These guidelines are designed
to give ordering physicians and clinicians information on
limited coverage tests that require specific medical documentation.
Provided are links for the 38 limited coverage tests and the
ICD-9 codes that support medical necessity. The links are
directed to the Centers for Medicaid and Medicare Services
website and list the complete medical review policy for each
The information provided is not a substitute for the ICD-9-CM manual therefore, please refer to the ICD-9-CM manual for a complete listing of ICD-9 codes. All ICD-9 codes must be medically appropriate for the patient's condition and consistent with the information found in the patient's medical record for the date of service. The ultimate responsibility for correct coding lies with the ordering physician or clinician.