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Date Printed: December 17, 2017: 04:22 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

04-70540-23

Original Effective Date: 12/15/13

Reviewed: 03/26/15

Revised: 04/15/15

Subject: Magnetic Resonance Angiography (MRA) Spinal Canal

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    

DESCRIPTION:

Magnetic resonance angiography (MRA) is a noninvasive imaging technology. Application of spinal magnetic resonance angiography (MRA) allows for more effective and noninvasive screening for vascular lesions than magnetic resonance imaging (MRI) alone. It may improve characterization of normal and abnormal intradural vessels while maintaining good spatial resolution. Spinal MRA is used for the evaluation of spinal arteriovenous malformations, cervical spine fractures and vertebral artery injuries. A contrast agent (gadolinium) may be used with MRA for better visualization and may be used in individuals who have a history of contrast allergy and who are at high risk of kidney failure.

POSITION STATEMENT:

Documentation Requirements

Documentation containing the medical necessity of the magnetic resonance angiography (MRA) of the spinal canal and imaging results (e.g., images, clinical reports) should be maintained in the member’s medical record. Documentation may be requested as part of the review process.

Magnetic resonance angiography (MRA) of the spinal canal meets the definition of medical necessity for the following:

BILLING/CODING INFORMATION:

CPT Coding:

72159

Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

Re-imaging or additional imaging due to poor contrast enhanced exam or technically limited exam is the responsibility of the imaging provider.

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment and reason for magnetic resonance angiography (MRA) of the spinal canal.

Documentation Table

LOINC Codes

LOINC

Time Frame

Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology reason for study

18785-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology comparison study-date and time

18779-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology comparison study observation

18834-2

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology-study observation

18782-3

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology-impression

19005-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology study-recommendation (narrative)

18783-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

PROGRAM EXCEPTIONS:

Coverage for the radiology services referenced in this guideline performed and billed in an outpatient or office location will be handled through the BCBSF Radiology Management program for select products. The National Imaging Associates (NIA) will determine coverage for these services for select products. Refer to the member’s contract benefits.

Federal Employee Plan (FEP): FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

Medicare Advantage products

The following Local Coverage Determination (LCD) was reviewed: Magnetic Resonance Angiography (MRA), (L29218 and L34372) located at fcso.com.

The following National Coverage Determination (NCD) was reviewed: Magnetic Resonance Angiography, (220.3) and Magnetic Resonance Imaging (MRI), (220.2) located at cms.gov.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Magnetic Resonance Angiography (MRA) Brain (Head), 04-70540-18
Magnetic Resonance Angiography (MRA) Neck, 04-70540-19

Magnetic Resonance Angiography (MRA) Chest, 04-70540-20

Magnetic Resonance Angiography (MRA) Abdomen and Pelvis, 04-70540-21

Magnetic Resonance Angiography (MRA) Extremity (Upper and Lower), 04-70540-22

OTHER:

None applicable.

REFERENCES:

  1. American College of Radiology ACR Appropriateness Criteria®: Suspected Spine Trauma, 2012.
  2. ACR-NASCI-SPR Practice Guideline for the Performance of Body Magnetic Resonance Angiography (MRA), 2014.
  3. National Imaging Associates, Inc.MR Angiography Spinal Canal, 2015.
  4. National Institute of Neurological Disorders and Stroke (NINDS) Arteriovenous Malformations and Other Vascular Lesions of the Central Nervous System Fact Sheet, NIH Publication No. 11-485, 02/11 (updated 02/13).
  5. Rohany M, Shaibani A, Arafat O, et al. Spinal arteriovenous malformations associated with Klippel-Trenaunay-Weber syndrome: A literature search and report of two cases. American Journal of Neuroradiology 2007; (3):28, 584-589.
  6. Saraf-Lavi E, Bowen BC, Quencer RM, et al. Detection of spinal dural arteriovenous fistulae with MR imaging and contrast-enhanced MR angiography: sensitivity, specificity, and prediction of vertebral level. American Journal of Neuroradiology 2002; 23(5); 858-867.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/26/15.

GUIDELINE UPDATE INFORMATION:

12/15/13

New Medical Coverage Guideline.

04/15/15

Annual review. No change to position statement. Revised description and updated references.

Date Printed: December 17, 2017: 04:22 PM