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.