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. Coverage is extended to the procedures listed in Category I. Periodic claims review by the intermediary’s 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/investigational, and therefore, not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

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 

Nationally Non-Covered Indications

Category II - (Clinical reliability and efficacy not proven) 

• B-Scan for atherosclerotic narrowing of peripheral arteries

Other Uses
The field of ultrasound is rapidly evolving. Uses for ultrasound diagnostic procedures not listed in Category I or II above should be given individual consideration. The patient’s clinical records should document the medical necessity for the procedure performed and be available for review upon request. 

Documentation Requirements

The patient’s clinical records must document the medical necessity for the procedure and that the indications specified as eligible. These records should be available for review upon request.

Provider News

08/2011, Attention FreedomBlue network providers: denial reason changing for certain services

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1156(a)(1). This section states that the healthcare practitioner must assure services will be provided economically and only when, and to the extent, medically necessary.

CMS Online Manual Pub. 100-3, Chapter 1, Section 220.5

Ultrasonic Guidance Procedures

Other Procedures