L29220-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Magnetic Resonance Imaging of the Brain (L29220)

Contractor Information

Contractor Name

First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29220

LCD Title

Magnetic Resonance Imaging of the Brain

Contractor's Determination Number 70551

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 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

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

Change Request 7441, Transmittals 134 and 2293, dated August 26, 2011

CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations, Chapter 1, Section 220.2 CMS Manual System, Pub. 100-08, Medicare Program Integrity, Chapter 13, Section 13.1.3

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 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 white from gray matter, tumor from normal tissue, and flowing blood within vascular structures.

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 (gadolinium chelate agents). Its major disadvantage over CT is the longer scanning time required for study, making it less useful for emergency evaluations of acute bleeding or for unstable patients. Because a powerful magnetic field is required

to obtain an MRI, patients with ferromagnetic materials in place may not be able to undergo MRI study. These include patients with cardiac pacemakers, implanted neurostimulators, cochlear implants, metal in the eye and older ferromagnetic intracranial aneurysm clips. All of these may be potentially displaced when exposed to the powerful magnetic fields used in MRI.

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

• For detecting or evaluating extra-axial tumors, A-V malformations, cavernous hemangiomas, small intracranial aneurysms, cranial nerve lesions, demyelination disorders including multiple sclerosis, lesions near dense bone, acoustic neuromas, pituitary lesions, and brain radiation injuries;

• For development abnormalities of the brain including neuroectodermal dysplasia;

• For subacute central nervous system hemorrhage or hematoma;

• For acute cerebrovascular accidents;

• For complex partial seizures, seizures refractory to therapy, temporal lobe epilepsy, or other atypical seizure disorders;

• MRI is usually not the procedure of choice in patients who have acute head trauma, acute intracranial bleeding, or investigation of skull fracture or other bone abnormality, or as follow-up for hydrocephalus. However, a MRI may be necessary in patients whose presentation indicates a focal problem or who have had a recent significant change in symptomatology;

• For brain infections;

• Where soft tissue contrast is necessary;

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

• 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.

When Magnetic Resonance Imaging is used for an investigational purpose, an acceptable advance notice of Medicare’s denial of payment must be given to the patient when the provider does not want to accept financial responsibility for the service.

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

70551 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL

70552 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITH CONTRAST MATERIAL(S)

70553 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES

MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM AND SKULL BASE), 70557 DURING OPEN INTRACRANIAL PROCEDURE (EG, TO ASSESS FOR RESIDUAL TUMOR OR RESIDUAL

VASCULAR MALFORMATION); WITHOUT CONTRAST MATERIAL

MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM AND SKULL BASE), 70558 DURING OPEN INTRACRANIAL PROCEDURE (EG, TO ASSESS FOR RESIDUAL TUMOR OR RESIDUAL

VASCULAR MALFORMATION); WITH CONTRAST MATERIAL(S)

MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM AND SKULL BASE), 70559 DURING OPEN INTRACRANIAL PROCEDURE (EG, TO ASSESS FOR RESIDUAL TUMOR OR RESIDUAL

VASCULAR MALFORMATION); WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST

MATERIAL(S) AND FURTHER SEQUENCES

ICD-9 Codes that Support Medical Necessity

For procedure codes 70551, 70552, and 70553:

006.5 AMEBIC BRAIN ABSCESS

013.00 -

013.06

013.10 -

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013.20 -

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013.30 -

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013.60 -

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013.80 -

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013.90 -

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TUBERCULOUS MENINGITIS UNSPECIFIED EXAMINATION - TUBERCULOUS MENINGITIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) TUBERCULOMA OF MENINGES UNSPECIFIED EXAMINATION - TUBERCULOMA OF MENINGES TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) TUBERCULOMA OF BRAIN UNSPECIFIED EXAMINATION - TUBERCULOMA OF BRAIN TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) TUBERCULOUS ABSCESS OF BRAIN UNSPECIFIED EXAMINATION - TUBERCULOUS ABSCESS OF BRAIN TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)

TUBERCULOUS ENCEPHALITIS OR MYELITIS UNSPECIFIED EXAMINATION - TUBERCULOUS ENCEPHALITIS OR MYELITIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)

OTHER SPECIFIED TUBERCULOSIS OF CENTRAL NERVOUS SYSTEM UNSPECIFIED EXAMINATION - OTHER SPECIFIED TUBERCULOSIS OF CENTRAL NERVOUS SYSTEM TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) UNSPECIFIED TUBERCULOSIS OF CENTRAL NERVOUS SYSTEM UNSPECIFIED EXAMINATION - UNSPECIFIED TUBERCULOSIS OF CENTRAL NERVOUS SYSTEM TUBERCLE BACILLI NOT

FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)

36.1 MENINGOCOCCAL MENINGITIS

36.2 MENINGOCOCCAL ENCEPHALITIS

36.3 MENINGOCOCCEMIA

042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE

046.0 -

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047.0 -

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049.0 -

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KURU - UNSPECIFIED SLOW VIRUS INFECTION OF CENTRAL NERVOUS SYSTEM

MENINGITIS DUE TO COXSACKIE VIRUS - UNSPECIFIED VIRAL MENINGITIS

NON-ARTHOPOD BORNE LYMPHOCYTIC CHORIOMENINGITIS - UNSPECIFIED NON- ARTHROPOD-BORNE VIRAL DISEASES OF CENTRAL NERVOUS SYSTEM

052.0 POSTVARICELLA ENCEPHALITIS

053.0 HERPES ZOSTER WITH MENINGITIS

054.3 HERPETIC MENINGOENCEPHALITIS

054.72 HERPES SIMPLEX MENINGITIS

054.74 HERPES SIMPLEX MYELITIS

055.0 POSTMEASLES ENCEPHALITIS

056.01 ENCEPHALOMYELITIS DUE TO RUBELLA

062.0 -

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063.0 -

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JAPANESE ENCEPHALITIS - MOSQUITO-BORNE VIRAL ENCEPHALITIS UNSPECIFIED

RUSSIAN SPRING-SUMMER (TAIGA) ENCEPHALITIS - TICK-BORNE VIRAL ENCEPHALITIS UNSPECIFIED

064 VIRAL ENCEPHALITIS TRANSMITTED BY OTHER AND UNSPECIFIED ARTHROPODS

72.1 MUMPS MENINGITIS

72.2 MUMPS ENCEPHALITIS

090.40 -

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094.0 -

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JUVENILE NEUROSYPHILIS UNSPECIFIED - OTHER JUVENILE NEUROSYPHILIS

TABES DORSALIS - NEUROSYPHILIS UNSPECIFIED

112.83 CANDIDAL MENINGITIS

114.2 COCCIDIOIDAL MENINGITIS

115.01 HISTOPLASMA CAPSULATUM MENINGITIS

115.11 HISTOPLASMA DUBOISII MENINGITIS

115.91 HISTOPLASMOSIS MENINGITIS UNSPECIFIED

130.0 MENINGOENCEPHALITIS DUE TO TOXOPLASMOSIS

162.0 -

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191.0 -

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MALIGNANT NEOPLASM OF TRACHEA - MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED

MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES - MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE

192.1 MALIGNANT NEOPLASM OF CRANIAL NERVES

192.2 MALIGNANT NEOPLASM OF CEREBRAL MENINGES

194.3 MALIGNANT NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT

194.4 MALIGNANT NEOPLASM OF PINEAL GLAND

196.0 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF HEAD FACE AND NECK

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

225.1 BENIGN NEOPLASM OF BRAIN

225.2 BENIGN NEOPLASM OF CRANIAL NERVES

225.3 BENIGN NEOPLASM OF CEREBRAL MENINGES

225.8 BENIGN NEOPLASM OF OTHER SPECIFIED SITES OF NERVOUS SYSTEM

227.3 BENIGN NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT

227.4 BENIGN NEOPLASM OF PINEAL GLAND

228.02 HEMANGIOMA OF INTRACRANIAL STRUCTURES

237.1 NEOPLASM OF UNCERTAIN BEHAVIOR OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT

237.2 NEOPLASM OF UNCERTAIN BEHAVIOR OF PINEAL GLAND

237.5 NEOPLASM OF UNCERTAIN BEHAVIOR OF BRAIN AND SPINAL CORD

237.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF MENINGES

237.70 -

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NEUROFIBROMATOSIS UNSPECIFIED - NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED PARTS OF NERVOUS SYSTEM

239.6 NEOPLASM OF UNSPECIFIED NATURE OF BRAIN

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

253.0 -

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ACROMEGALY AND GIGANTISM - UNSPECIFIED DISORDER OF THE PITUITARY GLAND AND ITS HYPOTHALAMIC CONTROL

298.9 UNSPECIFIED PSYCHOSIS

310.0 -

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320.0 - 326 opens in new window

FRONTAL LOBE SYNDROME - UNSPECIFIED NONPSYCHOTIC MENTAL DISORDER FOLLOWING ORGANIC BRAIN DAMAGE

HEMOPHILUS MENINGITIS - LATE EFFECTS OF INTRACRANIAL ABSCESS OR PYOGENIC INFECTION

Printed on 9/29/2012. Page 5 of 11

330.0 -

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331.0 -

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332.1 -

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333.0 -

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334.0 -

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LEUKODYSTROPHY - UNSPECIFIED CEREBRAL DEGENERATION IN CHILDHOOD

ALZHEIMER'S DISEASE - CEREBRAL DEGENERATION UNSPECIFIED PARALYSIS AGITANS - SECONDARY PARKINSONISM

OTHER DEGENERATIVE DISEASES OF THE BASAL GANGLIA - OTHER EXTRAPYRAMIDAL DISEASES AND ABNORMAL MOVEMENT DISORDERS

FRIEDREICH'S ATAXIA - SPINOCEREBELLAR DISEASE UNSPECIFIED

340 MULTIPLE SCLEROSIS

341.0 -

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342.00 -

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343.0 -

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344.00 -

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345.00 -

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348.0 -

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NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM

UNSPECIFIED

FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE

CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED

QUADRIPLEGIA UNSPECIFIED - PARALYSIS UNSPECIFIED

GENERALIZED NONCONVULSIVE EPILEPSY WITHOUT INTRACTABLE EPILEPSY - EPILEPSY UNSPECIFIED WITH INTRACTABLE EPILEPSY

CEREBRAL CYSTS - UNSPECIFIED CONDITION OF BRAIN

349.1 NERVOUS SYSTEM COMPLICATIONS FROM SURGICALLY IMPLANTED DEVICE

349.2 DISORDERS OF MENINGES NOT ELSEWHERE CLASSIFIED

349.31 -

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349.81 -

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ACCIDENTAL PUNCTURE OR LACERATION OF DURA DURING A PROCEDURE - OTHER DURAL

TEAR

CEREBROSPINAL FLUID RHINORRHEA - OTHER SPECIFIED DISORDERS OF NERVOUS SYSTEM

349.9 UNSPECIFIED DISORDERS OF NERVOUS SYSTEM

350.1 -

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351.0 -

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352.0 -

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358.1 -

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TRIGEMINAL NEURALGIA - TRIGEMINAL NERVE DISORDER UNSPECIFIED

BELL'S PALSY - FACIAL NERVE DISORDER UNSPECIFIED

DISORDERS OF OLFACTORY (1ST) NERVE - UNSPECIFIED DISORDER OF CRANIAL NERVES MYASTHENIA GRAVIS WITHOUT (ACUTE) EXACERBATION - MYASTHENIA GRAVIS WITH

(ACUTE) EXACERBATION

358.1 MYASTHENIC SYNDROMES IN DISEASES CLASSIFIED ELSEWHERE

368.11 SUDDEN VISUAL LOSS

368.12 TRANSIENT VISUAL LOSS

368.2 DIPLOPIA

368.40 VISUAL FIELD DEFECT UNSPECIFIED

368.8 OTHER SPECIFIED VISUAL DISTURBANCES

368.9 UNSPECIFIED VISUAL DISTURBANCE

374.31 PARALYTIC PTOSIS

377.1 PAPILLEDEMA UNSPECIFIED

377.2 PAPILLEDEMA ASSOCIATED WITH INCREASED INTRACRANIAL PRESSURE

377.51 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH PITUITARY NEOPLASMS AND DISORDERS

377.52 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH OTHER NEOPLASMS

377.61 DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH NEOPLASMS

377.71 DISORDERS OF VISUAL CORTEX ASSOCIATED WITH NEOPLASMS

378.51 -

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THIRD OR OCULOMOTOR NERVE PALSY PARTIAL - THIRD OR OCULOMOTOR NERVE PALSY

TOTAL

378.53 FOURTH OR TROCHLEAR NERVE PALSY

378.54 SIXTH OR ABDUCENS NERVE PALSY

378.55 -

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EXTERNAL OPHTHALMOPLEGIA - TOTAL OPHTHALMOPLEGIA

386.2 VERTIGO OF CENTRAL ORIGIN

388.2 SUDDEN HEARING LOSS UNSPECIFIED

388.5 DISORDERS OF ACOUSTIC NERVE

389.10 -

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389.20 -

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SENSORINEURAL HEARING LOSS UNSPECIFIED - SENSORINEURAL HEARING LOSS, BILATERAL

MIXED HEARING LOSS, UNSPECIFIED - MIXED HEARING LOSS, BILATERAL SUBARACHNOID HEMORRHAGE - UNSPECIFIED LATE EFFECTS OF CEREBROVASCULAR

DISEASE

572.2 HEPATIC ENCEPHALOPATHY

676.60 GALACTORRHEA ASSOCIATED WITH CHILDBIRTH UNSPECIFIED AS TO EPISODE OF CARE

739.0 NONALLOPATHIC LESIONS OF HEAD REGION NOT ELSEWHERE CLASSIFIED

742.0 -

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ENCEPHALOCELE - OTHER SPECIFIED CONGENITAL ANOMALIES OF BRAIN

742.8 OTHER SPECIFIED CONGENITAL ANOMALIES OF NERVOUS SYSTEM

742.9 UNSPECIFIED CONGENITAL ANOMALY OF BRAIN SPINAL CORD AND NERVOUS SYSTEM

747.81 CONGENITAL ANOMALIES OF CEREBROVASCULAR SYSTEM

759.2 ANOMALIES OF OTHER ENDOCRINE GLANDS CONGENITAL

759.3 SITUS INVERSUS

759.4 CONJOINED TWINS

759.5 TUBEROUS SCLEROSIS

759.6 OTHER CONGENITAL HAMARTOSES NOT ELSEWHERE CLASSIFIED

759.7 MULTIPLE CONGENITAL ANOMALIES SO DESCRIBED

759.81 -

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PRADER-WILLI SYNDROME - OTHER SPECIFIED CONGENITAL ANOMALIES

759.9 CONGENITAL ANOMALY UNSPECIFIED

767.0 SUBDURAL AND CEREBRAL HEMORRHAGE DUE TO BIRTH TRAUMA

768.5 SEVERE BIRTH ASPHYXIA

768.6 MILD OR MODERATE BIRTH ASPHYXIA

768.70 -

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HYPOXIC-ISCHEMIC ENCEPHALOPATHY, UNSPECIFIED - SEVERE HYPOXIC-ISCHEMIC ENCEPHALOPATHY

768.9 UNSPECIFIED SEVERITY OF BIRTH ASPHYXIA IN LIVEBORN INFANT

772.10 -

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INTRAVENTRICULAR HEMORRHAGE UNSPECIFIED GRADE - INTRAVENTRICULAR HEMORRHAGE GRADE IV

772.2 SUBARACHNOID HEMORRHAGE OF NEWBORN

780.01 -

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COMA - ALTERATION OF CONSCIOUSNESS OTHER

780.1 HALLUCINATIONS

780.2 SYNCOPE AND COLLAPSE

FEBRILE CONVULSIONS (SIMPLE), UNSPECIFIED - OTHER CONVULSIONS

780.31 -

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780.4 DIZZINESS AND GIDDINESS

780.60 FEVER, UNSPECIFIED

780.61 FEVER PRESENTING WITH CONDITIONS CLASSIFIED ELSEWHERE

780.62 POSTPROCEDURAL FEVER

780.91 -

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781.0 -

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FUSSY INFANT (BABY) - OTHER GENERAL SYMPTOMS

ABNORMAL INVOLUNTARY MOVEMENTS - NEUROLOGIC NEGLECT SYNDROME

781.94 FACIAL WEAKNESS

781.99 OTHER SYMPTOMS INVOLVING NERVOUS AND MUSCULOSKELETAL SYSTEMS

784.2 SWELLING MASS OR LUMP IN HEAD AND NECK

784.3 APHASIA

784.51 -

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784.60 -

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DYSARTHRIA - OTHER SPEECH DISTURBANCE

SYMBOLIC DYSFUNCTION UNSPECIFIED - OTHER SYMBOLIC DYSFUNCTION

793.0 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF SKULL AND HEAD

794.00 -

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800.00 -

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850.0 -

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950.0 -

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951.0 -

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UNSPECIFIED ABNORMAL FUNCTION STUDY OF BRAIN AND CENTRAL NERVOUS SYSTEM - OTHER NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF BRAIN AND CENTRAL NERVOUS SYSTEM

CLOSED FRACTURE OF VAULT OF SKULL WITHOUT INTRACRANIAL INJURY WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OPEN FRACTURE OF VAULT OF SKULL WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH CONCUSSION UNSPECIFIED

CLOSED FRACTURE OF BASE OF SKULL WITHOUT INTRA CRANIAL INJURY WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OPEN FRACTURE OF BASE OF SKULL WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH CONCUSSION UNSPECIFIED CONCUSSION WITH NO LOSS OF CONSCIOUSNESS - INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED

OPTIC NERVE INJURY - INJURY TO UNSPECIFIED OPTIC NERVE AND PATHWAYS

INJURY TO OCULOMOTOR NERVE - INJURY TO UNSPECIFIED CRANIAL NERVE

996.2 MECHANICAL COMPLICATION OF NERVOUS SYSTEM DEVICE IMPLANT AND GRAFT

997.1 NERVOUS SYSTEM COMPLICATION UNSPECIFIED

997.2 CENTRAL NERVOUS SYSTEM COMPLICATION

997.3 IATROGENIC CEREBROVASCULAR INFARCTION OR HEMORRHAGE

997.09 OTHER NERVOUS SYSTEM COMPLICATIONS

V10.85 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BRAIN

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

V10.88 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER ENDOCRINE GLANDS AND RELATED STRUCTURES

V45.2* POSTSURGICAL PRESENCE OF CEREBROSPINAL FLUID DRAINAGE DEVICE V67.1 FOLLOW-UP EXAMINATION FOLLOWING RADIOTHERAPY

V67.2 FOLLOW-UP EXAMINATION FOLLOWING CHEMOTHERAPY

* According to the ICD-9-CM book, diagnosis code V45.2 is a secondary diagnosis code and should not be billed as the primary diagnosis.

Diagnoses that Support Medical Necessity

See ICD-9 Codes that Support Medical Necessity.

ICD-9 Codes that DO NOT Support Medical Necessity

All other diagnosis codes not listed as covered in the “ICD-9 Codes that Support Medical Necessity” section of this policy.

XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

All other diagnosis not listed as covered in the “ICD-9 Codes that Support Medical Necessity” section of this policy.

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/nonphysician practitioner, that provider must maintain documentation of test results and interpretation, along with copies of the ordering/referring physician/nonphysician practitioner’s order for the studies. The physician/nonphysician

practitioner must state the clinical indication/medical necessity for the study in his/her 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

American College of Radiology (2008). Practice guideline for performing and interpreting magnetic resonance imaging (MRI) of the brain. Retrieved from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx

Grainger & Allison’s Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed. (2001). Retrieved September 26, 2005, from http://home.mdconsult.com/das/book/body/407046686/1047/1683.html

Hasso, A., Drayer, B., Anderson, R., Braffman, B., Davis, P., Deck, M., Johnson, B., Masaryk, T., Pomeranz, S., Seidenwurm, D., Tanenbaum, L., Masdeu, J. (2000). Vertigo and hearing loss. American College of Radiology- ACR Appropriateness Criteria, 215, 471-478. This reference consulted for guidelines used in management of hearing loss to establish indications and limitations.

Sedwick, J., Gajewski, B., Prevatt, A., Antonelli, P. (2001). Magnetic resonance imaging in the search for retrocochlear pathology. Otolaryngology-Head and Neck Surgery, 124(6), 652-655. This source consulted for clinical study results.

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 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 B2011-103

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 B2011-050

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:1

Start Date of Comment Period:N/A Start Date of Notice Period:10/01/2009 Revised Effective Date: 10/01/2009

LCR B2009-098

September 2009 Update

Explanation of Revision: Annual 2010 ICD-9-CM Update. Deleted diagnosis codes 768.7 and 784.5 and replaced with diagnosis code ranges 768.70-768.73 and 784.51-784.59, respectively for procedure codes 70551, 70552,

and 70553. Revised descriptor for diagnoses 572.2 and 793.0 for procedure codes 70551, 70552, and 70553. 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:02/02/2009

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 (L29220) replaces LCD L5858 as the policy in notice. This document (L29220) is effective on 02/02/2009.

08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update. 09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update. 08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

Reason for Change