The LCD Development Process

The coverage policy outlines that medically necessary procedures are covered for patients who meet specific clinical criteria, adhering to Title XVIII benefits, and are deemed safe and effective. However, the policy excludes services for conditions lacking medical necessity, experimental procedures, and routine care such as physical exams, cosmetic surgery, and most dental services. Documentation of clinical evaluations and test results is required, along with prior authorization for certain procedures, which must be performed by qualified personnel.

"Procedure is covered medically necessary when patient meets specific clinical criteria outlined in policy."

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