Local Coverage Determination (LCD)

Magnetic Resonance Angiography (MRA)

L34372

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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
L34372
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 07/01/2020
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 © 2024, 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

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Magnetic Resonance Angiography (MRA). Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for Magnetic Resonance Angiography (MRA) and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site. 

Internet Only Manual (IOM) Citations:  

  • CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
    • Chapter 15, Section 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
  • CMS IOM Publication 100-03, Medicare National Coverage Determination (NCD) Manual,
    • Chapter 1, Section 220.2 Magnetic Resonance Imaging (MRI)
  • CMS IOM Publication 100-08, Medicare Program Integrity Manual,
    • Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD

Social Security Act (Title XVIII) Standard References:  

  • Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury. 
  • Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations. 
  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim. 

Federal Register References:

  • Code of Federal Regulations (CFR), Title 42, Volume 2, Chapter IV, Part 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions and Part 410.33 Independent diagnostic testing facility.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

History/Background and/or General Information

Magnetic Resonance Angiography (MRA) is an application of magnetic resonance (MR) imaging that provides visualization of blood flow, as well as images of normal and diseased blood vessels. Since MRA contrast agents are not nephrotoxic and are rarely associated with allergic type reactions, MRA without or with gadolinium-based contrast enhancement is an imaging alternative for patients who cannot tolerate iodine-based contrast media.

Although MRA appears to be a rapidly developing technology, the clinical safety and effectiveness of this procedure for all anatomical regions has not been proven. As a result coverage will be provided on a limited basis. Below are the indications for coverage allowed for MRA. All other uses of MRA will not be covered.

Covered Indications

Please refer to CMS IOM Publication 100-03, Medicare National Coverage Determination (NCD) Manual, Chapter 1, Section 220.2 Magnetic Resonance Imaging for covered MRA Indications for Head and Neck, Peripheral Arteries of Lower Extremities, Abdomen and Pelvis, and Chest.

MRA and contrast angiography (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. The medical record must clearly document the medical necessity of performing both tests.

Examples of indications that support medical necessity of contrast angiography (CA) performed as an adjunct to MRA:

  • Clarify conditions where test results or clinical information are contradictory (e.g., MRA and duplex Doppler ultrasound are discordant with the clinical differential diagnosis and conventional angiography, with its ability to directly measure pressure gradients across stenosis of questionable hemodynamic significance, can provide more definitive information).
  • Verify the site of clinically important vascular stenosis and help map out the surgical/endovascular approach (e.g., to determine which lesions should have an angioplasty and/or stent vs. which lesions require surgical bypass graft or no treatment at all).
  • Identify situations where MRA is nonconclusive or degraded by metallic artifact.

Abdomen and Pelvis

Studies show that diagnostic evaluation of several upper abdominal malignancies may require an evaluation for vascular invasion by the tumor in deciding if the patient is a candidate for surgical resection of the tumor. One example is with pancreatic carcinoma. Pancreatic head carcinomas can grow in close proximity to the superior mesenteric vein. 

Evidence suggests that MRA provides reliable, noninvasive evaluation of the portal and hepatic veins. MRA can provide focused evaluation of particular areas of interest as well as a broad overview anatomic display that is helpful to surgeons and interventionalists planning procedures.

As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.

Summary of Evidence

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Analysis of Evidence (Rationale for Determination)

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Proposed Process Information

Synopsis of Changes
Changes Fields Changed
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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

Documentation Requirements

Please refer to the Local Coverage Article: Billing and Coding: Magnetic Resonance Angiography (MRA) (A57779) for documentation requirements that apply to the reasonable and necessary provisions outlined in this LCD.

Utilization Guidelines

Please refer to the Local Coverage Article: Billing and Coding: Magnetic Resonance Angiography (MRA) (A57779) for utilization guidelines that apply to the reasonable and necessary provisions outlined in this LCD.

Sources of Information

First Coast Service Options, Inc., reference LCD number(s) – L28925, L29218, L29447

American College of Radiology (2001). ACR Practice Guideline for the Performance of Pediatric and Adult Neurovascular Magnetic Resonance Angiography (MRA).

Grainger & Allison’s. (2001). “Diagnostic Radiology: A Textbook of Medical Imaging”, (4th ed.) Churchill Livingstone Inc.

Koelemay, M. et al. (2001). “Magnetic Resonance Angiography for the Evaluation of Lower Extremity Arterial Disease”, JAMA. 2001; 285:1338-1345.

Leung, D.A., et al., “MR Angiography of the Renal Arteries”, Radiology Clinics of North America, 40(4): 847-65, 2002.

NIA Diagnostic Imaging Guidelines. [on-line].

Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
07/01/2020 R8

Revision Number: 5
Publication: June 2020 Connection
LCR A/B2020-048

Explanation of Revision: Based on a CMS directive, the LCD was revised to remove language in the “Limitations” section. The effective date of this revision is based on date of service.

  • Other (Revision based on CMS directive)
11/28/2019 R7

Revision Number: 4
Publication: November 2019 Connection
LCR A/B2019-075

Explanation of Revision: Explanation of Revision: Based on Change Request (CR) 10901, the LCD was revised to remove all billing and coding and all language not related to reasonable and necessary provisions (“Bill Type Codes,” “Revenue Codes,” “CPT/HCPCS Codes,” “ICD-10 Codes that Support Medical Necessity,” “Documentation Requirements” and “Utilization Guidelines” sections of the LCD) and place them into a newly created billing and coding article. In addition, the Social Security Act Code, Code of Federal Regulations, and IOM reference sections were updated. Also, Also, the CMS IOM language has been removed from the LCD and instead, the IOM citation related to this language is referenced in the “Covered Indications” section of the LCD. The effective date of this revision is for claims processed on or after January 8, 2019, for dates of service on or after October 3, 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 LCD.

  • Other (Revision based on CR 10901)
01/22/2019 R6

Revision Number: 3
Publication: February 2019 Connection
LCR A/B2019-014

Explanation of Revision: Based on review of the LCD, grammatical errors were corrected. The effective date of this revision is based on process date. Also, it was determined that some of the italicized language in the “Coverage Indications, Limitations, and/or Medical Necessity” section of the LCD does not represent direct quotations from some of the CMS sources listed in the LCD; therefore, this LCD is being revised to assure consistency with the CMS sources. The effective date of this revision is based on date of service.

01/22/2019: 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 LCD.

  • Other (Revisions based on review)
04/12/2018 R5

Revision Number: 2

Publication: April 2018 Connection

LCR A/B2018-037

Explanation of Revision:  Based on an external correspondence, the “CPT/HCPCS Codes” section of the LCD was revised to remove language referring to Hospital OPPS and Ambulatory Surgical Centers (ASCs).  All the “C” codes listed in the LCD are billable to hospital OPPS and Ambulatory Surgical Centers (ASCs). Therefore, the “CPT/HCPCS Codes” section of the LCD was revised to consolidate the Part A and Part B groups that support medical necessity and groups that do not support medical necessity. The effective date of this revision is based on process date.

04/12/2018:  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.

  • Provider Education/Guidance
  • Public Education/Guidance
01/09/2018 R4

Revision Number: 1

Publication: January 2018 Connection

LCR A/B2018-008

Explanation of Revision:  Based on an annual review of the LCD, it was determined that some of the italicized language in the “Indications and Limitations of Coverage and/or Medical Necessity” section of the LCD does not represent direct quotation from the CMS sources listed in the LCD; therefore, this LCD is being revised to assure consistency with the CMS sources. The effective date of this revision is based on date of service.

01/09/2018:  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.

  • Other (Annual Review completed on 09/21/2017.)
10/01/2015 R3 The language and/or ICD-10-CM diagnoses were updated to be consistent with the current ICD-9-CM LCD’s language and coding.
  • Provider Education/Guidance
10/01/2015 R2 07/07/2015 - The language and/or ICD-10-CM diagnoses were updated to be consistent with the current ICD-9-CM LCD’s language and coding.
  • Public Education/Guidance
10/01/2015 R1 06/25/2015 The language and/or ICD-10-CM diagnoses were updated to be consistent with the current ICD-9-CM LCD’s language and coding.
  • Provider Education/Guidance
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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
06/19/2020 07/01/2020 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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