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.

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.

Medicare coverage for CT scans is allowed provided the service is medically reasonable and necessary.

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.



Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
085x Critical Access Hospital

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

032X Radiology - Diagnostic - General Classification
035X CT Scan - General Classification
040X Other Imaging Services - General Classification
061X Magnetic Resonance Technology (MRT) - General Classification

Procedure Codes and Description

Group 1 Paragraph: CT Scans

Group 1 Codes:
70450 Ct head/brain w/o dye
70460 Ct head/brain w/dye
70470 Ct head/brain w/o & w/dye
70480 Ct orbit/ear/fossa w/o dye
70481 Ct orbit/ear/fossa w/dye
70482 Ct orbit/ear/fossa w/o&w/dye
70486 Ct maxillofacial w/o dye
70487 Ct maxillofacial w/dye
70488 Ct maxillofacial w/o & w/dye
70490 Ct soft tissue neck w/o dye
70491 Ct soft tissue neck w/dye
70492 Ct sft tsue nck w/o & w/dye
72125 Ct neck spine w/o dye
72126 Ct neck spine w/dye
72127 Ct neck spine w/o & w/dye

Group 2 Paragraph: MRI Scans

Group 2 Codes:
70336 Magnetic image jaw joint
70540 Mri orbit/face/neck w/o dye
70542 Mri orbit/face/neck w/dye
70543 Mri orbt/fac/nck w/o &w/dye
70551 Mri brain stem w/o dye
70552 Mri brain stem w/dye
70553 Mri brain stem w/o & w/dye
70557 Mri brain w/o dye
70558 Mri brain w/dye
70559 Mri brain w/o & w/dye
72141 Mri neck spine w/o dye
72142 Mri neck spine w/dye
72156 Mri neck spine w/o & w/dye



ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph: The following list of ICD-10-CM codes represents diagnoses that, alone or together, support the medical necessity of either MRIs or CTs. These diagnoses must be supported by appropriate documentation of medical necessity in the medical record. These are the only covered diagnoses:


ICD-10 CODE DESCRIPTION

A02.21 Salmonella meningitis
A06.6 Amebic brain abscess
A17.0 Tuberculous meningitis
A17.1 Meningeal tuberculoma
A17.81 Tuberculoma of brain and spinal cord
A17.82 Tuberculous meningoencephalitis
A17.83 Tuberculous neuritis
A17.89 Other tuberculosis of nervous system
A17.9 Tuberculosis of nervous system, unspecified
A18.01 Tuberculosis of spine
A18.03 Tuberculosis of other bones
A18.2 Tuberculous peripheral lymphadenopathy
A18.50 Tuberculosis of eye, unspecified
A18.51 Tuberculous episcleritis
A18.52 Tuberculous keratitis
A18.53 Tuberculous chorioretinitis
A18.54 Tuberculous iridocyclitis
A18.59 Other tuberculosis of eye
A18.6 Tuberculosis of (inner) (middle) ear
A27.81 Aseptic meningitis in leptospirosis
A32.0 Cutaneous listeriosis
A32.11 Listerial meningitis
A32.12 Listerial meningoencephalitis
A32.7 Listerial sepsis
A32.81 Oculoglandular listeriosis
A32.82 Listerial endocarditis
A32.89 Other forms of listeriosis
A32.9 Listeriosis, unspecified
A39.0 Meningococcal meningitis
A39.1 Waterhouse-Friderichsen syndrome
A39.2 Acute meningococcemia
A39.3 Chronic meningococcemia
A39.4 Meningococcemia, unspecified
A39.50 Meningococcal carditis, unspecified
A39.51 Meningococcal endocarditis
A39.52 Meningococcal myocarditis
A39.53 Meningococcal pericarditis
A39.81 Meningococcal encephalitis
A39.82 Meningococcal retrobulbar neuritis
A39.83 Meningococcal arthritis
A39.84 Postmeningococcal arthritis
A39.89 Other meningococcal infections
A39.9 Meningococcal infection, unspecified
A41.9 Sepsis, unspecified organism
A50.30 Late congenital syphilitic oculopathy, unspecified
A50.32 Late congenital syphilitic chorioretinitis
A50.39 Other late congenital syphilitic oculopathy
A50.40 Late congenital neurosyphilis, unspecified
A50.41 Late congenital syphilitic meningitis
A50.42 Late congenital syphilitic encephalitis
A50.43 Late congenital syphilitic polyneuropathy
A50.44 Late congenital syphilitic optic nerve atrophy
A50.45 Juvenile general paresis
A50.49 Other late congenital neurosyphilis
A50.51 Clutton's joints
A50.52 Hutchinson's teeth
A50.53 Hutchinson's triad
A50.54 Late congenital cardiovascular syphilis
A50.55 Late congenital syphilitic arthropathy
A50.56 Late congenital syphilitic osteochondropathy
A50.57 Syphilitic saddle nose
A50.59 Other late congenital syphilis, symptomatic
A51.41 Secondary syphilitic meningitis
A51.49 Other secondary syphilitic conditions
A52.00 Cardiovascular syphilis, unspecified
A52.10 Symptomatic neurosyphilis, unspecified
A52.11 Tabes dorsalis
A52.12 Other cerebrospinal syphilis
A52.13 Late syphilitic meningitis
A52.14 Late syphilitic encephalitis
A52.15 Late syphilitic neuropathy
A52.16 Charcot's arthropathy (tabetic)
A52.17 General paresis
A52.19 Other symptomatic neurosyphilis
A52.2 Asymptomatic neurosyphilis
A52.3 Neurosyphilis, unspecified
A54.81 Gonococcal meningitis
A80.0 Acute paralytic poliomyelitis, vaccine-associated
A80.1 Acute paralytic poliomyelitis, wild virus, imported
A80.2 Acute paralytic poliomyelitis, wild virus, indigenous
A80.30 Acute paralytic poliomyelitis, unspecified
A80.39 Other acute paralytic poliomyelitis
A80.4 Acute nonparalytic poliomyelitis
A80.9 Acute poliomyelitis, unspecified
A81.00 Creutzfeldt-Jakob disease, unspecified
A81.01 Variant Creutzfeldt-Jakob disease
A81.09 Other Creutzfeldt-Jakob disease
A81.1 Subacute sclerosing panencephalitis
A81.2 Progressive multifocal leukoencephalopathy
A81.81 Kuru
A81.82 Gerstmann-Straussler-Scheinker syndrome
A81.83 Fatal familial insomnia
A81.89 Other atypical virus infections of central nervous system
A81.9 Atypical virus infection of central nervous system, unspecified
A82.0 Sylvatic rabies
A82.1 Urban rabies
A82.9 Rabies, unspecified
A83.0 Japanese encephalitis
A83.1 Western equine encephalitis
A83.2 Eastern equine encephalitis
Showing 1 to 100 of 6797 entries in Group 1
FirstPrevCurrently Selected12345NextLast





Group 2 Codes:


ICD-10 CODE DESCRIPTION
F19.180 Other psychoactive substance abuse with psychoactive substance-induced anxiety disorder
F19.181 Other psychoactive substance abuse with psychoactive substance-induced sexual dysfunction
F19.188 Other psychoactive substance abuse with other psychoactive substance-induced disorder
F19.220 Other psychoactive substance dependence with intoxication, uncomplicated
F19.222 Other psychoactive substance dependence with intoxication with perceptual disturbance
F19.230 Other psychoactive substance dependence with withdrawal, uncomplicated
F19.231 Other psychoactive substance dependence with withdrawal delirium
F19.232 Other psychoactive substance dependence with withdrawal with perceptual disturbance
F19.250 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with delusions
F19.251 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with hallucinations
F19.280 Other psychoactive substance dependence with psychoactive substance-induced anxiety disorder
F19.281 Other psychoactive substance dependence with psychoactive substance-induced sexual dysfunction
F19.288 Other psychoactive substance dependence with other psychoactive substance-induced disorder
F32.81 Premenstrual dysphoric disorder
F32.89 Other specified depressive episodes
F53 Puerperal psychosis
G83.5 Locked-in state
G92 Toxic encephalopathy
Showing 1 to 18 of 18 entries in Group 2
FirstPrevCurrently Selected1NextLast

Group 3 Paragraph: AND

ICD-10 CODE DESCRIPTION

S09.11XA Strain of muscle and tendon of head, initial encounter
S09.19XA Other specified injury of muscle and tendon of head, initial encounter
S09.8XXA Other specified injuries of head, initial encounter
S14.5XXA Injury of cervical sympathetic nerves, initial encounter
S16.8XXA Other specified injury of muscle, fascia and tendon at neck level, initial encounter
S19.81XA Other specified injuries of larynx, initial encounter
S19.82XA Other specified injuries of cervical trachea, initial encounter
S19.83XA Other specified injuries of vocal cord, initial encounter
S19.84XA Other specified injuries of thyroid gland, initial encounter
S19.85XA Other specified injuries of pharynx and cervical esophagus, initial encounter
S19.89XA Other specified injuries of other specified part of neck, initial encounter
Z91.410 Personal history of adult physical and sexual abuse