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Local Coverage Determination (LCD)

MRI and CT Scans of the Head and Neck

L37373

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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
L37373
Original ICD-9 LCD ID
Not Applicable
LCD Title
MRI and CT Scans of the Head and Neck
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL37373
Original Effective Date
For services performed on or after 10/08/2018
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
08/23/2018
Notice Period End Date
10/07/2018

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 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

Title XVIII of the Social Security Act, Section 1862(a)(7) excludes routine physical examinations. This provision excludes screening examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) allows coverage and payment for only those services that are considered reasonable and necessary.

Title XVIII of the Social Security Act, Section 1833(e) prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.

Title XVIII of the Social Security Act, Section 1862(a)(1)(D) prohibits Medicare payment for services and items that are experimental or investigational.

CMS publication 100-3, Medicare National Coverage Determinations, Sections 220.1 “Computerized Tomography”, and 220.2-220.2.B.2d and Section 220.2.C-220.2.D “Magnetic Resonance Imaging”.

Denies coverage of MRI for:

  1. Imaging of cortical bone and calcification;
  2. Procedures involving spatial resolution of bone or calcification;
  3. MRI is not covered for patients with metallic clips on vascular aneurysms

CMS publication 100-04 Medicare Claims Processing Manual Chapter 13 Section 40.

Denies coverage of MRI for:

  1. Measurement of blood flow and spectroscopy

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Note: Providers should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS) instructions in CMS Manuals. This LCD only pertains to the contractor's discretionary coverage related to this service.

This policy addresses standard CT and MR imaging. Magnetic Resonance Angiography (MRA) is not addressed in this policy.

Computerized Tomography (CT)
Computerized tomography (CT scanning) uses the attenuation of an x-ray beam by an object in its path to create cross-sectional images. As x-rays pass through planes of the body, the photons are detected and recorded as they exit from different angles. Computers process the signals to produce a cross-sectional view of the body. The signal data may be subjected to a variety of post-acquisitional processing algorithms to obtain a multiplanar view of the anatomy.

The use of the CT scan must be found medically appropriate considering the patient’s symptoms and preliminary diagnosis.

  1. A CT scan is considered reasonable and necessary for the patient when the diagnostic exam is medically appropriate given the patient's symptoms and preliminary (or provisional) diagnosis.
  2. CT scans (as opposed to MRI evaluations) are used effectively in the following situations or conditions:
    1. Patients who are not suitable candidates for MRI evaluation:
      1. Because of a pacemaker or intracranial metallic objects
      2. Because of extreme obesity
      3. Because of an inability to lie still
    2. Patients whose condition requires the visualization of fine bone detail or calcification
    3. Patients with the following conditions
      1. Acute CNS Hemorrhage
      2. Strokes or encephalomalacia
      3. New onset seizures, particularly if a focal component is present (contrast agent is appropriate for these patients)
      4. Intracranial (sic) lesions large enough to cause increased intracranial pressure (CT scan is useful to determine gross margins between tumor and edematous brain)
  3. There is no general rule that requires other diagnostic tests to be tried before CT scanning is used. However, in individual cases it may be determined that use of a CT scan as the initial diagnostic test was not reasonable and necessary because it was not supported by the patient’s symptoms or complaints as stated on the claim.
  4. CT imaging has not been useful in general for the evaluation of headache or dizziness and should be reserved for the patient whose presentation indicates a focal problem or who has experienced a significant change in symptomatology.
  5. A CT scan for the diagnosis of headache can be allowed for the following:
    1. After a head injury to rule out intracranial bleeding
    2. Headache unusual in duration (greater than two weeks) not responding to medical therapy, to rule out the possibility of a tumor
    3. A headache characterized by sudden onset and severity to rule out the possibility of an aneurysm, bleeding and/or arteriovenous malformation
  6. A CT Scan may be ordered without contrast, with contrast, or without contrast followed by contrast. Contrast administration is not without risk to the patient, and for some conditions, adds little or no benefit to the patient. The general indications for use of contrast CT scanning (as opposed to non-contrast scanning) are to:
    1. Assess perfusion (e.g. CVA)
    2. Characterize a specific lesion
    3. Detect defects in blood/brain barrier (e.g. infarct, tumor, infection, vasculitis)
    4. Detect neovascularity (tumor), and
    5. For staging of known lung cancer, breast cancer, and lymphomas likely to metastasize early to the brain
  7. Intravenous contrast generally adds no information to CT scans done secondary to head trauma. Additional symptoms suggesting a possible intracranial bleed may justify the use of contrast. These symptoms should be documented in the medical record, and if appropriate, included in the diagnostic codes listed on the claim.
  8. More than one contrast CT scan per episode of illness adds no information with the following exceptions:
    1. CVA
    2. Non-traumatic hemorrhage
    3. TIA
    4. Post-operative scan for residual tumor or post operative complication
    5. Known brain tumor/metastases with a change in mental status or other evidence of CNS change


Magnetic Resonance Imaging (MRI)
Magnetic Resonance Imaging (MRI) is a non-invasive diagnostic scanning technique that employs a powerful and highly uniform static magnetic field, rather than ionizing radiation, to produce images. Fluctuations in the strength of the magnetic field alter the motion and relaxation times of hydrogen molecules, which are related to the density of molecules and reflect the physicochemical properties of the tissues. Reconstructed images can be displayed in multiple planes to facilitate analysis. See national non-coverage in CMS section above.

Coverage is limited to those CT and MRI machines that have received pre-market approval by the FDA. Such units must be operated within the parameters specified by the approval.

Inconclusive findings on a CT scan may warrant a MRI study and, conversely, findings of a MRI study may be further clarified (under certain circumstances) with a subsequent CT scan. The information provided by the two modalities may be complementary.

Cancer Staging. Clinicians commonly use CT and MRI of the brain when metastatic involvement is suspected.

Non-covered indications: esophagus, oropharynx, and prostate, and non-melanoma skin cancer in the absence of symptoms of brain involvement. “Certain tumors almost never metastasize to the brain parenchyma. These include carcinomas of the esophagus, oropharynx, and prostate, and non-melanoma skin cancers.” (DeVita, Chapter 52.1) Accordingly, the related diagnoses found in the following diagnosis code list do not justify brain scans for “staging” purposes unless a patient has signs or symptoms suggesting brain involvement. Covered: In contrast, for those malignancies that commonly metastasize to the brain, staging in the absence of neurological findings may be appropriate.

Payment will be allowed for reasonable and necessary scans of different areas of the body that are performed on the same day and are not subject to this policy.
Summary of Evidence

NA
Analysis of Evidence (Rationale for Determination)

NA

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

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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

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

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

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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

See Bibliography

 
Bibliography
  1. Medicare Consultants
  2. Other contractor's policies
  3. DeVita, et al, eds, Cancer, Principles and Practice of Oncology, 6th edition, Philadelphia, Lippincott-Raven, 2001

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/01/2019 R8

The LCD is revised to remove CPT/HCPCS codes in the Keyword Section of 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.
  • Other (The LCD is revised to remove CPT/HCPCS codes in the Keyword Section of the LCD.
    )
10/01/2019 R7

The Code Description Change for diagnosis Z45.42 in Revision #4 was added in error. Diagnosis Z45.42 was never in the original MRI and CT Scans of the Head and Neck LCD.

In the Coverage Indications, Limitations and/or Medical Necessity section, under Computerized Tomography (CT) letter E, the ICD-10 code G44.1 was deleted. This code is listed in the associated Billing and Coding: MRI and CT Scans of the Head and Neck article.

10/01/2019 - 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 policy.
  • Typographical Error
  • Revisions Due To Code Removal
10/01/2019 R6

10/01/2019 - 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 policy.
  • Revisions Due To Code Removal
10/01/2019 R5

As required by CR 10901, all billing and coding information has been moved to the companion article, this article is linked to the LCD.

10/01/2019 - 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 policy.
  • Revisions Due To Code Removal
10/01/2019 R4

Effective 10/07/2018, G25.0 added as this is a covered indication.

Effective 10/01/2019, the following ICD-10 codes were added an deleted and code description was changed per the 2019 annual update

Added:

  • H81.4 - Vertigo of central origin
  • R11.15 - Cyclical vomiting syndrome unrelated to migraine
  • S02.121A - Fracture of orbital roof, right side, initial encounter for closed fracture
  • S02.121B - Fracture of orbital roof, right side, initial encounter for open fracture
  • S02.121D - Fracture of orbital roof, right side, subsequent encounter for fracture with routine healing
  • S02.121G - Fracture of orbital roof, right side, subsequent encounter for fracture with delayed healing
  • S02.121K - Fracture of orbital roof, right side, subsequent encounter for fracture with nonunion
  • S02.121S - Fracture of orbital roof, right side, sequela
  • S02.122A - Fracture of orbital roof, left side, initial encounter for closed fracture
  • S02.122B - Fracture of orbital roof, left side, initial encounter for open fracture
  • S02.122D - Fracture of orbital roof, left side, subsequent encounter for fracture with routine healing
  • S02.122G - Fracture of orbital roof, left side, subsequent encounter for fracture with delayed healing
  • S02.122K - Fracture of orbital roof, left side, subsequent encounter for fracture with nonunion
  • S02.122S - Fracture of orbital roof, left side, sequela
  • S02.831A - Fracture of medial orbital wall, right side, initial encounter for closed fracture
  • S02.831B - Fracture of medial orbital wall, right side, initial encounter for open fracture
  • S02.831D - Fracture of medial orbital wall, right side, subsequent encounter for fracture with routine healing
  • S02.831G - Fracture of medial orbital wall, right side, subsequent encounter for fracture with delayed healing
  • S02.831K - Fracture of medial orbital wall, right side, subsequent encounter for fracture with nonunion
  • S02.831S - Fracture of medial orbital wall, right side, sequela
  • S02.832A - Fracture of medial orbital wall, left side, initial encounter for closed fracture
  • S02.832B - Fracture of medial orbital wall, left side, initial encounter for open fracture
  • S02.832D - Fracture of medial orbital wall, left side, subsequent encounter for fracture with routine healing
  • S02.832G - Fracture of medial orbital wall, left side, subsequent encounter for fracture with delayed healing
  • S02.832K - Fracture of medial orbital wall, left side, subsequent encounter for fracture with nonunion
  • S02.832S - Fracture of medial orbital wall, left side, sequel
  • S02.841A - Fracture of lateral orbital wall, right side, initial encounter for closed fracture
  • S02.841B - Fracture of lateral orbital wall, right side, initial encounter for open fracture
  • S02.841D - Fracture of lateral orbital wall, right side, subsequent encounter for fracture with routine healing
  • S02.841G - Fracture of lateral orbital wall, right side, subsequent encounter for fracture with delayed healing
  • S02.841K - Fracture of lateral orbital wall, right side, subsequent encounter for fracture with nonunion
  • S02.841S - Fracture of lateral orbital wall, right side, sequela
  • S02.842A - Fracture of lateral orbital wall, left side, initial encounter for closed fracture
  • S02.842B - Fracture of lateral orbital wall, left side, initial encounter for open fracture
  • S02.842D - Fracture of lateral orbital wall, left side, subsequent encounter for fracture with routine healing
  • S02.842G - Fracture of lateral orbital wall, left side, subsequent encounter for fracture with delayed healing
  • S02.842K - Fracture of lateral orbital wall, left side, subsequent encounter for fracture with nonunion
  • S02.842S - Fracture of lateral orbital wall, left side, sequel
  • Z86.003 - Personal history of in-situ neoplasm of oral cavity, esophagus and stomach
  • Z86.005 - Personal history of in-situ neoplasm of middle ear and respiratory system
  • Z86.006 - Personal history of melanoma in-situ
  • Z86.007 - Personal history of in-situ neoplasm of skin

 Deleted:

Deleted from Group 1:

  • H81.41 Vertigo of central origin, right ear
  • H81.42 Vertigo of central origin, left ear
  • H81.43 Vertigo of central origin, bilateral

Code Description Change

  • From G43.A0 - Cyclical vomiting, not intractable to G43.A0 - Cyclical vomiting, in migraine, not intractable
  • From G43.A1 - Cyclical vomiting, intractable to G43.A1 - Cyclical vomiting, in migraine, intractable
  • From M50.120 - Mid-cervical disc disorder, unspecified to M50.120 - Mid-cervical disc disorder, unspecified level
  • From Z45.42 - Encounter for adjustment and management of neuropacemaker (brain) (peripheral nerve) (spinal cord) to Z45.42 - Encounter for adjustment and management of neurostimulator

09/12/19 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.
  • Creation of Uniform LCDs Within a MAC Jurisdiction
  • Revisions Due To ICD-10-CM Code Changes
10/08/2018 R3

11/29/18 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.

LCD revised to remove ICD-10 code R32 as it was unintentionally added with the last revision and added ICD-10 code C15.5
  • Creation of Uniform LCDs Within a MAC Jurisdiction
  • Typographical Error
10/08/2018 R2

10/23/18 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.

LCD revised to make editorial changes to B3d and H4 in the Coverage Indications, Limitations and/or Medical Necessity section. Added C15.3, C15.4 and C15.8, C88.0, C85.90, D32.9, E22.9, E23.7, E87.1, F80.1, G44.021, G62.89, H40.052, H40.053, H91.91-H91.93, H95.89, I60.9, I61.9, I63.20, I63.549, I63.9, I77.74, I82.C21, J36, J38.01, J38.02, J39.0, L02.811, M41.82, M43.22, M47.13, M50.03, M50.10, M50.20, M50.23, M54.2, Q40.9, R13.0, R13.10, R26.9, R29.898, R40.20, R43.9, S06.9X9A, S06.9X9D, S06.9X9S, S09.90XA, S09.90XD, S09.90XS, S19.9XXA, S19.9XXD, S19.9XXS. Moved F32.81 & F32.89 from Group 2 to Group 1, deleted all other Groups 2 and 3 codes as they are already listed in Group 1 and updated the CMS National Coverage Policy section.

  • Request for Coverage by a Practitioner (Part B)
  • Other (Updated per CMS Guidelines.)
10/08/2018 R1

09/06/2018 - 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.

 

This LCD is effective 10/08/18 to all allow for the required 45-day Notice period when a Draft policy finalizes. The Notice Period started on 8/23/18 and ends on 10/07/18. However, the Annual ICD-10 Code Update is effective 10/01/2018. The following codes were added and deleted to Group 1, Group 2 and revised from Group 1 will be effective on 10/01/2018.

Added to Group 1: C43.111, C43.112, C43.121, C43.122, C4A.111, C4A.112, C4A.121, C4A.122, C44.1121. C44.1122, C44.1191, C44.1192, C44.1221, C44.1222, C44.1291, C44.1292, C44.1921, C44.1922, C44.1991, C44.1992, D03.111, D03.112, D03.121, D03.122, D04.111, D04.112, D04.121, D04.122, D22.111, D22.112, D22.121, D22.122, D23.111, D23.112, D23.121, D23.122, E75.26, F53.0, F53.1, G51.31, G51.32, G51.33, H02.23A, H02.23B, H02.23C, H57.811, H57.812, H57.813, H57.819, H57.89, I63.81, I63.89, I67.850, I67.858, T81.40XA*, T81.40XD*, T81.40XS*, T81.41XA*, T81.41XD*, T81.41XS*, T81.42XA*, T81.42XD*, T81.42XS*, T81.43XA*, T81.43XD*, T81.43XS*, T81.44XA*, T81.44XD*, T81.44XS*, T81.49XA*, T81.49XD* and T81.49XS*

Added to Group 2: F53.0 and F53.1

Deleted from Group 1: C43.11, C43.12, C4A.11, C4A.12, C44.112, C44.119, C44.122, C44.129, C44.192, C44.199, D03.11, D03.12, D04.11, D04.12, D22.11, D22.12, D23.11, D23.12, F53, G51.3, H57.8, I63.8, T81.4XXA*, T81.4XXD* and T81.4XXS*

Deleted from Group 2: F53

Revised from Group 1: I63.333, I63.343, M50.01, M50.21, M50.31, M50.81 and M50.91

 

 

 
  • Revisions Due To ICD-10-CM Code Changes
N/A

Associated Documents

Attachments
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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
01/29/2020 10/01/2019 - N/A Currently in Effect You are here
11/20/2019 10/01/2019 - N/A Superseded View
09/19/2019 10/01/2019 - N/A Superseded View
09/19/2019 10/01/2019 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • MRI
  • CT
  • Head
  • Brain
  • Neck

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