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 test.

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.