About this policy
CMS National Coverage Determination | ncd_id=163 | manual_section=230.5 | coverage_level_code=2 | national_coverage_type=True | under_review=False | lab_ncd=False
Coverage indications
The use of this device is indicated where the patient exhibits clinical symptoms or signs suggestive of endometrial disease, such as irregular or heavy vaginal bleeding. Program payment cannot be made for the washer or the related diagnostic services when furnished in connection with the examination of an asymptomatic patient. Payment for routine physical checkups is precluded under the statute. (See §1862(a)(7) of the Act.)
Documentation requirements
Item/Service Description: The Gravlee Jet Washer is a sterile, disposable, diagnostic device for detecting endometrial cancer. Cross Reference: Also see the NCD on the Vabra Aspirator (§ 230.6 ), and the Medicare Benefit Policy Manual , Chapter 16 §90. Revision History: 05/1989 - Added statutory authority citation. Effective date NA. (TN 36) Benefit Categories: 20 - Diagnostic Tests (other) Transmittal: transmittal_number=36 | transmittal_issue_date=1989-05-01
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
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