R55, Syncope and collapse
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For services requiring a referring/ordering physician, the claim must report the referring/ordering physician's name and NPI.
- A valid ICD-10-CM diagnosis code that best describes the patient's condition for which the service was performed must be reported on the claim; claims without a valid code will be returned as incomplete.
- For diagnostic MRA tests, report the result of the test if known; if not known, report the symptoms that prompted the test.
- The patient's medical record must contain documentation fully supporting medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Key Coverage Criteria
- MRA is covered to evaluate blood flow in the internal carotid vessels of the head and neck.
- MRA of peripheral arteries of the lower extremities is covered to determine the presence and extent of peripheral vascular disease and may substitute for conventional angiography (CA).
- MRA is covered for pre-operative evaluation of patients undergoing elective abdominal aortic aneurysm (AAA) repair when it is comparable to CA for determining extent of AAA and evaluating aortoiliac occlusive disease and renal artery pathology necessary for surgical planning.
- MRA of the renal arteries and aortoiliac arteries (in the absence of AAA or aortic dissection) is covered when MRA is expected to avoid CA, physician history/physical and standard assessments are insufficient, and obtaining MRA has a high probability of positively affecting patient management.
- MRA of the chest is covered for diagnosis of suspected pulmonary embolism when the patient has a contraindication to receiving intravascular iodinated contrast material.
- MRA of the chest is covered for pre-operative and post-operative evaluation of thoracic aortic dissection and thoracic aortic aneurysm and may be used as an alternative to other non-invasive imaging when clinically appropriate.
20 Active Policies
CGS-L34087, Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based
J15
CGS-L40243, Temporary Nontherapeutic Ambulatory Cardiac Monitoring Devices
J15
CGS-L33952, Cardiac Event Detection
J15
CGS-L34338, Transthoracic Echocardiography (TTE)
J15
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