ShelbyGates-Discussion-Unit3.doc
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Purdue Global University *
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Medicine
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Apr 3, 2024
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Discussion
Medical necessity is determined by someone’s health plan, indicating a treatment, test, or procedure is essential for restoring health or treating
a diagnosed medical problem.
In the alphabetical index I found code L39553 which is Radiation Therapies. Medicare does cover these therapies, as long as they have been deemed medically necessary. There are different therapies, Intensity Modulated Radiation Therapy (IMRT), Stereotactic Radiosurgery (SRS), and Stereotactic Body Radiation Therapy (SBRT). These are only a few medically necessary reasons for each of these therapies and some limitations of coverage:
IMRT medical necessity – Primary, metastatic, or benign tumors of the brain, brain stem, spinal cord, thoracic malignancies, pelvic malignancies that include prostatic, gynecologic, and anal carcinomas. IMRT limitation – For palliative treatment of metastatic disease where the prescribed dose does not approach normal tissue tolerances, inability to allow for organ motion, when conventional or CRT technique
can deliver good clinical outcomes and low toxicity.
SRS medical necessity – Benign brain tumors, Uveal or ocular melanoma.
SRS limitation – When functional improvement is not expected, patients
with poor performance status.
SBRT medical necessity – Primary malignant tumors and tumors metastatic to the lung when early-stage primary tumors are medically inoperable, patient is high risk, recurrent early-stage lung cancer.
SBRT limitation – SBRT of clinically localized prostate cancer, primary spinal tumor, patient’s general medical condition.
These codes have been added due to the Annual ICD-10-CM Update – Effective 12/03/2023
ICD-10-CM Codes that Support Medical Necessity Group 1: D48.19 ICD-10-CM Codes that Support Medical Necessity Group 2:
G20.A1, G20.B1, G20.B2
Reference:
Bihari, M. (2023, September 24). The Definition of Medical Necessity in Health Insurance
. Very Well Health. https://www.verywellhealth.com/medical-necessity-1738748
Centers for Medicare & Medicaid Services. (2023, October 19). Radiation Therapies
. https://www.cms.gov/medicare-coverage-database/view/lcd
.aspx?
lcdid=39553&ver=7&lcdStatus=all&sortBy=title&bc
=6
Centers for Medicare and Medicaid Services. (n.d.). Local coverage determinations (LCDs) alphabetical index
. https://www.cms.gov/medicare-coverage-database/indexes/lcd-
alphabetical-index.aspx?DocType=Active&bc=AAIAAAAAAAAAAA%3d
%3d&
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