LCD L33619

Coverage Guidance

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Title XVIII of the Social Security Act, Section 1862(a)(1)(A).

This section states that no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e).

This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

CMS Publications:

CMS Publication 100-03,Medicare National Coverage Determinations Manual(NCD), Chapter 1:

220.5 Ultrasound Diagnostic Procedures

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 7:

50 Billing Part B Radiology Services and Other Diagnostic Procedures

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12:

70 Payment Conditions for Radiology Services

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 13:

10.1 Billing Part B Radiology Services and Other Diagnostic Procedures

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 16:

40.2 Payment Limit for Purchased Services

Indications and Limitations of Coverage

Abstract:

Ultrasound of the extremity is a non-invasive imaging technique that uses high-frequency sound waves to evaluate the extremities (arms and legs), providing real-time, two-dimensional images. Longitudinal, transverse and oblique images of the area of interest are obtained. Ultrasound, echography and sonography are all terms that may be used interchangeably to describe this particular imaging technique. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these services.

Indications:

Extremity ultrasound is indicated for the following conditions:

• To detect cysts, abscesses, tumors (including evaluation of size of tumors) and effusion;

• To distinguish solid tumors from fluid-filled cysts;

• To evaluate tendons (including tears, tendonitis and tenosynovitis), joints, plantar fascia, ligaments, soft tissue masses, ganglion cysts, intermetatarsal neuroma and stress fractures of the metatarsals;

• To aid in the diagnosis of and surgical removal of foreign bodies.

Limitations:

• Extremity ultrasound must be performed by qualified and knowledgeable physicians and/or technicians (sonographers) under the general supervision of a physician.

• Extremity ultrasound is limited to studies of the arms and legs.

• Extremity ultrasound is considered not medically necessary for the routine diagnosis or management of the following conditions:

- bunions;

- cellulitis;

- neuromas (where the clinical impression is obvious and ultrasound is not likely to add further information);

- paronychia;

- plantar warts; or

- superficial abscesses.

• Bilateral studies are allowed only if there is pathology of both extremities dictating medical necessity for two distinct examinations. It is not reasonable and necessary to perform the contralateral extremity as a "control."

• Extremity ultrasound is considered not medically necessary for diagnosis or management of neuromas, superficial ganglia, bursae and abscesses unless there is documented evidence of some clinical presentation that obscures the clinician's ability to establish these simple clinical diagnoses.

• Extremity ultrasound is considered not medically necessary in the initial determination (diagnosis) of plantar fasciitis. A single diagnostic extremity ultrasound may be medically necessary for plantar fasciitis when the diagnosis is still uncertain after a failed course of conservative management. Repeated extremity ultrasound is not medically necessary in plantar fasciitis.

• Extremity ultrasound of the same extremity more than two times in six months is rarely medically reasonable and necessary (see the “Documentation Requirements” and “Utilization Guidelines” sections below).

Summary of Evidence

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Analysis of Evidence

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Bibliography

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