Injections of a thrombolytic agent (37201, 92975), e.g., streptokinase, alteplase, urokinase, are eligible for payment for the following indications:
  • Treatment of acute arterial thrombosis (preferably within six hours on onset).
  • Treatment of acute ischemic stroke (preferably within three hours of onset).
  • Treatment of acute pulmonary thromboembolism.
  • Treatment of thrombosed central intravenous catheters.
An intravenous injection or infusion of a thrombolytic agent (e.g., streptokinase) should be processed under code 92977 when the physician has personally administered it. Monitoring of the patient and associated services should be processed in accordance with the level of medical care reported.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.

Drug Wastage
Medicare provides payment for the discarded drug/biological remaining in a single-use drug product after administering what is reasonable and necessary for the patient’s condition. If the physician has made good-faith efforts to minimize the unused portion of the drug/biological in how patients are scheduled and how he ordered, accepted, stored and used the drug, and made good-faith efforts to minimize the unused portion of the drug in how it is supplied, the program will cover the amount of drug discarded along with the amount administered. Documentation requirements are given below. Coding and billing instructions can be referenced in the attached article. Reference to national policy:Medicare Claims Processing Manual – Pub. 100-04, Chapter 17, Section 40.
Note: The JW modifier is not used on claims for drugs or biologicals provided under the Competitive Acquisition Program (CAP). Reference to national policy: Medicare Claims Processing Manual, Pub. 100-04, Chapter 17, Section 100.2.9.
Note: This LCD and the related Article do NOT describe drug and biological coverage under the Medicare Part D benefit.
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.
12X, 13X, 18X, 21X, 23X, 71X, 72X, 83X, 85X
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.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
Thrombolytic therapy, stroke
Transcatheter therapy infuse
Dissolve clot, heart vessel
Dissolve clot, heart vessel
Injection, anistreplase, per 30 units
Injection, reteplase, 18.1 mg
Injection, streptokinase, per 250,000 IU
Injection, alteplase recombinant, 1 mg
Injection, tenecteplase, 1 mg
Injection, urokinase, 5,000 IU
Injection, IV, urokinase, 250,000 IU
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
The Medicare is establishing the following limited coverage for CPT/HCPCS codes 37195, 37201, 92975, 92977, J0350, J2993, J2995, J2997, J3101, J3364 and J3365:
Covered for:
Acute myocardial infarction, of anterolateral wall
Acute myocardial infarction, of other anterior wall
Acute myocardial infarction, of inferolateral wall
Acute myocardial infarction, of inferoposterior wall
Acute myocardial infarction, of other inferior wall
Acute myocardial infarction, of other lateral wall
Acute myocardial infarction, of true posterior wall
Acute myocardial infarction, subendocardial
Acute myocardial infarction, of other specified site
Acute myocardial infarction, of unspecified site
Acute coronary occlusion without myocardial infarction
Iatrogenic pulmonary embolism and infarction
Other pulmonary embolism and infarction
Occlusion and stenosis of basilar artery
Occlusion and stenosis of carotid artery
Occlusion and stenosis of vertebral artery
Occlusion and stenosis of multiple and bilateral arteries
Occlusion and stenosis of other specified precerebral artery
Occlusion and stenosis of unspecified precerebral artery
Cerebral thrombosis
Cerebral embolism
Cerebral artery occlusion, unspecified
Acute, but ill-defined cerebrovascular disease
Other generalized ischemic cerebrovascular disease
Atherosclerosis of native arteries of the extremities
Other atherosclerosis of native arteries of the extremities
Atherosclerosis of bypass graft of the extremities
Peripheral angiopathy in diseases classified elsewhere
Arterial embolism and thrombosis
Arterial embolism and thrombosis of extremity
Embolism and thrombosis of iliac artery
Embolism and thrombosis of other artery
Embolism and thrombosis of unspecified artery
Atheroembolism of extremity
Atheroembolism, of other sites, kidney
Atheroembolism of other site
Embolism and thrombosis of unspecified site
Complication due to implanted device, implant or graft
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
ICD-9-CM Codes That DO NOT Support Medical Necessity
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Drug Wastage Documentation Requirements
Any amount wasted must be clearly documented in the medical record, regardless of whether the JW modifier will be used in billing for the drug/biological, with:
  • Date and time.
  • Amount of medication wasted.
  • Reason for the wastage.