B. Nationally Covered Indications
Category I - (Clinically effective, usually part of initial patient evaluation, may be an adjunct to radiologic and nuclear medicine diagnostic technique)
- Echoencephalography, (Diencephalic Midline) (A-Mode).
- Echoencephalography, Complete (Diencephalic Midline and Ventricular Size).
- Ocular and Orbital Echography (A-Mode).
- Covered procedures include efforts to determine the suitability of aphakic patients for implantation of an artificial lens (pseudophakoi) following cataract surgery.
- Ocular and Orbital Sonography (B-Mode).
- Echocardiography, Pericardial Effusion (M-Mode).
- Pericardiocentesis, by Ultrasonic Guidance.
- Echocardiography, Cardiac Valve(s) (M-Mode).
- Echocardiography, Complete (M-Mode).
- Echocardiography, limited (e.g., follow-up or limited study) (M-Mode).
- Pleural Effusion Echography.
- Thoracentesis, by Ultrasonic Guidance.
- Abdominal Sonography, complete survey study (B-Scan).
- Abdominal Sonography, limited (e.g., follow-up or limited study) (B-Scan).
- Abdominal Sonography is not synonymous with ultrasound examination of individual organs.
- Renal Cyst Aspiration, by Ultrasonic Guidance.
- Renal Biopsy, by Ultrasonic Guidance.
- Pancreas Sonography (B-Scan).
- Pancreatic Sonography has proven effective in diagnosing pseudocysts.
- Spleen Sonography (B-Scan).
- Abdominal Aorta Echography (A-Mode).
- Abdominal Aorta Sonography (B-Scan).
- Retroperitoneal Sonography (B-Scan).
- Retroperitoneal Sonography does not include planning of fields for radiation therapy.
- Urinary Bladder Sonography (B-Scan).
- Urinary bladder Sonography does not include staging of bladder tumors.
- Pregnancy Diagnosis Sonography (B-Scan).
- Fetal Age Determination (Biparietal Diameter) Sonography (B-Scan).
- Fetal Growth Rate Sonography (B-Scan).
- Placenta Localization Sonography (B-Scan).
- Pregnancy Sonography, Complete (B-Scan).
- Molar Pregnancy Diagnosis Sonography (B-Scan).
- Ectopic Pregnancy Diagnosis Sonography (B-Scan).
- Passive Testing (Antepartum Monitoring of Fetal Heart Rate In the Resting Fetus).
- Intrauterine Contraceptive Device Sonography (B-Scan).
- Pelvic Mass Diagnosis Sonography (B-Scan).
- Amniocentesis, by Ultrasonic Guidance.
- Arterial Flow Study, Peripheral (Doppler).
- Venous Flow Study, Peripheral (Doppler).
- Arterial Aneurysm, Peripheral (B-Scan).
- Radiation Therapy Planning Sonography (B-Scan).
- Thyroid Echography (A-Mode).
- Thyroid Sonography (B-Scan).
- Breast Echography (A-Mode).
- Breast Sonography (B-Scan).
- Hepatic Sonography (B-Scan).
- Gallbladder Sonography.
- Renal Sonography.
- Two-Dimensional Echocardiography (B-Mode).
- Monitoring of cardiac output (Esophageal Doppler) for ventilated patients in the ICU and operative patients with a need for intra-operative fluid optimization
C. Nationally Non-Covered Indications
Category II - (Clinical reliability and efficacy not proven):
- B-Scan for atherosclerotic narrowing of peripheral arteries.
D. Other
Uses for ultrasound diagnostic procedures not listed in Category I or II above are left to local MAC discretion. In view of the rapid changes in the field of ultrasound diagnosis, uses for ultrasound diagnostic procedures other than those listed under Categories I and II should be carefully reviewed before payment. Medical justification may be required.
(This NCD last reviewed June 2007.)