Print

Date Printed: June 26, 2017: 11:35 AM

Private Property of Blue Cross and Blue Shield of Florida.
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.

04-70540-14

Original Effective Date: 07/01/07

Reviewed: 04/28/16

Revised: 06/15/17

Subject: Magnetic Resonance Imaging (MRI) Abdomen and Pelvis

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 Update    
           

DESCRIPTION:

Magnetic resonance imaging (MRI) is a radiation-free, noninvasive, technique used to produce high quality sectional images of the inside of the body in multiple planes. MRI uses natural magnetic properties of the hydrogen atoms in the body that emit radiofrequency signals when exposed to radio waves within a strong magnetic field. These signals are processed and converted by a computer into high-resolution, three-dimensional, tomographic images. Images and resolution produced by MRI is quite detailed. For some MRI, contrast materials (e.g., gadolinium, gadoteridol, non-ionic and low osmolar contrast media, ionic and high osmolar contrast media) are used to enable visualization of a body system or body structure.

The U.S. Food and Drug Administration’s (FDA) cleared MRI systems for marketing through the 510(k) process. The Fonar Stand-Up MRI system received FDA marketing clearance in October 2000.

POSITION STATEMENT:

MRI of the pelvis and abdomen meets the definition of medical necessity for the following:

INDICATIONS FOR PELVIC MRI:

Evaluation of suspicious/known mass/tumors (unconfirmed diagnosis of cancer) for further evaluation of indeterminate or questionable findings:

Evaluation of known cancer for further evaluation of indeterminate or questionable findings identified by physical examination or imaging exams such as ultrasound (US) and computed tomography (CT):

For evaluation of suspected infection or inflammatory disease:

• Suspected acute appendicitis (or severe acute diverticulitis) if pelvic pain and tenderness to palpation is present, with AT LEAST ONE of the following:

For evaluation of known infection or inflammatory disease follow up:

For known or suspected prostate cancer for recurrence workup:

Indications for Musculoskeletal Pelvic MRI:

Pre-operative evaluation:

For post-operative/procedural evaluation:

Other Indications for a Pelvic MRI:

Indications for combination studies for the initial pre-therapy staging of cancer, OR ongoing tumor/cancer surveillance OR evaluation of suspected metastases:

≤ 5 concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: Neck, Abdomen, Pelvis, Chest, Brain, Cervical Spine, Thoracic Spine or Lumbar Spine

INDICATIONS FOR ABDOMINAL MRI:

Evaluation of suspicious known mass/tumors (unconfirmed diagnosis of cancer) for further evaluation of indeterminate or questionable findings:

Evaluation of known cancer for further evaluation of indeterminate or questionable findings identified by physical examination or imaging exams such as ultrasound (US) and computed tomography (CT):

For evaluation of suspected infection or inflammatory disease:

For evaluation of known infection or inflammatory disease follow up:

Pre-operative evaluation:

Post-operative/procedural evaluation:

Other Indications for an Abdominal MRI:

Indication for combination studies for the initial pre-therapy staging of cancer, OR ongoing tumor/cancer surveillance OR evaluation of suspected metastases:

≤ 5 concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: Neck, Abdomen, Pelvis, Chest, Brain, Cervical Spine, Thoracic Spine or Lumbar Spine

Fetal MRI:

Fetal MRI meets the definition of medical necessity for the evaluation of known or suspected abnormality of the fetus.

Note: Safety guidelines and possible contraindications:

There are no documented fetal indications for the use of MRI contrast, but there may be rare instances where contrast is considered potentially helpful in assessing maternal anatomy or pathology.

The decision to administer contrast must be made on a case-by-case basis by the covering level 2 MR personnel-designated attending radiologist who will assess the risk-benefit ratio for that particular patient. The decision to administer a gadolinium-based MR contrast agent to pregnant members should be accompanied by a well-documented and thoughtful risk-benefit analysis.

BILLING/CODING INFORMATION:

CPT Coding

72195

Magnetic resonance (e.g., proton) imaging, pelvis; without contrast material(s)

72196

Magnetic resonance (e.g., proton) imaging, pelvis; with contrast material(s)

72197

Magnetic resonance (e.g., proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences

74181

Magnetic resonance (e.g., proton) imaging, abdomen; without contrast material(s)

74182

Magnetic resonance (e.g., proton) imaging, abdomen; with contrast material(s)

74183

Magnetic resonance (e.g., proton) imaging, abdomen; without contrast material(s), followed by contrast material(s) and further sequences

74712

Magnetic resonance (e.g., proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation

74713

Magnetic resonance (e.g., proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary procedure)

HCPCS Coding

S8042

Magnetic resonance imaging (MRI), low-field

REIMBURSEMENT INFORMATION:

Reimbursement for MRI imaging (72195-72197, 74181-74183) performed on the same anatomical area is limited to one (1) MRI imaging within a 6-month period. MRI imaging (72195-72197, 74181-74183) in excess of one (1) within a 6-month period is subject to medical review for medical necessity. Documentation should include radiology reason for study, radiology comparison study-date and time, radiology comparison study observation, radiology impression, and radiology study recommendation.

Additional MRI imaging of the same anatomical area may be appropriate for the following, including, but not limited to: diagnosis, staging or follow-up of cancer, follow-up assessment during or after therapy for known metastases, follow-up of member who have had an operative, interventional or therapeutic procedure (e.g., surgery, embolization), reevaluation due to change in clinical status (e.g., deterioration), new or worsening clinical findings, (e.g., neurologic signs, symptoms), medical intervention which warrants reassessment, reevaluation for treatment planning, follow-up during and after completion of therapy or treatment to assess effectiveness, and evaluation after intervention or surgery.

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

Reimbursement for MRI imaging (72195-72197, 74181-74183) for an oncologic condition undergoing active treatment or active treatment completed within the previous 12 months on the same anatomical area is limited to four (4) MRI imaging (72195-72197, 74181-74183) within a 12-month period. MRI imaging (72195-72197, 74181-74183) for an oncologic condition in excess of four (4) within a 12-month period are subject to medical review of documentation to support medical necessity. Documentation should include radiology reason for study, radiology comparison study-date and time, radiology comparison study observation, radiology impression, and radiology study recommendation.

Open MRI Units (Stand-Up MRI/Sitting MRI-Positional MRI)

Open MRI units of any configuration, including MRI units that allow imaging when standing (Stand-up MRI) or when sitting (Sitting MRI), are considered to be an acceptable standard alternative to standard “closed” MRI units. Stand-up MRI and sitting MRI may be reported like a standard MRI. No additional payment will be made for stand-up MRI or sitting MRI.

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 imaging (MRI) abdomen and pelvis.

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 member's contract benefits.

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

Medicare Advantage:

No Local Coverage Determination (LCD) was found at the time of the last guideline reviewed date.

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Magnetic Resonance Imaging, (220.2) located at cms.gov.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Magnetic Resonance Spectroscopy (MRS), 04-70540-07
Magnetic Resonance Imaging (MRI) of the Breast, 04-70540-09

Magnetic Resonance Imaging (MRI) Brain and Head, 04-70540-11

Magnetic Resonance Imaging (MRI) Orbit, Face, Temporomandibular Joint (TMJ) and Neck, 04-70540-12

Magnetic Resonance Imaging (MRI) Chest & Cardiac, 04-70540-13

Magnetic Resonance Imaging (MRI) Upper Extremity, 04-70540-15

Magnetic Resonance Imaging (MRI) Lower Extremity, 04-70540-16

Magnetic Resonance Imaging (MRI) Spine (Cervical, Thoracic, Lumbar), 04-70540-17

OTHER:

Other names used to report MRI:

Nuclear Magnetic Resonance (NMR)
Open MRI

Other names used to report Positional MRI:

Position MRI (pMRI)
Sitting MRI
Stand-Up MRI
Standing MRI
Weight-bearing MRI

REFERENCES:

  1. ACR Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the Abdomen (Excluding the Liver), 2015.
  2. ACR Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the Liver, 2015.
  3. ACR Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the Soft-Tissue Components of the Pelvis, 2015.
  4. Blue Cross Blue Association Positional Magnetic Resonance Imaging (MRI) 6.01.18, 09/15.
  5. Centers for Medicare & Medicaid Service NCD for Magnetic Resonance Imaging (220.2), 06/03/10.
  6. National Imaging Associates, Inc. Fetal MRI Clinical Guidelines, 05/16.
  7. National Imaging Associates, Inc. MRI Abdomen Clinical Guidelines, 2016.
  8. National Imaging Associates, Inc. MRI Pelvis Clinical Guidelines, 2016.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/28/16.

GUIDELINE UPDATE INFORMATION:

07/01/07

New Medical Coverage Guideline.

01/21/08

Updated the Program Exceptions.

07/15/08

Scheduled review. No change in position statement. Updated references and related Internet links.

05/21/09

Removed Federal Employee Plan (FEP) from BCBSF Radiology Management program exception statement. Added FEP program exception statement: FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

07/01/09

Updated BCBSF Radiology Management program exception; added BlueSelect.

01/01/10

Revised BCBSF Radiology Management program exception section.

07/15/10

Annual review: format changes, added indications for bone marrow MRI, and updated references.

10/01/11

Revision; formatting changes.

12/15/12

Annual review; added indications for: pelvic and abdominal MRI. Added criteria for imaging which exceed limit and statement for re-imaging or additional imaging. Added Medicare Advantage program exception (nationally non-covered indications) for MRI of cortical bone and calcifications and procedures involving spatial resolution of bone and calcifications. Updated references.

01/01/14

Review. Revised pelvic indications (infection or inflammatory disease and vascular disease) and abdominal indications (cancer evaluation, infection or inflammatory disease, vascular disease, pre-operative evaluation and post-operative/procedural evaluation). Updated program exception.

01/01/15

Review. Added indications for pelvic: musculoskeletal pelvic MRI, congenital anomaly, and bicornuate uterus. Deleted spinal bifida. Added indications for abdomen: evaluation of suspected or known vascular disease, pre-operative evaluation, and post-operative/procedural evaluation. Added limitation statement for an oncologic condition; limited to four (4) computed tomography within a 12-month period. Updated references.

01/01/16

Annual HCPCS code update. Added 74712 and 74713.

01/11/16

Updated reimbursement information section; removed 74712 and 74713.

05/15/16

Revisions; Pelvic/Abdominal: deleted for evaluation of known or suspected vascular disease. Pelvic: added prostatic cancer (and criteria). Pelvic: deleted for evaluation of known or suspected aseptic/avascular necrosis of hip(s). Pelvic/Abdominal: added indications for combination studies for the initial pre-therapy staging of cancer, or ongoing tumor/cancer surveillance, or evaluation of suspected metastases. Abdominal: cancer surveillance, added “after known cancer”. Abdominal: suspected cholecystitis, added “retained gallstones”. Added indication for fetal MRI. Updated references.

06/15/17

Deleted duplicate codes; 74182 and 74183.

Date Printed: June 26, 2017: 11:35 AM