Local Coverage Determination (LCD)

Magnetic Resonance Angiography

L34424

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Palmetto GBA	A and B MAC	10111 - MAC A	J - J	Alabama
Palmetto GBA	A and B MAC	10211 - MAC A	J - J	Georgia
Palmetto GBA	A and B MAC	10311 - MAC A	J - J	Tennessee
Palmetto GBA	A and B and HHH MAC	11201 - MAC A	J - M	South Carolina
Palmetto GBA	A and B and HHH MAC	11301 - MAC A	J - M	Virginia
Palmetto GBA	A and B and HHH MAC	11401 - MAC A	J - M	West Virginia
Palmetto GBA	A and B and HHH MAC	11501 - MAC A	J - M	North Carolina

LCD Information

Document Information

LCD ID
L34424

LCD Title
Magnetic Resonance Angiography

Proposed LCD in Comment Period
N/A

Source Proposed LCD
DL34424

Original Effective Date
For services performed on or after 10/01/2015

Revision Effective Date
For services performed on or after 10/24/2019

Revision Ending Date
N/A

Retirement Date
N/A

Notice Period Start Date
04/13/2017

Notice Period End Date
05/28/2017

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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.

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 medically 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)(1)(E) excludes expenses for items or services which are not reasonable and necessary to carry out research conducted pursuant to §1142 of the Act.

Title XVIII of the Social Security Act, §1862(a)(7) states Medicare will not cover any services or procedures associated with routine physical checkups.

42 CFR §410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 16, §20 Services Not Reasonable and Necessary

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §220.2 Magnetic Resonance Imaging (MRI).

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

The coverage criteria and definition of Magnetic Resonance Angiography (MRA) are found in the CMS Internet-only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §220.2. MRA is considered appropriate when it can replace a more invasive test (e.g., contrast angiography) and reduce risk for beneficiaries. In addition, the services must be reasonable and necessary for the diagnosis or treatment of the specific patient involved.

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

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

Utilization Guidelines

Medicare will allow coverage of Magnetic Resonance Imaging (MRIs) for patients with implanted permanent pacemakers when used according to the Food and Drug Administration's approved labeling for use in a MRI environment.

Sources of Information
N/A

Bibliography

American College of Radiology. Blunt chest trauma-suspected aortic injury. ACR Appropriateness Criteria^®. 2014

American College of Radiology. Blunt chest trauma. ACR Appropriateness Criteria^®. 2013

American College of Radiology. Sudden onset of cold, painful leg. ACR Appropriateness Criteria^®. 2016

American College of Radiology. Follow-up of lower extremity arterial bypass surgery. ACR Appropriateness Criteria^®. 2013

American College of Radiology. Cerebrovascular disease. ACR Appropriateness Criteria^®. 2016

American College of Radiology. Recurrent symptoms following lower extremity angioplasty. ACR Appropriateness Criteria^®. 2012

Cambria RP, Kaufman JA, L’Italien GJ, et al. Magnetic resonance angiography in the management of lower extremity arterial occlusive disease: a prospective study. J Vasc Surg. 1997;25(2):380-389.

Fattori R, Celletti F, Descovich B, et al. Evolution of post-traumatic aortic aneurysm in the subacute phase: magnetic resonance imaging follow- up as a support of the surgical timing. Eur J Cardiothorac Surg. 1998;13(5):582-587.

Postma CT, Joosten FB, Rosenbusch G, Thien T. Magnetic resonance angiography has a high reliability in the detection of renal artery stenosis. Am J Hypertens. 1997;10(9Pt1):957-963.

Remonda L, Heid O, Schroth G. Carotid artery stenosis, occlusion, and pseudo-occlusion: first-pass, gadolinium-enhanced, three-dimensional MR angiography–preliminary study. Radiology. 1998;209(1):95-102.

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
10/24/2019	R12	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: Magnetic Resonance Angiography A56775 article. At this time 21^stCentury 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
08/01/2019	R11	All coding located in the *Coding Information* section has been moved into the related Billing and Coding: Magnetic Resonance Angiography A56775 article and removed from the LCD. Acronyms were inserted where appropriate throughout the LCD. At this time 21^stCentury 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	R10	Under *ICD-10 Codes that Support Medical Necessity: Group 1* added ICD-10 codes I63.81, I63.89, I67.850 and I67.858. Under *ICD-10 Codes that Support Medical Necessity: Group 1* deleted ICD-10 code I63.8. Under *ICD-10 Codes that Support Medical Necessity: Group 1* the code description was revised for ICD-10 codes I63.333 and I63.343. Under *ICD-10 Codes that Support Medical Necessity: Group 4* added ICD-10 code R93.89. Under *ICD-10 Codes that Support Medical Necessity: Group 4* deleted ICD-10 code R93.8. This revision is due to the 2018 Annual ICD-10 Code Update and is effective on October 1, 2018. At this time 21^stCentury 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
04/12/2018	R9	Under *CMS National Coverage Policy* updated 42 CFR, Sec 410.32 with the most current information and corrected the title on the CMS Internet-Only Manual, Pub 100-03, Ch 1, Part 4, Sec 220.2. Under *Bibliography* changes were made to citations to reflect AMA citation guidelines and all American College of Radiology references were updated to the most current year. At this time 21^stCentury 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
01/29/2018	R8	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
10/01/2017	R7	Under *ICD-10 Codes That Support Medical Necessity Group 1: Codes* the code description was revised for I63.211, I63.212, I63.22, I63.323, I63.333, I63.513, I63.523, and I63.533. Under *ICD-10 Codes That Support Medical Necessity Group 3: Codes* added K91.30, K91.31 and K91.32. Under *ICD-10 Codes That Support Medical Necessity Group 4: Codes* deleted I27.2 and added I27.20, I27.21, I27.22, I27.23, I27.24, I27.29, I27.83 and R06.03. This revision is due to the 2017 Annual ICD-10 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
08/03/2017	R6	Under **CPT/HCPCS Codes Group 1: Paragraph deleted codes 71555, 72198, 73225, 73725 and 74185 and added codes C8934, C8935 and C8936. Under CPT/HCPCS Group 2: Paragraph deleted 73725 from the verbiage “73725, C8912-C8914 Magnetic Resonance Angiography, Lower Extremity”. Under CPT/HCPCS Group 3: Paragraph deleted 74185 from the verbiage “74185, C8900-C8902 Magnetic Resonance Angiography, Abdomen”. Under CPT/HCPCS Group 4: Paragraph deleted 71555 from the verbiage “71555, C8909-C8911 Magnetic Resonance Angiography, Chest”. Under CPT/HCPCS Group 5: Paragraph deleted 72198 from the verbiage “72198, C8918-C8920 Magnetic Resonance Angiography, Pelvis”. Under CPT/HCPCS Group 6: Paragraph** deleted the verbiage “73225, Magnetic resonance angiography, upper extremity, with or without contrast material(s)” and added the verbiage “C8934, C8935, C8936, Magnetic Resonance Angiography, Upper Extremity, with or without contrast”. Revisions due to codes no longer payable under Outpatient Prospective Payment System" (OPPS) as of July 01, 2017.	Provider Education/Guidance
05/29/2017	R5	No revisions were made as there were no comments received from the provider community.	Provider Education/Guidance
10/01/2016	R4	Under *ICD-10 Codes That Support Medical Necessity Group 1: Codes* added ICD-10 codes H59.331, H59.332, H59.333, H59.339, H59.341, H59.342, H59.343, H59.349, H59.351, H59.352, H59.353, H59.359, H59.361, H59.362, H59.363, H59.369, H90.A11, H90.A12, H90.A21, H90.A22, H90.A31, H90.A32, H93.A1, H93.A2, H93.A3, H93.A9, H95.51, H95.52, H95.53, H95.54 I60.2, I63.013, I63.033, I63.113, I63.133, I63.213, I63.233, I63.313, I63.323, I63.333, I63.343, I63.413, I63.423, I63.433, I63.443, I63.513, I63.523, I63.533, I63.543, I72.5, I72.6, I77.75 and Q87.82 and deleted ICD-10 codes H34.811, H34.812, H34.813, H34.831, H34.832, H34.833, I60.21 and I60.22. Under *ICD-10 Codes That Support Medical Necessity Group 2: Codes* added ICD-10 code I77.77 and revised the code description for ICD-10 code I77.79. Under *ICD-10 Codes That Support Medical Necessity Group 3: Codes* added ICD-10 codes C49.A0, C49.A1, C49.A2, C49.A3, C49.A4, D49.511, D49.512, D49.519, D49.59, D78.31, D78.32, D78.33, D78.34, 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, K85.01, K85.02, K85.81, K85.82, K85.91, K85.92, K91.870, K91.871, K91.872, K91.873, N99.840, N99.841, Q25.42, Q25.43, Q25.44, Q25.49, Q87.82, R93.41, R93.421, R93.422, R93.429 and R93.49. Under *ICD-10 Codes That Support Medical Necessity Group 4: Codes* added ICD-10 codes J95.860, J95.861, J95.862, J95.863, Q25.21, Q25.29, Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49 and Q87.82. Under *ICD-10 Codes That Support Medical Necessity Group 5: Codes* added ICD-10 codes C49.A5, N99.840 and N99.841. This revision is due to the Annual ICD-10 Code Update and becomes effective 10/01/16.	Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes
01/22/2016	R3	Under CMS National Coverage Policy in the reference to CMS Internet-Only Manual Pub 100-03, Chapter 1, Part 4 removed “220.3” and “(replaced with section 220.2)”and under CMS Internet-Only Manual Pub 100-04, Chapter 13 removed “40 Magnetic Resonance Imaging (MRI) Procedures” as these references are not valid to the MRA policy. Under Associated Information corrected grammar and removed “for services on or after July 7, 2011”. Under Sources of Information and Basis for Decision updated the reference for American College of Radiology- Blunt Chest Trauma-Suspected Aortic Injury-ACR Appropriateness Criteria to show 2014 (latest version).	Provider Education/Guidance Public Education/Guidance Other (Annual Validation)
10/01/2015	R2	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	R1	Under Coverage Indications, Limitations and/or Medical Necessity changed Manual system to Internet-Only Manual in the first sentence. Added the verbiage MRA is considered appropriate when it can replace a more invasive test (e.g., contrast angiography) and reduce risk for beneficiaries. In addition, the services must be reasonable and necessary for the diagnosis or treatment of the specific patient involved. Under Bill Type Codes,, added 023x Skilled Nursing Outpatient. Under Sources of Information and Basis for Decision added individual citations for the American College of Radiology ACR Appropriateness Criteria for Blunt Chest trauma-Suspected Aortic injury; Blunt Chest Trauma; Sudden Onset of Cold, painful Leg; Follow up of lower extremity Arterial Bypass Surgery; Cerebrovascular Disease; and recurrent Symptoms following Lower Extremity Angioplasty.	Provider Education/Guidance Other (Annual Validation)

Associated Documents

Attachments
N/A

Updated On	Effective Dates	Status
10/14/2019	10/24/2019 - N/A	Currently in Effect	You are here
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Keywords

MRA
Magnetic Resonance Angiography

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Magnetic Resonance Angiography

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Issue

CMS National Coverage Policy

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Coding Information

Bill Type Codes

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Group 1

ICD-10-CM Codes that Support Medical Necessity

Group 1

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Group 1

Additional ICD-10 Information

General Information

Revision History Information

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