Non covered service denial

PR 96 N115

Non-covered charge(s).

This decision was based on a Local Coverage Determination (LCD). The LCD provides a guide
to assist in determining whether a particular item or service is covered. A copy of this policy is
available at http://www.cms.hhs.gov/mcd, or if you do not have web access, you may contact the
contractor to request a copy of the LCD.

CO 50
These are non-covered services because this is not
deemed a ‘medical necessity’ by the payer.

This decision was based on Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD.

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