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Local Coverage Determination (LCD)

Magnetic Resonance Angiography (MRA)

L34865

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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
L34865
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

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.

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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.

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 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.

IOM Citations:

  • CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
    • Chapter 6, Section 20.4: Outpatient Diagnostic Services.
    • Chapter 15, Section 80: Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests.
    • Chapter 16, Section 20: Services Not Reasonable and Necessary.
  • CMS IOM Publication 100-03: Medicare National Coverage Determinations (NCD) Manual,
    • Chapter 1, Part 4, Section 220.2: Magnetic Resonance Imaging (MRI).
  • CMS IOM Publication 100-04: Medicare Claims Processing Manual,
    • Chapter 13, Section 40.1: Magnetic Resonance Angiography (MRA), Section 40.1.1: Magnetic Resonance Angiography (MRA) Coverage Summary.
  • 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 1865 states effects of accreditation.


Code of Federal Regulations (CFR) References:

  • CFR, Title 42, Volume 2, Chapter IV, Part 410.32(d)(3) Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.


History/Background and/or General Information

Magnetic resonance angiography (MRA) is a non-invasive diagnostic test that is an application of magnetic resonance imaging (MRI). By analyzing the amount of energy released from tissues exposed to a strong magnetic field, MRA provides images of normal and diseased blood vessels as well as visualization and quantification of blood flow through these vessels.

Please refer to the National Coverage Determination for MRI and MRA documented in CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 220.2 Magnetic Resonance Imaging (MRI) for coverage details.


COVERED INDICATIONS

I. HEAD AND NECK

Please refer to CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 220.2.A.2 and 220.2.B.2 for coverage details and guidelines on the use of MRA of the head and neck.

MRA is appropriately used to verify the presence of a condition, suspected because of findings from another test (usually an imaging study). For example, a patient who presents with a transient ischemic attack (TIA) should not undergo MRA simply because he might have a lesion which is amenable to surgery. However, if that patient has a carotid bruit and is found by Doppler study to have carotid stenosis, an MRA may be appropriate to evaluate the stenotic section of artery for surgical intervention. Please note that the anticipated surgery may be a percutaneous procedure such as carotid angioplasty with stent insertion.

Another patient may present with a headache; it is not appropriate to proceed directly to MRA to rule out the possibility of an intracranial aneurysm. However, if that patient was found to have a clinically significant amount of blood in the cerebrospinal fluid, or the patient demonstrated signs and symptoms strongly suggesting an unruptured intracranial aneurysm, an MRA (or cerebral angiogram) may be appropriate.

An MRA is not considered medically reasonable and necessary for screening asymptomatic patients for intracranial aneurysms.

II. PERIPHERAL ARTERIES OF LOWER EXTREMITIES

Please refer to CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 220.2.B.2.b for coverage details and guidelines on the use of MRA in the peripheral arteries of the lower extremities.


III. ABDOMEN AND PELVIS

Please refer to CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 220.2.B.2.c for coverage details and guidelines on the use of MRA in the pre-operative evaluation of patients undergoing elective abdominal aortic aneurysm (AAA) repair and imaging of the renal arteries and aortoiliac arteries in the absence of AAA or aortic dissection.

An MRA of the abdomen for evaluation of possible renal artery stenosis would not be considered medically reasonable and necessary without some evidence consistent with renovascular hypertension. Such evidence might include:

  • a history of early or late onset of hypertension, hypertension refractory to medication, or worsening renal function;
  • the presence of a renal artery bruit;
  • laboratory tests (elevated serum renins, increasing creatinine); or
  • other radiologic tests (ultrasound, captopril scintigraphy, or other imaging showing small kidney or unequal kidney sizes).


IV. CHEST

Diagnosis of Pulmonary Embolism

Please refer to CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 220.2.B.2.d.i for coverage details and guidelines on the use of MRA in the diagnosis of pulmonary embolism.

Evaluation of Thoracic Aortic Dissection and Aneurysm

Please refer to CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 220.2.B.2.d.ii for coverage details and guidelines on the evaluation of thoracic aortic dissection and aneurysm.

NOTE: This LCD does not address cardiac magnetic resonance imaging.

Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.
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
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Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
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MAC Meeting Information URLs
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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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Revenue Codes

Code Description

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CPT/HCPCS Codes

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ICD-10-CM Codes that Support Medical Necessity

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Group 1

Group 1 Paragraph:

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 Group 1 Codes:

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

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Group 1

Group 1 Paragraph:

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 Group 1 Codes:

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Additional ICD-10 Information

General Information

Associated Information


Please refer to the Local Coverage Article: Billing and Coding: Magnetic Resonance Angiography (MRA), A56805, for all coding information.

Documentation Requirements

  1. All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The medical record documentation must support the medical necessity of the services as stated in this policy.
  4. Documentation to support the medical necessity of the combined use of MRA and CA must be maintained in the patient's medical record.
  5. Hospital, office or mobile unit records should clearly document the service was performed by or under direct physician supervision, reason for the exam and its frequency. In addition, mobile units must maintain a record of the attending physician's order for a scan performed in their facility.
  6. In instances where multiple diagnostic services are medically necessary, documentation supporting this need must be available upon request.


Utilization Guidelines

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Sources of Information


Contractor is not responsible for the continued viability of websites listed.

Other Contractor(s)' Policies

Individual Local medical Review Policies:
- Arkansas Magnetic Resonance Angiography Rev 2
- Louisiana Magnetic Resonance Angiography (MRA-Revision 1998);
- Missouri Magnetic Resonance Angiography, #99;
- Oklahoma and New Mexico Magnetic Resonance Angiography, #N001; and
- Rhode Island Magnetic Resonance Angiography (MRA), RI-2000-106.

AR Part A, ARA-03-010

L27392 Trispan Legacy Policy

L31399 Highmark Medicare Services MRA LCD International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), 6th Edition, Practice Management Information Corporation, 2008.

American Medical Association, 2009 CPT, Physicians' Current Procedural Terminology, Professional Edition, 2008.

Health Care Procedure Coding System (HCPCS) National Level II Medicare Codes, Millennium Edition, Practice Management Information Corporation, 2008.

Contractor Medical Directors
Bibliography

 

  1. Sanchez T, Santoro P, Torres de Medeiros I, et al. Magnetic resonance angiography in pulsatile tinnitus: The role of anatomical cariations. Int Tinnitus J. 1998;4(2):122-126.
  2. Kent, DL, Haynor, DR, Longstreth, WT, Larson, EB. The clinical efficacy of magnetic resonance imaging in neuroimaging. Annals Int Med. 1994;120(10); 856-871.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
07/01/2020 R10

LCD revised and published on 06/25/2020 effective for dates of service on and after 07/01/2020, as a non-discretionary update to remove the ‘Non-Covered Indications’ section indicating MRA of the spinal canal and contents and MRA of the upper extremities are considered not medically reasonable and necessary at this time.
  • Other (Revised in response to CMS direction)
10/17/2019 R9

LCD revised and published on 10/17/2019. Consistent with CMS Change Request 10901, the entire coding section has been removed from the LCD and placed into the related Billing and Coding Article, A56805. All CPT codes and coding information within the text of the LCD has been placed in the Billing and Coding Article.
  • Other (CMS Change Request 10901)
08/08/2019 R8

LCD revised and published on 8/8/2019. All codes and related coding information have been removed and placed in the related billing and coding article, A56805, consistent with Change Request (CR) 10901. NCD and Manual language has been removed from the Coverage Guidance section of the policy and replaced with the applicable references. All information removed from the LCD is contained in the referenced NCD. The sources have been moved to the bibliography section and numbered. There has been no coverage change with this LCD revision.
  • Other (changes in response to CMS change request)
10/01/2018 R7

LCD revised and published on 10/25/2018 effective for dates of service on and after 10/01/2018 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM code(s) have been deleted and therefore removed from the LCD: I63.8. The following ICD-10-CM code(s) have been added to the LCD Group 1 codes: I63.81 and I63.89. The following ICD-10-CM code(s) have undergone a descriptor change: I63.333 and I63.343.

Per LCD annual review, regrouped the CPT/HCPCS Code Groups to align with their respective ICD-10 Code Groups and added hyperlink to NCD 220.2 for Magnetic Resonance Imaging to the “Related National Coverage Documents” section.

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; therefore, not all the fields included on the LCD are applicable as noted in this policy.
  • Revisions Due To ICD-10-CM Code Changes
  • Other (Annual Review)
10/01/2017 R6

LCD revised and published on 10/05/2017 effective for dates of service on and after 10/01/2017 to reflect the ICD-10 Annual Code Updates. The following Group 1 ICD-10 code(s) have undergone a descriptor change: I63.211, I63.212, I63.22, I63.323, I63.333, I63.513, I63.523, I63.533.

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; therefore, not all the fields included on the LCD are applicable as noted in this policy.
  • Revisions Due To ICD-10-CM Code Changes
08/10/2017 R5

LCD revised and published on 08/10/2017 to update IOM Citations per LCD Annual review.

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 (Updated IOM Citations)
10/01/2016 R4 LCD revised and published on 09/29/2016 effective for dates of service on or after 10/01/2016 to reflect the annual ICD-10 code updates. The following ICD-10 codes have been deleted from the LCD: Group 1: I60.21 and I62.22; Group 3: K55.0; Group 4: Q25.2. The following ICD-10 codes have been added to the LCD: Group 1: H93.A1, H93.A2, H93.A3, 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 and I77.75; Group 3: K55.011, K55.012, K55.031 and K55.032; Group 4: Q25.21 and Q25.29. The following ICD-10 codes have undergone a descriptor change: Group 1: T85.110A, T85.110D, T85.110S, T85.120A, T85.120D, and T85.120S; Group 2: I77.79; Group 3 and Group 4: T82.818A, T82.818D, T82.818S, T82.828A, T82.828D, T82.828S, T82.838A, T82.838D, T82.838S, T82.848A, T82.848D, T82.848S, T82.858A, T82.858D, T82.858S, T82.868A, T82.868D, T82.868S; Group 4: T82.817A, T82.817D and T82.817S. Updates to the IOM Citations under the CMS National Coverage Policy were made.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R3 LCD revised and published 11/13/2015 to add additional ICD-10 codes with higher specificity effective for dates of service 10/01/2015 and after.
  • Other (Clarification )
10/01/2015 R2 LCD revised and published on 06/25/0215.
  • Creation of Uniform LCDs Within a MAC Jurisdiction
10/01/2015 R1 LCD revised on 05/28/2014 to add ICD-10 codes H93.11, H93.12, H93.13 and H93.19 as a covered diagnosis for MRA of the head and neck (Group 1 Diagnosis Codes) effective for dates of service on or after 10/01/2014. (LCD updated on 06/07/2014)
  • Reconsideration Request
  • Other (CPT/HCPCS codes formerly in ranges now listed as separate codes.)
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Associated Documents

Attachments
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Related National Coverage Documents
NCDs
220.2 - Magnetic Resonance Imaging
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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