LCD/NCD Portal

L29219

 

MAGNETIC RESONANCE IMAGING (MRI) OF ANY JOINT OF THE LOWER EXTREMITIES

 

07/07/2011

 

Indications and Limitations of Coverage and/or Medical Necessity

 

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.

• 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:

o 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.

 

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 MALIGNANT NEOPLASM OF LONG BONES OF LOWER LIMB

170.8 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 BENIGN NEOPLASM OF LONG BONES OF LOWER LIMB

213.8 BENIGN NEOPLASM OF SHORT BONES OF LOWER LIMB

238.0 NEOPLASM OF UNCERTAIN BEHAVIOR OF BONE AND ARTICULAR CARTILAGE

238.1 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 RHEUMATOID ARTHRITIS

714.1 FELTY'S SYNDROME

714.2 OTHER RHEUMATOID ARTHRITIS WITH VISCERAL OR SYSTEMIC INVOLVEMENT

714.30 CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS

714.31 ACUTE POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS

714.32 PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS

714.33 MONOARTICULAR JUVENILE RHEUMATOID ARTHRITIS

714.4 CHRONIC POSTRHEUMATIC ARTHROPATHY

714.81 RHEUMATOID LUNG

714.89 OTHER SPECIFIED INFLAMMATORY POLYARTHROPATHIES

714.9 UNSPECIFIED INFLAMMATORY POLYARTHROPATHY

715.15 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING PELVIC REGION AND THIGH

715.16 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING LOWER LEG

715.17 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING ANKLE AND FOOT

715.25 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING PELVIC REGION AND THIGH

715.26 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING LOWER LEG

715.27 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING ANKLE AND FOOT

715.35 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING PELVIC REGION AND THIGH

715.36 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING LOWER LEG

715.37 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING ANKLE AND FOOT

716.05 KASCHIN-BECK DISEASE INVOLVING PELVIC REGION AND THIGH

716.06 KASCHIN-BECK DISEASE INVOLVING LOWER LEG

716.07 KASCHIN-BECK DISEASE INVOLVING ANKLE AND FOOT

717.0 OLD BUCKET HANDLE TEAR OF MEDIAL MENISCUS

717.1 DERANGEMENT OF ANTERIOR HORN OF MEDIAL MENISCUS

717.2 DERANGEMENT OF POSTERIOR HORN OF MEDIAL MENISCUS

717.3 OTHER AND UNSPECIFIED DERANGEMENT OF MEDIAL MENISCUS

717.40 DERANGEMENT OF LATERAL MENISCUS UNSPECIFIED

717.41 BUCKET HANDLE TEAR OF LATERAL MENISCUS

717.42 DERANGEMENT OF ANTERIOR HORN OF LATERAL MENISCUS

717.43 DERANGEMENT OF POSTERIOR HORN OF LATERAL MENISCUS

717.49 OTHER DERANGEMENT OF LATERAL MENISCUS

717.5 DERANGEMENT OF MENISCUS NOT ELSEWHERE CLASSIFIED

717.6 LOOSE BODY IN KNEE

717.7 CHONDROMALACIA OF PATELLA

717.81 OLD DISRUPTION OF LATERAL COLLATERAL LIGAMENT

717.82 OLD DISRUPTION OF MEDIAL COLLATERAL LIGAMENT

717.83 OLD DISRUPTION OF ANTERIOR CRUCIATE LIGAMENT

717.84 OLD DISRUPTION OF POSTERIOR CRUCIATE LIGAMENT

717.85 OLD DISRUPTION OF OTHER LIGAMENTS OF KNEE

717.89 OTHER INTERNAL DERANGEMENT OF KNEE

717.9 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

718.25 PATHOLOGICAL DISLOCATION OF JOINT OF PELVIC REGION AND THIGH

718.26 PATHOLOGICAL DISLOCATION OF JOINT OF LOWER LEG

718.27 PATHOLOGICAL DISLOCATION OF ANKLE AND FOOT JOINT

718.35 RECURRENT DISLOCATION OF JOINT OF PELVIC REGION AND THIGH

718.36 RECURRENT DISLOCATION OF LOWER LEG JOINT

718.37 RECURRENT DISLOCATION OF ANKLE AND FOOT JOINT

718.45 CONTRACTURE OF JOINT OF PELVIC REGION AND THIGH

718.46 CONTRACTURE OF LOWER LEG JOINT

718.47 CONTRACTURE OF ANKLE AND FOOT JOINT

718.55 ANKYLOSIS OF JOINT OF PELVIC REGION AND THIGH

718.56 ANKYLOSIS OF LOWER LEG JOINT

718.57 ANKYLOSIS OF ANKLE AND FOOT JOINT

718.65 UNSPECIFIED INTRAPELVIC PROTRUSION OF ACETABULUM PELVIC REGION AND THIGH

718.85 OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING PELVIC REGION AND THIGH

718.86 OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING LOWER LEG

718.87 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 EFFUSION OF JOINT OF PELVIC REGION AND THIGH

719.06 EFFUSION OF LOWER LEG JOINT

719.07 EFFUSION OF ANKLE AND FOOT JOINT

719.25 VILLONODULAR SYNOVITIS INVOLVING PELVIC REGION AND THIGH

719.26 VILLONODULAR SYNOVITIS INVOLVING LOWER LEG

719.27 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 ENTHESOPATHY OF KNEE UNSPECIFIED

726.61 PES ANSERINUS TENDINITIS OR BURSITIS

726.62 TIBIAL COLLATERAL LIGAMENT BURSITIS

726.63 FIBULAR COLLATERAL LIGAMENT BURSITIS

726.64 PATELLAR TENDINITIS

726.65 PREPATELLAR BURSITIS

726.69 OTHER ENTHESOPATHY OF KNEE

726.70 ENTHESOPATHY OF ANKLE AND TARSUS UNSPECIFIED

726.71 ACHILLES BURSITIS OR TENDINITIS

726.72 TIBIALIS TENDINITIS

726.73 CALCANEAL SPUR

726.79 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 NONTRAUMATIC RUPTURE OF QUADRICEPS TENDON

727.66 NONTRAUMATIC RUPTURE OF PATELLAR TENDON

727.67 NONTRAUMATIC RUPTURE OF ACHILLES TENDON

727.68 NONTRAUMATIC RUPTURE OF OTHER TENDONS OF FOOT AND ANKLE

730.05 ACUTE OSTEOMYELITIS INVOLVING PELVIC REGION AND THIGH

730.06 ACUTE OSTEOMYELITIS INVOLVING LOWER LEG

730.07 ACUTE OSTEOMYELITIS INVOLVING ANKLE AND FOOT

730.15 CHRONIC OSTEOMYELITIS INVOLVING PELVIC REGION AND THIGH

730.16 CHRONIC OSTEOMYELITIS INVOLVING LOWER LEG

730.17 CHRONIC OSTEOMYELITIS INVOLVING ANKLE AND FOOT

733.14 PATHOLOGICAL FRACTURE OF NECK OF FEMUR

733.15 PATHOLOGICAL FRACTURE OF OTHER SPECIFIED PART OF FEMUR

733.16 PATHOLOGICAL FRACTURE OF TIBIA OR FIBULA

733.42 ASEPTIC NECROSIS OF HEAD AND NECK OF FEMUR

733.43 ASEPTIC NECROSIS OF MEDIAL FEMORAL CONDYLE

733.44 ASEPTIC NECROSIS OF TALUS

835.00 CLOSED DISLOCATION OF HIP UNSPECIFIED SITE

835.01 CLOSED POSTERIOR DISLOCATION OF HIP

835.02 CLOSED OBTURATOR DISLOCATION OF HIP

835.03 OTHER CLOSED ANTERIOR DISLOCATION OF HIP

835.10 OPEN DISLOCATION OF HIP UNSPECIFIED SITE

835.11 OPEN POSTERIOR DISLOCATION OF HIP

835.12 OPEN OBTURATOR DISLOCATION OF HIP

835.13 OTHER OPEN ANTERIOR DISLOCATION OF HIP

836.0 TEAR OF MEDIAL CARTILAGE OR MENISCUS OF KNEE CURRENT

836.1 TEAR OF LATERAL CARTILAGE OR MENISCUS OF KNEE CURRENT

836.2 OTHER TEAR OF CARTILAGE OR MENISCUS OF KNEE CURRENT

836.3 DISLOCATION OF PATELLA CLOSED

836.4 DISLOCATION OF PATELLA OPEN

836.50 CLOSED DISLOCATION OF KNEE UNSPECIFIED PART

836.51 ANTERIOR DISLOCATION OF TIBIA PROXIMAL END CLOSED

836.52 POSTERIOR DISLOCATION OF TIBIA PROXIMAL END CLOSED

836.53 MEDIAL DISLOCATION OF TIBIA PROXIMAL END CLOSED

836.54 LATERAL DISLOCATION OF TIBIA PROXIMAL END CLOSED

836.59 OTHER DISLOCATION OF KNEE CLOSED

836.60 DISLOCATION OF KNEE UNSPECIFIED PART OPEN

836.61 ANTERIOR DISLOCATION OF TIBIA PROXIMAL END OPEN

836.62 POSTERIOR DISLOCATION OF TIBIA PROXIMAL END OPEN

836.63 MEDIAL DISLOCATION OF TIBIA PROXIMAL END OPEN

836.64 LATERAL DISLOCATION OF TIBIA PROXIMAL END OPEN

836.69 OTHER DISLOCATION OF KNEE OPEN

837.0 CLOSED DISLOCATION OF ANKLE

837.1 OPEN DISLOCATION OF ANKLE

838.00 CLOSED DISLOCATION OF FOOT UNSPECIFIED PART

838.01 CLOSED DISLOCATION OF TARSAL (BONE) JOINT UNSPECIFIED

838.02 CLOSED DISLOCATION OF MIDTARSAL (JOINT)

838.03 CLOSED DISLOCATION OF TARSOMETATARSAL (JOINT)

838.04 CLOSED DISLOCATION OF METATARSAL (BONE) JOINT UNSPECIFIED

838.05 CLOSED DISLOCATION OF METATARSOPHALANGEAL (JOINT)

838.06 CLOSED DISLOCATION OF INTERPHALANGEAL (JOINT) FOOT

838.09 CLOSED DISLOCATION OF OTHER PART OF FOOT

838.10 OPEN DISLOCATION OF FOOT UNSPECIFIED PART

838.11 OPEN DISLOCATION OF TARSAL (BONE) JOINT UNSPECIFIED

838.12 OPEN DISLOCATION OF MIDTARSAL (JOINT)

838.13 OPEN DISLOCATION OF TARSOMETATARSAL (JOINT)

838.14 OPEN DISLOCATION OF METATARSAL (BONE) JOINT UNSPECIFIED

838.15 OPEN DISLOCATION OF METATARSOPHALANGEAL (JOINT)

838.16 OPEN DISLOCATION OF INTERPHALANGEAL (JOINT) FOOT

843.0 ILIOFEMORAL (LIGAMENT) SPRAIN

843.1 ISCHIOCAPSULAR (LIGAMENT) SPRAIN

843.8 SPRAIN OF OTHER SPECIFIED SITES OF HIP AND THIGH

843.9 SPRAIN OF UNSPECIFIED SITE OF HIP AND THIGH

844.0 SPRAIN OF LATERAL COLLATERAL LIGAMENT OF KNEE

844.1 SPRAIN OF MEDIAL COLLATERAL LIGAMENT OF KNEE

844.2 SPRAIN OF CRUCIATE LIGAMENT OF KNEE

844.3 SPRAIN OF TIBIOFIBULAR (JOINT) (LIGAMENT) SUPERIOR OF KNEE

844.8 SPRAIN OF OTHER SPECIFIED SITES OF KNEE AND LEG

844.9 SPRAIN OF UNSPECIFIED SITE OF KNEE AND LEG

845.00 UNSPECIFIED SITE OF ANKLE SPRAIN

845.01 DELTOID (LIGAMENT) ANKLE SPRAIN

845.02 CALCANEOFIBULAR (LIGAMENT) ANKLE SPRAIN

845.03 TIBIOFIBULAR (LIGAMENT) SPRAIN DISTAL

845.09 OTHER ANKLE SPRAIN

845.10 UNSPECIFIED SITE OF FOOT SPRAIN

845.11 TARSOMETATARSAL (JOINT) (LIGAMENT) SPRAIN

845.12 METATARSAOPHALANGEAL (JOINT) SPRAIN

845.13 INTERPHALANGEAL (JOINT) TOE SPRAIN

845.19 OTHER FOOT SPRAIN

924.00 CONTUSION OF THIGH

924.01 CONTUSION OF HIP

924.10 CONTUSION OF LOWER LEG

924.11 CONTUSION OF KNEE

924.20 CONTUSION OF FOOT

924.21 CONTUSION OF ANKLE

924.3 CONTUSION OF TOE

924.4 CONTUSION OF MULTIPLE SITES OF LOWER LIMB

924.5 CONTUSION OF UNSPECIFIED PART OF LOWER LIMB

924.8 CONTUSION OF MULTIPLE SITES NOT ELSEWHERE CLASSIFIED

924.9 CONTUSION OF UNSPECIFIED SITE

928.00 CRUSHING INJURY OF THIGH

928.01 CRUSHING INJURY OF HIP

928.10 CRUSHING INJURY OF LOWER LEG

928.11 CRUSHING INJURY OF KNEE

928.20 CRUSHING INJURY OF FOOT

928.21 CRUSHING INJURY OF ANKLE

928.3 CRUSHING INJURY OF TOE(S)

928.8 CRUSHING INJURY OF MULTIPLE SITES OF LOWER LIMB

928.9 CRUSHING INJURY OF UNSPECIFIED SITE OF LOWER LIMB

959.6 OTHER AND UNSPECIFIED INJURY TO HIP AND THIGH

959.7 OTHER AND UNSPECIFIED INJURY TO KNEE LEG ANKLE AND FOOT

 

 

Documentation 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.

o 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.

o 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.

o 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:

o 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:

o 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.

o  The interpreting physician must document accordingly in his/her report to the treating physician/practitioner.

• Test Design:

o 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.

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

 

Treatment Logic

• 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.

 

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.

 

07/07/2011

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

CMS LCD MAGNETIC RESONANCE IMAGING (MRI) OF ANY JOINT OF THE LOWER EXTREMITIES