Medical Necessity Guidelines
As your laboratory provider, HealthLink Laboratories is mandated to keep our clients informed and educated on
the compliance guidelines governing testing requirements for Medicare and Medicaid patients. HCFA, the
government agency that oversees Medicare and some Medicaid funding, maintains that physicians should only
order tests that are medically necessary. The medical necessity requirement stems from
42 U.S.C. Sect.1395y(a)(1)(A) which prohibits Medicare and Medicaid from reimbursing for items or services which are not
“reasonable and necessary” for the diagnosis or treatment of illness or injury or to improve the functioning of a
malformed body member. In order to seek reimbursement for services, a provider must provide medical
documentation or ICD9CM codes to assure that payment is made for items or services determined to be
“reasonable and necessary.”
In order to assist and educate our clients in providing the correct information, HealthLink Laboratories provides
tools to clarify the Medical Necessity regulations:
Local Medicare Review Manual:
A manual is provided to all HealthLink clients to define the Local Medical
Review Policies and define the procedure and the appropriate ICD9 codes that will be covered. The tests
listed in the manual are referred to as “Limited Coverage Tests.”
here to view/print the current LMRPs (now called LCDs)
Laboratory Order Form (Requisition):
Limited coverage tests as defined by the Local Medicare Review
Policy are highlighted on the laboratory order form as a reminder that physicians must refer to the manual to
ensure that the medical reason or ICD9 code falls within the acceptable guidelines for that test.
Client Education Inservices:
Inservices with the physicians and their staff members to introduce or update
information regarding medical necessity guidelines.
In instances of high volumes of referrals from physician offices or clinics, HealthLink
Laboratories offers a computerized laboratory ordering system called HealthLink Web. HealthLink has
updated medical necessity logic to check all tests against current Medicare or Medicaid guidelines. The system
will alert the user to any situations where the ICD9 code does not meet Local Review criteria.
HealthLink Laboratories will send client information updates as needed for changes in the medical necessity
review process. We encourage our clients to contact us for any questions by calling our customer service
department or contacting the Laboratory Outreach Coordinator directly at the numbers provided on the first
page of this manual.