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Check Medical Necessity

How to check medical necessity and determine whether an ABN is indicated:

  • Determine patient diagnosis.
  • Record the diagnosis code(s) in the appropriate space on the requisition form. ICD-10 codes are required.
  • Check the limited coverage test list below to determine whether the test is listed.
  • If the test is listed, ICD-10 code(s) must be checked to determine whether the code supports medical necessity for the test.
  • If the test is not listed, no further action is required.
  • If the test is listed, a list of Medicare covered ICD-10 codes is available within each test coverage policy. See instructions below to link to these lists.
  • If the ICD-10 code is listed, not further action is required.
  • If the patient ICD-10 code is not listed, inform the patient that payment for this test is likely to be denied by Medicare and the reason for which denial is expected.
  • Obtain an ABN.
  • Special Note: The reverse is true for the Blood Count (CBC) policy. The Blood Count policy lists codes that do NOT meet medical necessity requirements. If the ICD-10 code(s) is not listed, an ABN is indicated.

Limited Coverage Tests

The following tests require specific ICD-10 code(s) to support medical necessity for Medicare reimbursement. To review Medicare covered ICD-10 code list for each test click on link and follow instructions.

  1. Visit
  2. View AMA License, Click Accept
  3. Select Jurisdiction M Part A MAC – NC, SC, VA,WV
  4. Click LCDs, NCDs, Coverage Articles
  5. Select Active LCDs or National Coverage Determinations (NCDs)

Laboratory Tests NCDs:

Blood Counts (CBC)
Blood Glucose Testing
Carcinoembryonic Antigen (CEA)
Human Chorionic Gonadotropin
Tumor Antigen by Immunoassay CA 125
Tumor Antigen by Immunoassay CA 15-3 / CA 27.29
Tumor Antigen by Immunoassay CA 19-9
Collagen Crosslinks, Any Method
Fecal Occult Blood
Gamma Glutamyl Transferase (GGT)
Hemoglobin A1C (Glycated Hemoglobin) / Glycated Protein
Hepatitis Panel, Acute
HIV Testing, Diagnosis
HIV Testing, Prognosis and Monitoring
Iron Studies, Serum
Lipid Testing
Partial Thromboplastin (PTT)
Prostate Specific Antigen (PSA)
Prothrombin Time (PT)
Thyroid Testing
Urine Culture, Bacterial

Laboratory Tests LCDs:

APC and MUTYH Gene Testing
Biomarkers in Cardiovascular Risk Assessment
BRCA1 and BRCA2 Genetic Testing
Genetic Testing for BCR-ABL Negative Myeloproliferative Disease
Bladder / Urothelial Tumor Markers
B-Type Natriuretic Peptide Testing (BNP)
Controlled Substance Monitoring and Drugs of Abuse Testing
Flow Cytometry
Homocysteine Level, Serum
HLA-B*15:02 Genetic Testing
Molecular RBC Phenotyping
NRAS Genetic Testing