CMS Pub. 100-03, ch. 1, § 300.1

A. Diagnostic Tests

Do not routinely pay for the following diagnostic tests because they are obsolete and have been

replaced by more advanced procedures. The listed tests may be paid for only if the medical need

for the procedure is satisfactorily justified by the physician who performs it. When the services

are subject to the Quality Improvement Organization (QIO) review, the QIO is responsible for

determining that satisfactory medical justification exists.

When the services are not subject to QIO review, the A/B MAC (A) or (B) is responsible for

determining that satisfactory medical justification exists. This includes:

• Amylase, blood isoenzymes, electrophoretic,

• Chromium, blood,

• Guanase, blood,

• Zinc sulphate turbidity, blood,

• Skin test, cat scratch fever,

• Skin test, lymphopathia venereum,

• Circulation time, one test,

• Cephalin flocculation,

• Congo red, blood,

• Hormones, adrenocorticotropin quantitative animal tests,

• Hormones, adrenocorticotropin quantitative bioassay,

• Thymol turbidity, blood,

• Skin test, actinomycosis,

• Skin test, brucellosis,

• Skin test, psittacosis,

• Skin test, trichinosis,

• Calcium, feces, 24-hour quantitative,

• Starch, feces, screening,

• Chymotrypsin, duodenal contents,

• Gastric analysis, pepsin,

• Gastric analysis, tubeless,

• Calcium saturation clotting time,

• Capillary fragility test (Rumpel-Leede),

• Colloidal gold,

• Bendien’s test for cancer and tuberculosis,

• Bolen’s test for cancer,

• Rehfuss test for gastric acidity, and

• Serum seromucoid assay for cancer and other diseases.

B. Cardiovascular Tests

Do not pay for the following phonocardiography and vectorcardiography diagnostic tests

because they have been determined to be outmoded and of little clinical value. They include:

• Phonocardiogram with or without ECG lead; with supervision during recording with

interpretation and report (when equipment is supplied by the physician),

• Phonocardiogram; tracing only, without interpretation and report (e.g., when equipment

is supplied by the hospital, clinic),

• Phonocardiogram; interpretation and report,

• Phonocardiogram with ECG lead, with indirect carotid artery and/or jugular vein tracing,

and/or apex cardiogram; with interpretation and report,

• Phonocardiogram; without interpretation and report,

• Phonocardiogram; interpretation and report only,

• Intracardiac,

• Vectorcardiogram (VCG), with or without ECG; with interpretation and report,

• Vectorcardiogram; tracing only, without interpretation and report, and,

• Vectorcardiogram; interpretation and report only.