Each request for adding a service to the list of Medicare telehealth services must address the items outlined below.

• Name(s), address(es) and contact information of the requestor.
• The HCPCS code(s) that describes the service(s) proposed for addition or deletion to the list of Medicare telehealth services. If the requestor does not know the applicable HCPCS code, the request should include a description of services furnished during the telehealth session.
• A description of the type(s) of medical professional(s) providing the telehealth service at the distant site.
• A detailed discussion of the reasons the proposed service should be added to the definition of Medicare telehealth.
• An explanation as to why the requested service cannot be billed under the current scope of telehealth services, for example, the reason why the HCPCS codes currently on the list of Medicare telehealth services would not be appropriate for billing the service requested.
• If available, data showing that the use of a telecommunications system does not change the diagnosis or treatment plan as compared to the face-to-face delivery of the service.
• If available, data showing that patients who receive this service via a telecommunications system are satisfied with the service that is delivered.

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