CMS Pub. 100-03, ch. 1, § 220.5

A. General

Ultrasound diagnostic procedures utilizing low energy sound waves are being widely employed to determine

the composition and contours of nearly all body tissues except bone and air-filled spaces. This technique

permits noninvasive visualization of even the deepest structures in the body. The use of the ultrasound

technique is sufficiently developed that it can be considered essential to good patient care in diagnosing a

wide variety of conditions.

Ultrasound diagnostic procedures are listed below and are divided into two categories. Medicare coverage is

extended to the procedures listed in Category I. Periodic claims review by A/B MAC (A) medical

consultants should be conducted to ensure that the techniques are medically appropriate and the general

indications specified in these categories are met. Techniques in Category II are considered experimental and

should not be covered at this time.

B. Nationally Covered Indications

Category I - (Clinically effective, usually part of initial patient evaluation, may be an adjunct to radiologic

and nuclear medicine diagnostic technique)

• Echoencephalography, (Diencephalic Midline) (A-Mode)

• Echoencephalography, Complete (Diencephalic Midline and Ventricular Size)

• Ocular and Orbital Echography (A-Mode)

• Covered procedures include efforts to determine the suitability of aphakic patients for implantation of an

artificial lens (pseudophakoi) following cataract surgery.

• Ocular and Orbital Sonography (B-Mode)

• Echocardiography, Pericardial Effusion (M-Mode)

• Pericardiocentesis, by Ultrasonic Guidance

• Echocardiography, Cardiac Valve(s) (M-Mode)

• Echocardiography, Complete (M-Mode)

• Echocardiography, limited (e.g., follow-up or limited study) (M-Mode)

• Pleural Effusion Echography

• Thoracentesis, by Ultrasonic Guidance

• Abdominal Sonography, complete survey study (B-Scan)

• Abdominal Sonography, limited (e.g., follow-up or limited study) (B-Scan)

• Abdominal Sonography is not synonymous with ultrasound examination of individual organs.

• Renal Cyst Aspiration, by Ultrasonic Guidance

• Renal Biopsy, by Ultrasonic Guidance

• Pancreas Sonography (B-Scan)

• Pancreatic Sonography has proven effective in diagnosing pseudocysts.

• Spleen Sonography (B-Scan)

• Abdominal Aorta Echography (A-Mode)

• Abdominal Aorta Sonography (B-Scan)

• Retroperitoneal Sonography (B-Scan)

• Retroperitoneal Sonography does not include planning of fields for radiation therapy.

• Urinary Bladder Sonography (B-Scan)

• Urinary bladder Sonography does not include staging of bladder tumors.

• Pregnancy Diagnosis Sonography (B-Scan)

• Fetal Age Determination (Biparietal Diameter) Sonography (B-Scan)

• Fetal Growth Rate Sonography (B-Scan)

• Placenta Localization Sonography (B-Scan)

• Pregnancy Sonography, Complete (B-Scan)

• Molar Pregnancy Diagnosis Sonography (B-Scan)

• Ectopic Pregnancy Diagnosis Sonography (B-Scan)

• Passive Testing (Antepartum Monitoring of Fetal Heart Rate In the Resting Fetus)

• Intrauterine Contraceptive Device Sonography (B-Scan)

• Pelvic Mass Diagnosis Sonography (B-Scan)

• Amniocentesis, by Ultrasonic Guidance

• Arterial Flow Study, Peripheral (Doppler)

• Venous Flow Study, Peripheral (Doppler)

• Arterial Aneurysm, Peripheral (B-Scan)

• Radiation Therapy Planning Sonography (B-Scan)

• Thyroid Echography (A-Mode)

• Thyroid Sonography (B-Scan)

• Breast Echography (A-Mode)

• Breast Sonography (B-Scan)

• Hepatic Sonography (B-Scan)

• Gallbladder Sonography

• Renal Sonography

• Two-Dimensional Echocardiography (B-Mode)

• Monitoring of cardiac output (Esophageal Doppler) for ventilated patients in the ICU and operative

patients with a need for intra-operative fluid optimization

C. Nationally Non-Covered Indications

Category II - (Clinical reliability and efficacy not proven)

• B-Scan for atherosclerotic narrowing of peripheral arteries.

D. Other

Uses for ultrasound diagnostic procedures not listed in Category I or II above are left to local MAC

discretion. In view of the rapid changes in the field of ultrasound diagnosis, uses for ultrasound diagnostic

procedures other than those listed under Categories I and II should be carefully reviewed before payment.

Medical justification may be required.

Cross reference: §20.17