A9585, Injection, gadobutrol, 0.1 ml
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- A legible medical record must document the condition, clinical findings, relevant prior treatment, and clearly justify the necessity and reasonableness of the lumbar MRI.
- The documentation must clearly support the ICD-10-CM code(s) reported on the claim.
- An attending or treating physician's order, properly signed and dated, is required for each lumbar MRI test.
- Radiologists and ordering physicians must include sufficient clinical information in the MRI report to justify necessity; the MRI report or clinical record must document clinical findings and relevant prior treatment.
Key Coverage Criteria
- Initial lumbar MRI is covered when the test is medically reasonable and necessary and the medical record documents clinical rationale and supports the ICD-10-CM code(s) billed.
- A second lumbar MRI for the same patient is allowable when documentation shows comparative test results are needed to make a more definitive treatment decision.
- Multiple scans of different body areas performed on the same day for the same patient are payable when each scan is reasonable and necessary.
- Lumbar MRI is covered to evaluate suspected spinal neoplasm or to differentiate recurrent tumor from scar or granulation tissue.
- Lumbar MRI is covered to evaluate suspected infection of the spine, including osteomyelitis and spinal cord abnormalities associated with osteomyelitis.
- Lumbar MRI is covered when imaging information is necessary to determine need for surgery or other aggressive therapy (e.g., work-up for metastatic cancer or preoperative planning).
3 Active Policies
NORIDIAN-L34220, Lumbar MRI
JF
A57206, Billing and Coding: Lumbar MRI
EVICORE-HPLAN-CIGNA_MEDICARE-68F4526A04BF, 1199SEIU Radiology and Cardiology Claims Studio Code List - Effective 01/01/2026
Related Codes
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