L28907-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Magnetic Resonance Imaging of Upper Extremity (L28907)

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.

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number

09101

Contractor Type

MAC - Part A

LCD Information

Document Information

LCD ID Number L28907

LCD Title Magnetic Resonance Imaging of Upper Extremity

Contractor's Determination Number A73218

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 other wise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub 100-03, Medicare National Coverage Determinations Chapter 1, Part 3, Section 220.2

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 a non-invasive imaging technique used for a variety of diagnostic visualizations. 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 process employs the magnetic properties of the hydrogen nucleus (proton) and its interaction with strong external magnetic fields and radio frequency pulses. The patient is placed in a strong magnetic field and radio frequency pulses are transmitted into the patient in an extremely controlled and defined manner. The protons within the patient will subsequently emit a radio frequency signal, which is processed by a computer to produce an image.

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. Its major disadvantages over CT include longer scanning times, which make MRI less useful in emergency evaluations. The use of MRI on certain soft tissue structures for the purpose of detecting disruptive, neoplastic, degenerative, or inflammatory lesions has now become established in medical practice.

Medicare will consider MRI of the upper extremity CPT codes (73218-73223) medically reasonable and necessary under the following conditions:

Indications:

Soft Tissues

• Evaluating soft tissue masses and subtle bone injuries.

• Evaluation of traumatic muscle and tendon injuries, hematomas, compartment syndromes, entrapment syndromes, tendinosis, tenosynovitis, and bursitis.

• Evaluation of infections, abscesses and myositis.

• Evaluation of masses such as simple non-neoplastic cysts, abscesses, ganglion cysts, paramensical cysts, hematomas, muscle tears, and ligament and tendon tears.

• Detection, staging, and characterization of benign and malignant soft tissue neoplasms and for the follow-up evaluation of neoplastic disease and therapy.

Bones

• In trauma, for the evaluation of suspected x-ray occult injuries of the metaphysis and epiphysis and to assess fracture union.

• To detect and size acute and chronic osteomyelitis and to evaluate perioprosthetic infections in selected cases.

• To detect and stage primary bone tumors, both non-neoplastic and neoplastic (Please also consider whether follow-up for local recurrence of bone tumor should also be included).

• To detect and stage occult bony metastases.

Joints – Diseases affecting all joints. MRI can be used to evaluate the following:

• Pain or loss of function of undetermined etiology.

• Joint instability and internal derangement.

• Selected articular cartilage injuries.

• Degenerated joint disease.

• Traumatic injuries to joints and adjacent muscles, tendons, and ligaments

• Articular cartilage injuries

• Bursitis and synovitis from overuse, fragment stability and cartilage status in osteochondritis dissecans

• Posttraumatic osteonecrosis and degenerative joint disease

• Loose bodies, and tenosynovitis

• Joint infections (noninfectious inflammatory joint disease such as rheumatoid and the seronegative arthritis, overuse synovitis, tenosynovitis, and tendonopathy)

• Ganglion cysts, bursal cysts with bursitis, abscesses, benign neoplastic masses, and primary and metastatic masses

• Osteonecrosis including avascular necrosis, and degenerative joint disease

Elbow Joints MRI can be used in the evaluation of:

• Medical epicondylitis (tennis elbow)

• Fractures in children

• Osteochondral defects, and osteonecrosis

• Evaluation of suspected collateral ligament teat and suspected biceps tendon teat and/or bursitis

Wrist, Hand, and Fingers MRI can be used in the detection and evaluation of:

• Carpal tunnel syndrome

• Tendon and ligamentous injuries

• Triangular fibrocartilage injuries

• Extensor and flexor tenosynovitis

• De Quervain’s syndrome

• Keinbach’s disease

• Injuries of the flexor and extensor tendons

• Tenosynovitis and masses

Limitations of Coverage

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.

2. Nationally Noncovered Indications

The 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 Social Security Act, and are therefore noncovered.

Coverage is limited to MRI units that have FDA premarket approval, and such units must be operated within the parameters specified by the approval. In addition, the services must be reasonable and necessary for the diagnosis or treatment of the specific patient involved.

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

0610 Magnetic Resonance Technology (MRT) - General Classification

0619 Magnetic Resonance Technology (MRT) - Other MRT

CPT/HCPCS Codes

73218 MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)

73219 MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITH CONTRAST MATERIAL(S)

73220 MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES

73221 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S)

73222MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITH CONTRAST MATERIAL(S)

73223 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES

ICD-9 Codes that Support Medical Necessity

003.24 SALMONELLA OSTEOMYELITIS

115.10 - 115.19 INFECTION BY HISTOPLASMA DUBOISII WITHOUT MANIFESTATION - INFECTION BY HISTOPLASMA DUBOISII WITH OTHER MANIFESTATION

170.4 MALIGNANT NEOPLASM OF SCAPULA AND LONG BONES OF UPPER LIMB

170.5 MALIGNANT NEOPLASM OF SHORT BONES OF UPPER LIMB

170.9 MALIGNANT NEOPLASM OF BONE AND ARTICULAR CARTILAGE SITE UNSPECIFIED

171.0 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK

171.2 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF UPPER LIMB INCLUDING SHOULDER

171.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF CONNECTIVE AND OTHER SOFT TISSUE

172.6 MALIGNANT MELANOMA OF SKIN OF UPPER LIMB INCLUDING SHOULDER

173.60 - 173.69 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB, INCLUDING SHOULDER - OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB, INCLUDING SHOULDER

194.6 MALIGNANT NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA

195.4 MALIGNANT NEOPLASM OF UPPER LIMB

196.3 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF AXILLA AND UPPER LIMB

196.8 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF MULTIPLE SITES

196.9 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES SITE UNSPECIFIED

198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW

198.89 SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES

200.00 - 200.88 RETICULOSARCOMA UNSPECIFIED SITE - OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

201.00 - 201.98 HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE - HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES

202.00 - 202.98 NODULAR LYMPHOMA UNSPECIFIED SITE - OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES

203.00 - 203.82 MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE

208.90 UNSPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

208.92 UNSPECIFIED LEUKEMIA, IN RELAPSE

213.4 BENIGN NEOPLASM OF SCAPULA AND LONG BONES OF UPPER LIMB

213.5 BENIGN NEOPLASM OF SHORT BONES OF UPPER LIMB

213.9 BENIGN NEOPLASM OF BONE AND ARTICULAR CARTILAGE SITE UNSPECIFIED

215.2 OTHER BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF UPPER LIMB INCLUDING SHOULDER

215.8 OTHER BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF OTHER SPECIFIED SITES

216.6 BENIGN NEOPLASM OF SKIN OF UPPER LIMB INCLUDING SHOULDER

227.6 BENIGN NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA

228.1 LYMPHANGIOMA ANY SITE

232.6 CARCINOMA IN SITU OF SKIN OF UPPER LIMB INCLUDING SHOULDER

234.8 CARCINOMA IN SITU OF OTHER SPECIFIED SITES

237.3 NEOPLASM OF UNCERTAIN BEHAVIOR OF PARAGANGLIA NEUROFIBROMATOSIS UNSPECIFIED - OTHER NEUROFIBROMATOSIS

237.70 - 237.79 NEOPLASM OF UNCERTAIN BEHAVIOR OF PARAGANGLIA NEUROFIBROMATOSIS UNSPECIFIED - OTHER NEUROFIBROMATOSIS

238.1 NEOPLASM OF UNCERTAIN BEHAVIOR OF BONE AND ARTICULAR CARTILAGE

238.2 NEOPLASM OF UNCERTAIN BEHAVIOR OF CONNECTIVE AND OTHER SOFT TISSUE

238.71 - 238.79 ESSENTIAL THROMBOCYTHEMIA - OTHER LYMPHATIC AND HEMATOPOIETIC TISSUES

239.2 NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN

239.7 NEOPLASM OF UNSPECIFIED NATURE OF ENDOCRINE GLANDS AND OTHER PARTS OF NERVOUS SYSTEM

274.00 - 274.03 GOUTY ARTHROPATHY, UNSPECIFIED - CHRONIC GOUTY ARTHROPATHY WITH TOPHUS (TOPHI)

333.84 ORGANIC WRITERS' CRAMP

353.0 BRACHIAL PLEXUS LESIONS

354.0 - 354.9 CARPAL TUNNEL SYNDROME - MONONEURITIS OF UPPER LIMB UNSPECIFIED

359.21 - 359.29 MYOTONIC MUSCULAR DYSTROPHY - OTHER SPECIFIED MYOTONIC DISORDER

359.3 PERIODIC PARALYSIS

359.71 INCLUSION BODY MYOSITIS

442.0 - 442.9 ANEURYSM OF ARTERY OF UPPER EXTREMITY - OTHER ANEURYSM OF UNSPECIFIED SITE

444.21 ARTERIAL EMBOLISM AND THROMBOSIS OF UPPER EXTREMITY

444.9 EMBOLISM AND THROMBOSIS OF UNSPECIFIED ARTERY

447.0 ARTERIOVENOUS FISTULA ACQUIRED

447.70 - 447.73 AORTIC ECTASIA, UNSPECIFIED SITE - THORACOABDOMINAL AORTIC ECTASIA

457.1 POSTMASTECTOMY LYMPHEDEMA SYNDROME

457.2 OTHER LYMPHEDEMA

682.3 CELLULITIS AND ABSCESS OF UPPER ARM AND FOREARM

696.0 PSORIATIC ARTHROPATHY

711.1 PYOGENIC ARTHRITIS INVOLVING SHOULDER REGION

711.2 PYOGENIC ARTHRITIS INVOLVING UPPER ARM

711.3 PYOGENIC ARTHRITIS INVOLVING FOREARM

711.4 PYOGENIC ARTHRITIS INVOLVING HAND

711.41 - 711.47 ARTHROPATHY INVOLVING SHOULDER REGION ASSOCIATED WITH OTHER BACTERIAL DISEASES - ARTHROPATHY INVOLVING ANKLE AND FOOT ASSOCIATED WITH OTHER BACTERIAL DISEASE

711.61 - 711.67 ARTHROPATHY INVOLVING SHOULDER REGION ASSOCIATED WITH MYCOSES - ARTHROPATHY INVOLVING ANKLE AND FOOT ASSOCIATED WITH MYCOSES

711.91 - 711.97 UNSPECIFIED INFECTIVE ARTHRITIS INVOLVING SHOULDER REGION - UNSPECIFIED INFECTIVE ARTHRITIS INVOLVING ANKLE AND FOOT

714.0 RHEUMATOID ARTHRITIS

714.30 CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS

714.31 ACUTE POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS

714.9 UNSPECIFIED INFLAMMATORY POLYARTHROPATHY

715.00 OSTEOARTHROSIS GENERALIZED INVOLVING UNSPECIFIED SITE

715.04 OSTEOARTHROSIS GENERALIZED INVOLVING HAND

715.09 OSTEOARTHROSIS GENERALIZED INVOLVING MULTIPLE SITES

715.11 - 715.14 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING SHOULDER REGION -OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING HAND

715.20 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING UNSPECIFIED SITE

715.21 - 715.24 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING SHOULDER REGION -OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING HAND

715.30 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING UNSPECIFIED SITE

715.31 - 715.34 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING SHOULDER REGION - OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING HAND

715.80 OSTEOARTHROSIS INVOLVING OR WITH MORE THAN ONE SITE BUT NOT SPECIFIED AS GENERALIZED AND INVOLVING UNSPECIFIED SITE

715.89 OSTEOARTHROSIS INVOLVING OR WITH MULTIPLE SITES BUT NOT SPECIFIED AS GENERALIZED

715.90 - 715.94 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING UNSPECIFIED SITE - OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING HAND

715.98 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING OTHER SPECIFIED SITES

716.11 - 716.14 TRAUMATIC ARTHROPATHY INVOLVING SHOULDER REGION - TRAUMATIC ARTHROPATHY INVOLVING HAND

716.81 - 716.89 OTHER SPECIFIED ARTHROPATHY INVOLVING SHOULDER REGION - OTHER SPECIFIED ARTHROPATHY INVOLVING MULTIPLE SITES

716.91 - 716.99 UNSPECIFIED ARTHROPATHY INVOLVING SHOULDER REGION - UNSPECIFIED ARTHROPATHY INVOLVING MULTIPLE SITES

718.1 ARTICULAR CARTILAGE DISORDER SITE UNSPECIFIED

718.2 - 718.04 ARTICULAR CARTILAGE DISORDER INVOLVING SHOULDER REGION - ARTICULAR CARTILAGE DISORDER INVOLVING HAND

718.8 ARTICULAR CARTILAGE DISORDER INVOLVING OTHER SPECIFIED SITES

718.9 ARTICULAR CARTILAGE DISORDER INVOLVING MULTIPLE SITES

718.10 LOOSE BODY IN JOINT SITE UNSPECIFIED

718.11 - 718.14 LOOSE BODY IN JOINT OF SHOULDER REGION - LOOSE BODY IN HAND JOINT

718.18 LOOSE BODY IN JOINT OF OTHER SPECIFIED SITES

718.19 LOOSE BODY IN JOINT OF MULTIPLE SITES

718.20 - 718.24 PATHOLOGICAL DISLOCATION OF JOINT SITE UNSPECIFIED - PATHOLOGICAL DISLOCATION OF HAND JOINT

718.29 PATHOLOGICAL DISLOCATION OF JOINT OF MULTIPLE SITES

718.30 - 718.34 RECURRENT DISLOCATION OF JOINT SITE UNSPECIFIED - RECURRENT DISLOCATION OF HAND JOINT

718.39 RECURRENT DISLOCATION OF JOINT OF MULTIPLE SITES

718.40 - 718.44 CONTRACTURE OF JOINT SITE UNSPECIFIED - CONTRACTURE OF HAND JOINT

718.49 CONTRACTURE OF JOINT OF MULTIPLE SITES

718.50 - 718.54 ANKYLOSIS OF JOINT SITE UNSPECIFIED - ANKYLOSIS OF HAND JOINT

718.59 ANKYLOSIS OF JOINT OF MULTIPLE SITES

718.80 OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING UNSPECIFIED SITE

718.81 - 718.84 OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING SHOULDER REGION - OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING HAND

718.90 - 718.94 UNSPECIFIED DERANGEMENT OF JOINT SITE UNSPECIFIED - UNSPECIFIED DERANGEMENT OF HAND JOINT

718.98 UNSPECIFIED DERANGEMENT OF JOINT OF OTHER SPECIFIED SITES

719.1 EFFUSION OF JOINT OF SHOULDER REGION

719.2 EFFUSION OF UPPER ARM JOINT

719.3 EFFUSION OF FOREARM JOINT

719.4 EFFUSION OF HAND JOINT

719.11 - 719.14 HERARTHROSIS INVOLVING SHOULDER REGION - HEMARTHROSIS INVOLVING HAND

719.21 - 719.24 VILLONODULAR SYNOVITIS INVOLVING SHOULDER REGION - VILLONODULAR SYNOVITIS INVOLVING HAND

719.41 - 719.44 PAIN IN JOINT INVOLVING SHOULDER REGION - PAIN IN JOINT INVOLVING HAND STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING SHOULDER REGION - STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING ANKLE AND FOOT

719.51 - 719.57 STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING SHOULDER REGION - STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING ANKLE AND FOOT

719.61 - 719.67 OTHER SYMPTOMS REFERABLE TO JOINT OF SHOULDER REGION - OTHER SYMPTOMS REFERABLE TO ANKLE AND FOOT JOINT

719.81 - 719.87 OTHER SPECIFIED DISORDERS OF JOINT OF SHOULDER REGION - OTHER SPECIFIED DISORDERS OF ANKLE AND FOOT JOINT

726.0 ADHESIVE CAPSULITIS OF SHOULDER

726.10 - 726.19 DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION UNSPECIFIED - OTHER SPECIFIED DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION

726.2 OTHER AFFECTIONS OF SHOULDER REGION NOT ELSEWHERE CLASSIFIED

726.33 OLECRANON BURSITIS

726.4 ENTHESOPATHY OF WRIST AND CARPUS

727.00 SYNOVITIS AND TENOSYNOVITIS UNSPECIFIED

727.2 GIANT CELL TUMOR OF TENDON SHEATH

727.3 TRIGGER FINGER (ACQUIRED)

727.4 RADIAL STYLOID TENOSYNOVITIS

727.5 OTHER TENOSYNOVITIS OF HAND AND WRIST

727.40 SYNOVIAL CYST UNSPECIFIED

727.41 GANGLION OF JOINT

727.42 GANGLION OF TENDON SHEATH

727.51 SYNOVIAL CYST OF POPLITEAL SPACE

727.61 COMPLETE RUPTURE OF ROTATOR CUFF

727.62 NONTRAUMATIC RUPTURE OF TENDONS OF BICEPS (LONG HEAD)

727.63 NONTRAUMATIC RUPTURE OF EXTENSOR TENDONS OF HAND AND WRIST

727.64 NONTRAUMATIC RUPTURE OF FLEXOR TENDONS OF HAND AND WRIST

728.11 PROGRESSIVE MYOSITIS OSSIFICANS

728.12 TRAUMATIC MYOSITIS OSSIFICANS

728.19 OTHER MUSCULAR CALCIFICATION AND OSSIFICATION

728.86 NECROTIZING FASCIITIS

729.5 PAIN IN LIMB

729.71 NONTRAUMATIC COMPARTMENT SYNDROME OF UPPER EXTREMITY

730.01 - 730.04 ACUTE OSTEOMYELITIS INVOLVING SHOULDER REGION - ACUTE OSTEOMYELITIS INVOLVING HAND

730.08 ACUTE OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES

730.11 - 730.14 CHRONIC OSTEOMYELITIS INVOLVING SHOULDER REGION - CHRONIC OSTEOMYELITIS INVOLVING HAND

730.18 CHRONIC OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES

730.19 CHRONIC OSTEOMYELITIS INVOLVING MULTIPLE SITES

730.20 UNSPECIFIED OSTEOMYELITIS SITE UNSPECIFIED

730.21 - 730.24 UNSPECIFIED OSTEOMYELITIS INVOLVING SHOULDER REGION - UNSPECIFIED OSTEOMYELITIS INVOLVING HAND

730.91 - 730.94 UNSPECIFIED INFECTION OF BONE OF SHOULDER REGION - UNSPECIFIED INFECTION OF HAND BONE

731.0 OSTEITIS DEFORMANS WITHOUT BONE TUMOR

732.3 JUVENILE OSTEOCHONDROSIS OF UPPER EXTREMITY

732.9 UNSPECIFIED OSTEOCHONDROPATHY

733.00 - 733.09 OSTEOPOROSIS UNSPECIFIED - OTHER OSTEOPOROSIS

733.11 PATHOLOGICAL FRACTURE OF HUMERUS

733.12 PATHOLOGICAL FRACTURE OF DISTAL RADIUS AND ULNA

733.20 - 733.29 CYST OF BONE (LOCALIZED) UNSPECIFIED - OTHER BONE CYST

733.40 - 733.49 ASEPTIC NECROSIS OF BONE SITE UNSPECIFIED - ASEPTIC NECROSIS OF OTHER BONE SITES

733.81 MALUNION OF FRACTURE

733.82 NONUNION OF FRACTURE

733.90 DISORDER OF BONE AND CARTILAGE UNSPECIFIED

747.63 UPPER LIMB VESSEL ANOMALY

755.20 - 755.29 UNSPECIFIED REDUCTION DEFORMITY OF UPPER LIMB CONGENITAL - LONGITUDINAL DEFICIENCY PHALANGES COMPLETE OR PARTIAL

755.50 - 755.59 UNSPECIFIED ANOMALY OF UPPER LIMB CONGENITAL - OTHER CONGENITAL ANOMALIES OF UPPER LIMB INCLUDING SHOULDER GIRDLE

782.0 DISTURBANCE OF SKIN SENSATION

785.6 ENLARGEMENT OF LYMPH NODES

793.7 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF MUSCULOSKELETAL SYSTEM

795.4 OTHER NONSPECIFIC ABNORMAL HISTOLOGICAL FINDINGS

796.4 OTHER ABNORMAL CLINICAL FINDINGS

831.00 - 831.19 CLOSED DISLOCATION OF SHOULDER UNSPECIFIED SITE - OPEN DISLOCATION OF OTHER SITE OF SHOULDER

832.00 - 832.04 CLOSED DISLOCATION OF ELBOW UNSPECIFIED SITE - CLOSED LATERAL DISLOCATION OF ELBOW

832.10 - 832.14 OPEN DISLOCATION OF ELBOW UNSPECIFIED SITE - OPEN LATERAL DISLOCATION OF ELBOW

833.00 - 833.19 CLOSED DISLOCATION OF WRIST UNSPECIFIED PART - OPEN DISLOCATION OF OTHER PART OF WRIST

834.00 - 834.12 CLOSED DISLOCATION OF FINGER UNSPECIFIED PART - OPEN DISLOCATION INTERPHALANGEAL (JOINT) HAND

840.00 - 840.90 ACROMIOCLAVICULAR (JOINT) (LIGAMENT) SPRAIN - SPRAIN OF UNSPECIFIED SITE OF SHOULDER AND UPPER ARM

841.0 - 841.9 RADIAL COLLATERAL LIGAMENT SPRAIN - SPRAIN OF UNSPECIFIED SITE OF ELBOW AND FOREARM

842.00 - 842.19 SPRAIN OF UNSPECIFIED SITE OF WRIST - OTHER HAND SPRAIN

905.8 LATE EFFECT OF TENDON INJURY

909.2 LATE EFFECT OF RADIATION

927.00 - 927.9 CRUSHING INJURY OF SHOULDER REGION - CRUSHING INJURY OF UNSPECIFIED SITE OF UPPER LIMB

958.91 TRAUMATIC COMPARTMENT SYNDROME OF UPPER EXTREMITY

959.2 OTHER AND UNSPECIFIED INJURY TO SHOULDER AND UPPER ARM

959.3 OTHER AND UNSPECIFIED INJURY TO ELBOW FOREARM AND WRIST

959.4 OTHER AND UNSPECIFIED INJURY TO HAND EXCEPT FINGER

959.5 OTHER AND UNSPECIFIED INJURY TO FINGER

996.1 MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT

996.40 UNSPECIFIED MECHANICAL COMPLICATION OF INTERNAL ORTHOPEDIC DEVICE, IMPLANT, AND GRAFT

996.41 MECHANICAL LOOSENING OF PROSTHETIC JOINT

996.42 DISLOCATION OF PROSTHETIC JOINT

996.43 BROKEN PROSTHETIC JOINT IMPLANT

996.44 PERI-PROSTHETIC FRACTURE AROUND PROSTHETIC JOINT

996.45 PERI-PROSTHETIC OSTEOLYSIS

996.46 ARTICULAR BEARING SURFACE WEAR OF PROSTHETIC JOINT

996.47 OTHER MECHANICAL COMPLICATION OF PROSTHETIC JOINT IMPLANT

996.49 OTHER MECHANICAL COMPLICATION OF OTHER INTERNAL ORTHOPEDIC DEVICE, IMPLANT, AND GRAFT

996.62 INFECTION AND INFLAMMATORY REACTION DUE TO OTHER VASCULAR DEVICE IMPLANT AND GRAFT

996.90 - 996.94 COMPLICATIONS OF UNSPECIFIED REATTACHED EXTREMITY - COMPLICATIONS OF REATTACHED UPPER EXTREMITY OTHER AND UNSPECIFIED

999.2 OTHER VASCULAR COMPLICATIONS OF MEDICAL CARE NOT ELSEWHERE CLASSIFIED

999.31 - 999.39 OTHER AND UNSPECIFIED INFECTION DUE TO CENTRAL VENOUS CATHETER - INFECTION FOLLOWING OTHER INFUSION, INJECTION, TRANSFUSION, OR VACCINATION

V10.81 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BONE

V67.00 FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED SURGERY

V67.1 FOLLOW-UP EXAMINATION FOLLOWING RADIOTHERAPY

V67.2 FOLLOW-UP EXAMINATION FOLLOWING CHEMOTHERAPY

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

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.

Appendices

Utilization Guidelines N/A

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-Society of Skeletal Radiology (2007). Practice guideline for the performance of magnetic resonance imaging (MRI) of the wrist. Retrieved from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx

American College of Radiology-Society of Skeletal Radiology (2010). Practice guideline for the performance and interpretation of magnetic resonance imaging (MRI) of the shoulder. Retrieved from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx

American College of Radiology. (2000). ACR Appropriateness CriteriaTM Radiology, 215 (Suppl), 107-112, 225-

229, 299-302, 333-338, 339-343, 375-378, 597-605, 1029-1040. Source used for indications and limitations.

Goldman, L., & Bennett, C., (2000). Cecil Textbook of Medicine, (21st ed.). Philadelphia: W.B. Saunders. Source used to define further indications for intra-articular and periarticular soft tissue structures.

Magnetic Resonance Imaging Clinics of North America. (May, 2004). MR Imaging of Tumors and tumor-like lesions of the upper extremity, 12(2): 349-59.

Primary Care: Clinics In Office Practice. (2004). Rotator cuff injuries and treatment, 31, 807-829.

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 the advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 05/01/2011

Revision History Number 5

Revision History Explanation Revision Number:5 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2011 Revised Effective Date: 07/07/2011

LCR A2011-083

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:4

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. Added diagnosis code range 173.60-173.69. Changed individual diagnosis codes 999.31 and 999.32 to diagnosis code range 999.31-999.39, to include new diagnosis codes 999.32, 999.33, and 999.34. Deleted diagnosis code 173.6. 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:05/01/2011 Revised Effective Date: 02/24/2011

LCR A2011-041

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:2

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 Bulletin

Explanation of Revision: Annual 2011 ICD-9-CM Update. Changed diagnosis code range to 237.70-237.79 to add diagnosis codes 237.73 and 237.79. Added new diagnosis code range 447.70-447.73. The effective date of this revision is based on date of service.

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. Deleted diagnosis code 274.0. Added new diagnosis codes 274.00-274.03 and 359.71. Revised descriptors for diagnosis codes 793.7 and 996.43. 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 (L28907) replaces LCD L13718 as the policy in notice. This document (L28907) is effective on 02/16/2009.

08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update. 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 0610 was changed 8/1/2010 - The description for Revenue code 0619 was changed

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

Reason for Change