LCD/NCD Portal
Automated World Health
Local Coverage Determination (LCD) for Magnetic Resonance Imaging of the Brain (L28904)
Contractor Information
Contractor Name First Coast Service Options, Inc.
Contractor Number 09101
Contractor Type MAC - Part A
LCD Information
Document Information
LCD ID Number L28904
LCD Title Magnetic Resonance Imaging of the Brain
Contractor's Determination Number A70551
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 07/07/2011
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: Change Request 7296, Transmittals 132 and 2171, dated March 4, 2011
Change Request 7441, Transmittals 134 and 2293, dated August 26, 2011
CMS Manual System, Pub. 100-3, Medicare National Coverage Determinations, Chapter 1, Section 220.2 CMS Manual System, Pub. 100-8, Medicare Program Integrity, Chapter 13, Section 13.1.3
Indications and Limitations of Coverage and/or Medical Necessity
Magnetic Resonance Imaging (MRI) is used to diagnose a variety of central nervous system disorders. Unlike computed tomography (CT) scanning, MRI does not make use of ionizing radiation or require iodinated contrast material to distinguish normal from pathologic tissue. Rather, the difference in the number of protons contained within hydrogen-rich molecules in the body (water, proteins, lipids, and other macromolecules) determines recorded image qualities and makes possible the distinction of white from gray matter, tumor from normal tissue, and flowing blood within vascular structures.
MRI provides superior tissue contrast when compared to CT, is able to image in multiple planes, is not affected by bone artifact, provides vascular imaging capability, and makes use of safer contrast media (gadolinium chelate agents). Its major disadvantage over CT is the longer scanning time required for study, making it less useful for emergency evaluations of acute bleeding or for unstable patients. Because a powerful magnetic field is required
to obtain an MRI, patients with ferromagnetic materials in place may not be able to undergo MRI study. These include patients with cardiac pacemakers, implanted neurostimulators, cochlear implants, metal in the eye and older ferromagnetic intracranial aneurysm clips. All of these may be potentially displaced when exposed to the powerful magnetic fields used in MRI.
Medicare will consider Magnetic Resonance Imaging of the Brain medically reasonable and necessary when used to aid in the diagnosis of lesions of the brain and to assist in therapeutic decision making in the following conditions:
• For detecting or evaluating extra-axial tumors, A-V malformations, cavernous hemangiomas, small intracranial aneurysms, cranial nerve lesions, demyelination disorders including multiple sclerosis, lesions near dense bone, acoustic neuromas, pituitary lesions, and brain radiation injuries;
• For development abnormalities of the brain including neuroectodermal dysplasia;
• For subacute central nervous system hemorrhage or hematoma;
• For acute cerebrovascular accidents;
• For complex partial seizures, seizures refractory to therapy, temporal lobe epilepsy, or other atypical seizure disorders;
• MRI is usually not the procedure of choice in patients who have acute head trauma, acute intracranial bleeding, or investigation of skull fracture or other bone abnormality, or as follow-up for hydrocephalus. However, a MRI may be necessary in patients whose presentation indicates a focal problem or who have had a recent significant change in symptomatology;
• For brain infections;
• Where soft tissue contrast is necessary;
• When bone artifacts limit CT, or coronal, coronosagittal or parasagittal images are desired; [and]
• For procedures in which iodinated contrast material are contraindicated.
Contraindications:
The MRI is not covered when the following patient-specific contraindications are present:
• MRI is not covered for patients with cardiac pacemakers or with metallic clips on vascular aneurysms unless the Medicare beneficiary meets the provisions of the following exceptions:
Effective for claims with dates of service on or after July 7, 2011, the contraindications will not apply to pacemakers when used according to the FDA-approved labeling in an MRI environment, or effective for claims with dates of service on or after February 24, 2011, CMS believes that the evidence is promising although not yet convincing that MRI will improve patient health outcomes if certain safeguards are in place to ensure that the exposure of the device to an MRI environment adversely affects neither the interpretation of the MRI result nor the proper functioning of the implanted device itself. We believe that specific precautions (as listed below) could maximize benefits of MRI exposure for beneficiaries enrolled in clinical trials designed to assess the utility and safety of MRI exposure. Therefore, CMS determines that MRI will be covered by Medicare when provided in a clinical study under section 1862(a)(1)(E) (consistent with section 1142 of the Act) through the Coverage with Study Participation (CSP) form of Coverage with Evidence Development (CED) if the study meets the criteria in each of the three paragraphs in CMS Pub 100-03, CMS National Coverage Determination Manual, Chapter 1, Section 220.2.C.1.
• MRI during a viable pregnancy is also contraindicated at this time.
• The danger inherent in bringing ferromagnetic materials within range of MRI units generally constrains the use of MRI on acutely ill patients requiring life support systems and monitoring devices that employ ferromagnetic materials.
• In addition, the long imaging time and the enclosed position of the patient may result in claustrophobia, making patients who have a history of claustrophobia unsuitable candidates for MRI procedures.
Nationally Non-Covered Indications:
CMS has determined that MRI of cortical bone and calcifications, and procedures involving spatial resolution of bone and calcifications, are not considered reasonable and necessary indications within the meaning of section 1862(a)(1)(A) of the Act, and are therefore non-covered.
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
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
0611 Magnetic Resonance Technology (MRT) - MRI - Brain/Brainstem
CPT/HCPCS Codes
70551 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL
70552 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITH CONTRAST MATERIAL(S)
70553 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM AND SKULL BASE),
70557 DURING OPEN INTRACRANIAL PROCEDURE (EG, TO ASSESS FOR RESIDUAL TUMOR OR RESIDUAL VASCULAR MALFORMATION); WITHOUT CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM AND SKULL BASE),
70558 DURING OPEN INTRACRANIAL PROCEDURE (EG, TO ASSESS FOR RESIDUAL TUMOR OR RESIDUAL VASCULAR MALFORMATION); WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM AND SKULL BASE),
70559 DURING OPEN INTRACRANIAL PROCEDURE (EG, TO ASSESS FOR RESIDUAL TUMOR OR RESIDUAL VASCULAR MALFORMATION); WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES
ICD-9 Codes that Support Medical Necessity
For procedure codes 70551, 70552, and 70553:
006.5 AMEBIC BRAIN ABSCESS
013.00 - 013.06 TUBERCULOUS MENINGITIS UNSPECIFIED EXAMINATION - TUBERCULOUS MENINGITIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
013.10 - 013.16 TUBERCULOMA OF MENINGES UNSPECIFIED EXAMINATION - TUBERCULOMA OF MENINGES TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
013.20 - 013.26 TUBERCULOMA OF BRAIN UNSPECIFIED EXAMINATION - TUBERCULOMA OF BRAIN TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
013.30 - 013.36 TUBERCULOUS ABSCESS OF BRAIN UNSPECIFIED EXAMINATION - TUBERCULOUS ABSCESS OF BRAIN TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
013.60 - 013.66 TUBERCULOUS ENCEPHALITIS OR MYELITIS UNSPECIFIED EXAMINATION - TUBERCULOUS ENCEPHALITIS OR MYELITIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
013.80 - 013.86 OTHER SPECIFIED TUBERCULOSIS OF CENTRAL NERVOUS SYSTEM UNSPECIFIED EXAMINATION - OTHER SPECIFIED TUBERCULOSIS OF CENTRAL NERVOUS SYSTEM TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
013.90 - 013.96 UNSPECIFIED TUBERCULOSIS OF CENTRAL NERVOUS SYSTEM UNSPECIFIED EXAMINATION - UNSPECIFIED TUBERCULOSIS OF CENTRAL NERVOUS SYSTEM TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
36.1 MENINGOCOCCAL MENINGITIS
36.2 MENINGOCOCCAL ENCEPHALITIS
36.3 MENINGOCOCCEMIA
042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE
046.0 - 046.9 KURU - UNSPECIFIED SLOW VIRUS INFECTION OF CENTRAL NERVOUS SYSTEM
047.0 - 047.9 MENINGITIS DUE TO COXSACKIE VIRUS - UNSPECIFIED VIRAL MENINGITIS
049.0 - 049.9 NON-ARTHOPOD BORNE LYMPHOCYTIC CHORIOMENINGITIS - UNSPECIFIED NON- ARTHROPOD-BORNE VIRAL DISEASES OF CENTRAL NERVOUS SYSTEM
052.0 POSTVARICELLA ENCEPHALITIS
053.0 HERPES ZOSTER WITH MENINGITIS
054.3 HERPETIC MENINGOENCEPHALITIS
054.72 HERPES SIMPLEX MENINGITIS
054.74 HERPES SIMPLEX MYELITIS
055.0 POSTMEASLES ENCEPHALITIS
056.01 ENCEPHALOMYELITIS DUE TO RUBELLA
062.0 - 062.9 JAPANESE ENCEPHALITIS - MOSQUITO-BORNE VIRAL ENCEPHALITIS UNSPECIFIED
063.0 - 063.9 RUSSIAN SPRING-SUMMER (TAIGA) ENCEPHALITIS - TICK-BORNE VIRAL ENCEPHALITIS UNSPECIFIED
064 VIRAL ENCEPHALITIS TRANSMITTED BY OTHER AND UNSPECIFIED ARTHROPODS
72.1 MUMPS MENINGITIS
72.2 MUMPS ENCEPHALITIS
090.40 - 090.49 JUVENILE NEUROSYPHILIS UNSPECIFIED - OTHER JUVENILE NEUROSYPHILIS
094.0 - 094.9 TABES DORSALIS - NEUROSYPHILIS UNSPECIFIED
112.83 CANDIDAL MENINGITIS
114.2 COCCIDIOIDAL MENINGITIS
115.01 HISTOPLASMA CAPSULATUM MENINGITIS
115.11 HISTOPLASMA DUBOISII MENINGITIS
115.91 HISTOPLASMOSIS MENINGITIS UNSPECIFIED
130.0 MENINGOENCEPHALITIS DUE TO TOXOPLASMOSIS
162.0 - 162.9 MALIGNANT NEOPLASM OF TRACHEA - MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED
191.0 - 191.9 MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES - MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE
192.1 MALIGNANT NEOPLASM OF CRANIAL NERVES
192.2 MALIGNANT NEOPLASM OF CEREBRAL MENINGES
194.3 MALIGNANT NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT
194.4 MALIGNANT NEOPLASM OF PINEAL GLAND
196.0 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF HEAD FACE AND NECK
198.3 SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD
198.4 SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM
198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW
225.1 BENIGN NEOPLASM OF BRAIN
225.2 BENIGN NEOPLASM OF CRANIAL NERVES
225.3 BENIGN NEOPLASM OF CEREBRAL MENINGES
225.8 BENIGN NEOPLASM OF OTHER SPECIFIED SITES OF NERVOUS SYSTEM
227.3 BENIGN NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT
227.4 BENIGN NEOPLASM OF PINEAL GLAND
228.02 HEMANGIOMA OF INTRACRANIAL STRUCTURES
237.1 NEOPLASM OF UNCERTAIN BEHAVIOR OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT
237.2 NEOPLASM OF UNCERTAIN BEHAVIOR OF PINEAL GLAND
237.5 NEOPLASM OF UNCERTAIN BEHAVIOR OF BRAIN AND SPINAL CORD
237.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF MENINGES
237.70 - 237.9 NEUROFIBROMATOSIS UNSPECIFIED - NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED PARTS OF NERVOUS SYSTEM
239.6 NEOPLASM OF UNSPECIFIED NATURE OF BRAIN
239.7 NEOPLASM OF UNSPECIFIED NATURE OF ENDOCRINE GLANDS AND OTHER PARTS OF NERVOUS SYSTEM
253.0 - 253.9 ACROMEGALY AND GIGANTISM - UNSPECIFIED DISORDER OF THE PITUITARY GLAND AND ITS HYPOTHALAMIC CONTROL
298.9 UNSPECIFIED PSYCHOSIS
310.0 - 310.9 FRONTAL LOBE SYNDROME - UNSPECIFIED NONPSYCHOTIC MENTAL DISORDER FOLLOWING ORGANIC BRAIN DAMAGE
320.0 - 326 HEMOPHILUS MENINGITIS - LATE EFFECTS OF INTRACRANIAL ABSCESS OR PYOGENIC INFECTION
330.0 - 330.9 LEUKODYSTROPHY - UNSPECIFIED CEREBRAL DEGENERATION IN CHILDHOOD
331.0 - 331.9 ALZHEIMER'S DISEASE - CEREBRAL DEGENERATION UNSPECIFIED
332.1 - 332.2 PARALYSIS AGITANS - SECONDARY PARKINSONISM
333.0 - 333.99 OTHER DEGENERATIVE DISEASES OF THE BASAL GANGLIA - OTHER EXTRAPYRAMIDAL DISEASES AND ABNORMAL MOVEMENT DISORDERS
334.0 - 334.9 FRIEDREICH'S ATAXIA - SPINOCEREBELLAR DISEASE UNSPECIFIED
340 MULTIPLE SCLEROSIS
341.0 - 341.9 NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM
UNSPECIFIED
342.00 - 342.92 FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE
343.0 - 343.9 CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED
344.00 - 344.9 QUADRIPLEGIA UNSPECIFIED - PARALYSIS UNSPECIFIED
345.00 - 345.91 GENERALIZED NONCONVULSIVE EPILEPSY WITHOUT INTRACTABLE EPILEPSY - EPILEPSY UNSPECIFIED WITH INTRACTABLE EPILEPSY
348.0 - 348.9 CEREBRAL CYSTS - UNSPECIFIED CONDITION OF BRAIN
349.1 NERVOUS SYSTEM COMPLICATIONS FROM SURGICALLY IMPLANTED DEVICE
349.2 DISORDERS OF MENINGES NOT ELSEWHERE CLASSIFIED
349.31 - 349.39 ACCIDENTAL PUNCTURE OR LACERATION OF DURA DURING A PROCEDURE - OTHER DURAL
TEAR
349.81 - 349.89 CEREBROSPINAL FLUID RHINORRHEA - OTHER SPECIFIED DISORDERS OF NERVOUS SYSTEM
349.9 UNSPECIFIED DISORDERS OF NERVOUS SYSTEM
350.1 - 350.9 TRIGEMINAL NEURALGIA - TRIGEMINAL NERVE DISORDER UNSPECIFIED
351.0 - 351.9 BELL'S PALSY - FACIAL NERVE DISORDER UNSPECIFIED
352.0 - 352.9 DISORDERS OF OLFACTORY (1ST) NERVE - UNSPECIFIED DISORDER OF CRANIAL NERVES
358.1 - 358.2 MYASTHENIA GRAVIS WITHOUT (ACUTE) EXACERBATION - MYASTHENIA GRAVIS WITH (ACUTE) EXACERBATION
358.1 MYASTHENIC SYNDROMES IN DISEASES CLASSIFIED ELSEWHERE
368.11 SUDDEN VISUAL LOSS
368.12 TRANSIENT VISUAL LOSS
368.2 DIPLOPIA
368.40 VISUAL FIELD DEFECT UNSPECIFIED
368.8 OTHER SPECIFIED VISUAL DISTURBANCES
368.9 UNSPECIFIED VISUAL DISTURBANCE
374.31 PARALYTIC PTOSIS
377.1 PAPILLEDEMA UNSPECIFIED
377.2 PAPILLEDEMA ASSOCIATED WITH INCREASED INTRACRANIAL PRESSURE
377.51 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH PITUITARY NEOPLASMS AND DISORDERS
377.52 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH OTHER NEOPLASMS
377.61 DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH NEOPLASMS
377.71 DISORDERS OF VISUAL CORTEX ASSOCIATED WITH NEOPLASMS
378.51 - 378.52 THIRD OR OCULOMOTOR NERVE PALSY PARTIAL - THIRD OR OCULOMOTOR NERVE PALSY TOTAL
378.53 FOURTH OR TROCHLEAR NERVE PALSY
378.54 SIXTH OR ABDUCENS NERVE PALSY
378.55 - 378.56 EXTERNAL OPHTHALMOPLEGIA - TOTAL OPHTHALMOPLEGIA
386.2 VERTIGO OF CENTRAL ORIGIN
388.2 SUDDEN HEARING LOSS UNSPECIFIED
388.5 DISORDERS OF ACOUSTIC NERVE
389.10 - 389.18 SENSORINEURAL HEARING LOSS UNSPECIFIED - SENSORINEURAL HEARING LOSS, BILATERAL
389.20 - 389.22 MIXED HEARING LOSS, UNSPECIFIED - MIXED HEARING LOSS, BILATERAL
430 - 438.9 SUBARACHNOID HEMORRHAGE - UNSPECIFIED LATE EFFECTS OF CEREBROVASCULAR
DISEASE
572.2 HEPATIC ENCEPHALOPATHY
676.60 GALACTORRHEA ASSOCIATED WITH CHILDBIRTH UNSPECIFIED AS TO EPISODE OF CARE
739.0 NONALLOPATHIC LESIONS OF HEAD REGION NOT ELSEWHERE CLASSIFIED
742.0 - 742.4 ENCEPHALOCELE - OTHER SPECIFIED CONGENITAL ANOMALIES OF BRAIN
742.8 OTHER SPECIFIED CONGENITAL ANOMALIES OF NERVOUS SYSTEM
742.9 UNSPECIFIED CONGENITAL ANOMALY OF BRAIN SPINAL CORD AND NERVOUS SYSTEM
747.81 CONGENITAL ANOMALIES OF CEREBROVASCULAR SYSTEM
759.2 ANOMALIES OF OTHER ENDOCRINE GLANDS CONGENITAL
759.3 SITUS INVERSUS
759.4 CONJOINED TWINS
759.5 TUBEROUS SCLEROSIS
759.6 OTHER CONGENITAL HAMARTOSES NOT ELSEWHERE CLASSIFIED
759.7 MULTIPLE CONGENITAL ANOMALIES SO DESCRIBED
759.81 - 759.89 PRADER-WILLI SYNDROME - OTHER SPECIFIED CONGENITAL ANOMALIES
759.9 CONGENITAL ANOMALY UNSPECIFIED
767.0 SUBDURAL AND CEREBRAL HEMORRHAGE DUE TO BIRTH TRAUMA
768.5 SEVERE BIRTH ASPHYXIA
768.6 MILD OR MODERATE BIRTH ASPHYXIA
768.70 - 768.73 HYPOXIC-ISCHEMIC ENCEPHALOPATHY, UNSPECIFIED - SEVERE HYPOXIC-ISCHEMIC ENCEPHALOPATHY
768.9 UNSPECIFIED SEVERITY OF BIRTH ASPHYXIA IN LIVEBORN INFANT
772.10 - 772.14 INTRAVENTRICULAR HEMORRHAGE UNSPECIFIED GRADE - INTRAVENTRICULAR HEMORRHAGE GRADE IV
772.2 SUBARACHNOID HEMORRHAGE OF NEWBORN
780.01 - 780.09 COMA - ALTERATION OF CONSCIOUSNESS OTHER
780.1 HALLUCINATIONS
780.2 SYNCOPE AND COLLAPSE
780.31 - 780.39 FEBRILE CONVULSIONS (SIMPLE), UNSPECIFIED - OTHER CONVULSIONS
780.4 DIZZINESS AND GIDDINESS
780.60 FEVER, UNSPECIFIED
780.61 FEVER PRESENTING WITH CONDITIONS CLASSIFIED ELSEWHERE
780.62 POSTPROCEDURAL FEVER
780.91 - 780.99 FUSSY INFANT (BABY) - OTHER GENERAL SYMPTOMS
781.0 - 781.8 ABNORMAL INVOLUNTARY MOVEMENTS - NEUROLOGIC NEGLECT SYNDROME
781.94 FACIAL WEAKNESS
781.99 OTHER SYMPTOMS INVOLVING NERVOUS AND MUSCULOSKELETAL SYSTEMS
784.2 SWELLING MASS OR LUMP IN HEAD AND NECK
784.3 APHASIA
784.51 - 784.59 DYSARTHRIA - OTHER SPEECH DISTURBANCE
784.60 - 784.69 SYMBOLIC DYSFUNCTION UNSPECIFIED - OTHER SYMBOLIC DYSFUNCTION
793.0 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF SKULL AND HEAD
794.00 - 794.09 UNSPECIFIED ABNORMAL FUNCTION STUDY OF BRAIN AND CENTRAL NERVOUS SYSTEM - OTHER NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF BRAIN AND CENTRAL NERVOUS SYSTEM
800.00 - 800.99 CLOSED FRACTURE OF VAULT OF SKULL WITHOUT INTRACRANIAL INJURY WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OPEN FRACTURE OF VAULT OF SKULL WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH CONCUSSION UNSPECIFIED
801.00 - 801.99 CLOSED FRACTURE OF BASE OF SKULL WITHOUT INTRA CRANIAL INJURY WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OPEN FRACTURE OF BASE OF SKULL WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH CONCUSSION UNSPECIFIED
850.0 - 854.19 CONCUSSION WITH NO LOSS OF CONSCIOUSNESS - INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED
950.0 - 950.9 OPTIC NERVE INJURY - INJURY TO UNSPECIFIED OPTIC NERVE AND PATHWAYS
951.0 - 951.9 INJURY TO OCULOMOTOR NERVE - INJURY TO UNSPECIFIED CRANIAL NERVE
996.2 MECHANICAL COMPLICATION OF NERVOUS SYSTEM DEVICE IMPLANT AND GRAFT
997.1 NERVOUS SYSTEM COMPLICATION UNSPECIFIED
997.2 CENTRAL NERVOUS SYSTEM COMPLICATION
997.3 IATROGENIC CEREBROVASCULAR INFARCTION OR HEMORRHAGE
997.09 OTHER NERVOUS SYSTEM COMPLICATIONS
V10.85 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BRAIN
V10.86 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM
V10.88 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER ENDOCRINE GLANDS AND RELATED STRUCTURES
V45.2* POSTSURGICAL PRESENCE OF CEREBROSPINAL FLUID DRAINAGE DEVICE V67.1 FOLLOW-UP EXAMINATION FOLLOWING RADIOTHERAPY
V67.2 FOLLOW-UP EXAMINATION FOLLOWING CHEMOTHERAPY
* According to the ICD-9-CM book, diagnosis code V45.2 is a secondary diagnosis code and should not be billed as the primary diagnosis.
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
The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, reason for the test, and interpretive report and copies of all images obtained. The computerized data with image reconstruction should also be maintained.
The medical record must contain documentation, including a written or electronic request for the procedure which fully supports the medical necessity of the procedure performed. This documentation includes, but is not limited
to relevant medical history, physical examination, diagnosis (if known), pertinent signs and symptoms and results of pertinent diagnostic tests and/or procedures. This entire documentation-not just the test report or the findings/diagnosis on the order, must be made available to Medicare upon request.
When a CT scan and MRI are performed on the same day for the same anatomical area, the medical record must clearly reflect the medical necessity for performing both tests.
If the provider of the service is other than the ordering/referring physician/nonphysician practitioner, that provider must maintain documentation of test results and interpretation, along with copies of the ordering/referring physician/nonphysician practitioner’s order for the studies. The physician/nonphysician
practitioner must state the clinical indication/medical necessity for the study in his order for the test.
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 (2010). Practice guideline for communication of diagnostic imaging findings. Retrieved from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx
American College of Radiology (2006). Practice guideline for performing and interpreting magnetic resonance imaging (MRI). Retrieved from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx
American College of Radiology (2008). Practice guideline for performing and interpreting magnetic resonance imaging (MRI) of the brain. Retrieved from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx
Grainger & Allison’s Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed. (2001). Retrieved September 26, 2005, from http://home.mdconsult.com/das/book/body/407046686/1047/1683.html
Hasso, A., Drayer, B., Anderson, R., Braffman, B., Davis, P., Deck, M., Johnson, B., Masaryk, T., Pomeranz, S., Seidenwurm, D., Tanenbaum, L., Masdeu, J. (2000). Vertigo and hearing loss. American College of Radiology- ACR Appropriateness Criteria, 215, 471-478. This reference consulted for guidelines used in management of hearing loss to establish indications and limitations.
Sedwick, J., Gajewski, B., Prevatt, A., Antonelli, P. (2001). Magnetic resonance imaging in the search for retrocochlear pathology. Otolaryngology-Head and Neck Surgery, 124(6), 652-655. This source consulted for clinical study results.
Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from Florida Radiological Society.
Start Date of Comment Period
End Date of Comment Period
Start Date of Notice Period 05/01/2011
Revision History Number 3
Revision History Explanation Revision Number:3 Start Date of Comment Period:N/A
Start Date of Notice Period:10/01/2011 Revised Effective Date: 07/07/2011
LCR A2011-081
September 2011 Connection
Explanation of Revision: The Limitations section of the LCD has been revised to update language surrounding the coverage of MRI in patients with implantable pacemakers. CMS issued new language in the NCD for Pacemakers through Change Request 7441, transmittals 134 and 2293. These revisions are effective for claims processed on or after September 26, 2011 for dates of service on or after July 7, 2011.
Revision Number:2
Start Date of Comment Period:N/A Start Date of Notice Period:05/01/2011 Revised Effective Date:02/24/2011
LCR A2011-037
April 2011 Bulletin
Explanation of Revision: Under the “Documentation Requirements” section of the LCD, verbiage was updated to be in line with the guidelines used to develop the LCD. In addition, references were updated under the “Sources of Information and Basis for Decision” section of the LCD. The effective date of this LCD revision is based on date of service 04/05/2011. Under the “Indications and Limitations” section of the LCD, language was added according to instructions outlined in Change Request 7296, related to the National Coverage Determination (NCD) 220.2.Transmittal 132, dated 3/4/2011. Revisions related to CR 7296 will be effective for claims processed on or after April 4, 2011 for dates of service on or after 2/24/2011.
Revision Number:1
Start Date of Comment Period:N/A Start Date of Notice Period:11/30/2010 Revised Effective Date:01/14/2011
LCR A2010-055
December 2010 Bulletin
Explanation of Revision: Under the “ICD-9 Codes that support Medical Necessity” section of the LCD diagnosis codes, listed in the Part B LCD for “Magnetic Resonance Imaging of the Brain,” were added to the Part A LCD for consistency. 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-
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 (L28904) replaces LCD L1439 as the policy in notice. This document (L28904) is effective on 02/16/2009.
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 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 0611 was changed
08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.
Reason for Change
Related Documents
This LCD has no Related Documents.
LCD Attachments
Coding Guidelines effective 1/14/2011
All Versions
Updated on 09/23/2011 with effective dates 07/07/2011 - N/A Updated on 04/08/2011 with effective dates 02/24/2011 - 07/06/2011 Updated on 11/19/2010 with effective dates 01/14/2011 - 02/23/2011 Updated on 08/01/2010 with effective dates 02/16/2009 - N/A Updated on 08/01/2010 with effective dates 02/16/2009 - N/A Updated on 11/29/2008 with effective dates 02/16/2009 - N/A