CMS Pub. 100-04, ch. 32, § 170.3

The A/B MAC (A) will pay for LADR when approved under the IDE/clinical trial criteria only when

submitted with ICD-9-CM procedure code 84.65 if ICD-9 is applicable, with condition code 30 and if ICD-9-

CM is applicable, ICD-9-CM diagnosis code V70.7 when submitted on type of bill (TOB) 11X from May 16,

2006 through August 13, 2007.

Special Billing instructions:

For services performed on TOB 11X in critical access hospitals (CAH), the payment will be 101% of

reasonable cost.

For services performed on TOB 11X Indian Health Services (IHS) inpatient hospitals will pay under the

inpatient prospective payment system (IPPS) based on the DRG.

For services performed on TOB 11X, IHS CAHs will pay under 101% facility specific per diem rate.

NOTE: The ICD-9-CM procedure code 84.65 is not payable for beneficiaries over 60 years of age, with the

ChariteTM lumbar artificial disc, which is the only one that is FDA approved for any diagnosis. If a different

manufacture’s disc is used in an approved clinical trials or is an approved IDE, then condition code 30 and

ICD-9-CM diagnosis code V70.7 must be on the claim for it to be payable.

Effective for discharges on or after August 14, 2007, CMS has found that LADR is not reasonable and

necessary for the Medicare population over 60 years of age. Therefore, LADR is non-covered for Medicare

beneficiaries over 60 years of age as identified in section 150.10, of Pub.100-03, the NCD Manual. A/B

MACS (A) shall deny claims with ICD-9-CM procedure code 84.65 for Medicare beneficiaries over 60 years

of age.

For Medicare beneficiaries 60 years of age and younger, there is no NCD, leaving such determinations to

continue to be made by the local contractors.