Medical Review Guidelines Magnetic Resonance Imaging Upper and Lower Extremities

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1 Medical Guideline Number: MRG Effective Date: 5/18/2005 Revised Effective Date: 1/1/2008 Medical Review Guidelines Magnetic Resonance Imaging Upper and Lower Extremities OHCA Reference OAC 317: Radiology. (f) Magnetic Resonance Imaging. MRI /MRA scans are covered when medically necessary. Documentation in the progress notes must reflect medical necessity for the MRI. Description: MRI is a noninvasive diagnostic scanning technique of representing the distribution of water and other hydrogen-rich molecules in the body in the absence of ionizing radiation and in the presence of a powerful, highly uniform, static magnetic field. HCPCS CODES MRI upper extremity MRI upper extremity with contrast MRI upper extremity with and without contrast MRI lower extremity MRI lower extremity with contrast MRI lower extremity with and without contrast COVERED ICD-9 CODES Salmonella Osteomyelitis Malignant neoplasm of scapula and long bones of upper limb Malignant neoplasm of short bones of upper limb Malignant neoplasm of long bones of lower limb Malignant neoplasm of short bones of lower limb Malignant neoplasm of upper limb, including shoulder Maligant neoplasm of lower limb, including hip Malignant neoplasm of pelvis Malignant neoplasm of upper limb Malignant neoplasm of lower limb Secondary malignant neoplasm of bone and bone marrow Reticulosarcoma - lymph nodes of axilla and upper limb lymph nodes of inguinal region and lower limb intrapelvic lymph nodes Lymphosarcoma - lymph nodes of axilla and upper limb lymph nodes of inguinal region and lower limb intrapelvic lymph nodes Burkitt's tumor or lymphoma - lymph nodes of axilla and upper limb lymph nodes of inguinal region and lower limb intrapelvic lymph nodes Lymphosarcoma and reticulosarcoma, other named variants - lymph nodes of axilla and upper limb lymph nodes of inguinal region and lower limb intrapelvic lymph nodes Hodgkin's paragranuloma - lymph nodes of axilla and upper limb

2 lymph nodes of inguinal region and lower limb intrapelvic lymph nodes Hodgkin's granuloma - lymph nodes of axilla and upper limb lymph nodes of inguinal region and lower limb intrapelvic lymph nodes Hodgkin's sarcoma - lymph nodes of axilla and upper limb lymph nodes of inguinal region and lower limb intrapelvic lymph nodes Hodgkin's-Lymphocytic-histiocytic predominance - lymph nodes of axilla and upper limb lymph nodes of inguinal region and lower limb intrapelvic lymph nodes Hodgkin's - Nodular sclerosis - lymph nodes of axilla and upper limb lymph nodes of inguinal region and lower limb intrapelvic lymph nodes Hodgkin's - Mixed cellularity - lymph nodes of axilla and upper limb lymph nodes of inguinal region and lower limb intrapelvic lymph nodes Hodgkin's - Lymphocytic depletion - lymph nodes of axilla and upper limb lymph nodes of inguinal region and lower limb intrapelvic lymph nodes Nodular lymphoma - lymph nodes of axilla and upper limb lymph nodes of inguinal region and lower limb intrapelvic lymph nodes Mycosis fungoides - lymph nodes of axilla and upper limb lymph nodes of inguinal region and lower limb intrapelvic lymph nodes Sezary's disease - lymph nodes of axilla and upper limb lymph nodes of inguinal region and lower limb intrapelvic lymph nodes Malignant histiocytosis - lymph nodes of axilla and upper limb lymph nodes of inguinal region and lower limb intrapelvic lymph nodes Leukemic reticuloendotheliosis - lymph nodes of axilla and upper limb lymph nodes of inguinal region and lower limb intrapelvic lymph nodes Malignant mast cell tumors - lymph nodes of axilla and upper limb lymph nodes of inguinal region and lower limb intrapelvic lymph nodes Brachial plexus lesions Nerve root and plexus disorders, lumbosacral plexus lesions Abdominal aneurysm, without mention of rupture Arterial embolism and thrombosis, upper extremity Artheroembolism of upper extremity Kaschin-Beck disease, pelvic region and thigh Kaschin-Beck disease, lower leg Kaschin-Beck disease, ankle and foot Derangement of anterior horn of medial meniscus Derangement of posterior horn of medial meniscus Derangement of lateral meniscus, unspecified Bucket handle tear of lateral meniscus Derangement of anterior horn of lateral meniscus

3 Derangement of posterior horn of lateral meniscus Derangement of meniscus, not elsewhere classifed Loose body in knee Loose body in joint, shoulder region Loose body in joint, upper arm Loose body in joint, forearm Loose body in joint, hand Loose body in joint, pelvic region and thigh Loose body in joint, ankle and foot Pathological dislocation, shoulder region Pathological dislocation, upper arm Pathological dislocation, forearm Pathological dislocation, hand Pathological dislocation, pelvic region and thigh Pathological dislocation, lower leg Pathological dislocation, ankle and foot Recurrent dislocation of joint, shoulder region Recurrent dislocation of joint, upper arm Recurrent dislocation of joint, forearm Recurrent dislocation of joint, hand Recurrent dislocation of joint, pelvic region and thigh Recurrent dislocation of joint, lower leg Recurrent dislocation of joint, ankle and foot Contracture of joint, shoulder region Contracture of joint, upper arm Contracture of joint, forearm Hemathrosis, shoulder region Hemathrosis, upper arm Hemathrosis, forearm Hemathrosis, hand Hemathrosis, pelvic region and thigh Hemathrosis, ankle and foot Villondular synovitis, shoulder region Villondular synovitis, upper arm Villondular synovitis, forearm Villondular synovitis, hand Villondular synovitis, pelvic region and thigh Villondular synovitis, lower leg Villondular synovitis, ankle and foot Calcifying tendinitis of shoulder Enthesopathy of wrist and carpus Enthesopathy of hip region Giant cell tumor of tendon sheath Complete rupture of rotator cuff Nontraumatic rupture of tendons of biceps (long head) Nontraumatic rupture of extensor tendons of hand and wrist Nontraumatic rupture of flexor tendons of hand and wrist Nontraumatic rupture of quadriceps tendon Nontraumatic rupture of patellar tendon Nontraumatic rupture of achilles tendon Progressive myositis ossificans

4 Traumatic myositis ossificans Rupture of muscle, nontraumatic Necrotizing fasciitis Residual foreign body in soft tissue Acute osteomylitis, shoulder region Acute osteomylitis, upper arm Acute osteomylitis, forearm Acute osteomylitis, hand Acute osteomylitis, pelvic region and thigh Acute osteomylitis, lower limb Acute osteomylitis, ankle and foot Chronic osteomyelitis, shoulder region Chronic osteomyelitis, upper arm Chronic osteomyelitis, forearm Chronic osteomyelitis, hand Chronic osteomyelitis, pelvic region and thigh Chronic osteomyelitis, lower leg Chronic osteomyelitis, ankle and foot Periostitis without mention of osteomyelitis, shoulder region Periostitis without mention of osteomyelitis, upper arm Periostitis without mention of osteomyelitis, forearm Periostitis without mention of osteomyelitis, hand Periostitis without mention of osteomyelitis, pelvic region and thigh Periostitis without mention of osteomyelitis, lower leg Periostitis without mention of osteomyelitis, ankle and foot Osteopathy resulting from poliomyelitis, pelvic region and thigh Osteopathy resulting from poliomyelitis, lower leg Osteopathy resulting from poliomyelitis, ankle and foot Osteitis deformans without mention of bone tumor Juvenile osteochondrosis of hip and pelvis Nontraumatic slipped upper femoral epiphysis Juvenile osteochondrosis of upper extremity Juvenile osteochondrosis of lower extremity, excluding foot Juvenile osteochondrosis of foot Osteochondrosis dissecans Pathologic fracture of humerus Pathologic fracture of distal radius and ulna Pathologic fracture of neck of femur Pathologic fracture of other specified part of femur Pathologic fracture of tibia or fibula Pathologic fracture of other specified site Asceptic necrosis of bone, head of humerus Asceptic necrosis of bone, head and neck of femur Asceptic necrosis of bone, medial femoral condyle Asceptic necrosis of bone, talus Osteitis condensans Algoneurodystrophy Malunion of fracture Nonunion of fracture Longitudinal deficiency, radioulnar, complete or partial (with or without distal deficiencies, incomplete)

5 Longitudinal deficiency, radial, complete or partial (with or without distal deficiencies, incomplete) Longitudinal deficiency, ulnar, complete or partial (with or without distal deficiencies, incomplete) Longitudinal deficiency, carpals or metacarpals, complete or partial (w/wo incomplete phalangeal deficiency) Longitudinal deficiency, phalanges, complete or partial Longitudinal deficiency, combined, involving femur, tibia and fibula (complete of incomplete) Longitudinal deficiency, femoral, complete or partial (with or without distal deficiencies, incomplete) Longitudinal deficiency, tibiofibular, complete or partial (with or without distal deficiencies, incomplete) Longitudinal deficiency, tibia, complete or partial (with or without distal deficiencies, incomplete) Longitudinal deficiency, fibular, complete or partial (with or without distal deficiencies, incomplete) Longitudinal deficiency, tarsals or metatarsals, complete or partial (w/wo incomplete phalangeal deficiency) Longitudinal deficiency, phalanges, complete or partial Congenital deformity of clavicle Congenital elevation of scapula Radioulnar synostosis Madelung's deformity Acrocephalosyndactyly Accessory carpal bones Macodactylia (fingers) Cleft hand, congenital Coxa valga, congenital Coxa vara, congenital Congenital deformity of knee (joint) Macrodactylia of toes Closed dislocation of shoulder, anterior dislocation of humerus Closed dislocation of shoulder, posterior dislocation of humerus Closed dislocation of shoulder, inferior dislocation of humerus Closed dislocation of shoulder, acromioclavicular (joint) Open dislocation of shoulder, anterior dislocation of humerus Open dislocation of shoulder, posterior dislocation of humerus Open dislocation of shoulder, inferior dislocation of humerus Open dislocation of shoulder, acromioclavicular (joint) Closed dislocation of elbow, anterior Closed dislocation of elbow, posterior Closed dislocation of elbow, medial Closed dislocation of elbow, lateral Open dislocation of elbow, anterior Open dislocation of elbow, posterior Open dislocation of elbow, medial Open dislocation of elbow, lateral Closed dislocation of wrist, radioulnar (joint), distal Closed dislocation of wrist, radiocarpal (joint) Closed dislocation of wrist, midcarpal (joint) Closed dislocation of wrist, carpometacarpal (joint) Closed dislocation of wrist, metacarpal (bone), proximal end Open dislocation of wrist, radioulnar (joint), distal Open dislocation of wrist, radiocarpal (joint)

6 Open dislocation of wrist, midcarpal (joint) Open dislocation of wrist, carpometacarpal (joint) Open dislocation of wrist, metacarpal (bone), proximal end Closed dislocation of finger, metacarpophalangeal (joint) Closed dislocation of finger, interphalangeal (joint), hand Open dislocation of finger, metacarpophalangeal (joint) Open dislocation of finger, interphalangeal (joint), hand Closed dislocation of hip, posterior Closed dislocation of hip, obtruator Closed dislocation of hip, other anterior Open dislocation of hip, posterior Open dislocation of hip, obtruator Open dislocation of hip, other anterior Tear of medial cartilage or meniscus of knee, current Tear of lateral cartilage or meniscus of knee, current Other tear of cartilage or meniscus of knee, current Dislocation of patella, closed Dislocation of patella, open Other dislocation of knee, closed, anterior dislocation of tibia, proximal end Other dislocation of knee, closed, posterior dislocation of tibia, proximal end Other dislocation of knee, closed, medial dislocation of tibia, proximal end Other dislocation of knee, closed, lateral dislocation of tibia, proximal end Other dislocation of knee, open, anterior dislocation of tibia, proximal end Other dislocation of knee, open, posterior dislocation of tibia, proximal end Other dislocation of knee, open, medial dislocation of tibia, proximal end Other dislocation of knee, open, lateral dislocation of tibia, proximal end Dislocation of ankle, closed Dislocation of ankle, open Closed dislocation of foot, midtarsal (joint) Closed dislocation of foot, tarsometatarsal (joint) Closed dislocation of foot, metatarsophangeal (joint) Closed dislocation of foot, interphalangeal (joint), foot Open dislocation of foot, midtarsal (joint) Open dislocation of foot, tarsometatarsal (joint) Open dislocation of foot, metatarsophangeal (joint) Open dislocation of foot, interphalangeal (joint), foot Complications of reattached extremity or body part, forearm Complications of reattached extremity or body part, hand Complications of reattached extremity or body part, finger(s) Complications of reattached extremity or body part, foot and toe(s) Contraindications: 1. Patients with cardiac pacemakers or metallic clips on vascular aneurysms or other metallic implants. 2. Patients requiring life support systems and monitoring devices which employ Ferro magnetic materials (metal that could be magnetized). 3. Patients who have claustrophobia. 4. Patients who have ferrous ocular foreign bodies, imbedded shrapnel fragments or cochlear implants. Coding Guidelines:

7 Diagnosis codes other than those listed above will require review for medical necessity and prior authorization. Documentation Requirements The ordering physician is responsible for certifying the medical necessity of the procedure. The physician must have documentation in the medical record to support the referral. Documentation in the progress notes must reflect medical necessity for the MRI. Medical records can be used in any post-payment review and must include the information necessary to substantiate the need for the procedure.