L29121-LCD

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Local Coverage Determination (LCD) for Computed Tomography Scans of the Head or Brain (L29121)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29121

LCD Title Computed Tomography Scans of the Head or Brain

Contractor's Determination Number 70450

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

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 02/02/2009 Original Determination Ending Date

Revision Effective Date

For services performed on or after 04/05/2011 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. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.6 - 80.6.4

CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations, Chapter 1, Section 220.1

Indications and Limitations of Coverage and/or Medical Necessity

Computed Tomography is the recording of internal body images at a pre-determined plane by x-ray. Computed tomography, or CT scans, involve the measurement of the emergent x-ray beam by a scintillation counter. The electronic pulses are recorded on a magnetic disk and then processed by a minicomputer for reconstruction display of the body in cross-section on an electronic display.

Computed Tomography Scans head of brain:

Medicare will consider a computed tomography scan of the head or brain to be medically reasonable and necessary based on the American College of Radiology guidelines when performed to establish a diagnosis or to monitor treatment for the following conditions:

• Acute head trauma

• Suspected acute intracranial hemorrhage

• Detection or evaluation of calcification

• Immediate postoperative evaluation for surgical treatment of tumor or for surgical treatment of hemorrhage or hemorrhagic lesions

• Shunted hydrocephalus, or shunt revision

• Mental status change

• Increased intracranial pressure

• Treated/untreated vascular lesions

• Acute neurologic deficits

• Suspected intracranial infection

• Suspected hydrocephalus

• Congenital lesions (such as, but not limited to, craniosynotosis, macrocephaly, and microcephaly)

• Evaluating psychiatric disorders

• Brain herniation

• Suspected mass or tumor

• Evaluation prior to MR to detect presence of metallic objects that would constitute a contraindication to MR evaluation. (This should be used to detect small metallic objects in an at-risk patient that would be too small or inadequate to detect with plain film evaluation.)

Coverage for headache should only be for the following situations:

• Patient suffering from headaches after a head injury.

• Patient suffering from headaches unusual in duration and not responding to medical therapy or those that are considered unusual in duration, character, severity or suddenness of onset.

Generally, a CT scan should only be considered for the evaluation of a headache after a history and physical exam has been performed.

When MR imaging is unavailable or contraindicated, or if the supervising physician deems CT to be appropriate, Medicare will consider CT to be medically necessary for the following secondary indications:

• Diplopia

• Cranial nerve dysfunction

• Seizures

• Apnea

• Syncope

• Ataxia (including dizziness and vertigo)

• Suspicion of neurodegenerative disease

• Developmental delay

• Neuroendocrine dysfunction

• Encephalitis

• Vascular occlusive disease or vasculitis (including use of CT angiography and/or venography

• Aneurysm

• Drug toxicity

• Cortical dysplasia

• Migration anomalies or other morphologic brain abnormalities

• Sinusitis

• Hearing loss and other otolaryngologic presentations, whose evaluation reaches the level of requiring such imaging

• Non-traumatic neurological central deficit with suspicion of infarction or bleeding

• Foreign body

• Thyroid ophthalmopathy/proptosis

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.

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.

99999 Not Applicable

CPT/HCPCS Codes

70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL

70460 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S)

70470 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS

ICD-9 Codes that Support Medical Necessity N/A

XX000 Not Applicable

Diagnoses that Support Medical Necessity N/A

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

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.

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

Rules for Testing Facility to Furnish Additional Tests:

If the testing facility cannot reach the treating physician/practitioner to change the order or obtain a new order and documents this in the medical record, then the testing facility may furnish the additional diagnostic test if all of the following criteria apply:

• The testing center performs the diagnostic test ordered by the treating physician/practitioner;

• The interpreting physician at the testing facility determines and documents that, because of the abnormal result of the diagnostic test performed, an additional diagnostic test is medically necessary;

• Delaying the performance of the additional diagnostic test would have an adverse effect on the care of the beneficiary;

• The result of the test is communicated to and is used by the treating physician/practitioner in the treatment of the beneficiary; and

• The interpreting physician at the testing facility documents in his/her report why additional testing was done.

Rules for Testing Facility Interpreting Physician to Furnish Different or Additional Tests:

The following applies to an interpreting physician of a testing facility who furnishes a diagnostic test to a beneficiary who is not a hospital inpatient or outpatient. The interpreting physician must document accordingly in his/her report to the treating physician/practitioner.

Test Design:

Unless specified in the order, the interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test (e.g., number of radiographic views obtained, thickness or tomographic sections acquired, use or non-use of contrast media).

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 Emergency Physicians. (2002). Clinical policy Critical issues in the evaluation and management of patients presenting to the emergency department with acute headache. Annals Emergency Medicine, 39:108-122.

American College of Radiology (2010). Practice guideline for communication of diagnostic imaging findings. Retreived from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx

American College of Radiology. (2009). Practice guideline for the performance of computed tomography (CT) of the brain. Retrieved August 9, 2010,from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/head-neck/ct_brain.aspx

American College of Radiology. (2001). Practice guidelines for the performance of computed tomography (CT) of the extra-cranial head and neck in adults and children.

American College of Radiology (2010). Practice guideline for communication of diagnostic imaging findings. Retreived from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx

National Guideline Clearinghouse. (2005). Clinical policy: critical issues in the evaluation and management of patients presenting to the emergency department with acute headache.

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 numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 05/01/2011

Revision History Number 2

Revision History Explanation Revision Number:2 Start Date of Comment Period:N/A

Start Date of Notice Period:05/01/2011 Revision Effective Date:04/05/2011

LCR B2011-048

April 2011 Update

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 revision is based on date of service.

Revision Number1

Start Date of Comment Period:N/A Start Date of Notice Period:09/01/2010 Revision Effective Date 08/17/2010

LCR B2010-069

August 2010 Update

Explanation of Revision: Under the “Documentation Requirements” section of the LCD, CMS language was updated regarding rules for different or additional tests. In addition, references were updated under “The CMS National Coverage Policy” section, and 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.

Revision Number:Original

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

LCR B2009-

December 2008 Bulletin

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

For Florida (00590) this LCD (L29121) replaces LCD L6165 as the policy in notice. This document (L29121) is effective on 02/02/2009.

Reason for Change