Coverage Indications, Limitations, and/or Medical Necessity

Computerized axial tomography (CAT) is a non-invasive neurodiagnostic tool that combines X-ray technology with computer capability to create a cross-sectional image. Scanning the head in successive layers by a narrow beam of X-rays enables the transmission of X-ray photons in each layer to be measured. A computer processes the accumulated X-ray photon data to construct a graphic image of a tomographic “slice”. Normal intracranial structures and a wide variety of intracranial disorders may be demonstrated.

A diagnostic examination of the head performed by computerized tomography (CT) scanners is covered by Medicare if there is effective use of the scan for a specific condition, if it is reasonable and necessary for the individual patient, and if the scanning device is FDA approved. The use of the CCT scan must be found medically appropriate considering the patient’s symptoms and preliminary diagnosis.

A. A CCT scan is considered reasonable and necessary for the patient when the diagnostic exam is medically appropriate given the patient’s symptoms and preliminary (or provisional) diagnosis.

B. CCT scans (as opposed to MRI evaluations) are used effectively in the following situations or conditions:

1. Patients who are not suitable candidates for MRI evaluation:

a) because of a pacemaker or intracranial metallic objects
b) because of extreme obesity
c) because of an inability to lie still

2. Patients whose condition requires the visualization of fine bone detail or calcification

3. Patients with the following conditions:

a) Acute CNS Hemorrhage
b) Strokes or encephalomalacia
c) New onset seizures, particularly if a focal component is present (contrast agent is appropriate for these patients)
d) Meningiomas or CNS lesions large enough to cause increased intracranial pressure (CCT scan is useful to determine gross margins between tumor and edematous brain)

C. There is no general rule that requires other diagnostic tests to be tried before CCT scanning is used. However, in individual cases it may be determined that use of a CCT scan as the initial diagnostic test was not reasonable and necessary because it was not supported by the patient’s symptoms or complaints as stated on the claim.

D. CCT imaging has not been useful in general for the evaluation of headache or dizziness and should be reserved for the patient whose presentation indicates a focal problem or who has experienced a significant change in symptomatology.

E. A CCT scan for the diagnosis of headache (ICD-10 code G44.1) can be allowed for the following:

1. After a head injury to rule out intracranial bleeding
2. Headache unusual in duration (greater than two weeks) not responding to medical therapy, to rule out the possibility of a tumor
3. A headache characterized by sudden onset and severity to rule out the possibility of an aneurysm, bleeding and/or arteriovenous malformation

F. A CCT Scan may be ordered without contrast, with contrast, or without contrast followed by contrast. Contrast administration is not without risk to the patient, and for some conditions, adds little or no benefit to the patient. The general indications for use of contrast CCT scanning (as opposed to non-contrast scanning) are to:

1. Assess perfusion (e.g. CVA)
2. Characterize a specific lesion
3. Detect defects in blood/brain barrier (e.g. infarct, tumor, infection, vasculitis)
4. Detect neovascularity (tumor), and
5. For staging of known lung cancer, breast cancer, and lymphomas likely to metastasize early to the brain

G. Intravenous contrast generally adds no information to CCT scans done secondary to head trauma (ICD-10 CM codes S02.XXA, S02.0XXB, S02.110A, S02.111A, S02.112A, S02.118A, S02.110B, S02.111B, S02.112B, S02.118B, S02.19XB, S02.2XXA, S02.2XXB, S02.69XA, S02.61XA, S02.62XA, S02.63XA, S02.64XA, S02.65XA, S02.66XA, S02.67XA, S02.69XA, S02.69XB, S02.61XB, S02.62XB, S02.63XB, S02.64XB, S02.65XB, S02.66XB, S02.67XB, S02.69XB, S02.411A, S02.412A, S02.413A, S02.411B, S02.412B, S02.413B, S2.411B, S02.412B, S02.413B, S02.3XXA, S02.3XXB, S02.42XA, S02.8XXA, S02.42XB, S02.8XXB, S06.6X0A, S06.6X1A, S06.6X2A, S06.6X3A, S06.6X4A, S06.6X5A, S06.6X6A, S06.6X7A, S06.6X8A, S06.6X0A, S06.5X0A, S06.5X1A, S06.5X2A, S06.5X3A, S06.5X4A, S06.5X5A, S06.5X6A, S06.5X7A, S06.5X8A, S06.5X0A, S06.4X0A, S06.4X1A, S06.4X2A, S06.4X3A, S06.4X4A, S06.4X5A, S06.4X6A, S06.4X7A, S06.4X8A, S06.340A, S06.350A, S06.341A, S06.342A, S06.351A, S06.352A, S06.343A, S06.344A, S06.353A, S06.354A, S06.345A, S06.355A, S06.346A, S06.347A, S06.348A, S06.356A, S06.357A, S06.358A, S06.890A, S06.1X0A, S06.2X0A, S06.810A, S06.820A, S06.890A, S06.1X1A, S06.1X2A, S06.2X1A, S06.2X2A, S06.811A, S06.812A, S06.821A, S06.822A, S06.891A, S06.892A, S06.1X3A, S06.1X4A, S06.2X3A, S06.2X4A, S06.813A, S06.814A, S06.823A, S06.824A, S06.893A, S06.894A, S06.1X5A, S06.2X5A, S06.815A, S06.825A, S06.895A, S06.1X6A, S06.1X7A, S06.1X8A, S06.2X6A, S06.2X7A, S06.2X8A, S06.816A, S06.817A, S06.818A, S06.826A, S06.827A, S06.828A, S06.896A, S06.897A, S06.898A). Additional symptoms suggesting a possible intracranial bleed may justify the use of contrast. These symptoms should be documented in the medical record, and if appropriate, included in the diagnostic codes listed on the claim.

H. More than one contrast CCT scan per episode of illness adds no information with the following exceptions:

1. CVA
2. Non-traumatic hemorrhage
3. TIA
4. Post-operative scan for residual tumor
5. Known brain tumor/metastases with a change in mental status

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.
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
085x Critical Access Hospital

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.

0250 Pharmacy – General Classification
0254 Pharmacy – Drugs Incident to Other Diagnostic Services
0255 Pharmacy – Drugs Incident to Radiology
0258 Pharmacy – IV Solutions
0351 CT Scan – Head Scan

Computerized Axial Tomography (CT) Procedures – Medicare payment policy

A/B MACs (B) do not reduce or deny payment for medically necessary multiple CT scans of different areas of the body that are performed on the same day.The TC RVUs for CT procedures that specify “with contrast” include payment for high osmolar contrast media. When separate payment is made for low osmolar contrast media under the conditions set forth in §30.1.1, reduce payment for the contrast media as setforth in §30.1.2.

Bone Mass Measurements (BMMs)

(Rev. 1416; Issued: 01-18-08; Effective: 01-01-07; Implementation: 02-20-08) Sections 1861(s)(15) and (rr)(1) of the Social Security Act (the Act) (as added by §4106 of the Balanced Budget Act (BBA) of 1997) standardize Medicare coverage of medically necessary bone mass measurements by providing for uniform coverage under Medicare Part B. This coverage is effective for claims with dates of service furnished on or after July 1, l998.

Effective for dates of service on and after January 1, 2007, the CY 2007 Physician Fee Schedule final rule expanded the number of beneficiaries qualifying for BMM by reducing the dosage requirement for glucocorticoid (steroid) therapy from 7.5 mg of prednisone per day to 5.0 mg. It also changed the definition of BMM by removing coverage for a single-photon absorptiometry as it is not considered reasonable and necessary under section 1862 (a)(1)(A) of the Act. Finally, it required that in the case of monitoring and confirmatory baseline BMMs, they be performed with a dual-energy xray absorptiometry (axial) test.

Dual-energy x-ray absorptiometry (axial) tests are covered when used to monitor FDA-approved osteoporosis drug therapy subject to the 2-year frequency standards described in chapter 15, section 80.5.5 of the Medicare Benefit Policy Manual.

o Contractors will pay claims for monitoring tests when coded as follows:

• Contains CPT procedure code 77080, and
• Contains 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0

as the ICD-9-CM diagnosis code or M81.0, M81.8, M81.6 or M94.9 as the ICD-10-CM diagnosis code.

o Contractors will deny claims for monitoring tests when coded as follows:

• Contains CPT procedure code 77078, 77079, 77081, 77083, 76977 or G0130, and

• Contains 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0 as the ICD-9-CM diagnosis code,

ICD-10 Codes that Support Medical Necessity


A06.6 Amebic brain abscess
A17.0 Tuberculous meningitis
A17.1 Meningeal tuberculoma
A17.81 Tuberculoma of brain and spinal cord
A17.82 Tuberculous meningoencephalitis
A17.83 Tuberculous neuritis
A17.89 Other tuberculosis of nervous system
A18.03 Tuberculosis of other bones
A18.51 Tuberculous episcleritis
A18.52 Tuberculous keratitis
A18.53 Tuberculous chorioretinitis
A18.54 Tuberculous iridocyclitis
A18.59 Other tuberculosis of eye
A18.6 Tuberculosis of (inner) (middle) ear
A39.0 Meningococcal meningitis
A39.1 Waterhouse-Friderichsen syndrome
A39.2 Acute meningococcemia
A39.3 Chronic meningococcemia
A39.51 Meningococcal endocarditis
A39.52 Meningococcal myocarditis
A39.53 Meningococcal pericarditis
A39.81 Meningococcal encephalitis
A39.82 Meningococcal retrobulbar neuritis
A39.83 Meningococcal arthritis
A39.84 Postmeningococcal arthritis
A39.89 Other meningococcal infections
A50.32 Late congenital syphilitic chorioretinitis
A50.39 Other late congenital syphilitic oculopathy
A50.41 Late congenital syphilitic meningitis
A50.42 Late congenital syphilitic encephalitis
A50.43 Late congenital syphilitic polyneuropathy
A50.44 Late congenital syphilitic optic nerve atrophy
A50.45 Juvenile general paresis
A50.49 Other late congenital neurosyphilis
A50.51 Clutton’s joints
A50.52 Hutchinson’s teeth
A50.53 Hutchinson’s triad
A50.54 Late congenital cardiovascular syphilis
A50.55 Late congenital syphilitic arthropathy
A50.56 Late congenital syphilitic osteochondropathy
A50.57 Syphilitic saddle nose
A50.59 Other late congenital syphilis, symptomatic
A50.6 Late congenital syphilis, latent
A52.11 Tabes dorsalis
A52.12 Other cerebrospinal syphilis
A52.13 Late syphilitic meningitis
A52.14 Late syphilitic encephalitis
A52.15 Late syphilitic neuropathy
A52.16 Charcot’s arthropathy (tabetic)
A52.17 General paresis
A52.19 Other symptomatic neurosyphilis
A52.2 Asymptomatic neurosyphilis
A81.01 Variant Creutzfeldt-Jakob disease
A81.09 Other Creutzfeldt-Jakob disease
A81.1 Subacute sclerosing panencephalitis
A81.2 Progressive multifocal leukoencephalopathy
A81.81 Kuru
A81.82 Gerstmann-Straussler-Scheinker syndrome
A81.83 Fatal familial insomnia
A81.89 Other atypical virus infections of central nervous system
A83.0 Japanese encephalitis
A83.1 Western equine encephalitis
A83.2 Eastern equine encephalitis
A83.3 St Louis encephalitis
A83.4 Australian encephalitis
A83.5 California encephalitis
A83.6 Rocio virus disease
A83.8 Other mosquito-borne viral encephalitis
A84.0 Far Eastern tick-borne encephalitis [Russian spring-summer encephalitis]
A84.1 Central European tick-borne encephalitis
A84.8 Other tick-borne viral encephalitis
A85.0 Enteroviral encephalitis
A85.1 Adenoviral encephalitis
A85.8 Other specified viral encephalitis
A87.0 Enteroviral meningitis
A87.1 Adenoviral meningitis
A87.2 Lymphocytic choriomeningitis
A87.8 Other viral meningitis
A88.8 Other specified viral infections of central nervous system
A92.31 West Nile virus infection with encephalitis
B00.4 Herpesviral encephalitis
B01.0 Varicella meningitis
B01.11 Varicella encephalitis and encephalomyelitis
B01.12 Varicella myelitis
B01.2 Varicella pneumonia
B01.81 Varicella keratitis
B01.89 Other varicella complications
B01.9 Varicella without complication
B02.0 Zoster encephalitis
B02.1 Zoster meningitis
B02.21 Postherpetic geniculate ganglionitis
B02.22 Postherpetic trigeminal neuralgia
B02.23 Postherpetic polyneuropathy
B02.24 Postherpetic myelitis
B02.29 Other postherpetic nervous system involvement
B02.31 Zoster conjunctivitis
B02.32 Zoster iridocyclitis
B02.33 Zoster keratitis
B02.34 Zoster scleritis
B02.39 Other herpes zoster eye disease