Local Coverage Determination (LCD)

Magnetic Resonance Angiography (MRA)

L33633

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L33633
Original ICD-9 LCD ID
Not Applicable
LCD Title
Magnetic Resonance Angiography (MRA)
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
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
N/A
Notice Period End Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 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 © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced 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. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (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 Section 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:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Code of Federal Regulations:

42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).

CMS Publications:

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6 – Hospital Services Covered Under Part B:

    20.4 Outpatient Diagnostic Services.


CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services:

    80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests.


CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Part 4:

    220.2 Magnetic Resonance Imaging


CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 13 – Radiology Services and Other Diagnostic Procedures:

    40.1 Magnetic Resonance Angiography

CMS Transmittal No. 7040, Publication 100-03, Medicare National Coverage Determinations (NCD)Manual, Change Request #7040, July 9, 2010, Magnetic Resonance Angiography (MRA).

CMS Transmittal No. 2045, Publication 100-04, Medicare Claims Processing Manual, Change Request #7147, September 10, 2010, October 2010 Update of the Ambulatory Surgical Center (ASC) Payment System.

CMS Transmittal No. 2050, Publication 100-04, Medicare Claims Processing Manual, Change Request #7117, September 17, 2010, October 2010 Update of the Hospital Outpatient Prospective Payment System (OPPS).

CMS Transmittal No. 2051, Publication 100-04, Medicare Claims Processing Manual, Change Request #7112, September 17, 2010, October Update to the 2010 Medicare Physician Fee Schedule Database (MPFSDB).

National Coverage Analysis (NCA); Magnetic Resonance Angiography of the Abdomen and Pelvis (CAG-00142N). http://www.cms.hhs.gov/ncdr/memo.asp?id=51. Accessed June 4, 2003.

National Coverage Determination. Magnetic Resonance Angiography. Publication 6. http://www.cms.hhs.gov/ncd/searchdisplay.asp?NCD_ID=178&NCD_vrsn_num=2. Accessed June 4, 2003.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Indications:

Please refer to Article A56747, Billing and Coding: Magnetic Resonance Angiography, for national coverage provisions.

Head and Neck
All of the following criteria must apply in order for Medicare to provide coverage for MRA of the head and neck:

  • MRA is used to evaluate the carotid arteries, the circle of Willis, the anterior, middle or posterior cerebral arteries, the vertebral or basilar arteries or the venous sinuses;

  • MRA is performed on patients with conditions of the head and neck for which surgery is anticipated and may be found to be appropriate based on the MRA. These conditions include, but are not limited to, tumor, aneurysms, vascular malformations, vascular occlusion or thrombosis. Within this broad category of disorders, medical necessity is the underlying determinant of the need for an MRA in specific diseases. The medical records should clearly justify and demonstrate the existence of medical necessity; and,

  • MRA and CA are not expected to be performed on the same patient for diagnostic purposes prior to the application of anticipated therapy. Only one of these tests will be covered routinely unless the physician can demonstrate the medical need to perform both tests.

MRA is appropriately used to verify the presence of a condition, suspected because of findings from another test (usually an imaging study). For example, a patient who presents with a transient ischemic attack (TIA) should not undergo MRA simply because he might have a lesion which is amenable to surgery. However, if that patient has a carotid bruit and is found by Doppler study to have carotid stenosis, an MRA may be appropriate to evaluate the stenotic section of artery for surgical intervention. Please note that the anticipated surgery may be a percutaneous procedure such as carotid angioplasty with stent insertion.

Another patient may present with a headache; it is not appropriate to proceed directly to MRA to rule out the possibility of an intracranial aneurysm. However, if that patient was found to have a clinically significant amount of blood in the cerebrospinal fluid, or the patient demonstrated signs and symptoms strongly suggesting an unruptured intracranial aneurysm, an MRA (or cerebral angiogram) may be appropriate. An MRA is not considered medically necessary for screening asymptomatic patients for intracranial aneurysms.

Please note that the anticipated surgery may be a percutaneous procedure such as carotid angioplasty with stent insertion.

Peripheral Arteries of Lower Extremities

  • Both MRA and CA may be useful in some cases, such as:
    A patient has had CA and this test was unable to identify a viable run-off vessel for bypass. When exploratory surgery is not believed to be a reasonable medical course of action for this patient, MRA may be performed to identify the viable runoff vessel; or,
  • A patient has had MRA, but the results are inconclusive.


Abdomen and Pelvis

An MRA of the abdomen for evaluation of possible renal artery stenosis would not be considered medically necessary without some evidence consistent with renovascular hypertension. Such evidence might include:

  • a history of early or late onset of hypertension, hypertension refractory to medication, or worsening renal function;
  • the presence of a renal artery bruit;
  • laboratory tests (elevated serum renins, increasing creatinine); or
  • other radiologic tests (ultrasound, captopril scintigraphy, or other imaging showing small kidney or unequal kidney sizes).

 

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information
N/A
Sources of Information

This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below.

American College of Radiology Expert Panel on Cardiovascular Imaging. Acute Chest Pain, Blunt Trauma, sudden Onset of Cold, Painful Leg, Recurrent Symptoms Following Lower Extremity Angioplasty, Recurrent Symptoms Following Lower Extremity Bypass Surgery. ACR Appropriateness Criteria 1996; Vol 1&2: CV-1.l-CV-1.7, CV-3.1-CV-3.7, CV-6.1-CV-6.7, CV2-1, 1-CV2-1.8, CV2-7, 1-CV2-7.6, CV2-8.8, CV2-9.1-CV2-9-10.

American College of Radiology Expert Panel on Neuro Imaging. Asymptomatic Cerebrovascular Disease. ACR Appropriateness Criteria 1996; Vol 1&2:NI-1.25.

American College of Radiology. Vascular/MRA. Techniques and indications [ACR standard for MRI]. http://acr.org/departments/stan-accred/standards/pdf-standards/mri/monograph-vasc.pdf. Accessed June 15, 1999.

Cambria RP, Kaufman JA, L’Italien GJ, et al. Magnetic resonance angiography in the management of lower extremity arterial occlusive disease: a prospective study. J Vasc Surg. 1997;25:380-389.

Fattori R, Celleti F, Descovich B, et al. Evolution of post-traumatic aortic aneurysm in the subacute phase: magnetic resonance imaging follow up as a support of the surgical timing. Eur J Cardiothorac Surg. 1998;13:582-587.

Other Medicare contractors.

Postma CT, Joosten FB, Rosenbusch G, Thien T. Magnetic resonance angiography has a high reliability in the detection of renal artery stenosis. Am J Hypertens. 1997;10:957-963.

Remonda L, Heid O, Schroth G. Carotid artery stenosis, occlusion, and pseudo-occlusion: first-pass, gadolinium-enhanced, three-dimensional MR angiography – preliminary study. Radiology. 1998;209(1):95-102. 

Source added from reconsideration request April 2018.

Thompson BG, Brown RD, Jr., Amin-Hanjani S, et al. Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015;46(8):2368-2400.

Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/01/2019 R20

This LCD was converted to the new "no-codes" format. There has been no change in coverage with this LCD revision.

  • Revisions Due To Code Removal
08/01/2019 R19

Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A56747. There has been no change in coverage with this LCD revision.

  • Provider Education/Guidance
10/01/2018 R18

Corrected Source listing.

  • Typographical Error
10/01/2018 R17

LCD revised for annual ICD-10 updates.

For Group 1, ICD-10 code I63.8 is deleted and replaced by I63.81 and I63.89 and ICD-10 codes I67.850 and I67.858 are being added.

For Group 4, ICD-10 code R93.8 is deleted and replaced by R93.811, R93.812, R93.913, R93.819, and R93.89.

DATE (10/01/2018): At this time, the 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 ICD-10-CM Code Changes
05/01/2018 R16

LCD revised to add sources submitted for a reconsideration request to add “history of aneurysm” to Indications and a diagnosis code for personal history of other diseases of the circulatory system to covered ICD-10 codes for MRA of the head/neck. No change was made in coverage.

DATE (05/01/2018): At this time, the 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.

  • Reconsideration Request
11/01/2017 R15

LCD revised to add ICD-10 code I72.6 as payable for MRA of the head and neck (group 1), effective for dates of service on or after 10/01/2016.

DATE (11/01/2017): At this time, the 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 Provider (Part A)
10/01/2017 R14

LCD revised for annual ICD-10 updates for 2018.

Deleted ICD-10 codes S06.4X7D, S06.4X7S, S06.4X8D, S06.4X8S, S06.5X7D, S06.5X7S, S06.5X8D, S06.5X8S, S06.6X7D, S06.6X7S, S06.6X8D, and S06.6X8S were removed from Group 1 (70544, 70545, 70546, 70547, 70548, 70549).

Minor wording changes made.

DATE (10/01/2017): At this time, the 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 ICD-10-CM Code Changes
03/16/2017 R13 Added ICD-10 codes H93.A1-H93.A3 for MRA of the head/neck, effective 10/01/2016.
  • Request for Coverage by a Practitioner (Part B)
10/01/2016 R12 Added ICD-10 code I60.2 for MRA of the head/neck, replacing deleted codes I60.21 and I60.22.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2016 R11 LCD revised for annual ICD-10 updates for 2017 with the following changes:
• For MRA of the head/neck, ICD-10 codes T85.113A-T85.113S, T85.123A-T85.123S, T85.193A-T85.193S, I72.5, I77.70, I77.75 were added.
• For MRA of the chest, ICD-10 codes Q25.21 and Q25.29 replaced deleted code Q25.2
• For MRA of the abdomen and pelvis, ICD-10 codes K55.011-K55.069 replaced deleted code K55.0
• For MRA of peripheral arteries, ICD-10 codes I72.6 and I77.77 were added.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R10 Bill type codes added.
  • Typographical Error
10/01/2015 R9 ICD-10 codes I60.9 and I61.9 were added as payable for MRA of the head/neck (group 1) effective 10/01/2015.
  • Request for Coverage by a Practitioner (Part B)
10/01/2015 R8 ICD-10 code G45.9 was added as payable for MRA of the head/neck (group 1) effective 10/01/2015.
  • Request for Coverage by a Practitioner (Part B)
10/01/2015 R7 The following ICD-10 codes have been added as payable for MRA of the head/neck (Group 1), effective 10/01/2015:
I63.00, I63.019, I63.039, I63.10, I63.119, I63.139, I63.20, I63.211, I63.212, I63.219, I63.22, I63.231, I63.232, I63.239, I63.29, I63.30, I63.319, I63.329, I63.339, I63.349, I63.40, I63.419, I63.429, I63.439, I63.449, I63.50, I63.511, I63.512, I63.519, I63.521, I63.522, I63.529, I63.531, I63.532, I63.539, I63.541, I63.542, I63.549, I63.59, I63.9.
  • Request for Coverage by a Practitioner (Part B)
10/01/2015 R6 ICD-10 codes were revised to add the 7th digit for D=subsequent encounter in the S15. range.
  • Provider Education/Guidance
10/01/2015 R5 ICD-10 codes were revised to add the 7th digit for D=subsequent encounter and S=sequela, where the 7th digit, A=initial encounter, was already included.
  • Provider Education/Guidance
10/01/2015 R4 Added ICD-10 code I73.9 to covered diagnoses for MRA of lower extremities, and for abdomen and pelvis.
  • Request for Coverage by a Provider (Part A)
10/01/2015 R3 Revised to add asterisk note for ICD-10 Group 1.
  • Typographical Error
10/01/2015 R2 Revised to add asterisk note for ICD-10 Group 1.
  • Other
10/01/2015 R1 Updated to include changes made to LCD since April 2014.
  • Other
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Associated Documents

Attachments
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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
09/17/2019 10/01/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • MRA

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