Local Coverage Determination (LCD)

Magnetic Resonance Imaging of the Orbit, Face, and/or Neck

L34425

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Contractor Information

LCD Information

Document Information

LCD ID
L34425
LCD Title
Magnetic Resonance Imaging of the Orbit, Face, and/or Neck
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 09/09/2021
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 2022 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 © 2022 American Dental Association. All rights reserved.

Copyright © 2022, 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.

CMS National Coverage Policy

Title XVIII of the Social Security Act §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §220.2 Magnetic Resonance Imaging (MRI)

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Magnetic Resonance Imaging (MRI) is a noninvasive diagnostic imaging modality used to diagnose a variety of central nervous system (CNS) disorders. MRI provides superior tissue contrast when compared to a Computerized Tomography (CT) scan, 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 a CT scan is the longer scanning time required for study, making it less useful for emergency evaluations. Contraindications include patients with implanted neurostimulators or cochlear implants. Potential contraindications may include patients with cardiac pacemakers (refer to the CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §220.2), metal fragments in the eye, magnetic ocular implants or patients with older ferromagnetic intracranial aneurysm clips. All of these objects may be potentially displaced when exposed to the powerful magnetic fields used in MRI.

MRI of the orbit, face, and/or neck may be considered medically reasonable and necessary when used to diagnose and characterize pathology of the eye, nasopharynx, oropharynx, and neck including tumors, infection, soft tissue pathologies, and congenital abnormalities. In cases involving trauma to the orbit, face and/or neck, a CT scan is frequently superior to MRI for assessing injury.

MRI is considered investigational when medical records document the service was performed only for one of the following:

    • measurement of blood flow and spectroscopy,
    • imaging of cortical bone and calcifications, and
    • procedures involving spatial resolution of bone or calcifications.


In some instances, ordering a MRI of the brain in addition to a MRI of the orbit, face, and/or neck may be medically necessary on the same day. The medical record should document the medical necessity for these two procedures being performed on the same day.

Initial imaging of the thyroid should be done with ultrasound or nuclear medicine, unless there is a known carcinoma present.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information

Documentation Requirements

Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the A/B MAC upon request.

Utilization Guildelines

In general, it is not medically necessary to perform myelography, CT examinations, and MRI examinations for evaluation of the same condition on the same day. The medical record should document the necessity for evaluations in addition to a MRI.

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
N/A
Bibliography
  1. Ahmad A, Branstetter BF. CT versus MR: Still a Tough Decision. Otolaryngol Clin North Amer. 2008;41(1):1-22.
  2. American College of Radiology.  ACR Practice Parameter for Performing and Interpreting Magnetic Resonance Imaging (MRI). Published 2011. Revised 2017. Accessed on 8/3/21.
  3. Cummings CW, Flint PW, Harker LA, et al. Diagnostic and Interventional Neuroradiology. Cummings Otolaryngology: Head & Neck Surgery. 4th ed, Vol. 4. Philadelphia, Pa: Mosby; 2005:3675-3697.
  4. Cummings CW, Flint PW, Harker LA, et al. Overview of Diagnostic Imaging of the Head and Neck. Cummings Otolaryngology: Head & Neck Surgery. 4th ed, Vol. 1. Philadelphia, Pa: Mosby; 2005:25-92.

Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
09/09/2021 R14

Under CMS National Coverage Policy revised description to the CMS Internet-Only Manual regulation. Under Bibliography changes were made to citations to reflect AMA citation guidelines.

  • Provider Education/Guidance
11/05/2020 R13

Under CMS National Coverage Policy removed the regulation “Title XVIII of the Social Security Act 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim” and added it to the related billing and coding article.

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.

  • Provider Education/Guidance
10/24/2019 R12

This LCD is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Magnetic Resonance Imaging of the Orbit, Face and/or Neck A56729 article.

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.

  • Provider Education/Guidance
07/25/2019 R11

All coding located in the Coding Information section has been moved into the related Billing and Coding: Magnetic Resonance Imaging of the Orbit, Face, and/or Neck A56729 article and removed from 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.

  • Provider Education/Guidance
10/01/2018 R10

Under ICD-10 Codes that Support Medical Necessity: Group 1 added ICD-10 codes C43.111, C43.112, C43.121, C43.122, C44.1021, C44.1022, C44.1091, C44.1092, C44.1121, C44.1122, C44.1191, C44.1192, C44.1221, C44.1222, C44.1291, C44.1292, C44.1321, C44.1322, C44.1391, C44.1392, C44.1921, C44.1922, C44.1991, C44.1992, C4A.111, C4A.112, C4A.121, C4A.122, D03.111, D03.112, D03.121, D03.122, D04.111, D04.112, D04.121, D04.122, D23.111, D23.112, D23.121, D23.122, H02.23A, H02.23B and H02.23C. Under ICD-10 Codes that Support Medical Necessity: Group 1 deleted ICD-10 codes C43.11, C43.12, C44.102, C44.109, C44.112, C44.119, C44.122, C44.129, C44.192, C44.199, D03.11, D03.12 and H57.8. This revision is due to the 2018 Annual ICD-10 Code Update and is effective on October 1, 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.

  • Revisions Due To ICD-10-CM Code Changes
08/16/2018 R9

Under CMS National Coverage Policy added (a)(2) in front of (E) in the third policy. Under Coverage Indications, Limitations and/or Medical Necessity added the acronym (CNS) after the verbiage “central nervous system” in the first paragraph.  The verbiage “Orbit, Face and/or Neck” was changed to lower case letters in the beginning of the second paragraph. The verbiage “Magnetic Resonance Imaging” was replaced with the acronym MRI in the third paragraph. Under Bibliography deleted the verbiage “ACR: Quality is our image” and changed the access date to 8/7/2018 in the second reference. Formatting was corrected throughout the policy.

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.

  • Provider Education/Guidance
01/29/2018 R8 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
09/21/2017 R7

Under Coverage Indications, Limitations and/or Medical Necessity in the first paragraph revised the second sentence to define the acronym for CT and added “a scan” to the verbiage. In the third sentence of the first paragraph and the last sentence of the second paragraph added “a scan” to the verbiage. Under Sources of Information and Basis for Decision updated the source “American College of Radiology. ACR:Quality is our image. ACR Practice Guideline for Performance of Magnetic Resonance Imaging Published 2011. Amended 2014” to “American College of Radiology. ACR:Quality is our image.ACR Practice Parameter for Performing and Interpreting Magnetic Resonance Imaging (MRI) Published 2011. Revised 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.

  • Provider Education/Guidance
10/13/2016 R6 Under CMS National Coverage Policy for Title XVIII of the Social Security Act 1833(e) deleted the verbiage “states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim” and revised the verbiage to read “prohibits Medicare payment for any claim which lacks the necessary information to process the claim”.
  • Provider Education/Guidance
10/22/2015 R5 Under ICD-10 Codes That Support Medical Necessity Group 1 added H59.331, H59.332, H59.333, H59.341, H59.342, H59.343, H59.351, H59.352, H59.353, H59.361, H59.362, H59.363, L03.213, S02.30XA, S02.30XB, S02.30XD, S02.30XG, S02.30XK, S02.30XS, S02.31XA, S02.31XB, S02.31XD, S02.31XG, S02.31XK, S02.31XS, S02.32XA, S02.32XB, S02.32XD, S02.32XG, S02.32XK, S02.32XS, 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, S02.601A, S02.601B, S02.601D, S02.601G, S02.601K, S02.601S, S02.602A, S02.602B, S02.602D, S02.602G, S02.602K, S02.602S, S02.610A, S02.610B, S02.610D, S02.610G, S02.610K, S02.610S, S02.611A, S02.611B, S02.611D, S02.611G, S02.611K, S02.611S, S02.612A, S02.612B, S02.612D, S02.612G, S02.612K, S02.612S, S02.620A, S02.620B, S02.620D, S02.620G, S02.620K, S02.620S, S02.621A, S02.621B, S02.621D, S02.621G, S02.621K, S02.621S, S02.622A, S02.622B, S02.622D, S02.622G, S02.622K, S02.622S, S02.630A, S02.630B, S02.630D, S02.630G, S02.630K, S02.630S, S02.631A, S02.631B, S02.631D, S02.631G, S02.631K, S02.631S, S02.632A, S02.632B, S02.632D, S02.632G, S02.632K, S02.632S, S02.640A, S02.640B, S02.640D, S02.640G, S02.640K, S02.640S, S02.641A, S02.641B, S02.641D, S02.641G, S02.641K, S02.641S, S02.642A, S02.642B, S02.642D, S02.642G, S02.642K, S02.642S, S02.650A, S02.650B, S02.650D, S02.650G, S02.650K, S02.650S, S02.651A, S02.651B, S02.651D, S02.651G, S02.651K, S02.651S, S02.652A, S02.652B, S02.652D, S02.652G, S02.652K, S02.652S, S02.670A, S02.670B, S02.670D, S02.670G, S02.670K, S02.670S, S02.671A, S02.671B, S02.671D, S02.671G, S02.671K, S02.671S, S02.672A, S02.672B, S02.672D, S02.672G, S02.672K, S02.672S, S02.80XA, S02.80XB, S02.80XD, S02.80XG, S02.80XK, S02.80XS, S02.81XA, S02.81XB, S02.81XD, S02.81XG, S02.81XK, S02.81XS, S02.82XA, S02.82XB, S02.82XD, S02.82XG, S02.82XK, S02.82XS, S03.00XA, S03.00XD, S03.00XS, S03.01XA, S03.01XD, S03.01XS, S03.02XA, S03.02XD, S03.02XS, S03.03XA, S03.03XD, S03.03XS, S03.40XA, S03.40XD, S03.40XS, S03.41XA, S03.41XD, S03.41XS, S03.42XA, S03.42XD, S03.42XS, S03.43XA, S03.43XD, S03.43XS, T85.730A, T85.730D, and T85.730S. Under ICD-10 Codes That Support Medical Necessity Group 1 revised code descriptions for C81.11, C81.21, C81.31, C81.41, and C81.71. This revision is due to the Annual ICD-10 Code Update that becomes effective October 1, 2016.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
10/22/2015 R4 Under CMS National Coverage Policy corrected Title XVII to now read XVIII. Under Coverage Indications, Limitations and or Medical Necessity added and revised verbiage to the first paragraph regarding contraindications for MRI. Under Associated Information added Documentation Requirements. Under Sources of Information and Basis for Decision corrected the volume number and added the page numbers to the following: Ahmad A, Branstetter BF. CT versus MR: Still a Tough Decision. Otolaryngol Clin North Amer. 2008;41(1):1-22. The access date was corrected for the second cited reference. The following references were deleted: Khan KM, Visentini PJ, Kiss ZS, et al. Correlation of Ultrasound and Magnetic Resonance Imaging with Clinical Outcome After Patellar Tenotomy: Prospective and retrospective Studies. Clin Jour Sport Med. 1999;9:129-137 and Sexton, S, Bettmann, M. Introducing the American College of Radiology Series. [editorial] Am Fam Phy. 2007; 76 (Issue 4).
  • Provider Education/Guidance
  • Typographical Error
  • Other
10/01/2015 R3 Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed.
  • Other (Bill type and/or revenue code removal)
10/01/2015 R2 Corrected the formatting of the ACR MRI source to correctly open hyperlink.
  • Typographical Error
10/01/2015 R1 Under CMS National Coverage Policy, In Pub 100-03 corrected the section to 220.2 (Was 220.0); Added CMS Internet-Only manual Pub 100-04 Medicare Claims Processing Manual, Chapter 13, Section40; Added Title XVIII of the SSA section 1833(e) No payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period and 1833(E) Outpatient Radiology Services.
Under Sources of Information and Basis for Decision removed citation for Latchaw RE, Silva, P. Diagnostic and Interventional Neuro Radiology. Cummings Otolaryngology Head & Neck Surgery. 4th ed. Philadelphia, Pa. Mosby Inc; 2005:3675-3697 as it was a duplicate citation and added citation for Khan K, Visentini PJ, Kiss ZS, et al. Correlation of Ultrasound and Magnetic Resonance Imaging with Clinical Outcome After Patellar Tenotomy: Prospective and retrospective Studies; Corrected all citations to AMA formatting.
  • Provider Education/Guidance
  • Other (Annual Validation)

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
09/03/2021 09/09/2021 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Magnetic Resonance Imaging
  • MRI
  • Orbit, Face, and/or Neck
  • MRI of Orbit, Face, and/or Neck

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