Local Coverage Determination (LCD):
Heavy Metal Testing (L33384)
Contractor Information
Contractor Name
National Government Services,
Inc.
LCD Information
Document Information
LCD ID
L33384
LCD Title
Heavy Metal Testing
AMA CPT/ADA CDT Copyright Statement
CPT only copyright 2002-2012 American
Medical Association. All Rights Reserved. CPT
is a registered trademark of the American
Medical Association. Applicable
FARS/DFARS Apply to Government Use. Fee
schedules, relative value units, conversion
factors and/or related components are not
assigned by the AMA, are not part of CPT, and
the AMA is not recommending their use. The
AMA does not directly or indirectly practice
medicine or dispense medical services. The
AMA assumes no liability for data contained or
not contained herein. The Code on Dental
Procedures and Nomenclature (Code) is
published in Current Dental Terminology
(CDT). Copyright © American Dental
Association. All rights reserved. CDT and
CDT-2010 are trademarks of the American
Dental Association.
CMS National Coverage Policy
Original Effective Date
For services performed on or after 07/13/2013
Revision Effective Date
For services performed on or after 08/10/2013
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
Title XVIII of the Social Security Act section 1862 (a)(1)(A). This section allows coverage and
payment of those services that are considered to be medically reasonable and necessary.
Title XVIII of the Social Security Act section 1862 (a)(7). This section excludes routine physical
examinations and services.
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
The term heavy metal testing is historically used to describe elements such as lead, arsenic,
mercury, cadmium, and chromium. In general, all of the heavy metals in inorganic form cause GI
irritation, resulting in nausea, vomiting, abdominal pain and diarrhea. The next most consistent
toxicity for the heavy metals as a group, but not for every heavy metal, is renal toxicity. A
further generalization is that each member of the heavy metal group tends to cause multi-organ
toxicity. Many metals cause cutaneous abnormalities, such as irritant and allergic contact
dermatitis, urticaria, keratoses, and premalignant and malignant lesions. Several of the heavy
metals produce central and peripheral nervous system toxicity. Other metals cause pulmonary
illness.
However, before any testing for heavy metal is ordered, a detailed medical history of the patient
must be obtained, including a careful documentation of occupational and avocational exposure to
these toxins. A complete physical examination must be done.
1. Aluminum. Serum aluminum testing is payable for beneficiaries who have been on dialysis
with evidence suggesting aluminum toxicity, or for beneficiaries with chronic industrial exposure
history
2. Antimony. Serum and/or urine antimony testing is payable for beneficiaries with documented
treatment in the past with antileishmaniasis agents or with documented chronic antimony
industrial exposure history.
3. Arsenic. Serum and whole blood and/or urine arsenic testing is payable for beneficiaries with
unexplained peripheral neuropathies, industrial exposure to arsenic, histories of arsenic pesticide
exposure, unexplained encephalopathies, unexplained weight loss, chronic glomerulonephritis,
bone marrow hypoplasia, or melanosis of skin, unexplained chronic diarrhea, persistent
abdominal pain, or nausea and vomiting.
4. Barium. Serum and or/urine barium testing is payable for beneficiaries with pulmonary
disease with industrial exposure to barium or unexplained flaccid paralysis.
5. Beryllium. Serum and/or urine beryllium testing is payable for beneficiaries with pulmonary
disease with industrial exposure to beryllium.
6. Bismuth. Serum and/or urine bismuth testing is payable for beneficiaries with bismuth lines on
their gums, methemoglobinemia, unexplained pathological fractures, or a history of bismuth
medicine abuse.
7. Cadmium. Serum and whole blood and/or urine cadmium testing is payable for beneficiaries
with an exposure to cadmium with evidence of pulmonary disease or unexplained renal failure.
8. Chromium. Serum chromium testing is payable for beneficiaries with an industrial exposure to
chromium with evidence of pulmonary disease.
9. Cobalt. Serum cobalt testing is payable for beneficiaries with an industrial exposure to cobalt
with evidence of pulmonary disease
10. Copper. Serum copper testing is payable for beneficiaries with an industrial exposure to
copper with evidence of pulmonary disease, or for beneficiaries with Wilson’s Disease,
unexplained cardiomyopathy, unexplained renal failure, polycythemia. unexplained
myelodysplastic syndrome or known ingestion of zinc.
11. Iron. See the Laboratory National Coverage Determinations (NCDs) Database.
12. Lead. Blood (serum and whole) and/or urine lead testing is covered if there is documented
industrial exposure to lead, documented avocation exposure to lead, retained bullet fragments at
or near joints, a blue gum line, a history of moonshine abuse, unexplained peripheral
neuropathies, evidence of lead contaminated drinking water, paint stripping, lead lines on bones
on radiographs, or basophilic stippling of red blood cells.
13. Lithium. Serum and/or urine lithium testing is covered for beneficiaries on lithium
medications.
14. Manganese. Serum manganese testing is covered for beneficiaries with documented
industrial exposure to manganese.
15. Mercury. Serum, whole blood, and/or urine mercury testing is covered for beneficiaries with
documented industrial exposure to mercury, with a blue line in their mouth, those with a history
of laxative abuse, with a history of pesticide exposure, mercury spillage with vacuuming of the
liquid metal, unexplained renal failure, or a history of skin lightening treatments.
16. Molybdenum. Serum molybdenum testing is covered for beneficiaries with documented
industrial exposure to molybdenum.
17. Nickel. Serum and/or urine nickel testing is covered for beneficiaries with documented
industrial exposure to nickel, unexplained renal failure, unexplained pulmonary disease.
18. Selenium. Serum and/or urine selenium testing is covered for beneficiaries with documented
industrial exposure to selenium or on chronic renal dialysis.
20. Thallium. Serum thallium testing is covered for beneficiaries with documented industrial
exposure to thallium and unexplained ataxia.
21. Tin. Serum tin testing is covered for beneficiaries with documented industrial exposure to tin.
22. Titanium. Serum titanium testing is covered for beneficiaries with documented industrial
exposure to titanium.
23. Zinc. Serum zinc and/or urine testing is covered for beneficiaries with documented industrial
exposure to zinc, on chronic renal dialysis, with malabsorption syndromes, Crohn’s disease,
unexplained myelodysplastic syndrome or known ingestion of zinc.
Documented recent, long-term total parenteral nutrition (TPN) with clinical trace element
deficiency evidence is acceptable medical indications for testing for copper, manganese, and
zinc.
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to
report this service. Absence of a Bill Type does not guarantee that the policy does not apply to
that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by
Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes
typically used to report this service. In most instances Revenue Codes are purely advisory; unless
specified in the policy services reported under other Revenue Codes are equally subject to this
coverage determination. Complete absence of all Revenue Codes indicates that coverage is not
influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue
Codes.
Revenue codes only apply to providers who bill these services to the fiscal intermediary.
Revenue codes do not apply to physicians, other professionals and suppliers who bill these
services to the carrier.
Please note that not all revenue codes apply to every type of bill code. Providers are encouraged
to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes
apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for
allowable revenue codes.
99999 Not Applicable
CPT/HCPCS Codes
Group 1 Paragraph: N/A
Group 1 Codes:
80178 LITHIUM
82108 ALUMINUM
82175 ARSENIC
82300 CADMIUM
82495 CHROMIUM
82525 COPPER
HEAVY METAL (EG, ARSENIC, BARIUM, BERYLLIUM, BISMUTH, ANTIMONY,
83015
MERCURY); SCREEN
HEAVY METAL (EG, ARSENIC, BARIUM, BERYLLIUM, BISMUTH, ANTIMONY,
83018
MERCURY); QUANTITATIVE, EACH
83540 IRON
83655 LEAD
83785 MANGANESE
83825 MERCURY, QUANTITATIVE
83885 NICKEL
84255 SELENIUM
84285 SILICA
84630 ZINC
84999 UNLISTED CHEMISTRY PROCEDURE
ICD-9 Codes that Support Medical Necessity
Group 1 Paragraph: Note: ICD-9 codes must be coded to the highest level of specificity.
Aluminum
Group 1 Codes:
292.2
PATHOLOGICAL DRUG INTOXICATION
292.81
DRUG-INDUCED DELIRIUM
292.82
DRUG-INDUCED PERSISTING DEMENTIA
292.83
DRUG-INDUCED PERSISTING AMNESTIC DISORDER
292.84
DRUG-INDUCED MOOD DISORDER
292.89
OTHER SPECIFIED DRUG-INDUCED MENTAL DISORDERS
293.9
UNSPECIFIED TRANSIENT MENTAL DISORDER IN CONDITIONS
294.8
585.1 585.6
585.9
973.0
985.8
996.73
CLASSIFIED ELSEWHERE
OTHER PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS
CLASSIFIED ELSEWHERE
CHRONIC KIDNEY DISEASE, STAGE I - END STAGE RENAL DISEASE
CHRONIC KIDNEY DISEASE, UNSPECIFIED
POISONING BY ANTACIDS AND ANTIGASTRIC SECRETION DRUGS
TOXIC EFFECT OF OTHER SPECIFIED METALS
OTHER COMPLICATIONS DUE TO RENAL DIALYSIS DEVICE IMPLANT
AND GRAFT
Group 2 Paragraph: Antimony
Group 2 Codes:
085.9 LEISHMANIASIS UNSPECIFIED
985.4 TOXIC EFFECT OF ANTIMONY AND ITS COMPOUNDS
Group 3 Paragraph: Arsenic
Group 3 Codes:
284.89 OTHER SPECIFIED APLASTIC ANEMIAS
348.30 ENCEPHALOPATHY UNSPECIFIED
348.31 METABOLIC ENCEPHALOPATHY
348.39 OTHER ENCEPHALOPATHY
356.0 HEREDITARY PERIPHERAL NEUROPATHY
356.9 UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY
357.7 POLYNEUROPATHY DUE TO OTHER TOXIC AGENTS
569.89 OTHER SPECIFIED DISORDERS OF INTESTINES
CHRONIC GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL
582.9
LESION IN KIDNEY
CONTACT DERMATITIS AND OTHER ECZEMA DUE TO OTHER CHEMICAL
692.4
PRODUCTS
783.21 LOSS OF WEIGHT
787.01 NAUSEA WITH VOMITING
787.91 DIARRHEA
961.1 POISONING BY ARSENICAL ANTI-INFECTIVES
985.1 TOXIC EFFECT OF ARSENIC AND ITS COMPOUNDS
Group 4 Paragraph: Barium
Group 4 Codes:
518.89 OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED
985.8 TOXIC EFFECT OF OTHER SPECIFIED METALS
Group 5 Paragraph: Beryllium
Group 5 Codes:
518.89 OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED
985.3 TOXIC EFFECT OF BERYLLIUM AND ITS COMPOUNDS
Group 6 Paragraph: Bismuth
Group 6 Codes:
289.7 METHEMOGLOBINEMIA
523.8 OTHER SPECIFIED PERIODONTAL DISEASES
733.10 PATHOLOGICAL FRACTURE UNSPECIFIED SITE
985.8 TOXIC EFFECT OF OTHER SPECIFIED METALS
Group 7 Paragraph: Cadmium
Group 7 Codes:
518.89 OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED
586 RENAL FAILURE UNSPECIFIED
985.5 TOXIC EFFECT OF CADMIUM AND ITS COMPOUNDS
Group 8 Paragraph: Chromium
Group 8 Codes:
518.89 OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED
985.6 TOXIC EFFECT OF CHROMIUM
Group 9 Paragraph: Cobalt
Group 9 Codes:
518.89 OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED
985.8 TOXIC EFFECT OF OTHER SPECIFIED METALS
Group 10 Paragraph: Copper
Group 10 Codes:
238.72 LOW GRADE MYELODYSPLASTIC SYNDROME LESIONS 238.75
MYELODYSPLASTIC SYNDROME, UNSPECIFIED
275.1
DISORDERS OF COPPER METABOLISM
425.9
SECONDARY CARDIOMYOPATHY UNSPECIFIED
518.89
OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED
571.40
CHRONIC HEPATITIS UNSPECIFIED
571.41
CHRONIC PERSISTENT HEPATITIS
571.5
571.9
573.9
586
759.89
783.3
790.5
985.8
CIRRHOSIS OF LIVER WITHOUT ALCOHOL
UNSPECIFIED CHRONIC LIVER DISEASE WITHOUT ALCOHOL
UNSPECIFIED DISORDER OF LIVER
RENAL FAILURE UNSPECIFIED
OTHER SPECIFIED CONGENITAL ANOMALIES
FEEDING DIFFICULTIES AND MISMANAGEMENT
OTHER NONSPECIFIC ABNORMAL SERUM ENZYME LEVELS
TOXIC EFFECT OF OTHER SPECIFIED METALS
Group 11 Paragraph: Iron
See Laboratory National Coverage Determinations (NCDs) Database
Group 11 Codes:
XX000 Not Applicable
Group 12 Paragraph: Lead
Group 12 Codes:
348.30 ENCEPHALOPATHY UNSPECIFIED
348.31 METABOLIC ENCEPHALOPATHY
348.39 OTHER ENCEPHALOPATHY
354.8 OTHER MONONEURITIS OF UPPER LIMB
354.9 MONONEURITIS OF UPPER LIMB UNSPECIFIED
355.8 MONONEURITIS OF LOWER LIMB UNSPECIFIED
355.9 MONONEURITIS OF UNSPECIFIED SITE
356.0 HEREDITARY PERIPHERAL NEUROPATHY
356.1 PERONEAL MUSCULAR ATROPHY
356.2 HEREDITARY SENSORY NEUROPATHY
356.3 REFSUM'S DISEASE
356.4 IDIOPATHIC PROGRESSIVE POLYNEUROPATHY
356.8 OTHER SPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY
356.9 UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY
790.01 PRECIPITOUS DROP IN HEMATOCRIT
790.09 OTHER ABNORMALITY OF RED BLOOD CELLS
NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER
793.7
EXAMINATION OF MUSCULOSKELETAL SYSTEM
984.0 TOXIC EFFECT OF INORGANIC LEAD COMPOUNDS
984.1 TOXIC EFFECT OF ORGANIC LEAD COMPOUNDS
984.8 TOXIC EFFECT OF OTHER LEAD COMPOUNDS
984.9 TOXIC EFFECT OF UNSPECIFIED LEAD COMPOUND
Group 13 Paragraph: Lithium
Group 13 Codes:
296.00 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, UNSPECIFIED
296.01 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, MILD
296.02 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, MODERATE
BIPOLAR I DISORDER, SINGLE MANIC EPISODE, SEVERE, WITHOUT
296.03
MENTION OF PSYCHOTIC BEHAVIOR
BIPOLAR I DISORDER, SINGLE MANIC EPISODE, SEVERE, SPECIFIED AS
296.04
WITH PSYCHOTIC BEHAVIOR
BIPOLAR I DISORDER, SINGLE MANIC EPISODE, IN PARTIAL OR
296.05
UNSPECIFIED REMISSION
296.06 BIPOLAR I DISORDER, SINGLE MANIC EPISODE, IN FULL REMISSION
296.10 MANIC AFFECTIVE DISORDER RECURRENT EPISODE UNSPECIFIED DEGREE
296.11 MANIC AFFECTIVE DISORDER RECURRENT EPISODE MILD DEGREE
296.12 MANIC AFFECTIVE DISORDER RECURRENT EPISODE MODERATE DEGREE
MANIC AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE
296.13
WITHOUT PSYCHOTIC BEHAVIOR
MANIC AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE
296.14
SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
MANIC AFFECTIVE DISORDER RECURRENT EPISODE IN PARTIAL OR
296.15
UNSPECIFIED REMISSION
296.16 MANIC AFFECTIVE DISORDER RECURRENT EPISODE IN FULL REMISSION
MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE UNSPECIFIED
296.20
DEGREE
296.21 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE MILD DEGREE
MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE MODERATE
296.22
DEGREE
MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE SEVERE
296.23
DEGREE WITHOUT PSYCHOTIC BEHAVIOR
MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE SEVERE
296.24
DEGREE SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE IN PARTIAL
296.25
OR UNSPECIFIED REMISSION
MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE IN FULL
296.26
REMISSION
MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE
296.30
UNSPECIFIED DEGREE
MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE MILD
296.31
DEGREE
MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE
296.32
MODERATE DEGREE
MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE SEVERE
296.33
DEGREE WITHOUT PSYCHOTIC BEHAVIOR
296.34 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE SEVERE
296.35
296.36
296.40
296.41
296.42
296.43
296.44
296.45
296.46
296.50
296.51
296.52
296.53
296.54
296.55
296.56
296.60
296.61
296.62
296.63
296.64
296.65
296.66
DEGREE SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE IN
PARTIAL OR UNSPECIFIED REMISSION
MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE IN FULL
REMISSION
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC,
UNSPECIFIED
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, MILD
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC,
MODERATE
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC,
SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC,
SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, IN
PARTIAL OR UNSPECIFIED REMISSION
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, IN
FULL REMISSION
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED,
UNSPECIFIED
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED,
MILD
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED,
MODERATE
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED,
SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED,
SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED,
IN PARTIAL OR UNSPECIFIED REMISSION
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED,
IN FULL REMISSION
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED,
UNSPECIFIED
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, MILD
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED,
MODERATE
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED,
SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED,
SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, IN
PARTIAL OR UNSPECIFIED REMISSION
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, IN
FULL REMISSION
296.7 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) UNSPECIFIED
296.80 BIPOLAR DISORDER, UNSPECIFIED
296.81 ATYPICAL MANIC DISORDER
296.82 ATYPICAL DEPRESSIVE DISORDER
296.89 OTHER AND UNSPECIFIED BIPOLAR DISORDERS, OTHER
296.90 UNSPECIFIED EPISODIC MOOD DISORDER
296.99 OTHER SPECIFIED EPISODIC MOOD DISORDER
311
DEPRESSIVE DISORDER NOT ELSEWHERE CLASSIFIED
969.8 POISONING BY OTHER SPECIFIED PSYCHOTROPIC AGENTS
985.8 TOXIC EFFECT OF OTHER SPECIFIED METALS
V58.63 LONG-TERM (CURRENT) USE OF ANTIPLATELETS/ANTITHROMBOTICS
V58.64 LONG-TERM (CURRENT) USE OF NONSTEROIDAL ANTI-INFLAMMATORIES
V58.65 LONG-TERM (CURRENT) USE OF STEROIDS
V58.69 LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS
V58.83 ENCOUNTER FOR THERAPEUTIC DRUG MONITORING
Group 14 Paragraph: Manganese
Group 14 Codes:
UNSPECIFIED EXTRAPYRAMIDAL DISEASE AND ABNORMAL MOVEMENT
333.90
DISORDER
OTHER EXTRAPYRAMIDAL DISEASES AND ABNORMAL MOVEMENT
333.99
DISORDERS
783.3 FEEDING DIFFICULTIES AND MISMANAGEMENT
985.2 TOXIC EFFECT OF MANGANESE AND ITS COMPOUNDS
Group 15 Paragraph: Mercury
Group 15 Codes:
UNSPECIFIED EXTRAPYRAMIDAL DISEASE AND ABNORMAL MOVEMENT
333.90
DISORDER
OTHER EXTRAPYRAMIDAL DISEASES AND ABNORMAL MOVEMENT
333.99
DISORDERS
334.0 FRIEDREICH'S ATAXIA
334.3 OTHER CEREBELLAR ATAXIA
334.4 CEREBELLAR ATAXIA IN DISEASES CLASSIFIED ELSEWHERE
438.84 ATAXIA
586 RENAL FAILURE UNSPECIFIED
781.3 LACK OF COORDINATION
961.2 POISONING BY HEAVY METAL ANTI-INFECTIVES
973.3 POISONING BY OTHER CATHARTICS INCLUDING INTESTINAL ATONIA
976.8 POISONING BY OTHER AGENTS PRIMARILY AFFECTING SKIN AND MUCOUS
MEMBRANE
985.0 TOXIC EFFECT OF MERCURY AND ITS COMPOUNDS
Group 16 Paragraph: Molybdenum
Group 16 Codes:
985.8 TOXIC EFFECT OF OTHER SPECIFIED METALS
Group 17 Paragraph: Nickel
Group 17 Codes:
518.89 OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED
586 RENAL FAILURE UNSPECIFIED
985.8 TOXIC EFFECT OF OTHER SPECIFIED METALS
Group 18 Paragraph: Selenium5
Group 18 Codes:
586 RENAL FAILURE UNSPECIFIED
985.8 TOXIC EFFECT OF OTHER SPECIFIED METALS
Group 19 Paragraph: Thallium
Group 19 Codes:
357.7 POLYNEUROPATHY DUE TO OTHER TOXIC AGENTS
781.3 LACK OF COORDINATION
985.8 TOXIC EFFECT OF OTHER SPECIFIED METALS
Group 20 Paragraph: Tin
Group 20 Codes:
985.8 TOXIC EFFECT OF OTHER SPECIFIED METALS
Group 21 Paragraph: Titanium
Group 21 Codes:
985.8 TOXIC EFFECT OF OTHER SPECIFIED METALS
Group 22 Paragraph: Zinc
Group 22 Codes:
238.72 LOW GRADE MYELODYSPLASTIC SYNDROME LESIONS 238.75
MYELODYSPLASTIC SYNDROME, UNSPECIFIED
555.9
REGIONAL ENTERITIS OF UNSPECIFIED SITE
579.9
UNSPECIFIED INTESTINAL MALABSORPTION
586
783.3
985.8
RENAL FAILURE UNSPECIFIED
FEEDING DIFFICULTIES AND MISMANAGEMENT
TOXIC EFFECT OF OTHER SPECIFIED METALS
Group 23 Paragraph: Boron
Phosphorous
Silica
Strontium
Sulfur
Uranium
Vanadium
No covered ICD-9 codes
Group 23 Codes:
XX000 Not Applicable
ICD-9 Codes that DO NOT Support Medical Necessity
Paragraph: ICD-9 codes not listed above
N/A
General Information
Associated Information
N/A
Sources of Information and Basis for Decision
1. National Library of Medicine: IGM Full Record Screen
2. Carrier Advisory Committee
Revision History Information
Please note: The Revision History information included in this LCD prior to 1/24/2013 will now
display with a Revision History Number of "R1" at the bottom of this table. All new Revision
History information entries completed on or after 1/24/2013 will display as a row in the Revision
History section of the LCD and numbering will begin with "R2".
Revision Revision
Revision History Explanation
Reason(s) for Change
History
History
Date
Number
08/10/2013 R2

Change in
Assigned States
or Affiliated
Contract
Numbers

Change in
Assigned States
or Affiliated
Contract
Numbers
08/10/2013 - This LCD was revised to add the
Jurisdiction 6 Minnesota Part A Contract
Number 06201.
This LCD is effective for Illinois and Wisconsin
- Part A on July 13, 2013; for Minnesota – Part
A on August 10, 2013; for Illinois, Minnesota
and Wisconsin - Part B on September 7, 2013.
07/13/2013 R1
The CMS Statement of Work for the
Jurisdiction 6 Medicare Administrative
Contractor (MAC) requires that the contractor
consolidate LCDs and retain the most clinically
appropriate LCD within the jurisdiction. This
Wisconsin Physicians Service Insurance
Corporation LCD is being promulgated to
Jurisdiction 6 as the most clinically appropriate
LCD within that jurisdiction.
Associated Documents
Attachments
N/A
Related Local Coverage Documents
N/A
Related National Coverage Documents
N/A
Public Version(s)
Updated on 06/10/2013 with effective dates 08/10/2013 - N/A
Updated on 05/15/2013 with effective dates 07/13/2013 - 08/09/2013
Keywords
N/A