Absolute Words and Prerequisite Therapies

3.3.2.2 - Absolute Words and Prerequisite Therapies (Rev. 13008; Issued: 12-18-24; Effective: 01-17-25; Implementation: 01-17-25) This section applies to MACs, CERT, RACs, SMRC, and UPICs, as indicated. The MACs, CERT, RACs, SMRC, and UPICs shall not deviate from coverage provisions if absolute words such as “never” or “only if” are used when making claim determinations where a regulation, CMS ruling, NCD, LCD, or MAC policy article exists. In these cases, reviewers shall not make any exceptions or give individual consideration. Requirements for prerequisite therapies shall be followed when deciding whether to cover a service if listed in coverage provisions in interpretive manuals (e.g., “conservative treatment has been tried, but failed”).