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  • NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden to download the files unless you read, agree to, and abide by the provisions of the copyright statement. Read the copyright statement now and you will be linked back to here.

  • Retroperitoneal Ultrasound (DL34577) Page 1 of 46

    PROPOSED/DRAFT Local Coverage

    Determination (LCD):

    Retroperitoneal Ultrasound (DL34577)

    Please Note: This view is an approximation of the CMS MCD LCD Detail page.

    ICD-10 codes R74.0, R74.8, R10.11 and R10.12 will be added to this draft LCD when it is finalized due to a reconsideration request that was received on the current active LCD.

    Please Note: This is a Proposed/Draft policy. Proposed/Draft LCDs are works in progress that are available on the Medicare Coverage

    Database site for public review. Proposed/Draft LCDs are not necessarily a reflection of the current policies or practices of the contractor.

    Contractor Information

    Contract Name

    Contract Type Contract Number

    Jurisdiction State(s)

    Palmetto GBA

    A and B and HHH MAC

    11201 J - M South Carolina

    Palmetto GBA

    A and B and HHH MAC

    11301 J - M Virginia

    Palmetto GBA

    A and B and HHH MAC

    11401 J - M West Virginia

    Palmetto GBA

    A and B and HHH MAC

    11501 J - M North Carolina

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  • Retroperitoneal Ultrasound (DL34577) Page 2 of 46

    Proposed/Draft LCD Information

    Document Information

    Source LCD ID L34577

    Proposed/Draft LCD ID DL34577

    Proposed/Draft LCD Title Retroperitoneal Ultrasound

    AMA CPT / ADA CDT / AHA NUBC Copyright

    Statement CPT only copyright 2002-2016 American

    Medical Association. All rights reserved.

    CDT only copyright 2016 American Dental Association. All rights reserved.

    UB-04 Manual. OFFICIAL UB-04 DATA


    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


    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.

    Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical 9/23/2016

  • Retroperitoneal Ultrasound (DL34577) Page 3 of 46


    CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.6.2

    CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §220.5 Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity

    Retroperitoneal ultrasound studies represent the ultrasonic imaging of retroperitoneal organs for the diagnosis and management of abnormalities that occur in the retroperitoneum.

    A complete study visualizes all the structures or organs within the anatomic description of that study. A limited study involves a single quadrant or a single diagnostic problem or an evaluation of an organ of interest.

    Retroperitoneal ultrasonography may be considered reasonable and necessary for the diagnosis and treatment of the following areas:

    1. Pancreas

    2. Abdominal aorta - Ultrasound is accurate for aortic measurement and may be used to follow patients with aneurysms.

    3. Inferior vena cava- Ultrasound is useful in the detection of invasion by adjacent tumors and identification of obstruction levels.

    4. Kidneys, ureter, and bladder:

    a) Kidneys-

    i) May confirm scarred or small kidneys in chronic renal cortical disease (but may be of no use in detecting early or mild cortical disorders or to categorize specific types of cortical diseases).

    ii) May be useful in detecting and following renal cysts and localizing solid masses.

    iii) May be useful as a primary diagnostic tool in patients with suspected renal disease.

    b) Ureter- Normal ureters are usually not well visualized by ultrasound, especially in their mid-portions. Renal ultrasound is the primary mode of diagnosis of a renal obstruction which is demonstrated by dilated ureters. It may be helpful in identifying filling defects or a mass, in its most proximal or distal portions. Ultrasound has no role 9/23/2016

  • Retroperitoneal Ultrasound (DL34577) Page 4 of 46

    in vesicle ureteral reflux.

    c) Bladder- Tumors of the bladder are most efficiently followed by cystoscopy and urography. However, ultrasound is useful in following intraluminal bladder tumors with or without extraluminal extension, including evaluation of bladder wall thickness and irregularity and evaluating post void residual at the bedside.

    5. Renal transplants- Ultrasound is indicated to detect urinary obstruction, fluid collection, and complications of renal transplants and is considered a primary tool in this endeavor. The presence or absence of signs and symptoms dictate utilization frequency of this modality for renal transplants.

    6. Adenopathy- CT is far more accurate than ultrasound in detecting and delineating adenopathy. Ultrasound in this instance should be considered secondary and rarely utilized in the detection or follow up of nodal disease.

    7. Prostate- Evaluation of the prostate is primarily done transrectally by ultrasound.

    8. Adrenal Gland- Ultrasound is of little value since a computed tomography (CT) scan is considered more accurate.

    9. Organs located in the retroperitoneal region-Ultrasound may be helpful in the evaluation of wounds, contusions, and lacerations of organs located in the retroperitoneal region.

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    Proposed/Draft Process Information

    Associated Information Documentation Requirements

    Documentation supporting 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 Guidelines

    If the physical exam has primary findings for the involvement of non-retroperitoneal structures/organs (gallbladder, liver, spleen, common bile duct, etc.), even though it may be necessary to visualize retroperitoneal structures in the course of the procedure, a full abdominal ultrasound would be required in most cases to be diagnostic, and that is the procedure that should be performed and billed.

    For screening coding instructions, refer to the Once in a Lifetime Abdominal Aortic 9/23/2016

  • Retroperitoneal Ultrasound (DL34577) Page 5 of 46

    Aneurysm (AAA) Screening Article A55071 located in the Related Local

    Coverage Documents section of this LCD. Sources of Information and Basis for Decision Clemente CD, ed. Anatomy, A Regional Atlas of the Human Body. Baltimore-Munich:

    Urban and Schwarzenberg;1981.

    Fauci AS, Braunwald E, Isselbacher KJ, et al. Harrison's Principles of Internal

    Medicine.14th ed. New York, NY: McGraw-Hill;1998.

    Open Meetings/Part B MAC Contractor Advisory Committee (CAC) Meetings

    Meeting Date Meeting Type Meeting State(s) Meeting Information

    10/13/2016 Open Meeting North Carolina Durham

    10/13/2016 CAC Meeting North Carolina Durham

    Comment Period Start Date 10/13/2016 Comment Period End Date 11/28/2016 Released to Final LCD Date Not yet released. Reason for Proposed LCD Provider Education/Guidance Other: Proposed Contact Part A Policy PO Box 100238 AG-275 Columbia, South Carolina 29202-3238 [email protected]

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    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. 9/23/2016

  • Retroperitoneal Ultrasound (DL34577) Page 6 of 46

    Revenue Codes:

    Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this s