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, 77066, 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
75572 - 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 76981-76983 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.
5.9 CT,
heart, with 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 is unproven.
5.15 MRS
of the brain is unproven with the exception of
paragraph 4.16.
5.16 Imaging,
including x-ray, ultrasound, CT scan, and MRI, for acute low back
pain (LBP) within six weeks of the onset of symptoms is excluded
in the absence of clinical warning signs (“red flags”) indicating
an underlying cause from patient history and/or physical exam. This
policy clarification is applicable to claims with dates of service
on or after October 30, 2020. Red flags are as follows:5.16.1 Possible
fracture, such as from a major trauma, or a more minor trauma in
older or potentially osteoporotic patients; history of osteoporosis;
chronic steroid use.
5.16.2 Possible
tumor, cancer, or infection, as evidenced by: a history of cancer;
a history of intravenous drug use; fevers, chills, or unexplained
weight loss; or immune suppression.
5.16.3 Possible
cauda equina syndrome, as evidenced by: bowel or bladder dysfunction;
or saddle anesthesia (loss of sensation in the buttocks, perineum,
and inner surfaces of the thighs).
5.16.4 Major
motor weakness.
5.16.5 Progressive
neurological symptoms.
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.