Diagnostic Imaging - Medicare Advantage Form

Please refer to CMS website for the most current applicable CMS Online Manual System (IOMs)/National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/ Transmittals.
Type Title ID Number NCD Computed Tomography 220.1 Jurisdiction Medicare Administrative Contractors (MACs) Applicable States/Territories

NCD Lung Cancer Screening with Low Dose Computed Tomography (LDCT) 210.14 LCD LCA Cardiac Computed Tomography & Angiography (CCTA) L33423 A56691 LCD LCA LCD LCA LCD LCA Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) L33559 A56737 Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) Coronary Computed Tomography Angiography (CCTA) L33947 A56451 L35121 A57552 LCD LCA Computerized Axial Tomography (CT), Thorax L33459 A56580 LCD LCA LCD LCA LCD LCA CT of the Abdomen and Pelvis CT of the Head L34415 A56421 L34417 A56612 Computed Tomography (CT) Colonography for Diagnostic Uses L33562 A57026 Diagnostic Imaging Page: 2 of 25 JJ - Palmetto GBA (Part A/B MAC) AL, GA, TN JM - Palmetto GBA (Part A/B MAC) J6 - National Government Services, Inc. (Part A/B MAC) JK - National Government Services, Inc. (Part A/B MAC NC, SC, VA, WV IL, MN, WI CT, NY, ME, MA, NH, RI, VT J15 - CGS Administrators, LLC (Part A/B MAC) KY, OH J5 - Wisconsin Physicians Service Insurance Corporation JJ - Palmetto GBA (Part A/B MAC) JM - Palmetto GBA (Part A/B MAC) JJ - Palmetto GBA (Part A/B MAC) JM - Palmetto GBA (Part A/B MAC) JJ - Palmetto GBA (Part A/B MAC) JM - Palmetto GBA (Part A/B MAC) J6 - National Government Services, Inc. (Part A/B MAC) IA, KS, MO, NE AL, GA, TN NC, SC, VA, WV AL, GA, TN NC, SC, VA, WV AL, GA, TN NC, SC, VA, WV IL, MN, WI

LCD LCA LCD LCA Virtual Colonoscopy (CT Colonography) Virtual Colonoscopy (CT Colonography) L34055 A56800 L33452 A56772 NCD Magnetic Resonance Imaging 220.2 MRI and CT Scans of the Head and Neck L37373 A57204 MRI and CT Scans of the Head and Neck L35175 A57215 LCD LCA LCD LCA LCD LCA LCD LCA LCD LCA LCD LCA Lumbar MRI Lumbar MRI Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography LCD LCA Magnetic Resonance Angiography (MRA) L34220 A57206 L37281 A57207 L33585 A52849 L33950 A56448 L33633 A56747 Diagnostic Imaging Page: 3 of 25 CT, NY, ME, MA, NH, RI, VT KY, OH AL, GA, TN NC, SC, VA, WV CA, HI, NV, American Samoa, Guam, Northern Mariana Islands AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY CA, HI, NV, American Samoa, Guam, Northern Mariana Islands AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY IL, MN, WI CT, NY, ME, MA, NH, RI, VT JK - National Government Services, Inc. (Part A/B MAC J15 - CGS Administrators, LLC (Part A/B MAC) JJ - Palmetto GBA (Part A/B MAC) JM - Palmetto GBA (Part A/B MAC) JE - Noridian Healthcare Solutions, LLC JF - Noridian Healthcare Solutions, LLC JE - Noridian Healthcare Solutions, LLC JF - Noridian Healthcare Solutions, LLC J6 - National Government Services, Inc. (Part A/B MAC) JK - National Government Services, Inc. (Part A/B MAC J15 - CGS Administrators, LLC (Part A/B MAC) KY, OH IL, MN, WI J6 - National Government Services, Inc. (Part A/B MAC)

Diagnostic Imaging Page: 4 of 25 CT, NY, ME, MA, NH, RI, VT AR, CO, NM, OK, TX, LA, MS DE, D.C., MD, NJ, PA AL, GA, TN NC, SC, VA, WV FL, PR, U.S. VI JK - National Government Services, Inc. (Part A/B MAC JH - Novitas Solutions, Inc. (Part A/B MAC) JL - Novitas Solutions, Inc. (Part A/B MAC) JJ - Palmetto GBA (Part A/B MAC) JM - Palmetto GBA (Part A/B MAC) JN - First Coast Service Options, Inc. (Part A/B MAC) J15 - CGS Administrators, LLC (Part A/B MAC) KY, OH LCD LCA Magnetic Resonance Angiography (MRA) L34865 A56805 Magnetic Resonance Angiography (MRA) Magnetic Resonance Angiography (MRA) L34424 A56775 L34372 A57779 220.6.13 220.6.8 FDG PET for Dementia and Neurodegenerative Diseases FDG PET for Myocardial Viability FDG PET for Refractory Seizures 220.6.9 PET for Perfusion of the Heart 220.6.1 Positron Emission Tomography (FDG) for Oncologic Conditions Positron Emission Tomography (NaF-18) to Identify Bone Metastasis of Cancer Beta Amyloid Positron Tomography in Dementia and Neurodegenerative Disease Positron Emission Tomography (PET) Scan for Inflammation and Infection L39521 A59318 220.6.17 220.6.20 220.6.19 LCD LCA LCD LCA NCD NCD
NCD NCD NCD NCD NCD LCD LCA LCA Billing and Coding: Positron Emission Tomography Scans Coverage A54668 JF - Noridian Healthcare Solutions, LLC AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY

LCD LCA Cardiac Catheterization and Coronary Angiography L33959 A56500 J15 - CGS Administrators, LLC (Part A/B MAC) KY, OH Diagnostic Imaging Page: 5 of 25 LCD LCA Cardiology Non-emergent Outpatient Stress Testing L35083 A56423 LCD LCA Cardiology Non-emergent Outpatient Stress Testing L38396 A56952 Cardiac Radionuclide Imaging Multiple Imaging in Oncology L33457 A56476 L35391 A56848 LCD LCA LCD LCA Description JH - Novitas Solutions, Inc. (Part A/B MAC) JL - Novitas Solutions, Inc. (Part A/B MAC) JN - First Coast Service Options, Inc. (Part A/B MAC) AR, CO, NM, OK, TX, LA, MS DE, D.C., MD, NJ, PA FL, PR, U.S. VI JJ - Palmetto GBA (Part A/B MAC) AL, GA, TN JM - Palmetto GBA (Part A/B MAC) NC, SC, VA, WV AR, CO, NM, OK, TX, LA, MS DE, D.C., MD, NJ, PA JH - Novitas Solutions, Inc. (Part A/B MAC) JL - Novitas Solutions, Inc. (Part A/B MAC) Diagnostic imaging provides visualization of tissues and organs in the body to diagnose abnormalities and guide therapy. Techniques include, but may not be limited to: • Computed tomography (CT) refers to a computerized x-ray imaging procedure in which a three- dimensional image (3D) of a body structure is revealed through a series of cross-sectional images or "slices." CT scans are often used to diagnose such conditions as blood clots, internal bleeding or injury or tumors. • Computed tomography angiography (CTA) is a medical test that combines a CT scan with an injection of a special dye to produce pictures of blood vessels and tissues in a part of the body. Typical uses include, but may not be limited to, aneurysms, blood clots, congenital (birth-related) abnormalities or tumors.

Diagnostic Imaging Page: 6 of 25 • Computed tomographic colonography (CTC), also known as virtual colonoscopy, is a minimally invasive method to examine the colon and rectum for abnormalities (eg, colorectal cancer, polyps). Helical CT and computer generated images are used to produce high-resolution two- and 3D images.
• Magnetic resonance angiography (MRA) is a procedure that uses radio waves and a powerful magnet linked to a computer to create detailed pictures of the blood vessels and blood flow inside the body. A dye may be injected into a vein to make the blood vessels and blood flow easier to see. MRA can be used to diagnose such conditions as aneurysm, renal artery stenosis or stroke. • Magnetic resonance cholangiopancreatography (MRCP) is a special type of magnetic resonance imaging (MRI) exam that provides detailed images of the bile ducts, gallbladder, pancreas and pancreatic duct. Common uses of MRCP include, but may not be limited to, examination for infection, inflammation, stones or tumors, evaluation of pancreatitis and/or diagnosis of unexplained abdominal pain. • Magnetic resonance imaging (MRI) is a non-invasive diagnostic technique that produces computerized images of internal body tissues and is based on nuclear magnetic resonance of atoms within the body induced by the application of radio waves. MRI is often used to detect such conditions as brain tumors, traumatic brain injury, dementia, infection or stroke. • Cardiac magnetic resonance imaging (CMR) is a specific type of MRI that uses a magnetic field and radiofrequency waves to create detailed pictures of the heart and coronary arteries. Cardiac MRI can help providers to find the cause of heart failure or identify tissue damage due to a heart attack. • Positron emission tomography (PET) scan is a procedure in which a small amount of radioactive glucose (sugar) is injected into a vein, and a scanner is used to make detailed, computerized pictures of areas inside the body where the glucose is taken up. Typical uses for PET scans include, but may not be limited to, assessing cancers, neurological (brain) diseases and cardiovascular diseases. Coverage Determination Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare. Please refer to the above CMS guidance for cardiac magnetic resonance, computed tomography, computed tomography angiography, magnetic resonance imaging, magnetic resonance angiography and positron emission tomography. In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the criteria contained in the following: Abdominal MRI Abdominal/Pelvic CT Angiography (CTA) Abdominal/Pelvic CT Scan Abdominal/Pelvic MR Angiography (MRA)

Diagnostic Imaging Page: 7 of 25 Ankle CT Scan Ankle MRI Arm CT Scan Arm MRI Arthrography, CT Arthrography, MR Bone Marrow MRI Brain CT Scan Brain Functional MRI Brain MRI Brain Positron Emission Tomography (PET) Breast MRI Cardiac CT Angiography (CTA) Cardiac CT Scan Cardiac MR Angiography (MRA) Cardiac MRI Cervical Spine CT Scan Cervical Spine MRI Chest CT Angiography (CTA) Chest CT Scan Chest MR Angiography (MRA) Chest MRI Cholangiopancreatography, MR (MRCP) Colonography, CT (Virtual Colonoscopy) Elbow CT Scan Elbow MRI Face and Sinuses CT Scan Foot and Foot Joints CT Scan Foot and Foot Joints MRI Hand MRI Head CT Angiography (CTA) Head MR Angiography (MRA) Hip CT Scan Hip MRI Knee MRI Lower Extremity CT Scan Lower Extremity MR Angiography (MRA) Lower Extremity MRI Lumbar Spine CT Lumbar Spine MRI Myelography, CT Myocardial Positron Emission Tomography (PET) and PET-CT Neck CT Angiography (CTA) Neck CT Scan
Neck MR Angiography (MRA) Neck, Orbit, and Face MRI

Diagnostic Imaging Page: 8 of 25 Orbit and Ear CT Scan Pelvic MRI
Shoulder MRI Temporomandibular Joint MRI Thoracic Spine CT Thoracic Spine MRI Tumor Imaging Positron Emission Tomography (PET) and PET-CT Upper Extremity CT Angiography (CTA) Upper Extremity MR Angiography (MRA) Urography, CT (CT, IVP) Wrist CT Scan Wrist MRI The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy. Coverage Limitations US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage