L28906-LCD

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Automated World Health

Local Coverage Determination (LCD) for Magnetic Resonance Imaging of the Spine (L28906)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28906

LCD Title Magnetic Resonance Imaging of the Spine

Contractor's Determination Number A72141

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 Determination (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 represent quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-3, Medicare National Coverage Determinations, Chapter 1, Part 4, Section 220.2

CMS Manual System, Pub. 100-4, Medicare Claims Processing, Chapter 13, Sections 140-140.3

Change Request 7296, Transmittals 132 and 2171, dated March 4, 2011

Change Request 7441, Transmittals 134 and 2293, dated August 26, 2011 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 (known for causing hypersensitivity reactions and nephrotoxicity in susceptible patients) 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 spinal cord from intra- vertebral disc, tumor from normal tissue, and flowing blood within vascular structures.

MRI is able to image in multiple planes, a distinct advantage in the diagnosis of spinal cord and vertebral column anomalies. MRI is also superior to myelography, a riskier, more uncomfortable, and less informative procedure than MRI.

Medicare will consider Magnetic Resonance Imaging of the Spine medically reasonable and necessary when used to aid in the diagnosis and to assist in therapeutic decision making of the following:

• Lesions in the spinal cord;

• Syringomyelia;

• Spinal cord demyelination or inflammation;

• Tumors of the spine and spinal cord;

• Spinal cord infarcts;

• Spinal trauma;

• Discitis and osteomyelitis;

• Epidural abscess;

• Spinal dysraphism and other developmental abnormalities of the spine;

• Spinal stenosis;

• Spinal cord compression and post-operative scarring;

• Herniation of disc;

• Where soft tissue contrast is necessary;

• When bone artifacts limit CT, or coronal, coronosagittal or parasagittal images are desired; and/or

• 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

014x Hospital - Laboratory Services Provided to Non-patients

021x Skilled Nursing - Inpatient (Including Medicare Part A)

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

023x Skilled Nursing - 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

0612 Magnetic Resonance Technology (MRT) - MRI - Spinal Cord/Spine

CPT/HCPCS Codes

72141 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL

72142 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITH CONTRAST MATERIAL(S)

72146 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL

72147 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITH CONTRAST MATERIAL(S)

72148 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL

72149 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITH CONTRAST MATERIAL(S)

72156 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL

72157 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC

72158 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR

ICD-9 Codes that Support Medical Necessity

The following ICD-9 codes are allowed to establish a diagnosis or monitor treatment:

015.00 - 015.06 TUBERCULOSIS OF VERTEBRAL COLUMN UNSPECIFIED EXAMINATION - TUBERCULOSIS OF VERTEBRAL COLUMN TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)

170.2 MALIGNANT NEOPLASM OF VERTEBRAL COLUMN EXCLUDING SACRUM AND COCCYX

170.6 MALIGNANT NEOPLASM OF PELVIC BONES SACRUM AND COCCYX

195.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES

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

198.89 SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES

200.00 - 208.92 RETICULOSARCOMA UNSPECIFIED SITE - UNSPECIFIED LEUKEMIA, IN RELAPSE

213.2 BENIGN NEOPLASM OF VERTEBRAL COLUMN EXCLUDING SACRUM AND COCCYX

213.6 BENIGN NEOPLASM OF PELVIC BONES SACRUM AND COCCYX

215.7 OTHER BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF TRUNK UNSPECIFIED

225.3 - 225.4 BENIGN NEOPLASM OF SPINAL CORD - BENIGN NEOPLASM OF SPINAL MENINGES

228.1 - 228.2 HEMANGIOMA OF UNSPECIFIED SITE - LYMPHANGIOMA ANY SITE

229.0 - 229.9 BENIGN NEOPLASM OF LYMPH NODES - BENIGN NEOPLASM OF UNSPECIFIED SITE

238.0 - 238.2 NEOPLASM OF UNCERTAIN BEHAVIOR OF BONE AND ARTICULAR CARTILAGE - NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN

239.89 NEOPLASMS OF UNSPECIFIED NATURE, OTHER SPECIFIED SITES

320.0 - 320.9 HEMOPHILUS MENINGITIS - MENINGITIS DUE TO UNSPECIFIED BACTERIUM

321.0 - 321.8 CRYPTOCOCCAL MENINGITIS - MENINGITIS DUE TO OTHER NONBACTERIAL ORGANISMS CLASSIFIED ELSEWHERE

322.0 - 322.9 NONPYOGENIC MENINGITIS - MENINGITIS UNSPECIFIED

324.1 INTRASPINAL ABSCESS

324.9 INTRACRANIAL AND INTRASPINAL ABSCESS OF UNSPECIFIED SITE

335.0 - 335.9 WERDNIG-HOFFMANN DISEASE - ANTERIOR HORN CELL DISEASE UNSPECIFIED

336.0 - 336.9 SYRINGOMYELIA AND SYRINGOBULBIA - UNSPECIFIED DISEASE OF SPINAL CORD

337.00 - 337.9 IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY, UNSPECIFIED - UNSPECIFIED DISORDER OF AUTONOMIC NERVOUS SYSTEM

340 MULTIPLE SCLEROSIS

341.0 - 341.9 NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED

344.00 - 344.9 QUADRIPLEGIA UNSPECIFIED - PARALYSIS UNSPECIFIED

353.0 - 353.4 BRACHIAL PLEXUS LESIONS - LUMBOSACRAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED

353.8 OTHER NERVE ROOT AND PLEXUS DISORDERS

353.9 UNSPECIFIED NERVE ROOT AND PLEXUS DISORDER

357.0 ACUTE INFECTIVE POLYNEURITIS

715.18 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING OTHER SPECIFIED SITES

715.28 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING OTHER SPECIFIED SITES

715.38 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING OTHER SPECIFIED SITES

720.0 - 720.9 ANKYLOSING SPONDYLITIS - UNSPECIFIED INFLAMMATORY SPONDYLOPATHY

721.0 - 721.91 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY - SPONDYLOSIS OF UNSPECIFIED SITE WITH MYELOPATHY

722.0 - 722.93 DISPLACEMENT OF CERVICAL INTERVERTEBRAL DISC WITHOUT MYELOPATHY - OTHER AND UNSPECIFIED DISC DISORDER OF LUMBAR REGION

723.0 - 723.4 SPINAL STENOSIS IN CERVICAL REGION - BRACHIAL NEURITIS OR RADICULITIS NOS

723.9 UNSPECIFIED MUSCULOSKELETAL DISORDERS AND SYMPTOMS REFERABLE TO NECK

724.00 - 724.70 SPINAL STENOSIS OF UNSPECIFIED REGION - UNSPECIFIED DISORDER OF COCCYX

724.9 OTHER UNSPECIFIED BACK DISORDERS

730.08 ACUTE OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES

730.18 CHRONIC OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES

730.28 UNSPECIFIED OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES

730.98 UNSPECIFIED INFECTION OF BONE OF OTHER SPECIFIED SITES

733.00 - 733.9 OSTEOPOROSIS UNSPECIFIED - OTHER OSTEOPOROSIS

733.10 PATHOLOGICAL FRACTURE UNSPECIFIED SITE

733.13 PATHOLOGICAL FRACTURE OF VERTEBRAE

733.40 ASEPTIC NECROSIS OF BONE SITE UNSPECIFIED

737.10 KYPHOSIS (ACQUIRED) (POSTURAL)

737.30 - 737.9 SCOLIOSIS (AND KYPHOSCOLIOSIS) IDIOPATHIC - UNSPECIFIED CURVATURE OF SPINE ASSOCIATED WITH OTHER CONDITIONS

738.4 ACQUIRED SPONDYLOLISTHESIS

738.5 OTHER ACQUIRED DEFORMITY OF BACK OR SPINE

739.1 - 739.4 NONALLOPATHIC LESIONS OF CERVICAL REGION NOT ELSEWHERE CLASSIFIED - NONALLOPATHIC LESIONS OF SACRAL REGION NOT ELSEWHERE CLASSIFIED

741.00 - 741.93 SPINA BIFIDA UNSPECIFIED REGION WITH HYDROCEPHALUS - SPINA BIFIDA LUMBAR

REGION WITHOUT HYDROCEPHALUS

742.51 - 742.59 DIASTEMATOMYELIA - OTHER SPECIFIED CONGENITAL ANOMALIES OF SPINAL CORD

742.9 UNSPECIFIED CONGENITAL ANOMALY OF BRAIN SPINAL CORD AND NERVOUS SYSTEM

756.10 - 756.19 CONGENITAL ANOMALY OF SPINE UNSPECIFIED - OTHER CONGENITAL ANOMALIES OF SPINE

781.0 - 781.99 ABNORMAL INVOLUNTARY MOVEMENTS - OTHER SYMPTOMS INVOLVING NERVOUS AND MUSCULOSKELETAL SYSTEMS

792.0 NONSPECIFIC ABNORMAL FINDINGS IN CEREBROSPINAL FLUID

793.91 IMAGE TEST INCONCLUSIVE DUE TO EXCESS BODY FAT

793.99 OTHER NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF BODY STRUCTURE

794.10 NONSPECIFIC ABNORMAL RESPONSE TO UNSPECIFIED NERVE STIMULATION

794.17 NONSPECIFIC ABNORMAL ELECTROMYOGRAM (EMG)

796.1 ABNORMAL REFLEX

805.00 - 805.9 CLOSED FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL - OPEN FRACTURE OF UNSPECIFIED PART OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY

806.00 - 806.9 CLOSED FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY

839.00 - 839.59 CLOSED DISLOCATION CERVICAL VERTEBRA UNSPECIFIED - OPEN DISLOCATION OTHER VERTEBRA

952.00 - 952.9 C1-C4 LEVEL SPINAL CORD INJURY UNSPECIFIED - UNSPECIFIED SITE OF SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

953.0 - 953.9 INJURY TO CERVICAL NERVE ROOT - INJURY TO UNSPECIFIED SITE OF NERVE ROOTS AND SPINAL PLEXUS

V10.81 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BONE

V10.86 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM

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, that provider must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician’s

order for the study. The physician must state the clinical indication/medical necessity for the study in his order for the test.

Appendices

Utilization Guidelines N/A

Sources of Information and Basis for Decision

American College of Physicians: Position paper: Magnetic resonance imaging of the brain and spine. Annals of Internal Medicine, 120(10), 872-75.

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-American Society of Neuroradiology (2006). Practice guideline for the performance of magnetic resonance imaging (MRI) of the adult spine. Retrieved from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx

American College of Radiology. (2002). Suspected Cervical Spine Trauma, ACR Appropriateness Criteria. [On- line] Available at http://www.acr.org/ac_pda.

American Journal of Neuroradiology. (2003). Nomenclature and Classification of Lumbar Disc Pathology. [On-line] Available at http://www.asnr.org/spine_nomenclature/Discterms-dec_14.shtml.

Eck, J.C., Hodges, S.D., Humphreys, S.C. (2002). Radiologic Decision-Making. American Family Physician, 65(11): 2299-306.

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 A2011-082

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 A2011-039

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 A2010-054

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 Spine,” were added to this 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 (L28906) replaces LCD L1444 as the policy in notice. This document (L28906) 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 14 was changed 8/1/2010 - The description for Bill Type Code 21 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 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 0612 was changed

Reason for Change