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04-70450-22

Original Effective Date: 09/15/09

Reviewed: 10/23/14

Revised: 12/15/14

Subject: Computed Tomography (CT) Abdomen and Pelvis

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           

Position Statement

Billing/Coding

Reimbursement

Program Exceptions

Definitions

Related Guidelines

           

Other

References

Update

 

 

Previous Information

           

DESCRIPTION:

Computed tomography (CT) is a radiologic modality that provides clinical information in the detection, differentiation and demarcation of disease. CT is a form of medical imaging that involves the exposure of members to ionizing radiation. CT should only be performed under the supervision of a physician with training in radiation protection to optimize examination safety. Radiation exposure should be taken into account when considering the use of this technology. This guideline addresses the use of CT of the abdomen and pelvis for evaluation, diagnosis and management of abdomen and pelvis related conditions in the outpatient setting.

POSITION STATEMENT:

Documentation Requirements

Documentation containing the medical necessity of the computed tomography (CT) of the abdomen and pelvis and imaging results (e.g., images, clinical reports) should be maintained in the member’s medical record. Documentation may be requested as part of the review process.

Computed tomography (CT) of the abdomen and pelvis meets the definition of medical necessity for the diagnosis and evaluation of the following:

Abdomen

• Abdominal pain (persistent) unexplained by clinical findings, including physical examination and other imaging studies (e.g., ultrasonography, plain film radiography, endoscopy, capsule endoscopy (colonoscopy), intravenous pyelogram (IVP))

• Abnormalities noted on other imaging studies (e.g., ultrasonography, radiography), which require further evaluation

• Abnormalities of abdominal vascular structures

• Adrenal gland mass (pheochromocytoma)

• Aorta aneurysm limited to the abdomen: suspected or known < four (4) cm and equivocal or indeterminate ultrasound results; or prior imaging demonstrated aneurysm ≥ four (4) cm in diameter; or suspected complications of known aneurysm as evidenced by physical exam such as new onset of abdominal pain

• Appendicitis (acute) (suspected) evidenced by physical exam (e.g., abdominal pain, tenderness) with at least one of the following: elevated white blood count (WBC), fever, anorexia or nausea and vomiting

• Cancer (known) with suspected abdominal metastasis based on signs, symptoms or an abnormal lab value

• Cancer: Initial staging of known cancer, excluding the following:

• Basel cell carcinoma of the skin

• Melanoma without symptoms of signs of metastasis

• Cancer follow-up: Three (3) month follow-up of known abdominal cancer undergoing active treatment within the past year

• Cancer follow-up: Six (6) month follow-up of known abdominal cancer undergoing active treatment within the past year

• Cancer follow-up: Cancer (known) of member undergoing active treatment with the past year

• Cancer (known); Surveillance once per year (previous CT must be over ten (10) months ago)

• Cholecystitis (suspected) with equivocal ultrasound

Congenital anomaly of abdominal organs (known or suspected)

Diverticulitis (suspected or known) with at least one of the following: elevated white blood count (WBC), fever, anorexia or nausea and vomiting

• Diverticulitis (complications) with abdominal pain or tenderness not responding to antibiotic treatment

• Fistula; history of fistula limited to the abdomen that requires re-evaluation, or is suspected to have recurred

• Hematoma

• Hematuria (e.g., renal stones/urinary tract calculi, renal tumors, urothelia tumors)

• Hemorrhage

• Hepatitis C/hepatoma with elevated alpha-fetoprotein (AFP) and equivocal ultrasound results

• Hepatomegaly ( physical findings, laboratory studies, intravenous pyelogram or ultrasound)

• Hernia (suspected): Spigelian hernia (ventral hernia) or incisional hernia evidenced by a surgical abdominal scar)

• Hydronephrosis (evidenced by physical exam or confirmed on imaging study e.g., intravenous pyelogram, renal scan, ultrasound abdomen/kidney)

• Infection in the abdomen (known)

• Infection (suspected)

• Infection that is suspected to have created an abscess in the abdomen

• Inflammatory bowel disease (known or suspected) (e.g., Crohn’s disease, ulcerative colitis) with abdominal pain and diarrhea or bloody diarrheaInflammatory bowel disease (e.g., Crohn’s, ulcerative colitis) with recurrence or worsening signs/symptoms (e.g., abdominal pain) requiring re-evaluation

• Ischemic bowel

• Mass/tumor

• Initial evaluation of suspicious mass/tumor found in the abdomen by physical exam or imaging study (e.g., ultrasound).

• Surveillance: One (1) follow-up exam to ensure no suspicious change has occurred in tumor(s) in the abdomen. No further surveillance CT unless tumor(s) are specified as highly suspicious, or a change was found on previous follow-up CT (new or changing signs/symptoms) or abnormal lab values(e.g., blood, urea, nitrogen (BUN), creatinine, liver function tests)

• Pancreatitis (known), including pancreatic pseudocyst with recurrence or worsening signs/symptoms requiring re-evaluation

• Pancreatitis (suspected) with abnormal elevation of serum amylase or lipase

• Pancreatic mass

• Peritonitis (follow-up) if abdominal pain and tenderness to palpation is present, and at least one of the following: rebound, rigid abdomen, or tenderness to palpation present over entire abdomen

• Primary or metastatic malignancies of the abdomen

• Renal colic

• Renal mass

• Retroperitoneal hematoma or hemorrhage (suspected)

• Splenomegaly (physical exam, prior ultrasound results equivocal and further imaging required)

• Trauma with physical or lab (e.g., complete blood count (CBC)) findings of intra-abdominal bleeding

• Unexplained weight loss (more than 10% of body weight in two months) unexplained by clinical findings, including physical examination

• Urinary calculus (kidney, ureteral) (known or suspected) and or flank pain

Vascular abnormality (known or suspected) (e.g., aneurysm, hematoma, retroperitoneal hematoma or hemorrhage) evidenced by imaging study (e.g., x-ray, ultrasound, Doppler)

Other

• Abnormal fluid collection (ascites) seen on prior imaging (e.g., ultrasonography, plain film radiography) that require follow-up evaluation

• Evaluation after treatment, procedure, intervention or surgery involving the abdomen

• Follow-up tumor evaluation (to ensure no suspicious changes has occurred in a tumor in the abdomen)

• Post-operative evaluation for complications (suspected or known) involving the abdomen

• Pre-operative evaluation for abdominal surgery or procedure

• Persistent abdominal pain unexplained by physical findings or imaging studies (e.g., x-ray, abdominal ultrasound, endoscopy (including capsule endoscopy), colonoscopy, sigmoidoscopy, intravenous pyelogram)

• Completed or high-grade partial small bowel obstruction (suspected)

• Follow-up evaluation of aortoiliac endograft

Pelvis

• Abnormalities noted on other imaging studies, which require further evaluation (e.g., urinary calculus)

• Abnormalities of pelvic vascular structure

• Aorta aneurysm limited to the abdomen: suspected or known < four (4) cm and equivocal or indeterminate ultrasound results; or prior imaging demonstrated aneurysm ≥ four (4) cm in diameter; or suspected complications of known aneurysm as evidenced by physical exam such as new onset of abdominal pain

• Appendicitis (acute) ( suspected) evidenced by physical exam (e.g., abdominal pain, tenderness) with at least one of the following: elevated white blood count (WBC), fever, anorexia or nausea and vomitingAseptic/avascular necrosis of hips (MRI is contraindicated)

• Bowel obstruction of unknown etiology

• Cancer (known) with suspected pelvic metastasis based on signs, symptoms or an abnormal lab value

• Cancer: Initial staging of known cancer, excluding the following:

• Basel cell carcinoma of the skin

• Melanoma without symptoms of signs of metastasis

• Cancer follow-up: Three (3) month follow-up of known pelvic cancer undergoing active treatment within the past year

• Cancer follow-up: Six (6) month follow-up of known pelvic cancer undergoing active treatment within the past year

• Cancer follow-up: Cancer (known) of member undergoing active treatment with the past year

• Cancer (known); Surveillance once per year (previous CT must be over ten (10) months ago)

• Congenital anomaly of pelvic organs (known or suspected)

Diverticulitis (suspected or known) with at least one of the following: elevated white blood count (WBC), fever, anorexia or nausea and vomiting

• Diverticulitis (complications) with abdominal pain or tenderness, not responding to antibiotic treatment

• Fistula; history of fistula limited to the abdomen that requires re-evaluation, or is suspected to have recurred

• Follow-up tumor evaluation (to ensure no suspicious changes has occurred in a tumor in the pelvis)

• Hematoma

• Hematuria (e.g., renal stones/urinary tract calculi, renal tumors, urothelia tumors)

• Hemorrhage

Hepatomegaly (seen on ultrasonography or x-ray)

• Hernia (suspected): Spigelian hernia (ventral hernia) or incisional hernia evidenced by a surgical abdominal scar)

Hydronephrosis when ultrasound is abnormal or unexplained, further evaluation required

• Infection in the pelvis (known)

• Infection that is suspected to have created an abscess in the pelvis

• Inflammatory bowel disease (e.g., Crohn’s, ulcerative colitis) with recurrence or worsening signs/symptoms (e.g., abdominal pain) requiring re-evaluation

• Inguinal hernia suspect incarceration

• Ischemic bowel (known or suspected)

Lymphadenopathy (for initial detection and follow-up)

• Mass/tumor

• Initial evaluation of suspicious mass/tumor found in the pelvis by physical exam or imaging study (e.g., ultrasound).

• Surveillance: One (1) follow-up exam to ensure no suspicious change has occurred in tumor(s) in the pelvis. No further surveillance CT unless tumor(s) are specified as highly suspicious, or a change was found on previous follow-up CT (new or changing signs/symptoms) or abnormal lab values

• Organ enlargement (e.g., uterus, ovaries, prostate) evidenced by physical exam or confirmed on imaging study (e.g., ultrasonography)

• Pelvic fracture

• Pelvic mass (palpable)

• Pelvic pain (persistent) unexplained by clinical findings, physical examination or other imaging studies (e.g., ultrasound, barium examination or endoscopy)

• Pelvic vein thrombosis

• Prostate cancer recurrence work-up with:

• PSA greater than twenty (20)

• Gleason score of seven (7) or greater

• Prostate cancer; Failure of PSA to fall to undetectable after radical prostatectomy or PSA detectable and rising on 2 or more subsequent determinations

• Renal Colic

• Renal mass

• Retroperitoneal hematoma or hemorrhage (suspected)

Septic arthritis, osteomyelitis of pelvic bones (suspected)

• Splenomegaly (palpated on exam or seen on ultrasonography or x-ray)

• Trauma with physical or lab findings of pelvic bleeding

• Urinary tract calculus (kidney, ureter, urethra)

Vascular abnormality (known or suspected) (e.g., aneurysm, hematoma, retroperitoneal hematoma or hemorrhage) evidenced by imaging study (e.g., x-ray, ultrasound, Doppler)

Other

• Abnormal fluid collection (ascites) seen on prior imaging (e.g., ultrasonography, plain film radiography) that require follow-up evaluation

• Evaluation of known cancer with suspected pelvis metastasis (based on signs and symptoms (e.g., weight loss, ascites, anorexia) or an abnormal lab value (e.g., elevated BUN or creatinine))

• Evaluation after treatment, procedure, intervention or surgery

• Evaluation of physical or radiological evidence of pelvic fracture

• Follow-up evaluation of aortoiliac endograft

• Post-operative evaluation for complications (suspected or known) involving the pelvis

• Pre-operative evaluation for pelvic infection, pelvic surgery or procedure

• Suspected complications of diverticulitis (known to be limited to pelvis by prior imaging) with pelvic pain or severe tenderness, not responding to antibiotic treatment

• Unexplained abdominal pain in members seventy-five (75) years or older

Abdomen and Pelvis CT Combination

• Abdomen and pelvic trauma (blunt or penetrating)

• Abdomen/pelvic pain not explained by clinical findings, physical examination and imaging studies (e.g., ultrasound, abdominal radiography)

• Abdominal/pelvic mass (papable), known or suspected

• Abnormalities noted on other imaging studies, which require further evaluation

• Adrenal mass (pheochromocytoma) suspected based on clinical presentation (e.g., hypertension), diagnostic testing/ imaging (e.g., 24-our blood and urine test (catecholamines), CT scan, MRI, MIBG scan)

• Aorta aneurysm: suspected or known < four (4) cm and equivocal or indeterminate ultrasound results; or prior imaging demonstrated aneurysm ≥ four (4) cm in diameter; or suspected complications of known aneurysm as evidenced by physical exam such as new onset of abdominal or pelvic pain

• Appendicitis (acute) (suspected ) evidenced by physical exam (e.g., abdominal pain, tenderness) with at least one of the following: elevated white blood count (WBC), fever, anorexia or nausea and vomiting

• Ascites

• Bowel obstruction of unknown etiology

• Cancer (known) with suspected abdominal/pelvic metastasis based on signs, symptoms or an abnormal lab value

• Cancer: Initial staging of known cancer, excluding the following:

• Basel cell carcinoma of the skin

• Melanoma without symptoms of signs of metastasis

• Prostate cancer unless Gleason score is seven plus (7+) or PSA over twenty (20)

• Cancer follow-up: Three (3) month follow-up of known abdominal/pelvic cancer undergoing active treatment within the past year

• Cancer follow-up: Six (6) month follow-up of known abdominal/pelvic cancer undergoing active treatment within the past year

• Cancer follow-up: Cancer (known) of member undergoing active treatment with the past year

• Cancer (known); Surveillance once per year (previous CT must be over ten (10) months ago)

• Congenital anomaly (known or suspected)

Diverticulitis (suspected or known) with at least one of the following: elevated white blood count (WBC), fever, anorexia or nausea and vomiting

• Diverticulitis (complications) with abdominal/ pelvic pain or tenderness not responding to antibiotic treatment

• Fistula; history of fistula that requires re-evaluation, or is suspected to have recurred in the abdomen or pelvis

• Gastroparesis (diabetic)

• Hematoma

• Hematuria (e.g., renal stones/urinary tract calculi, renal tumors, urothelia tumors)

• Hemorrhage

• Hernia (suspected): Spigelian hernia (ventral hernia) or incisional hernia evidenced by a surgical abdominal scar)

• Hydronephrosis when ultrasound is abnormal or unexplained, further evaluation required

• Infection (known) in the abdomen/pelvis area

• Infection that is suspected to have created an abscess in the abdomen or pelvis

• Infectious or inflammatory process-known or suspected (e.g., abscess, diffuse inflammation, pelvic inflammatory disease, Crohn’s disease, ulcerative colitis acute non-ulcerative colitis, diverticulitis, retroperitoneal abscess)

• Inflammatory bowel disease (e.g., Crohn’s, ulcerative colitis) with recurrence or worsening signs/symptoms (e.g., abdominal pain) requiring re-evaluation

• Ischemic bowel

• Lymphadenopathy unexplained by clinical history and imaging (chest radiography, ultrasonography and physical exam)

• Mass/tumor

• Initial evaluation of suspicious mass/tumor found in the abdomen/pelvis by physical exam or imaging study (e.g., ultrasound).

• Surveillance: One (1) follow-up exam to ensure no suspicious change has occurred in tumor(s) in the abdomen/pelvis. No further surveillance CT unless tumor(s) are specified as highly suspicious, or a change was found on previous follow-up CT (new or changing signs/symptoms) or abnormal lab values

• Organ enlargement (e.g., splenomegaly, hepatomegaly, uterus, ovaries, prostate) evidenced by physical exam or confirmed on imaging study e.g., ultrasonography)

• Pancreatic mass

• Pancreatic pseudocyst (seen on ultrasound)

• Pancreatitis (suspected) with abnormal elevation of amylase or lipase

• Pancreatitis (known), including pancreatic pseudocyst with recurrence or worsening signs/symptoms requiring re-evaluation

• Peritonitis (follow-up) if abdominal pain and tenderness to palpation is present, and at least one of the following: rebound, rigid abdomen, or tenderness to palpation present over entire abdomen

• Renal colic

• Renal mass

• Retroperitoneal hematoma or hemorrhage (suspected)

• Cholecystitis (suspected) with equivocal ultrasound

• Inflammatory bowel disease (suspected) (Crohn’s or ulcerative colitis) with abdominal pain and persistent diarrhea or bloody diarrheaTrauma with physical or lab findings of intra-abdominal bleeding

• Unexplained weight loss of 10% if body weight in two months unexplained by clinical findings, including physical examination

• Unexplained weight loss of 5% if body weight in six months confirmed by documentation to include (related member history, chest x-ray, abdominal ultrasound, lab tests (TSH), colonoscopy (if member is 50+ years old)

• Unexplained abdominal pain in members 75 years or older

Vascular abnormality (known or suspected) (e.g., aneurysm, hematoma, retroperitoneal hematoma or hemorrhage) evidenced by imaging study (e.g., x-ray, ultrasound, Doppler)

Other

• Abnormal fluid collection (ascites) seen on prior imaging (e.g., ultrasonography, plain film radiography) that require follow-up evaluation

• Delineation of known or suspected renal calculi or ureteral calculi with completion of initial work-up

• Evaluation of suspicious mass/tumor found on physical findiangs or imaging study and both the abdomen and pelvis are likely affected

• Evaluation after treatment, procedure, intervention or surgery

• Follow-up evaluation of aortoiliac endograft

• Follow-up study for known diagnosis/condition (e.g., mass, abscess)

• Post-operative evaluation for complications

• Preoperative evaluation

• Suspected complications of diverticulitis (known to be limited to the abdomen/pelvis by prior imaging)

BILLING/CODING INFORMATION:

The following codes may be used to describe computed tomography of the abdomen and pelvis.

CPT Coding:

72192

Computed tomography, pelvis; without contrast material

72193

Computed tomography, pelvis; with contrast material(s)

72194

Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections

74150

Computed tomography, abdomen; without contrast material

74160

Computed tomography, abdomen; with contrast material(s)

74170

Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections

74176

Computed tomography, abdomen and pelvis; without contrast material

74177

Computed tomography, abdomen and pelvis; with contrast material(s)

74178

Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions

76380

Computed tomography, limited or localized follow-up study

REIMBURSEMENT INFORMATION:

Reimbursement for computed tomography (72192 – 72194, 74150 – 74170, and 74176 – 74178, 76380) performed on the same anatomical area is limited to two (2) computed tomography (72192 – 72194, 74150 – 74170, and 74176 – 74178, 76380) within a 6-month period. Computed tomography (72192 – 72194, 74150 – 74170, and 74176 – 74178, 76380) in excess of two (2) computed tomography (72192 – 72194, 74150 – 74170, and 74176 – 74178, 76380) within a 6-month period are subject to medical review of documentation to support medical necessity. Documentation should include radiology reason for study, radiology comparison study-date and time, radiology comparison study observation, radiology impression, and radiology study recommendation.

Reimbursement for computed tomography (72192 – 72194, 74150 – 74170, and 74176 – 74178, 76380) for an oncologic condition undergoing active treatment or active treatment completed within the previous 12 months on the same anatomical area is limited to four (4) computed tomography (72192 – 72194, 74150 – 74170, and 74176 – 74178, 76380) within a 12-month period. Computed tomography (72192 – 72194, 74150 – 74170, and 74176 – 74178, 76380) for an oncologic condition in excess of four (4) computed tomography (72192 – 72194, 74150 – 74170, and 74176 – 74178, 76380) within a 12-month period are subject to medical review of documentation to support medical necessity. Documentation should include radiology reason for study, radiology comparison study-date and time, radiology comparison study observation, radiology impression, and radiology study recommendation.

Re-imaging or additional imaging of the abdomen, pelvis and abdomen and pelvis due to poor contrast enhanced exam or technically limited exam is the responsibility of the imaging provider.

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment and reason for computed tomography (CT) of the abdomen and pelvis.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology reason for study

18785-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology comparison study-date and time

18779-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology comparison study observation

18834-2

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology-study observation

18782-3

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology-impression

19005-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology study-recommendation (narrative)

18783-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

PROGRAM EXCEPTIONS:

Coverage for the radiology services referenced in this guideline performed and billed in an outpatient or office location will be handled through the Radiology Management program for select products. The National Imaging Associates (NIA) will determine coverage for these services for select products. Refer to member's contract benefits.

Federal Employee Plan (FEP): FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

Medicare Advantage products:

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Computed Tomography of the Abdomen and Pelvis, (L29119) located at fcso.com.

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Computed Tomography, (220.1) located at cms.gov.

DEFINITIONS:

Ascites: effusion and accumulation of serous fluid in the abdominal cavity.

Congenital anomaly: congenital anomaly present at birth; it may be a malformation, disruption, deformation, or dysplasia.

Diverticulitis: inflammation of a diverticulum, especially inflammation related to colonic diverticula, which may undergo perforation with abscess formation.

Gastroparesis: paralysis of the stomach, usually from damage to its nerve supply, so that food empties out much more slowly, if at all.

Hematoma: a localized collection of blood, usually clotted, in an organ, space, or tissue, usually due to a break in the wall of a blood vessel.

Hematuria: blood (erythrocytes) in the urine; called also erythrocyturia.

Hepatitis C: a viral disease caused by the hepatitis C virus. Although the chronic infection is usually mild and asymptomatic, cirrhosis may occur.

Hepatomegaly: enlargement of the liver.

Hydronephrosis: distention of the pelvis and calices of the kidney with urine, as a result of obstruction of the ureter.

Lymphadenopathy: disease of the lymph nodes, usually with swelling; called also adenopathy.

Pancreatitis (acute): pancreatitis with sudden onset, fever, abdominal pain, nausea, vomiting, tachycardia, and often increased blood levels of pancreatic enzymes. It may be accompanied by complications such as hemorrhaging or necrosis.

Pancreatic pseudocyst: a cystic collection of fluid and necrotic debris whose walls are formed by the pancreas and nearby organs. It occurs as a complication of acute pancreatitis and may subside spontaneously or become secondarily infected and develops into an abscess.

Septic arthritis: infectious arthritis, usually acute, characterized by inflammation of synovial membranes with purulent effusion into a joint or joints, most often due to Staphylococcus aureus, Streptococcus pyogenes, S. pneumoniae, or Neisseria gonorrhoeae, usually caused by hematogenous spread from a primary site of infection although joints may also become infected by direct inoculation or local extension. Called also bacterial, pyogenic, or suppurative.

Splenomegaly: enlargement of the spleen.

RELATED GUIDELINES:

Computed Tomography to Detect Coronary Artery Calcification, 04-70450-02
Computed Tomographic Angiography (CTA), 04-70450-03

Computerized Axial Tomography (CT ), Head/Brain 04-70450-18

Computerized Axial Tomography (CT ), Temporal Bone/Mastoid & Maxillofacial 04-70450-19

Computerized Axial Tomography (CT ), of the Neck for Soft Tissue Evaluation 04-70450-20

Computerized Axial Tomography (CT ), Thorax (Chest) 04-70450-21

Computerized Axial Tomography (CT ), Spine (Cervical, Thoracic, Lumbar) 04-70450-23

Computerized Axial Tomography (CT ), Extremity (Upper & Lower) 04-70450-24

Whole Body Computed Tomography (CT) Scanning, 04-70450-25

OTHER:

Other name used to report computed tomography (CT):

CAT scanning

Pediatric Examinations

The use of CT in pediatric examinations requires assessment of the risks, benefits and use of the studies. The lowest possible radiation dose consistent with acceptable diagnostic image quality should be used in pediatric examinations. Radiation doses should be determined periodically based on a reasonable sample of pediatric examinations. Technical factors should be appropriate for the size and the age of the child and should be determined with consideration of parameters (e.g., characteristics of the imaging system, organs in the radiation field, lead shielding).

REFERENCES:

  1. American College of Radiology (ACR) Appropriateness Criteria® Chronic Hip Pain, 2011.
  2. American College of Radiology (ACR) Appropriateness Criteria® Stress/Insufficiency Fracture, Including Sacrum, Excluding Other Vertebrae, 2011.
  3. American College of Radiology (ACR) and Society for Pediatric Radiology (SPR) Practice Guideline for the Performance of Computed Tomography (CT) of the Abdomen and Computed Tomography (CT) of the Pelvis, 2011.
  4. Armerding MD, Rubin GD, Beaulieu CF et al. Aortic aneurismal disease: assessment of stent-graft treatment-CT versus conventional angiography. Radiology 2000; 215: 138-146.
  5. Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology 2002; 223: 603-613.
  6. Brancatelli G, Federle MP, Grazioli L et al. Focal nodular hyperplasia: CT findings with emphasis on multiphasic helical CT in 78 patients. Radiology 2001; 219: 61-68.
  7. Cannistra SA. Cancer of the ovary. The New England Journal of Medicine 2004; 351: 2519-2529.
  8. Centers for Medicare & Medicaid Services NCD for Computed Tomography (220.1), 03/12/08.
  9. First Coast Service Options, Inc. LCD for Computed Tomography of the Abdomen and Pelvis L29119, 04/05/11.
  10. Grazioli L, Federle MP, Brancatelli G et al. Hepatic adenomas: imaging and pathologic findings. Radiographics 2001; 21: 877-892.
  11. Hopper KD, Singapuri K, Finkel A. Body CT and oncologic imaging. Radiology 2000; 215:27-40.
  12. Jeong YY, Kang HK, Chung TW et al. Uterine cervical carcinoma after therapy: CT and MR imaging findings. Radiographics 2003; 23: 969-981.
  13. Kim T, Federle MP, Baron RL et al. Discrimination of small hepatic hemangiomas from hypervascular malignant tumors smaller than 3 cm with three-phase helical CT. Radiology 2001; 219: 699-706.
  14. Kirkpatrick ID, Greenberg HM. Evaluating the CT diagnosis of Clostridium difficile colitis: should CT guide therapy? American Journal of Roentgenology 2001; 176: 635-639.
  15. Macedo TA. Stanson AW, Oderich GS et al. Infected aortic aneurysms: imaging findings. Radiology 2004; 231: 250-257.
  16. National Cancer Institute-Radiation risks and pediatric computed tomography (CT): A guide for health care providers, 12/12/08.
  17. National Imaging Associates, Inc. CT Abdomen, Pelvis, and Abdomen and Pelvis CT Combo Clinical Guidelines, 06/12.
  18. Paulson EK, Kalady MF, Pappas TN. Suspected appendicitis. The New England Journal of Medicine 2003; 348: 236-242.
  19. Rozenblit AM, Patlas M, Rosenbaum AT. Detection of endoleaks after endovascular repair of abdominal aortic aneurysm: value of unenhanced and delayed helical CT acquisitions. Radiology 2003; 227: 426-433.
  20. Teichman JMH. Acute renal colic from ureteral calculus. The New England Journal of Medicine 2004; 350: 684-693.
  21. Tolia AJ, Landis R, Lamparello P et al. Type II endoleaks after endovascular repair of abdominal aortic aneurysms: natural history. Radiology 2005; 235: 683-686.
  22. Wiesner W. Khurana B, Ji H, et al. CT of acute bowel ischemia. Radiology 2003; 226: 635-650.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 10/23/14.

GUIDELINE UPDATE INFORMATION:

09/15/09

New Medical Coverage Guideline.

01/01/10

Revised BCBSF Radiology Management program exception section and updated the references.

01/01/11

Annual HCPCS coding update: added 74176, 74177 and 74178.

08/15/11

Scheduled review. Updated position statement. Added 76380. Revised limitation to two (2) within a 6-month period. Updated references.

10/01/11

Revision; formatting changes.

05/15/12

Revised and expanded position statement for: abdomen; appendicitis (added acute), diverticulitis, gastroparesis (added diabetic), infectious or inflammatory process, inflammatory bowel disease and added vascular abnormality. Revised and expanded position statement for: abdomen-other, added persistent abdominal pain, partial small bowel obstruction (complete or high-grade) and tumor evaluation. Revised and expanded position statement for: pelvis (appendicitis (added acute), and added organ enlargement and vascular abnormality. Revised and expanded position statement for: pelvic-other, added tumor evaluation. Revised and expanded position statement for abdomen and pelvis CT combination: adrenal mass, appendicitis (added acute), added organ enlargement and vascular abnormality. Revised and expanded position statement for: abdomen and pelvic CT combination-other, added tumor evaluation. Deleted but is not limited to. Updated references.

11/15/13

Scheduled review; MCG subject changed to “Computed Tomography Abdomen and Pelvis”. Added; aorta aneurysm, cholecystitis, diverticulitis, hepatitis C/hepatoma, inflammatory bowel disease (recurrence), pancreatitis, fistula, peritonitis, retroperitoneal hematoma or hemorrhage. Renal colic (add to abdomen, pelvis and abdomen/pelvis), renal mass (add to pelvis and abdomen/pelvis), prostate cancer (add to pelvis); add/revise indications: cancer, infection, and mass/tumor. Updated definitions, program exceptions and reference sections.

11/15/14

Scheduled review. No change to position statements.

12/15/14

Added diverticulitis (suspected or known) to abdomen and pelvis CT combination.

Date Printed: August 22, 2017: 07:14 AM