I89.1 — Lymphangitis
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This billing and coding guideline complements Local Coverage Determination (LCD) L34424 for Magnetic Resonance Angiography; refer to LCD L34424 for clinical indications, medical necessity criteria, and specific coding rules.
- Medical records must document that MRA is reasonable and necessary for the patient's diagnosis or treatment and, where claimed, that it replaces a more invasive test and reduces risk; coverage follows CMS NCD Pub. 100-03, Ch.1, Pt.4, §220.2.
- For lymphedema: documentation of failure of a four-week trial of conservative medical management including ALL of the following: home exercise program; limb elevation; compression bandage or compression garment use.
- For CVI with venous stasis ulcers: documentation that the individual has received medically-supervised treatment of the ulcer(s) for at least 24 weeks using standard wound care treatment (including compression, wound dressings, exercise, elevation), and documentation of failure of the ulcer(s) to decrease in size or demonstrate improvement despite conventional therapy.
Key Coverage Criteria
- MRA (with or without contrast) is covered when it can replace a more invasive diagnostic test (e.g., contrast angiography) and thereby reduce risk to the beneficiary.
- MRA is covered for diagnosis and assessment of diseases and abnormalities of the arterial, venous, and lymphatic systems at any anatomic location when reasonable and necessary for the specific patient's diagnosis or treatment.
- Coverage and definition of MRA are subject to the CMS Internet-Only Manual, Pub. 100-03, Medicare NCD Manual, Chapter 1, Part 4, §220.2; MRA is considered appropriate consistent with that NCD.
- A standard pneumatic compression device (HCPCS code E0650, E0651) and associated appliances (HCPCS code E0655, E0660, E0665-E0669, E0671-E0673) used in the home setting are considered medically necessary for EITHER of the following:
- - for the treatment of intractable lymphedema when there is failure of a four-week trial of conservative medical management including ALL of the following: > home exercise program > limb elevation > compression bandage or compression garment use
- - for the treatment of chronic venous insufficiency (CVI) with venous stasis ulcer(s) of lower extremities when BOTH of the following criteria are met: > The individual has received medically-supervised treatment of the ulcer(s) for at least 24 weeks using standard wound care treatment, including compression, wound dressings, exercise, and elevation of the limb. > Failure of the ulcer(s) to decrease in size or demonstrate improvement despite conventional therapy.
6 Active Policies
CIGNA-0538 — Flow Cytometry - (0538)
CIGNA-CPG129 — Electrodiagnostic Testing (EMG/NCV) - (CPG129)
CIGNA-0354 — Compression Devices - (0354)
A59845 — Billing and Coding: Magnetic Resonance Angiography
A56775 — Billing and Coding: Magnetic Resonance Angiography
Related Codes
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