Intraocular Lenses (IOLs)

80.12 - Intraocular Lenses (IOLs) Foreword - Purpose for National Coverage Determinations (NCD) Manual (Rev. 173, Issued: 09-04-14, Effective: Upon Implementation: of ICD-10, Implementation: Upon Implementation of ICD-10) A. Purpose The statutory and policy framework within which National Coverage Determinations (NCDs) are made may be found in title XVIII of the Social Security Act (the Act), and in Medicare regulations and rulings. The NCD Manual describes whether specific medical items, services, treatment procedures, or technologies can be paid for under Medicare. NCDs have been made on the items addressed in this manual. Decisions that items/services are not covered are generally based on §1862(a)(1) of the Act (the “not reasonable and necessary” exclusion) unless otherwise specifically noted. Where another statutory authority for denial is indicated, that is the authority for denial. Where an item/service is stated to be covered, but such coverage is explicitly limited to specified indications or specified circumstances, all limitations on coverage of the items/services because they do not meet those specified indications or circumstances are based on §1862(a)(1) of the Act. Where coverage of an item/service is provided for specified indications or circumstances but is not explicitly excluded for others, or where the item/service is not mentioned at all in the Centers for Medicare & Medicaid Services (CMS) NCD Manual the Medicare Administrative Contractor (MAC) has the discretion to make the coverage decision, in consultation with its medical staff, and with CMS when appropriate, based on the law, regulations, rulings, and general program instructions The coverage determinations in the manual will be revised based on the most recent medical and other scientific and technical evidence available to CMS. Other manuals in this system in which coverage-related instructions may be found are: Pub 100-02 (Benefit Policy); Pub 100-04 (Claims Processing); Pub 100-05 (Medicare Secondary Payer); and Pub 100-08 (Program Integrity) These manuals usually contain more general coverage descriptions and/or claims processing instructions. There should be no inconsistencies among the instructions in any of these manuals and the NCD Manual pertaining to coverage. If any such inconsistencies are found, bring them to the attention of CMS, Center for Clinical Standards and Quality, Coverage and Analysis Group, Division of Operations and Information Management. B. Organization The NCD Manual is organized by categories, e.g., medical procedures, supplies, diagnostic services. A table of contents is provided at the beginning of the manual designating coverage determination categories. Each subject discussed within the category is listed and identified by a number. The revision transmittal sheet identifies new material and summarizes the principal changes. When a change in policy or procedure is involved, the background and effective date for the change is provided. If, at a later date, the reader wishes to refer to the background explanation given on a transmittal sheet, the reader can identify the transmittal by its number which appears on each manual page. C. CMS Coverage Web site The CMS Coverage Web page http://www.cms.gov/Center/Special-Topic/Medicare- Coverage-Center.html?redirect=/center/coverage.asp contains information about pending NCDs and also provides access to a database of NCDs, National Coverage Analyses, and Local Medical review Policies.