FUTURE Local Coverage Determination (LCD)

Magnetic Resonance Imaging of the Head and Neck

L34425

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Proposed LCD
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Future Effective
To see the currently-in-effect version of this document, go to the section.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34425
Original ICD-9 LCD ID
Not Applicable
LCD Title
Magnetic Resonance Imaging of the Head and Neck
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL34425
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 03/27/2025
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
12/12/2024
Notice Period End Date
03/26/2025

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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.

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Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.

Issue - Explanation of Change Between Proposed LCD and Final LCD

No changes between Proposed LCD and Final LCD.

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 (NCD) 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 radiation-free, noninvasive technique used to produce high-quality sectional images of the inside of the body in multiple planes. MRI uses natural magnetic properties of the hydrogen atoms in the body that emit radiofrequency signals when exposed to radio waves within a strong magnetic field. These signals are processed and converted by a computer into high-resolution, three-dimensional, tomographic images. Images and resolution produced by MRI is quite detailed. For some MRI, contrast materials (e.g., gadolinium, gadoteridol, non-ionic and low-osmolar contrast media, ionic and high-osmolar contrast media) are used to enable visualization of a body system or body structure.1

MRI provides superior tissue contrast when compared to a computerized tomography (CT) scan, can image in multiple planes, is not affected by bone artifact, provides vascular imaging capability, and makes use of safer contrast media (gadolinium chelate agents).1 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 (NCD) Manual, Chapter 1, Part 4, §220.2), metal fragments in the eye, magnetic ocular implants or patients with older ferromagnetic intracranial aneurysm clips. All 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.

In many instances, ordering an MRI of the brain, in addition to an 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 2 procedures being performed on the same day.

Summary of Evidence

A literature review was conducted to highlight some of the areas where MRI of the orbit, face and neck was used to demonstrate the utility of this imaging modality. Sources include published peer-reviewed articles and published society guidelines from the last 25 years.

MRI is superior for the evaluation of the visual pathways, globe and soft tissues; CT is preferred for visualizing bony detail and calcifications.2,3

Orbital MRI may be used for abnormalities detected on external or direct eye examinations, optic neuritis, orbital trauma, ocular mass(es), known or suspected orbital infection, osteomyelitis, congenital anomalies and strabismus concerns.4-25

Sinus MRI may be required to detect abnormalities and conditions such as rhinosinusitis with suspicion of fungal infections, clinical suspicion of orbital or intracranial complications, suspected mass based upon exam, nasal endoscopy or previous imaging and for conditions such as anosmia or osteomyelitis.20,21,26-31

Various facial masses, facial trauma, autoimmune diseases and neuropathies, such as trigeminal neuralgia, may be diagnosed or evaluated further with MRI imaging.18,19,26,27,33-39

In addition, neck MRI may be useful for the management of conditions involving the neck, including lesions involving the mouth, throat or neck; suspicious masses/tumors found on another imaging modality that needs additional clarification; neck masses or lymphadenopathy; infections of the face, neck or neck spaces involving any of the fascial planes; neurological conditions such as Bell’s palsy, hemifacial spasm or other neuropathies; and suspected thyroid or parathyroid neoplasms. Other neck indications could include evaluation of the salivary glands, vocal cords, and internal auditory canals and middle ear.12,29,34,40-55

Analysis of Evidence (Rationale for Determination)

MRI is reasonable and necessary in the evaluation of medical and surgical conditions involving the orbit, face and neck region; such conditions may include but are not limited to congenital and inherited diseases, neoplasms, trauma, and infection. The soft tissue contrast between normal and abnormal tissues provided by MRI is sensitive for differentiating between inflammatory disease and malignant tumors and permits the precise delineation of tumor margins. MRI is useful for therapy planning and follow-up of face and neck neoplasms. It is also used for the evaluation of neck lymphadenopathy and vocal cord lesions.

CT scanning remains the study of choice for the imaging evaluation of acute and chronic inflammatory diseases of the sinonasal cavities. MRI is not considered the first-line study for routine sinus imaging because of limitations in the definition of the bony anatomy and length of imaging time. MRI for confirmation of diagnosis of sinusitis is discouraged because of hypersensitivity (overdiagnosis) in comparison to CT without contrast. MRI, however, is superior to CT in differentiating inflammatory conditions from neoplastic processes. MRI may better depict intraorbital and intracranial complications in cases of aggressive sinus infection, as well as differentiating soft-tissue masses from inflammatory mucosal disease. MRI may also identify fungal invasive sinusitis or encephaloceles.

Therefore, based upon an extensive review of the literature, MRI of the orbit, face and neck is reasonable and necessary for the diagnosis of various medical and surgical conditions of the head and neck region and the sinuses, when medically indicated.

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

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

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N/A

CPT/HCPCS Codes

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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

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 Guidelines

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 an MRI scan.

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. National Institute of Biomedical Imaging and Bioengineering (NIBIB). Magnetic resonance imaging (MRI). NIBIB lecture. Published April 2022. Accessed 6/18/24.
  2. Hande PC, Talwar I. Multimodality imaging of the orbit. Indian J Radiol Imaging. 2012;22(3):227-239.
  3. Kennedy TA, Corey AS, Policeni B, et al. ACR Appropriateness Criteria® orbits vision and visual loss. J Am Coll Radiol. 2018;15(5S):S116-S131.
  4. Margolin E. The swollen optic nerve: An approach to diagnosis and management. Pract Neurol. 2019;19(4):302-309.
  5. Passi N, Degnan AJ, Levy LM. MR imaging of papilledema and visual pathways: Effects of increased intracranial pressure and pathophysiologic mechanisms. AJNR Am J Neuroradiol. 2013;34(5):919-924.
  6. Hata M, Miyamoto K. Causes and prognosis of unilateral and bilateral optic disc swelling. Neuro-Ophthalmology. 2017;41(4):187-191.
  7. Fadzli F, Ramli N, Ramli NM. MRI of optic tract lesions: Review and correlation with visual field defects. Clin Radiol. 2013;68(10):e538-e551.
  8. Kedar S, Ghate D, Corbett JJ. Visual fields in neuro-ophthalmology. Indian J Ophthalmol. 2011;59(2):103-109.
  9. Prasad S, Galetta SL. Approach to the patient with acute monocular visual loss. Neurol Clin Pract. 2012;2(1):14-23.
  10. Sadun AA, Wang MY. Abnormalities of the optic disc. Handb Clin Neurol. 2011;102:117-157.
  11. Beck RW, Cleary PA, Anderson MM, Jr., et al. A randomized, controlled trial of corticosteroids in the treatment of acute optic neuritis. The Optic Neuritis Study Group. N Engl J Med. 1992;326(9):581-588.
  12. Consortium of Multiple Sclerosis Centers (CMSC). MRI protocol and clinical guidelines for the diagnosis and follow-up of MS: 2018 revised guidelines. CMSC. Updated 5/22/18. Accessed 6/18/24.
  13. Gala F. Magnetic resonance imaging of optic nerve. Indian J Radiol Imaging. 2015;25(4):421-438.
  14. Srikajon J, Siritho S, Ngamsombat C, Prayoonwiwat N, Chirapapaisan N. Differences in clinical features between optic neuritis in neuromyelitis optica spectrum disorders and in multiple sclerosis. Mult Scler J Exp Transl Clin. 2018;4(3):1-12.
  15. Voss E, Raab P, Trebst C, Stangel M. Clinical approach to optic neuritis: Pitfalls, red flags and differential diagnosis. Ther Adv Neurol Disord. 2011;4(2):123-134.
  16. Kaur K, Gurnani B, Devy N. Atypical optic neuritis - a case with a new surprise every visit. GMS Ophthalmol Cases. 2020;10:Doc11.
  17. Phuljhele S, Kedar S, Saxena R. Approach to optic neuritis: An update. Indian J Ophthalmol. 2021;69(9):2266-2276.
  18. Lin KY, Ngai P, Echegoyen JC, Tao JP. Imaging in orbital trauma. Saudi J Ophthalmol. 2012;26(4):427-432.
  19. Sung EK, Nadgir RN, Fujita A, et al. Injuries of the globe: What can the radiologist offer? Radiographics. 2014;34(3):764-776.
  20. Lee YJ, Sadigh S, Mankad K, Kapse N, Rajeswaran G. The imaging of osteomyelitis. Quant Imaging Med Surg. 2016;6(2):184-198.
  21. Arunkumar JS, Naik AS, Prasad KC, Santhosh SG. Role of nasal endoscopy in chronic osteomyelitis of maxilla and zygoma: A case report. Case Rep Med. 2011;2011:802964.
  22. Pakdaman MN, Sepahdari AR, Elkhamary SM. Orbital inflammatory disease: Pictorial review and differential diagnosis. World J Radiol. 2014;6(4):106-115.
  23. Kadom N. Pediatric strabismus imaging. Curr Opin Ophthalmol. 2008;19(5):371-378.
  24. Demer JL, Clark RA, Kono R, Wright W, Velez F, Rosenbaum AL. A 12-year, prospective study of extraocular muscle imaging in complex strabismus. J AAPOS. 2002;6(6):337-347.
  25. Engle EC. The genetic basis of complex strabismus. Pediatr Res. 2006;59(3):343-348.
  26. Kirsch CF, Bykowski J, Aulino JM, et al. ACR Appropriateness Criteria® sinonasal disease. J Am Coll Radiol. 2017;14(11S):S550-S559.
  27. Gavito-Higuera J, Mullins CB, Ramos-Duran L, Sandoval H, Akle N, Figueroa R. Sinonasal fungal infections and complications: A pictorial review. J Clin Imaging Sci. 2016;6(2):23.
  28. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): Adult sinusitis. Otolaryngol Head Neck Surg. 2015;152(2 Suppl):S1-S39.
  29. American College of Radiology (ACR). ACR Appropriateness Criteria® Cranial neuropathy. ACR. Updated 2022. Accessed 6/18/24.
  30. Rouby C, Thomas-Danguin T, Vigouroux M, et al. The Lyon clinical olfactory test: Validation and measurement of hyposmia and anosmia in healthy and diseased populations. Int J Otolaryngol. 2011;2011:203805.
  31. Zaghouani H, Slim I, Zina NB, Mallat N, Tajouri H, Kraiem C. Kallmann syndrome: MRI findings. Indian J Endocrinol Metab. 2013;17(Suppl 1):S142-S145.
  32. Koeller KK. Radiologic features of sinonasal tumors. Head Neck Pathol. 2016;10(1):1-12.
  33. Kuno H, Onaya H, Fujii S, Ojiri H, Otani K, Satake M. Primary staging of laryngeal and hypopharyngeal cancer: CT, MR imaging and dual-energy CT. Eur J Radiol. 2014;83(1):e23-e35.
  34. Haynes J, Arnold KR, Aguirre-Oskins C, Chandra S. Evaluation of neck masses in adults. Am Fam Physician. 2015;91(10):698-706.
  35. Raju NS, Ishwar P, Banerjee R. Role of multislice computed tomography and three-dimensional rendering in the evaluation of maxillofacial injuries. J Oral Maxillofac Radiol. 2017;5(3):67-73.
  36. Echo A, Troy JS, Hollier LH, Jr. Frontal sinus fractures. Semin Plast Surg. 2010;24(4):375-382.
  37. Kozakiewicz M, Olszycki M, Arkuszewski P, Stefanczyk L. [Magnetic resonance imaging in facial injuries and digital fusion CT/MRI]. Otolaryngol Pol. 2006;60(6):911-916.
  38. Hughes MA, Frederickson AM, Branstetter BF, Zhu X, Sekula RF, Jr. MRI of the trigeminal nerve in patients with trigeminal neuralgia secondary to vascular compression. AJR Am J Roentgenol. 2016;206(3):595-600.
  39. Pakalniskis MG, Berg AD, Policeni BA, et al. The many faces of granulomatosis with polyangiitis: A review of the head and neck imaging manifestations. AJR Am J Roentgenol. 2015;205(6):W619-W629.
  40. American College of Radiology (ACR). ACR Appropriateness Criteria® Neck mass/adenopathy. ACR. Updated 2018. Accessed 6/18/24.
  41. Pynnonen MA, Gillespie MB, Roman B, et al. Clinical practice guideline: Evaluation of the neck mass in adults. Otolaryngol Head Neck Surg. 2017;157(2 Suppl):S1-S30.
  42. American College of Radiology (ACR). ACR Appropriateness Criteria® Thyroid disease. ACR. Updated 2018. Accessed 6/18/24.
  43. Gharib H, Papini E, Garber JR, et al. American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules- 2016 update. Endocr Pract. 2016;22:622-639.
  44. Lin YS, Wu HY, Lee CW, Hsu CC, Chao TC, Yu MC. Surgical management of substernal goitres at a tertiary referral centre: A retrospective cohort study of 2,104 patients. Int J Surg. Mar 2016;27:46-52.
  45. Meyer AC, Kimbrough TG, Finkelstein M, Sidman JD. Symptom duration and CT findings in pediatric deep neck infection. Otolaryngol Head Neck Surg. 2009;140(2):183-186.
  46. Burke CJ, Thomas RH, Howlett D. Imaging the major salivary glands. Br J Oral Maxillofac Surg. 2011;49(4):261-269.
  47. Ren YD, Li XR, Zhang J, Long LL, Li WX, Han YQ. Conventional MRI techniques combined with MR sialography on T2-3D-DRIVE in Sjögren syndrome. Int J Clin Exp Med. 2015;8(3):3974-3982.
  48. Dankbaar JW, Pameijer FA. Vocal cord paralysis: Anatomy, imaging and pathology. Insights Imaging. 2014;5(6):743-751.
  49. Earwood JS, Rogers TS, Rathjen NA. Ear pain: Diagnosing common and uncommon causes. Am Fam Physician. 2018;97(1):20-27.
  50. Khan MA, Rafiq S, Lanitis S, et al. Surgical treatment of primary hyperparathyroidism: Description of techniques and advances in the field. Indian J Surg. 2014;76(4):308-315.
  51. Piciucchi S, Barone D, Gavelli G, Dubini A, Oboldi D, Matteuci F. Primary hyperparathyroidism: Imaging to pathology. J Clin Imaging Sci. 2012;2:59.
  52. Quesnel AM, Lindsay RW, Hadlock TA. When the bell tolls on Bell's palsy: Finding occult malignancy in acute-onset facial paralysis. Am J Otolaryngol. 2010;31(5):339-342.
  53. Mumtaz S, Jensen MB. Facial neuropathy with imaging enhancement of the facial nerve: A case report. Future Neurol. 2014;9(6):571-576.
  54. Vijayasarathi A, Chokshi FH. MRI of the brachial plexus: A practical review. Appl Radiol. 2016;45(4):9-18.
  55. American College of Radiology (ACR). ACR Appropriateness Criteria® Plexopathy. ACR. Updated 2021. Accessed 6/18/24.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
03/27/2025 R15

This LCD is being presented for notice. No changes were made from the proposed LCD that was presented for comment.

  • Provider Education/Guidance
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)
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220.2 - Magnetic Resonance Imaging
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Keywords

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

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