100-03 Medicare National Coverage Determinations (NCD) Manual: Crosswalk from CIM to NCD Manual

Medicare National Coverage Determinations Manual
Crosswalk CIM to NCD Sections
The column on the far right (column 3) is in CIM sequence. Column 1 shows the NDC
Manual section. Note that the sections in the NCD are in CPT category sequence and not
in Medicare benefit category sequence.
NCD Section 	Title 	CIM Section
310.1 	Routine Costs in Clinical Trails 	CIM 30-1
10.8.1 	Stem Cell Transplantation 	CIM 35.30.1
100.7 	Colonic Irrigation 	CIM 35-1
20.29 	Hyperbaric Oxygen Therapy 	CIM 35-10
80.2 	Photodynamic Therapy 	CIM 35-100
250.4 	Treatment of Actinic Keratosis 	CIM 35-101
160.25 	Multiple Electroconvulsive Therapy (MECT) 	CIM 35-103
260.5 	Intestinal and Multivisceral Transplantation 	CIM 35-104
230.3 	Sterilization 	CIM 35-11
140.4 	Plastic Surgery to Correct "Moon Face" 	CIM 35-12
150.7 	Prolotherapy; Joint Sclerotherapy, and
Ligamentous Injections with Sclerosing Agents
CIM 35-13
70.1 	Consultations With a Beneficiary’s Family and
Associates
CIM 35-14
240.7 	Postural Drainage Procedures and Pulmonary
Exercises
CIM 35-15
80.11 	Vitrectomy 	CIM 35-16
160.1 	Induced Lesions of Nerve Tracts 	CIM 35-17
30.4 	Electrosleep Therapy 	CIM 35-18
30.6 	Intravenous Histamine Therapy 	CIM 35-19

NCD Section 	Title 	CIM Section
150.1 	Manipulation 	CIM 35-2
160.2 	Treatment of Motor Function Disorders with
Electric Nerve Stimulation
CIM 35-20
10.3 	Inpatient Hospital Pain Rehabilitation Programs 	CIM 35-21
10.4 	Outpatient Hospital Pain Rehabilitation Programs 	CIM 35-21.1
130.1 	Inpatient Hospital Stays for the Treatment of
Alcoholism
CIM 35-22
130.2 	Outpatient Hospital Services for Treatment of
Alcoholism
CIM 35-22
130.6 	Treatment of Drug Abuse (Chemical
Dependency)
CIM 35-22.2
130.5 	Treatment of Alcoholism and Drug Abuse in a
Freestanding Clinic
CIM 35-22.3
130.3 	Chemical Aversion Therapy for Treatment of
Alcoholism
CIM 35-23
130.4 	Electrical Aversion Therapy for Treatment of
Alcoholism
CIM 35-23.1
230.4 	Diagnosis and Treatment of Impotence 	CIM 35-24
20.10 	Cardiac Rehabilitation Programs 	CIM 35-25
40.5 	Treatment of Obesity 	CIM 35-26
30.1 	Biofeedback Therapy 	CIM 35-27
30.1.1 	Biofeedback Therapy For The Treatment Of
Urinary Incontinence
CIM 35-27.1
50.5 	Oxygen Treatment of Inner Ear/Carbon Therapy 	CIM 35-29
240.3 	Heat Treatment, Including the Use of Diathermy
and Ultra-Sound for Pulmonary Conditions
CIM 35-3
110.8 	Blood Platelet Transfusions 	CIM 35-30

NCD Section 	Title 	CIM Section
270.4 	Treatment Of Decubitus Ulcers 	CIM 35-31
100.8 	Intestinal By-Pass Surgery 	CIM 35-33
230.2 	Uroflowmetric Evaluations 	CIM 35-33
20.23 	Fabric Wrapping of Abdominal Aneurysms 	CIM 35-34
20.28 	Therapeutic Embolization 	CIM 35-35
20. 01 	Vertebral Artery Surgery 	CIM 35-37
20. 2 	Extracranial-Intracranial (EC-IC) Arterial Bypass
Surgery
CIM 35-37
110.15 	Ultrafiltration, Hemoperfusion and
Hemofiltration
CIM 35-38
80.6 	Intraocular Photography 	CIM 35-39
50.8 	Ultrasonic Surgery 	CIM 35-4
100.1 	Gastric Bypass Surgery for Obesity 	CIM 35-40
150.5 	Diathermy Treatment 	CIM 35-41
130.7 	Withdrawal Treatments for Narcotic Addictions 	CIM 35-42
10.1 	Use Of Visual Tests Prior To And General
Anesthesia During Cataract Surgery
CIM 35-44
20.25 	Cardiac Catheterization Performed in Other Than
a Hospital Setting
CIM 35-45
160.3 	Assessing Patients Suitability for Electrical Nerve
Stimulation
CIM 35-46
160.7.1 	Assessing Patients Suitability for Electrical Nerve
Stimulation Therapy
CIM 35-46
140.2 	Breast Reconstruction Following Mastectomy 	CIM 35-47
150.2 	Osteogenic Stimulator 	CIM 35-48
160.11 	Osteogenic Stimulation 	CIM 35-48

NCD Section 	Title 	CIM Section
110.1 	Hyperthermia for Treatment of Cancer 	CIM 35-49
30.8 	Cellular Therapy 	CIM 35-5
50.7 	Cochleostomy with Neurovascular Transplant for
Meniere’s Disease
CIM 35-50
130.8 	Hemodialysis for Treatment of Schizophrenia 	CIM 35-51
140.5 	Laser Procedures 	CIM 35-52
260.1 	Adult Liver Transplantation 	CIM 35-53
260.2 	Pediatric Liver Transplantation 	CIM 35-53.1
80.7 	Refractive Keratoplasty 	CIM 35-54
240.6 	Transvenous (Catheter) Pulmonary Embolectomy 	CIM 35-55
150.8 	Fluidized Therapy Dry Heat for Certain
Musculoskeletal Disorders
CIM 35-56
160.8 	Electroencephalographic Monitoring During
Surgical Procedures Involving the Cerebral
Vasculature
CIM 35-57
160.9 	Electroencephalographic (EEG) Monitoring
During Open-Heart Surgery
CIM 35-57.1
20.3 	Thoracic Duct Drainage (TDD) In Renal
Transplants
CIM 35-58
100.2 	Endoscopy 	CIM 35-59
30.2 	Thermogenic Therapy 	CIM 35-6
110.14 	Apheresis (Therapeutic Pheresis) 	CIM 35-60
140.3 	Transsexual Surgery 	CIM 35-61
160.14 	Invasive Intracranial Pressure Monitoring 	CIM 35-62
50.6 	Tinnitus Masking 	CIM 35-63
20.21 	Chelation Therapy for Treatment of
Atherosclerosis
CIM 35-64

NCD Section 	Title 	CIM Section
Atherosclerosis
100.6 	Gastric Freezing 	CIM 35-65
250.1 	Treatment of Psoriasis 	CIM 35-66
170.2 	Melodic Intonation Therapy 	CIM 35-67
100.9 	Implantation of Anti-Gastroesophageal Reflux
Device
CIM 35-69
20.18 	Carotid Body Resection/Carotid Body
Denervation
CIM 35-7
40.3 	Closed-Loop Blood Glucose Control Device
(CBGCD)
CIM 35-70
110.16 	Nonselective (Random) Transfusions and Living
Related Donor Specific Transfusions (DST) in
Kidney Transplantation
CIM 35-71
160.15 	Electrotherapy for Treatment of Facial Nerve
Palsy (Bell’s Palsy)
CIM 35-72
100.10 	Injection Sclerotherapy for Esophageal Variceal
Bleeding
CIM 35-73
20.20 	External Counterpulsation (ECP) for Severe
Angina
CIM 35-74
20.11 	Intraoperative Ventricular Mapping 	CIM 35-75
150.4 	Neuromuscular Electrical Stimulator (NMES) in
the Treatment of Disuse Atrophy
CIM 35-77
160.12 	Neuromuscular Electrical Stimulation (NMES) in
the Treatment of Disuse Atrophy
CIM 35-77
20.12 	Diagnostic Endocardial Electrical Stimulation
(Pacing)
CIM 35-78
10.6 	Anesthesia in Cardiac Pacemaker Surgery 	CIM 35-79
20.8.3 	Anesthesia in Cardiac Pacemaker Surgery 	CIM 35-79
30.3 	Acupuncture 	CIM 35-8

NCD Section 	Title 	CIM Section
230.1 	Treatment of Kidney Stones 	CIM 35-81
260.3 	Pancreas Transplants 	CIM 35-82
100.3 	24-Hour Ambulatory Esophegeal pH Monitoring 	CIM 35-83
160.4 	Steroetactic Cingulotomy as a Means of
Psychosurgery
CIM 35-84
20.4 	Implantation of Automatic Defibrillators 	CIM 35-85
100.11 	Gastric Balloon for Treatment of Obesity 	CIM 35-86
260.9 	Heart Transplants 	CIM 35-87
110.4 	Extracorporeal Photopheresis 	CIM 35-88
170.3 	Speech Pathology Services for the Treatment of
Dysphagia
CIM 35-89
80.10 	Phaco-Emulsification Procedure (Cataract
Extraction)
CIM 35-9
20.5 	Extracorporeal Immunoadsorption (ECI) Using
Protein A Columns
CIM 35-90
100.13 	Laproscopic Cholecystectomy 	CIM 35-91
30.5 	Transcendental Meditation 	CIM 35-92
240.1 	Lung Volume Reduction Surgery (Reduction
Pneumoplasty)
CIM 35-93
20.6 	Transmyocardial Revascularization (TMR) 	CIM 35-94
20.26 	Partial Ventriculectomy 	CIM 35-95
230.9 	Cryosurgery of Prostate 	CIM 35-96
160.16 	Vertebral Axial Decompression (VAX-D) 	CIM 35-97
270.1 	Electrostimulation in the Treatment of Wounds 	CIM 35-98
140.1 	Abortion 	CIM 35-99

NCD Section 	Title 	CIM Section
160.17 	L-Dopa 	CIM 45-1
30.7 	Laetrile and Related Substances 	CIM 45-10
10.5 	Autogenous Epidural Blood Graft 	CIM 45-11
270.5 	Porcine Skin and Gradient Pressure Dressings 	CIM 45-12
70.3 	Physician’s Office Within an Institution –
Coverage of Services and Supplies Incident to a
Physician’s Services
CIM 45-15
110.2 	Certain Drugs Distributed by the National Cancer
Institute
CIM 45-16
160.20 	Transfer Factor For Treatment of Multiple
Sclerosis
CIM 45-17
110.5 	Granulocyte Transfusions 	CIM 45-18
10.2 	Transcutaneous Electrical Nerve Stimulation
(TENS) for Acute Post-Operative Pain
CIM 45-19
20.22 	Ethylenediamine-Tetra-Acetic (EDTA) Chelation
Therapy for Treatment of Atherosclerosis
CIM 45-20
110.6 	Scalp Hypothermia During Chemotherapy to
Prevent Hair Loss
CIM 45-21
260.7 	Lymphocyte Immune Globulin, Anti-Thymocyte
Globulin (Equine)
CIM 45-22
230.12 	Dimethyl Sulfoxide (DMSO) 	CIM 45-23
110.3 	Anti-Inhibitor Coagulant Complex (AICC) 	CIM 45-24
160.13 	Supplies Used in the Delivery of Transcutaneous
Electrical Nerve Stimulation (TENS) and
Neuromuscular Electrical Stimulation (NMES)
CIM 45-25
270.3 	Platelet-Derived Wound Healing Formula 	CIM 45-26
110.7 	Blood Transfusions 	CIM 45-27
110.9 	Antigens Prepared for Sublingual Administration 	CIM 45-28

NCD Section 	Title 	CIM Section
110.10 	Intravenous Iron Therapy 	CIM 45-29
40.4 	Insulin Syringe 	CIM 45-3
80.3 	Photosensitive Drugs 	CIM 45-30
250.3 	Intravenous Immune Globulin For The Treatment
Of Autoimmune Mucutaneous Blistering
Diseases
CIM 45-31
230.19 	Levocarnitine for Use in the Treatment of
Carnitine Deficiency in ESRD Patients
CIM 45-32
150.6 	Vitamin B12 Injections to Strengthen Tendons;
Ligaments; etc; of the Foot
CIM 45-4
80.1 	Hydrophilic Contact Lens for Corneal Bandage 	CIM 45-7
70.2.1 	Services Provided for the Diagnosis and
Treatment of Diabetic Sensory Neuropathy with
Loss of Protective Sensation (aka Diabetic
Peripheral Neuropathy)
CIM 50.8.1
20.8.1 	Cardiac Pacemaker Evaluation Services 	CIM 50-1
20.8.1.1 	Transtelephonic Monitoring of Cardiac
Pacemakers
CIM 50-1
230.6 	Vabra Aspirator 	CIM 50-10
220.1 	Computerized Tomography 	CIM 50-12
220.2 	Magnetic Resonance Imaging 	CIM 50-13
220.3 	Magnetic Resonance Angiography 	CIM 50-14
20.15 	Electrocardiographic Services 	CIM 50-15
250.2 	Hemorheograph 	CIM 50-16
190.4 	Electron Microscope 	CIM 50-18
70.4 	Pronouncement of Death 	CIM 50-19
110.13 	Cytotoxic Food Tests 	CIM 50-2

NCD Section 	Title 	CIM Section
190.2 	Diagnostic Pap Smears 	CIM 50-20
230.11 	Diagnostic Pap Smears 	CIM 50-20
210.2 	Screening Pap Smears and Pelvic Examinations
for Early Detection of Cervical or Vaginal Cance
CIM 50-20.1
220.4 	Mammograms 	CIM 50-21
110.12 	Challenge Ingestion Food Testing 	CIM 50-22
190.1 	Histocompatibility Testing 	CIM 50-23
190.6 	Hair Analysis 	CIM 50-24
100.4 	Esophageal Manometry 	CIM 50-25
260.6 	Dental Examination Prior to Kidney
Transplantation
CIM 50-26
220.7 	Xenon Scan 	CIM 50-27
70.5 	Hospital and Skilled Nursing Facility Admission
Diagnostic Procedures
CIM 50-28
190.3 	Cytogenetic Studies 	CIM 50-29
20.13 	HIS Bundle Study 	CIM 50-3
220.8 	Nuclear Radiology Procedure 	CIM 50-30
160.10 	Evoked Response Tests 	CIM 50-31
20.7 	Percutaneous Transluminal Angioplasty (PTA) 	CIM 50-32
300.1 	Obsolete or Unreliable Diagnostic Tests 	CIM 50-34
190.5 	Sweat Test 	CIM 50-35
220.6 	Positron Emission Tomography (PET) Scans 	CIM 50-36
20.17 	Noninvasive Tests of Carotid Function 	CIM 50-37
80.8 	Endothelial Cell Photography 	CIM 50-38
160.21 	Telephone Transmission of EEGs 	CIM 50-39

NCD Section 	Title 	CIM Section
160.22 	Ambulatory EEG Monitoring 	CIM 50-39.1
230.5 	Gravlee Jet Washer 	CIM 50-4
160.5 	Sterotaxic Depth Electrode Implantation 	CIM 50-40
190.7 	Human Tumor Stem Cell Drug Sensitivity Assays 	CIM 50-41
20.19 	Ambulatory Blood Pressure Monitoring 	CIM 50-42
220.9 	Digital Subtraction Angiography 	CIM 50-43
150.3 	Bone (Mineral) Density Studies 	CIM 50-44
190.8 	Lymphocyte Mitogen Response Assays 	CIM 50-45
30.9 	Transillumination Light Scanning or
Diaphanography
CIM 50-46
20.27 	Cardiointegram (CIG) as an Alternative to Stress
Test or Thallium Stress Test
CIM 50-47
220.10 	Portable Hand-Held X-Ray Instrument 	CIM 50-48
80.9 	Computer Enhanced Perimetry 	CIM 50-49
220.11 	Thermography 	CIM 50-5
20.24 	Displacement Cardiography 	CIM 50-50
100.5 	Diagnostic Breath Analyses 	CIM 50-51
190.9 	Serologic Testing for Acquired
Immunodeficiency Syndrome (AIDS)
CIM 50-52
110.11 	Food Allergy Testing and Treatment 	CIM 50-53
20.16 	Cardiac Output Monitoring By Electrical
Bioimpedance
CIM 50-54
210.1 	Prostate Cancer Screening Tests 	CIM 50-55
190.11 	Home Prothrombin Time INR Monitoring for
Anticoagulation Management
CIM 50-56

NCD Section 	Title 	CIM Section
160.23 	Current Perception Threshold/Sensory Nerve
Conduction Threshold Test (sNCT)
CIM 50-57.1
220.12 	Single Photon Emission Computed Tomograph
(SPECT)
CIM 50-58
220.13 	Percutaneous Image-Guided Breast Biopsy 	CIM 50-59
20.14 	Plethysmography 	CIM 50-6
220.5 	Ultrasound Diagnostic Procedures 	CIM 50-7
70.2 	Consultation Services Rendered By a Podiatrist in
a Skilled Nursing Facility
CIM 50-8
100.12 	Gastrophotography 	CIM 50-9
230.7 	Water Purification and Softening Systems Used
in Conjunction with Home Dialysis
CIM 55-1
230.13 	Peridex CAPD Filter Set 	CIM 55-2
230.14 	Ultrafiltration Monitor 	CIM 55-3
40.2 	Home Blood Glucose Monitors 	CIM 60-11 and CIM
60-14
280.14 	Infusion Pumps 	CIM 60-14
280.5 	Safety Roller 	CIM 60-15
280.6 	Pneumatic Compression Devices 	CIM 60-16
240.4 	Continuous Positive Airway Pressure (CPAP) 	CIM 60-17
280.7 	Hospital Beds 	CIM 60-18
280.8 	Air-Fluidized Bed 	CIM 60-19
280.13 	Transcutaneous Electrical Nerve Stimulators
(TENS)
CIM 60-20
240.5 	Intrapulmonary Percussive Ventilator (IPV) 	CIM 60-21

NCD Section 	Title 	CIM Section
160.18 	Vagus Nerve Stimulation for Treatment of
Seizures
CIM 60-22
50.1 	Speech Generating Devices 	CIM 60-23
230.8 	Non-Implantable Pelvic Flood Electrical
Stimulator
CIM 60-24
270.2 	Noncontact Normothermic Wound Therapy
(NNWT)
CIM 60-25
280.2 	White Cane for Use by a Blind Person 	CIM 60-3
240.2 	Home Use of Oxygen 	CIM 60-4
280.9 	Power Operated Vehicles That May Be Used as
Wheelchairs
CIM 60-5
280.3 	Specially Sized Wheelchairs 	CIM 60-6
20.8.2 	Self-Contained Pacemaker Monitors 	CIM 60-7
280.4 	Seat Lift 	CIM 60-8
280.1 	Durable Medical Equipment Reference List 	CIM 60-9
80.5 	Scleral Shell 	CIM 65.3
80.4 	Hydrophilic Contact Lenses 	CIM 65-1
180.2 	Enteral and Parenteral Nutritional Therapy 	CIM 65-10
230.16 	Bladder Stimulators (Pacemakers) 	CIM 65-11
160.19 	Phrenic Nerve Stimulator 	CIM 65-13
50.3 	Cochlear Implantation 	CIM 65-14
20.9 	Artificial Hearts and Related Devices 	CIM 65-16
50.4 	Tracheostomy Speaking Valve 	CIM 65-165
230.17 	Urinary Drainage Bags 	CIM 65-17
230.18 	Sacral Nerve Stimulation for Urinary
Incontinence
CIM 65-18

NCD Section 	Title 	CIM Section
Incontinence
160.24 	Deep Brain Stimulation for Essential Tremor and
Parkinson’s Disease
CIM 65-19
230.15 	Electrical Continence Aid 	CIM 65-2
160.6 	Carotid Sinus Nerve Stimulator 	CIM 65-4
50.2 	Electronic Speech Aids 	CIM 65-5
20.8 	Cardiac Pacemakers 	CIM 65-6
80.12 	Intraocular Lenses (IOLs) 	CIM 65-7
160.7 	Electrical Nerve Stimulators 	CIM 65-8
230.10 	Incontinence Control Devices 	CIM 65-9
280.11 	Corset Used as Hernia Support 	CIM 70-1
280.12 	Sykes Hernia Control 	CIM 70-2
280.10 	Prosthetic Shoe 	CIM 70-3
170.1 	Institutional and Home Care Patient Education
Programs
CIM 80-1
40.1 	Diabetes Outpatient Self-Management Training 	CIM 80-2
180.1 	Medical Nutrition Therapy 	CIM 80-3
290.1 	Home Health Visits to a Blind Diabetic 	CIM 90-1
290.2 	Home Health Nurses' Visits to Patients Requiring
Heparin Injections
CIM 90-2