Comments on a Proposed LMRP:
Indiana Response

This response to SVT's comments on a proposed LMRP shows how your comments can make a difference

June 26. 2000

Claudia A. Benge, RDMS, RVT, RDCS
Director of Peripheral Vascular
Shumacker Isch
8333 Naab Road, Suite 300
Indianapolis, IN 46260

Dear Ms. Benge:

I am writing to thank you for your and your colleagues' contribution to the AdminaStar Federal Local Medical Review Policy process. I have reviewed the comments that you supplied regarding our Noninvasive Vascular Studies policy, and have carefully considered your suggestions. I believe you have sent us input from several people, please forward this response as you deem appropriate.

From the Society of Vascular Technology, letter dated June 5, 2000:

• Page 2, paragraph 1: We have added an effective date of January 1, 2002 for the credentialing process.
• Page 2, paragraph 2: We have modified this text as suggested.
• Page 2, description: We need more information and peer-reviewed literature regarding laser Doppler studies before we can consider this change.
• Page 3, paragraph 1: The current text regarding non-invasive vascular studies and angiography does not preclude ultrasound followed by angiography.
• Page 3, paragraph 2: "Clinical management" is broader, more complete and less restrictive than the phrase you suggest.
• Page 3, paragraph 3: The list of ICD-9 codes includes the various conditions you suggest, so no change is needed in the text.
• Page 4, indications, 8: "Known extra-cranial or intra-cranial arthrosclerotic disease" is insufficient basis for medical necessity. There must be current signs and symptoms.
• Page 4, I.B: No change is needed. This is already addressed in A.1 of this section.
• Page 4, LC: We have modified this text as you suggested.
• Page 4, I.C.I: You may submit peer-reviewed literature in support of changing the percentages and we will consider them the next review of this policy.
• Page 5, paragraph 1: The suggested change would change the entire intent of the statement which is to allow someone not part of the operating team to bill for services they rendered during the operative procedure.
• Page 5, paragraph 2: You may provide us the peer-reviewed literature in support of sickle cell anemia. We will be happy to consider this the next time this policy is reviewed.
• Page 5, II: We have adopted this verbiage in part.
• Page 6, paragraph 1: The suggested change would change the intent of the policy.
• Page 6, paragraph 2: We have corrected the ABI value. The purpose of this policy is to encompass all non-invasive vascular studies from the less to the more sophisticated or complete.
• Page 6, A: We will not remove the word "claudication". "Exertional" is implied in the reference to occupation and lifestyle. We did adopt your suggested verbiage regarding inability to stress.
• Page 7, B: We have adopted this suggestion.
• Page 7, III.C.2: We have adopted this suggestion.
• Page 7, IV: We have modified this text in part, We have not changed the text regarding 76936 not being separately reportable. We have referred this to CCI.
• Page 8, paragraph 1: We have modified this discussion to allow for individual consideration of a lesser time period.
• Page 8, paragraph 2: We have covered this in follow-up studies on page 19 of the policy.
• Page 8: 437.0 will not be added since there is no indication of symptoms or problems with this code. 782.2 will not be added because it does not refer to vascular disease.
• Page 9. 440.0 is already on the policy. 782.2 same reason as above. 707.8 and 903.00 will not be added since by definition these are unspecified codes. In addition, 903.02 is already on the policy and is more specific than 903.00. 786.05 has been added.
• Page 9, paragraph 1: We can not change this text. We are stating reason for exclusion per HCFA.
• Page 9, paragraph 2: Please send us copies of peer-reviewed literature in support of adding sickle cell anemia and we will consider it the next time this policy is reviewed.
• Page 10, paragraph 1. Many of the duplex scans CPT definitions do say they are bilateral procedures.
• Page 10, paragraph 2: It is not necessary to make these suggested changes. We already have a standard statement in the policy that CCI edits may be applicable.
• Page 10, paragraph 3: This suggested change is not needed since the term "follow-up" implies a history of disease. A history of disease in and of itself is not sufficient reason to support medical necessity. The patient must have current signs and symptoms.
• Page 10, paragraph 4: No change is needed. New onset of signs and symptoms can always be considered and testing done if medically justified.
• Page 11. paragraph 1: We do not understand the meaning of the suggested additional phrase. Bilateral -studies are not automatically denied.
• Page 11, paragraph 2: HCFA has stated that the performing provider must reasonable access to the attending/ordering physician's medical record for documentation of medical necessity.
• Page 11, paragraph 3: We have adopted this suggested date.
• Page 11, paragraph 4-5: We have made these changes.
• Page 11, paragraph 6: We have modified this text to more clearly state this intent.

In addition, I have some responses to comments provided to me by Shumacker Isch on my visit to your offices on May 25, 2000.

• The references provided to me by your office on ultrasound-guided compression therapy state that ultrasound-guided thrombotic injection is superior to ultrasound-guided compression therapy. Therefore, we have not changed our position on this topic.
• We have maintained verbiage regarding claudication for peripheral artery disease, but we have added a reference to lifestyle. The problem is that lifestyle is not measurable with objective data.
• Please send us any peer-reviewed literature you may have on photo plethysmography/light reflection phleborheography.
• We will not be adding 459.81 because it is not specified. We will not be adding 250.0 or 250.1 because they are secondary diagnoses in this instance. The patient must have calcification. We will not be adding V72.83 because this is too general and not specific enough.

Please also let Dr. Baker know we received and appreciate his support of our policy as noted in the e-mail message you forwarded to us.

Dr.Herring also provided comments on this policy. I will send him a direct response.

This policy will be printed in a forthcoming Medicare Bulletin. If you have additional questions and/or comments, please do not hesitate to contact me.

Again, thank you for your time and expertise, and for being actively involved in our policy development process. Your contributions are very much appreciated by this contractor.

Sincerely,