MA PPO

Magnetic Resonance Imaging (MRI) Contrast Agents
MA09.010b


Policy

The Company covers magnetic resonance imaging (MRI) contrast agents. However, the contrast agents are not eligible for reimbursement separate from the diagnostic or therapeutic procedure. The contrast agents are included in the claim payment for the procedure.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, the following: records from the professional provider's office, hospital, nursing home, home health agencies, and therapies, as well as test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Description


Magnetic resonance (MR) contrast agents, also known as contrast media, are diagnostic pharmaceutical compounds containing paramagnetic ions that affect MR signal properties of surrounding tissues. They are used to improve the visibility of internal body structures in magnetic resonance imaging. Gadolinium chelates are the most commonly utilized MR contrast agents. Other MR contrast agents are iron oxide contrast agents such as superparamagnetic iron oxide (SPIO), ultrasmall superparamagnetic iron oxide (USPIO), and superparamagnetic iron-platinum particles (SIPPs).

References


Adam, Andy. Grainger & Allison's Diagnostic Radiology, 2-Volume Set: A Textbook of Medical Imaging. Sixth edition.

Brant MD, William E, Helms MD, Clyde A., Klein MD FACR, Jeffrey, Vinson MD, Emily N. Fundamentals of Diagnostic Radiology, Fifth edition. Philadelphia: LWW; Lippincott, Williams & Wilkins, 2018.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Transmittal 804. Pub 100-04: Medicare claims processing. [CMS Web site]. 01/03/06. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R804CP.pdf. Accessed August 12, 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 13: Radiology Services and Other Diagnostic Procedures. [CMS Web site]. Revised 03/27/19. Available at:https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c13.pdf. Accessed August 12, 2019.

Centers for Medicare & Medicaid Services (CMS). MLN Matters. 3847: New Healthcare Common Procedure Coding System (HCPCS) drug codes. [CMS Web site]. 03/28/13. Available at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3847.pdf. Accessed August 12, 2019.

Centers for Medicare & Medicaid Services (CMS). MLN Matters. 4250: January 2006 update of the hospital outpatient prospective payment system (OPPS): Summary of payment policy changes and OPPS PRICER logic changes. [CMS Web site]. 01/01/06. Revised 04/03/2013. Available at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4250.pdf. Accessed August 12, 2019.

Coding

CPT Procedure Code Number(s)
N/A

ICD - 10 Procedure Code Number(s)


ICD - 10 Diagnosis Code Number(s)


HCPCS Level II Code Number(s)

A9575

Injection, gadoterate meglumine, 0.1 ml
A9576Injection, gadoteridol, (ProHance multipack), per ml
A9577Injection, gadobenate dimeglumine (MultiHance), per ml
A9578Injection, gadobenate dimeglumine (MultiHance multipack), per ml
A9579Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (NOS), per ml
A9581Injection, gadoxetate disodium, 1 ml
A9585Injection, gadobutrol, 0.1 ml
Q9953Injection, iron-based magnetic resonance contrast agent, per ml
Q9954Oral magnetic resonance contrast agent, per 100 ml


THE FOLLOWING CODE(S) IS/ARE USED TO REPRESENT A9698 (NONRADIOACTIVE CONTRAST IMAGING MATERIAL, NOT OTHERWISE CLASSIFIED, PER STUDY):

A9698Nonradioactive contrast imaging material, not otherwise classified, per study

Revenue Code Number(s)



Coding and Billing Requirements



Policy History

11/18/2019
11/18/2019
MA09.010
Claim Payment Policy Bulletin
Medicare Advantage
Yes