LCD Reference Article Response To Comments Article

Response to Comments: Lumbar MRI

A56017

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Source Article ID
N/A
Article ID
A56017
Original ICD-9 Article ID
Not Applicable
Article Title
Response to Comments: Lumbar MRI
Article Type
Response to Comments
Original Effective Date
08/27/2018
Revision Effective Date
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Revision Ending Date
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The Comment Period for the Lumbar MRI LCD L34220 began 06/01/2017 and ended 08/14/2017. Comments were received from the provider community. The notice period starts 07/12/2018 and ends on 08/27/2018.

 

Response To Comments

Number Comment Response
1

There were requests from a society to address some language changes in the “Indications and Limitations” section of the policy to make coverage and non-coverage distinctions clearer.   There were objections to words such as “severe, major” and “age-related”, particularly. 

Several of the suggestions were accepted and the document language was adjusted to reflect these changes.  The Contractor did not accept the substitution of “asymptomatic” in place of “uncomplicated” as it could envision situations where this substitution would not have the same meaning as what was intended.

2

An objection was raised over the suggestion that lumbar MRI and lumbar CT are duplicative studies. 

The language has been changed to reflect that there may be times when the two studies could be complementary.  However, the medical record must show why there was medical necessity for both in those circumstances.

3

Some comments expressed concern that medically necessary information for test performance would have to be in the report of the radiologist.

The language of the policy has been altered to allow such information to be in the radiology report or in the record of the ordering physician, who should also be the treating physician for the purposes of ordering a diagnostic study.

4

There was a request to remove “Certain uses of lumbar MRI are considered investigational and are therefore not covered by Medicare.  These include the measurement of blood flow, spectroscopy, imaging of cortical bone…”

These services are not covered in keeping with NDC direction.  Citations have been added to the header of the policy to explain the coverage restrictions.

5

There was a concern that the use of asterisks and the explanation of the use of the ICD 10 codes in that section of the policy were confusing and a request was made to use Group 1 and Group 2 ICD 10s instead to be clearer. 

 A change was made in the format of the policy and asterisked codes were moved to Group 2 codes with an explanation of their use. 

6

There were requests to add several diagnoses codes to the Group 1 ICD 10 listing in the policy. 

Review of the ICD 10 codes listed in the policy revealed that several were left over from the time the policy was combined with head, neck and thoracic spine.  Technically, these should have been removed from the lumbar spine MRI document before the draft was posted.  At this point in time, that could not be done without a new draft.  In some areas of the policy, only lumbar diagnoses are included and in others there are still some head and neck codes present.

We believe that the Group I and 2 ICD 10 code lists will clear up some of the confusion that occurred with the asterisked terminology.

7

There was a request to add codes from the osteoporosis section of the ICD 10 listing.

The Contractor agreed to add four codes from the range suggested to the Group 1 listing; each dealing with the initial visit.

8

There was a request to add the following ICD 10 codes to the policy:

M54.9, M54.10, M62.81, M25.551, M25.552 and R 52. 

The Contractor felt several of these were non-specific but did agree to add M25.551 and M25.552. 

9

A request was made to add ICD 10 codes from the ranges of M47.11- M48.02 and S22.080A through S32.2XXS to the ICD 10 listing in Group I.   Two articles were sent in support of the position. 

Reliability of Magnetic Resonance Imaging in Detecting Posterior Ligament Complex Injury in Thoracolumbar Spinal Fractures,” by Hwan-Mo Lee, MD, et al., published in Spine Volume 25, Number 16, pp 2079–2084, discusses a prospective study of 34 patients with thoracolumbar spinal fractures.  It was done to assess the reliability of magnetic resonance imaging (MRI) for posterior ligament complex injury in thoracolumbar spinal fractures and compared to operative findings.

The study was small and prospective.  T2 fat suppressed sagittal MRI may be best to assess the posterior longitudinal ligament but it is not the best technique for other areas that may be injured.  There was a suspicion of injury to this area with a combination of radiographs and traditional exam.   With a study of only 37 patients, the Contractor currently feels that medical necessity should be demonstrated on appeal for these special cases, to avoid the unnecessary use of repetitive MRIs that may inadvertently be used by many in screening.

“Thoracolumbar Spine Trauma Classification,” by Alpesh A. Patel, MD Alexander R. Vaccaro, MD, PhD, published in Journal of the American Academy of Orthopedic Surgeons, February 2010, Vol 18, No 2 is a review article.  It is an attempt to help with management of thoracolumbar spine trauma.  The Thoracolumbar Spine Trauma Classification System (TLICS) is the first system to incorporate the neurologic status of the patient.  It was published in 2010.  The authors have some conflict of interest.  The articles used as the basis of this were all level II evidence and below.  At the time of publication, it was unknown what the use of this was for other than adults with traumatic acute thoracolumbar spine injuries.  Also, only limited information was available on the clinical application at the time of publication.  Most studies related to this classification were performed by those involved in the creation of this system of classification.  The Contractor was not given updated information or studies from other investigators.  Again, the Contractor currently feels that medical necessity should be demonstrated on appeal for these special cases.

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Revision History Information

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
DL34220 - (MCD Archive Site)
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Public Versions
Updated On Effective Dates Status
07/02/2018 08/27/2018 - N/A Currently in Effect You are here

Keywords

  • Response
  • Comments
  • Lumbar
  • MRI
  • 72148
  • 72149
  • 72158
  • A9585
  • Q9953