Magnetic Resonance Angiography (L31355)

Contractor Information

Contractor Name
Wisconsin Physicians Service Insurance Corporation
Contractor Number
00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402
Contractor Type
Carrier - FI - MAC

LCD Information

Document Information
LCD ID Number
L31355

LCD Title
Magnetic Resonance Angiography

Contractor's Determination Number
RAD-023

AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction


Oversight Region



Original Determination Effective Date
For services performed on or after 04/15/2011

Original Determination Ending Date


Revision Effective Date
For services performed on or after 12/01/2011

Revision Ending Date


CMS National Coverage Policy
Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Pub 100-3, Ch. 1, Part 4, §220.2
Indications and Limitations of Coverage and/or Medical Necessity
MRA is an adaptation of the MRI in which three-dimensional views of arterial and venous blood vessels and blood flow is demonstrated without the need for intravascular injections of contrast agents. As a non-invasive diagnostic imaging technique that generates images of blood flow through vessels, this test utilizes the principals of MRI, in that any body part placed in magnetic field yields different signal intensity for blood flow in contrast to surrounding stationary vascular tissues. Multiple images are produced and processed to duplicate the route of the blood flow. The subsequent computer reconstruction presents a series of these cross-sectional images to create a vascular image similar to angiographic versions. The physician then may evaluate the anatomy of the vessels, the blood flow, and the surrounding structures for diagnosis of a disease process or abnormality; determine or evaluate treatment; or observe an existing problem.

MRA can thus be used to demonstrate obstructive vascular lesions, eliminating the risk associated with angiography and the use of contrast material. Accordingly, MRA is generally covered only to the extent that it is used as a substitute for contrast angiography (CA). However, if the MRA is not conclusive, a CA may then be medically necessary.

Advantages of MRA include:

1. It is considered non-invasive
2. Multiple angles and three-dimensional images can be visualized
3. Conventional angiography utilizes contrast materials and sedation, which has a significant risk of
adverse reactions
4. There is essentially no risk of arterial puncture-associated complications
5. MRA may be used for those patients with whom conventional angiography is contraindicated
6. MRA allows adjacent structures to be visualized; and
7. MRA is capable of evaluating any vessel of the body, regardless of its location. In contrast,
ultrasonography (US) is limited to vessels, which are not obscured by bone, calcification, air or
excessive fat.

In summary, Magnetic resonance angiography (MRA) is an application of magnetic resonance imaging (MRI) that provides visualization of blood flow, as well as images of normal and diseased blood vessels

A. Qualifications of the provider:

The physician should be qualified to perform these procedures and have advanced knowledge of the anatomy and the disease process of the study area.

B. Contraindications:

1. Patients with non-removable intradural and/or intraorbital devices including:

a. metallic clips on vascular or intracranial aneurysms; or
b. intraorbital metallic foreign body.

C. Patients with devices containing ferromagnetic materials (metal that could be magnetized) that cannot be removed or substituted for MRA compatible devices, including, but not limited to non-MRA compatible life support equipment or monitoring equipment.

In the absence of symptoms or signs of neurological concern, an MRA of the head and neck would be considered to be screening, thus non-payable by Medicare.

While the intent of this policy is to provide reimbursement for either MRA or CA, CMS is also allowing flexibility for physicians to make appropriate decisions concerning the use of these tests based on the needs of individual patients. CMS anticipates, however, low utilization of the combined use of MRA and CA. As a result, CMS has encouraged contractors to monitor the use of these tests and, where indicated, and require evidence of the need to perform both MRA and CA.

All other uses of MRA for which CMS has not specifically indicated coverage continue to be noncovered.

Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.


Coding Information

Bill Type Codes:

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

011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
085x Critical Access Hospital

Revenue Codes:

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

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

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.

0615 Magnetic Resonance Technology (MRT) - MRA - Head and Neck
0616 Magnetic Resonance Technology (MRT) - MRA - Lower Extremities
0618 Magnetic Resonance Technology (MRT) - MRA - Other

CPT/HCPCS Codes

CPT/HCPCS Codes (70544, 70545, 70546, 70547, 70548, 70549, 71555, 72198, 73725, 74185, C8900, C2901, C8902, C8909, C8910, C28911, C8912, C8913, C8914, C8914, C8918, C8919, C8920)

70544MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S)
70545MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITH CONTRAST MATERIAL(S)
70546MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES
70547MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S)
70548MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITH CONTRAST MATERIAL(S)
70549MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES
71555MAGNETIC RESONANCE ANGIOGRAPHY, CHEST (EXCLUDING MYOCARDIUM), WITH OR WITHOUT CONTRAST MATERIAL(S)
72198MAGNETIC RESONANCE ANGIOGRAPHY, PELVIS, WITH OR WITHOUT CONTRAST MATERIAL(S)
73725MAGNETIC RESONANCE ANGIOGRAPHY, LOWER EXTREMITY, WITH OR WITHOUT CONTRAST MATERIAL(S)
74185MAGNETIC RESONANCE ANGIOGRAPHY, ABDOMEN, WITH OR WITHOUT CONTRAST MATERIAL(S)
C8900MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, ABDOMEN
C8901MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, ABDOMEN
C8902MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, ABDOMEN
C8909MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM)
C8910MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, CHEST (EXCLUDING MYOCARDIUM)
C8911MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM)
C8912MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, LOWER EXTREMITY
C8913MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, LOWER EXTREMITY
C8914MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, LOWER EXTREMITY
C8918MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, PELVIS
C8919MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, PELVIS
C8920MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, PELVIS

ICD-9 Codes that Support Medical Necessity

Note: ICD-9 codes must be coded to the highest level of specificity.
For CPT Codes 70544, 70545, 70546, 70547, 70548 and 70549 (MRA of Head and Neck)

094.81 - 094.89SYPHILITIC ENCEPHALITIS - OTHER SPECIFIED NEUROSYPHILIS
140.0 - 140.9MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - MALIGNANT NEOPLASM OF LIP UNSPECIFIED VERMILION BORDER
141.0 - 141.9MALIGNANT NEOPLASM OF BASE OF TONGUE - MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED
142.0 - 142.9MALIGNANT NEOPLASM OF PAROTID GLAND - MALIGNANT NEOPLASM OF SALIVARY GLAND UNSPECIFIED
143.0 - 143.9MALIGNANT NEOPLASM OF UPPER GUM - MALIGNANT NEOPLASM OF GUM UNSPECIFIED
144.0 - 144.9MALIGNANT NEOPLASM OF ANTERIOR PORTION OF FLOOR OF MOUTH - MALIGNANT NEOPLASM OF FLOOR OF MOUTH PART UNSPECIFIED
145.0 - 145.9MALIGNANT NEOPLASM OF CHEEK MUCOSA - MALIGNANT NEOPLASM OF MOUTH UNSPECIFIED
146.0 - 146.9MALIGNANT NEOPLASM OF TONSIL - MALIGNANT NEOPLASM OF OROPHARYNX UNSPECIFIED SITE
147.0 - 147.9MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX - MALIGNANT NEOPLASM OF NASOPHARYNX UNSPECIFIED SITE
148.0 - 148.9MALIGNANT NEOPLASM OF POSTCRICOID REGION OF HYPOPHARYNX - MALIGNANT NEOPLASM OF HYPOPHARYNX UNSPECIFIED SITE
149.0 - 149.9MALIGNANT NEOPLASM OF PHARYNX UNSPECIFIED - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY
170.0MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE
171.0MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK
191.0 - 191.9MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES - MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE
192.1MALIGNANT NEOPLASM OF CEREBRAL MENINGES
194.3MALIGNANT NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT
194.4MALIGNANT NEOPLASM OF PINEAL GLAND
194.5MALIGNANT NEOPLASM OF CAROTID BODY
194.6MALIGNANT NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA
195.0MALIGNANT NEOPLASM OF HEAD FACE AND NECK
198.3SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD
198.4SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM
225.0BENIGN NEOPLASM OF BRAIN
225.1BENIGN NEOPLASM OF CRANIAL NERVES
225.2BENIGN NEOPLASM OF CEREBRAL MENINGES
227.3BENIGN NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT
227.4BENIGN NEOPLASM OF PINEAL GLAND
227.5BENIGN NEOPLASM OF CAROTID BODY
227.6BENIGN NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA
228.02HEMANGIOMA OF INTRACRANIAL STRUCTURES
228.03HEMANGIOMA OF RETINA
228.09HEMANGIOMA OF OTHER SITES
237.0 - 237.73NEOPLASM OF UNCERTAIN BEHAVIOR OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT - SCHWANNOMATOSIS
237.79OTHER NEUROFIBROMATOSIS
239.6NEOPLASM OF UNSPECIFIED NATURE OF BRAIN
290.40 - 290.43VASCULAR DEMENTIA, UNCOMPLICATED - VASCULAR DEMENTIA, WITH DEPRESSED MOOD
325PHLEBITIS AND THROMBOPHLEBITIS OF INTRACRANIAL VENOUS SINUSES
326LATE EFFECTS OF INTRACRANIAL ABSCESS OR PYOGENIC INFECTION
342.00 - 342.92FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE
345.00 - 345.91GENERALIZED NONCONVULSIVE EPILEPSY WITHOUT INTRACTABLE EPILEPSY - EPILEPSY UNSPECIFIED WITH INTRACTABLE EPILEPSY
346.00 - 346.93MIGRAINE WITH AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS - MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS
348.0CEREBRAL CYSTS
348.1ANOXIC BRAIN DAMAGE
348.4COMPRESSION OF BRAIN
348.5CEREBRAL EDEMA
350.1 - 350.9TRIGEMINAL NEURALGIA - TRIGEMINAL NERVE DISORDER UNSPECIFIED
351.9FACIAL NERVE DISORDER UNSPECIFIED
362.30 - 362.37RETINAL VASCULAR OCCLUSION UNSPECIFIED - VENOUS ENGORGEMENT OF RETINA
362.81RETINAL HEMORRHAGE
368.11SUDDEN VISUAL LOSS
368.12TRANSIENT VISUAL LOSS
368.2DIPLOPIA
368.40 - 368.47VISUAL FIELD DEFECT UNSPECIFIED - HETERONYMOUS BILATERAL FIELD DEFECTS
374.31PARALYTIC PTOSIS
377.01PAPILLEDEMA ASSOCIATED WITH INCREASED INTRACRANIAL PRESSURE
377.04FOSTER-KENNEDY SYNDROME
377.41 - 377.49ISCHEMIC OPTIC NEUROPATHY - OTHER DISORDERS OF OPTIC NERVE
377.51 - 377.54DISORDERS OF OPTIC CHIASM ASSOCIATED WITH PITUITARY NEOPLASMS AND DISORDERS - DISORDERS OF OPTIC CHIASM ASSOCIATED WITH INFLAMMATORY DISORDERS
377.61DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH NEOPLASMS
377.62DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH VASCULAR DISORDERS
377.71DISORDERS OF VISUAL CORTEX ASSOCIATED WITH NEOPLASMS
377.72DISORDERS OF VISUAL CORTEX ASSOCIATED WITH VASCULAR DISORDERS
378.51THIRD OR OCULOMOTOR NERVE PALSY PARTIAL
378.52THIRD OR OCULOMOTOR NERVE PALSY TOTAL
388.02TRANSIENT ISCHEMIC DEAFNESS
388.30 - 388.32TINNITUS UNSPECIFIED - OBJECTIVE TINNITUS
430SUBARACHNOID HEMORRHAGE
431INTRACEREBRAL HEMORRHAGE
432.0NONTRAUMATIC EXTRADURAL HEMORRHAGE
432.1SUBDURAL HEMORRHAGE
432.9UNSPECIFIED INTRACRANIAL HEMORRHAGE
433.00 - 433.91OCCLUSION AND STENOSIS OF BASILAR ARTERY WITHOUT CEREBRAL INFARCTION - OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL INFARCTION
434.00 - 434.91CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION - CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL INFARCTION
435.0 - 435.9BASILAR ARTERY SYNDROME - UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA
436ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE
437.0 - 437.9CEREBRAL ATHEROSCLEROSIS - UNSPECIFIED CEREBROVASCULAR DISEASE
438.0 - 438.9COGNITIVE DEFICITS - UNSPECIFIED LATE EFFECTS OF CEREBROVASCULAR DISEASE
442.81ANEURYSM OF ARTERY OF NECK
442.82ANEURYSM OF SUBCLAVIAN ARTERY
443.21DISSECTION OF CAROTID ARTERY
446.0POLYARTERITIS NODOSA
446.20HYPERSENSITIVITY ANGIITIS UNSPECIFIED
446.29OTHER SPECIFIED HYPERSENSITIVITY ANGIITIS
446.5GIANT CELL ARTERITIS
446.6THROMBOTIC MICROANGIOPATHY
446.7TAKAYASU'S DISEASE
447.0ARTERIOVENOUS FISTULA ACQUIRED
447.1STRICTURE OF ARTERY
447.2RUPTURE OF ARTERY
447.8OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES
453.9EMBOLISM AND THROMBOSIS OF UNSPECIFIED SITE
459.9UNSPECIFIED CIRCULATORY SYSTEM DISORDER
710.0SYSTEMIC LUPUS ERYTHEMATOSUS
723.1CERVICALGIA
747.10COARCTATION OF AORTA (PREDUCTAL) (POSTDUCTAL)
747.81CONGENITAL ANOMALIES OF CEREBROVASCULAR SYSTEM
753.10 - 753.19CYSTIC KIDNEY DISEASE UNSPECIFIED - OTHER SPECIFIED CYSTIC KIDNEY DISEASE
756.83EHLERS-DANLOS SYNDROME
757.39OTHER SPECIFIED CONGENITAL ANOMALIES OF SKIN
759.82MARFAN SYNDROME
780.01 - 780.4COMA - DIZZINESS AND GIDDINESS
780.93MEMORY LOSS
780.97ALTERED MENTAL STATUS
781.0 - 781.8ABNORMAL INVOLUNTARY MOVEMENTS - NEUROLOGIC NEGLECT SYNDROME
784.0HEADACHE
784.2SWELLING MASS OR LUMP IN HEAD AND NECK
784.3APHASIA
784.59OTHER SPEECH DISTURBANCE
784.69OTHER SYMBOLIC DYSFUNCTION
784.99OTHER SYMPTOMS INVOLVING HEAD AND NECK
785.9OTHER SYMPTOMS INVOLVING CARDIOVASCULAR SYSTEM
793.0NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF SKULL AND HEAD
794.09OTHER NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF BRAIN AND CENTRAL NERVOUS SYSTEM
800.20 - 800.29CLOSED FRACTURE OF VAULT OF SKULL WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - CLOSED FRACTURE OF VAULT OF SKULL WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED
800.30 - 800.39CLOSED FRACTURE OF VAULT OF SKULL WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - CLOSED FRACTURE OF VAULT OF SKULL WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED
800.70 - 800.79OPEN FRACTURE OF VAULT OF SKULL WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OPEN FRACTURE OF VAULT OF SKULL WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED
800.80 - 800.89OPEN FRACTURE OF VAULT OF SKULL WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OPEN FRACTURE OF VAULT OF SKULL WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED
801.20 - 801.29CLOSED FRACTURE OF BASE OF SKULL WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - CLOSED FRACTURE OF BASE OF SKULL WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED
801.30 - 801.39CLOSED FRACTURE OF BASE OF SKULL WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - CLOSED FRACTURE OF BASE OF SKULL WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED
801.70 - 801.79OPEN FRACTURE OF BASE OF SKULL WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OPEN FRACTURE OF BASE OF SKULL WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED
801.80 - 801.89OPEN FRACTURE OF BASE OF SKULL WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OPEN FRACTURE OF BASE OF SKULL WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED
803.20 - 803.29OTHER CLOSED SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER CLOSED SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED
803.30 - 803.39OTHER CLOSED SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF UNCONSCIOUSNESS UNSPECIFIED - OTHER CLOSED SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED
803.70 - 803.79OTHER OPEN SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED
803.80 - 803.89OTHER OPEN SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED
804.20 - 804.29CLOSED FRACTURES INVOLVING SKULL OR FACE WITH OTHER BONES WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - CLOSED FRACTURES INVOLVING SKULL OR FACE WITH OTHER BONES WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED
804.30 - 804.39CLOSED FRACTURES INVOLVING SKULL OR FACE WITH OTHER BONES WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - CLOSED FRACTURES INVOLVING SKULL OR FACE WITH OTHER BONES WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED
804.70 - 804.79OPEN FRACTURES INVOLVING SKULL OR FACE WITH OTHER BONES WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OPEN FRACTURES INVOLVING SKULL OR FACE WITH OTHER BONES WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED
804.80 - 804.89OPEN FRACTURES INVOLVING SKULL OR FACE WITH OTHER BONES WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OPEN FRACTURES INVOLVING SKULL OR FACE WITH OTHER BONES WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED
805.10 - 805.18OPEN FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL - OPEN FRACTURE OF MULTIPLE CERVICAL VERTEBRAE
806.00 - 806.09CLOSED FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY
806.10 - 806.19OPEN FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY
852.00 - 852.59SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED - EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED
853.00 - 853.19OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED
900.00 - 900.9INJURY TO CAROTID ARTERY UNSPECIFIED - INJURY TO UNSPECIFIED BLOOD VESSEL OF HEAD AND NECK
908.3LATE EFFECT OF INJURY TO BLOOD VESSEL OF HEAD NECK AND EXTREMITIES
959.01OTHER AND UNSPECIFIED INJURY TO HEAD
959.09OTHER AND UNSPECIFIED INJURY TO FACE AND NECK
998.11HEMORRHAGE COMPLICATING A PROCEDURE
998.12HEMATOMA COMPLICATING A PROCEDURE
998.13SEROMA COMPLICATING A PROCEDURE
For CPT Code 71555 (MRA of chest):
093.0ANEURYSM OF AORTA SPECIFIED AS SYPHILITIC
415.0ACUTE COR PULMONALE
415.11IATROGENIC PULMONARY EMBOLISM AND INFARCTION
415.13SADDLE EMBOLUS OF PULMONARY ARTERY
415.19OTHER PULMONARY EMBOLISM AND INFARCTION
416.0 - 416.9PRIMARY PULMONARY HYPERTENSION - CHRONIC PULMONARY HEART DISEASE UNSPECIFIED
417.0ARTERIOVENOUS FISTULA OF PULMONARY VESSELS
417.1ANEURYSM OF PULMONARY ARTERY
441.00 - 441.9DISSECTION OF AORTA ANEURYSM UNSPECIFIED SITE - AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT RUPTURE
442.82ANEURYSM OF SUBCLAVIAN ARTERY
444.1EMBOLISM AND THROMBOSIS OF THORACIC AORTA
447.5NECROSIS OF ARTERY
447.8OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES
453.89ACUTE VENOUS EMBOLISM AND THROMBOSIS OF OTHER SPECIFIED VEINS
511.81MALIGNANT PLEURAL EFFUSION
511.89OTHER SPECIFIED FORMS OF EFFUSION, EXCEPT TUBERCULOUS
511.9UNSPECIFIED PLEURAL EFFUSION
794.2NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF PULMONARY SYSTEM
V12.51PERSONAL HISTORY OF VENOUS THROMBOSIS AND EMBOLISM
V12.55PERSONAL HISTORY OF PULMONARY EMBOLISM
V12.59PERSONAL HISTORY OF OTHER DISEASES OF CIRCULATORY SYSTEM NOT ELSEWHERE CLASSIFIED
V14.8PERSONAL HISTORY OF ALLERGY TO OTHER SPECIFIED MEDICINAL AGENTS
For CPT Codes 72198 (MRA Pelvis) and 74185 (MRA of Abdomen):

Note: codes 440.8 and 747.69 may be used only when the specified
artery or site is the iliac artery.

403.00 - 403.91HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
404.00 - 404.93HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
405.01MALIGNANT RENOVASCULAR HYPERTENSION
405.11BENIGN RENOVASCULAR HYPERTENSION
405.91UNSPECIFIED RENOVASCULAR HYPERTENSION
440.0ATHEROSCLEROSIS OF AORTA
440.1ATHEROSCLEROSIS OF RENAL ARTERY
440.8ATHEROSCLEROSIS OF OTHER SPECIFIED ARTERIES
441.01 - 441.9DISSECTION OF AORTA THORACIC - AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT RUPTURE
442.1ANEURYSM OF RENAL ARTERY
442.2ANEURYSM OF ILIAC ARTERY
442.83ANEURYSM OF SPLENIC ARTERY
442.84ANEURYSM OF OTHER VISCERAL ARTERY
444.01SADDLE EMBOLUS OF ABDOMINAL AORTA
444.09OTHER ARTERIAL EMBOLISM AND THROMBOSIS OF ABDOMINAL AORTA
444.1EMBOLISM AND THROMBOSIS OF THORACIC AORTA
444.81EMBOLISM AND THROMBOSIS OF ILIAC ARTERY
445.81ATHEROEMBOLISM OF KIDNEY
447.0 - 447.5ARTERIOVENOUS FISTULA ACQUIRED - NECROSIS OF ARTERY
453.89ACUTE VENOUS EMBOLISM AND THROMBOSIS OF OTHER SPECIFIED VEINS
747.69ANOMALIES OF OTHER SPECIFIED SITES OF PERIPHERAL VASCULAR SYSTEM
902.0INJURY TO ABDOMINAL AORTA
996.81COMPLICATIONS OF TRANSPLANTED KIDNEY
997.72VASCULAR COMPLICATIONS OF RENAL ARTERY
For CPT Code 73725 (MRA of Lower Extremity):
040.0GAS GANGRENE
250.70 - 250.73DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], UNCONTROLLED
415.11IATROGENIC PULMONARY EMBOLISM AND INFARCTION
415.13SADDLE EMBOLUS OF PULMONARY ARTERY
415.19OTHER PULMONARY EMBOLISM AND INFARCTION
440.20 - 440.29ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED - OTHER ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES
440.30 - 440.32ATHEROSCLEROSIS OF UNSPECIFIED BYPASS GRAFT OF THE EXTREMITIES - ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT OF THE EXTREMITIES
442.2ANEURYSM OF ILIAC ARTERY
442.3ANEURYSM OF ARTERY OF LOWER EXTREMITY
443.0RAYNAUD'S SYNDROME
443.1THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE)
443.22DISSECTION OF ILIAC ARTERY
443.29DISSECTION OF OTHER ARTERY
443.81PERIPHERAL ANGIOPATHY IN DISEASES CLASSIFIED ELSEWHERE
443.89OTHER PERIPHERAL VASCULAR DISEASE
443.9PERIPHERAL VASCULAR DISEASE UNSPECIFIED
444.22ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY
444.81EMBOLISM AND THROMBOSIS OF ILIAC ARTERY
444.89EMBOLISM AND THROMBOSIS OF OTHER ARTERY
445.02ATHEROEMBOLISM OF LOWER EXTREMITY
447.0 - 447.8ARTERIOVENOUS FISTULA ACQUIRED - OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES
451.0PHLEBITIS AND THROMBOPHLEBITIS OF SUPERFICIAL VESSELS OF LOWER EXTREMITIES
451.11 - 451.19PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (DEEP) (SUPERFICIAL) - PHLEBITIS AND THROMBOPHLEBITIS OF OTHER
451.2PHLEBITIS AND THROMBOPHLEBITIS OF LOWER EXTREMITIES UNSPECIFIED
451.81PHLEBITIS AND THROMBOPHLEBITIS OF ILIAC VEIN
453.89ACUTE VENOUS EMBOLISM AND THROMBOSIS OF OTHER SPECIFIED VEINS
459.11 - 459.19POSTPHLEBETIC SYNDROME WITH ULCER - POSTPHLEBETIC SYNDROME WITH OTHER COMPLICATION
671.22 - 671.24SUPERFICIAL THROMBOPHLEBITIS WITH DELIVERY WITH POSTPARTUM COMPLICATION - POSTPARTUM SUPERFICIAL THROMBOPHLEBITIS
671.31DEEP PHLEBOTHROMBOSIS ANTEPARTUM WITH DELIVERY
671.33DEEP PHLEBOTHROMBOSIS ANTEPARTUM
671.42DEEP PHLEBOTHROMBOSIS POSTPARTUM WITH DELIVERY
671.44DEEP PHLEBOTHROMBOSIS POSTPARTUM
682.6CELLULITIS AND ABSCESS OF LEG EXCEPT FOOT
682.7CELLULITIS AND ABSCESS OF FOOT EXCEPT TOES
747.64LOWER LIMB VESSEL ANOMALY
747.69ANOMALIES OF OTHER SPECIFIED SITES OF PERIPHERAL VASCULAR SYSTEM
782.5CYANOSIS
785.4GANGRENE
904.0 - 904.7INJURY TO COMMON FEMORAL ARTERY - INJURY TO OTHER SPECIFIED BLOOD VESSELS OF LOWER EXTREMITY
906.7LATE EFFECT OF BURN OF OTHER EXTREMITIES
928.00 - 928.9CRUSHING INJURY OF THIGH - CRUSHING INJURY OF UNSPECIFIED SITE OF LOWER LIMB
959.6OTHER AND UNSPECIFIED INJURY TO HIP AND THIGH
959.7OTHER AND UNSPECIFIED INJURY TO KNEE LEG ANKLE AND FOOT
996.1MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT
996.62INFECTION AND INFLAMMATORY REACTION DUE TO OTHER VASCULAR DEVICE IMPLANT AND GRAFT
996.74OTHER COMPLICATIONS DUE TO OTHER VASCULAR DEVICE IMPLANT AND GRAFT
996.95COMPLICATION OF REATTACHED FOOT AND TOE(S)
996.96COMPLICATION OF REATTACHED LOWER EXTREMITY OTHER AND UNSPECIFIED
997.2PERIPHERAL VASCULAR COMPLICATIONS NOT ELSEWHERE CLASSIFIED
997.62INFECTION (CHRONIC) OF AMPUTATION STUMP
997.69OTHER LATE AMPUTATION STUMP COMPLICATION
V43.4BLOOD VESSEL REPLACED BY OTHER MEANS

Diagnoses that Support Medical Necessity
Diagnoses listed in this LCD
ICD-9 Codes that DO NOT Support Medical Necessity
ICD-9 codes not listed in this LCD
XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity
Diagnoses not listed in this LCD

General Information

Documentations Requirements
The patient's contemporaneous medical record must clearly document the basis for the diagnoses billed, and must demonstrate the medical necessity for the procedure and the incremental diagnostic information provided by MRA. In other words, there must be clear justification in the medical record for the MRA. Upon request, this information must be made available to Medicare for review. Examples include:

1) When the frequency of examination can be anticipated to exceed that considered reasonable and necessary as accepted in general medical practice
2) When both MRA and CA (defined earlier in this LCD under Indications and Limitations of Coverage and/or Medical Necessity) are required in the clinical decision making process, for the same disease (diagnosis)
3) This policy contains all the symptoms that reasonably suggest pathology of the vessels in question

If a contrast angiography of the cerebral arteries is done on the same day as the MRA of the head or neck, the medical record must justify this combination of imaging tests.

A provider may bill for an MRA of the lower extremity (73725) when it is a runoff study following an MRA of the abdomen (74185) or pelvis (72198) only if that study (73725) is itself both reasonable and medically necessary.

If mobile MRA services are furnished at an ambulatory test care facility other than a hospital based facility (e.g... a free standing physician directed clinic), the diagnostic procedure must be performed by or under the direct supervision of a radiologist or other qualified physician. In addition, the facility must maintain a record of the attending physician's order for a scan performed in a mobile unit.
— These services must be performed in a setting, in which a physician is present and immediately available to furnish assistance and direction throughout the performance of the procedure, or in an approved mobile unit in which a physician is always in attendance, for clinical and reimbursement purposes.

- Please select the correct indication for the test to be performed. Note that not all covered ICD-9-CM codes apply to each CPT code.

- When both MRA and CA are billed, documentation to support medical necessity for both procedures must be present in the medical record.

Examples of circumstances in which CA may be performed as an adjunct to MRA:
1. To clarify conditions where test results or clinical information are contradictory (for example, CE-MRA and duplex Doppler ultrasound are discordant with the clinical differential diagnosis and conventional angiography, with its ability to directly measure pressure gradients across stenosis of questionable hemodynamic significance, can provide more definitive information).

2. To verify the site of clinically important vascular stenosis and help map out the surgical/endovascular approach (for example, to determine which lesions should have an angioplasty and/or stent vs. which lesions require surgical bypass graft or no treatment at all).

3. To identify situations where MRA is inconclusive or degraded by metallic artifact.

4. To demonstrate anatomic abnormalities.

The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

The patient's medical record must clearly support the medical necessity of the test. These records must be available to Medicare upon request.

When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.

When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.
Appendices
Utilization Guidelines
See Indications and limitations section of this LCD
Sources of Information and Basis for Decision
Annals of Internal Medicine, May 1994; Vol 120:10, pages 856-875
Other Carriers' LCDs

*- An asterisk indicates a revision to that section of the policy.

Notes
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction.

Italicized font represents CMS national policy language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national policy language/wording. Providers, through their associations/societies, should contact CMS to request changes to national policy through the Medicare Coverage Policy Process at http://www.cms.gov/center/coverage.asp

NCDs are binding on all carriers, fiscal intermediaries, MAC Contractors, quality improvement organizations, health maintenance organizations, competitive medical plans, and health care prepayment plans. Under 42 CFR 422.256(b), an NCD that expands coverage is also binding on Medicare Advantage Organizations. In addition, an administrative law judge may not review an NCD. (See §1869(f)(1)(A)(i) of the Social Security Act.)

Advisory Committee Meeting Notes
Meeting Date:
Wisconsin 09/24/2010
Illinois 09/22/2010
Michigan 09/15/2010
Minnesota 09/16/2010
Iowa, Kansas, Missouri, Nebraska 10/07/2010
Open Meeting: 09/02/2010
Start Date of Comment Period
10/07/2010
End Date of Comment Period
11/21/2010
Start Date of Notice Period
03/01/2011
Revision History Number
X
Revision History Explanation
08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

10/01/2011: ICD-9-CM 2012 revisions; For CPT code 71555, added new ICD-9-CM codes 415.13 and V12.55. For CPT codes 72198 and 74185, ICD-9-CM code 444.0 truncated, added new codes 444.01 and 444.09. For CPT code 73725, added new ICD-9-CM code 415.13. Effective 10/01/2011 (one).

12/01/2011: Inadvertent omission from ICD-9 list for CPT code 71555, new ICD-9 code V12.55. Effective 10/01/2011 (two).
Reason for Change
Related Documents
This LCD has no Related Documents.

LCD Attachments

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