Jurisdiction Virginia. Retirement Date N/A

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1 Local Coverage Determination (LCD): CT of the Head (L31576) Contractor Information Contractor Name Palmetto GBA opens in Back to Top LCD Information Document Information Contract Number Contract Type MAC - Part A LCD ID L31576 LCD Title CT of the Head AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. Jurisdiction Virginia Original Effective Date For services performed on or after 01/24/2011 Revision Effective Date For services performed on or after 12/11/2014 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date 12/09/2010 Notice Period End Date N/A CMS National Coverage Policy 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. 42 CFR (a)(b) ordering diagnostic tests CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Printed on 1/8/2015. Page 1 of 18

2 Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Cranial Computerized Tomographic (CT) Scan is a very useful and informative neurodiagnostic tool. Scanning of 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 is used to process the accumulated x-ray photon data and constructs a graphic image of a tomographic slicee. Normal intracranial structures and a wide variety of intracranial disorders may be demonstrated. Cranial CT scan may be ordered without contrast (70450), with injection of standard roentgenographic contrast material (70460) or without contrast material, followed by contrast material and further sections (70470). Contrast administration is not without risk to the patient and for some conditions adds little or no benefit to the examination. Cranial Computerized Tomographic Scans are determined to be reasonable and necessary and are a covered service when the patient has clinical evidence of an intracranial disorder or an established intracranial disorder or disease. The general indications for use of contrast CT scanning are: 1. assess perfusion (e.g. CVA) 2. characterize a specific lesion 3. detect defects in blood/brain barrier (e.g. infarcts, tumors, infection, vasculitis) 4. detect neovascularity (tumors) 5. for staging of known lung cancer, breast cancer, and lymphomas which are likely to metastasize early to the brain Back to Top 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. 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 071x Clinic - Rural Health 077x Clinic - Federally Qualified Health Center (FQHC) 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 CT Scan - CT - Head Scan CPT/HCPCS Codes Group 1 Paragraph: N/A Group 1 Codes: COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S) Printed on 1/8/2015. Page 2 of 18

3 70470 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS ICD-9 Codes that Support Medical Necessity Group 1 Paragraph: N/A Group 1 Codes: AMEBIC BRAIN ABSCESS opens in TUBERCULOUS MENINGITIS UNSPECIFIED EXAMINATION - UNSPECIFIED TUBERCULOSIS OF CENTRAL NERVOUS SYSTEM TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) MENINGOCOCCAL MENINGITIS - WATERHOUSE-FRIDERICHSEN SYNDROME opens in new MENINGOCOCCAL 042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE KURU VARIANT CREUTZFELDT-JAKOB DISEASE OTHER AND UNSPECIFIED CREUTZFELDT-JAKOB DISEASE SUBACUTE SCLEROSING PANENCEPHALITIS PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY FATAL FAMILIAL INSOMNIA OTHER AND UNSPECIFIED PRION DISEASE OF CENTRAL NERVOUS SYSTEM OTHER SPECIFIED SLOW VIRUS INFECTION OF CENTRAL NERVOUS SYSTEM UNSPECIFIED SLOW VIRUS INFECTION OF CENTRAL NERVOUS SYSTEM opens in new MENINGITIS DUE TO COXSACKIE VIRUS - UNSPECIFIED VIRAL MENINGITIS 048 OTHER ENTEROVIRUS DISEASES OF CENTRAL NERVOUS SYSTEM NON-ARTHOPOD BORNE LYMPHOCYTIC CHORIOMENINGITIS - UNSPECIFIED NON opens in new ARTHROPOD-BORNE VIRAL DISEASES OF CENTRAL NERVOUS SYSTEM POSTVARICELLA ENCEPHALITIS HERPES ZOSTER WITH MENINGITIS opens in HERPES ZOSTER WITH UNSPECIFIED NERVOUS SYSTEM COMPLICATION - POSTHERPETIC POLYNEUROPATHY HERPES ZOSTER WITH OTHER NERVOUS SYSTEM COMPLICATIONS HERPETIC MENINGOENCEPHALITIS HERPES SIMPLEX MENINGITIS POSTMEASLES ENCEPHALITIS ENCEPHALOMYELITIS DUE TO RUBELLA opens in new JAPANESE ENCEPHALITIS - MOSQUITO-BORNE VIRAL ENCEPHALITIS UNSPECIFIED RUSSIAN SPRING-SUMMER (TAIGA) ENCEPHALITIS - TICK-BORNE VIRAL ENCEPHALITIS opens in new UNSPECIFIED 064 VIRAL ENCEPHALITIS TRANSMITTED BY OTHER AND UNSPECIFIED ARTHROPODS 071 RABIES opens in new MUMPS MENINGITIS - MUMPS ENCEPHALITIS CYTOMEGALOVIRAL DISEASE opens in JUVENILE NEUROSYPHILIS UNSPECIFIED - OTHER JUVENILE NEUROSYPHILIS ACUTE SYPHILITIC MENINGITIS (SECONDARY) opens in new TABES DORSALIS - ASYMPTOMATIC NEUROSYPHILIS Printed on 1/8/2015. Page 3 of 18

4 SYPHILITIC ENCEPHALITIS - OTHER SPECIFIED NEUROSYPHILIS opens in LEPTOSPIRAL MENINGITIS (ASEPTIC) CANDIDAL MENINGITIS COCCIDIOIDAL MENINGITIS HISTOPLASMA CAPSULATUM MENINGITIS HISTOPLASMA DUBOISII MENINGITIS HISTOPLASMOSIS MENINGITIS UNSPECIFIED ASPERGILLOSIS CRYPTOCOCCOSIS MENINGOENCEPHALITIS DUE TO TOXOPLASMOSIS 135 SARCOIDOSIS LATE EFFECTS OF CENTRAL NERVOUS SYSTEM TUBERCULOSIS LATE EFFECTS OF VIRAL ENCEPHALITIS MALIGNANT NEOPLASM OF WALDEYER'S RING MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE MALIGNANT NEOPLASM OF NASAL CAVITIES - MALIGNANT NEOPLASM OF ACCESSORY opens in new SINUS UNSPECIFIED MALIGNANT NEOPLASM OF TRACHEA - MALIGNANT NEOPLASM OF BRONCHUS AND LUNG opens in new UNSPECIFIED MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP BASAL CELL CARCINOMA OF SKIN OF LIP SQUAMOUS CELL CARCINOMA OF SKIN OF LIP OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP UNSPECIFIED MALIGNANT NEOPLASM OF EYELID, INCLUDING CANTHUS BASAL CELL CARCINOMA OF EYELID, INCLUDING CANTHUS SQUAMOUS CELL CARCINOMA OF EYELID, INCLUDING CANTHUS OTHER SPECIFIED MALIGNANT NEOPLASM OF EYELID, INCLUDING CANTHUS UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL BASAL CELL CARCINOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL SQUAMOUS CELL CARCINOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE BASAL CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE SQUAMOUS CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE UNSPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF NECK BASAL CELL CARCINOMA OF SCALP AND SKIN OF NECK SQUAMOUS CELL CARCINOMA OF SCALP AND SKIN OF NECK OTHER SPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF NECK UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM BASAL CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT SCROTUM SQUAMOUS CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT SCROTUM OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB, INCLUDING SHOULDER BASAL CELL CARCINOMA OF SKIN OF UPPER LIMB, INCLUDING SHOULDER SQUAMOUS CELL CARCINOMA OF SKIN OF UPPER LIMB, INCLUDING SHOULDER OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB, INCLUDING SHOULDER UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LOWER LIMB, INCLUDING HIP BASAL CELL CARCINOMA OF SKIN OF LOWER LIMB, INCLUDING HIP SQUAMOUS CELL CARCINOMA OF SKIN OF LOWER LIMB, INCLUDING HIP OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LOWER LIMB, INCLUDING HIP Printed on 1/8/2015. Page 4 of 18

5 UNSPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SKIN BASAL CELL CARCINOMA OF OTHER SPECIFIED SITES OF SKIN SQUAMOUS CELL CARCINOMA OF OTHER SPECIFIED SITES OF SKIN OTHER SPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SKIN UNSPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE UNSPECIFIED BASAL CELL CARCINOMA OF SKIN, SITE UNSPECIFIED SQUAMOUS CELL CARCINOMA OF SKIN, SITE UNSPECIFIED OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE UNSPECIFIED MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT opens in new NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST - MALIGNANT NEOPLASM opens in new OF OTHER AND UNSPECIFIED SITES OF MALE BREAST MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID MALIGNANT NEOPLASM OF ORBIT MALIGNANT NEOPLASM OF LACRIMAL GLAND - MALIGNANT NEOPLASM OF EYE PART opens in new UNSPECIFIED MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES - MALIGNANT opens in new NEOPLASM OF BRAIN UNSPECIFIED SITE MALIGNANT NEOPLASM OF CRANIAL NERVES MALIGNANT NEOPLASM OF CEREBRAL MENINGES 193 MALIGNANT NEOPLASM OF THYROID GLAND MALIGNANT NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT MALIGNANT NEOPLASM OF PINEAL GLAND MALIGNANT NEOPLASM OF HEAD FACE AND NECK SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF HEAD FACE AND NECK SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM - SECONDARY opens in new MALIGNANT NEOPLASM OF BONE AND BONE MARROW DISSEMINATED MALIGNANT NEOPLASM - OTHER MALIGNANT NEOPLASM OF UNSPECIFIED opens in new SITE MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANT ORGAN opens in RETICULOSARCOMA UNSPECIFIED SITE - RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES LYMPHOSARCOMA UNSPECIFIED SITE LYMPHOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK opens in LYMPHOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES - LYMPHOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK opens in opens in opens in opens in BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES - BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - MARGINAL ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF MULTIPLE SITES Printed on 1/8/2015. Page 5 of 18

6 opens in opens in opens in opens in ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA UNSPECIFIED SITE - OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE - HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S GRANULOMA UNSPECIFIED SITE HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK opens in HODGKIN'S GRANULOMA INVOLVING INTRATHORACIC LYMPH NODES - HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S SARCOMA UNSPECIFIED SITE HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK opens in HODGKIN'S SARCOMA INVOLVING INTRATHORACIC LYMPH NODES - HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE UNSPECIFIED SITE HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF HEAD FACE AND NECK opens in HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRATHORACIC LYMPH NODES - HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE NODULAR SCLEROSIS UNSPECIFIED SITE HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK opens in HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRATHORACIC LYMPH NODES - HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE MIXED CELLULARITY UNSPECIFIED SITE HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF HEAD FACE AND NECK HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRATHORACIC LYMPH NODES opens in HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION UNSPECIFIED SITE HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF HEAD FACE AND NECK opens in HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRATHORACIC LYMPH NODES - HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE UNSPECIFIED TYPE UNSPECIFIED SITE HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF HEAD FACE AND NECK HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRATHORACIC LYMPH NODES opens in HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES opens in opens in opens in opens in Printed on 1/8/2015. Page 6 of 18 NODULAR LYMPHOMA UNSPECIFIED SITE - NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES MYCOSIS FUNGOIDES UNSPECIFIED SITE - MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF MULTIPLE SITES PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE - OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES

7 opens in OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE UNSPECIFIED SITE - OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION MULTIPLE MYELOMA IN REMISSION MULTIPLE MYELOMA, IN RELAPSE PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION PLASMA CELL LEUKEMIA IN REMISSION PLASMA CELL LEUKEMIA, IN RELAPSE OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING ACHIEVED REMISSION OTHER IMMUNOPROLIFERATIVE NEOPLASMS IN REMISSION OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION LYMPHOID LEUKEMIA ACUTE IN REMISSION ACUTE LYMPHOID LEUKEMIA, IN RELAPSE CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION LYMPHOID LEUKEMIA CHRONIC IN REMISSION CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION LYMPHOID LEUKEMIA SUBACUTE IN REMISSION SUBACUTE LYMPHOID LEUKEMIA, IN RELAPSE OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION OTHER LYMPHOID LEUKEMIA IN REMISSION OTHER LYMPHOID LEUKEMIA, IN RELAPSE UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION UNSPECIFIED LYMPHOID LEUKEMIA IN REMISSION UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION MYELOID LEUKEMIA ACUTE IN REMISSION ACUTE MYELOID LEUKEMIA, IN RELAPSE CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION MYELOID LEUKEMIA CHRONIC IN REMISSION CHRONIC MYELOID LEUKEMIA, IN RELAPSE SUBACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION MYELOID LEUKEMIA SUBACUTE IN REMISSION SUBACUTE MYELOID LEUKEMIA, IN RELAPSE MYELOID SARCOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION MYELOID SARCOMA IN REMISSION MYELOID SARCOMA, IN RELAPSE OTHER MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION OTHER MYELOID LEUKEMIA IN REMISSION OTHER MYELOID LEUKEMIA, IN RELAPSE UNSPECIFIED MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION UNSPECIFIED MYELOID LEUKEMIA IN REMISSION UNSPECIFIED MYELOID LEUKEMIA, IN RELAPSE ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION MONOCYTIC LEUKEMIA ACUTE IN REMISSION ACUTE MONOCYTIC LEUKEMIA, IN RELAPSE CHRONIC MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION MONOCYTIC LEUKEMIA CHRONIC IN REMISSION CHRONIC MONOCYTIC LEUKEMIA, IN RELAPSE SUBACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION MONOCYTIC LEUKEMIA SUBACUTE IN REMISSION SUBACUTE MONOCYTIC LEUKEMIA, IN RELAPSE OTHER MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION OTHER MONOCYTIC LEUKEMIA IN REMISSION OTHER MONOCYTIC LEUKEMIA, IN RELAPSE UNSPECIFIED MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION Printed on 1/8/2015. Page 7 of 18

8 UNSPECIFIED MONOCYTIC LEUKEMIA IN REMISSION UNSPECIFIED MONOCYTIC LEUKEMIA, IN RELAPSE ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA IN REMISSION ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, IN RELAPSE CHRONIC ERYTHREMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION CHRONIC ERYTHREMIA IN REMISSION CHRONIC ERYTHREMIA, IN RELAPSE MEGAKARYOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION MEGAKARYOCYTIC LEUKEMIA IN REMISSION MEGAKARYOCYTIC LEUKEMIA, IN RELAPSE OTHER SPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION OTHER SPECIFIED LEUKEMIA IN REMISSION OTHER SPECIFIED LEUKEMIA, IN RELAPSE ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION LEUKEMIA OF UNSPECIFIED CELL TYPE ACUTE IN REMISSION ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION LEUKEMIA OF UNSPECIFIED CELL TYPE CHRONIC IN REMISSION CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION LEUKEMIA OF UNSPECIFIED CELL TYPE SUBACUTE IN REMISSION SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE IN REMISSION OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE UNSPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION UNSPECIFIED LEUKEMIA IN REMISSION UNSPECIFIED LEUKEMIA, IN RELAPSE MALIGNANT CARCINOID TUMOR OF THE SMALL INTESTINE, UNSPECIFIED PORTION opens in MALIGNANT CARCINOID TUMOR OF THE ILEUM opens in opens in MALIGNANT CARCINOID TUMOR OF THE LARGE INTESTINE, UNSPECIFIED PORTION - MALIGNANT CARCINOID TUMOR OF THE RECTUM MALIGNANT CARCINOID TUMOR OF UNKNOWN PRIMARY SITE - MALIGNANT CARCINOID TUMOR OF OTHER SITES MALIGNANT POORLY DIFFERENTIATED NEUROENDOCRINE CARCINOMA, ANY SITE BENIGN CARCINOID TUMOR OF THE SMALL INTESTINE, UNSPECIFIED PORTION - BENIGN opens in CARCINOID TUMOR OF THE ILEUM opens in opens in BENIGN CARCINOID TUMOR OF THE LARGE INTESTINE, UNSPECIFIED PORTION - BENIGN CARCINOID TUMOR OF THE RECTUM BENIGN CARCINOID TUMOR OF UNKNOWN PRIMARY SITE - BENIGN CARCINOID TUMOR OF OTHER SITES SECONDARY MERKEL CELL CARCINOMA BENIGN NEOPLASM OF NASAL CAVITIES MIDDLE EAR AND ACCESSORY SINUSES BENIGN NEOPLASM OF BONES OF SKULL AND FACE OTHER BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK BENIGN NEOPLASM OF ORBIT opens in new BENIGN NEOPLASM OF BRAIN - BENIGN NEOPLASM OF CEREBRAL MENINGES Printed on 1/8/2015. Page 8 of 18

9 227.3 BENIGN NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT BENIGN NEOPLASM OF PINEAL GLAND HEMANGIOMA OF INTRACRANIAL STRUCTURES NEOPLASM OF UNCERTAIN BEHAVIOR OF PITUITARY GLAND AND CRANIOPHARYNGEAL opens in new DUCT - NEOPLASM OF UNCERTAIN BEHAVIOR OF MENINGES NEUROFIBROMATOSIS UNSPECIFIED opens in NEUROFIBROMATOSIS TYPE 1 VON RECKLINGHAUSEN'S DISEASE - NEUROFIBROMATOSIS TYPE 2 ACOUSTIC NEUROFIBROMATOSIS SCHWANNOMATOSIS OTHER NEUROFIBROMATOSIS NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED PARTS OF NERVOUS SYSTEM POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER (PTLD) NEOPLASM OF UNSPECIFIED NATURE OF BRAIN DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT opens in STATED AS UNCONTROLLED - DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED HYPOGLYCEMIC COMA ACROMEGALY AND GIGANTISM - UNSPECIFIED DISORDER OF THE PITUITARY GLAND AND opens in new ITS HYPOTHALAMIC CONTROL CUSHING'S SYNDROME MULTIPLE ENDOCRINE NEOPLASIA [MEN] TYPE I AMYLOIDOSIS, UNSPECIFIED OTHER AMYLOIDOSIS OTHER SECONDARY THROMBOCYTOPENIA opens in SENILE DEMENTIA UNCOMPLICATED - VASCULAR DEMENTIA, WITH DEPRESSED MOOD OTHER SPECIFIED SENILE PSYCHOTIC CONDITIONS opens in new ALCOHOL WITHDRAWAL DELIRIUM - ALCOHOL-INDUCED PERSISTING DEMENTIA opens in new DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE - SUBACUTE DELIRIUM opens in opens in PSYCHOTIC DISORDER WITH DELUSIONS IN CONDITIONS CLASSIFIED ELSEWHERE - OTHER SPECIFIED TRANSIENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE, OTHER DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT BEHAVIORAL DISTURBANCE - DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCE DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE DEMENTIA, UNSPECIFIED, WITH BEHAVIORAL DISTURBANCE OTHER PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE opens in new UNSPECIFIED PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE opens in SCHIZOPHRENIFORM DISORDER, UNSPECIFIED - SCHIZOPHRENIFORM DISORDER, CHRONIC WITH ACUTE EXACERBATION REACTIVE CONFUSION UNSPECIFIED PSYCHOSIS FRONTAL LOBE SYNDROME PERSONALITY CHANGE DUE TO CONDITIONS CLASSIFIED ELSEWHERE POSTCONCUSSION SYNDROME PSEUDOBULBAR AFFECT OTHER SPECIFIED NONPSYCHOTIC MENTAL DISORDERS FOLLOWING ORGANIC BRAIN DAMAGE UNSPECIFIED NONPSYCHOTIC MENTAL DISORDER FOLLOWING ORGANIC BRAIN DAMAGE INTERMITTENT EXPLOSIVE DISORDER Printed on 1/8/2015. Page 9 of 18

10 opens HEMOPHILUS MENINGITIS - LATE EFFECTS OF INTRACRANIAL ABSCESS OR PYOGENIC in INFECTION opens in ORGANIC INSOMNIA, UNSPECIFIED - OTHER ORGANIC INSOMNIA opens in ORGANIC HYPERSOMNIA, UNSPECIFIED - OTHER ORGANIC HYPERSOMNIA ORGANIC SLEEP APNEA, UNSPECIFIED PRIMARY CENTRAL SLEEP APNEA IDIOPATHIC SLEEP RELATED NON OBSTRUCTIVE ALVEOLAR HYPOVENTILATION CONGENITAL CENTRAL ALVEOLAR HYPOVENTILATION SYNDROME SLEEP RELATED HYPOVENTILATION/HYPOXEMIA IN CONDITIONS CLASSIFIABLE ELSEWHERE CENTRAL SLEEP APNEA IN CONDITIONS CLASSIFIED ELSEWHERE OTHER ORGANIC SLEEP APNEA ORGANIC PARASOMNIA, UNSPECIFIED CONFUSIONAL AROUSALS PARASOMNIA IN CONDITIONS CLASSIFIED ELSEWHERE OTHER ORGANIC PARASOMNIA OTHER ORGANIC SLEEP DISORDERS opens in new LEUKODYSTROPHY - UNSPECIFIED CEREBRAL DEGENERATION IN CHILDHOOD opens in new ALZHEIMER'S DISEASE - OBSTRUCTIVE HYDROCEPHALUS IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS (INPH) CORTICOBASAL DEGENERATION CEREBRAL DEGENERATION IN DISEASES CLASSIFIED ELSEWHERE opens in new REYE'S SYNDROME - CEREBRAL DEGENERATION UNSPECIFIED opens in new PARALYSIS AGITANS - SECONDARY PARKINSONISM OTHER DEGENERATIVE DISEASES OF THE BASAL GANGLIA - OTHER EXTRAPYRAMIDAL opens in DISEASES AND ABNORMAL MOVEMENT DISORDERS opens in new FRIEDREICH'S ATAXIA - SPINOCEREBELLAR DISEASE UNSPECIFIED opens in new WERDNIG-HOFFMANN DISEASE - ANTERIOR HORN CELL DISEASE UNSPECIFIED opens in new SYRINGOMYELIA AND SYRINGOBULBIA - UNSPECIFIED DISEASE OF SPINAL CORD IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY, UNSPECIFIED CAROTID SINUS SYNDROME OTHER IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY PERIPHERAL AUTONOMIC NEUROPATHY IN DISORDERS CLASSIFIED ELSEWHERE opens in REFLEX SYMPATHETIC DYSTROPHY UNSPECIFIED - REFLEX SYMPATHETIC DYSTROPHY OF OTHER SPECIFIED SITE AUTONOMIC DYSREFLEXIA UNSPECIFIED DISORDER OF AUTONOMIC NERVOUS SYSTEM opens in new CENTRAL PAIN SYNDROME - CHRONIC PAIN SYNDROME opens in CLUSTER HEADACHE SYNDROME, UNSPECIFIED - OTHER HEADACHE SYNDROMES 340 MULTIPLE SCLEROSIS Printed on 1/8/2015. Page 10 of 18

11 opens in new NEUROMYELITIS OPTICA - SCHILDER'S DISEASE ACUTE (TRANSVERSE) MYELITIS NOS - DEMYELINATING DISEASE OF CENTRAL NERVOUS opens in new SYSTEM UNSPECIFIED opens in FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE opens in new CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED QUADRIPLEGIA UNSPECIFIED opens in QUADRIPLEGIA C1-C4 COMPLETE - OTHER QUADRIPLEGIA PARAPLEGIA DIPLEGIA OF UPPER LIMBS opens in new MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - PARALYSIS UNSPECIFIED opens in Printed on 1/8/2015. Page 11 of 18 GENERALIZED NONCONVULSIVE EPILEPSY WITH INTRACTABLE EPILEPSY - EPILEPSY UNSPECIFIED WITH INTRACTABLE EPILEPSY MIGRAINE WITH AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINE WITH AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS HEMIPLEGIC MIGRAINE, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS HEMIPLEGIC MIGRAINE, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MENSTRUAL MIGRAINE, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MENSTRUAL MIGRAINE, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS

12 opens in MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS OTHER FORMS OF MIGRAINE, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS OTHER FORMS OF MIGRAINE, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS NARCOLEPSY, WITHOUT CATAPLEXY - NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE, WITH CATAPLEXY CEREBRAL CYSTS ANOXIC BRAIN DAMAGE BENIGN INTRACRANIAL HYPERTENSION ENCEPHALOPATHY UNSPECIFIED METABOLIC ENCEPHALOPATHY OTHER ENCEPHALOPATHY COMPRESSION OF BRAIN CEREBRAL EDEMA TEMPORAL SCLEROSIS OTHER CONDITIONS OF BRAIN UNSPECIFIED CONDITION OF BRAIN opens in REACTION TO SPINAL OR LUMBAR PUNCTURE - TOXIC ENCEPHALOPATHY UNSPECIFIED DISORDERS OF NERVOUS SYSTEM opens in new TRIGEMINAL NEURALGIA - UNSPECIFIED DISORDER OF CRANIAL NERVES Printed on 1/8/2015. Page 12 of 18

13 SUDDEN VISUAL LOSS TRANSIENT VISUAL LOSS DIPLOPIA opens in BINOCULAR VISION DISORDER UNSPECIFIED - GENERALIZED VISUAL FIELD CONTRACTION OR CONSTRICTION HOMONYMOUS BILATERAL FIELD DEFECTS HETERONYMOUS BILATERAL FIELD DEFECTS opens in TRITAN DEFECT - OTHER COLOR VISION DEFICIENCIES OTHER SPECIFIED VISUAL DISTURBANCES ORBITAL CELLULITIS PULSATING EXOPHTHALMOS opens in PAPILLEDEMA UNSPECIFIED - PAPILLEDEMA ASSOCIATED WITH INCREASED INTRACRANIAL PRESSURE PRIMARY OPTIC ATROPHY PARTIAL OPTIC ATROPHY opens in OPTIC NEURITIS UNSPECIFIED - RETROBULBAR NEURITIS (ACUTE) DISORDERS OF OPTIC CHIASM ASSOCIATED WITH PITUITARY NEOPLASMS AND DISORDERS DISORDERS OF OPTIC CHIASM ASSOCIATED WITH VASCULAR DISORDERS DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH VASCULAR DISORDERS opens in DISORDERS OF VISUAL CORTEX ASSOCIATED WITH NEOPLASMS - DISORDERS OF VISUAL CORTEX ASSOCIATED WITH VASCULAR DISORDERS CORTICAL BLINDNESS UNSPECIFIED DISORDER OF OPTIC NERVE AND VISUAL PATHWAYS opens in PARALYTIC STRABISMUS UNSPECIFIED - TOTAL OPHTHALMOPLEGIA PALSY OF CONJUGATE GAZE INTERNUCLEAR OPHTHALMOPLEGIA opens in OTHER FORMS OF NYSTAGMUS - DEFICIENCIES OF SMOOTH PURSUIT MOVEMENTS VERTIGO OF CENTRAL ORIGIN opens in LABYRINTHINE DYSFUNCTION UNSPECIFIED - OTHER FORMS AND COMBINATIONS OF LABYRINTHINE DYSFUNCTION DISORDERS OF ACOUSTIC NERVE CEREBROSPINAL FLUID OTORRHEA CONDUCTIVE HEARING LOSS UNSPECIFIED CONDUCTIVE HEARING LOSS TYMPANIC MEMBRANE CONDUCTIVE HEARING LOSS MIDDLE EAR CONDUCTIVE HEARING LOSS INNER EAR CONDUCTIVE HEARING LOSS, UNILATERAL CONDUCTIVE HEARING LOSS, BILATERAL CONDUCTIVE HEARING LOSS OF COMBINED TYPES SENSORINEURAL HEARING LOSS UNSPECIFIED SENSORY HEARING LOSS, BILATERAL NEURAL HEARING LOSS, BILATERAL NEURAL HEARING LOSS, UNILATERAL CENTRAL HEARING LOSS SENSORINEURAL HEARING LOSS, UNILATERAL SENSORINEURAL HEARING LOSS, ASYMMETRICAL SENSORY HEARING LOSS, UNILATERAL SENSORINEURAL HEARING LOSS, BILATERAL MIXED HEARING LOSS, UNSPECIFIED - MIXED HEARING LOSS, BILATERAL Printed on 1/8/2015. Page 13 of 18

14 opens in opens in SUBARACHNOID HEMORRHAGE - UNSPECIFIED CEREBROVASCULAR DISEASE COGNITIVE DEFICITS LATE EFFECTS OF CEREBROVASCULAR DISEASE, DYSARTHRIA LATE EFFECTS OF CEREBROVASCULAR DISEASE, FLUENCY DISORDER INFLUENZA WITH OTHER MANIFESTATIONS HEPATIC ENCEPHALOPATHY CENTRAL NERVOUS SYSTEM COMPLICATIONS OF ANESTHESIA OR OTHER SEDATION IN LABOR AND DELIVERY DELIVERED WITH POSTPARTUM COMPLICATION DIFFICULTY IN WALKING ENCEPHALOCELE - UNSPECIFIED CONGENITAL ANOMALY OF BRAIN SPINAL CORD AND opens in new NERVOUS SYSTEM CONGENITAL ANOMALIES OF CEREBROVASCULAR SYSTEM CONGENITAL ANOMALIES OF SKULL AND FACE BONES SUBDURAL AND CEREBRAL HEMORRHAGE DUE TO BIRTH TRAUMA EPICRANIAL SUBAPONEUROTIC HEMORRHAGE (MASSIVE) OTHER INJURIES TO SKELETON DUE TO BIRTH TRAUMA opens in opens in INTRAVENTRICULAR HEMORRHAGE UNSPECIFIED GRADE - INTRAVENTRICULAR HEMORRHAGE GRADE IV COMA - COMPLEX FEBRILE CONVULSIONS POST TRAUMATIC SEIZURES opens in new OTHER CONVULSIONS - DIZZINESS AND GIDDINESS MEMORY LOSS ALTERED MENTAL STATUS opens in new ABNORMAL INVOLUNTARY MOVEMENTS - ABNORMALITY OF GAIT LACK OF COORDINATION TRANSIENT PARALYSIS OF LIMB FACIAL WEAKNESS OTHER SYMPTOMS INVOLVING NERVOUS AND MUSCULOSKELETAL SYSTEMS DISTURBANCE OF SKIN SENSATION HEADACHE SWELLING MASS OR LUMP IN HEAD AND NECK APHASIA DYSPHONIA DYSARTHRIA FLUENCY DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE OTHER SPEECH DISTURBANCE NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF SKULL AND HEAD SOLITARY PULMONARY NODULE OTHER NONSPECIFIC ABNORMAL FINDING OF LUNG FIELD NONSPECIFIC ABNORMAL ELECTROENCEPHALOGRAM (EEG) FRONTAL LOBE AND EXECUTIVE FUNCTION DEFICIT CLOSED FRACTURE OF VAULT OF SKULL WITHOUT INTRACRANIAL INJURY WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OPEN FRACTURES INVOLVING SKULL OR FACE WITH opens in OTHER BONES WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH CONCUSSION UNSPECIFIED CONCUSSION WITH NO LOSS OF CONSCIOUSNESS opens in Printed on 1/8/2015. Page 14 of 18 CONCUSSION WITH LOSS OF CONSCIOUSNESS OF 30 MINUTES OR LESS - CONCUSSION WITH LOSS OF CONSCIOUSNESS FROM 31 TO 59 MINUTES

15 opens in CONCUSSION WITH MODERATE LOSS OF CONSCIOUSNESS - INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED PENETRATING WOUND OF ORBIT WITHOUT FOREIGN BODY - PENETRATING WOUND OF opens in new ORBIT WITH FOREIGN BODY AVULSION OF EYE OPEN WOUND OF SCALP COMPLICATED OTHER AND UNSPECIFIED OPEN WOUND OF HEAD COMPLICATED LATE EFFECT OF INTRACRANIAL INJURY WITHOUT SKULL FRACTURE 920 CONTUSION OF FACE SCALP AND NECK EXCEPT EYE(S) CRUSHING INJURY OF FACE AND SCALP OPTIC NERVE INJURY INJURY TO OPTIC CHIASM INJURY TO OPTIC PATHWAYS opens in new INJURY TO VISUAL CORTEX - INJURY TO UNSPECIFIED OPTIC NERVE AND PATHWAYS opens in new INJURY TO OCULOMOTOR NERVE - INJURY TO OTHER SPECIFIED CRANIAL NERVES OTHER AND UNSPECIFIED INJURY TO HEAD opens in new POISONING BY BARBITURATES - POISONING BY GLUTETHIMIDE GROUP POISONING BY CENTRAL NERVOUS SYSTEM MUSCLE-TONE DEPRESSANTS - SURFACE opens in new (TOPICAL) AND INFILTRATION ANESTHETICS POISONING BY ANTIDEPRESSANT, UNSPECIFIED POISONING BY MONOAMINE OXIDASE INHIBITORS POISONING BY SELECTIVE SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITORS POISONING BY SELECTIVE SEROTONIN REUPTAKE INHIBITORS POISONING BY TETRACYCLIC ANTIDEPRESSANTS POISONING BY TRICYCLIC ANTIDEPRESSANTS POISONING BY OTHER ANTIDEPRESSANTS POISONING BY PHENOTHIAZINE-BASED TRANQUILIZERS POISONING BY BUTYROPHENONE-BASED TRANQUILIZERS POISONING BY OTHER ANTIPSYCHOTICS NEUROLEPTICS AND MAJOR TRANQUILIZERS POISONING BY BENZODIAZEPINE-BASED TRANQUILIZERS POISONING BY OTHER TRANQUILIZERS POISONING BY PSYCHODYSLEPTICS (HALLUCINOGENS) POISONING BY PSYCHOSTIMULANT, UNSPECIFIED POISONING BY CAFFEINE POISONING BY AMPHETAMINES POISONING BY METHYLPHENIDATE POISONING BY OTHER PSYCHOSTIMULANTS 986 TOXIC EFFECT OF CARBON MONOXIDE TOXIC EFFECT OF LIQUEFIED PETROLEUM GASES - TOXIC EFFECT OF OTHER SPECIFIED opens in new GASES FUMES OR VAPORS TOXIC EFFECT OF VENOM MECHANICAL COMPLICATION OF NERVOUS SYSTEM DEVICE IMPLANT AND GRAFT INFECTION AND INFLAMMATORY REACTION DUE TO NERVOUS SYSTEM DEVICE IMPLANT AND GRAFT HEMORRHAGE COMPLICATING A PROCEDURE V10.85 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BRAIN V12.41 PERSONAL HISTORY OF BENIGN NEOPLASM OF THE BRAIN V45.2 POSTSURGICAL PRESENCE OF CEREBROSPINAL FLUID DRAINAGE DEVICE V53.01 FITTING AND ADJUSTMENT OF CEREBRAL VENTRICULAR (COMMUNICATING) SHUNT V67.1 FOLLOW-UP EXAMINATION FOLLOWING RADIOTHERAPY V67.2 FOLLOW-UP EXAMINATION FOLLOWING CHEMOTHERAPY Printed on 1/8/2015. Page 15 of 18

16 ICD-9 Codes that DO NOT Support Medical Necessity Paragraph: N/A N/A Back to Top General Information Associated Information Documentation Requirements 1. The patient's medical record should include symptomatology indicating the medical necessity of this test. 2. The ICD-9-CM (Headache) will only be covered in the following situations: a. The patient is suffering from headaches and a head injury. Head CT is performed to rule out the possibility of an intracranial bleed. b. Patient is suffering from headaches unusual in duration (greater than 2 weeks) and not responding to medical therapy. Head CT is performed to rule out the possibility of a tumor. c. The patient is suffering from new onset headache (less than 2 weeks) suggestive of intracranial bleeding as evidenced by signs (e.g. weakness or paralysis), symptoms (e.g., blurred vision, nausea and vomiting), or clinical history. 3. Any claim billed with ICD-9-CM (headache) may be subject to manual review. 4. Claims billed with ICD-9-CM (head injury, unspecified) should have documented associated signs and symptoms to support the need for CT scan of the head and may be subject to manual review. 5. 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. Sources of Information and Basis for Decision American College of Emergency Physicians. Clinical policy: Critical issues in the evaluation and management of patients presenting to the emergency department with acute headache. Annals of Emerg Medicine. 2002;39(1): Hasbun R, Abrahams J, Jekel J, Quagliarello VJ. Computed Tomography of the head before lumbar puncture in adults with suspected meningitis. The New England Jour Medicine.2001;345(24): Vilke GM, Chan TC, Guss DA. Use of a Complete Neurological Examination to Screen for Significant Intracranial Abnormalities in Minor Head Injury. The American Jour of Emerg Medicine,.2000;18(2): Inamasu J, Hori S, Aoki K, Suga S, et. al. CT scans essential after posttraumatic loss of consciousness. The American Journal of Emerg Medicine.2000;18(7): Edlow JA. Diagnosis of subarachnoid hemorrhage in the emergency department. Emergency Medicine Clinics of North America.2003;21(1): Clinch CR. Evaluation of Acute Headaches in Adults. American Family Physician.2001;63(4): Eng J, Chanmugam A. Examining the Role of Cranial CT in the Evaluation of Patients with Minor Head Injury: a Systematic Review. Neuroimaging Clinics of North America.2003;13(2): Back to Top Printed on 1/8/2015. Page 16 of 18

17 Revision History Information Please note: Most Revision History entries effective on or before 01/24/2013 display with a Revision History Number of "R1" at the bottom of this table. However, there may be LCDs where these entries will display as a separate and distinct row. Revision Revision History History Date Number 12/11/2014 R4 10/17/2014 R3 12/12/2013 R2 Revision History Explanation Under CMS National Coverage Policy changed Manual System to read Internet-Only Manual. Under Sources of Information and Basis for Decision added citations for American College of Emergency Physicians. Clinical policy: Critical issues in the evaluation and management of patients presenting to the emergency department with acute headache; Hasbun R, Abrahams J, Jekel J, Quagliarello VJ. Computed Tomography of the head before lumbar puncture in adults with suspected meningitis; Vilke GM, Chan TC, Guss DA. Use of a Complete Neurological Examination to Screen for Significant Intracranial Abnormalities in Minor Head Injury; Inamasu J, Hori S, Aoki K, Suga S, et. al. CT scans essential after posttraumatic loss of consciousness; Edlow JA. Diagnosis of subarachnoid hemorrhage in the emergency department; Clinch CR. Evaluation of Acute Headaches in Adults; Eng J, Chanmugam A. Examining the Role of Cranial CT in the Evaluation of Patients with Minor Head Injury: a Systematic Review. Corrected the underline closure formatting in Associated Information. Under CMS National Coverage Policy the following citation was added: 42 CFR (a)(b) ordering diagnostic tests. The following two citations were deleted: CMS Manual System, Pub , Medicare Program Integrity Manual, Chapter 13, and CMS Manual System, Pub , One-Time Notification, Transmittal 477, dated April 24, 2009, Change request Under Indications and Limitations of Coverage and/or Medical Necessity removed the Social Security citation in the verbiage as it is cited under CMS National Coverage Policy section. Reason(s) for Change Provider Education/Guidance Other (Annual Validation) Typographical Error Provider Education/Guidance Revision #4, 12/20/2012 Under Documentation Requirements changed the word "Intermediary" to "A/B MAC." Annual Review completed. This revision becomes effective on 12/20/ /20/2012 R1 Revision #3, 10/24/2011 Clarification: was not added. Under ICD-9 Codes That Support Medical Necessity section the following ICD-9 code was added: Revision #2, 10/01/2011 Under ICD-9 Codes That Support Medical Necessity section the following ICD-9 codes have been revised: , , , , , , , , , , , and The following ICD-9 codes were added: , , , 331.6, and ICD-9 code expanded to and This revision becomes effective on 10/01/2011. Revision #1, 05/16/2011 Per scheduled J11 implementation, contractor numbers (Virginia) and (West Virginia) were added to this LCD. This revision becomes effective on 05/16/2011. N/A Printed on 1/8/2015. Page 17 of 18

18 Revision History Date Revision History Number Revision History Explanation Reason(s) for Change Back to Top 01/24/ In accordance with Section 911 of the Medicare Modernization Act of 2003, in compliance with the J11 AB MAC Statement of Work (SOW), C Consolidation of Local Coverage Determinations, this LCD has been selected for implementation within the Palmetto GBA J11 AB MAC territory. Effective date of this implementation is January 24, Associated Documents Attachments N/A Related Local Coverage Documents N/A Related National Coverage Documents N/A Public Version(s) Updated on 12/03/2014 with effective dates 12/11/ N/A Updated on 10/08/2014 with effective dates 10/17/ /10/2014 Updated on 12/05/2013 with effective dates 12/12/ /16/2014 Some older versions have been archived. Please visit the MCD Archive Site opens in to retrieve them. Back to Top Keywords CT of the Head CT Scans Computerized Tomographic Read the LCD Disclaimer opens in Back to Top Printed on 1/8/2015. Page 18 of 18