L29219-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Magnetic Resonance Imaging (MRI)

of Any Joint of the Lower Extremities (L29219)

Contractor Information

Contractor Name

First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29219

LCD Title

Magnetic Resonance Imaging (MRI) of Any Joint of the Lower Extremities

Contractor's Determination Number 73721

Primary Geographic Jurisdiction opens in new window

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 02/02/2009

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 other wise specified, italicized text represents quotation from one or more of the following CMS sources: Medicare National Coverage Determinations Manual Chapter 1-220.2

CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.6 - 80.6.4

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.

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.

MRI can enhance diagnostic sensitivity and facilitate early diagnosis in a limited number of articular disorders and is indicated in selected circumstances when conventional radiography is not adequate.

Medicare will consider MRI of any joint of the lower extremities (73721-73723) medically reasonable and necessary under the following conditions:

• Avascular necrosis;

• Osteomyelitis;

• Intraarticular derangement; and

• Villonodular synovitis. Contraindications and non-covered uses

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.

• Patients with a viable pregnancy.

• Patients with devices containing ferromagnetic materials.

• Patients who are claustrophobic. 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.

999x Not Applicable

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

73721 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL

73722 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITH CONTRAST MATERIAL(S)

73723 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES

ICD-9 Codes that Support Medical Necessity

170.7 - 170.8

MALIGNANT NEOPLASM OF LONG BONES OF LOWER LIMB - MALIGNANT NEOPLASM OF SHORT BONES OF LOWER LIMB

171.3 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF LOWER LIMB INCLUDING HIP

198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW

213.7 - 213.8 opens in new window 238.0 - 238.1

BENIGN NEOPLASM OF LONG BONES OF LOWER LIMB - BENIGN NEOPLASM OF SHORT BONES OF LOWER LIMB

NEOPLASM OF UNCERTAIN BEHAVIOR OF BONE AND ARTICULAR CARTILAGE - NEOPLASM OF UNCERTAIN BEHAVIOR OF CONNECTIVE AND OTHER SOFT TISSUE

457.1 OTHER LYMPHEDEMA

682.6 CELLULITIS AND ABSCESS OF LEG EXCEPT FOOT

714.0 - 714.9 RHEUMATOID ARTHRITIS - UNSPECIFIED INFLAMMATORY POLYARTHROPATHY

715.15 -715.17

715.25 -715.27

715.35 -715.37

716.05 -716.07

717.0 - 717.9

OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING PELVIC REGION AND THIGH -

OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING ANKLE AND FOOT

OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING PELVIC REGION AND THIGH - OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING ANKLE AND FOOT

OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING PELVIC REGION AND THIGH - OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING ANKLE AND FOOT

KASCHIN-BECK DISEASE INVOLVING PELVIC REGION AND THIGH - KASCHIN-BECK DISEASE INVOLVING ANKLE AND FOOT

OLD BUCKET HANDLE TEAR OF MEDIAL MENISCUS - UNSPECIFIED INTERNAL DERANGEMENT OF KNEE

718.05 ARTICULAR CARTILAGE DISORDER INVOLVING PELVIC REGION AND THIGH

718.07 ARTICULAR CARTILAGE DISORDER INVOLVING ANKLE AND FOOT

718.15 LOOSE BODY IN JOINT OF PELVIC REGION AND THIGH

718.17 LOOSE BODY IN ANKLE AND FOOT JOINT

PATHOLOGICAL DISLOCATION OF JOINT OF PELVIC REGION AND THIGH - PATHOLOGICAL DISLOCATION OF ANKLE AND FOOT JOINT

718.25 -718.27

718.35 -718.37

718.45 -718.47

718.55 -718.57

RECURRENT DISLOCATION OF JOINT OF PELVIC REGION AND THIGH - RECURRENT DISLOCATION OF ANKLE AND FOOT JOINT

CONTRACTURE OF JOINT OF PELVIC REGION AND THIGH - CONTRACTURE OF ANKLE AND FOOT JOINT

ANKYLOSIS OF JOINT OF PELVIC REGION AND THIGH - ANKYLOSIS OF ANKLE AND FOOT JOINT

718.65 UNSPECIFIED INTRAPELVIC PROTRUSION OF ACETABULUM PELVIC REGION AND THIGH

718.85 -718.87

OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING PELVIC REGION AND THIGH - OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING ANKLE AND FOOT

718.95 UNSPECIFIED DERANGEMENT OF JOINT OF PELVIC REGION AND THIGH

718.97 UNSPECIFIED DERANGEMENT OF ANKLE AND FOOT JOINT

719.05 -719.07

719.25 -719.27

EFFUSION OF JOINT OF PELVIC REGION AND THIGH - EFFUSION OF ANKLE AND FOOT JOINT

VILLONODULAR SYNOVITIS INVOLVING PELVIC REGION AND THIGH - VILLONODULAR SYNOVITIS INVOLVING ANKLE AND FOOT

719.45 PAIN IN JOINT INVOLVING PELVIC REGION AND THIGH

719.46 PAIN IN JOINT INVOLVING LOWER LEG

719.47 PAIN IN JOINT INVOLVING ANKLE AND FOOT

726.60 -726.69

726.70 -726.79

ENTHESOPATHY OF KNEE UNSPECIFIED - OTHER ENTHESOPATHY OF KNEE

ENTHESOPATHY OF ANKLE AND TARSUS UNSPECIFIED - OTHER ENTHESOPATHY OF ANKLE AND TARSUS

727.06 TENOSYNOVITIS OF FOOT AND ANKLE

727.42 GANGLION OF TENDON SHEATH

727.51 SYNOVIAL CYST OF POPLITEAL SPACE

727.60 NONTRAUMATIC RUPTURE OF UNSPECIFIED TENDON

727.65 -727.68

730.05 -730.07

730.15 -730.17

733.14 -733.16

733.42 -733.44

835.00 -838.16

843.0 - 845.19

NONTRAUMATIC RUPTURE OF QUADRICEPS TENDON - NONTRAUMATIC RUPTURE OF OTHER TENDONS OF FOOT AND ANKLE

ACUTE OSTEOMYELITIS INVOLVING PELVIC REGION AND THIGH - ACUTE OSTEOMYELITIS INVOLVING ANKLE AND FOOT

CHRONIC OSTEOMYELITIS INVOLVING PELVIC REGION AND THIGH - CHRONIC OSTEOMYELITIS INVOLVING ANKLE AND FOOT

PATHOLOGICAL FRACTURE OF NECK OF FEMUR - PATHOLOGICAL FRACTURE OF TIBIA OR FIBULA

ASEPTIC NECROSIS OF HEAD AND NECK OF FEMUR - ASEPTIC NECROSIS OF TALUS CLOSED DISLOCATION OF HIP UNSPECIFIED SITE - OPEN DISLOCATION OF

INTERPHALANGEAL (JOINT) FOOT

in new window ILIOFEMORAL (LIGAMENT) SPRAIN - OTHER FOOT SPRAIN

924.00 - 924.9 opens

in new window CONTUSION OF THIGH - CONTUSION OF UNSPECIFIED SITE

928.00 - 928.9 opens

in new window CRUSHING INJURY OF THIGH - CRUSHING INJURY OF UNSPECIFIED SITE OF LOWER LIMB

959.6 - 959.7 opens in new window

OTHER AND UNSPECIFIED INJURY TO HIP AND THIGH - OTHER AND UNSPECIFIED INJURY TO KNEE LEG ANKLE AND FOOT

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.

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).

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.

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

Brigham and Women’s Hospital. Lower extremity musculoskeletal disorders. A guide to diagnosis and treatment. Boston (MA): Brigham and Women’s Hospital; 2003. 11p. [12 references]

Hospital For Special Surgery (2004). Ultrasound and MRI in the Early Diagnosis of Joint Damage in RA. Available: www.hss.edu/professionals/conditions/RheumatoidArthritis/ultrasound-and-mri-in-early-ra [2004, November 5]

Kee, J. (1999). Laboratory & Diagnostic Tests. Stamford: Appleton & Lange.

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:10/01/2011 Revised Effective Date: 07/07/2011

LCR B2011-106

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: 1

Start Date of Comment Period:N/A Start Date of Notice Period:05/01/2011 Revised Effective Date: 02/24/2011

LCR B2011-055

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 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: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 (L29219) replaces LCD L5851 as the policy in notice. This document (L29219) is effective on 02/02/2009.

Reason for Change