3.0 DESCRIPTION
3.1 Radiology is the science that deals with the
use of radiant energy, such as X-rays, radium, and radioactive isotopes,
in the diagnosis and treatment of disease. Radiology is an important
diagnostic tool useful for the evaluation of a variety of conditions.
The techniques used for diagnostic radiology are as follows:
3.2 Magnetic Resonance Imaging (MRI) is a non-invasive
method of graphically representing the distribution of water and
other hydrogen-rich molecules in the human body. MRI uses radio
frequency radiation in the presence of a carefully controlled magnetic
field to produce high quality cross-sectional images of the head
and body in any plane. These tomographic images represent the tissue
being analyzed and the environment surrounding it. MRI has become
a useful diagnostic imaging modality that is capable of demonstrating
a wide variety of soft-tissue lesions with contrast resolution equal
or superior to Computerized Tomography (CT) scanning in various
parts of the body. Among the advantages of MRI are the absence of
ionizing radiation and the ability to achieve high levels of tissue contrast
resolution without injected iodinated contrast agents.
3.3 Magnetic Resonance Angiography (MRA) techniques
generate contrast between flowing blood and surrounding tissue,
and provide anatomic images that can be provided in a format similar
to that of conventional x-ray angiography, and can also provide
physiologic information.
3.4 A CT/Computerized Axial Tomography (CAT) scan
is interchangeably referred to as either a CT or CAT scan. This
diagnostic test uses x-ray technology to create three-dimensional,
computerized images of internal organs. However, unlike a traditional
x-ray, CT/CAT scans are able to distinguish between obscured and
overlapping parts of the body. CAT scans are also capable of producing
images of several different internal components, including soft
tissue, blood vessels and bones.
4.0 POLICY
4.1 MRI and MRI with contrast media are covered
when medically necessary, appropriate, and the standard of care.
(Current Procedural Terminology (CPT) procedure codes 70336, 70540
- 70543, 70551 - 70553, 71550 - 71552, 72141 - 72158, 72195 - 72197,
73218 - 73223, 73718 - 73723, 74181 - 74183, 75552 - 75556, and
76400.)
4.2 Breast
MRI (CPT procedure codes 77058 and 77059) is covered for the following
indications. This list of indications is not all inclusive. Other
indications may be covered when determined by the contractor to
be medically necessary and appropriate:
4.2.1 To detect breast implant rupture (the implantation
of the breast implants must have been covered by TRICARE).
4.2.2 For detection of occult breast cancer in the
setting of axillary nodal adenocarcinoma with negative physical
exam and negative mammography.
4.2.3 For presurgical planning for locally advanced
breast cancer before and after completion of neoadjuvant chemotherapy,
to permit tumor localization and characterization.
4.2.4 For presurgical planning to evaluate the presence
of multicentric disease in patients with localized or locally advanced
breast cancer who are candidates for breast conservation treatment.
4.2.5 Evaluation of suspected cancer recurrence.
4.2.6 To determine the presence of pectoralis major
muscle/chest wall invasion in patients with posteriorly located
tumor.
4.2.7 For guidance
of interventional procedures such as vacuum assisted biopsy and preoperative
wire localization for lesions that are occult on mammography or
sonography and are demonstrable only with MRI.
4.3 Open MRI and Open MRI with contrast media are
covered when medically necessary, appropriate, and the standard
of care.
4.4 Cardiovascular
Magnetic Resonance (CMR) (CPT procedure codes 75557, 75559, 75561,
75563, and 75565) is covered for the following indications:
4.4.1 Detection Of Coronary Artery Disease (CAD).
Symptomatic--evaluation of chest pain syndrome (use of vasodilator
perfusion CMR or dobutamine stress function CMR).
• Intermediate pre-test
probability of CAD.
• Electrocardiogram
(ECG) uninterpretable OR unable to exercise.
4.4.2 Detection of CAD:
• Symptomatic--evaluation
of intracardiac structures (use of Magnetic Resonance (MR) coronary
angiography).
• Evaluation
of suspected coronary anomalies.
4.4.3 Risk assessment with prior test results (use
of vasolidator perfusion CMR or dobutamine stress function CMR).
• Coronary
angiography (catheterization or CT).
• Stenosis of unclear
significance.
4.4.4 Structure and Function. Evaluation of ventricular
and valvular function. Procedures may include Left Ventricular (LV)/Right
Ventricular (RV) mass and volumes, MRA, quantification of valvular disease,
and delayed contrast enhancement.
4.4.4.1 Assessment of complex congenital heart disease
including anomalies of coronary circulation, great vessels, and
cardiac chambers and valves.
4.4.4.2 Evaluation of LV function following Myocardial
Infarction (MI) OR in heart failure patients. Patients with technically
limited images from echocardiogram.
4.4.4.3 Quantification of LV function. Discordant information
that is clinically significant from prior tests.
4.4.4.4 Evaluation
of specific cardiomyopathies (infiltrative [amyloid, sarcoid], Hypertrophic Cardiomyopathy
(HCM), or due to cardiotoxic therapies.
4.4.4.5 Characterization of native and prosthetic cardiac
valves--including planimetry of stenotic disease and quantification
of regurgitant disease. Patients with technically limited images
from echocardiogram or Transesophageal Echocardiography (TEE).
4.4.4.6 Evaluation
for Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC). Patients presenting
with syncope or ventricular arrhythmia.
4.4.4.7 Evaluation of myocarditis or MI with normal
coronary arteries. Positive cardiac enzymes without obstructive
atherosclerosis on angiography.
4.4.5 Structure and Function. Evaluation of intracardiac
and extracardiac structures.
4.4.5.1 Evaluation of cardiac mass (suspected tumor
or thrombus). Use of contrast for perfusion and enhancement.
4.4.5.2 Evaluation
of pericardial conditions (pericardial mass, constrictive pericarditis).
4.4.5.3 Evaluation
for aortic dissection.
4.4.5.4 Evaluation of pulmonary veins prior to radiofrequency
ablation for atrial fibrillation. Left atrial and pulmonary venous
anatomy including dimensions of veins for mapping purposes.
4.4.6 Detection of Myocardial Scar and Viability.
Evaluation of myocardial scar (use of late gadolinium enhancement).
4.4.6.1 To determine
the location and extent of myocardial necrosis including “no reflow”
regions. Post acute MI.
4.4.6.2 To determine viability prior to revascularization.
Establish likelihood of recovery of function with revascularization
(Percutaneous Coronary Intervention [PCI] or Coronary Artery Bypass
Graft [CABG]) or medical therapy.
4.4.6.3 To determine viability prior to revascularization.
Viability assessment by Single Photon Emission Tomography (SPECT)
or dobutamine echo has provided “equivocal or indeterminate” results.
4.5 MRA is covered when medically necessary, appropriate
and the standard of care. (CPT procedure codes 70544 - 70549, 71555,
72159, 72198, 73225, 73725, and 74185.)
4.6 CT scans are covered when medically necessary,
appropriate and the standard of care and all criteria stipulated
in
32 CFR 199.4(e) are met. (CPT procedure codes
70450 - 70498, 71250 - 71275, 72125 - 72133, 72191 - 72194, 73200
- 73206, 73700 - 73706, 74150 - 74175, 75635, and 76355 - 76380.)
4.7 TRICARE considers three-dimensional (3D) rendering
(CPT procedure codes 76376 and 76377) medically necessary under
certain circumstances (see
Section 2.1),
for exclusion with maternity ultrasound.
4.8 Helical (spiral) CT scans, with or without
contrast enhancement, are covered when medically necessary, appropriate
and the standard of care.
4.9 Chest x-rays (CPT procedure codes 71010 - 71035)
are covered.
4.10 Diagnostic
mammography to include Digital Breast Tomosynthesis (DBT) (CPT procedure
codes 77061, 77062, 77065 - 77067,
and HCPCS code G0279) to further define breast abnormalities
or other problems is covered.
4.11 Portable X-ray services are covered. The suppliers
must meet the conditions of coverage of the Medicare program, set
forth in the Medicare regulations, or the Medicaid program in that
state in which the covered service is provided. In addition to the
specific radiology services, reasonable transportation and set-up
charges are covered and separately reimbursable.
4.12 Bone density studies (CPT procedure codes 77078
- 77086) are covered for the following:
4.12.1 The diagnosis and monitoring of osteoporosis.
4.12.2 The diagnosis and monitoring of osteopenia.
4.12.3 When medically necessary and appropriate.
4.12.4 Patients must present with signs and symptoms
of bone disease or be considered at high-risk for developing osteoporosis.
High-risk factors for osteoporosis are those identified as the standard of
care by the American College of Obstetricians and Gynecologists
(ACOG).
4.13 Radiological supervision and interpretation,
percutaneous vertebroplasty or vertebral augmentation including
cavity creation, per vertebral body; under fluoroscopic guidance
(CPT procedure code 72291) or under CT guidance (CPT procedure code
72292) is covered.
4.14 Multislice or multidetector row CT angiography
(CT, heart) (CPT procedure codes 75571 - 75574) is covered for the
following indications:
4.14.1 Evaluation
of heart failure of unknown origin when invasive coronary angiography
+/- Percutaneous Coronary Intervention (PCI) is not planned, unable
to be performed or is equivocal.
4.14.2 In an Emergency Department (ED) for patients
with acute chest pain, but no other evidence of cardiac disease
(low-pretest probability), when results would be used to determine
the need for further testing or observation.
4.14.3 Acute chest pain or unstable angina when invasive
coronary angiography or a PCI cannot be performed or is equivocal.
4.14.4 Chronic stable angina and chest pain of uncertain
etiology or other cardiac findings prompting evaluation for CAD
(for example: new or unexplained heart failure or new bundle branch block).
4.14.4.1 When invasive
coronary angiography or PCI is not planned, unable to be performed,
or is equivocal; AND
4.14.4.2 Exercise stress test is unable to be performed
or is equivocal; AND
4.14.4.3 At least one of the following non-invasive
tests were attempted and results could not be interpreted or where
equivocal or none of the following tests could be performed:
4.14.4.3.1 Exercise
stress echocardiography.
4.14.4.3.2 Exercise stress echo with dobutamine.
4.14.4.3.3 Exercise
myocardial perfusion (SPECT).
4.14.4.3.4 Pharmacologic myocardial perfusion (SPECT).
4.14.5 Evaluation of anomalous native coronary arteries
in symptomatic patients when conventional angiography is unsuccessful
or equivocal and when results would impact treatment.
4.14.6 Evaluation of complex congenital anomaly of
coronary circulation or of the great vessels.
4.14.7 Presurgical evaluation prior to biventricular
pacemaker placement.
4.14.8 Presurgical evaluation of coronary anatomy
prior to non-coronary surgery (valve placement or repair; repair
of aortic aneurysm or dissection).
4.14.9 Presurgical cardiovascular evaluation for patients
with equivocal stress study prior to kidney or liver transplantation.
4.14.10 Presurgical
evaluation prior to electrophysiologic procedure to isolate pulmonary
veins for radiofrequency ablation of arrhythmia focus.
4.14.11 CT angiography for acute ischemic stroke (CPT
procedure codes 70496 and 70498) are proven when medically necessary
and appropriate.
4.14.12 CT angiography
for intracerebral aneurysm and subarachnoid hemorrhage (CPT procedure codes
70496 and 70498) are proven when medically necessary and appropriate.
4.15 Transient elastography (TE) (ultrasound-based
transient elastography or FibroScan®) (CPT procedure codes 0346T
and 91200) for the detection and monitoring of hepatic cirrhosis
in patients with chronic hepatitis C is covered.
4.16 Magnetic
Resonance Spectroscopy (MRS) (CPT procedure code 76390) is covered
for the following indications:
• Distinguishing
low grade from high grade gliomas;
• Evaluating
a brain lesion of indeterminate nature when MRS findings will impact
the medical management of the patient;
• Distinguishing
recurrent brain tumor from radiation-induced tumor necrosis.
5.0 EXCLUSIONS
5.1 Bone density studies for the routine screening
of osteoporosis.
5.2 Ultrafast
CT (electron beam CT (HCPCS code S8092)) to predict asymptomatic
heart disease is preventive. Ultrafast CT (electron beam CT) is
excluded for symptomatic patients and for screening asymptomatic
patients for CAD.
5.3 MRIs (CPT procedure codes 77058 and 77059)
to screen for breast cancer in asymptomatic women considered to
be at low or average risk of developing breast cancer; for diagnosis
of suspicious lesions to avoid biopsy, to evaluate response to neoadjuvant
chemotherapy, to differentiate cysts from solid lesions.
5.4 MRIs (CPT procedure codes 76058 and 77059)
to assess implant integrity or confirm implant rupture, if implants
were not originally covered or coverable.
5.5 3D rendering (CPT procedure codes 76376 and
76377) for monitoring coronary artery stenosis activity in patients
with angiographically confirmed CAD is unproven.
5.6 3D rendering (CPT procedure codes 76376 and
76377) for evaluating graft patency in individuals who have undergone
revascularization procedures is unproven.
5.7 3D rendering (CPT procedure codes 76376 and
76377) for use as a screening test for CAD in healthy individuals
or in asymptomatic patients who have one or more traditional risk
factors for CAD is unproven.
5.8 CT, heart, without contrast material, with
quantitative evaluation of coronary calcium (CPT procedure code
75571) is excluded for patients with typical anginal chest pain
with high suspicion of CAD; patients with acute MI; and for screening
asymptomatic patients for CAD.
5.9 CT, heart, without contrast material, for evaluation
of cardiac structure and morphology (including 3D image postprocessing,
assessment of cardiac function, and evaluation of venous structures,
if performed) (CPT procedure code 75572) is excluded for patients
with typical anginal chest pain with high suspicion for CAD; patients
with acute MI; and for screening asymptomatic patients for CAD.
5.10 CT, heart, with contrast material, for evaluation
of cardiac structure and morphology in the setting of congenital
heart disease (including 3D image postprocessing, assessment of
LV cardiac function, RV structure and function and evaluation of
venous structures, if performed) (CPT procedure code 75573) is excluded
for patients with typical anginal chest pain with high suspicion
for CAD; patients with acute MI; and for screening asymptomatic
patients for CAD.
5.11 CT angiography heart, coronary arteries and
bypass (when present), with contrast material, including 3D image
postprocessing (including evaluation of cardiac structure and morphology, assessment
of cardiac function, and evaluation of venous structures, if performed)
(CPT procedure code 75574) is excluded for patients with typical
anginal chest pain with high suspicion for CAD; patients with acute
MI; and for screening asymptomatic patients for CAD.
5.12 Multislice or multidetector row CT angiography
of less than 16 slices per sec and 1mm or less resolution is excluded.
5.13 Radiological supervision and interpretation
of percutaneous vertebroplasty (CPT procedure codes 72291 and 72292).
5.14 Computer-Aided Detection with breast MRI (CPT
procedure code 0159T) is unproven.
5.15 MRS of the brain is unproven with the exception
of
paragraph 4.16.
6.0 EFFECTIVE
DATES
6.1 The effective
date for MRIs with contrast media is dependent on the U.S. Food
and Drug Administration (FDA) approval of the contrast media and
a determination by the contractor of whether the labeled or unlabeled
use of the contrast media is medically necessary and a proven indication.
6.2 March 31, 2006, for breast MRI.
6.3 March 31, 2006, for coverage of multislice
or multidetector row CT angiography.
6.4 January 1, 2007, for CPT procedure codes 72291
and 72292.
6.5 January
1, 2007, for coverage of multislice of multidetector row CT angiography
performed for presurgical evaluation prior to electrophysiological
procedure to isolate pulmonary veins for radiofrequency ablation
of arrhythmia focus.
6.6 October 1, 2008, for breast MRI for guidance
of interventional procedures such as vacuum assisted biopsy and
preoperative wire localization for lesions that are occult on mammography
or sonography and are demonstrable only with MRI.
6.7 October 3, 2006, for CMR.
6.8 December 9, 2014, for TE.
6.9 January 15, 2016, for MRS for distinguishing
low grade from high grade gliomas, evaluating a brain lesion of
indeterminate nature when MRS findings will impact the medical management
of the patient, and distinguishing recurrent brain tumor from radiation-induced
tumor necrosis.
6.10 June 22,
2017, for DBT.