Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that three-dimensional imaging is medically reasonable and necessary only if the outcome will 
potentially impact the diagnosis or clinical course of the patient. Providers are encouraged to obtain additional 
information from referring providers and/or patients or medical records to determine the medical necessity of 
studies performed. Referring physicians are required to provide appropriate diagnostic information to the 
performing provider. As with any diagnostic testing, the procedure should be furnished in accordance with 
accepted standards of medical practice based on the patients diagnosis, signs, and symptoms. This additional 
procedure applied to a base procedure must meet but not exceed the patients medical need. Three dimensional 
rendering codes should be reserved for situations where the additional image is necessary for a complete 
depiction of an abnormality from the 2D study or for surgical planning. For non-hospital based outpatient 
services, it is expected that the ordering/referring physician/non-physician practitioner generate a written 
order/referral indicating the medical necessity for the additional 3D imaging. In addition, it is expected that the 
interpreting physician maintain a copy of the test results and interpretation along with a copy of the 
ordering/referring physician/non-physician practitioners order for the study. The interpreting physicians 
report should address the medical necessity identified by the ordering/referring physician/non-physician 
practitioner. In the event it is deemed by the interpreting physician that a 3D interpretation is urgently needed 
and the ordering/referring physician/non-physician practitioner is not immediately available, the interpreting 
physician must document the following on the radiology report: the time of the study; specific medical need for 
the study; and a legible summary of the findings that were urgently transmitted to the ordering/referring 
physician/non-physician practitioner whose name is on the order for the study. For hospital based services 
(inpatient/outpatient), it is expected that there should be an order for the 3D image. In the absence of the order 
for the 3D image, if the hospitals interpreting physician deems that the 3D interpretation is needed, he or she 
should clearly state in the interpretation the medical necessity for this separate service, in addition to the base 
procedure. 
 
Limitations 
3D rendering with interpretation and reporting requiring and not requiring image post processing will not be 
considered medically reasonable and necessary if equivalent information obtained from the test has already 
been provided by another procedure (ultrasound, MRI, angiography, etc.) or if it could be provided by a 
standard CT scan (two-dimensional) without reconstruction. 3D rendering with interpretation and reporting during a radiation oncology episode of care is included in 3D 
simulation when applicable or IMRT plan when applicable and, therefore, should not be billed. 
Three-dimensional imaging will not be covered when performed based on internal protocols of the testing 
facility; a referral for one 3D imaging is not a blanket referral for all studies. In most cases, it is expected that 
the provider treating the patient specifically orders the procedure in writing and that the order should be on 
record for each 3D imaging performed. For guidance regarding ordering tests, provider qualifications and 
supervision of diagnostic testing, please refer to 42 CFR 410.32 - Diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests: Conditions. For guidelines regarding conditions of participation, please refer to 
42 CFR 482.26 - Condition of participation: Radiologic services. As published in the CMS IOM Publication 
100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by 
a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). 
Contractors shall determine and describe the circumstances under which the item or service is considered 
reasonable and necessary. You can find this rule at the Medicare Local Coverage Determination (LCD)- 
L33256, 3D Interpretation and Reporting of Imaging Studies.  
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.