US · guidance
CMS Pub. 100-08, ch. 3, § 3.3.2.2
Absolute Words and Prerequisite Therapies
This section applies to MACs, CERT, RACs, SMRC, and UPICs, as indicated.
The MACs, CERT, RACs, SMRC, and UPICs shall not deviate from coverage provisions
if absolute words such as “never” or “only if” are used when making claim
determinations where a regulation, CMS ruling, NCD, LCD, or MAC policy article
exists. In these cases, reviewers shall not make any exceptions or give individual
consideration.
Requirements for prerequisite therapies shall be followed when deciding whether to
cover a service if listed in coverage provisions in interpretive manuals (e.g.,
“conservative treatment has been tried, but failed”).
History
(Rev. 13008; Issued: 12-18-24; Effective: 01-17-25; Implementation: 01-17-25)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
40a09df8d6974f836407cfa5214452e723f20333c463cc2c366a62e06e4954c5
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