
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Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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