L28903-LCD

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Local Coverage Determination (LCD) for Magnetic Resonance Angiography (MRA) (L28903)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28903

LCD Title Magnetic Resonance Angiography (MRA)

Contractor's Determination Number A70544

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/16/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/01/2011

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-3, Medicare National Coverage, Chapter 1, Section 220.3

Program Memorandum A-02-076 (Change Request 2298)

Program Memorandum, Transmittal 38, 170, 803, 1795, 1883 (Change Request 2673) Change Request 7040,

Transmittals 123 and 1998, dated July 9, 2010

Change Request 7271, Transmittal 2141, dated January 24, 2011

Indications and Limitations of Coverage and/or Medical Necessity

Magnetic Resonance Angiography (MRA) is an application of magnetic resonance (MR) imaging that provides visualization of blood flow, as well as images of normal and diseased blood vessels. Since MRA contrast agents are not nephrotoxic and are rarely associated with allergic type reactions, MRA without or with gadolinium-based contrast enhancement is an imaging alternative for patients who cannot tolerate iodine-based contrast media.

Although MRA appears to be a rapidly developing technology, the clinical safety and effectiveness of this procedure for all anatomical regions has not been proven. As a result Medicare will provide coverage on a limited basis. Below are the indications for which Medicare coverage is allowed for MRA. All other uses of MRA will not be covered.

Indications

Head and Neck (Procedure codes 70544-70549)

All of the following criteria must apply in order for Medicare to provide coverage for MRA of the head and neck:

a. to evaluate the carotid arteries, the circle of Willis, the anterior, middle or posterior cerebral arteries, the vertebral or basilar arteries or the venous sinuses;

b. to verify the need for anticipated surgery for conditions that include, but are not limited to, tumor, aneurysms, vascular malformations, vascular occlusion, or thrombosis. Within this broad category of disorders, medical necessity is the underlying determinant of the need for an MRA. Because MRA and CA perform the same diagnostic function, the medical records should clearly justify and demonstrate the existence of medical necessity; and

c. MRA and contrast angiography (CA) are not expected to be performed on the same patient for diagnostic purposes prior to the application of anticipated therapy. Only one of these tests will be covered routinely unless the physician can demonstrate the medical need to perform both tests.

Chest (procedure code 71555)

a. Diagnosis of Pulmonary Embolism

Patients who are allergic to iodinated contrast material face a high risk of developing complications if they undergo pulmonary angiography or computed tomography angiography. Therefore, Medicare will cover MRA of the chest for diagnosing a suspected pulmonary embolism only when it is contraindicated for the patient to receive intravascular iodinated contrast material.

b. Evaluation of Thoracic Aortic Dissection and Aneurysm

Medicare will provide coverage only for MRA or for CA when used as a diagnostic test. However, if both MRA and CA of the chest are used, the physician must demonstrate the medical need for performing these tests. While the intent of this policy is to provide reimbursement for either MRA or CA, CMS is also allowing flexibility for physicians to make appropriate decisions concerning the use of these tests based on the needs of individual patients

Peripheral Arteries of Lower Extremities (procedure code 73725)

Studies have proven that MRA of peripheral arteries is useful in determining the presence and extent of

peripheral vascular disease in lower extremities. This procedure is non-invasive and has been shown to find occult vessels in some patients for which those vessels were not apparent when CA was performed. Medicare will cover either MRA or CA to evaluate peripheral arteries of the lower extremities. However, both MRA and CA may be useful is some cases, such as:

a. A patient has had CA and this test was unable to identify a viable run-off vessel for bypass. When exploratory surgery is not believed to be a reasonable medical course of action for this patient, MRA may be performed to identify the viable runoff vessel; or

b. A patient has had MRA, but the results are inconclusive.

Abdomen (procedure codes 74185, C8900, C8901, C8902) and Pelvis (procedure codes 72198, C8918, C8919, C8920)

a. Pre-operative Evaluation of Patients Undergoing Elective Abdominal Aortic Aneurysm (AAA) Repair (Effective July 1, 1999)

The MRA is covered for pre-operative evaluation of patients undergoing elective AAA repair if the scientific evidence reveals MRA is considered comparable to CA in determining the extent of AAA, as well as in evaluating aortoiliac occlusion disease and renal artery pathology that may be necessary in the surgical planning of AAA repair. These studies also reveal that MRA could provide a net benefit to the patient. If preoperative CA is avoided, then patients are not exposed to the risks associated with invasive procedures, contrast media, end- organ damage, or arterial injury.

b. Imaging the Renal Arteries and the Aortoiliac Arteries in the Absence of AAA or Aortic Dissection (Effective July 1, 2003)

The MRA coverage is expanded to include imaging the renal arteries and the aortoiliac arteries in the absence of AAA or aortic dissection. MRA should be obtained in those circumstances in which using MRA is expected to avoid obtaining CA, when physician history, physical examination, and standard assessment tools provide insufficient information for patient management, and obtaining an MRA has a high probability of positively affecting patient management. However, CA may be ordered after obtaining the results of an MRA in those rare instances where medical necessity is demonstrated.

Studies show that diagnostic evaluation of several upper abdominal malignancies may require an evaluation for vascular invasion by the tumor in deciding if the patient is a candidate for surgical resection of the tumor. One example is with pancreatic carcinoma. Pancreatic head carcinomas can grow in close proximity to the superior mesenteric vein.

Evidence suggests that MRA provides reliable, noninvasive evaluation of the portal and hepatic veins. MRA can provide focused evaluation of particular areas of interest as well as a broad overview anatomic display that is helpful to surgeons and interventionalists planning procedures.

Limitations

The following MRA services are NOT considered medically reasonable and necessary: MRA of the spinal canal and contents MRA of the upper extremities.

Coding Information

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.

012x Hospital Inpatient (Medicare Part B only)

013x Hospital Outpatient

014x Hospital - Laboratory Services Provided to Non-patients

022x Skilled Nursing - Inpatient (Medicare Part B only)

023x Skilled Nursing - Outpatient

071x Clinic - Rural Health

077x Clinic - Federally Qualified Health Center (FQHC)

085x Critical Access Hospital

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.

032X Radiology - Diagnostic - General Classification

0520 Free-Standing Clinic - General Classification

0521 Free-Standing Clinic - Clinic Visit by Member to RHC/FQHC

0615 Magnetic Resonance Technology (MRT) - MRA - Head and Neck

0616 Magnetic Resonance Technology (MRT) - MRA - Lower Extremities

0618 Magnetic Resonance Technology (MRT) - MRA - Other

CPT/HCPCS Codes

CPT/HCPCS Codes that Support Medical Necessity:

70544 MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S)

70545 MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITH CONTRAST MATERIAL(S)

70546 MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES

70547 MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S)

70548 MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITH CONTRAST MATERIAL(S)

70549 MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES

71555 MAGNETIC RESONANCE ANGIOGRAPHY, CHEST (EXCLUDING MYOCARDIUM), WITH OR WITHOUT CONTRAST MATERIAL(S)

72198 MAGNETIC RESONANCE ANGIOGRAPHY, PELVIS, WITH OR WITHOUT CONTRAST MATERIAL(S)

73725 MAGNETIC RESONANCE ANGIOGRAPHY, LOWER EXTREMITY, WITH OR WITHOUT CONTRAST MATERIAL(S)

74185 MAGNETIC RESONANCE ANGIOGRAPHY, ABDOMEN, WITH OR WITHOUT CONTRAST MATERIAL(S)

For hospital OPPS only:

For procedure code 71555 Magnetic resonance angiography, chest, (excluding myocardium), with or without contrast material(s) use codes:

C8909 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM)

C8910 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, CHEST (EXCLUDING MYOCARDIUM)

C8911 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM)

For Procedure code 72198 Magnetic resonance angiography, pelvis, with or without contrast material(s) use codes:

C8918 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, PELVIS

C8919 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, PELVIS

C8920 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, PELVIS

For procedure code 73725 Magnetic resonance angiography, lower extremity, with or without contrast material(s) use codes:

C8912 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, LOWER EXTREMITY

C8913 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, LOWER EXTREMITY

C8914 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, LOWER EXTREMITY

For procedure code 74185 Magnetic resonance angiography, abdomen, with or without contrast material(s) use codes:

C8900 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, ABDOMEN

C8901 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, ABDOMEN

C8902 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, ABDOMEN

HCPCS Codes that DO NOT Support Medical Necessity:

C8931 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, SPINAL CANAL AND CONTENTS

C8932 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, SPINAL CANAL AND CONTENTS

C8933 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, SPINAL CANAL AND CONTENTS

C8934 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, UPPER EXTREMITY

C8935 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, UPPER EXTREMITY

C8936 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, UPPER EXTREMITY

ICD-9 Codes that Support Medical Necessity Head and Neck (procedure codes 70544-70549)

094.89 OTHER SPECIFIED NEUROSYPHILIS

191.0 - 191.9 MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES - MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE

192.1 MALIGNANT NEOPLASM OF CEREBRAL MENINGES

194.5 MALIGNANT NEOPLASM OF CAROTID BODY

227.5 BENIGN NEOPLASM OF CAROTID BODY

228.02 HEMANGIOMA OF INTRACRANIAL STRUCTURES

239.6 NEOPLASM OF UNSPECIFIED NATURE OF BRAIN

325 PHLEBITIS AND THROMBOPHLEBITIS OF INTRACRANIAL VENOUS SINUSES

430 SUBARACHNOID HEMORRHAGE

431 INTRACEREBRAL HEMORRHAGE

432.1 SUBDURAL HEMORRHAGE

432.9 UNSPECIFIED INTRACRANIAL HEMORRHAGE

433.00 - 433.91 OCCLUSION AND STENOSIS OF BASILAR ARTERY WITHOUT CEREBRAL INFARCTION - OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL INFARCTION

434.00 - 434.91 CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION - CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL INFARCTION

435.0 - 435.9 BASILAR ARTERY SYNDROME - UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA

436 ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE

437.3 CEREBRAL ANEURYSM NONRUPTURED

437.4 CEREBRAL ARTERITIS

437.6 NONPYOGENIC THROMBOSIS OF INTRACRANIAL VENOUS SINUS

442.81 ANEURYSM OF ARTERY OF NECK

446.5 GIANT CELL ARTERITIS

747.81 CONGENITAL ANOMALIES OF CEREBROVASCULAR SYSTEM

900.00 - 900.9 INJURY TO CAROTID ARTERY UNSPECIFIED - INJURY TO UNSPECIFIED BLOOD VESSEL OF HEAD AND NECK

Chest (procedure codes 71555, C8909, C8910, C8911)

415.0 ACUTE COR PULMONALE

415.11 - 415.19 IATROGENIC PULMONARY EMBOLISM AND INFARCTION - OTHER PULMONARY EMBOLISM AND INFARCTION

416.0 PRIMARY PULMONARY HYPERTENSION

416.2 CHRONIC PULMONARY EMBOLISM

416.8 OTHER CHRONIC PULMONARY HEART DISEASES

416.9 CHRONIC PULMONARY HEART DISEASE UNSPECIFIED

441.01 DISSECTION OF AORTA THORACIC

441.03 DISSECTION OF AORTA THORACOABDOMINAL

441.2 THORACIC ANEURYSM WITHOUT RUPTURE

441.7 THORACOABDOMINAL ANEURYSM WITHOUT RUPTURE

786.00 RESPIRATORY ABNORMALITY UNSPECIFIED

786.5 SHORTNESS OF BREATH

786.6 TACHYPNEA

786.30 HEMOPTYSIS, UNSPECIFIED

786.39 OTHER HEMOPTYSIS

MRA of pelvis (procedure code 72198, C8918, C8919, C8920)

233.9 CARCINOMA IN SITU OF OTHER AND UNSPECIFIED URINARY ORGANS

236.90 - 236.99 NEOPLASM OF UNCERTAIN BEHAVIOR OF URINARY ORGAN UNSPECIFIED - NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED URINARY ORGANS

442.2 ANEURYSM OF ILIAC ARTERY

443.22 DISSECTION OF ILIAC ARTERY

444.81 EMBOLISM AND THROMBOSIS OF ILIAC ARTERY

Peripheral Arteries of Lower Extremities (procedure codes 73725, C8912, C8913, C8914)

250.70 - 250.73 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], UNCONTROLLED

440.20 -440.29 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED - OTHER ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES

440.30 - 440.32 ATHEROSCLEROSIS OF UNSPECIFIED BYPASS GRAFT OF THE EXTREMITIES - ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT OF THE EXTREMITIES

440.4 CHRONIC TOTAL OCCLUSION OF ARTERY OF THE EXTREMITIES

442.3 ANEURYSM OF ARTERY OF LOWER EXTREMITY

443.1 THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE)

443.81 PERIPHERAL ANGIOPATHY IN DISEASES CLASSIFIED ELSEWHERE

443.82 ERYTHROMELALGIA

443.89 OTHER PERIPHERAL VASCULAR DISEASE

443.9 PERIPHERAL VASCULAR DISEASE UNSPECIFIED

444.22 ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY

Abdomen (procedure codes 74185, C8900, C8901, C8902)

151.0 - 151.9 MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE

152.0 - 152.9 MALIGNANT NEOPLASM OF DUODENUM - MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE

153.0 - 153.9 MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE

154.0 MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION

155.0 - 155.2 MALIGNANT NEOPLASM OF LIVER PRIMARY - MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY OR SECONDARY

156.0 - 156.9 MALIGNANT NEOPLASM OF GALLBLADDER - MALIGNANT NEOPLASM OF BILIARY TRACT PART UNSPECIFIED SITE

157.0 - 157.9 MALIGNANT NEOPLASM OF HEAD OF PANCREAS - MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED

158.0 - 158.9 MALIGNANT NEOPLASM OF RETROPERITONEUM - MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED

159.0 - 159.9 MALIGNANT NEOPLASM OF INTESTINAL TRACT PART UNSPECIFIED - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE DIGESTIVE ORGANS AND PERITONEUM

171.5 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF ABDOMEN

188.0 - 189.9 MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER - MALIGNANT NEOPLASM OF URINARY ORGAN SITE UNSPECIFIED

198.0 SECONDARY MALIGNANT NEOPLASM OF KIDNEY

223.1 BENIGN NEOPLASM OF KIDNEY EXCEPT PELVIS

223.2 BENIGN NEOPLASM OF RENAL PELVIS

233.9 CARCINOMA IN SITU OF OTHER AND UNSPECIFIED URINARY ORGANS

236.90 - 236.99 NEOPLASM OF UNCERTAIN BEHAVIOR OF URINARY ORGAN UNSPECIFIED - NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED URINARY ORGANS

401.0 - 401.9 MALIGNANT ESSENTIAL HYPERTENSION - UNSPECIFIED ESSENTIAL HYPERTENSION

402.00 - 402.91 MALIGNANT HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE - UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

403.00 - 403.91 HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.00 - 404.93 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

405.01 MALIGNANT RENOVASCULAR HYPERTENSION

405.11 BENIGN RENOVASCULAR HYPERTENSION

405.91 UNSPECIFIED RENOVASCULAR HYPERTENSION

440.1 ATHEROSCLEROSIS OF RENAL ARTERY

441.2 DISSECTION OF AORTA ABDOMINAL

441.3 DISSECTION OF AORTA THORACOABDOMINAL

441.4 ABDOMINAL ANEURYSM WITHOUT RUPTURE

441.7 THORACOABDOMINAL ANEURYSM WITHOUT RUPTURE

441.9 AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT RUPTURE

444.01 - 444.09 SADDLE EMBOLUS OF ABDOMINAL AORTA - OTHER ARTERIAL EMBOLISM AND THROMBOSIS OF ABDOMINAL AORTA

447.1 STRICTURE OF ARTERY

447.3 HYPERPLASIA OF RENAL ARTERY

580.0 - 580.9 ACUTE GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - ACUTE GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY

581.0 - 581.9 NEPHROTIC SYNDROME WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - NEPHROTIC SYNDROME WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY

582.0 - 582.9 CHRONIC GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - CHRONIC GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY

583.0 - 583.9 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY

588.0 - 588.9 RENAL OSTEODYSTROPHY - UNSPECIFIED DISORDER RESULTING FROM IMPAIRED RENAL FUNCTION

593.81 VASCULAR DISORDERS OF KIDNEY

593.9 UNSPECIFIED DISORDER OF KIDNEY AND URETER

996.81 COMPLICATIONS OF TRANSPLANTED KIDNEY

V12.59 PERSONAL HISTORY OF OTHER DISEASES OF CIRCULATORY SYSTEM NOT ELSEWHERE CLASSIFIED

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Documentation maintained in the patient’s file must indicate the medical necessity of this procedure. All coverage criteria listed in the “Indications and Limitations of Coverage and/or Medical Necessity” section must be documented in the patient’s medical record, as well as a hard copy of the procedure results and made available to Medicare upon request. This information can generally be found in the office/progress notes, history and physical, and/or operative notes.

If the provider of the magnetic resonance angiography study is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician’s order for the studies. The physician must state the reason for the MRA in his order for the test.

MRA and contrast angiography (CA) are not expected to be performed on the same patient for diagnostic purposes prior to the application of anticipated therapy. Only one of these tests will be covered routinely unless the physician can demonstrate the medical need to perform both tests. The medical record must clearly document the medical necessity of performing both tests.

Examples of indications that support medical necessity of contrast angiography (CA) performed as an adjunct to MRA are given below:

• Clarify conditions where test results or clinical information are contradictory (e.g., MRA and duplex Doppler ultrasound are discordant with the clinical differential diagnosis and conventional angiography, with its ability to directly measure pressure gradients across stenosis of questionable hemodynamic significance, can provide more definitive information).

• Verify the site of clinically important vascular stenosis and help map out the surgical/endovascular approach (e.g., to determine which lesions should have an angioplasty and/or stent vs. which lesions require surgical bypass graft or no treatment at all).

• Identify situations where MRA is nonconclusive or degraded by metallic artifact.

Appendices

Utilization Guidelines

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they

may be subject to review for medical necessity.

Sources of Information and Basis for Decision

American College of Radiology (2001). ACR Practice Guideline for the Performance of Pediatric and Adult Neurovascular Magnetic Resonance Angiography (MRA).

Grainger & Allison’s. (2001). “Diagnostic Radiology: A Textbook of Medical Imaging”, (4th ed.) Churchill Livingstone Inc.

Koelemay, M. et al. (2001). “Magnetic Resonance Angiography for the Evaluation of Lower Extremity Arterial Disease”, JAMA. 2001; 285:1338-1345.

Leung, D.A., et al., “MR Angiography of the Renal Arteries”, Radiology Clinics of North America, 40(4): 847-65, 2002.

NIA Diagnostic Imaging Guidelines. [on-line]. Available: http://www.radmd.com/assets/20050305_guidelines.pdf [2005, March]

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which includes representatives from the Florida Radiological Society, Inc.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 10/01/2010

Revision History Number 6

Revision History Explanation Revision Number:6 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2011 Revised Effective Date:10/01/2011

LCR A2011-078

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Deleted diagnosis code 444.0 and replaced it with diagnosis code range 444.01-444.09 for CPT/HCPCS codes 74185, C8900, C8901, and C8902. The effective date of this revision is based on date of service.

Revision Number:5

Start Date of Comment Period:N/A Start Date of Notice Period:08/01/2011 Revised Effective Date: 09/12/2011

LCR A2011-067

July 2011 Connection

Explanation of Revision: The ‘Indications and Limitations of Coverage and/or Medical Necessity’ section of the LCD has been revised to add a ‘Limitations’ section. The ‘CPT/HCPCS Codes’ section of the LCD has also been revised to add a section, ‘HCPCS Codes that DO NOT Support Medical Necessity’. The effective date of this revision is based on date of service.

Revision Number:4

Start Date of Comment Period:N/A Start Date of Notice Period:10/01/2010 Revised Effective Date: 10/01/2010

LCR A2010-050

September 2010 Update

Explanation of Revision: Annual 2011 ICD-9-CM Update. Deleted diagnosis code 786.3 and replaced with diagnosis codes 786.30 and 786.39 and descriptor for CPT/HCPCS codes 71555, C8909, C8910, and C8911. The effective date of this revision is based on date of service.

Revision Number:3

Start Date of Comment Period:N/A Start Date of Notice Period:08/01/2010 Revised Effective Date:08/09/2010

LCR A2010-039

July 2010 Bulletin

Explanation of Revision: LCD revised in accordance with the CMS Transmittals 123 and 1998, Change Request 7040, dated July 9, 2010. The ‘Indications and Limitations of Coverage and/or Medical Necessity’ section has been revised to delete the following statement: All other uses of MRA for which CMS has not specifically indicated coverage continue to be noncovered. This revision is effective for claims processed on or after 08/09/2010 for dates of service on or after 06/03/2010.

Revision Number:2

Start Date of Comment Period:N/A Start Date of Notice Period:11/01/2009 Revised Effective Date: 10/05/2009

LCR A2009-079

October 2009 Bulletin

Explanation of Revision: The TOB for Federally Qualified Health Clinics was changed from 73x to 77x based on Change Request 6338. The effective date of this revision is 10/05/2009 for dates of service on or after 04/01/2010.

Revision Number:1

Start Date of Comment Period:N/A Start Date of Notice Period:10/01/2009 Revised Effective Date: 10/01/2009

LCR A2009-081

September 2009 Bulletin

Explanation of Revision: Annual 2010 ICD-9-CM Update. Added diagnosis code 416.2 for procedure codes 71555, C8909, C8910 and C8911. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/16/2009

LCR A2009-034FL

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L28903) replaces LCD L1435 as the policy in notice. This document (L28903) is effective on 02/16/2009.

8/10/2009 - The description for Revenue code 0521 was changed 3/7/2010 - The description for Bill Type Code 77 was changed 8/1/2010 - The description for Bill Type Code 12 was changed

8/1/2010 - The description for Bill Type Code 13 was changed 8/1/2010 - The description for Bill Type Code 14 was changed 8/1/2010 - The description for Bill Type Code 22 was changed 8/1/2010 - The description for Bill Type Code 23 was changed 8/1/2010 - The description for Bill Type Code 71 was changed 8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0320 was changed 8/1/2010 - The description for Revenue code 0321 was changed 8/1/2010 - The description for Revenue code 0322 was changed 8/1/2010 - The description for Revenue code 0323 was changed 8/1/2010 - The description for Revenue code 0324 was changed 8/1/2010 - The description for Revenue code 0329 was changed 8/1/2010 - The description for Revenue code 0520 was changed 8/1/2010 - The description for Revenue code 0521 was changed 8/1/2010 - The description for Revenue code 0615 was changed 8/1/2010 - The description for Revenue code 0616 was changed 8/1/2010 - The description for Revenue code 0618 was changed

09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update.

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

74185 descriptor was changed in Group 1

08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

Reason for Change