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Centers for Medicare & Medicaid Services

Local Coverage Determination (LCD):
MRI and CT Scans of the Head and Neck (L35175)

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	State(s)
Noridian Healthcare Solutions, LLC	A and B MAC	02101 - MAC A	J - F	Alaska
Noridian Healthcare Solutions, LLC	A and B MAC	02102 - MAC B	J - F	Alaska
Noridian Healthcare Solutions, LLC	A and B MAC	02201 - MAC A	J - F	Idaho
Noridian Healthcare Solutions, LLC	A and B MAC	02202 - MAC B	J - F	Idaho
Noridian Healthcare Solutions, LLC	A and B MAC	02301 - MAC A	J - F	Oregon
Noridian Healthcare Solutions, LLC	A and B MAC	02302 - MAC B	J - F	Oregon
Noridian Healthcare Solutions, LLC	A and B MAC	02401 - MAC A	J - F	Washington
Noridian Healthcare Solutions, LLC	A and B MAC	02402 - MAC B	J - F	Washington
Noridian Healthcare Solutions, LLC	A and B MAC	03101 - MAC A	J - F	Arizona
Noridian Healthcare Solutions, LLC	A and B MAC	03102 - MAC B	J - F	Arizona
Noridian Healthcare Solutions, LLC	A and B MAC	03201 - MAC A	J - F	Montana
Noridian Healthcare Solutions, LLC	A and B MAC	03202 - MAC B	J - F	Montana
Noridian Healthcare Solutions, LLC	A and B MAC	03301 - MAC A	J - F	North Dakota
Noridian Healthcare Solutions, LLC	A and B MAC	03302 - MAC B	J - F	North Dakota
Noridian Healthcare Solutions, LLC	A and B MAC	03401 - MAC A	J - F	South Dakota
Noridian Healthcare Solutions, LLC	A and B MAC	03402 - MAC B	J - F	South Dakota
Noridian Healthcare Solutions, LLC	A and B MAC	03501 - MAC A	J - F	Utah
Noridian Healthcare Solutions, LLC	A and B MAC	03502 - MAC B	J - F	Utah
Noridian Healthcare Solutions, LLC	A and B MAC	03601 - MAC A	J - F	Wyoming
Noridian Healthcare Solutions, LLC	A and B MAC	03602 - MAC B	J - F	Wyoming

LCD Information

Document Information

LCD ID
L35175

LCD Title
MRI and CT Scans of the Head and Neck

Proposed LCD in Comment Period
N/A

Source Proposed LCD
DL35175

AMA CPT / ADA CDT / AHA NUBC Copyright Statement
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

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.

Current Dental Terminology © 2020 American Dental Association. All rights reserved.

Copyright © 2013 - 2020, the American Hospital Association, Chicago, Illinois. Reproduced by CMS with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816. You may also contact us at ub04@aha.org.

Original Effective Date
For services performed on or after 10/01/2015

Revision Effective Date
For services performed on or after 10/01/2019

Revision Ending Date
N/A

Retirement Date
N/A

Notice Period Start Date

08/23/2018

Notice Period End Date

10/07/2018

CMS National Coverage Policy

Title XVIII of the Social Security Act, Section 1862(a)(7) excludes routine physical examinations. This provision excludes screening examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) allows coverage and payment for only those services that are considered reasonable and necessary.

Title XVIII of the Social Security Act, Section 1833(e) prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.

Title XVIII of the Social Security Act, Section 1862(a)(1)(D) prohibits Medicare payment for services and items that are experimental or investigational.

CMS publication 100-3, Medicare National Coverage Determinations, Sections 220.1 “Computerized Tomography”, and 220.2-220.2.B.2d and Section 220.2.C-220.2.D “Magnetic Resonance Imaging”.

Denies coverage of MRI for:

Imaging of cortical bone and calcification;
Procedures involving spatial resolution of bone or calcification;
MRI is not covered for patients with metallic clips on vascular aneurysms

CMS publication 100-04 Medicare Claims Processing Manual Chapter 13 Section 40.

Denies coverage of MRI for:

Measurement of blood flow and spectroscopy

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Note: Providers should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS) instructions in CMS Manuals. This LCD only pertains to the contractor's discretionary coverage related to this service.

This policy addresses standard CT and MR imaging. Magnetic Resonance Angiography (MRA) is not addressed in this policy.

Computerized Tomography (CT)
Computerized tomography (CT scanning) uses the attenuation of an x-ray beam by an object in its path to create cross-sectional images. As x-rays pass through planes of the body, the photons are detected and recorded as they exit from different angles. Computers process the signals to produce a cross-sectional view of the body. The signal data may be subjected to a variety of post-acquisitional processing algorithms to obtain a multiplanar view of the anatomy.

The use of the CT scan must be found medically appropriate considering the patient’s symptoms and preliminary diagnosis.

A CT scan is considered reasonable and necessary for the patient when the diagnostic exam is medically appropriate given the patient's symptoms and preliminary (or provisional) diagnosis.
CT scans (as opposed to MRI evaluations) are used effectively in the following situations or conditions:
1. Patients who are not suitable candidates for MRI evaluation:
  1. Because of a pacemaker or intracranial metallic objects
  2. Because of extreme obesity
  3. Because of an inability to lie still
2. Patients whose condition requires the visualization of fine bone detail or calcification
3. Patients with the following conditions
  1. Acute CNS Hemorrhage
  2. Strokes or encephalomalacia
  3. New onset seizures, particularly if a focal component is present (contrast agent is appropriate for these patients)
  4. Intracranial (sic) lesions large enough to cause increased intracranial pressure (CT scan is useful to determine gross margins between tumor and edematous brain)
There is no general rule that requires other diagnostic tests to be tried before CT scanning is used. However, in individual cases it may be determined that use of a CT scan as the initial diagnostic test was not reasonable and necessary because it was not supported by the patient’s symptoms or complaints as stated on the claim.
CT imaging has not been useful in general for the evaluation of headache or dizziness and should be reserved for the patient whose presentation indicates a focal problem or who has experienced a significant change in symptomatology.
A CT scan for the diagnosis of headache can be allowed for the following:
1. After a head injury to rule out intracranial bleeding
2. Headache unusual in duration (greater than two weeks) not responding to medical therapy, to rule out the possibility of a tumor
3. A headache characterized by sudden onset and severity to rule out the possibility of an aneurysm, bleeding and/or arteriovenous malformation
A CT Scan may be ordered without contrast, with contrast, or without contrast followed by contrast. Contrast administration is not without risk to the patient, and for some conditions, adds little or no benefit to the patient. The general indications for use of contrast CT scanning (as opposed to non-contrast scanning) are to:
1. Assess perfusion (e.g. CVA)
2. Characterize a specific lesion
3. Detect defects in blood/brain barrier (e.g. infarct, tumor, infection, vasculitis)
4. Detect neovascularity (tumor), and
5. For staging of known lung cancer, breast cancer, and lymphomas likely to metastasize early to the brain
Intravenous contrast generally adds no information to CT scans done secondary to head trauma. Additional symptoms suggesting a possible intracranial bleed may justify the use of contrast. These symptoms should be documented in the medical record, and if appropriate, included in the diagnostic codes listed on the claim.
More than one contrast CT scan per episode of illness adds no information with the following exceptions:
1. CVA
2. Non-traumatic hemorrhage
3. TIA
4. Post-operative scan for residual tumor or post operative complication
5. Known brain tumor/metastases with a change in mental status or other evidence of CNS change

Magnetic Resonance Imaging (MRI)
Magnetic Resonance Imaging (MRI) is a non-invasive diagnostic scanning technique that employs a powerful and highly uniform static magnetic field, rather than ionizing radiation, to produce images. Fluctuations in the strength of the magnetic field alter the motion and relaxation times of hydrogen molecules, which are related to the density of molecules and reflect the physicochemical properties of the tissues. Reconstructed images can be displayed in multiple planes to facilitate analysis. See national non-coverage in CMS section above.

Coverage is limited to those CT and MRI machines that have received pre-market approval by the FDA. Such units must be operated within the parameters specified by the approval.

Inconclusive findings on a CT scan may warrant a MRI study and, conversely, findings of a MRI study may be further clarified (under certain circumstances) with a subsequent CT scan. The information provided by the two modalities may be complementary.

Cancer Staging. Clinicians commonly use CT and MRI of the brain when metastatic involvement is suspected.

Non-covered indications: esophagus, oropharynx, and prostate, and non-melanoma skin cancer in the absence of symptoms of brain involvement. “Certain tumors almost never metastasize to the brain parenchyma. These include carcinomas of the esophagus, oropharynx, and prostate, and non-melanoma skin cancers.” (DeVita, Chapter 52.1) Accordingly, the related diagnoses found in the following diagnosis code list do not justify brain scans for “staging” purposes unless a patient has signs or symptoms suggesting brain involvement. Covered: In contrast, for those malignancies that commonly metastasize to the brain, staging in the absence of neurological findings may be appropriate.

Payment will be allowed for reasonable and necessary scans of different areas of the body that are performed on the same day and are not subject to this policy.

Summary of Evidence

Analysis of Evidence
(Rationale for Determination)

General Information

Associated Information

N/A

Sources of Information

See Bibliography.

Bibliography

Medicare Consultants
Other contractor's policies
DeVita, et al, eds, Cancer, Principles and Practice of Oncology, 6th edition, Philadelphia, Lippincott-Raven, 2001

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reason(s) for Change
10/01/2019	R15	The LCD is revised to remove CPT/HCPCS codes in the Keyword Section of the LCD. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Other (The LCD is revised to remove CPT/HCPCS codes in the Keyword Section of the LCD. )
10/01/2019	R14	The Code Description Change for diagnosis Z45.42 in Revision #11 was added in error. Diagnosis Z45.42 was never in the original MRI and CT Scans of the Head and Neck LCD. In the Coverage Indications, Limitations and/or Medical Necessity section, under Computerized Tomography (CT) letter E, the ICD-10 code G44.1 was deleted. This code is listed in the associated Billing and Coding: MRI and CT Scans of the Head and Neck article. 10/01/2019 - At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Typographical Error Revisions Due To Code Removal
10/01/2019	R13	10/01/2019 - At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Revisions Due To Code Removal
10/01/2019	R12	As required by CR 10901, all billing and coding information has been moved to the companion article, this article is linked to the LCD. 10/01/19 At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Revisions Due To Code Removal
10/01/2019	R11	Effective 10/07/2018, G25.0 added as this is a covered indication. Effective 10/01/2019, the following ICD-10 codes were added an deleted and code description was changed per the 2019 annual update Added: H81.4 - Vertigo of central origin R11.15 - Cyclical vomiting syndrome unrelated to migraine S02.121A - Fracture of orbital roof, right side, initial encounter for closed fracture S02.121B - Fracture of orbital roof, right side, initial encounter for open fracture S02.121D - Fracture of orbital roof, right side, subsequent encounter for fracture with routine healing S02.121G - Fracture of orbital roof, right side, subsequent encounter for fracture with delayed healing S02.121K - Fracture of orbital roof, right side, subsequent encounter for fracture with nonunion S02.121S - Fracture of orbital roof, right side, sequela S02.122A - Fracture of orbital roof, left side, initial encounter for closed fracture S02.122B - Fracture of orbital roof, left side, initial encounter for open fracture S02.122D - Fracture of orbital roof, left side, subsequent encounter for fracture with routine healing S02.122G - Fracture of orbital roof, left side, subsequent encounter for fracture with delayed healing S02.122K - Fracture of orbital roof, left side, subsequent encounter for fracture with nonunion S02.122S - Fracture of orbital roof, left side, sequela S02.831A - Fracture of medial orbital wall, right side, initial encounter for closed fracture S02.831B - Fracture of medial orbital wall, right side, initial encounter for open fracture S02.831D - Fracture of medial orbital wall, right side, subsequent encounter for fracture with routine healing S02.831G - Fracture of medial orbital wall, right side, subsequent encounter for fracture with delayed healing S02.831K - Fracture of medial orbital wall, right side, subsequent encounter for fracture with nonunion S02.831S - Fracture of medial orbital wall, right side, sequela S02.832A - Fracture of medial orbital wall, left side, initial encounter for closed fracture S02.832B - Fracture of medial orbital wall, left side, initial encounter for open fracture S02.832D - Fracture of medial orbital wall, left side, subsequent encounter for fracture with routine healing S02.832G - Fracture of medial orbital wall, left side, subsequent encounter for fracture with delayed healing S02.832K - Fracture of medial orbital wall, left side, subsequent encounter for fracture with nonunion S02.832S - Fracture of medial orbital wall, left side, sequel S02.841A - Fracture of lateral orbital wall, right side, initial encounter for closed fracture S02.841B - Fracture of lateral orbital wall, right side, initial encounter for open fracture S02.841D - Fracture of lateral orbital wall, right side, subsequent encounter for fracture with routine healing S02.841G - Fracture of lateral orbital wall, right side, subsequent encounter for fracture with delayed healing S02.841K - Fracture of lateral orbital wall, right side, subsequent encounter for fracture with nonunion S02.841S - Fracture of lateral orbital wall, right side, sequela S02.842A - Fracture of lateral orbital wall, left side, initial encounter for closed fracture S02.842B - Fracture of lateral orbital wall, left side, initial encounter for open fracture S02.842D - Fracture of lateral orbital wall, left side, subsequent encounter for fracture with routine healing S02.842G - Fracture of lateral orbital wall, left side, subsequent encounter for fracture with delayed healing S02.842K - Fracture of lateral orbital wall, left side, subsequent encounter for fracture with nonunion S02.842S - Fracture of lateral orbital wall, left side, sequel Z86.003 - Personal history of in-situ neoplasm of oral cavity, esophagus and stomach Z86.005 - Personal history of in-situ neoplasm of middle ear and respiratory system Z86.006 - Personal history of melanoma in-situ Z86.007 - Personal history of in-situ neoplasm of skin Deleted: Deleted from Group 1: H81.41 Vertigo of central origin, right ear H81.42 Vertigo of central origin, left ear H81.43 Vertigo of central origin, bilateral Code Description Change From G43.A0 - Cyclical vomiting, not intractable to G43.A0 - Cyclical vomiting, in migraine, not intractable From G43.A1 - Cyclical vomiting, intractable to G43.A1 - Cyclical vomiting, in migraine, intractable From M50.120 - Mid-cervical disc disorder, unspecified to M50.120 - Mid-cervical disc disorder, unspecified level From Z45.42 - Encounter for adjustment and management of neuropacemaker (brain) (peripheral nerve) (spinal cord) to Z45.42 - Encounter for adjustment and management of neurostimulator 09/12/19 At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Request for Coverage by a Supplier Creation of Uniform LCDs Within a MAC Jurisdiction Revisions Due To ICD-10-CM Code Changes
10/08/2018	R10	11/29/18 At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy. LCD revised to add ICD-10 code C15.5.	Creation of Uniform LCDs Within a MAC Jurisdiction
10/08/2018	R9	10/23/18 At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy. LCD revised to make editorial changes to B3d and H4 in the Coverage Indications, Limitations and/or Medical Necessity section. Added C15.3, C15.4 and C15.8, C85.90, C88.0, D32.9, E22.9, E23.7, E87.1, F80.1, G44.021, G62.89, H40.052, H40.053, H91.91-H91.93, H95.89, I60.9, I61.9, I63.20, I63.549, I63.9, I77.74, I82.C21, J36, J38.01, J38.02, J39.0, L02.811, M41.82, M43.22, M47.13, M50.03, M50.10, M50.20, M50.23, M54.2, Q40.9, R13.0, R13.10, R26.9, R29.898, R40.20, R43.9, S06.9X9A, S06.9X9D, S06.9X9S, S09.90XA, S09.90XD, S09.90XS, S19.9XXA, S19.9XXD, S19.9XXS. Moved F32.81 & F32.89 from Group 2 to Group 1, deleted all other Groups 2 and 3 codes as they are already listed in Group 1 and updated the CMS National Coverage Policy section.	Request for Coverage by a Practitioner (Part B) Other (Updated per CMS Guidelines.)
10/08/2018	R8	09/06/2018 - At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy. This LCD is effective 10/08/18 to all allow for the required 45-day Notice period when a Draft policy finalizes. The Notice Period started on 8/23/18 and ends on 10/07/18. However, the Annual ICD-10 Code Update is effective 10/01/2018. The following codes were added and deleted to Group 1, Group 2 and revised from Group 1 will be effective on 10/01/2018. Added to Group 1: C43.111, C43.112, C43.121, C43.122, C4A.111, C4A.112, C4A.121, C4A.122, C44.1121. C44.1122, C44.1191, C44.1192, C44.1221, C44.1222, C44.1291, C44.1292, C44.1921, C44.1922, C44.1991, C44.1992, D03.111, D03.112, D03.121, D03.122, D04.111, D04.112, D04.121, D04.122, D22.111, D22.112, D22.121, D22.122, D23.111, D23.112, D23.121, D23.122, E75.26, F53.0, F53.1, G51.31, G51.32, G51.33, H02.23A, H02.23B, H02.23C, H57.811, H57.812, H57.813, H57.819, H57.89, I63.81, I63.89, I67.850, I67.858, T81.40XA, T81.40XD, T81.40XS, T81.41XA, T81.41XD, T81.41XS, T81.42XA, T81.42XD, T81.42XS, T81.43XA, T81.43XD, T81.43XS, T81.44XA, T81.44XD, T81.44XS, T81.49XA, T81.49XD* and T81.49XS* Added to Group 2: F53.0 and F53.1 Deleted from Group 1: C43.11, C43.12, C4A.11, C4A.12, C44.112, C44.119, C44.122, C44.129, C44.192, C44.199, D03.11, D03.12, D04.11, D04.12, D22.11, D22.12, D23.11, D23.12, F53, G51.3, H57.8, I63.8, T81.4XXA, T81.4XXD and T81.4XXS* Deleted from Group 2: F53 Revised from Group 1: I63.333, I63.343, M50.01, M50.21, M50.31, M50.81 and M50.91	Revisions Due To ICD-10-CM Code Changes
10/08/2018	R7	0717/18 - At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy. Added and deleted the following ICD-10 codes in Group 1 related to 2018 annual ICD-10 updates and Response to Comments. All added codes are considered within the indications of the LCD. Added: C96.21 C96.22 C96.29 D47.02 G12.23 G12.24 G12.25 H54.0X33 H54.0X34 H54.0X35 H54.0X43 H54.0X44 H54.0X45 H54.0X53 H54.0X54 H54.0X55 H54.1131 H54.1132 H54.1141 H54.1142 H54.1151 H54.1152 H54.1213 H54.1214 H54.1215 H54.1223 H54.1224 H54.1225 H54.2X11 H54.2X12 H54.2X21 H54.2X22 H54.413A H54.414A H54.415A H54.42A3 H54.42A4 H54.42A5 H54.511A H54.512A H54.52A1 H54.52A2 I63.513 I63.523 I63.533 P91.811 P91.819 P91.88 S02.40AA S02.40AB S02.40AD S02.40AG S02.40AK S02.40AS S02.40BA S02.40BB S02.40BD S02.40BG S02.40BK S02.40BS S02.40CA S02.40CB S02.40CD S02.40CG S02.40CK S02.40CS S02.40DA S02.40DB S02.40DD S02.40DG S02.40DK S02.40DS S02.40EA S02.40EB S02.40ED S02.40EG S02.40EK S02.40ES S02.40FA S02.40FB S02.40FD S02.40FG S02.40FK S02.40FS Deleted: C96.2 D47.0 H54.0 H54.11 H54.12 H54.2 H54.41 H54.42 H54.51 H54.52 S06.1X7D S06.1X7S S06.1X8D S06.1X8S S06.2X7D S06.2X7S S06.2X8D S06.2X8S S06.307D S06.307S S06.308D S06.308S S06.317D S06.317S S06.318D S06.318S S06.327D S06.327S S06.328D S06.328S S06.337D S06.337S S06.338D S06.338S S06.347D S06.347S S06.348D S06.348S S06.357D S06.357S S06.358D S06.358S S06.367D S06.367S S06.368D S06.368S S06.377D S06.377S S06.378D S06.378S S06.387D S06.387S S06.388D S06.388S S06.4X7S S06.4X8S S06.5X7D S06.5X7S S06.5X8D S06.5X8S S06.6X7D S06.6X7S S06.6X8D S06.6X8S S06.817D S06.817S S06.818D S06.818S S06.827D S06.827S S06.828D S06.828S S06.897D S06.897S S06.898D S06.898S S06.9X7D S06.9X7S S06.9X8D S06.9X8S	Creation of Uniform LCDs Within a MAC Jurisdiction
10/01/2017	R6	08/24/2017: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy. Effective DOS 10/01/2016 the following ICD-10-CM codes were added: S02.40AA S02.40AB S02.40AD S02.40AG S02.40AK S02.40AS S02.40BA S02.40BB S02.40BD S02.40BG S02.40BK S02.40BS S02.40CA S02.40CB S02.40CD S02.40CG S02.40CK S02.40CS S02.40DA S02.40DB S02.40DD S02.40DG S02.40DK S02.40DS S02.40EA S02.40EB S02.40ED S02.40EG S02.40EK S02.40ES S02.40FA S02.40FB S02.40FD S02.40FG S02.40FK S02.40FS Effective DOS 10/01/2017 the following ICD-10-CM codes were added, deleted and had a description change: Added: C96.21 C96.22 C96.29 D47.02 G12.23 G12.24 G12.25 H54.0X33 H54.0X34 H54.0X35 H54.0X43 H54.0X44 H54.0X45 H54.0X53 H54.0X54 H54.0X55 H54.1131 H54.1132 H54.1141 H54.1142 H54.1151 H54.1152 H54.1213 H54.1214 H54.1215 H54.1223 H54.1224 H54.1225 H54.2X11 H54.2X12 H54.2X21 H54.2X22 H54.413A H54.414A H54.415A H54.42A3 H54.42A4 H54.42A5 H54.511A H54.512A H54.52A1 H54.52A2 I63.323 I63.333 I63.513 I63.523 I63.533 C96.2 was deleted from Group 1 D47.0 was deleted from Group 1 E85.8 was deleted from Group 1 H54.0 was deleted from Group 1 H54.11 was deleted from Group 1 H54.12 was deleted from Group 1 H54.2 was deleted from Group 1 H54.41 was deleted from Group 1 H54.42 was deleted from Group 1 H54.51 was deleted from Group 1 H54.52 was deleted from Group 1 S06.1X7D was deleted from Group 1 S06.1X7S was deleted from Group 1 S06.1X8D was deleted from Group 1 S06.1X8S was deleted from Group 1 S06.2X7D was deleted from Group 1 S06.2X7S was deleted from Group 1 S06.2X8D was deleted from Group 1 S06.2X8S was deleted from Group 1 S06.307D was deleted from Group 1 S06.307S was deleted from Group 1 S06.308D was deleted from Group 1 S06.308S was deleted from Group 1 S06.317D was deleted from Group 1 S06.317S was deleted from Group 1 S06.318D was deleted from Group 1 S06.318S was deleted from Group 1 S06.327D was deleted from Group 1 S06.327S was deleted from Group 1 S06.328D was deleted from Group 1 S06.328S was deleted from Group 1 S06.337D was deleted from Group 1 S06.337S was deleted from Group 1 S06.338D was deleted from Group 1 S06.338S was deleted from Group 1 S06.347D was deleted from Group 1 S06.347S was deleted from Group 1 S06.348D was deleted from Group 1 S06.348S was deleted from Group 1 S06.357D was deleted from Group 1 S06.357S was deleted from Group 1 S06.358D was deleted from Group 1 S06.358S was deleted from Group 1 S06.367D was deleted from Group 1 S06.367S was deleted from Group 1 S06.368D was deleted from Group 1 S06.368S was deleted from Group 1 S06.377D was deleted from Group 1 S06.377S was deleted from Group 1 S06.378D was deleted from Group 1 S06.378S was deleted from Group 1 S06.387D was deleted from Group 1 S06.387S was deleted from Group 1 S06.388D was deleted from Group 1 S06.388S was deleted from Group 1 S06.4X7S was deleted from Group 1 S06.4X8S was deleted from Group 1 S06.5X7D was deleted from Group 1 S06.5X7S was deleted from Group 1 S06.5X8D was deleted from Group 1 S06.5X8S was deleted from Group 1 S06.6X7D was deleted from Group 1 S06.6X7S was deleted from Group 1 S06.6X8D was deleted from Group 1 S06.6X8S was deleted from Group 1 S06.817D was deleted from Group 1 S06.817S was deleted from Group 1 S06.818D was deleted from Group 1 S06.818S was deleted from Group 1 S06.827D was deleted from Group 1 S06.827S was deleted from Group 1 S06.828D was deleted from Group 1 S06.828S was deleted from Group 1 S06.897D was deleted from Group 1 S06.897S was deleted from Group 1 S06.898D was deleted from Group 1 S06.898S was deleted from Group 1 S06.9X7D was deleted from Group 1 S06.9X7S was deleted from Group 1 S06.9X8D was deleted from Group 1 S06.9X8S was deleted from Group 1 T14.90 was deleted from Group 1 I63.211 descriptor was changed in Group 1 I63.212 descriptor was changed in Group 1 I63.22 descriptor was changed in Group 1 S04.031A descriptor was changed in Group 1 S04.032A descriptor was changed in Group 1 S04.039A descriptor was changed in Group 1 S04.041A descriptor was changed in Group 1 S04.042A descriptor was changed in Group 1 S04.049A descriptor was changed in Group 1	Revisions Due To ICD-10-CM Code Changes Reconsideration Request
10/01/2016	R5	LCD updated to add the A & D 7th characters to ICD-10-CM codes T20.211-T20.212, T20.22X-T20.27X, T20.29X, T20.311-T20.312, T20.32X-T20.327X, T20.39X, T20.511-T20.512, T20.52X-T20.57X, T20.59X, T20.611-T20.612, T20.62X-T20.67X, T20.69X, T20.711-T20.712, T20.72X-T20.77X, and T20.729X in Group 1 effective DOS 10/01/2015.	Reconsideration Request
10/01/2016	R4	Effective 10/01/2015 LCD revised to add the 7th character 'D' to S06.0X0D, S06.0X1D, S06.0X2D, S06.0X3D, S06.0X4D S06.0X5D, S06.0X6D, S06.0X7D, S06.0X8D, S06.0X9D. S06.1X0D, S06.1X1D, S06.1X2D, S06.1X3D, S06.1X4D. S06.1X5D, S06.1X6D, S06.1X7D, S06.1X8D, S06.1X9D, S06.2X0D S06.2X1D, S06.2X2D, S06.2X3D, S06.2X4D, S02.2X5D, S06.2X6D, S06.2X7D, S06.2X8D, S06.2X9D, S06.300D, S06.301D, S06.302D, S06.303D, S06.304D, S06.305D, S06.306D, S06.307D, S06.308D, S06.309D, S06.310D, S06.311D, S06.312D, S06.313D, S06.314D, S06.315D, S06.316D, S06.317D, S06.318D, S06.319D, S06.320D, S06.321D, S06.322D, S06.323D, S06.324D, S06.325D, S06.326D, S26.327D, S06.328D, S06.329D, S06.330D, S06.331D, S06.332D S06.333D, S06.334D, S06.335D, S06.336D, S06.337D, S06.338D, S06.339D, S06.340D, S06.341D, S06.342D, S06.343D, S06.344D, S06.345D, S06.346D, S06.347D, S06.348D, S06.349D, S06.350D, S06.351D, S06.352D, S06.353D, S06.354D, S06.355D, S06.356D, S06.357D, S06.358D, S06.359D, S06.360D, S06.361D, S06.362D, S06.363D, S06.364D, S06.365D, S06.366D, S06.367D, S06.368D, S06.369D, S06.370D, S06.371D, S06.372D, S06.373D, S06.374D, S06.375D, S06.376D, S06.377D, S06.378D, S06.379D, S06.380D, S06.381D, S06.382D, S06.383D, S06.384D, S06.385D, S06.386D, S06.387D, S06.388D, S06.389D, S06.5X0D, S06.5X1D, S06.5X2D, S06.5X3D, S06.5X4D, S06.5X5D, S06.5X6D, S06.5X7D, S06.5X8D, S06.5X9D, S06.6X0D, S06.6X1D, S06.6X2D, S06.6X3D, S06.6X4D, S06.6X5D, S06.6X6D, S06.6X7D, S06.6X8D, S06.6X9D, S06.810D, S06.811D, S06.812D, S06.813D, S06.814D, S06.815D, S06.816D, S06.817D, S06.818D, S06.819D, S06.820D, S06821D, S06.822D, S06.823D, S06.824D, S06.825D, S06.826D, S06.827D, S06.828D, S06.829D, S06.890D, S06.891D, S06.892D, S06.893D, S06.894D, S06.895D, S06.896D, S06.897D, S06.898D, S06.899D, S06.9X0D, S06.9X1D, S06.9X2D, S06.9X3D, S06.9X4D, S06.9X5D, S06.9X6D, S06.9X7D, S06.9X8D and S06.9X9D. The ICD-10-CM codes added with this revision effective 10/01/2015 S06.0X2D, S06.0X3D, S06.0X4D S06.0X5D, S06.0X6D, S06.0X7D, S06.0X8D are deleted effective 10/01/2016 and cannot be displayed in this LCD version due to the application of the 2017 ICD-10 annual code update. Noridian will ensure these codes will be payable through 09/30/2016. Added Effective 8/11/16, E08.630, E09.630, E13.630, K04.8, M26.00, M26.01, M26.02, M26.03, M26.04, M26.05, M26.06, M26.07, M26.09, M26.10, M26.11, M26.12, M26.19, M26.50, M26.51, M26.52, M26.53, M26.54, M26.55, M26.56, M26.57, M26.59, M26.69, S02.5XXA, S02.5XXB, S03.2XXA and S03.2XXS* may be considered routine dental services. Providers must have documentation available for review to support these services are reasonable and necessary and not routine dental services to the Group 1: Medical Necessity ICD-10 Codes Asterisk Explanation section. Effective 10/01/2016 this LCD is also revised to add ICD-10-CM codes to D47.Z2, D49.511, D49.512, D49.519, D49.59, I60.2, M26.601, M26.602, M26.603, M26.611, M26.612, M26.613, M26.621, M26.622, M26.623, M26.631, M26.632, M26.633, M50.021, M50.022, M50.023, M50.120, M50.121, M50.122, M50.123, M50.221, M50.222, M50.223, M50.321, M50.322, M50.32, M50.821, M50.822, M50.823, M50.921, M50.922, M50.9233, S02.101A, S02.101B, S02.101D, S02.101K, S02.101S, S02.102A, S02.102B, S02.102D, S02.102K, S02.102S, S02.31XA, S02.31XB, S02.31XD, S02.31XK, S02.31XS, S02.32XA, S02.32XB, S02.32XD, S02.32XK, S02.32XS, S02.611A, S02.611B, S02.611D, S02.611K, S02.611S, S02.612A, S02.612B, S02.612D, S02.612K, S02.612S, S02.621A, S02.621B, S02.621D,,S02.621K, S02.621S, S02.622A, S02.622B, S02.622D, S02.622K, S02.622S, S02.631A, S02.631B, S02.631D, S02.631K, S02.631S, S02.632A, S02.632B, S02.632D, S02.632K, S02.632S, S02.641A, S02.641B, S02.641D, S02.641K, S02.641S, S02.642A, S02.642B, S02.642D, S02.642K, ,S02.642S, S02.651A S02.651B, S02.651D, S02.651K, S02.651S, S02.652A, S02.652B, S02.652D, S02.652K, S02.652S, S02.671A, S02.671B, S02.671D, S02.671K, S02.671S, S02.672A, S02.672B, S02.672D, S02.672K, S02.672S, S02.81XA, S02.81XB, S02.81XD, S02.81XK, S02.81XS, S02.82XA, S02.82XB, S02.82XD, S02.82XK, S02.82XS, S03.01XA, S03.02XA, S03.03XA, T85.810A, T85.818A, T85.820A, T85.828A, T85.830A, T85.838A, T85.840A, T85.848A, T85.850A, T85.858A, T85.860A, T85.868A, T85.890A and T85.898A to Group 1 and F32.81 and F32.89 were added to Group 2. TEffective 10/01/2016, ICD-10-CM codes are deleted D49.5, E08.321, E08.329. E08.331, E08.339 E08.341, E08.349, E08.351, E08.359, E09.321 1E09.329, E09.331, E09.339, E09.341, E09.349, E09.351, E09.359, E10.351, E10.359, E11.351, E11.359, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359, H34.811, H34.812, H34.813, H34.819, H34.831, H34.832, H34.833, H34.839, I60.20, I60.21, I60.22, I69.01, I69.11, I69.21, I69.31, I69.81, I69.91, I97.62, M26.60, M26.61 M26.62, M26.63, M50.02, M50.12, M50.22, M50.32, M50.82, M50.92, S02.10XA, S02.10XB, S02.10XD, S02.10XK, S02.10XS, S02.3XXA, S02.3XXB, S02.3XXD, S02.3XXK, S02.3XXS S02.61XA, S02.61XB, S02.61XD, S02.61XK, S02.61XS, S02.62XA, S02.62XB, S02.62XD, S02.62XK, S02.62XS, S02.63XA, S02.63XB, S02.63XD, S02.63XK, S02.63XS, S02.64XA, S02.64XB, S02.64XD, S02.64XK, S02.64XS, S02.65XA, S02.65XB, S02.65XD, S02.65XK, S02.65XS, S02.67XA, S02.67XB, S02.67XD, S02.67XK, S02.67XS, S02.8XXA, S02.8XXB S02.8XXD, S02.8XXK, S02.8XXS, S03.0XX, S03.4XXA, S06.0X2A, S06.0X2S, S06.0X3A, S06.0X3S, S06.0X4A, S06.0X4S, S06.0X5A, S06.0X5S, S06.0X6A, S06.0X6S, S06.0X7A, S06.0X7S, S06.0X8A, S06.0X8S, T85.81XA, T85.82XA, T85.83XA, T85.84XA, T85.85XA, T85.86XA and T85.89XA from Group 1. Effective 10/01/2016 the following ICD-10 code descriptions were changed in the ICD-10 Codes that Support Medical Necessity field: C81.11, C81.21, C81.28, C81.29, C81.31, C81.38, C81.39, C81.41, C81.48, C81.49, C81.71, C81.78, C81.79, D3A.094, D3A.095, D3A.096, D78.21, D78.22, G97.51, G97.52, H59.311, H59.312, H59.313, H59.319, H59.321, H59.322, H59.323 H59.329, H95.41 H95.42 I97.610 I97.611 I97.618 I97.820 I97.821 J95.830, J95.831 L76.21 L76.22 P02.1 S02.110A S02.110B S02.110D S02.110K S02.110S S02.111A S02.111B S02.111D S02.111K S02.111S S02.112A S02.112B S02.112D S02.112K S02.112S S02.118A S02.118B S02.118D S02.118K S02.118S S02.400A S02.400B S02.400D S02.400K S02.400S S02.401A S02.401B S02.401D S02.401K S02.401S S02.402A S02.402B S02.402D S02.402K S02.402S S02.600A S02.600B S02.600D S02.600K S02.600S T85.110A T85.111A T85.112A T85.120A T85.121A T85.122A T85.190A T85.191A T85.192A T85.610A T85.620A T85.630A and T85.690A. LCD number L35177 JFA retired effective October 01, 2016 and combined into JFB LCD number L35175. JFA and JFB contract numbers will have the same final MCD LCD number and remain an Active LCD.	Revisions Due To ICD-10-CM Code Changes Reconsideration Request Other (Clarify use of some possible dental ICD-10-CM codes.)
10/01/2015	R3	R3 LCD revised to add ICD 10 codes R41.89, R53.81, R53.83, S02.0XXD, S02.10XD, S02.110D, S02.111D, S02.112D, S02113D, S02.118D, S02.119D, S02.19XD, S02.2XXD, S02.3XXD, S02.400D, S02.401D, S02.402D, S02.411D, S02.412D, S02.413D, S02.42XD, S02.5XXD, S02600D, S02.609D, S02.61XD, S02.62XD, S02.63XD, S02.64XD, S02.65XD, S02.66XD, S02.67XD, S02.69XD, S02.8XXD, S02.91XD, S02.92XD, Z85.01, Z85.020, Z85.028, Z85.030, Z85.038, Z85.040, Z85.048, Z85.05, Z85.07, Z85.060, Z85.068, Z85.110, Z85.118, Z85.12, Z85.21, Z85.22, Z85.230, Z85.238, Z85.3, Z85.41, Z85.42 , Z85.43, Z85.44, Z85.47, Z85.48, Z85.51, Z85.520, Z85.528, Z85.53 and Z85.54 to Group 1 Codes that Support Medical Necessity.	Creation of Uniform LCDs Within a MAC Jurisdiction Reconsideration Request
10/01/2015	R2	LCD revised to add ICD 10 codes R20.0, R20.1, R20.2, R20.3 R20.8 and H92.02 to Group I only. Note: In Revision 1 Revision History Explanation - ICD-10 codes C45.0 and C45.2 were also added when this revision was made	Revisions Due To ICD-10-CM Code Changes
10/01/2015	R1	The LCD is revised to add ICD10 codes C34.00-C41.9 in group 1 only. The effective date remains 10/1/15.	Revisions Due To ICD-10-CM Code Changes

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