Local Coverage Determination (LCD):

Retroperitoneal Ultrasound (L34577)

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Contractor Information
CONTRACTOR NAME CONTRACT TYPE CONTRACT NUMBER JURISDICTION STATE(S)

Palmetto GBA A and B MAC 10111 - MAC A J-J Alabama

Palmetto GBA A and B MAC 10112 - MAC B J-J Alabama

Palmetto GBA A and B MAC 10211 - MAC A J-J Georgia

Palmetto GBA A and B MAC 10212 - MAC B J-J Georgia

Palmetto GBA A and B MAC 10311 - MAC A J-J Tennessee

Palmetto GBA A and B MAC 10312 - MAC B J-J Tennessee

Palmetto GBA A and B and HHH MAC 11201 - MAC A J-M South Carolina

Palmetto GBA A and B and HHH MAC 11202 - MAC B J-M South Carolina

Palmetto GBA A and B and HHH MAC 11301 - MAC A J-M Virginia

Palmetto GBA A and B and HHH MAC 11302 - MAC B J-M Virginia

Palmetto GBA A and B and HHH MAC 11401 - MAC A J-M West Virginia

Palmetto GBA A and B and HHH MAC 11402 - MAC B J-M West Virginia

Palmetto GBA A and B and HHH MAC 11501 - MAC A J-M North Carolina

Palmetto GBA A and B and HHH MAC 11502 - MAC B J-M North Carolina

LCD Information
Document Information
LCD ID Original Effective Date
L34577 For services performed on or after 10/01/2015

Original ICD-9 LCD ID Revision Effective Date

L31601 For services performed on or after 06/13/2019

LCD Title Revision Ending Date

Retroperitoneal Ultrasound N/A

Proposed LCD in Comment Period Retirement Date

N/A N/A

Created on 07/11/2019. Page 1 of 11

 Source Proposed LCD Notice Period Start Date
DL34577 05/18/2017

AMA CPT / ADA CDT / AHA NUBC Copyright Notice Period End Date
Statement 07/02/2017
CPT codes, descriptions and other data only are
copyright 2018 American Medical Association. All Rights
Reserved. Applicable FARS/HHSARS apply.

Current Dental Terminology © 2018 American Dental

Association. All rights reserved.

Copyright © 2019, the American Hospital Association,

Chicago, Illinois. Reproduced with permission. No
portion of the AHA copyrighted materials contained
within this publication may be copied without the
express written consent of the AHA. AHA copyrighted
materials including the UB-04 codes and descriptions
may not be removed, copied, or utilized within any
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Specifications, contact Tim Carlson at (312) 893-6816
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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are
considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the
functioning of a malformed body member.

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

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.6.2

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4,
§220.5

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Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity

Retroperitoneal ultrasound (US) studies represent the ultrasonic imaging of retroperitoneal organs for the diagnosis
and management of abnormalities that occur within the retroperitoneum. A complete retroperitoneal US study
visualizes all the structures or organs within the anatomic description of that study. A limited study involves an
imaging of only a single quadrant, a single diagnostic problem, or an evaluation of a specific organ of interest.
Retroperitoneal ultrasonography may be considered reasonable and necessary for the diagnosis and treatment of the
following organs and retroperitoneal structures:

1. Pancreas

2. Abdominal aorta- US is accurate for aortic measurement and may be used to follow patients with aortic
aneurysms.

3. Inferior vena cava - US is useful in the detection of invasion by adjacent tumors and identification of obstruction
levels.

4. Kidneys, ureter, and bladder:

a) Kidneys-

i) May confirm scarred or small kidneys in chronic renal cortical disease (but may be of no use in detecting
early or mild cortical disorders or to categorize specific types of cortical diseases).

ii) May be useful in detecting and following renal cysts and localizing solid masses.

iii) May be useful as a primary diagnostic tool in patients with suspected renal disease.

b) Ureter- Normal ureters are usually not well visualized by US, especially in their mid-portions. Renal US is the
primary mode of diagnosis of a renal obstruction which is demonstrated by dilated ureters. It may be helpful in
identifying filling defects or a mass, in its most proximal or distal portions. US has no role in vesicular ureteral
reflux.

c) Bladder- Tumors of the bladder are most efficiently followed by cystoscopy and urography. However, US is
useful in following intraluminal bladder tumors with or without extraluminal extension, including evaluation of
bladder wall thickness and irregularity and evaluating post void residual at the bedside.

5. Renal transplants- US is indicated to detect urinary obstruction, fluid collection, and complications of renal
transplants and is considered a primary tool in this endeavor. The presence or absence of signs and symptoms
dictate utilization frequency of this modality for renal transplants.

6. Adenopathy- Computed tomography (CT) is far more accurate than US in detecting and delineating adenopathy.
US in this instance should be considered secondary and rarely utilized in the detection or follow up of nodal disease.

7. Prostate- Evaluation of the prostate is primarily done transrectally by US.

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8. Adrenal Gland- US is of little value since a CT scan is considered more accurate.

9. Organs located in the retroperitoneal region- US may be helpful in the evaluation of wounds, contusions, and
lacerations of organs located in the retroperitoneal region.

Summary of Evidence

N/A

Analysis of Evidence
(Rationale for Determination)

N/A

Coding Information
Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.
Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.Complete absence of all
Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally
to all claims.

N/A

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report
this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services
reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all
Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to
apply equally to all Revenue Codes.

N/A

CPT/HCPCS Codes

Group 1 Paragraph:

N/A

Group 1 Codes:

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 CODE DESCRIPTION

XX000 Not Applicable

ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph:

N/A

Group 1 Codes:

ICD-10 CODE DESCRIPTION

XX000 Not Applicable

ICD-10 Codes that DO NOT Support Medical Necessity

N/A

Additional ICD-10 Information

N/A

General Information
Associated Information

Documentation Requirements

Documentation supporting medical necessity should be legible, maintained in the patient's medical record, and must
be made available to the A/B MAC upon request.

Sources of Information

N/A

Bibliography

Clemente CD. Anatomy, A Regional Atlas of the Human Body. 2nd ed. Baltimore MD: Urban and
Schwarzenberg;1981.

Fauci AS, Braunwald E, Isselbacher KJ, et al. Harrison's Principles of Internal Medicine.14th ed. New York, NY:
McGraw-Hill;1998.

Revision History Information

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REVISION REVISION REVISION HISTORY EXPLANATION REASON(S) FOR CHANGE
HISTORY HISTORY
DATE NUMBER

06/13/2019 R21
All coding located in the Coding Information section and all • Provider
verbiage regarding billing and coding under the Associated Education/Guidance
Information section has been moved into the related Billing
and Coding: Retroperitoneal Ultrasound A55336 article and
removed from the LCD. Under Bibliography changes were
made to citations to reflect AMA citation guidelines. Formatting
and punctuation were corrected throughout the LCD.
Acronyms were inserted and defined where appropriate
throughout the LCD.

At this time 21st Century Cures Act will apply to new and
revised LCDs that restrict coverage which requires comment
and notice. This revision is not a restriction to the coverage
determination; and, therefore not all the fields included on the
LCD are applicable as noted in this policy.

10/01/2018 R20
Under ICD-10 Codes that Support Medical Necessity • Revisions Due To
Group 1: Codes the following ICD-10 codes have been ICD-10-CM Code
added: K35.20, K35.21, K35.30, K35.31, K35.32, K35.33, Changes
K35.890, K35.891, K61.31, K61.39, K61.5, K82.A1, K82.A2,
K83.01, K83.09, R82.991, R82.992, R82.993, R82.994,
R93.811, R93.812, R93.813, R93.89, T81.40XA, T81.40XD,
T81.40XS, T81.41XA, T81.41XD, T81.41XS, T81.42XA,
T81.42XD, T81.42XS, T81.43XA, T81.43XD, T81.43XS,
T81.44XA, T81.44XD, T81.44XS, T81.49XA, T81.49XD,
T81.49XS. This revision is due to the Annual ICD-10 Code
Update and becomes effective October 1, 2018.

At this time 21st Century Cures Act will apply to new and
revised LCDs that restrict coverage which requires comment
and notice. This revision is not a restriction to the coverage
determination; and, therefore not all the fields included on the
LCD are applicable as noted in this policy.

05/10/2018 R19
Under ICD-10 Codes That Support Medical Necessity • Reconsideration
added ICD-10 codes N30.01, N30.11, N30.21, N30.31, Request
N30.41, N30.81 and N30.91.

At this time 21st Century Cures Act will apply to new and
revised LCDs that restrict coverage which requires
comment and notice. This revision is not a restriction to
the coverage determination; and, therefore not all the

Created on 07/11/2019. Page 6 of 11

REVISION REVISION REVISION HISTORY EXPLANATION REASON(S) FOR CHANGE
HISTORY HISTORY
DATE NUMBER

fields included on the LCD are applicable as noted in this

policy.

02/26/2018 R18 The Jurisdiction "J" Part B Contracts for Alabama (10112),
• Change in Affiliated
Georgia (10212) and Tennessee (10312) are now being
Contract Numbers
serviced by Palmetto GBA. The notice period for this LCD
begins on 12/14/17 and ends on 02/25/18. Effective
02/26/18, these three contract numbers are being added to
this LCD. No coverage, coding or other substantive changes
(beyond the addition of the 3 Part B contract numbers) have
been completed in this revision.

01/29/2018 R17 The Jurisdiction "J" Part A Contracts for Alabama (10111),
• Change in Affiliated
Georgia (10211) and Tennessee (10311) are now being
Contract Numbers
serviced by Palmetto GBA. The notice period for this LCD
begins on 12/14/17 and ends on 01/28/18. Effective
01/29/18, these three contract numbers are being added to
this LCD. No coverage, coding or other substantive changes
(beyond the addition of the 3 Part A contract numbers) have
been completed in this revision.

10/01/2017 R16
Under ICD-10 Codes That Support Medical Necessity • Revisions Due To
ICD-10-CM Code
Group 1: Codes deleted ICD-10 code E85.8. Under ICD-
Changes
10 Codes That Support Medical Necessity
Group 1: Codes added ICD-10 codes E85.81,
E85.82, E85.89, Q53.111, Q53.112, Q53.211 and
Q53.212. This revision is due to the 2017 Annual ICD-10
Code Updates.

At this time 21st Century Cures Act will apply to new and
revised LCDs that restrict coverage which requires comment
and notice. This revision is not a restriction to the coverage
determination; and, therefore not all the fields included on the
LCD are applicable as noted in this policy.

07/03/2017 R15
Under ICD-10 Codes That Support Medical Necessity • Provider
Group 1: Codes added ICD-10 codes N31.1, N31.2, Education/Guidance
• Reconsideration
N31.8, and N31.9.
Request

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REVISION REVISION REVISION HISTORY EXPLANATION REASON(S) FOR CHANGE
HISTORY HISTORY
DATE NUMBER

07/03/2017 R14 Comments were received. However, no changes were made to

• Provider
this LCD.
Education/Guidance

03/16/2017 R13 Under Coverage Indications, Limitations and/or Medical

• Provider
Necessity deleted CPT code 76706 from the first paragraph.
Education/Guidance
Under CPT/HCPCS Group 1: Codes deleted CPT code 76706.
CPT 76706 is a new CPT effective on 1/1/17 which replaced
the existing Medicare G code (G0389) that was specific to a
screening ultrasound for an abdominal aortic aneurysm (AAA).
Medicare has criteria outlined in the Medicare Claims
Processing Manual which must be met in order for a
beneficiary to be eligible for the AAA screening benefit. This
LCD addresses only diagnostic ultrasound procedures whose
criteria for coverage differ from those for the screening
procedure. CPT 76706 was inadvertently added to the LCD for
diagnostic ultrasound and is being removed. There is no
change in coverage of either the screening or any diagnostic
procedure referenced in the LCD as a result of this action.
Coverage for screening ultrasound for AAA is addressed in
article A55071 which was in effect prior to any changes to LCD
L34577 regarding CPT 76706. Under Associated
Information- Utilization Guidelines deleted the following
verbiage from the last sentence, “…located in the Related
Local Coverage Documents section of this LCD.”

02/27/2017 R12 Under ICD-10 Codes That Support Medical Necessity

• Provider
deleted ICD-10 codes C45.1, C48.1, C48.2, C86.2, C86.3,
Education/Guidance
R10.0, R10.13, R10.84, R11.2, R19.03, R19.04, R19.05, • Revisions Due To
R19.06, R19.07, R19.09, S36.81XA, S36.81XD, and S36.81XS. ICD-10-CM Code
Changes

01/01/2017 R11 Under CPT/HCPCS Codes added CPT code 76706. This
• Provider
revision is due to the 2017 Annual CPT/HCPCS Code Update
Education/Guidance
and becomes effective 1/1/17. • Revisions Due To
CPT/HCPCS Code
Changes

10/31/2016 R10 Under Coverage Indications, Limitations and/or Medical

• Provider
Necessity verbiage was revised for clarification for the first,
Education/Guidance
second, and third paragraphs and for statements #2 and • Other
#4(b). Under Related Local Coverage Documents added
the Retroperitoneal Ultrasound Coding and Billing Article
A55336.

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REVISION REVISION REVISION HISTORY EXPLANATION REASON(S) FOR CHANGE
HISTORY HISTORY
DATE NUMBER

10/31/2016 R9 Under CPT/HCPCS Group 1: Codes deleted CPT codes 76700

• Provider
and 76705 as these codes are not specific to retroperitoneal
Education/Guidance
ultrasound but are standard abdominal ultrasounds which • Other
include an examination of the retroperitoneal structures. This
revision is retroactive to 10/01/2015.

10/24/2016 R8 Under ICD-10 Codes that Support Medical Necessity

• Provider
Group 1: Codes added R74.0, R74.8, R10.11 and R10.12 as
Education/Guidance
these codes were inadvertently omitted in the ICD-10 • Revisions Due To
transition to the current LCD. These codes are effective on or ICD-10-CM Code
after October 01, 2015. Changes

10/01/2016 R7 Under ICD-10 Codes That Support Medical Necessity

• Provider
added D47.Z2, K85.00, K85.01, K85.02, K85.10, K85.11,
Education/Guidance
K85.12, K85.20, K85.21, K85.22, K85.30, K85.31, K85.32, • Revisions Due To
K85.80, K85.81, K85.82, K85.90, K85.91, K85.92, K86.81, ICD-10-CM Code
N13.0, R31.21, R31.29, R93.41, R93.421, R93.422, R93.429, Changes
R93.49, R83.011A, T83.011D, T83.011S, T83.012A,
T83.012D, T83.012S, T83.021A, T83.021D, T83.021S,
T83.022A, T83.022D, T83.022S, T83.032A, T83.032D,
T83.032S, T83.512A, T83.512D, T83.512S, T83.592A,
T83.592D, T83.592S, T83.714A, T83.714D, T83.714S,
T83.722A, T83.722D, T83.722S, T83.723A, T83.723D,
T83.723S, T83.724A, T83.724D, T83.724S, D49.511,
D49.512, D49.519, D49.59, I97.620, I97.621, I97.622,
I97.638, I97.648, Q25.42, Q25.43, and Q25.44. Under ICD-
10 Codes That Support Medical Necessity deleted K85.3,
K86.8, K85.0, K85.2, K85.9, K85.1, K85.8, R31.2, and R93.4.
Under ICD-10 Codes That Support Medical Necessity code
descriptions were revised for C81.10, C81.11, C81.12, C81.13,
C81.14, C81.15, C81.16, C81.17, C81.18, C81.19, C81.20,
C81.21, C81.22, C81.23, C81.24, C81.25, C81.26, C81.27,
C81.28, C81.29, C81.30, C81.31, C81.32, C81.33, C81.34,
C81.35, C81.36, C81.37, C81.38, C81.39, C81.40, C81.41,
C81.42, C81.43, C81.44, C81.45, C81.46, C81.47, C81.48,
C81.49, C81.70, C81.71, C81.72, C81.73, C81.74, C81.75,
C81.76, C81.77, C81.78, C81.79, N10, N40.0, and N40.1. This
revision is due to the Annual ICD-10 Code Update and
becomes effective 10/01/16.

09/08/2016 R6 Under Associated Information- Utilization Guidelines for

• Provider
clarification purposes, verbiage was added related to when a
Education/Guidance
full abdominal ultrasound might be required and for coding
instructions for screening procedures.

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REVISION REVISION REVISION HISTORY EXPLANATION REASON(S) FOR CHANGE
HISTORY HISTORY
DATE NUMBER

09/01/2016 R5 Under ICD-10 Codes that Support Medical Necessity

• Provider
added K56.3, K80.00, K80.01, K80.10, K80.11, K80.12,
Education/Guidance
K80.13, K80.18, K80.19, K80.20, K80.21, K80.60, K80.61, • Reconsideration
K80.62, K80.63, K80.64, K80.65, K80.66, K80.67, K80.70, Request
K80.71, K82.0, K82.1, K82.2, K82.3, K82.4, Q44.0, Q44.1 and • Revisions Due To
R11.2. ICD-10-CM Code
Changes

07/21/2016 R4 Under Coverage Indications, Limitations and/or Medical

• Provider
Necessity added the word “the” in front of the word
Education/Guidance
“detection” in 3. Under 4. Kidneys, ureter and bladder the • Reconsideration
verbiage was revised for a(i) and (iii), b and c for clarification Request
purposes. Under 8. added the words “a computed • Other (Verbiage
tomography” in front of the abbreviation “CT” and added the changes made for
word “the” in front of the word “evaluation” in 9. Under clarification.)

CPT/HCPCS Codes added CPT codes 76700 and 76705 due

to a Reconsideration Request.

10/01/2015 R3 Under Coverage Indications, Limitations and/or Medical

• Provider
Necessity under number 2, removed “the” from the
Education/Guidance
description and made a few formatting revisions. • Typographical Error
Under ICD-10 Codes that support Medical Necessity, • Other (Annual
removed “C64.9” as C64.1 and C64.2 are the correct coding validation)
locations for this diagnosis.
Under Associated Information removed “J11”.

10/01/2015 R2 Per CMS Internet-Only Manual, Pub 100-08, Medicare Program

• Other (Bill type
Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only
and/or revenue
“reasonable and necessary” information. All bill type and code removal)
revenue codes have been removed.

10/01/2015 R1 Under Associated Information-Documentation

• Provider
Requirements corrected the sentence to read,
Education/Guidance
“Documentation supporting medical necessity should be • Typographical Error
legible, maintained in the patient's medical record, and must • Other
be made available to the J11 A/B MAC upon request.” Under
Sources of Information and Basis for Decision corrected
the spelling of “Harrison’s” in the following: Fauci AS,
Braunwald E, Isselbacher KJ, et al. Harrison’s Principles of
Internal Medicine. 14th ed. New York, NY: McGraw-Hill;1998.

Associated Documents
Attachments

N/A
Created on 07/11/2019. Page 10 of 11
Related Local Coverage Documents

Article(s)
A55336 - Billing and Coding: Retroperitoneal Ultrasound
A55546
- (MCD Archive Site)LCD(s)
DL34577
- (MCD Archive Site)

Related National Coverage Documents

N/A

Public Version(s)

Updated on 06/07/2019 with effective dates 06/13/2019 - N/A

Updated on 08/31/2018 with effective dates 10/01/2018 - 06/12/2019
Updated on 04/13/2018 with effective dates 05/10/2018 - 09/30/2018
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords
• Retroperitoneal Ultrasound
• Ultrasound

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