Local Coverage Determination (LCD):

Magnetic Resonance Imaging of the Orbit, Face, and/or Neck

(L34425)
Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website.

Contractor Information
CONTRACTOR NAME CONTRACT TYPE CONTRACT NUMBER JURISDICTION STATE(S)

Palmetto GBA A and B MAC 10111 - MAC A J-J Alabama

Palmetto GBA A and B MAC 10211 - MAC A J-J Georgia

Palmetto GBA A and B MAC 10311 - MAC A J-J Tennessee

Palmetto GBA A and B and HHH MAC 11201 - MAC A J-M South Carolina

Palmetto GBA A and B and HHH MAC 11301 - MAC A J-M Virginia

Palmetto GBA A and B and HHH MAC 11401 - MAC A J-M West Virginia

Palmetto GBA A and B and HHH MAC 11501 - MAC A J-M North Carolina

LCD Information
Document Information
LCD ID Original Effective Date
L34425 For services performed on or after 10/01/2015

Original ICD-9 LCD ID Revision Effective Date

L31605 For services performed on or after 07/25/2019

LCD Title Revision Ending Date

Magnetic Resonance Imaging of the Orbit, Face, and/or N/A
Neck
Retirement Date
Proposed LCD in Comment Period N/A
N/A
Notice Period Start Date
Source Proposed LCD N/A
N/A
Notice Period End Date
AMA CPT / ADA CDT / AHA NUBC Copyright N/A
Statement
CPT codes, descriptions and other data only are
copyright 2018 American Medical Association. All Rights
Reserved. Applicable FARS/HHSARS apply.

Created on 08/01/2019. Page 1 of 10

 Current Dental Terminology © 2018 American Dental
Association. All rights reserved.

Copyright © 2019, the American Hospital Association,

Chicago, Illinois. Reproduced with permission. No
portion of the AHA copyrighted materials contained
within this publication may be copied without the
express written consent of the AHA. AHA copyrighted
materials including the UB-04 codes and descriptions
may not be removed, copied, or utilized within any
software, product, service, solution or derivative work
without the written consent of the AHA. If an entity
wishes to utilize any AHA materials, please contact the
AHA at 312-893-6816. Making copies or utilizing the
content of the UB-04 Manual, including the codes and/or
descriptions, for internal purposes, resale and/or to be
used in any product or publication; creating any
modified or derivative work of the UB-04 Manual and/or
codes and descriptions; and/or making any commercial
use of UB-04 Manual or any portion thereof, including
the codes and/or descriptions, is only authorized with an
express license from the American Hospital Association.
To license the electronic data file of UB-04 Data
Specifications, contact Tim Carlson at (312) 893-6816
or Laryssa Marshall at (312) 893-6814. You may also
contact us at ub04@healthforum.com.

CMS National Coverage Policy

Title XVIII of the Social Security Act 1833(e) prohibits Medicare payment for any claim which lacks the necessary
information to process the claim.

Title XVIII of the Social Security Act §1862(a)(1)(A) allows coverage and payment for only those services that are
considered to be 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 §1833(a)(2)(E) related to outpatient hospital radiology services.

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4,
§220.2

CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 13, §40

Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity

Created on 08/01/2019. Page 2 of 10

Magnetic Resonance Imaging (MRI) is a noninvasive diagnostic imaging modality used to diagnose a variety of
central nervous system (CNS) disorders. MRI provides superior tissue contrast when compared to a Computerized
Tomography (CT) scan, is able to image in multiple planes, is not affected by bone artifact, provides vascular
imaging capability, and makes use of safer contrast media (gadolinium chelate agents). Its major disadvantage over
a CT scan is the longer scanning time required for study, making it less useful for emergency evaluations.
Contraindications include patients with implanted neurostimulators or cochlear implants. Potential contraindications
may include patients with cardiac pacemakers (refer to the CMS Internet-Only Manual, Pub 100-03, Medicare
National Coverage Determinations Manual, Chapter 1, Part 4, §220.2), metal fragments in the eye, magnetic ocular
implants or patients with older ferromagnetic intracranial aneurysm clips. All of these objects may be potentially
displaced when exposed to the powerful magnetic fields used in MRI.

MRI of the orbit, face, and/or neck may be considered medically reasonable and necessary when used to diagnose
and characterize pathology of the eye, nasopharynx, oropharynx, and neck including tumors, infection, soft tissue
pathologies, and congenital abnormalities. In cases involving trauma to the orbit, face and/or neck, a CT scan is
frequently superior to MRI for assessing injury.

MRI is considered investigational when medical records document the service was performed only for one of the
following:

• measurement of blood flow and spectroscopy,

• imaging of cortical bone and calcifications, and
• procedures involving spatial resolution of bone or calcifications.

In some instances, ordering a MRI of the brain in addition to a MRI of the orbit, face, and/or neck may be medically
necessary on the same day. The medical record should document the medical necessity for these two procedures
being performed on the same day.

Initial imaging of the thyroid should be done with ultrasound or nuclear medicine, unless there is a known carcinoma
present.

Summary of Evidence

N/A

Analysis of Evidence
(Rationale for Determination)

N/A

Coding Information
Bill Type Codes:

Created on 08/01/2019. Page 3 of 10

 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.

N/A

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.

N/A

CPT/HCPCS Codes

Group 1 Paragraph:

N/A

Group 1 Codes:

CODE DESCRIPTION

XX000 Not Applicable

ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph:

N/A

Group 1 Codes:

ICD-10 CODE DESCRIPTION

XX000 Not Applicable

ICD-10 Codes that DO NOT Support Medical Necessity

N/A

Additional ICD-10 Information

N/A

General Information
Created on 08/01/2019. Page 4 of 10
Associated Information

Documentation Requirements

Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and
must be made available to the A/B MAC upon request.

Utilization Guildelines

In general, it is not medically necessary to perform myelography, CT examinations, and MRI examinations for
evaluation of the same condition on the same day. The medical record should document the necessity for evaluations
in addition to a MRI.

It is expected that these services would be performed as indicated by current medical literature and/or standards of
practice. When services are performed in excess of established parameters, they may be subject to review for
medical necessity.

Sources of Information

Bibliography

Ahmad A, Branstetter BF. CT versus MR: Still a Tough Decision. Otolaryngol Clin North Amer. 2008;41(1):1-22.

American College of Radiology. ACR Practice Parameter for Performing and Interpreting Magnetic Resonance
Imaging (MRI). Published 2011. Revised 2017. Accessed on August 7, 2018.

Cummings CW, Flint PW, Harker LA, et al. Diagnostic and Interventional Neuroradiology. Cummings Otolaryngology:
Head & Neck Surgery. 4th ed, Vol. 4. Philadelphia, Pa: Mosby; 2005:3675-3697.

Cummings CW, Flint PW, Harker LA, et al. Overview of Diagnostic Imaging of the Head and Neck. Cummings
Otolaryngology: Head & Neck Surgery. 4th ed, Vol. 1. Philadelphia, Pa: Mosby; 2005:25-92.

Revision History Information

REVISION REVISION REVISION HISTORY EXPLANATION REASON(S) FOR CHANGE
HISTORY HISTORY
DATE NUMBER

07/25/2019 R11
All coding located in the Coding Information section has been • Provider
moved into the related Billing and Coding: Magnetic Resonance Education/Guidance
Imaging of the Orbit, Face, and/or Neck A56729 article and
removed from the LCD.

Created on 08/01/2019. Page 5 of 10

REVISION REVISION REVISION HISTORY EXPLANATION REASON(S) FOR CHANGE
HISTORY HISTORY
DATE NUMBER

At this time 21st Century Cures Act will apply to new and
revised LCDs that restrict coverage which requires comment
and notice. This revision is not a restriction to the coverage
determination; and, therefore not all the fields included on the
LCD are applicable as noted in this policy.

10/01/2018 R10
Under ICD-10 Codes that Support Medical Necessity: • Revisions Due To
Group 1 added ICD-10 codes C43.111, C43.112, C43.121, ICD-10-CM Code
C43.122, C44.1021, C44.1022, C44.1091, C44.1092, Changes
C44.1121, C44.1122, C44.1191, C44.1192, C44.1221,
C44.1222, C44.1291, C44.1292, C44.1321, C44.1322,
C44.1391, C44.1392, C44.1921, C44.1922, C44.1991,
C44.1992, C4A.111, C4A.112, C4A.121, C4A.122, D03.111,
D03.112, D03.121, D03.122, D04.111, D04.112, D04.121,
D04.122, D23.111, D23.112, D23.121, D23.122, H02.23A,
H02.23B and H02.23C. Under ICD-10 Codes that Support
Medical Necessity: Group 1 deleted ICD-10 codes C43.11,
C43.12, C44.102, C44.109, C44.112, C44.119, C44.122,
C44.129, C44.192, C44.199, D03.11, D03.12 and H57.8. This
revision is due to the 2018 Annual ICD-10 Code Update and is
effective on October 1, 2018.

At this time 21st Century Cures Act will apply to new and
revised LCDs that restrict coverage which requires comment
and notice. This revision is not a restriction to the coverage
determination; and, therefore not all the fields included on the
LCD are applicable as noted in this policy.

08/16/2018 R9
Under CMS National Coverage Policy added (a)(2) in front • Provider
of (E) in the third policy. Under Coverage Indications, Education/Guidance
Limitations and/or Medical Necessity added the acronym
(CNS) after the verbiage “central nervous system” in the
first paragraph. The verbiage “Orbit, Face and/or Neck”
was changed to lower case letters in the beginning of the
second paragraph. The verbiage “Magnetic Resonance
Imaging” was replaced with the acronym MRI in the third
paragraph. Under Bibliography deleted the verbiage “ACR:
Quality is our image” and changed the access date to
8/7/2018 in the second reference. Formatting was
corrected throughout the policy.

At this time 21st Century Cures Act will apply to new and
revised LCDs that restrict coverage which requires
comment and notice. This revision is not a restriction to

Created on 08/01/2019. Page 6 of 10

REVISION REVISION REVISION HISTORY EXPLANATION REASON(S) FOR CHANGE
HISTORY HISTORY
DATE NUMBER

the coverage determination; and, therefore not all the

fields included on the LCD are applicable as noted in this
policy.

01/29/2018 R8 The Jurisdiction "J" Part A Contracts for Alabama (10111),

• Change in Affiliated
Georgia (10211) and Tennessee (10311) are now being
Contract Numbers
serviced by Palmetto GBA. The notice period for this LCD begins
on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these
three contract numbers are being added to this LCD. No
coverage, coding or other substantive changes (beyond the
addition of the 3 Part A contract numbers) have been
completed in this revision.

09/21/2017 R7
Under Coverage Indications, Limitations and/or Medical • Provider
Necessity in the first paragraph revised the second Education/Guidance
sentence to define the acronym for CT and added “a scan”
to the verbiage. In the third sentence of the first
paragraph and the last sentence of the second paragraph
added “a scan” to the verbiage. Under Sources of
Information and Basis for Decision updated the source “
American College of Radiology. ACR:Quality is our image. ACR
Practice Guideline for Performance of Magnetic Resonance
Imaging Published 2011. Amended 2014” to “American
College of Radiology. ACR:Quality is our image.ACR Practice
Parameter for Performing and Interpreting Magnetic Resonance
Imaging (MRI) Published 2011. Revised 2017”.

At this time 21st Century Cures Act will apply to new and
revised LCDs that restrict coverage which requires
comment and notice. This revision is not a restriction to
the coverage determination; and, therefore not all the
fields included on the LCD are applicable as noted in this
policy.

10/13/2016 R6 Under CMS National Coverage Policy for Title XVIII of the
• Provider
Social Security Act 1833(e) deleted the verbiage “states that no
Education/Guidance
payment shall be made to any provider for any claim that lacks
the necessary information to process the claim” and revised the
verbiage to read “prohibits Medicare payment for any claim
which lacks the necessary information to process the claim”.

10/22/2015 R5 Under ICD-10 Codes That Support Medical Necessity

• Provider
Group 1 added H59.331, H59.332, H59.333, H59.341,
Education/Guidance
H59.342, H59.343, H59.351, H59.352, H59.353, H59.361,

Created on 08/01/2019. Page 7 of 10

REVISION REVISION REVISION HISTORY EXPLANATION REASON(S) FOR CHANGE
HISTORY HISTORY
DATE NUMBER

H59.362, H59.363, L03.213, S02.30XA, S02.30XB, S02.30XD,

• Revisions Due To
S02.30XG, S02.30XK, S02.30XS, S02.31XA, S02.31XB,
ICD-10-CM Code
S02.31XD, S02.31XG, S02.31XK, S02.31XS, S02.32XA, Changes
S02.32XB, S02.32XD, S02.32XG, S02.32XK, S02.32XS,
S02.40AA, S02.40AB, S02.40AD, S02.40AG, S02.40AK,
S02.40AS, S02.40BA, S02.40BB, S02.40BD, S02.40BG,
S02.40BK, S02.40BS, S02.40CA, S02.40CB, S02.40CD,
S02.40CG, S02.40CK, S02.40CS, S02.40DA, S02.40DB,
S02.40DD, S02.40DG, S02.40DK, S02.40DS, S02.40EA,
S02.40EB, S02.40ED, S02.40EG, S02.40EK, S02.40ES,
S02.40FA, S02.40FB, S02.40FD, S02.40FG, S02.40FK,
S02.40FS, S02.601A, S02.601B, S02.601D, S02.601G,
S02.601K, S02.601S, S02.602A, S02.602B, S02.602D,
S02.602G, S02.602K, S02.602S, S02.610A, S02.610B,
S02.610D, S02.610G, S02.610K, S02.610S, S02.611A,
S02.611B, S02.611D, S02.611G, S02.611K, S02.611S,
S02.612A, S02.612B, S02.612D, S02.612G, S02.612K,
S02.612S, S02.620A, S02.620B, S02.620D, S02.620G,
S02.620K, S02.620S, S02.621A, S02.621B, S02.621D,
S02.621G, S02.621K, S02.621S, S02.622A, S02.622B,
S02.622D, S02.622G, S02.622K, S02.622S, S02.630A,
S02.630B, S02.630D, S02.630G, S02.630K, S02.630S,
S02.631A, S02.631B, S02.631D, S02.631G, S02.631K,
S02.631S, S02.632A, S02.632B, S02.632D, S02.632G,
S02.632K, S02.632S, S02.640A, S02.640B, S02.640D,
S02.640G, S02.640K, S02.640S, S02.641A, S02.641B,
S02.641D, S02.641G, S02.641K, S02.641S, S02.642A,
S02.642B, S02.642D, S02.642G, S02.642K, S02.642S,
S02.650A, S02.650B, S02.650D, S02.650G, S02.650K,
S02.650S, S02.651A, S02.651B, S02.651D, S02.651G,
S02.651K, S02.651S, S02.652A, S02.652B, S02.652D,
S02.652G, S02.652K, S02.652S, S02.670A, S02.670B,
S02.670D, S02.670G, S02.670K, S02.670S, S02.671A,
S02.671B, S02.671D, S02.671G, S02.671K, S02.671S,
S02.672A, S02.672B, S02.672D, S02.672G, S02.672K,
S02.672S, S02.80XA, S02.80XB, S02.80XD, S02.80XG,
S02.80XK, S02.80XS, S02.81XA, S02.81XB, S02.81XD,
S02.81XG, S02.81XK, S02.81XS, S02.82XA, S02.82XB,
S02.82XD, S02.82XG, S02.82XK, S02.82XS, S03.00XA,
S03.00XD, S03.00XS, S03.01XA, S03.01XD, S03.01XS,
S03.02XA, S03.02XD, S03.02XS, S03.03XA, S03.03XD,
S03.03XS, S03.40XA, S03.40XD, S03.40XS, S03.41XA,
S03.41XD, S03.41XS, S03.42XA, S03.42XD, S03.42XS,

Created on 08/01/2019. Page 8 of 10

REVISION REVISION REVISION HISTORY EXPLANATION REASON(S) FOR CHANGE
HISTORY HISTORY
DATE NUMBER

S03.43XA, S03.43XD, S03.43XS, T85.730A, T85.730D, and

T85.730S. Under ICD-10 Codes That Support Medical
Necessity Group 1 revised code descriptions for C81.11,
C81.21, C81.31, C81.41, and C81.71. This revision is due to
the Annual ICD-10 Code Update that becomes effective October
1, 2016.

10/22/2015 R4 Under CMS National Coverage Policy corrected Title XVII to

• Provider
now read XVIII. Under Coverage Indications, Limitations
Education/Guidance
and or Medical Necessity added and revised verbiage to the • Typographical Error
first paragraph regarding contraindications for MRI. Under • Other
Associated Information added Documentation
Requirements. Under Sources of Information and Basis
for Decision corrected the volume number and added the
page numbers to the following: Ahmad A, Branstetter BF. CT
versus MR: Still a Tough Decision. Otolaryngol Clin North Amer.
2008;41(1):1-22. The access date was corrected for the second
cited reference. The following references were deleted: Khan
KM, Visentini PJ, Kiss ZS, et al. Correlation of Ultrasound and
Magnetic Resonance Imaging with Clinical Outcome After
Patellar Tenotomy: Prospective and retrospective Studies. Clin
Jour Sport Med. 1999;9:129-137 and Sexton, S, Bettmann, M.
Introducing the American College of Radiology Series.
[editorial] Am Fam Phy. 2007; 76 (Issue 4).

10/01/2015 R3 Per CMS Internet-Only Manual, Pub 100-08, Medicare Program

• Other (Bill type
Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only
and/or revenue
“reasonable and necessary” information. All bill type and code removal)
revenue codes have been removed.

10/01/2015 R2 Corrected the formatting of the ACR MRI source to correctly

• Typographical Error
open hyperlink.

10/01/2015 R1 Under CMS National Coverage Policy, In Pub 100-03

• Provider
corrected the section to 220.2 (Was 220.0); Added CMS
Education/Guidance
Internet-Only manual Pub 100-04 Medicare Claims Processing • Other (Annual
Manual, Chapter 13, Section40; Added Title XVIII of the SSA Validation)
section 1833(e) No payment shall be made to any provider of
services or other person under this part unless there has been
furnished such information as may be necessary in order to
determine the amounts due such provider or other person
under this part for the period with respect to which the
amounts are being paid or for any prior period and 1833(E)
Outpatient Radiology Services.
Under Sources of Information and Basis for Decision
removed citation for Latchaw RE, Silva, P. Diagnostic and
Created on 08/01/2019. Page 9 of 10
REVISION REVISION REVISION HISTORY EXPLANATION REASON(S) FOR CHANGE
HISTORY HISTORY
DATE NUMBER

Interventional Neuro Radiology. Cummings Otolaryngology

Head & Neck Surgery. 4th ed. Philadelphia, Pa. Mosby Inc;
2005:3675-3697 as it was a duplicate citation and added
citation for Khan K, Visentini PJ, Kiss ZS, et al. Correlation of
Ultrasound and Magnetic Resonance Imaging with Clinical
Outcome After Patellar Tenotomy: Prospective and
retrospective Studies; Corrected all citations to AMA formatting.

Associated Documents
Attachments

N/A

Related Local Coverage Documents

Article(s)
A56729 - Billing and Coding: Magnetic Resonance Imaging of the Orbit, Face, and/or Neck

Related National Coverage Documents

N/A

Public Version(s)

Updated on 07/19/2019 with effective dates 07/25/2019 - N/A

Updated on 08/31/2018 with effective dates 10/01/2018 - 07/24/2019
Updated on 08/09/2018 with effective dates 08/16/2018 - 09/30/2018
Updated on 12/07/2017 with effective dates 01/29/2018 - 08/15/2018
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords
• Magnetic Resonance Imaging
• MRI
• Orbit, Face, and/or Neck
• MRI of Orbit, Face, and/or Neck

Created on 08/01/2019. Page 10 of 10