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Local Coverage Determination (LCD)

CT of the Abdomen and Pelvis

L34415

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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
L34415
Original ICD-9 LCD ID
Not Applicable
LCD Title
CT of the Abdomen and Pelvis
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL34415
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 08/28/2022
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
07/14/2022
Notice Period End Date
08/27/2022

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Issue

Issue Description

This LCD provides coverage guidance for computed tomography of the abdomen and pelvis.
Issue - Explanation of Change 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.

Title XVIII of the Social Security Act, §1862 (a)(7) excludes routine physical examinations.

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §220.1 Computed Tomography (CT)

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

A computed tomographic (CT) image is a display of the anatomy of a thin slice of the body developed from multiple x-ray absorption measurements made around the periphery of the body. Unlike conventional tomography, where the image of a thin section is created by blurring out the information from unwanted regions, the CT image is constructed mathematically using data arising only from the section of interest. Generating such an image is confined to cross sections of the anatomy that are oriented essentially perpendicular to the axial dimensions of the body. Reconstruction of the final image can be accomplished in any plane.

Abdominal CT

The CT of the abdomen extends from the dome of the diaphragm to the pelvic brim or pubic symphysis, depending upon whether one groups the pelvis with the abdomen or treats it separately.

A CT scan of the abdomen will be considered medically reasonable and necessary under the following circumstances2:

• Evaluation of abdominal pain3,8,9

• Evaluation of known or suspected abdominal masses or fluid collections

• Evaluation of primary or metastatic malignancies

• Evaluation of abdominal inflammatory processes

• Evaluation of abnormalities of abdominal vascular structures (Note: Medical necessity for CT angiography is not addressed in this LCD)

• Evaluation of abdominal trauma

• Clarification of findings from other imaging studies of the abdomen or laboratory abnormalities suggesting abdominal pathology

• Guidance for interventional diagnostic or therapeutic procedures within the abdomen

• Treatment planning for radiation therapy

• For patients being evaluated for potential transcatheter aortic valve implantation/replacement (TAVI or TAVR) provided that the patient has not undergone a CT of the abdomen within the preceding 60 days1,4,6

Pelvic CT

The CT scan of the pelvic area includes all pelvic structures including the bladder, the prostate in males, ovaries, uterus, and uterine adnexa in females, and the lower retroperitoneum, and iliac lymph node chains. The CT scan of the pelvis is useful in evaluating cysts, tumors, masses, metastases to one or more of these organs, and iliac lymph nodes. Intravenous contrast material may be administered.

A CT scan of the pelvis will be considered medically necessary and reasonable under the following circumstances2:

• Evaluation of cysts, tumors, or masses of the pelvic structure (i.e., that which lies at or below the pelvic brim or true pelvis)

• Evaluation of metastasis of primary cancers to this region

• Evaluation of inflammatory processes in this region

• Evaluation of abnormalities of pelvic vascular structures

• Evaluation of lymphadenopathies of this region

• Evaluation of lower abdominal, generalized abdominal or pelvic pain3,8,9

• Evaluation of other genitourinary (GU) disorders in which the physician cannot make a diagnosis on physical examination and/or by ultrasound (US)

• Evaluation of trauma to the pelvic structure/organs

• Evaluation of the effectiveness of a radiation treatment plan

• For patients being evaluated for potential TAVI or TAVR provided that the patient has not undergone a CT of the pelvis within the preceding 60 days.1,4,6

Intravenous contrast material may be administered with any of the above studies.

In addition to the medical necessity requirements, the CT scan must be performed on a model of CT equipment that meets the following criteria:

• The model must be known to the Food and Drug Administration (FDA); and

• Must be in the full market release phase of development.
Summary of Evidence

The American College of Radiology (ACR) (2016) published its practice parameters for the performance of CT of the abdomen and pelvis.2 This publication includes the indications for abdominal and/or pelvic CT examinations. In 2018, Scheirey et al published the ACR Appropriateness Criteria® for nonlocalized abdominal pain.9 This review focused on imaging the adult population with nonlocalized abdominal pain, including patients with fever, recent abdominal surgery, or neutropenia. The authors concluded that imaging of the entire abdomen and pelvis to evaluate for infectious or inflammatory processes of the abdominal viscera and solid organs, abdominal and pelvic neoplasms, and screen for ischemic or vascular etiologies is essential for prompt diagnosis and treatment. The authors state that computed tomography, which is often the first-line modality, quickly evaluates the abdomen/pelvis, providing for accurate diagnoses and management of patients with abdominal pain. Furthermore, while often performed, abdominal radiographs may not alter management.

Haller et al (2010) performed a retrospective review to evaluate whether non-contrast CT (NCT) provided more diagnostic information than abdominal plain film (APF) in patients that presented with acute non-traumatic abdominal pain.3 The authors also addressed if use of CT could reduce the total number of additional radiograms. A total of 222 patients were retrospectively reviewed. 86 patients had APF, 60 had standard-dose CT (SDCT), and 76 had low-dose CT (LDCT). The radiological report of each patient was compared with the final diagnosis obtained from the medical record within 30 days. Additional radiograms were registered, and a total radiation dose excluding or including APF or NCT was calculated. Results showed that NCT gave a correct diagnosis in 50% compared to 20% with APF (P < 0.001). The total number of additional radiograms was substantially lower in the CT group compared to the APF group (P < 0.001). In addition, the average sum of radiation dose was similar for APF and LDCT. The authors concluded that NCT was significantly better at providing diagnostic information when compared to AFP in patients presenting with acute abdominal pain as well as reducing the number of additional radiograms.

Pandharipande et al (2016) conducted a prospective study to determine how the diagnoses, diagnostic uncertainty, and management decisions of physicians are affected by the results of CT in the emergency department (ED).8 Physicians were surveyed before and after CT to determine the leading diagnosis, diagnostic confidence, alternative “rule out” diagnosis, and management decisions. Primary measures were the proportion of patients for whom the leading diagnosis or admission decision changed and median changes in diagnostic confidence. Secondary measures addressed alternative diagnoses and return-to-care visits (e.g., to emergency department) at 1-month follow-up. The leading diagnosis changed in 235 of 460 patients with abdominal pain (51%). Pre-CT diagnostic confidence was inversely associated with the likelihood of a diagnostic change (P < 0.0001). Median post-CT confidence was 95%. CT helped confirm or exclude at least 95% of alternative diagnoses. Admission decisions changed in 116 of 457 patients with abdominal pain (25%). During follow-up, 70 of 450 patients with abdominal pain (15%) returned for the same indication. The authors concluded that physicians’ diagnoses and admission decisions changed frequently after CT. Diagnostic uncertainty was alleviated.

Multiple publications (Achenbach et al, 2012; Hawkey et al, 2014; Leipsic et al, 2011) have described the important role CT plays in screening protocols of patients who are candidates for transcatheter aortic valve implantation (TAVI) or transcatheter aortic valve replacement (TAVR).1,4,6 CT imaging provides information on the suitability of the peripheral access vessels and accurate dimensions of the involved vasculature and aortic annulus, which assists in sizing of the prosthesis.
Analysis of Evidence (Rationale for Determination)

Published evidence, including recommendations from the American College of Radiology (ACR), supports the use of CT of the abdomen and pelvis as a first-line modality for the evaluation of abdominal/pelvic pathology as listed in this policy. The published literature also supports the use of CT of the abdomen and pelvis for treatment planning for radiation therapy as well as guidance of interventional, diagnostic, or therapeutic procedures within the abdomen and pelvis, including preparation for TAVI/TAVR.

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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Please accept the License to see the codes.

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

Documentation Requirements

Medical record documentation maintained by the performing physician must clearly indicate the medical necessity of the service being billed. In addition, documentation that the service was performed must be included in the patient's medical record. This information is normally found in the office/progress notes, hospital notes, and/or procedure report.

Documentation should support the criteria for coverage as set forth in the Coverage Indications, Limitations and/or Medical Necessity section of this policy.

Documentation supporting medical necessity should be legible, maintained in the patient's medical record, and must be made available to the A/B MAC upon request.
Sources of Information

N/A
Bibliography
  1. Achenbach S, Delgado V, Hausleiter J, et al. SCCT expert consensus document on computed tomography imaging before transcatheter aortic valve implantation (TAVI)/transcatheter aortic valve replacement (TAVR). Journal of Cardiovascular Computed Tomography. 2012;6(6):366-380.
  2. American College of Radiology. ACR-SPR practice parameter for the performance of computed tomography (CT) of the abdomen and computed tomography (CT) of the pelvis. 2016.
  3. Haller O, Karlsson L, Nyman R. Can low-dose abdominal CT replace abdominal plain film in evaluation of acute abdominal pain? Upsala Journal of Medical Sciences. 2010;115:113-20.
  4. Hawkey MC, Lauck SB, Perpetua EM, et al. Transcatheter aortic valve replacement program development: Recommendations for best practice. Catheterization and Cardiovascular Interventions. 2014;84(6):859-867.
  5. Lee J, Stanley RJ, Sagel SS, Heiken JP. Computed Body Tomography With MRI Correlation. 3rd ed. Philadelphia, PA: Lippincott-Raven;1998.
  6. Leipsic J, Gurvitch R, LaBounty TM, et al. Multidetector computed tomography in transcatheter aortic valve implantation. JACC Cardiovascular Imaging. 2011;4(4):416-429.
  7. Michota FA, ed. Diagnostic Procedures Handbook. 2nd ed. Hudson, OH: Lexi-Comp Inc;2001.
  8. Pandharipande PV, Reisner AT, Binder WD, et al. CT in the Emergency Department: A Real-Time Study of Changes in Physician Decision Making. Radiology. 2016;278:812-21.
  9. Scheirey CD, Fowler KJ, Therrien JA, et al. ACR Appropriateness Criteria® Acute Nonlocalized Abdominal Pain. Journal of the American College of Radiology. 2018;15:S217-S231.
  10. Taylor RB, Paulman P, Paulman AA, Nasir LS. Family Medicine: Principles and Practice. 7th ed. New York, NY: Springer-Verlag;1994.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
08/28/2022 R19

This LCD is being presented for notice. No changes were made during the comment period.
  • Provider Education/Guidance
10/10/2019 R18

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: CT of the Abdomen and Pelvis A56421 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
03/28/2019 R17

All coding located in the Coding Information section has been moved into the related Billing and Coding: CT of the Abdomen and Pelvis A56421 article and removed from the LCD. Under Covered ICD-10 Codes Group 1: Codes added S32.10XA, S32.10XB, S32.10XD, S32.10XG, S32.10XK, S32.10XS, S32.110A, S32.110B, S32.110D, S32.110G, S32.110K, S32.110S, S32.111A, S32.111B, S32.111D, S32.111G, S32.111K, S32.111S, S32.112A, S32.112B, S32.112D, S32.112G, S32.112K, S32.112S, S32.119A, S32.119B, S32.119D, S32.119G, S32.119K, S32.119S, S32.120A, S32.120B, S32.120D, S32.120G, S32.120K, S32.120S, S32.121A, S32.121B, S32.121D, S32.121G, S32.121K, S32.121S, S32.122A, S32.122B, S32.122D, S32.122G, S32.122K, S32.122S, S32.129A, S32.129B, S32.129D, S32.129G, S32.129K, S32.129S, S32.130A, S32.130B, S32.130D, S32.130G, S32.130K, S32.130S, S32.131A, S32.131B, S32.131D, S32.131G, S32.131K, S32.131S, S32.132A, S32.132B, S32.132D, S32.132G, S32.132K, S32.132S, S32.139A, S32.139B, S32.139D, S32.139G, S32.139K, S32.139S, S32.14XA, S32.14XB, S32.14XD, S32.14XG, S32.14XK, S32.14XS, S32.15XA, S32.15XB, S32.15XD, S32.15XG, S32.15XK, S32.15XS, S32.16XA, S32.16XB, S32.16XD, S32.16XG, S32.16XK, S32.16XS, S32.17XA, S32.17XB, S32.17XD, S32.17XG, S32.17XK, S32.17XS, S32.19XA, S32.19XB, S32.19XD, S32.19XG, S32.19XK, S32.19XS, S32.2XXA, S32.2XXB, S32.2XXD, S32.2XXG, S32.2XXK, and S32.2XXS with a retroactive effective date of 1/1/19.

Under Coverage Indications, Limitations and/or Medical Necessity – Pelvic CT removed italicized text from all verbiage. Under Bibliography changes were made to citations to reflect AMA citation guidelines. Acronyms were inserted where appropriate throughout 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 R16

Under ICD-10 Codes That Support Medical Necessity 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, K35.2, K35.3, K35.89, K61.3, K83.0, Q51.2 and R93.8. Under ICD-10 Codes That Support Medical Necessity 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, K35.20, K35.21, K35.30, K35.31, K35.32, K35.33, K35.890, K35.891, K61.31, K61.39, K61.5, K82.A1, K82.A2, K83.01, K83.09, N35.016, N35.116, N35.812, N35.813, N35.814, N35.816, N35.819, N35.82, N35.912, N35.913, N35.914, N35.916, N35.919, N35.92, N99.116, O86.00, O86.01, O86.02, O86.03, O86.04, O86.09, Q51.20, Q51.21, Q51.22, Q51.28, R93.811, R93.812, R93.813, R93.819, R93.89, 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. This revision is due to the Annual ICD-10 Code Update and becomes effective 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
07/13/2018 R15

Under ICD-10 Codes that Support Medical Necessity, Group 1: Codes added C88.0. This revision is due to a reconsideration request.

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
05/10/2018 R14

Punctuation was corrected and words were capitalized or changed to lower case as appropriate throughout the policy. Under Coverage Indications, Limitations and/or Medical Necessity - Pelvic CT removed the words “transcatheter aortic valve implantation/replacement” and the parentheses around the acronyms TAVI and TAVR in the tenth bullet.  The second set of bullets were italicized. Under Bibliography changes were made to citations to reflect AMA citation guidelines. The reference date was updated from 2014 to 2016 in the second citation. A correction was made to the first author’s initials, and the author Heiken JP and the publishing state was added to the fourth citation. The edition was changed and the author listing was corrected in the seventh citation.

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
  • Typographical Error
02/26/2018 R13 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
01/29/2018 R12 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
11/06/2017 R11

Under ICD-10 codes that support Medical Necessity added ICD -10 codes N02.2, N02.4, N02.7, N30.00, N30.01, N30.10, N30.11, N30.20, N30.21, N30.30, N30.31, N30.40, N30.41, N30.80, N30.81, N30.90, and N30.91.
  • Provider Education/Guidance
  • Reconsideration Request
10/01/2017 R10

Under ICD-10 Codes That Support Medical Necessity Group 1:Codes added ICD-10 codes C96.20, C96.21, C96.22, C96.29, D47.02, D47.09, E85.81, E85.82, E85.89, K56.50, K56.51, K56.52, K56.600, K56.601, K56.609, K56.690, K56.691, K56.699, K91.30, K91.31, K91.32, Q53.111, Q53.112, Q53.211, and Q53.212.  Under ICD-10 Codes That Support Medical Necessity Group 1: Codes ICD-10 codes C96.2, E85.8, K56.5, K56.60, K56.69, K91.3, Q53.11, and Q53.21 were deleted.  Under ICD-10 Codes That Support Medical Necessity Group 1: Codes the code description was revised for Q64.12. This revision is due to the 2017 Annual ICD-10 Code Updates.

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
  • Revisions Due To ICD-10-CM Code Changes
10/01/2016 R9 Under ICD-10 Codes That Support Medical Necessity: Group 1 C49.A0, C49.A1, C49.A2, C49.A3, C49.A4, C49.A5, C49.A9, D47.Z2, D49.511, D49.512, D49.519, D49.59, G97.61, G97.62, G97.63, G97.64, I97.620, I97.621, I97.622, I97.630, I97.631, I97.638, I97.640, I97.641, I97.648, K52.21, K52.22, K52.29, K52.3, K52.831, K52.832, K52.838, K52.839, K55.011, K55.012, K55.019, K55.021, K55.022, K55.029, K55.031, K55.032, K55.039, K55.041, K55.042, K55.049, K55.051, K55.052, K55.059, K55.061, K55.062, K55.069, K55.30, K55.31, K55.32, K55.33, K58.1, K58.2, K58.8, K59.03, K59.04, K59.31, K59.39, K85.00, K85.01, K85.02, K85.10, K85.11, K85.12, K85.20, K85.21, K85.22, K85.30, K85.31, K85.32, K85.80, K85.81, K85.82, K85.90, K85.91, K85.92, K86.81, K86.89, K90.41, K90.49, K91.870, K91.871, K91.872, K91.873, M96.840, M96.841, M96.842, M96.843, N83.01, N83.02, N83.11, N83.12, N83.201, N83.202, N83.291, N83.292, N83.311, N83.312, N83.321, N83.322, N83.331, N83.332, N83.41, N83.42, N83.511, N83.512, N83.521, N83.522, N99.523, N99.524, N99.533, N99.534, N99.840, N99.841, N99.842, N99.843, R31.21, R31.29, R93.41, R93.421, R93.422, R93.429, R93.49, T83.113A, T83.113D, T83.113S, T83.123A, T83.123D, T83.123S, T83.193A, T83.193D, T83.193S, T83.24XA, T83.24XD, T83.24XS, T83.25XA, T83.25XD, T83.25XS, T83.512A, T83.512D, T83.512S, T83.590A, T83.590D, T83.590S, T83.592A, T83.592D, T83.592S, T83.593A, T83.593D, T83.593S, T83.598A, T83.598D, T83.598S, T83.61XA, T83.61XD, T83.61XS, T83.69XA, T83.69XD, T83.69XS, T83.712A, T83.712D, T83.712S, T83.713A, T83.713D, T83.713S, T83.714A, T83.714D, T83.714S, T83.719A, T83.719D, T83.719S, T83.722A, T83.722D, T83.722S, T83.723A, T83.723D, T83.723S, T83.724A, T83.724D, T83.724S, T83.729A, T83.729D, T83.729S, T83.79XA, T83.79XD and T83.79XS. Under ICD-10 Codes That Support Medical Necessity: Group 1 deleted D49.5, I97.62, K52.2, K55.0, K59.3, K85.0, K85.1, K85.2, K85.3, K85.8, K85.9, K86.8, N83.0, N83.1, N83.20, N83.29, N83.31, N83.32, N83.33, N83.4, N83.51, N83.52, Q52.12, R31.2 and R93.4. Under ICD-10 Codes That Support Medical Necessity: Group 1 updated code description for C7A.094, C7A.095, C7A.096, C81.10, C81.11, C81.12, C81.13, C81.14, C81.15, C81.16, C81.17, C81.18, C81.19, C81.20, C81.21, C81.22, C81.23, C81.24, C81.25, C81.26, C81.27, C81.28, C81.29, C81.30, C81.31, C81.32, C81.33, C81.34, C81.35, C81.36, C81.37, C81.38, C81.39, C81.40, C81.41, C81.42, C81.43, C81.44, C81.45, C81.46, C81.47, C81.48, C81.49, C81.70, C81.71, C81.72, C81.73, C81.74, C81.75, C81.76, C81.77, C81.78, C81.79, D3A.094, D3A.095, D3A.096, D78.21, D78.22, G97.51, G97.52, I97.610, I97.611, I97.618, K91.61, K91.840, K91.841, L76.21, L76.22, M96.830, M96.831, N40.0, N40.1, N99.520, N99.521, N99.522, N99.528, N99.530, N99.531, N99.532, N99.538, N99.820, N99.821, T83.018A, T83.018D, T83.018S, T83.028A, T83.028D, T83.028S, T83.038A, T83.038D, T83.038S, T83.098A, T83.098D, T83.098S, T83.111A, T83.111D, T83.111S, T83.112A, T83.112D, T83.112S, T83.121A, T83.121D, T83.121S, T83.122A, T83.122D, T83.122S, T83.191A, T83.191D, T83.191S, T83.192A, T83.192D, T83.192S, T83.420A, T83.420D, T83.420S, T83.711A, T83.711D, T83.711S, T83.718A, T83.718D, T83.718S, T83.721A, T83.721D, T83.721S, T83.728A, T83.728D and T83.728S. This revision is due to the Annual ICD-10 Code Update and becomes effective October 1, 2016.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
07/03/2016 R8 Under Indications, Limitations and/or Medical Necessity – Abdominal CT the paragraph describing the requirements of the CT equipment was deleted and moved to the last paragraph under Pelvic CT. The medical necessity criteria for a CT of the abdomen was clarified. A notation was added that CT angiography is not addressed in this LCD. Under Pelvic CT the first paragraph was reworded and the last paragraph addresses the requirements of the CT equipment. A statement was added related to the use of contrast material. Under CPT/HCPCS Codes removed CPT code 74174 [Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing]. Under Sources of Information and Basis for Decision the initial “J” was added to "Lee" in the fourth citation.
  • Provider Education/Guidance
  • Typographical Error
02/01/2016 R7 Under ICD-10 Codes That Support Medical Necessity added ICD-10 codes C34.90, Z85.00, Z85.01, Z85.020, Z85.028, Z85.030, Z85.040, Z85.05, Z85.060, Z85.068, Z85.07, Z85.09, Z85.40, Z85.45, Z85.50, Z85.520, Z85.71, Z85.72, and Z85.79.
  • Provider Education/Guidance
11/27/2015 R6 Under ICD-10 Codes That Support Medical Necessity added C34.90-Malignant neoplasm of unspecified part of unspecified bronchus and lung.
  • Reconsideration Request
10/01/2015 R5 Under ICD-10 Codes That Support Medical Necessity added ICD-10 codes I08.0, I35.0, I35.1, I35.2, I35.8, and I35.9 for individuals being evaluated for TAVI or TAVR.
  • Provider Education/Guidance
  • Reconsideration Request
10/01/2015 R4 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 R3 Under Coverage Indications, Limitations and/or Medical Necessity added “release” to the last sentence. Under Associated Information-Documentation Requirements deleted “the” in the first sentence of the third paragraph. Under Sources of Information and Basis for Decision revised “Guidelines” to read “Parameter” and revised the date for the following citation to now read “2014”: American College of Radiology. ACR-SPR Practice Parameter for the Performance of Computed Tomography (CT) of the Abdomen and Computed Tomography (CT) of the Pelvis.2014.
  • Provider Education/Guidance
  • Other
10/01/2015 R2 Under Coverage Indications, Limitations and/or Medical Necessity added the following indication, “For patients being evaluated for potential transcatheter aortic valve implantation/replacement (TAVI or TAVR) provided that the patient has not undergone a CT of the abdomen within the preceding 60 days.” Under Sources of Information and Basis for Decision added three new journal sources.
  • Provider Education/Guidance
  • Request for Coverage by a Provider (Part A)
  • Reconsideration Request
10/01/2015 R1 Under CMS National Coverage Policy removed “§10 and” from citation of CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 6. Under Associated Information, changed section citation to Coverage Indications, Limitations and/or Medical Necessity.
  • Other (Annual Review)
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Keywords

  • CT of the Abdomen
  • CT of the Pelvis

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