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Date Printed: May 27, 2018: 07:42 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.

04-70540-26

Original Effective Date: 05/15/18

Reviewed: 04/26/18

Revised: 00/00/00

Next Review: No Longer Scheduled for Routine Review (NLR)

Subject: Magnetic Resonance Imaging Chest (Thorax)

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 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:

Magnetic resonance imaging (MRI) of the chest and heart meets the definition of medical necessity for the following:

Indications for Chest MRI

• Evaluation of mediastinal or hilar mass of patient with renal failure or allergy to contrast material.

• Evaluation of myasthenia gravis with suspected thymoma.

• Evaluation of brachial plexus dysfunction (brachial plexopathy/thoracic outlet syndrome).

• Evaluation of an aneurysm or dissection of the thoracic aorta.

• Evaluation of congenital heart disease and malformations, (e.g., aortic arch anomalies and patent ductus arteriosus (PDA)).

• Evaluating whether masses invade into specific thoracic structures (e.g., aorta, pulmonary artery, brachial plexus, subclavian vessels, thoracic spine).

• To determine the consistency of thoracic masses (cystic vs. solid vs. mixed).

• Initial evaluation of suspicious abnormality found on an imaging study and needing clarification or found by physical examination and remains non-diagnostic after x-ray or ultrasound is completed.

• Post-surgical follow-up when medical records document medical reason requiring additional imaging.

BILLING/CODING INFORMATION:

CPT Coding:

71550

Magnetic resonance (e.g., proton) imaging, chest (e.g., for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s)

71551

Magnetic resonance (e.g., proton) imaging, chest (e.g., for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s)

71552

Magnetic resonance (e.g., proton) imaging, chest (e.g., for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequence

HCPCS Coding

S8042

Magnetic resonance imaging (MRI), low-field

REIMBURSEMENT INFORMATION:

Reimbursement for magnetic resonance imaging chest (71550, 71551, and 71552) is limited to one (1) magnetic resonance imaging chest within a 6-month period. Magnetic resonance imaging of the chest 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.

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, chest.

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:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

None applicable.

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. Conti-Fine BM, Milani M, Kaminski HJ. Myasthenia gravis: past, present, and future. Journal of Clinical Investigation 2006 Nov 1; 116(11): 2843–2854.
  2. Dillman JR, Yarram SG, D'Amico AR et al. Interrupted aortic arch: spectrum of MRI findings. American Journal of Roentgenology 2008 Jun; 190 (6): 1467-1474.
  3. Goiten O, Fuhrman CR, Lacomis JM. Incidental finding on MDCT of patent ductus arteriosus: use of CT and MRI to assess clinical importance. American Journal of Roentgenology 2005 Jun; 184 (6): 1924-193.
  4. Konen E, Merchant N, Provost Y et al. Coarctation of the aorta before and after correction: the role of cardiovascular MRI. American Journal of Roentgenology 2004 May; 182 (5): 1333-1339.
  5. Kurukumbi M, Weir R, Kalyanam J et al. Rare association of thymoma, myasthenia gravis and sarcoidosis : a case report. Journal of Medical Case Reports 2008 Jul 25; 2:245.
  6. National Imaging Associates, Inc. Clinical Guidelines Chest (Thorax) MRI, 2018.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/26/18.

GUIDELINE UPDATE INFORMATION:

05/15/18

New Medical Coverage Guideline.

Date Printed: May 27, 2018: 07:42 PM