LCD for Lumbar Spine MRI (L1326)

Contractor Information

Contractor Name 

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)

Contractor Number 

00390 

Contractor Type 

FI 

LCD Information

LCD ID Number 

L1326 

LCD Title 

Lumbar Spine MRI 

Contractor's Determination Number 

1326 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.  

CMS National Coverage Policy 

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section excludes coverage of items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

Coverage Issues Manual 50-13

Hospital Manual Section 443

Intermediary Manual 3631 

Primary Geographic Jurisdiction

New Jersey
Tennessee

Secondary Geographic Jurisdiction

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming

Oversight Region 

Region IV

Original Determination Effective Date 

For services performed on or after 12/27/1996  

Original Determination Ending Date 

Revision Effective Date 

For services performed on or after 07/27/2005  

Revision Ending Date 

Indications and Limitations of Coverage and/or Medical Necessity 

Magnetic Resonance Imagine (MRI) is used to diagnose a variety of central nervous system disorders. Unlike computed tomography (CT) scanning, MRI does not make use of ionizing radiation or require iodinated contrast material (known for causing hypersensitivity reactions and nephrotoxicity in susceptible patients) to distinguish normal from pathologic tissue. Rather, the difference in the number or protons contained within hydrogen-rich molecules in the body (water, proteins, lipids, and other macromolecules) determines recorded image qualities and makes possible the distinction of spinal cord from intra-vertebral disc, tumor form normal tissue, and flowing blood within vascular structures.

MRI is able to image in multiple planes, a distinct advantage in the diagnosis of spinal cord and vertebral column anomalies. MRI is also superior to myelography, a riskier, more uncomfortable, and less informative procedure that MRI.

Medicare will provide coverage for lumbar MRIs that are medically necessary based on specific symptoms, illnesses or injuries.

This is a covered procedure when used to aid in the diagnosis and to assist in therapeutic decision making of the following:

• Lesions in the spinal cord;
• Syringomyelia;
• Spinal cord demyelination or inflammation;
• Spinal cord infarcts;
• Spinal trauma;
• Discitis and osteomyelitis;
• Epidural abscess
• Spinal dysraphism and other developmental abnormalities of the spine;
• Spinal stenosis;
• Spinal cord compression and post-operative scarring;
• Herniation of disc;
• Where soft tissue contrast is necessary’
• When bone artifacts limit CT, or coronal, coronosagittal or parasagittal images are desired, and/or;

For procedures in which iodinated contrast material are contraindicated.

Coverage Topic 

Diagnostic Tests and X-Rays

Coding Information

Bill Type Codes: 

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12x	Hospital-inpatient or home health visits (Part B only)
13x	Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)
14x	Non-Patient Laboratory Specimens
15x	Hospital-intermediate care - level I
16x	Hospital-intermediate care - level II
17x	Hospital-intermediate care - level III
18x	Hospital-swing beds
19x	Hospital-reserved for national assignment
21x	SNF-inpatient, Part A
22x	SNF-inpatient or home health visits (Part B only)
23x	SNF-outpatient (HHA-A also)
24x	SNF-other (Part B)
25x	SNF-intermediate care - level I
26x	SNF-intermediate care - level II
27x	SNF-intermediate care - level III
28x	SNF-swing beds
29x	SNF-reserved for national assignment
31x	HHA-inpatient (including Part A)
32x	HHA-inpatient or home health visits (Part B only)
33x	HHA-outpatient (HHA-A also)
34x	HHA-other (Part B)
35x	HHA-intermediate care - level I
36x	HHA-intermediate care - level II
37x	HHA-intermediate care - level III
38x	HHA-swing beds
39x	HHA-reserved for national assignment
41x	Religious Nonmedical Health Care Institution (RNHCI) hospital-inpatient (including Part A) (all references to Christian Science (CS) is obsolete eff. 8/00 and replaced with RNHCI)
42x	RNHCI hospital-inpatient or home health visits (Part B only)
43x	RNHCI hospital-outpatient (HHA-A also)
44x	RNHCI hospital-other (Part B)
45x	RNHCI hospital-intermediate care - level I
46x	RNHCI hospital-intermediate care - level II
47x	RNHCI hospital-intermediate care - level III
48x	RNHCI hospital-swing beds
49x	RNHCI hospital-reserved for national assignment
51x	CS extended care-inpatient (including Part A) OBSOLETE eff. 7/00 - implementation of Religious Nonmedical Health Care Institutions (RNHCI)
52x	RNHCI extended care-inpatient or home health visits (Part B only) (eff. 7/00); prior to 7/00 Christian Science (CS)
53x	RNHCI extended care-outpatient (HHA-A also) (eff. 7/00); prior to 7/00 referenced CS
54x	RNHCI extended care-other (Part B)(eff. 7/00); prior to 7/00 referenced CS
55x	RNHCI extended care-intermediate care - level I (eff. 7/00) prior to 7/00 referenced CS
56x	RNHCI extended care-intermediate care - level II (eff. 7/00) prior to 7/00 referenced CS
57x	RNHCI extended care-intermediate care - level III (eff. 7/00) prior to 7/00 referenced CS
58x	RNHCI extended care-swing beds (eff. 7/00) prior to 7/00 referenced CS
59x	RNHCI extended care-reserved for national assignment (eff. 7/00); prior to 7/00 referenced CS
61x	Intermediate care-inpatient (including Part A)
62x	Intermediate care-inpatient or home health visits (Part B only)
63x	Intermediate care-outpatient (HHA-A also)
64x	Intermediate care-other (Part B)
65x	Intermediate care-intermediate care - level I
66x	Intermediate care-intermediate care - level II
67x	Intermediate care-intermediate care - level III
68x	Intermediate care-swing beds
69x	Intermediate care-reserved for national assignment
71x	Clinic-rural health

Revenue Codes: 

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

032X	Radiology diagnostic-general classification
033X	Radiology therapeutic-general classification
034X	Nuclear medicine-general classification
035X	Computed tomographic (CT) scan-general classification
040X	Other imaging services-general classification
061X	Magnetic resonance technology (MRT)-general classification

CPT/HCPCS Codes 

72148	MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL
72149	MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITH CONTRAST MATERIAL(S)
72158	MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR

ICD-9 Codes that Support Medical Necessity 

The following ICD-9 codes are allowed to establish a diagnosis or monitor:

015.00 - 015.06	TUBERCULOSIS OF VERTEBRAL COLUMN UNSPECIFIED EXAMINATION - TUBERCULOSIS OF VERTEBRAL COLUMN TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
170.2	MALIGNANT NEOPLASM OF VERTEBRAL COLUMN EXCLUDING SACRUM AND COCCYX
170.6	MALIGNANT NEOPLASM OF PELVIC BONES SACRUM AND COCCYX
195.8	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES
198.3	SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD
198.4	SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM
198.5	SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW
198.89	SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES
200.00 - 208.91	RETICULOSARCOMA UNSPECIFIED SITE - UNSPECIFIED LEUKEMIA IN REMISSION
213.2	BENIGN NEOPLASM OF VERTEBRAL COLUMN EXCLUDING SACRUM AND COCCYX
213.6	BENIGN NEOPLASM OF PELVIC BONES SACRUM AND COCCYX
215.7	OTHER BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF TRUNK UNSPECIFIED
225.3 - 225.4	BENIGN NEOPLASM OF SPINAL CORD - BENIGN NEOPLASM OF SPINAL MENINGES
228.00 - 228.1	HEMANGIOMA OF UNSPECIFIED SITE - LYMPHANGIOMA ANY SITE
229.0 - 229.9	BENIGN NEOPLASM OF LYMPH NODES - BENIGN NEOPLASM OF UNSPECIFIED SITE
238.0 - 238.2	NEOPLASM OF UNCERTAIN BEHAVIOR OF BONE AND ARTICULAR CARTILAGE - NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN
239.8	NEOPLASM OF UNSPECIFIED NATURE OF OTHER SPECIFIED SITES
320.0 - 320.9	HEMOPHILUS MENINGITIS - MENINGITIS DUE TO UNSPECIFIED BACTERIUM
321.0 - 321.8	CRYPTOCOCCAL MENINGITIS - MENINGITIS DUE TO OTHER NONBACTERIAL ORGANISMS CLASSIFIED ELSEWHERE
322.0 - 322.9	NONPYOGENIC MENINGITIS - MENINGITIS UNSPECIFIED
324.1	INTRASPINAL ABSCESS
324.9	INTRACRANIAL AND INTRASPINAL ABSCESS OF UNSPECIFIED SITE
335.0 - 335.9	WERDNIG-HOFFMANN DISEASE - ANTERIOR HORN CELL DISEASE UNSPECIFIED
336.0 - 336.9	SYRINGOMYELIA AND SYRINGOBULBIA - UNSPECIFIED DISEASE OF SPINAL CORD
337.0 - 337.9	IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY - UNSPECIFIED DISORDER OF AUTONOMIC NERVOUS SYSTEM
340	MULTIPLE SCLEROSIS
341.0 - 341.9	NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED
344.00 - 344.9	QUADRIPLEGIA UNSPECIFIED - PARALYSIS UNSPECIFIED
353.0 - 353.4	BRACHIAL PLEXUS LESIONS - LUMBOSACRAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED
353.8	OTHER NERVE ROOT AND PLEXUS DISORDERS
353.9	UNSPECIFIED NERVE ROOT AND PLEXUS DISORDER
357.0	ACUTE INFECTIVE POLYNEURITIS
715.18	OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING OTHER SPECIFIED SITES
715.28	OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING OTHER SPECIFIED SITES
715.38	OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING OTHER SPECIFIED SITES
720.0 - 720.9	ANKYLOSING SPONDYLITIS - UNSPECIFIED INFLAMMATORY SPONDYLOPATHY
721.1 - 721.91	CERVICAL SPONDYLOSIS WITH MYELOPATHY - SPONDYLOSIS OF UNSPECIFIED SITE WITH MYELOPATHY
722.10 - 722.93	DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY - OTHER AND UNSPECIFIED DISC DISORDER OF LUMBAR REGION
723.0 - 723.4	SPINAL STENOSIS IN CERVICAL REGION - BRACHIAL NEURITIS OR RADICULITIS NOS
723.9	UNSPECIFIED MUSCULOSKELETAL DISORDERS AND SYMPTOMS REFERABLE TO NECK
724.00 - 724.9	SPINAL STENOSIS OF UNSPECIFIED REGION - OTHER UNSPECIFIED BACK DISORDERS
730.08	ACUTE OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES
730.18	CHRONIC OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES
730.28	UNSPECIFIED OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES
730.98	UNSPECIFIED INFECTION OF BONE OF OTHER SPECIFIED SITES
732.0	JUVENILE OSTEOCHONDROSIS OF SPINE
732.7	OSTEOCHONDRITIS DISSECANS
732.8	OTHER SPECIFIED FORMS OF OSTEOCHONDROPATHY
732.9	UNSPECIFIED OSTEOCHONDROPATHY
733.00 - 733.09	OSTEOPOROSIS UNSPECIFIED - OTHER OSTEOPOROSIS
733.10 - 733.19	PATHOLOGICAL FRACTURE UNSPECIFIED SITE - PATHOLOGICAL FRACTURE OF OTHER SPECIFIED SITE
733.20 - 733.29	CYST OF BONE (LOCALIZED) UNSPECIFIED - OTHER BONE CYST
733.40	ASEPTIC NECROSIS OF BONE SITE UNSPECIFIED
737.0 - 737.9	ADOLESCENT POSTURAL KYPHOSIS - UNSPECIFIED CURVATURE OF SPINE ASSOCIATED WITH OTHER CONDITIONS
738.4	ACQUIRED SPONDYLOLISTHESIS
738.5	OTHER ACQUIRED DEFORMITY OF BACK OR SPINE
738.8 - 738.9	ACQUIRED MUSCULOSKELETAL DEFORMITY OF OTHER SPECIFIED SITE - ACQUIRED MUSCULOSKELETAL DEFORMITY OF UNSPECIFIED SITE
739.1 - 739.4	NONALLOPATHIC LESIONS OF CERVICAL REGION NOT ELSEWHERE CLASSIFIED - NONALLOPATHIC LESIONS OF SACRAL REGION NOT ELSEWHERE CLASSIFIED
741.00 - 741.93	SPINA BIFIDA UNSPECIFIED REGION WITH HYDROCEPHALUS - SPINA BIFIDA LUMBAR REGION WITHOUT HYDROCEPHALUS
742.51 - 742.59	DIASTEMATOMYELIA - OTHER SPECIFIED CONGENITAL ANOMALIES OF SPINAL CORD
742.8	OTHER SPECIFIED CONGENITAL ANOMALIES OF NERVOUS SYSTEM
742.9	UNSPECIFIED CONGENITAL ANOMALY OF BRAIN SPINAL CORD AND NERVOUS SYSTEM
756.10 - 756.19	CONGENITAL ANOMALY OF SPINE UNSPECIFIED - OTHER CONGENITAL ANOMALIES OF SPINE
781.0 - 781.8	ABNORMAL INVOLUNTARY MOVEMENTS - NEUROLOGICAL NEGLECT SYNDROME
792.0	NONSPECIFIC ABNORMAL FINDINGS IN CEREBROSPINAL FLUID
793.91	IMAGE TEST INCONCLUSIVE DUE TO EXCESS BODY FAT
793.99	OTHER NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATIONS OF BODY STRUCTURE
794.10	NONSPECIFIC ABNORMAL RESPONSE TO UNSPECIFIED NERVE STIMULATION
794.17	NONSPECIFIC ABNORMAL ELECTROMYOGRAM (EMG)
796.1	ABNORMAL REFLEX
805.00 - 805.9	CLOSED FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL - OPEN FRACTURE OF UNSPECIFIED PART OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY
806.00 - 806.9	CLOSED FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY
839.00 - 839.59	CLOSED DISLOCATION CERVICAL VERTEBRA UNSPECIFIED - OPEN DISLOCATION OTHER