Local Coverage Determination (LCD)

Magnetic Resonance Angiography (MRA)

L34372

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
First Coast Service Options, Inc.	A and B MAC	09101 - MAC A	J - N	Florida
First Coast Service Options, Inc.	A and B MAC	09102 - MAC B	J - N	Florida
First Coast Service Options, Inc.	A and B MAC	09201 - MAC A	J - N	Puerto Rico Virgin Islands
First Coast Service Options, Inc.	A and B MAC	09202 - MAC B	J - N	Puerto Rico
First Coast Service Options, Inc.	A and B MAC	09302 - MAC B	J - N	Virgin Islands

LCD Information

Document Information

LCD ID
L34372

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

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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

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes

Changes	Fields Changed
	N/A

Associated Information

Sources of Information

Bibliography

Open Meetings

Contractor Advisory Committee (CAC) Meetings

MAC Meeting Information URLs

Proposed LCD Posting Date

Comment Period Start Date

Comment Period End Date

Reason for Proposed LCD

Requestor Name	Requestor Letter
	View Letter

Requestor Information

Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code	Description
Please accept the License to see the codes.

Revenue Codes

Code	Description
Please accept the License to see the codes.

ICD-10-CM Codes that Support Medical Necessity

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

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

Associated Documents

Attachments
N/A

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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Magnetic Resonance Angiography (MRA)

Document Note

Note History

Contractor Information

LCD Information

Document Information

Issue

CMS National Coverage Policy

Coverage Guidance

Proposed Process Information

Coding Information

Bill Type Codes

Please accept the License to see the codes.

Revenue Codes

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CPT/HCPCS Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

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

Group 1

Additional ICD-10 Information

General Information

Revision History Information

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