CMS 2014 Clinical Guidelines

Guidelines for Clinical Review Determination

Preamble NIA is committed to the philosophy of supporting safe and effective treatment for patients. The medical necessity criteria that follow are guidelines for the provision of diagnostic imaging. These criteria are designed to guide both providers and reviewers to the most appropriate diagnostic tests based on a patient’s unique circumstances. In all cases, clinical judgment consistent with the standards of good medical practice will be used when applying the guidelines. Guideline determinations are made based on the information provided at the time of the request. It is expected that medical necessity decisions may change as new information is provided or based on unique aspects of the patient’s condition. The treating clinician has final authority and responsibility for treatment decisions regarding the care of the patient.

All inquiries should be directed to: National Imaging Associates, Inc. 6950 Columbia Gateway Drive Columbia, MD 21046 Attn: NIA Associate Chief Medical Officer

TABLE OF CONTENTS TOC 70544 – MR Angiography Head/Brain ______4 70547 – MR Angiography Neck ______4 71555 – MR Angiography Chest (excluding myocardium)______12 72159 – MR Angiography Spinal Canal ______14 73225 – MR Angiography Upper Extremity ______15 73725 – MR Angiography, Lower Extremity ______16 74185 – MR Angiography, Abdomen ______18 72198 – MR Angiography, Pelvis ______18 74261 – CT Colonoscopy Diagnostic (Virtual) ______23 75572 – CT Heart & CT Heart Congenital ______33 75574 – CTA Coronary Arteries (CCTA ______33 76390 – MR Spectroscopy ______39 77058 – MRI Breast ______40 78451 – Nuclear Cardiology/Myocardial Perfusion Imaging______43 78472 - MUGA ______43 78459 – PET Scan, Heart (Cardiac) ______53 78608 – PET Scan, Brain______54 78813 – PET Scan ______57

TOC 70544 – MR Angiography Head/Brain Last Review Date: October 2013 70547 – MR Angiography Neck

“FOR CMS (MEDICARE) MEMBERS ONLY”

COVERAGE INDICATIONS LIMITATIONS AND/OR MEDICAL NECESSITY FOR A HEAD AND NECK MRA:

HEAD AND NECK: MRA is effective for evaluating flow in internal carotid vessels of the head and neck. However, not all potential applications of MRA have been shown to be reasonable and necessary. All of the following criteria must apply in order for Medicare to provide coverage for MRA of the head and neck:

 MRA is used to evaluate the carotid arteries, the circle of Willis, the anterior, middle or posterior cerebral arteries, the vertebral or basilar arteries or the venous sinuses.

 MRA is performed on patients with conditions of the head and neck for which surgery is anticipated and may be found to be appropriate based on the MRA. These conditions include, but are not limited to, tumor, aneurysms, vascular malformations, vascular occlusion or thrombosis. Within this broad category of disorders, medical necessity is the underlying determinant of the need for an MRA in specific diseases. The medical records should clearly justify and demonstrate the existence of medical necessity; and,

 MRA and 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.

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 necessary for screening asymptomatic patients for intracranial aneurysms.

Please note that the anticipated surgery may be a percutaneous procedure such as carotid angioplasty with stent insertion.

MRA of the Head & Neck is covered for these diagnoses:

094.87 SYPHILITIC RUPTURED CEREBRAL ANEURYSM MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA 190.0 AND CHOROID 190.1 MALIGNANT NEOPLASM OF ORBIT 190.2 MALIGNANT NEOPLASM OF LACRIMAL GLAND 190.3 MALIGNANT NEOPLASM OF CONJUNCTIVA 190.4 MALIGNANT NEOPLASM OF CORNEA 190.5 MALIGNANT NEOPLASM OF RETINA 190.6 MALIGNANT NEOPLASM OF CHOROID 190.7 MALIGNANT NEOPLASM OF LACRIMAL DUCT 190.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF EYE 191.0 MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES 191.1 MALIGNANT NEOPLASM OF FRONTAL LOBE 191.2 MALIGNANT NEOPLASM OF TEMPORAL LOBE 191.3 MALIGNANT NEOPLASM OF PARIETAL LOBE 191.4 MALIGNANT NEOPLASM OF OCCIPITAL LOBE 191.5 MALIGNANT NEOPLASM OF VENTRICLES 191.6 MALIGNANT NEOPLASM OF CEREBELLUM NOS 191.7 MALIGNANT NEOPLASM OF BRAIN STEM 191.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRAIN 191.9 MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE 192.1 MALIGNANT NEOPLASM OF CEREBRAL MENINGES 194.3 MALIGNANT NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT 194.4 MALIGNANT NEOPLASM OF PINEAL GLAND 194.5 MALIGNANT NEOPLASM OF CAROTID BODY 194.6 MALIGNANT NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA 198.3 SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD 198.4 SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM 225.0 BENIGN NEOPLASM OF BRAIN 225.1 BENIGN NEOPLASM OF CRANIAL NERVES 225.2 BENIGN NEOPLASM OF CEREBRAL MENINGES 227.3 BENIGN NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT 227.4 BENIGN NEOPLASM OF PINEAL GLAND 227.5 BENIGN NEOPLASM OF CAROTID BODY 227.6 BENIGN NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA 228.02 HEMANGIOMA OF INTRACRANIAL STRUCTURES 228.03 HEMANGIOMA OF RETINA 237.5 NEOPLASM OF UNCERTAIN BEHAVIOR OF BRAIN AND SPINAL CORD 237.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF MENINGES

237.70 NEUROFIBROMATOSIS UNSPECIFIED 237.71 NEUROFIBROMATOSIS TYPE 1 VON RECKLINGHAUSEN'S DISEASE 237.72 NEUROFIBROMATOSIS TYPE 2 ACOUSTIC NEUROFIBROMATOSIS 239.6 NEOPLASM OF UNSPECIFIED NATURE OF BRAIN 282.60 SICKLE-CELL DISEASE UNSPECIFIED 325 PHLEBITIS AND THROMBOPHLEBITIS OF INTRACRANIAL VENOUS SINUSES 350.1 TRIGEMINAL NEURALGIA 350.2 ATYPICAL FACE PAIN 350.8 OTHER SPECIFIED TRIGEMINAL NERVE DISORDERS 362.30 RETINAL VASCULAR OCCLUSION UNSPECIFIED 362.31 CENTRAL RETINAL ARTERY OCCLUSION 362.32 RETINAL ARTERIAL BRANCH OCCLUSION 362.33 PARTIAL RETINAL ARTERIAL OCCLUSION 362.34 TRANSIENT RETINAL ARTERIAL OCCLUSION 368.11 SUDDEN VISUAL LOSS 368.12 TRANSIENT VISUAL LOSS 368.40 VISUAL FIELD DEFECT UNSPECIFIED 368.46 HOMONYMOUS BILATERAL FIELD DEFECTS 368.47 HETERONYMOUS BILATERAL FIELD DEFECTS 377.01 PAPILLEDEMA ASSOCIATED WITH INCREASED INTRACRANIAL PRESSURE 377.04 FOSTER-KENNEDY SYNDROME 377.42 HEMORRHAGE IN OPTIC NERVE SHEATHS DISORDERS OF OPTIC CHIASM ASSOCIATED WITH PITUITARY NEOPLASMS AND 377.51 DISORDERS 377.52 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH OTHER NEOPLASMS 377.53 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH VASCULAR DISORDERS 377.54 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH INFLAMMATORY DISORDERS 377.61 DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH NEOPLASMS DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH VASCULAR 377.62 DISORDERS 377.71 DISORDERS OF VISUAL CORTEX ASSOCIATED WITH NEOPLASMS 377.72 DISORDERS OF VISUAL CORTEX ASSOCIATED WITH VASCULAR DISORDERS 378.51 THIRD OR OCULOMOTOR NERVE PALSY PARTIAL 378.52 THIRD OR OCULOMOTOR NERVE PALSY TOTAL 378.53 FOURTH OR TROCHLEAR NERVE PALSY 378.54 SIXTH OR ABDUCENS NERVE PALSY 386.2 VERTIGO OF CENTRAL ORIGIN 388.30 TINNITUS UNSPECIFIED 388.31 SUBJECTIVE TINNITUS 388.32 OBJECTIVE TINNITUS 430 SUBARACHNOID HEMORRHAGE 431 INTRACEREBRAL HEMORRHAGE 432.0 NONTRAUMATIC EXTRADURAL HEMORRHAGE 432.1 SUBDURAL HEMORRHAGE

432.9 UNSPECIFIED INTRACRANIAL HEMORRHAGE OCCLUSION AND STENOSIS OF BASILAR ARTERY WITHOUT CEREBRAL 433.00 INFARCTION 433.01 OCCLUSION AND STENOSIS OF BASILAR ARTERY WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF CAROTID ARTERY WITHOUT CEREBRAL 433.10 INFARCTION 433.11 OCCLUSION AND STENOSIS OF CAROTID ARTERY WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITHOUT CEREBRAL 433.20 INFARCTION OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITH CEREBRAL 433.21 INFARCTION OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL 433.30 ARTERIES WITHOUT CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL 433.31 ARTERIES WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY 433.80 WITHOUT CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY WITH 433.81 CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY WITHOUT 433.90 CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY WITH 433.91 CEREBRAL INFARCTION 434.00 CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION 434.01 CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION 434.10 CEREBRAL EMBOLISM WITHOUT CEREBRAL INFARCTION 434.11 CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION 434.90 CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITHOUT CEREBRAL INFARCTION 434.91 CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL INFARCTION 435.0 BASILAR ARTERY SYNDROME 435.1 VERTEBRAL ARTERY SYNDROME 435.2 SUBCLAVIAN STEAL SYNDROME 435.3 VERTEBROBASILAR ARTERY SYNDROME 435.9 UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA 436 ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE 437.3 CEREBRAL ANEURYSM NONRUPTURED 442.81 ANEURYSM OF ARTERY OF NECK 442.82 ANEURYSM OF SUBCLAVIAN ARTERY 443.21 DISSECTION OF CAROTID ARTERY 443.24 DISSECTION OF VERTEBRAL ARTERY 444.01 SADDLE EMBOLUS OF ABDOMINAL AORTA 444.09 OTHER ARTERIAL EMBOLISM AND THROMBOSIS OF ABDOMINAL AORTA 444.1 EMBOLISM AND THROMBOSIS OF THORACIC AORTA 444.21 ARTERIAL EMBOLISM AND THROMBOSIS OF UPPER EXTREMITY

444.22 ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY 444.81 EMBOLISM AND THROMBOSIS OF ILIAC ARTERY 444.89 EMBOLISM AND THROMBOSIS OF OTHER ARTERY 444.9 EMBOLISM AND THROMBOSIS OF UNSPECIFIED ARTERY 446.7 TAKAYASU'S DISEASE 447.0 ARTERIOVENOUS FISTULA ACQUIRED 447.1 STRICTURE OF ARTERY 447.2 RUPTURE OF ARTERY 447.5 NECROSIS OF ARTERY 447.8 OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES 449 SEPTIC ARTERIAL EMBOLISM 747.81 CONGENITAL ANOMALIES OF CEREBROVASCULAR SYSTEM 753.13 POLYCYSTIC KIDNEY AUTOSOMAL DOMINANT 780.2 SYNCOPE AND COLLAPSE 780.4 DIZZINESS AND GIDDINESS 781.4 TRANSIENT PARALYSIS OF LIMB 781.99* OTHER SYMPTOMS INVOLVING NERVOUS AND MUSCULOSKELETAL SYSTEMS 784.2 SWELLING MASS OR LUMP IN HEAD AND NECK NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER 793.0 EXAMINATION OF SKULL AND HEAD SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN 852.00 INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN 852.01 INTRACRANIAL WOUND WITH NO LOSS OF CONSCIOUSNESS SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN 852.02 INTRACRANIAL WOUND WITH BRIEF (LESS THAN ONE HOUR) LOSS OF CONSCIOUSNESS SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN 852.03 INTRACRANIAL WOUND WITH MODERATE (1-24 HOURS) LOSS OF CONSCIOUSNESS SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN 852.04 INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN 852.05 INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE-EXISTING CONSCIOUS LEVEL SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN 852.06 INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN 852.09 INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN 852.10 INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN 852.11 INTRACRANIAL WOUND WITH NO LOSS OF CONSCIOUSNESS 852.12 SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN

INTRACRANIAL WOUND WITH BRIEF (LESS THAN ONE HOUR) LOSS OF CONSCIOUSNESS SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN 852.13 INTRACRANIAL WOUND WITH MODERATE (1-24 HOURS) LOSS OF CONSCIOUSNESS SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN 852.14 INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN 852.15 INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE-EXISTING CONSCIOUS LEVEL SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN 852.16 INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN 852.19 INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL 852.20 WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL 852.21 WOUND WITH NO LOSS OF CONSCIOUSNESS SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL 852.22 WOUND WITH BRIEF (LESS THAN ONE HOUR) LOSS OF CONSCIOUSNESS SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL 852.23 WOUND WITH MODERATE (1-24 HOURS) LOSS OF CONSCIOUSNESS SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL 852.24 WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL 852.25 WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE-EXISTING CONSCIOUS LEVEL SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL 852.26 WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL 852.29 WOUND WITH CONCUSSION UNSPECIFIED SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL 852.30 WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL 852.31 WOUND WITH NO LOSS OF CONSCIOUSNESS SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL 852.32 WOUND WITH BRIEF (LESS THAN ONE HOUR) LOSS OF CONSCIOUSNESS SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL 852.33 WOUND WITH MODERATE (1-24 HOURS) LOSS OF CONSCIOUSNESS SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL 852.34 WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL 852.35 WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS

WITHOUT RETURN TO PRE-EXISTING CONSCIOUS LEVEL SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL 852.36 WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL 852.39 WOUND WITH CONCUSSION UNSPECIFIED EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN 852.40 INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN 852.41 INTRACRANIAL WOUND WITH NO LOSS OF CONSCIOUSNESS EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN 852.42 INTRACRANIAL WOUND WITH BRIEF (LESS THAN 1 HOUR) LOSS OF CONSCIOUSNESS EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN 852.43 INTRACRANIAL WOUND WITH MODERATE (1-24 HOURS) LOSS OF CONSCIOUSNESS EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN 852.44 INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN 852.45 INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE-EXISTING CONSCIOUS LEVEL EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN 852.46 INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN 852.49 INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL 852.50 WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL 852.51 WOUND WITH NO LOSS OF CONSCIOUSNESS EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL 852.52 WOUND WITH BRIEF (LESS THAN ONE HOUR) LOSS OF CONSCIOUSNESS EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL 852.53 WOUND WITH MODERATE (1-24 HOURS) LOSS OF CONSCIOUSNESS EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL 852.54 WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL 852.55 WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE-EXISTING CONSCIOUS LEVEL EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL 852.56 WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL 852.59 WOUND WITH CONCUSSION UNSPECIFIED 900.00 INJURY TO CAROTID ARTERY UNSPECIFIED 900.01 INJURY TO COMMON CAROTID ARTERY 900.02 INJURY TO EXTERNAL CAROTID ARTERY

900.03 INJURY TO INTERNAL CAROTID ARTERY 900.82 INJURY TO MULTIPLE BLOOD VESSELS OF HEAD AND NECK 900.89 INJURY TO OTHER SPECIFIED BLOOD VESSELS OF HEAD AND NECK 908.3 LATE EFFECT OF INJURY TO BLOOD VESSEL OF HEAD NECK AND EXTREMITIES MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND 996.1 GRAFT MECHANICAL COMPLICATION OF NERVOUS SYSTEM DEVICE IMPLANT AND 996.2 GRAFT Group 1 Medical Necessity ICD-9 Codes Asterisk Explanation: *781.99* - Use for patients presenting with signs and symptoms strongly suggesting an intracerebral aneurysm, without the MRA finding of an aneurysm.

TOC 71555 – MR Angiography Chest (excluding Last Review Date: October 2013 myocardium)

“FOR CMS (MEDICARE) MEMBERS ONLY”

COVERAGE INDICATIONS LIMITATIONS AND/OR MEDICAL NECESSITY FOR A CHEST MRA:

CHEST:  Diagnosis of Pulmonary Embolism Current scientific data has shown that diagnostic pulmonary MRAs are improving due to recent developments such as faster imaging capabilities and gadolinium-enhancement. However, these advances in MRA are not significant enough to warrant replacement of pulmonary angiography in the diagnosis of pulmonary embolism for patients who have no contraindication to receiving intravenous iodinated contrast material. Patients who are allergic to iodinated contrast material face a high risk of developing complications if they undergo pulmonary angiography or computed tomography angiography. Therefore, Medicare will cover MRA of the chest for diagnosing a suspected pulmonary embolism when it is contraindicated for the patient to receive intravascular iodinated contrast material.  Evaluation of Thoracic Aortic Dissection and Aneurysm. Studies have shown that MRA of the chest has a high level of diagnostic accuracy for preoperative and post-operative evaluation of aortic dissection of aneurysm. Depending on the clinical presentation, MRA may be used as an alternative to other non-invasive imaging technologies, such as transesophageal echocardiography and CT. Generally, Medicare will provide coverage only for MRA or for CA when used as a diagnostic test. However, if both MRA and CA of the chest are used, the physician must demonstrate the medical need for performing these tests.

MRA of the Chest is covered for the following diagnoses:

093.0 ANEURYSM OF AORTA SPECIFIED AS SYPHILITIC 415.0 ACUTE COR PULMONALE 415.11 IATROGENIC PULMONARY EMBOLISM AND INFARCTION 415.12 SEPTIC PULMONARY EMBOLISM 415.13 SADDLE EMBOLUS OF PULMONARY ARTERY 415.19 OTHER PULMONARY EMBOLISM AND INFARCTION 417.1 ANEURYSM OF PULMONARY ARTERY 441.01 DISSECTION OF AORTA THORACIC 441.03 DISSECTION OF AORTA THORACOABDOMINAL 441.2 THORACIC ANEURYSM WITHOUT RUPTURE 441.7 THORACOABDOMINAL ANEURYSM WITHOUT RUPTURE 441.9 AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT RUPTURE 444.1 EMBOLISM AND THROMBOSIS OF THORACIC AORTA 447.70 AORTIC ECTASIA, UNSPECIFIED SITE

447.71 THORACIC AORTIC ECTASIA 447.73 THORACOABDOMINAL AORTIC ECTASIA 449 SEPTIC ARTERIAL EMBOLISM 584.9 ACUTE KIDNEY FAILURE, UNSPECIFIED 585.3 CHRONIC KIDNEY DISEASE, STAGE III (MODERATE) 585.4 CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) 585.5 CHRONIC KIDNEY DISEASE, STAGE V 585.6 END STAGE RENAL DISEASE 586 RENAL FAILURE UNSPECIFIED 747.10 COARCTATION OF AORTA (PREDUCTAL) (POSTDUCTAL) 747.11 INTERRUPTION OF AORTIC ARCH 759.82 MARFAN SYNDROME NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND 793.2 OTHER EXAMINATION OF OTHER INTRATHORACIC ORGANS NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF 794.2 PULMONARY SYSTEM PERSONAL HISTORY OF OTHER DISEASES OF CIRCULATORY V12.59 SYSTEM NOT ELSEWHERE CLASSIFIED PERSONAL HISTORY OF ALLERGY TO OTHER SPECIFIED V14.8 MEDICINAL AGENTS V15.08 PERSONAL HISTORY OF ALLERGY TO RADIOGRAPHIC DYE V67.00 FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED SURGERY

TOC 72159 – MR Angiography Spinal Canal Last Review Date: October 2013

All indications for MRA Spinal Canal are nationally noncovered by Medicare.

TOC 73225 – MR Angiography Upper Extremity Last Review Date: October 2013

All indications for MRA Upper Extremity are nationally noncovered by Medicare.

TOC 73725 – MR Angiography, Lower Extremity Last Review Date: October 2013

“FOR CMS (MEDICARE) MEMBERS ONLY”

COVERAGE INDICATIONS LIMITATIONS AND/OR MEDICAL NECESSITY FOR A LOWER EXTREMITY MRA:

MRA of peripheral arteries is useful in determining the presence and extent of peripheral vascular disease in lower extremities. This procedure is non-invasive and has been shown to find occult vessels in some patients for which those vessels were not apparent when CA was performed. Medicare will cover either MRA or CA to evaluate peripheral arteries of the lower extremities. However, both MRA and CA may be useful in some cases, such as:  A patient has had CA and this test was unable to identify a viable run-off vessel for bypass. When exploratory surgery is not believed to be a reasonable medical course of action for this patient, MRA may be performed to identify the viable runoff vessel; or,  A patient has had MRA, but the results are inconclusive.

MRA of the Peripheral Arteries of Lower Extremities is covered for the following diagnoses:

228.09 HEMANGIOMA OF OTHER SITES SECONDARY DIABETES MELLITUS WITH PERIPHERAL CIRCULATORY DISORDERS, 249.70 NOT STATED AS UNCONTROLLED, OR UNSPECIFIED SECONDARY DIABETES MELLITUS WITH PERIPHERAL CIRCULATORY DISORDERS, 249.71 UNCONTROLLED DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR 250.70 UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE 250.71 TYPE], NOT STATED AS UNCONTROLLED DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR 250.72 UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE 250.73 TYPE], UNCONTROLLED 440.20 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH 440.21 INTERMITTENT CLAUDICATION 440.22 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH REST PAIN ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH 440.23 ULCERATION ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH 440.24 GANGRENE 440.30 ATHEROSCLEROSIS OF UNSPECIFIED BYPASS GRAFT OF THE EXTREMITIES 440.31 ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT OF THE EXTREMITIES ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT OF THE 440.32 EXTREMITIES

442.2 ANEURYSM OF ILIAC ARTERY 442.3 ANEURYSM OF ARTERY OF LOWER EXTREMITY 443.1 THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE) 443.22 DISSECTION OF ILIAC ARTERY 443.29 DISSECTION OF OTHER ARTERY 443.81 PERIPHERAL ANGIOPATHY IN DISEASES CLASSIFIED ELSEWHERE 443.9 PERIPHERAL VASCULAR DISEASE UNSPECIFIED 444.22 ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY 444.81 EMBOLISM AND THROMBOSIS OF ILIAC ARTERY 444.89 EMBOLISM AND THROMBOSIS OF OTHER ARTERY 445.02 ATHEROEMBOLISM OF LOWER EXTREMITY 447.1 STRICTURE OF ARTERY 447.5 NECROSIS OF ARTERY 447.6 ARTERITIS UNSPECIFIED 447.8 OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES 449 SEPTIC ARTERIAL EMBOLISM 747.64 LOWER LIMB VESSEL ANOMALY 747.69 ANOMALIES OF OTHER SPECIFIED SITES OF PERIPHERAL VASCULAR SYSTEM 785.4 GANGRENE 904.0 INJURY TO COMMON FEMORAL ARTERY 904.1 INJURY TO SUPERFICIAL FEMORAL ARTERY 904.41 INJURY TO POPLITEAL ARTERY 904.51 INJURY TO ANTERIOR TIBIAL ARTERY 904.53 INJURY TO POSTERIOR TIBIAL ARTERY MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND 996.1 GRAFT V67.00 FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED SURGERY V67.59 OTHER FOLLOW-UP EXAMINATION

TOC 74185 – MR Angiography, Abdomen Last Review Date: October 2013 72198 – MR Angiography, Pelvis

“FOR CMS (MEDICARE) MEMBERS ONLY”

COVERAGE INDICATIONS LIMITATIONS AND/OR MEDICAL NECESSITY FOR AN ABDOMEN AND PELVIS MRA:

 Pre-operative Evaluation of Patients Undergoing Elective Abdominal Aortic Aneurysm (AAA) Repair. MRA is covered for pre-operative evaluation of patients undergoing elective AAA repair if the scientific evidence reveals MRA is considered comparable to CA in determining the extent of AAA, as well as in evaluating aortoiliac occlusion disease and renal artery pathology that may be necessary in the surgical planning of AAA repair. These studies also reveal that MRA could provide a net benefit to the patient. If preoperative CA is avoided, then patients are not exposed to the risks associated with invasive procedures, contrast media, end-organ damage, or arterial injury.  Imaging the Renal Arteries and the Aortoiliac Arteries in the Absence of AAA or Aortic Dissection.

MRA coverage is expanded to include imaging the renal arteries and the aortoiliac arteries in the absence of AAA or aortic dissection. MRA should be obtained in those circumstances in which using MRA is expected to avoid obtaining CA, when physician history, physical examination, and standard assessment tools provide insufficient information for patient management, and obtaining an MRA has a high probability of positively affecting patient management. However, CA may be ordered after obtaining the results of an MRA in those rare instances where medical necessity is demonstrated. (CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 220.2.B.2.c).

An MRA of the abdomen for evaluation of possible renal artery stenosis would not be considered medically necessary without some evidence consistent with renovascular hypertension. Such evidence might include: o a history of early or late onset of hypertension, hypertension refractory to medication, or worsening renal function; o the presence of a renal artery bruit; o laboratory tests (elevated serum renins, increasing creatinine); or o other radiologic tests (ultrasound, captopril scintigraphy, or other imaging showing small kidney or unequal kidney sizes).

MRA of the Abdomen and Pelvis is covered for the following diagnoses:

189.0 MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS 189.1 MALIGNANT NEOPLASM OF RENAL PELVIS

MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF 189.8 URINARY ORGANS 223.0 BENIGN NEOPLASM OF KIDNEY EXCEPT PELVIS 401.0 MALIGNANT ESSENTIAL HYPERTENSION 401.1 BENIGN ESSENTIAL HYPERTENSION MALIGNANT HYPERTENSIVE HEART DISEASE WITHOUT HEART 402.00 FAILURE MALIGNANT HYPERTENSIVE HEART DISEASE WITH HEART 402.01 FAILURE HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH 403.00 CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH 403.01 CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH 403.10 CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH 403.11 CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, 403.90 WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, 403.91 WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC 404.00 KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC 404.01 KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, 404.02 MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, 404.03 MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITHOUT HEART FAILURE AND WITH CHRONIC 404.10 KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, 404.11 BENIGN, WITH HEART FAILURE AND WITH CHRONIC KIDNEY

DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, 404.12 BENIGN, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, 404.13 BENIGN, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITHOUT HEART FAILURE AND WITH CHRONIC 404.90 KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND WITH CHRONIC 404.91 KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, 404.92 UNSPECIFIED, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, 404.93 UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 405.01 MALIGNANT RENOVASCULAR HYPERTENSION 405.11 BENIGN RENOVASCULAR HYPERTENSION 405.91 UNSPECIFIED RENOVASCULAR HYPERTENSION 440.0 ATHEROSCLEROSIS OF AORTA 440.1 ATHEROSCLEROSIS OF RENAL ARTERY ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES 440.20 UNSPECIFIED ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES 440.21 WITH INTERMITTENT CLAUDICATION ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES 440.22 WITH REST PAIN ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES 440.23 WITH ULCERATION ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES 440.24 WITH GANGRENE 441.02 DISSECTION OF AORTA ABDOMINAL 441.03 DISSECTION OF AORTA THORACOABDOMINAL 441.4 ABDOMINAL ANEURYSM WITHOUT RUPTURE 441.7 THORACOABDOMINAL ANEURYSM WITHOUT RUPTURE 441.9 AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT RUPTURE 442.1 ANEURYSM OF RENAL ARTERY 442.2 ANEURYSM OF ILIAC ARTERY 442.3 ANEURYSM OF ARTERY OF LOWER EXTREMITY 442.83 ANEURYSM OF SPLENIC ARTERY 442.84 ANEURYSM OF OTHER VISCERAL ARTERY

442.89 ANEURYSM OF OTHER SPECIFIED SITE 443.22 DISSECTION OF ILIAC ARTERY 443.23 DISSECTION OF RENAL ARTERY 443.9 PERIPHERAL VASCULAR DISEASE UNSPECIFIED 444.01 SADDLE EMBOLUS OF ABDOMINAL AORTA OTHER ARTERIAL EMBOLISM AND THROMBOSIS OF 444.09 ABDOMINAL AORTA 444.1 EMBOLISM AND THROMBOSIS OF THORACIC AORTA 444.81 EMBOLISM AND THROMBOSIS OF ILIAC ARTERY 445.81 ATHEROEMBOLISM OF KIDNEY 447.0 ARTERIOVENOUS FISTULA ACQUIRED 447.1 STRICTURE OF ARTERY 447.3 HYPERPLASIA OF RENAL ARTERY 447.5 NECROSIS OF ARTERY 447.70 AORTIC ECTASIA, UNSPECIFIED SITE 447.72 ABDOMINAL AORTIC ECTASIA 447.73 THORACOABDOMINAL AORTIC ECTASIA 447.8 OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES 449 SEPTIC ARTERIAL EMBOLISM 557.0 ACUTE VASCULAR INSUFFICIENCY OF INTESTINE 557.1 CHRONIC VASCULAR INSUFFICIENCY OF INTESTINE 584.5 ACUTE KIDNEY FAILURE WITH LESION OF TUBULAR NECROSIS ACUTE KIDNEY FAILURE WITH LESION OF RENAL CORTICAL 584.6 NECROSIS ACUTE KIDNEY FAILURE WITH LESION OF RENAL MEDULLARY 584.7 [PAPILLARY] NECROSIS ACUTE KIDNEY FAILURE WITH OTHER SPECIFIED 584.8 PATHOLOGICAL LESION IN KIDNEY 584.9 ACUTE KIDNEY FAILURE, UNSPECIFIED 585.1 CHRONIC KIDNEY DISEASE, STAGE I 585.2 CHRONIC KIDNEY DISEASE, STAGE II (MILD) 585.3 CHRONIC KIDNEY DISEASE, STAGE III (MODERATE) 585.4 CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) 585.5 CHRONIC KIDNEY DISEASE, STAGE V 585.6 END STAGE RENAL DISEASE 585.9 CHRONIC KIDNEY DISEASE, UNSPECIFIED 587 RENAL SCLEROSIS UNSPECIFIED 589.0 UNILATERAL SMALL KIDNEY 589.1 BILATERAL SMALL KIDNEYS 589.9 SMALL KIDNEY UNSPECIFIED 593.81 VASCULAR DISORDERS OF KIDNEY 747.62 RENAL VESSEL ANOMALY 747.64 LOWER LIMB VESSEL ANOMALY NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND 793.6 OTHER EXAMINATION OF ABDOMINAL AREA, INCLUDING

RETROPERITONEUM UNSPECIFIED INJURY TO KIDNEY WITHOUT OPEN WOUND 866.00 INTO CAVITY HEMATOMA OF KIDNEY WITHOUT RUPTURE OF CAPSULE 866.01 WITHOUT OPEN WOUND INTO CAVITY 866.02 LACERATION OF KIDNEY WITHOUT OPEN WOUND INTO CAVITY COMPLETE DISRUPTION OF KIDNEY PARENCHYMA WITHOUT 866.03 OPEN WOUND INTO CAVITY UNSPECIFIED INJURY TO KIDNEY WITH OPEN WOUND INTO 866.10 CAVITY HEMATOMA OF KIDNEY WITHOUT RUPTURE OF CAPSULE WITH 866.11 OPEN WOUND INTO CAVITY 866.12 LACERATION OF KIDNEY WITH OPEN WOUND INTO CAVITY COMPLETE DISRUPTION OF KIDNEY PARENCHYMA WITH OPEN 866.13 WOUND INTO CAVITY 902.0 INJURY TO ABDOMINAL AORTA 902.40 INJURY TO RENAL VESSEL(S) UNSPECIFIED 902.41 INJURY TO RENAL ARTERY 902.49 INJURY TO OTHER RENAL BLOOD VESSELS 902.50 INJURY TO ILIAC VESSEL(S) UNSPECIFIED 902.51 INJURY TO HYPOGASTRIC ARTERY 902.53 INJURY TO ILIAC ARTERY MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE 996.1 IMPLANT AND GRAFT INFECTION AND INFLAMMATORY REACTION DUE TO OTHER 996.62 VASCULAR DEVICE IMPLANT AND GRAFT OTHER COMPLICATIONS DUE TO OTHER VASCULAR DEVICE 996.74 IMPLANT AND GRAFT 996.81 COMPLICATIONS OF TRANSPLANTED KIDNEY 996.86 COMPLICATIONS OF TRANSPLANTED PANCREAS 997.72 VASCULAR COMPLICATIONS OF RENAL ARTERY V42.0 KIDNEY REPLACED BY TRANSPLANT AFTERCARE FOLLOWING SURGERY OF THE CIRCULATORY V58.73 SYSTEM NOT ELSEWHERE CLASSIFIED V59.4 KIDNEY DONORS V70.8 OTHER SPECIFIED GENERAL MEDICAL EXAMINATIONS

TOC 74261 – CT Colonoscopy Diagnostic (Virtual) Last Review Date: October 2013

“FOR CMS (MEDICARE) MEMBERS ONLY”

COVERAGE INDICATIONS LIMITATIONS AND/OR MEDICAL NECESSITY FOR CT COLONOSCOPY (VIRTUAL COLONOSCOPY):

Indications:  CT colonography is indicated in those patients in whom a diagnostic (performed for signs/symptoms of disease) optical colonoscopy of the entire colon is incomplete. Failure to complete the optical colonoscopy may be secondary to conditions such as, but not limited to, an obstructing neoplasm, stricture, tortuosity, spasm, redundant colon diverticulitis, extrinsic compression or aberrant anatomy scarring from prior surgery.

 CT colonography is indicated when a board certified or board eligible gastroenterologist, a surgeon trained in endoscopy or a physician with equivalent endoscopic training determines from an evaluation of the patient that optical colonoscopy can not be safely attempted.

 CT colonography is also indicated for the evaluation of a submucosal abnormality detected on colonoscopy or other imaging study.

 CT colonography should be performed soon after the failed standard colonoscopy, if appropriate, so that the patient will not have to endure repeat colonic preparation.

Limitations: CT colonography is not reimbursable when used in the absence of signs or symptoms of disease, regardless of family history or other risk factors for the development of colonic disease.

CPT code 74263 is a noncovered service, and is a Status Indicator “N” on the Medicare Physician Fee Schedule Database (MPFSDB). CT colonography is not reimbursable when performed for screening purposes, regardless of whether billed with CPT codes 74261, 74262 or 74263 or any other HCPCS/CPT code.

Since any colonography with abnormal or suspicious findings would require a subsequent instrument colonoscopy for diagnosis (e.g., biopsy) or for treatment (e.g., polypectomy), CT colonography is not reimbursable when used as an alternative to an instrument colonoscopy, even though performed for signs or symptoms of disease.

Irritable bowel syndrome and abdominal pain when representing chronic stable symptoms rarely represent reasonable indications for colonoscopy and CT colonography. These conditions have been placed on the list of covered diagnoses for use when a colonoscopy/colonography exam is normal in the face of compelling symptoms. When diagnosis codes representing these conditions are used, the codes must be applicable and the rationale for the colonoscopy/colonography must be carefully documented in the medical record.

ICD-9 Codes that Support Medical Necessity:

It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g., to the fourth or fifth digit). The correct use of an ICD-9-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

For the purposes of this LCD, ICD-9-CM code V64.3 indicates that the instrument colonoscopy has been attempted and was incomplete or when a board certified or board eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training determined from an evaluation of the patient that optical colonoscopy cannot be safely attempted.

V64.3 PROCEDURE NOT CARRIED OUT FOR OTHER REASONS In addition to reporting ICD-9-CM code V64.3, one (or more) of the ICD-9-CM codes below must be reported in order to support medical necessity. 004.9 SHIGELLOSIS UNSPECIFIED 006.1 CHRONIC INTESTINAL AMEBIASIS WITHOUT ABSCESS 006.2 AMEBIC NONDYSENTERIC COLITIS 006.9 AMEBIASIS UNSPECIFIED 007.0 BALANTIDIASIS 007.2 COCCIDIOSIS 007.8 OTHER SPECIFIED PROTOZOAL INTESTINAL DISEASES 008.04 INTESTINAL INFECTION DUE TO ENTEROHEMORRHAGIC E. COLI 008.2 INTESTINAL INFECTION DUE TO AEROBACTER AEROGENES 008.43 INTESTINAL INFECTION DUE TO CAMPYLOBACTER 008.44 INTESTINAL INFECTION DUE TO YERSINIA ENTEROCOLITICA 008.45 INTESTINAL INFECTION DUE TO CLOSTRIDIUM DIFFICILE 008.46 INTESTINAL INFECTION DUE TO OTHER ANAEROBES 008.5 BACTERIAL ENTERITIS UNSPECIFIED 008.61 ENTERITIS DUE TO ROTAVIRUS 008.62 ENTERITIS DUE TO ADENOVIRUS 008.63 ENTERITIS DUE TO NORWALK VIRUS 008.64 ENTERITIS DUE TO OTHER SMALL ROUND VIRUSES [SRV'S] 008.65 ENTERITIS DUE TO CALICIVIRUS 008.66 ENTERITIS DUE TO ASTROVIRUS 008.67 ENTERITIS DUE TO ENTEROVIRUS NEC 008.69 ENTERITIS DUE TO OTHER VIRAL ENTERITIS

009.0 INFECTIOUS COLITIS ENTERITIS AND GASTROENTERITIS 009.1 COLITIS ENTERITIS AND GASTROENTERITIS OF PRESUMED INFECTIOUS ORIGIN 009.2 INFECTIOUS DIARRHEA 009.3 DIARRHEA OF PRESUMED INFECTIOUS ORIGIN 014.00 TUBERCULOUS PERITONITIS UNSPECIFIED EXAMINATION TUBERCULOUS PERITONITIS BACTERIOLOGICAL OR HISTOLOGICAL 014.01 EXAMINATION NOT DONE TUBERCULOUS PERITONITIS BACTERIOLOGICAL OR HISTOLOGICAL 014.02 EXAMINATION RESULTS UNKNOWN (AT PRESENT) TUBERCULOUS PERITONITIS TUBERCLE BACILLI FOUND (IN SPUTUM) BY 014.03 MICROSCOPY TUBERCULOUS PERITONITIS TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY 014.04 MICROSCOPY BUT FOUND BY BACTERIAL CULTURE TUBERCULOUS PERITONITIS TUBERCLE BACILLI NOT FOUND BY 014.05 BACTERIOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOUS PERITONITIS TUBERCLE BACILLI NOT FOUND BY 014.06 BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) OTHER TUBERCULOSIS OF INTESTINES AND MESENTERIC GLANDS UNSPECIFIED 014.80 EXAMINATION OTHER TUBERCULOSIS OF INTESTINES AND MESENTERIC GLANDS 014.81 BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE OTHER TUBERCULOSIS OF INTESTINES AND MESENTERIC GLANDS 014.82 BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION RESULTS UNKNOWN (AT PRESENT) OTHER TUBERCULOSIS OF INTESTINES AND MESENTERIC GLANDS TUBERCLE 014.83 BACILLI FOUND (IN SPUTUM) BY MICROSCOPY OTHER TUBERCULOSIS OF INTESTINES AND MESENTERIC GLANDS TUBERCLE 014.84 BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY BUT FOUND BY BACTERIAL CULTURE OTHER TUBERCULOSIS OF INTESTINES AND MESENTERIC GLANDS TUBERCLE 014.85 BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY

OTHER TUBERCULOSIS OF INTESTINES AND MESENTERIC GLANDS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION 014.86 BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) 042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE 098.7 GONOCOCCAL INFECTION OF ANUS AND RECTUM 099.1 LYMPHOGRANULOMA VENEREUM 112.85 CANDIDAL ENTERITIS 120.1 SCHISTOSOMIASIS DUE TO SCHISTOSOMA MANSONI 123.0 TAENIA SOLIUM INFECTION INTESTINAL FORM 123.2 TAENIA SAGINATA INFECTION 123.3 TAENIASIS UNSPECIFIED 123.4 DIPHYLLOBOTHRIASIS INTESTINAL 123.6 HYMENOLEPIASIS 123.8 OTHER SPECIFIED CESTODE INFECTION 126.9 ANCYLOSTOMIASIS AND NECATORIASIS UNSPECIFIED 127.0 ASCARIASIS 127.2 STRONGYLOIDIASIS 127.3 TRICHURIASIS 127.4 ENTEROBIASIS 127.9 INTESTINAL HELMINTHIASIS UNSPECIFIED 128.9 HELMINTH INFECTION UNSPECIFIED 129 INTESTINAL PARASITISM UNSPECIFIED 152.2 MALIGNANT NEOPLASM OF ILEUM 153.0 MALIGNANT NEOPLASM OF HEPATIC FLEXURE 153.1 MALIGNANT NEOPLASM OF TRANSVERSE COLON 153.2 MALIGNANT NEOPLASM OF DESCENDING COLON 153.3 MALIGNANT NEOPLASM OF SIGMOID COLON 153.4 MALIGNANT NEOPLASM OF CECUM 153.5 MALIGNANT NEOPLASM OF APPENDIX VERMIFORMIS 153.6 MALIGNANT NEOPLASM OF ASCENDING COLON 153.7 MALIGNANT NEOPLASM OF SPLENIC FLEXURE 153.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARGE INTESTINE

153.9 MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE 154.0 MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION 154.1 MALIGNANT NEOPLASM OF RECTUM 154.2 MALIGNANT NEOPLASM OF ANAL CANAL 154.3 MALIGNANT NEOPLASM OF ANUS UNSPECIFIED SITE MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION 154.8 AND ANUS SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRA-ABDOMINAL 196.2 LYMPH NODES SECONDARY MALIGNANT NEOPLASM OF SMALL INTESTINE INCLUDING 197.4 DUODENUM 197.5 SECONDARY MALIGNANT NEOPLASM OF LARGE INTESTINE AND RECTUM 197.7 MALIGNANT NEOPLASM OF LIVER SECONDARY MALIGNANT CARCINOID TUMOR OF THE LARGE INTESTINE, UNSPECIFIED 209.10 PORTION 209.11 MALIGNANT CARCINOID TUMOR OF THE APPENDIX 209.12 MALIGNANT CARCINOID TUMOR OF THE CECUM 209.13 MALIGNANT CARCINOID TUMOR OF THE ASCENDING COLON 209.14 MALIGNANT CARCINOID TUMOR OF THE TRANSVERSE COLON 209.15 MALIGNANT CARCINOID TUMOR OF THE DESCENDING COLON 209.16 MALIGNANT CARCINOID TUMOR OF THE SIGMOID COLON 209.17 MALIGNANT CARCINOID TUMOR OF THE RECTUM 209.50 BENIGN CARCINOID TUMOR OF THE LARGE INTESTINE, UNSPECIFIED PORTION 209.51 BENIGN CARCINOID TUMOR OF THE APPENDIX 209.52 BENIGN CARCINOID TUMOR OF THE CECUM 209.53 BENIGN CARCINOID TUMOR OF THE ASCENDING COLON 209.54 BENIGN CARCINOID TUMOR OF THE TRANSVERSE COLON 209.55 BENIGN CARCINOID TUMOR OF THE DESCENDING COLON 209.56 BENIGN CARCINOID TUMOR OF THE SIGMOID COLON 209.57 BENIGN CARCINOID TUMOR OF THE RECTUM 211.3 BENIGN NEOPLASM OF COLON 211.4 BENIGN NEOPLASM OF RECTUM AND ANAL CANAL 214.3 LIPOMA OF INTRA-ABDOMINAL ORGANS

228.04 HEMANGIOMA OF INTRA-ABDOMINAL STRUCTURES 228.1 LYMPHANGIOMA ANY SITE 230.3 CARCINOMA IN SITU OF COLON 230.4 CARCINOMA IN SITU OF RECTUM 230.5 CARCINOMA IN SITU OF ANAL CANAL 230.6 CARCINOMA IN SITU OF ANUS UNSPECIFIED 235.2 NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACH INTESTINES AND RECTUM NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED DIGESTIVE 235.5 ORGANS 239.0 NEOPLASM OF UNSPECIFIED NATURE OF DIGESTIVE SYSTEM 280.0 IRON DEFICIENCY ANEMIA SECONDARY TO BLOOD LOSS (CHRONIC) 280.9 IRON DEFICIENCY ANEMIA UNSPECIFIED 421.0 ACUTE AND SUBACUTE BACTERIAL ENDOCARDITIS 447.2 RUPTURE OF ARTERY 448.0 HEREDITARY HEMORRHAGIC TELANGIECTASIA 456.8 VARICES OF OTHER SITES 540.9 ACUTE APPENDICITIS WITHOUT PERITONITIS 543.0 HYPERPLASIA OF APPENDIX (LYMPHOID) 543.9 OTHER AND UNSPECIFIED DISEASES OF APPENDIX 555.0 REGIONAL ENTERITIS OF SMALL INTESTINE 555.1 REGIONAL ENTERITIS OF LARGE INTESTINE 555.2 REGIONAL ENTERITIS OF SMALL INTESTINE WITH LARGE INTESTINE 555.9 REGIONAL ENTERITIS OF UNSPECIFIED SITE 556.0 ULCERATIVE (CHRONIC) ENTEROCOLITIS 556.1 ULCERATIVE (CHRONIC) ILEOCOLITIS 556.2 ULCERATIVE (CHRONIC) PROCTITIS 556.3 ULCERATIVE (CHRONIC) PROCTOSIGMOIDITIS 556.4 PSEUDOPOLYPOSIS OF COLON 556.5 LEFT-SIDED ULCERATIVE (CHRONIC) COLITIS 556.6 UNIVERSAL ULCERATIVE (CHRONIC) COLITIS 556.8 OTHER ULCERATIVE COLITIS 556.9 ULCERATIVE COLITIS UNSPECIFIED 557.0 ACUTE VASCULAR INSUFFICIENCY OF INTESTINE

557.1 CHRONIC VASCULAR INSUFFICIENCY OF INTESTINE 557.9 UNSPECIFIED VASCULAR INSUFFICIENCY OF INTESTINE 558.1 GASTROENTERITIS AND COLITIS DUE TO RADIATION 558.2 TOXIC GASTROENTERITIS AND COLITIS 558.3 ALLERGIC GASTROENTERITIS AND COLITIS 558.42 EOSINOPHILIC COLITIS 558.9 OTHER AND UNSPECIFIED NONINFECTIOUS GASTROENTERITIS AND COLITIS 560.0 INTUSSUSCEPTION 560.1 PARALYTIC ILEUS 560.2 VOLVULUS 560.30 IMPACTION OF INTESTINE UNSPECIFIED 560.31 GALLSTONE ILEUS 560.39 OTHER IMPACTION OF INTESTINE INTESTINAL OR PERITONEAL ADHESIONS WITH OBSTRUCTION (POSTOPERATIVE) 560.81 (POSTINFECTION) 560.89 OTHER SPECIFIED INTESTINAL OBSTRUCTION 560.9 UNSPECIFIED INTESTINAL OBSTRUCTION 562.00 DIVERTICULOSIS OF SMALL INTESTINE (WITHOUT HEMORRHAGE) 562.02 DIVERTICULOSIS OF SMALL INTESTINE WITH HEMORRHAGE 562.10 DIVERTICULOSIS OF COLON (WITHOUT HEMORRHAGE) 562.11 DIVERTICULITIS OF COLON (WITHOUT HEMORRHAGE) 562.12 DIVERTICULOSIS OF COLON WITH HEMORRHAGE 562.13 DIVERTICULITIS OF COLON WITH HEMORRHAGE 564.00 UNSPECIFIED CONSTIPATION 564.01 SLOW TRANSIT CONSTIPATION 564.02 OUTLET DYSFUNCTION CONSTIPATION 564.09 OTHER CONSTIPATION 564.1 IRRITABLE BOWEL SYNDROME 564.4 OTHER POSTOPERATIVE FUNCTIONAL DISORDERS 564.5 FUNCTIONAL DIARRHEA 564.7 MEGACOLON OTHER THAN HIRSCHSPRUNG'S 564.81 NEUROGENIC BOWEL 564.89 OTHER FUNCTIONAL DISORDERS OF INTESTINE

569.0 ANAL AND RECTAL POLYP 569.2 STENOSIS OF RECTUM AND ANUS 569.3 HEMORRHAGE OF RECTUM AND ANUS 569.41 ULCER OF ANUS AND RECTUM 569.43 ANAL SPHINCTER TEAR (HEALED) (OLD) 569.5 ABSCESS OF INTESTINE 569.60 COLOSTOMY AND ENTEROSTOMY COMPLICATION UNSPECIFIED 569.62 MECHANICAL COMPLICATION OF COLOSTOMY AND ENTEROSTOMY 569.69 OTHER COLOSTOMY AND ENTEROSTOMY COMPLICATION 569.81 FISTULA OF INTESTINE EXCLUDING RECTUM AND ANUS 569.82 ULCERATION OF INTESTINE 569.83 PERFORATION OF INTESTINE 569.84 ANGIODYSPLASIA OF INTESTINE (WITHOUT HEMORRHAGE) 569.85 ANGIODYSPLASIA OF INTESTINE WITH HEMORRHAGE 569.86 DIEULAFOY LESION (HEMORRHAGIC) OF INTESTINE 569.89 OTHER SPECIFIED DISORDERS OF INTESTINES 576.1 CHOLANGITIS 578.1 BLOOD IN STOOL 578.9 HEMORRHAGE OF GASTROINTESTINAL TRACT UNSPECIFIED 579.8 OTHER SPECIFIED INTESTINAL MALABSORPTION 593.82 URETERAL FISTULA 596.1 INTESTINOVESICAL FISTULA 619.1 DIGESTIVE-GENITAL TRACT FISTULA FEMALE CONGENITAL ATRESIA AND STENOSIS OF LARGE INTESTINE RECTUM AND ANAL 751.2 CANAL HIRSCHSPRUNG'S DISEASE AND OTHER CONGENITAL FUNCTIONAL DISORDERS 751.3 OF COLON 751.4 CONGENITAL ANOMALIES OF INTESTINAL FIXATION 751.5 OTHER CONGENITAL ANOMALIES OF INTESTINE 759.6 OTHER CONGENITAL HAMARTOSES NOT ELSEWHERE CLASSIFIED 777.50 NECROTIZING ENTEROCOLITIS IN NEWBORN, UNSPECIFIED 777.51 STAGE I NECROTIZING ENTEROCOLITIS IN NEWBORN 777.52 STAGE II NECROTIZING ENTEROCOLITIS IN NEWBORN

777.53 STAGE III NECROTIZING ENTEROCOLITIS IN NEWBORN 787.91 DIARRHEA 787.99 OTHER SYMPTOMS INVOLVING DIGESTIVE SYSTEM 789.00 ABDOMINAL PAIN UNSPECIFIED SITE 789.01 ABDOMINAL PAIN RIGHT UPPER QUADRANT 789.02 ABDOMINAL PAIN LEFT UPPER QUADRANT 789.03 ABDOMINAL PAIN RIGHT LOWER QUADRANT 789.04 ABDOMINAL PAIN LEFT LOWER QUADRANT 789.05 ABDOMINAL PAIN PERIUMBILIC 789.06 ABDOMINAL PAIN EPIGASTRIC 789.07 ABDOMINAL PAIN GENERALIZED 789.09 ABDOMINAL PAIN OTHER SPECIFIED SITE 789.33 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP RIGHT LOWER QUADRANT 789.34 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP LEFT LOWER QUADRANT 789.35 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP PERIUMBILIC 789.37 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP GENERALIZED 789.39 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP OTHER SPECIFIED SITE 792.1 NONSPECIFIC ABNORMAL FINDINGS IN STOOL CONTENTS NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER 793.4 EXAMINATION OF GASTROINTESTINAL TRACT 863.40 INJURY TO COLON UNSPECIFIED SITE WITHOUT OPEN WOUND INTO CAVITY 863.41 INJURY TO ASCENDING (RIGHT) COLON WITHOUT OPEN WOUND INTO CAVITY 863.42 INJURY TO TRANSVERSE COLON WITHOUT OPEN WOUND INTO CAVITY 863.43 INJURY TO DESCENDING (LEFT) COLON WITHOUT OPEN WOUND INTO CAVITY 863.44 INJURY TO SIGMOID COLON WITHOUT OPEN WOUND INTO CAVITY 863.45 INJURY TO RECTUM WITHOUT OPEN WOUND INTO CAVITY INJURY TO MULTIPLE SITES IN COLON AND RECTUM WITHOUT OPEN WOUND 863.46 INTO CAVITY 863.50 INJURY TO COLON UNSPECIFIED SITE WITH OPEN WOUND INTO CAVITY 863.51 INJURY TO ASCENDING (RIGHT) COLON WITH OPEN WOUND INTO CAVITY 863.52 INJURY TO TRANSVERSE COLON WITH OPEN WOUND INTO CAVITY 863.53 INJURY TO DESCENDING (LEFT) COLON WITH OPEN WOUND INTO CAVITY 863.54 INJURY TO SIGMOID COLON WITH OPEN WOUND INTO CAVITY

863.55 INJURY TO RECTUM WITH OPEN WOUND INTO CAVITY INJURY TO MULTIPLE SITES IN COLON AND RECTUM WITH OPEN WOUND INTO 863.56 CAVITY 936 FOREIGN BODY IN INTESTINE AND COLON 937 FOREIGN BODY IN ANUS AND RECTUM 938 FOREIGN BODY IN DIGESTIVE SYSTEM UNSPECIFIED 996.56 MECHANICAL COMPLICATION DUE TO PERITONEAL DIALYSIS CATHETER INFECTION AND INFLAMMATORY REACTION DUE TO OTHER VASCULAR DEVICE 996.62 IMPLANT AND GRAFT OTHER COMPLICATIONS DUE TO OTHER VASCULAR DEVICE IMPLANT AND 996.74 GRAFT PERSONAL HISTORY OF MALIGNANT NEOPLASM OF UNSPECIFIED SITE IN V10.00 GASTROINTESTINAL TRACT V10.03 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF ESOPHAGUS V10.04 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF STOMACH V10.05 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LARGE INTESTINE PERSONAL HISTORY OF MALIGNANT NEOPLASM OF RECTUM RECTOSIGMOID V10.06 JUNCTION AND ANUS V10.07 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LIVER V12.70 PERSONAL HISTORY OF UNSPECIFIED DIGESTIVE DISEASE V12.72 PERSONAL HISTORY OF COLONIC POLYPS V45.3 POSTSURGICAL INTESTINAL BYPASS OR ANASTOMOSIS STATUS V67.09 FOLLOW-UP EXAMINATION FOLLOWING OTHER SURGERY V71.1 OBSERVATION FOR SUSPECTED MALIGNANT NEOPLASM

TOC 75572 – CT Heart & CT Heart Congenital Last Review Date: October 2013 75574 – CTA Coronary Arteries (CCTA

“FOR CMS (MEDICARE) MEMBERS ONLY”

COVERAGE INDICATIONS LIMITATIONS AND/OR MEDICAL NECESSITY FOR CCTA OR HEART CT OR HEART CT CONGENITAL:

Current available body of evidence demonstrates that CCTA can reliably rule out the presence of significant coronary artery disease (CAD) in patients with a low to intermediate probability of having CAD and can reliably achieve a high degree of diagnostic accuracy and technical performance necessary to replace conventional angiography.

 Patient presenting with chest pain syndrome. CCTA may be used in lieu of an imaging stress test. The clinician must have a high degree of suspicion that CAD is high on the differential diagnosis of the symptoms.

 To facilitate the management decision of a patient with an equivocal stress test. CCTA might be chosen in select patients who have an equivocal stress (or stress imaging) test. The rationale is that a noninvasive coronary anatomic test (CCTA) allows an alternate method of assessing the coronary arteries, which would limit the number of negative invasive coronary angiograms.

 When the recurrence of symptoms in patients with known coronary artery disease may be related to progression/exacerbation of underlying disease. The use of CCTA in this setting would be to evaluate the extent of previously diagnosed coronary artery disease. Patients with known disease may have had remote invasive angiography and/or stress testing to evaluate prior events or symptoms. New or recurrent symptoms may relate to a change in the coronary anatomy that can be assessed with CCTA.

 When patients with prior bypass surgery or intracoronary artery stent placement present with chest pain or dyspnea. Coronary bypass grafts are relatively well seen with CCTA. The rationale for CCTA would be to determine the patency and severity of possible graft stenoses that may be the source of chest pain. Patients with prior intracoronary stents often present with recurrent chest pain. The rationale for a CCTA as an alternative to invasive angiography is to rule out in-stent restenosis as the cause of symptoms. (Accurate assessment of in-stent restenosis may be limited by the artifact caused by the stent material itself and the quality of the scan and scanner).

 Suspected congenital anomalies of the coronary circulation. CCTA is used to assess patients suspected of having a congenital coronary anomaly. The cross- sectional nature of this technique allows one to determine accurately both the presence and possible future harm that could result from the anomaly. It is often used after an anomaly has been identified following a different test such as prior invasive coronary angiogram. A CCTA is used to decide if surgery is indicated and for surgical planning.

 The assessment of coronary or pulmonary venous anatomy. This application of CTA for the coronary and pulmonary veins is primarily for pre-surgical

planning. Coronary venous anatomy can be useful for the cardiologist who needs to place a pacemaker lead in the lateral coronary vein in order to resynchronize cardiac contraction in patients with heart failure. This may be helpful to guide biventricular pacemaker placement.

Pulmonary vein anatomy can vary from patient to patient. Pulmonary vein catheter ablation can isolate electrical activity from the pulmonary veins and allow for the elimination of recurrent atrial fibrillation. The presence of a pulmonary venous anatomic map may help eliminate procedural complications and allow for the successful completion of the procedure.

 The patient undergoing non-coronary artery cardiac surgery. Certain patients who have non-coronary artery cardiac surgery (valve or ascending aortic surgery) may need a pre-operative invasive coronary angiogram. The surgical planning may also depend upon the exact location of the coronary arteries. The rationale for the use of CCTA in these patient subsets is to avoid potentially unnecessary invasive testing and still provide appropriate pre-surgical information.

 The test may be medically necessary in patients presenting to the emergency room with complaints consistent with cardiac ischemia, but without diagnostic electrocardiography (ECG) or enzymes.

 The test may be considered medically necessary in patients’ status post revascularization procedures who present with recurrent symptoms not clearly identifiable as ischemic.

Limitations:

1. The test is never covered for screening, i.e., in the absence of signs, symptoms or disease. 2. The test will be considered not medically necessary if the anticipated results are not expected to provide new, additional information to that already previously obtained from other tests (such as stress myocardial perfusion images or cardiac ultrasound). New or additional information should facilitate the management decision, not merely add a new layer of testing. 3. For dates of service prior to 01/01/2010, determination of cardiac ejection fraction (CPT code 0151T) should not be billed when previously determined by other techniques. CPT code 0151T is deleted effective 12/31/2009. 4. The test will be considered not medically necessary if it is anticipated that the patient would require invasive cardiac angiography for further diagnosis or for therapeutic intervention. (e.g., angina decubitus, unstable angina, Prinzmetal angina, etc.) 5. The test may be denied, on post-pay review, as not medically necessary when used for cardiac evaluation if there were pre-test knowledge of sufficiently extensive calcification of the suspect coronary segment that would diminish the interpretive value. 6. Effective 12/01/2009, coverage for evaluation of coronary artery or bypass graft stenosis, or for functional status (e.g., wall motion), is limited to multidetector scanners having at least 64 slices per rotation capability. This two year period (12/01/2007 - 12/01/2009 will allow for a phase-in of new technology. 7. The administration of beta blockers and the monitoring of the patient during MDCT/CCTA by a physician experienced in the use of cardiovascular drugs is included as part of the test and is not a separately payable service. 8. All studies must be ordered by the physician/qualified non-physician practitioner treating the patient and who will use the results of the test in the management of the patient. 9. The test must be performed under the direct supervision of a physician.

10. This LCD does not address electron beam tomography (EBT) technology or Ultrafast CT for coronary artery examination. There is no extension of coverage of EBT based on this policy. 11. Quantitative calcium scoring (CPT code 0144T for dates of service prior to 01/01/2010, and CPT 75571 on or after 01/01/2010) is not a covered service and will be denied as not medically necessary. Calcium scoring reported in isolation is considered a screening service. When performed in association with CT angiography, there is neither separate nor additional included reimbursement for the calcium scoring.

Other Comments:

For claims submitted to the fiscal intermediary or Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated National Government Services to process their claims.

Bill type codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Limitation of liability and refund requirements apply when denials are anticipated, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

ICD-9 Codes that Support Medical Necessity

164.1 MALIGNANT NEOPLASM OF HEART 198.89 SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES 212.7 BENIGN NEOPLASM OF HEART 411.1 INTERMEDIATE CORONARY SYNDROME 411.81 ACUTE CORONARY OCCLUSION WITHOUT MYOCARDIAL INFARCTION 412 OLD MYOCARDIAL INFARCTION 413.9 OTHER AND UNSPECIFIED ANGINA PECTORIS CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL NATIVE OR 414.00 GRAFT

414.01 CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY 414.02 CORONARY ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT CORONARY ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS 414.03 GRAFT 414.04 CORONARY ATHEROSCLEROSIS OF ARTERY BYPASS GRAFT 414.05 CORONARY ATHEROSCLEROSIS OF UNSPECIFIED BYPASS GRAFT CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY OF 414.06 TRANSPLANTED HEART CORONARY ATHEROSCLEROSIS OF BYPASS GRAFT (ARTERY) (VEIN) OF 414.07 TRANSPLANTED HEART 414.10 ANEURYSM OF HEART (WALL) 414.11 ANEURYSM OF CORONARY VESSELS 414.12 DISSECTION OF CORONARY ARTERY 414.19 OTHER ANEURYSM OF HEART 414.8 OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE 414.9 CHRONIC ISCHEMIC HEART DISEASE UNSPECIFIED 416.0 PRIMARY PULMONARY HYPERTENSION 423.0 HEMOPERICARDIUM 423.1 ADHESIVE PERICARDITIS 423.2 CONSTRICTIVE PERICARDITIS 423.3 CARDIAC TAMPONADE 423.8 OTHER SPECIFIED DISEASES OF PERICARDIUM 423.9 UNSPECIFIED DISEASE OF PERICARDIUM 424.0 MITRAL VALVE DISORDERS 424.1 AORTIC VALVE DISORDERS 427.31* ATRIAL FIBRILLATION 427.32* ATRIAL FLUTTER 427.41 VENTRICULAR FIBRILLATION 427.42 VENTRICULAR FLUTTER 441.01 DISSECTION OF AORTA THORACIC 441.1 THORACIC ANEURYSM RUPTURED 441.2 THORACIC ANEURYSM WITHOUT RUPTURE 745.10 COMPLETE TRANSPOSITION OF GREAT VESSELS

745.11 DOUBLE OUTLET RIGHT VENTRICLE 745.12 CORRECTED TRANSPOSITION OF GREAT VESSELS 745.19 OTHER TRANSPOSITION OF GREAT VESSELS 745.2 TETRALOGY OF FALLOT 745.3 COMMON VENTRICLE 745.4 VENTRICULAR SEPTAL DEFECT 745.5 OSTIUM SECUNDUM TYPE ATRIAL SEPTAL DEFECT 745.60 ENDOCARDIAL CUSHION DEFECT UNSPECIFIED TYPE 745.61 OSTIUM PRIMUM DEFECT 745.69 OTHER ENDOCARDIAL CUSHION DEFECTS 745.7 COR BILOCULARE OTHER BULBUS CORDIS ANOMALIES AND ANOMALIES OF CARDIAC SEPTAL 745.8 CLOSURE 745.9 UNSPECIFIED DEFECT OF SEPTAL CLOSURE 746.00 CONGENITAL PULMONARY VALVE ANOMALY UNSPECIFIED 746.01 ATRESIA OF PULMONARY VALVE CONGENITAL 746.02 STENOSIS OF PULMONARY VALVE CONGENITAL 746.09 OTHER CONGENITAL ANOMALIES OF PULMONARY VALVE 746.1 TRICUSPID ATRESIA AND STENOSIS CONGENITAL 746.2 EBSTEIN'S ANOMALY 746.3 CONGENITAL STENOSIS OF AORTIC VALVE 746.4 CONGENITAL INSUFFICIENCY OF AORTIC VALVE 746.5 CONGENITAL MITRAL STENOSIS 746.6 CONGENITAL MITRAL INSUFFICIENCY 746.7 HYPOPLASTIC LEFT HEART SYNDROME 746.81 SUBAORTIC STENOSIS CONGENITAL 746.82 COR TRIATRIATUM 746.83 INFUNDIBULAR PULMONIC STENOSIS CONGENITAL CONGENITAL OBSTRUCTIVE ANOMALIES OF HEART NOT ELSEWHERE 746.84 CLASSIFIED 746.85 CORONARY ARTERY ANOMALY CONGENITAL 746.87 MALPOSITION OF HEART AND CARDIAC APEX 746.89 OTHER SPECIFIED CONGENITAL ANOMALIES OF HEART

746.9 UNSPECIFIED CONGENITAL ANOMALY OF HEART 747.0 PATENT DUCTUS ARTERIOSUS 747.10 COARCTATION OF AORTA (PREDUCTAL) (POSTDUCTAL) 747.11 INTERRUPTION OF AORTIC ARCH 747.20 CONGENITAL ANOMALY OF AORTA UNSPECIFIED 747.21 CONGENITAL ANOMALIES OF AORTIC ARCH 747.22 CONGENITAL ATRESIA AND STENOSIS OF AORTA 747.29 OTHER CONGENITAL ANOMALIES OF AORTA 747.31 PULMONARY ARTERY COARCTATION AND ATRESIA 747.32 PULMONARY ARTERIOVENOUS MALFORMATION 747.39 OTHER ANOMALIES OF PULMONARY ARTERY AND PULMONARY CIRCULATION 747.40 CONGENITAL ANOMALY OF GREAT VEINS UNSPECIFIED 747.41 TOTAL ANOMALOUS PULMONARY VENOUS CONNECTION 747.42 PARTIAL ANOMALOUS PULMONARY VENOUS CONNECTION 747.49 OTHER ANOMALIES OF GREAT VEINS 786.50 UNSPECIFIED CHEST PAIN 786.51 PRECORDIAL PAIN 786.59 OTHER CHEST PAIN 794.30 UNSPECIFIED ABNORMAL FUNCTION STUDY OF CARDIOVASCULAR SYSTEM OTHER NONSPECIFIC ABNORMAL FUNCTION STUDY OF CARDIOVASCULAR 794.39 SYSTEM V53.31 FITTING AND ADJUSTMENT OF CARDIAC PACEMAKER *Coverage for these diagnoses is limited to patients in whom ablation for these dysrhythmias has already been planned and scheduled.

TOC 76390 – MR Spectroscopy Last Review Date: January 2014

“FOR CMS (MEDICARE) MEMBERS ONLY”

INDICATIONS AND LIMITATIONS OF COVERAGE FOR BRAIN MRS:

Nationally Covered Indications  Not applicable.

Nationally Noncovered Indications  After thorough review and reconsideration of the existing national noncoverage determination for MRS, as well as the available evidence for the use of MRS as a diagnostic tool for distinguishing indeterminate brain lesions, and/or as an aid in conducting brain biopsies, CMS has determined that the evidence is not adequate to conclude that MRS is reasonable and necessary within the meaning of section 1862(a)(1)(A) of the Social Security Act, for use in the diagnosis of brain tumors. Therefore, CMS reaffirms its current national noncoverage determination for all indications of MRS.

TOC 77058 – MRI Breast Last Review Date: January 2014

“FOR CMS (MEDICARE) MEMBERS ONLY”

COVERAGE INDICATIONS LIMITATIONS AND/OR MEDICAL NECESSITY FOR BREAST MRI:

Indications:  When diagnosis is inconclusive, even after standard work-up.  For an evaluation of the post-operative patient when scar tissue cannot be differentiated from tumors.  For patients with positive axillary nodes but no known primary.  For patients with rupture of a breast implant.  To determine the extent of disease in patients with known malignancy prior to treatment (to assure confinement to one segment of the breast).

Limitations:  Breast MRI should be performed under the general supervision of a physician qualified in magnetic resonance imaging.  A treating provider's (physician or qualified non-physician practitioner) order is required for breast MRI. This requirement is not applicable to hospital based radiologists for inpatient or outpatient breast MRI.

ICD-9 Codes that Support Medical Necessity: It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g., to the fourth or fifth digit). The correct use of an ICD-9-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

For Breast MRI (77058 (non-OPPS code), 77059 (non-OPPS code), C8903, C8904, C8905, C8906, C8907 and C8908): 174.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST 174.1 MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST 174.2 MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST 174.3 MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST 174.4 MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST 174.5 MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST 174.6 MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST 174.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST 174.9 MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE 175.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST

175.9 MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF 196.3 AXILLA AND UPPER LIMB 198.2 SECONDARY MALIGNANT NEOPLASM OF SKIN 198.81 SECONDARY MALIGNANT NEOPLASM OF BREAST 199.1 OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE 217 BENIGN NEOPLASM OF BREAST 233.0 CARCINOMA IN SITU OF BREAST 238.3 NEOPLASM OF UNCERTAIN BEHAVIOR OF BREAST 239.2 NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN 239.3 NEOPLASM OF UNSPECIFIED NATURE OF BREAST 610.0 SOLITARY CYST OF BREAST 610.1* DIFFUSE CYSTIC MASTOPATHY 610.2* FIBROADENOSIS OF BREAST 610.3* FIBROSCLEROSIS OF BREAST 610.4* MAMMARY DUCT ECTASIA 610.8* OTHER SPECIFIED BENIGN MAMMARY DYSPLASIAS 610.9* BENIGN MAMMARY DYSPLASIA UNSPECIFIED 611.0 INFLAMMATORY DISEASE OF BREAST 611.1 HYPERTROPHY OF BREAST 611.2* FISSURE OF NIPPLE 611.3* FAT NECROSIS OF BREAST 611.4* ATROPHY OF BREAST 611.5* GALACTOCELE 611.6* GALACTORRHEA NOT ASSOCIATED WITH CHILDBIRTH 611.71 MASTODYNIA 611.72 LUMP OR MASS IN BREAST 611.79 OTHER SIGNS AND SYMPTOMS IN BREAST 611.89* OTHER SPECIFIED DISORDERS OF BREAST 611.9* UNSPECIFIED BREAST DISORDER 612.0 DEFORMITY OF RECONSTRUCTED BREAST 612.1 DISPROPORTION OF RECONSTRUCTED BREAST 793.80 UNSPECIFIED ABNORMAL MAMMOGRAM

793.81 MAMMOGRAPHIC MICROCALCIFICATION 793.82 INCONCLUSIVE MAMMOGRAM 793.89 OTHER (ABNORMAL) FINDINGS ON RADIOLOGICAL EXAMINATION OF BREAST 996.54 MECHANICAL COMPLICATION OF BREAST PROSTHESIS INFECTION AND INFLAMMATORY REACTION DUE TO OTHER INTERNAL 996.69 PROSTHETIC DEVICE IMPLANT AND GRAFT V10.3 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST *ICD-9-CM codes 610.1-610.4, 610.8-610.9, 611.2-611.6, 611.89-611.9 should be reported only after mammography and focal findings.

TOC 78451 – Nuclear Cardiology/Myocardial Perfusion Imaging Last Review Date: November 2013 78472 - MUGA

“FOR CMS (MEDICARE) MEMBERS ONLY”

COVERAGE INDICATIONS LIMITATIONS AND/OR MEDICAL NECESSITY FOR CARDIOVASCULAR NUCLEAR MEDICINE (MYOCARDIAL PERFUSION IMAGING OR MUGA):

Cardiovascular nuclear imaging employs non-invasive techniques to assess alterations in coronary artery flow, and ventricular function.

The specific imaging technique (perfusion versus ventricular function) and the reason for the imaging determine which radionuclide agent is employed. A myocardial perfusion study utilizes an imaging isotope agent that reflects segmental and global myocardial blood flow and uptake, the interpretation of which is used to make inference about the presence of scar and ischemia.

Ventricular function studies utilize specific imaging isotopes to outline the borders of the ventricular endocardium, or to identify the ventricular blood pool independent of the surrounding myocardium. The motion of the left ventricle, synchronized with the electrocardiogram, is used to generate wall motion and ejection fraction information.

These tests may be performed at rest and during exercise, or with pharmacologic intervention when exercise cannot be performed. The acquisition of the images may be planar (single plane) or by multiple planes with computer integration, SPECT (single-photon emission computer tomography).

Indications: Cardiovascular nuclear imaging may be indicated for the following:

 Assessment of the functional and prognostic importance of angina.  Diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG changes caused by drugs, bundle branch block, or left ventricular hypertrophy.  Assessment of congenital anomalies of coronary arteries.  Risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, for patients who have not had a revascularization procedure within the past two years.  Detection of coronary artery disease in patients, without chest pain syndrome, with new-onset of diagnosed heart failure or left ventricular systolic dysfunction.  Evaluation of ischemic versus non-ischemic cardiomyopathy when cardiac catheterization / coronary angiography are not planned.  Evaluation of myocardial perfusion and/or function before and after coronary artery bypass surgery or other re-perfusion procedures.  Quantification and surveillance of myocardial infarction and prognostication in patients with infarction.  Preoperative assessment for non-cardiac surgery, when used to determine risk for surgery and/or perioperative management in: o Patients with minor or intermediate clinical risk predictors and poor functional capacity.

o Patients with intermediate or high likelihood of coronary heart disease, or patients with poor functional capacity undergoing high risk non-cardiac surgery. o The "ACA/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Non-Cardiac Surgery" (JACC 2007; 50:e159-e242) provides this information. . High risk surgery: aortic and peripheral vascular surgery. . Intermediate risk surgery: intraperitoneal and intrathoracic surgery, carotid endarterectomy, head & neck surgery, orthopedic surgery, prostate surgery. . Low risk surgery: endoscopic procedures, superficial surgery, cataract surgery, breast surgery, ambulatory surgery. . Poor functional capacity = less than 4 METS . Clinical risk factors: 1) history of ischemic heart disease 2) history of compensated or prior heart failure 3) history of cerebrovascular disease 4) diabetes mellitus 5) renal insufficiency Decision-making for testing is based upon the presence of multiple clinical risk factors, the level of functional capacity, the risk of the surgery and the likelihood that the results of the cardiac testing would change the management.  Evaluation of ventricular function in patients with non-ischemic myocardial disease.  Evaluation of patients in whom an accurate measure of the ejection fraction is needed to make a determination of whether to implant a defibrillator or biventricular pacemaker.  Evaluation of a patient receiving chemotherapeutic drugs which are potentially cardiotoxic (e.g., Adriamycin).

 First pass studies will be considered medically necessary only when information sought is immediately relevant to the management of the patient’s clinical condition, and has not been previously obtained or likely to be obtained from other planned tests such as echocardiography or equilibrium gated blood pool studies. First pass studies may be indicated for the assessment and identification of shunts.

 Infarct avid scintigraphy is indicated in patients in whom it is not possible to make a definitive diagnosis of myocardial infarction by EKG or enzyme testing.

Patient selection should be based on clinical grounds:  Patients with a high pretest probability of disease are not usually candidates for a study for diagnostic purposes, though the size and reversibility of a defect and its functional consequences may be required for clinical decision-making.  Patients with a moderate probability of disease benefit the most from the study when the diagnosis is in question. Selection of tests should be made within the context of other tests, scheduled and previously performed, so that the anticipated information obtained is unique and not redundant.

Limitations:

 Given the limitations of uptake, low photon energy and redistribution, the cardiac blood pool codes and perfusion imaging codes are not generally covered on the same date of service. However, in light of the predictive value of exercise-induced changes in ejection fraction, an

exception will be made to allow first pass, single study with exercise along with the appropriate perfusion studies. Providers who bill this service must certify within their records that their laboratories are specially equipped to process such studies.  The rapid uptake, relatively low photon energy and redistribution of thallium 201 preclude its application to studies for gated images (78478 and 78480, for dates of service prior to 01/01/2010) in most laboratories. Therefore, CPT procedure codes 78478 and 78480 (for dates of service prior to 01/01/2010) are generally not payable with HCPCS code A9505 (thallous chloride). However, an exception will be made to allow this combination for laboratories that have at least double-headed cameras and the appropriate software to facilitate the count. Such providers must certify that their laboratories are specially equipped to process such studies.  Cardiac blood pool imaging studies are described by the codes 78472, 78473, 78481, 78483, 78494 (with add-on code 78496). Only one code from the series (with appropriate add-on) may be reported on a single date of service.  All cardiovascular nuclear tests and stress tests must be referred by a physician or a qualified non-physician provider.  All stress tests must be performed under the direct supervision of a physician. The nuclear test components must be performed under the general supervision of a physician.  Myocardial perfusion studies performed based on the presence of risk factors in the absence of cardiac symptoms, cardiac abnormalities on physical examination, or abnormalities on cardiac testing (e.g., electrocardiographic tests, echocardiography, etc) will be considered screening and denied as not covered by Medicare.  Tests that are anticipated to provide information duplicative of another test already performed will be denied as not medically necessary.  Tests performed when the results would not be anticipated to influence medical management decisions will be denied as not medically necessary.  Myocardial perfusion studies performed subsequent to a diagnostic myocardial PET scan will denied as not medically necessary.  Infarct avid scintigraphy will be denied if the diagnosis of myocardial infarction has already been confirmed by enzymes and/or EKG.  Tests performed unrelated to changes in a patient's signs or symptoms, or for immediate preoperative evaluation will be denied as medically unnecessary.  Tests performed for risk assessment prior to high risk non-cardiac surgery in asymptomatic patients within one year following normal catheterization or non-invasive test will be considered medically unnecessary and denied. Tests performed for preoperative evaluation in patients undergoing low-risk surgery will be denied.

ICD-9 Codes that Support Medical Necessity

It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g., to the fourth or fifth digit). The correct use of an ICD-9-CM code does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

ICD-9-CM Codes That Support Medical Necessity for Perfusion with or without Functional Studies: CPT codes 78451, 78452, 78453, 78454 CPT codes 78472, 78473, 78481, 78483, 93015, 93016, 93017, and 93018

Group 1 Codes: ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE 410.00 OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL INITIAL 410.01 EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL 410.02 SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL EPISODE 410.10 OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL INITIAL 410.11 EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL 410.12 SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL EPISODE 410.20 OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL INITIAL 410.21 EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL 410.22 SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL 410.30 EPISODE OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL INITIAL 410.31 EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL 410.32 SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL EPISODE 410.40 OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL INITIAL 410.41 EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL 410.42 SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL EPISODE 410.50 OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL INITIAL 410.51 EPISODE OF CARE

ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL 410.52 SUBSEQUENT EPISODE OF CARE 410.60 TRUE POSTERIOR WALL INFARCTION EPISODE OF CARE UNSPECIFIED 410.61 TRUE POSTERIOR WALL INFARCTION INITIAL EPISODE OF CARE 410.62 TRUE POSTERIOR WALL INFARCTION SUBSEQUENT EPISODE OF CARE 410.70 SUBENDOCARDIAL INFARCTION EPISODE OF CARE UNSPECIFIED 410.71 SUBENDOCARDIAL INFARCTION INITIAL EPISODE OF CARE 410.72 SUBENDOCARDIAL INFARCTION SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES EPISODE 410.80 OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES INITIAL 410.81 EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES 410.82 SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE EPISODE OF 410.90 CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE INITIAL 410.91 EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT 410.92 EPISODE OF CARE 411.0 POSTMYOCARDIAL INFARCTION SYNDROME 411.1 INTERMEDIATE CORONARY SYNDROME 411.81 ACUTE CORONARY OCCLUSION WITHOUT MYOCARDIAL INFARCTION OTHER ACUTE AND SUBACUTE FORMS OF ISCHEMIC HEART DISEASE 411.89 OTHER 412 OLD MYOCARDIAL INFARCTION 413.0 ANGINA DECUBITUS 413.1 PRINZMETAL ANGINA 413.9 OTHER AND UNSPECIFIED ANGINA PECTORIS CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL 414.00 NATIVE OR GRAFT 414.01 CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY 414.02 CORONARY ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT 414.03 CORONARY ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL

BYPASS GRAFT 414.04 CORONARY ATHEROSCLEROSIS OF ARTERY BYPASS GRAFT CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY OF 414.06 TRANSPLANTED HEART CORONARY ATHEROSCLEROSIS OF BYPASS GRAFT (ARTERY) (VEIN) OF 414.07 TRANSPLANTED HEART 414.10 ANEURYSM OF HEART (WALL) 414.11 ANEURYSM OF CORONARY VESSELS 414.12 DISSECTION OF CORONARY ARTERY 414.19 OTHER ANEURYSM OF HEART 414.2 CHRONIC TOTAL OCCLUSION OF CORONARY ARTERY 414.3 CORONARY ATHEROSCLEROSIS DUE TO LIPID RICH PLAQUE CORONARY ATHEROSCLEROSIS DUE TO CALCIFIED CORONARY 414.4 LESION 414.8 OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE 414.9 CHRONIC ISCHEMIC HEART DISEASE UNSPECIFIED 427.31 ATRIAL FIBRILLATION 427.41 VENTRICULAR FIBRILLATION 427.42 VENTRICULAR FLUTTER 427.5 CARDIAC ARREST 428.0 CONGESTIVE HEART FAILURE UNSPECIFIED 428.1 LEFT HEART FAILURE 428.20 UNSPECIFIED SYSTOLIC HEART FAILURE 428.21 ACUTE SYSTOLIC HEART FAILURE 428.22 CHRONIC SYSTOLIC HEART FAILURE 428.23 ACUTE ON CHRONIC SYSTOLIC HEART FAILURE 428.40 UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE 428.41 ACUTE COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE 428.42 CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART 428.43 FAILURE CERTAIN SEQUELAE OF MYOCARDIAL INFARCTION NOT ELSEWHERE 429.79 CLASSIFIED OTHER 429.83 TAKOTSUBO SYNDROME © 2000-2014 National Imaging Associates, Inc Page 48 of 59 This document is the proprietary information of Magellan Health Services and its affiliates

429.89 OTHER ILL-DEFINED HEART DISEASES 746.85 CORONARY ARTERY ANOMALY CONGENITAL 786.05 SHORTNESS OF BREATH 786.09 RESPIRATORY ABNORMALITY OTHER 786.50 UNSPECIFIED CHEST PAIN 786.51 PRECORDIAL PAIN 786.59 OTHER CHEST PAIN 794.31 NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG) OTHER COMPLICATIONS DUE TO OTHER CARDIAC DEVICE IMPLANT 996.72 AND GRAFT 996.83 COMPLICATIONS OF TRANSPLANTED HEART V42.1 HEART REPLACED BY TRANSPLANT V45.81 POSTSURGICAL AORTOCORONARY BYPASS STATUS V45.82 PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY STATUS V72.81* PRE-OPERATIVE CARDIOVASCULAR EXAMINATION Group 1 Medical Necessity ICD-9 Codes Asterisk Explanation: ** Use ICD-9 code V72.81 for those tests which were performed to evaluate pre-operative risk (see Indications section above) but for whom the test was negative. (A positive test should be coded with the results of the test.)

Group 2 Paragraph: ICD-9-CM Codes That Support Medical Necessity for Cardiac Blood Pool Studies, CPT codes 78472, 78473, 78481, 78483, 78494 and 78496

Group 2 Codes: 428.20* UNSPECIFIED SYSTOLIC HEART FAILURE 428.21* ACUTE SYSTOLIC HEART FAILURE 428.22* CHRONIC SYSTOLIC HEART FAILURE 428.23* ACUTE ON CHRONIC SYSTOLIC HEART FAILURE 428.40* UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE 428.41* ACUTE COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE 428.42* CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART 428.43* FAILURE V58.11 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY V58.12 ENCOUNTER FOR IMMUNOTHERAPY FOR NEOPLASTIC CONDITION V58.83* ENCOUNTER FOR THERAPEUTIC DRUG MONITORING

V67.2* FOLLOW-UP EXAMINATION FOLLOWING CHEMOTHERAPY V72.85* OTHER SPECIFIED EXAMINATION Group 2 Medical Necessity ICD-9 Codes Asterisk Explanation: **Report V72.85 when the test is performed as a baseline study before chemotherapy *Report V58.83 for subsequent monitoring while the patient is receiving chemotherapy. *Report V67.2 for testing when chemotherapy is completed.

ICD-9 codes 428.20-428.23 and 428.40-428.43 will be considered to support medical necessity only when performed to calculate ejection fraction in those patients being actively considered for defibrillator or biventricular pacemaker placement, where ejection fraction is a determining factor in the decision. Group 3 Paragraph: ICD-9-CM Codes That Support Medical Necessity for Infarct avidity studies only, CPT 78466, 78468 and 78469:

Group 3 Codes: ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL 410.00 EPISODE OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL 410.01 INITIAL EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL 410.02 SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL 410.10 EPISODE OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL 410.11 INITIAL EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL 410.12 SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL 410.20 EPISODE OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL 410.21 INITIAL EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL 410.22 SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL 410.30 EPISODE OF CARE UNSPECIFIED

ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL 410.31 INITIAL EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL 410.32 SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL 410.40 EPISODE OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL 410.41 INITIAL EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL 410.42 SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL 410.50 EPISODE OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL 410.51 INITIAL EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL 410.52 SUBSEQUENT EPISODE OF CARE TRUE POSTERIOR WALL INFARCTION EPISODE OF CARE 410.60 UNSPECIFIED 410.61 TRUE POSTERIOR WALL INFARCTION INITIAL EPISODE OF CARE TRUE POSTERIOR WALL INFARCTION SUBSEQUENT EPISODE 410.62 OF CARE SUBENDOCARDIAL INFARCTION EPISODE OF CARE 410.70 UNSPECIFIED 410.71 SUBENDOCARDIAL INFARCTION INITIAL EPISODE OF CARE SUBENDOCARDIAL INFARCTION SUBSEQUENT EPISODE OF 410.72 CARE ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES 410.80 EPISODE OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES 410.81 INITIAL EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES 410.82 SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE 410.90 EPISODE OF CARE UNSPECIFIED

ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE 410.91 INITIAL EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE 410.92 SUBSEQUENT EPISODE OF CARE 414.2 CHRONIC TOTAL OCCLUSION OF CORONARY ARTERY 786.50 UNSPECIFIED CHEST PAIN 786.51 PRECORDIAL PAIN 786.59 OTHER CHEST PAIN 794.31 NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG)

TOC 78459 – PET Scan, Heart (Cardiac) Last Review Date: July 2014

“FOR CMS (MEDICARE) MEMBERS ONLY”

INDICATIONS AND LIMITATIONS OF COVERAGE FOR HEART PET SCAN:

Perfusion of the Heart: PET scans performed at rest or with pharmacological stress used for noninvasive imaging of the perfusion of the heart for the diagnosis and management of patients with known or suspected coronary artery disease using the FDA-approved radiopharmaceutical Rubidium 82 (Rb 82) or Ammonia N-13 are covered, provided the requirements below are met.

 The PET scan, whether at rest alone, or rest with stress, is performed in place of, but not in addition to, a SPECT.  The PET scan, whether at rest alone or rest with stress, is used following a SPECT that was found to be inconclusive. In these cases, the PET scan must have been considered necessary in order to determine what medical or surgical intervention is required to treat the patient. (For purposes of this requirement, an inconclusive test is a test whose results are equivocal, technically uninterpretable, or discordant with a patient's other clinical data and must be documented in the patient’s file.)

Myocardial Viability: The identification of patients with partial loss of heart muscle movement or hibernating myocardium is important in selecting candidates with compromised ventricular function to determine appropriateness for revascularization. Diagnostic tests such as FDG PET distinguish between dysfunctional but viable myocardial tissue and scar tissue in order to affect management decisions in patients with ischemic cardiomyopathy and left ventricular dysfunction.

 For the determination of myocardial viability as a primary or initial diagnostic study prior to revascularization, or following an inconclusive SPECT.

Limitations: In the event a patient receives a SPECT test with inconclusive results, a PET scan may be covered. However, if a patient receives a FDG PET study with inconclusive results, a follow up SPECT test is not covered.

TOC 78608 – PET Scan, Brain Last Review Date: July 2014

“FOR CMS (MEDICARE) MEMBERS ONLY”

IMPORTANT NOTE:

Any request for CPT code 78609; CPT code 78609 is a non-covered service for CMS (effective date retroactive to 01/28/2005). http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/downloads/R1301CP.pdf

INDICATIONS AND LIMITATIONS OF COVERAGE FOR BRAIN PET:

For patients with epilepsy (Refractory Seizures): o Pre surgical evaluation for refractory seizures (seizures continue to occur despite treatment).

FDG PET for Dementia and Neurodegenerative Diseases:

Medicare covers FDG PET scans for either the differential diagnosis of fronto-temporal dementia (FTD) and Alzheimer’s disease (AD) under specific requirements listed below:  A scan is reasonable and necessary in patients (who meet all 3 indications below) with: 1. A recent diagnosis of dementia or fronto-temporal dementia (FTD) AND have documented cognitive decline of at least six months (request date of onset of symptoms). 2. Who have had more than one assessment done of patient’s mental status - documented by MMSE or other neuro-diagnostic testing, such as: o For MMSE, a score of 23 or lower is indicative of cognitive impairment o EEG and long-term EEG monitoring o Transcranial Dopplers o Evoked Potentials o Intraoperative Monitoring 3. Have had an appropriate baseline work-up for other treatable causes, including appropriate medication restriction or reduction to test for reversibility. (Refer to the Additional Information section of this document).

Information applicable to Dementia/Alzheimer’s utilizing FDG PET:

 Cognition is the act or process of thinking, perceiving, and learning.  Symptoms develop when the underlying condition affects areas of the brain involved with learning, memory, decision-making, and language.  Memory impairment is often the first symptom to be noticed. Someone with dementia may be unable to remember ordinary information, such as their birth date and address, and may be unable to recognize friends and family members.  There is progressive decline in these cognitive functions as well: o Decision making o Judgment o Orientation in time and space o Problem solving o Verbal communication © 2000-2014 National Imaging Associates, Inc Page 54 of 59 This document is the proprietary information of Magellan Health Services and its affiliates

 Behavioral changes may include the following: o Eating, dressing, toileting (e.g., unable to dress without help; becomes incontinent) o Interests (e.g., abandons hobbies) o Routine activities (e.g., unable to perform household tasks) o Personality (e.g., inappropriate responses, lack of emotional control).  Frontotemporal dementia diagnostic criteria- o Behavioral symptoms that should be recorded include apathy, aspontaneity, or, oppositely, disinhibition. o Executive function should also be assessed- patients would show impairment in ability to perform skills that require complex planning or sequencing (multi-step commands, drawing the face of a clock). o Primitive reflexes showing frontal release should be assessed including palmomental reflex, rooting reflex and palmar grasp.  Alzheimer’s criteria o Memory impairment (assessed as part of mini-mental status exam MMSE) o Cognitive disturbance (one or more) evidenced by o Aphasia (language disturbance) o Apraxia (impaired ability to carry out motor activities despite intact motor function) o Agnosia- failure to recognize or identify objects despite intact sensory (vision, touch, etc) function o Disturbance in executive function- patients would show impairment in ability to perform skills that require complex planning or sequencing (multi-step commands, drawing the face of a clock).  Metabolic testing (in addition to neurologic examination, MMSE) o Urinalysis (to r/o urinary tract infection as a cause of dementia) o CBC (to r/o infection or anemia as a cause of impaired mental function) o Serum electrolytes, including magnesium o Serum chemistries, including liver function testing o Thyroid function tests (TSH or super sensitive (ss) TSH) o Vitamin B12 o Erythrocyte Sedimentation Rate (ESR, “Sed Rate”, etc) o Serologic test for syphilis (to r/o tertiary syphilis) o Possibly toxicology tests to r/o poisoning or overdose- salicylates, alcohol, other  Medicines that may be causing cognitive impairment- o Anti-diarrheals o Anti-epileptic medications o Antihistamines, cold and flu medications o Lithium o Sleeping pills o Tricylic antidepressants o Opiates o Salicylates

Nationally Non- Covered Indications  All other uses of FDG PET for patients with a presumptive diagnosis of dementia-causing neurodegenerative disease (e.g., possible or probable AD, clinically typical FTD, dementia of Lewy bodies, or Creutzfeld-Jacob disease) for which CMS has not specifically indicated coverage continue to be noncovered.

o Any request for CPT code 78609; CPT code 78609 is a non-covered service for CMS (effective date retroactive to 01/28/2005). http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/downloads/R1301CP.pdf

ADDITIONAL INFORMATION RELATED TO A BRAIN PET SCAN:

 The request should be for evaluation of the brain, not to be confused with “head/neck” PET

TOC 78813 – PET Scan Last Review Date: May 2014

FOR CMS (MEDICARE) MEMBERS ONLY”

NATIONALLY NON-COVERD INDICATIONS:

 CMS continues to nationally non-cover initial anti-tumor treatment strategy in Medicare beneficiaries who have adenocarcinoma of the prostate.

 CMS continues to nationally non-cover FDG PET imaging for diagnosis of breast cancer and initial staging of axillary nodes.

 CMS continues to nationally non-cover FDG PET imaging for initial anti-tumor treatment strategy for the evaluation of regional lymph nodes in melanoma.

 CMS continues to nationally non-cover FDG PET imaging for the diagnosis of cervical cancer related to initial anti-tumor treatment strategy.

 Infection and/or Inflammation - PET for chronic osteomyelitis, infection of hip arthroplasty, and fever of unknown origin.

 CPT code G0219: Whole body melanoma for non-covered indications - CMS does not cover this code.

 CPT code G0235: PET any site; – CMS does not cover this code. If case created with this code, withdraw and use CPT codes 78813.

NATIONALLY COVERED INDICATIONS:

CLINICAL INDICATIONS FOR INITIAL ANTI-TUMOR TREATMENT STRATEGY:

CMS continues to nationally cover one FDG PET study for beneficiaries who have cancers that are biopsy proven or strongly suspected based on other diagnostic testing when the beneficiary’s treating physician determines that the FDG PET study is needed to determine the location and/or extent of the tumor for the following therapeutic purposes related to the initial anti-tumor treatment strategy:  To determine if patient is an appropriate candidate for an invasive diagnostic or therapeutic procedure, or  To determine the optimal anatomic location for an invasive procedure, or  To determine the anatomic extent of tumor when the recommended anti-tumor treatment reasonably depends on the extent of the tumor.

Initial Anti-Tumor Treatment Strategy Coverage:  All other solid tumors  All other cancers not listed © 2000-2014 National Imaging Associates, Inc Page 57 of 59 This document is the proprietary information of Magellan Health Services and its affiliates

 Brain  Breast (female and male)*  Cervical with exception*  Colorectal  Esophageal  Head & Neck (not thyroid or CNS)  Lymphoma  Melanoma with exception*  Myeloma  Non-small cell lung  Ovarian  Pancreatic  Small cell lung  Soft Tissue Sarcoma  Testicular  Thyroid

*Breast: Initial anti-tumor treatment strategy for male and female breast cancer only when used in staging distant metastasis.

*Cervical: For the detection of pre-treatment metastasis (i.e., staging) in newly diagnosed cervical cancers following conventional imaging.

*Melanoma: Initial anti-tumor treatment strategy for melanoma other than for the evaluation of regional lymph nodes.

CLINICAL INDICATIONS FOR SUBSEQUENT ANTI-TUMOR TREATMENT STRATEGY:

Three FDG PET scans are nationally covered when used to guide subsequent management of anti- tumor treatment strategy after completion of initial anti-cancer therapy for the same diagnosis. Coverage of more than three FDG PET scans to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy shall be determined by the local Medicare Administrative Contractors.

Subsequent Anti-Tumor Treatment Strategy Coverage:

 All other solid tumors  All other cancers not listed  Brain  Breast (female and male)  Cervical  Colorectal  Esophageal  Head & Neck (not thyroid or CNS)  Lymphoma  Melanoma  Myeloma  Non-small cell lung © 2000-2014 National Imaging Associates, Inc Page 58 of 59 This document is the proprietary information of Magellan Health Services and its affiliates

 Ovarian  Pancreas  Prostate  Small cell lung  Soft tissue sarcoma  Testicular  Thyroid

All guidelines

TOC