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04-70450-22

Original Effective Date: 09/15/09

Reviewed: 02/22/18

Revised: 02/22/18

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, pelvis and abdomen and pelvis meets the definition of medical necessity for the diagnosis and evaluation of the following:

Abdomen CT:

Indications for Abdomen CT:

Evaluation of suspicious known mass/tumors (unconfirmed diagnosis of cancer) for further evaluation of indeterminate or questionable findings

Initial evaluation of suspicious masses/tumors found only in the abdomen by physical exam or imaging study, such as ultrasound (US).

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

Evaluation of known cancer for further evaluation of indeterminate or questionable findings, identified by physical examination or imaging exams such as ultrasound (US)

Initial staging of known cancer

o All cancers, excluding the following:

§ Basal cell carcinoma of the skin;

§ Melanoma without symptoms or signs of metastasis.

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

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

Follow-up of known cancer of member undergoing active treatment within the past year.

Known cancer with suspected abdominal metastasis based on a sign, symptom or an abnormal lab value.

Cancer surveillance: Active monitoring for recurrence as clinically indicated.

Evaluation of an organ or abnormality seen on previous imaging

Evaluation of an organ enlargement such as splenomegaly or hepatomegaly as evidenced by physical examination or confirmed on any previous imaging study.

Evaluation of suspected infection or inflammatory disease

Suspected acute appendicitis (or severe acute diverticulitis) if abdominal pain and tenderness to palpation is present, and at LEAST one of the following:

o Elevated WBC;

o Fever;

o Anorexia; OR

o Nausea and vomiting.

Suspected peritonitis (from any cause) if abdominal pain and tenderness to palpation is present, and at LEAST one of the following:

o Rebound, rigid abdomen; OR

o Severe tenderness to palpation present over entire abdomen.

Suspected complications of diverticulitis (known to be limited to the abdomen/pelvis by prior imaging) with abdominal/pelvic pain or severe tenderness, not responding to antibiotics treatment. Suspected pancreatitis; can have pancreatitis without abnormally elevated amylase and lipase.

Suspected inflammatory bowel disease (Crohn’s or ulcerative colitis) with abdominal pain, and persistent diarrhea or bloody diarrhea.

Suspected cholecystitis or retained gallstones with recent equivocal ultrasound.

Suspected infection in the abdomen.

Evaluation of known infection or inflammatory disease follow up

Complications of diverticulitis with severe abdominal pain or severe tenderness or mass, not responding to antibiotic treatment (prior imaging study is not required for diverticulitis diagnosis).

Pancreatitis by history (including pancreatic pseudocyst) with abdominal pain suspicious for worsening or re-exacerbation.

Known inflammatory bowel disease, (Crohn’s or ulcerative colitis) with recurrence or worsening signs/symptoms requiring re-evaluation.

Any known infection that is clinically suspected to have created an abscess in the abdomen.

Any history of fistula limited to the abdomen that requires re-evaluation, or is suspected to have recurred.

Abnormal fluid collection seen on prior imaging that needs follow-up evaluation.

Follow up for peritonitis (from any cause) if abdominal/pelvic pain and tenderness to palpation is present, and at LEAST one of the following:

o Rebound, rigid abdomen; OR

o Severe tenderness to palpation present over entire abdomen.

Hepatitis/hepatoma screening after ultrasound and alpha-fetoprotein (AFP) have been obtained and either elevated alpha-fetoprotein (AFP) is elevated or ultrasound is abnormal, equivocal or non-diagnostic.

Known infection in the abdomen.

For evaluation of known or suspected vascular disease (e.g., aneurysms or hematomas)*

Evidence of vascular abnormality seen on imaging studies.

Evaluation of suspected or known aneurysm limited to abdomen or in evaluating abdominal extent of aortic aneurysm**

o Suspected or known aneurysm > 2.5 cm AND equivocal or indeterminate ultrasound results; OR

o Prior imaging (e.g. ultrasound) demonstrating aneurysm >2.5cm cm in diameter; OR

o Suspected complications of known aneurysm as evidenced by clinical findings such as new onset of abdominal pain.

Scheduled follow-up evaluation of aorto/iliac endograft or stent (abdomen/pelvis CTA is preferred).

Asymptomatic at six (6) month intervals, for two (2) years.

Symptomatic/complications related to stent graft (more frequent imaging may be needed).

Suspected retroperitoneal hematoma or hemorrhage.

Evaluation of trauma

Evaluation of trauma with lab results or physical findings of intra-abdominal bleeding limited to the abdomen.

Pre-operative evaluation

For abdominal surgery or procedure.

Post-operative/procedural evaluation

Follow-up of known or suspected post-operative complication involving only the abdomen.

A follow-up study to help evaluate a member’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed.

Indication for combination studies for the initial pre-therapy staging of cancer, OR ongoing tumor/cancer surveillance OR evaluation of suspected metastases

≤5 concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: neck, abdomen, pelvis, chest, brain, cervical spine, thoracic spine or lumbar spine.

Cancer surveillance: Active monitoring for recurrence as clinically indicated.

Other indications for an abdomen CT

Suspected adrenal mass based on diagnostic testing/imaging results, and/or a suspicious clinical presentation.

Persistent abdominal pain not explained by previous imaging/procedure.

Unexplained weight loss of 10% of body weight in two months (patient history is acceptable); with a second MD visit documenting some further decline in weight.

Unexplained weight loss of 5% of body weight in six (6) months confirmed by documentation to include the following:

o Related history and abdominal exam

o Chest x-ray

o Abdominal ultrasound

o Lab tests (must include TSH)

o Colonoscopy if member is fifty plus (50+) years old.

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

Hernia with suspected complications (e.g. bowel obstruction or strangulation) or prior to surgical repair.

Ischemic bowel.

Suspected complete or high-grade partial small bowel obstruction limited to the abdomen.

Combination of studies with abdomen CT:

Abdomen CT/Pelvis CT/Chest CT/Neck MRI/Neck CT with MUGA

Known tumor/cancer for initial staging or evaluation before starting chemotherapy or radiation treatment.

*Abdominal aneurysms and general guidelines for follow-up

The normal diameter of the suprarenal abdominal aorta is 3.0 cm and that of the infrarenal is 2.0cm. Aneurysmal dilatation of the infrarenal aorta is defined as diameter >/= 3.0 cm or dilatation of the aorta >/= 1.5x the normal diameter. Initial evaluation of abdominal aortic aneurysn (AAA) is accurately made by ultrasound. Ultrasound can detect and size AAA, with the advantage of being relatively inexpensive, noninvasive and not require iodinate contrast1. The limitations are that overlying bowel gas can obscure findings and the technique is operator dependent.

Pelvic CT

Indications for Pelvic CT

Initial staging of prostate cancer

PSA levels >20 ng/mL, biopsy, Gleason Score ≥8, or clinically advanced disease (T3, T4 or T1-T2 and nomogram (e.g. Partin table (prostate cancer staging nomogram), cancer of prostate risk assessment CAPRA) indicating probability of lymph node involvement >10%).

Known prostate cancer for workup of recurrence and response to treatment

Initial treatment by radical prostatectomy:

o Failure of PSA to fall to undetectable levels or PSA detectable and rising on at least 2 subsequent determinations.

Initial treatment radiation therapy:

o Post radiation therapy rising PSA or positive digital exam and is candidate for local therapy.

Evaluation of suspicious known mass/tumors (unconfirmed diagnosis of cancer) for further evaluation of indeterminate or questionable findings

Initial evaluation of suspicious pelvic masses/tumors found only in the pelvis by physical exam and ultrasound has been performed or for further evaluation of abnormality seen on ultrasound (US) or when US would be inconclusive.

Surveillance: One follow-up exam to ensure no suspicious change has occurred in a tumor in the pelvis. No further surveillance CT unless tumor(s) are specified as highly suspicious, or change was found on last follow-up.

Evaluation of known cancer for further evaluation of indeterminate or questionable findings, identified by physical examination or imaging exams such as ultrasound (US)

Initial staging of known cancer

o All cancers, excluding the following:

§ Basal Cell Carcinoma of the skin

§ Melanoma without symptoms or signs of metastasis

§ Prostate cancer: unless PSA > 20 ng/ml, Gleason score on biopsy >/= 8 or clinically advanced disease (T3, T4 or T1-T2 and nomogram (e.g. Partin table (prostate cancer staging nomogram), cancer of prostate risk assessment CAPRA) indicating probability of lymph node involvement >10%).

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

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

Follow-up of known cancer of patient undergoing active treatment within the past year.

Known cancer with suspected pelvis metastasis based on a sign, symptom or an abnormal lab value.

Cancer surveillance: Active monitoring for recurrence as clinically indicated.

Evaluation of enlargement of organ or abnormality seen on previous imaging

Evaluation of an organ enlargement such as uterus or ovaries as evidenced by physical examination or an abnormality on prior ultrasound.

Further evaluation of organ enlargement or abnormality seen on previous imaging.

Evaluation of suspected infection or inflammatory disease

Suspected acute appendicitis (or severe acute diverticulitis) if pelvic pain and tenderness to palpation is present, with at LEAST one of the following:

o Elevated WBC; OR

o Fever; OR

o Anorexia; OR

o Nausea and vomiting.

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

Suspected infection in the pelvis.

Evaluation of known infection or inflammatory disease follow-up

Complications of diverticulitis with severe pelvic pain or severe tenderness or mass, not responding to antibiotic treatment, (prior imaging study is not required for diverticulitis diagnosis).

Known inflammatory bowel disease, (Crohn’s or ulcerative colitis) with recurrence or worsening signs/symptoms requiring re-evaluation.

Any known infection that is clinically suspected to have created an abscess in the pelvis.

Any history of fistula limited to the pelvis that requires re-evaluation, or is suspected to have recurred.

Abnormal fluid collection seen on prior imaging that needs follow-up evaluation.

Known infection in the pelvis.

Evaluation of known or suspected vascular disease (e.g., aneurysms, hematomas)**

Evidence of vascular abnormality identified on imaging studies.

Evaluation of suspected or known aneurysms limited to the pelvis or in evaluating pelvic extent of aortic aneurysm

o Suspected or known iliac artery aneurysm >2.5 cm AND equivocal or indeterminate ultrasound results; OR

o Prior imaging (e.g. ultrasound) demonstrating iliac artery aneurysm >2.5cm in diameter; OR

o Suspected complications of known aneurysm as evidenced by clinical findings such as new onset of pelvic pain; OR

o Follow up of iliac artery aneurysm: Six (6) month if between 3.0-3.5 cm and if stable follow yearly. If >3.5cm, <six month follow up (and consider intervention).

Scheduled follow-up evaluation of aorto/iliac endograft or stent.

o Asymptomatic at six (6) month intervals, for two (2) years.

o Symptomatic/complications related

Suspected retroperitoneal hematoma or hemorrhage.

For evaluation of trauma

For evaluation of trauma with lab or physical findings of pelvic bleeding.

For evaluation of physical or radiological evidence of pelvis fracture.

Pre-operative evaluation

For pelvic surgery or procedure.

For post-operative/procedural evaluation

Follow-up of known or suspected post-operative complication involving the hips or the pelvis.

A follow-up study to help evaluate a member’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed.

Indication for combination studies for the initial pre-therapy staging of cancer, OR ongoing tumor/cancer surveillance OR evaluation of suspected metastases

< 5 concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: neck, abdomen, pelvis, chest, brain, cervical spine, thoracic spine or lumbar spine.

Cancer surveillance: Active monitoring for recurrence as clinically indicated.

Other indications for pelvic CT

Persistent pelvic pain not explained by previous imaging/procedure.

Unexplained pelvic pain in patients seventy-five (75) years or older.

Hernia with suspected complications (e.g. bowel obstruction or strangulation) or prior to surgical repair.

Ischemic bowel.

Known or suspected aseptic/avascular necrosis of hip(s) and MRI is contraindicated after completion of initial x-ray.

Sacroiliitis (infectious or inflammatory) after completion of initial x-ray and MRI is contraindicated.

Sacroiliac joint dysfunction and MRI contraindicated:

Persistent back and/or sacral pain unresponsive to four (4) weeks of conservative treatment, received within the past six (6) months, including physical therapy or physician supervised ***home exercise program (HEP).

Combination of studies with Pelvis CT

Abdomen CT/Pelvis CT/Chest CT/Neck MRI/Neck CT

Known tumor/cancer for initial staging or evaluation before starting chemotherapy or radiation treatment.

**Follow-up of asymptomatic incidentally detected iliac artery aneurysms

<3.0 cm: rarely rupture, grow slowly, follow-up not generally needed.

3.0-3.5 cm: followed up initially at 6 months

o If stable, then annual imaging.

>3.5 cm: greater likelihood of rupture

o <6 month follow up

o Consider intervention.

***Home Exercise Program (HEP)

The following two elements are required to meet guidelines for completion of conservative therapy:

Information provided on exercise prescription/plan; AND

Follow-up with member with documentation provided regarding completion of HEP (after suitable 6 week period), or inability to complete HEP due to physical reason (i.e., increased pain, inability to physically perform exercises. (Member inconvenience or noncompliance without explanation does not constitute “inability to complete” HEP).

Abdomen/Pelvic CT

Indications for Abdomen/Pelvic CT

For evaluation of hematuria

Hematuria

For evaluation of known or suspected kidney or ureteral stones

Delineation of known or suspected renal calculi or ureteral calculi.

Evaluation of suspicious known mass/tumors (unconfirmed diagnosis of cancer) for further evaluation of indeterminate or questionable findings

Initial evaluation of suspicious masses/tumors found by physical exam or imaging study, such as ultrasound (US) and both the abdomen and pelvis are likely affected.

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

Evaluation of known cancer for further evaluation of indeterminate or questionable findings identified by physical examination or imaging exams such as ultrasound (US)

Initial staging of known cancer.

o All cancers, excluding the following:

§ Basal cell carcinoma of the skin

§ Melanoma without symptoms or signs of metastasis

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

Three (3) month follow-up of known abdomen/pelvic cancer undergoing active treatment within the past year.

Six (6) month follow-up of known abdomen/pelvic cancer undergoing active treatment within the past year.

Follow-up of known cancer of member undergoing active treatment within the past year.

Known cancer with suspected abdominal/pelvic metastasis based on a sign, symptom or an abnormal lab value.

Cancer surveillance: Active monitoring for recurrence as clinically indicated.

For evaluation of an organ enlargement

For the evaluation of an organ enlargement such as splenomegaly, hepatomegaly, uterus or ovaries as evidenced by physical examination or confirmed on any previous imaging study.

For evaluation of suspected infection or inflammatory disease

Suspected acute appendicitis (or severe acute diverticulitis) if abdominal pain and tenderness to palpation is present, and at LEAST one of the following:

o Elevated WBC; OR

o Fever; OR

o Anorexia; OR

o Nausea and vomiting.

Suspected peritonitis (from any cause) if abdominal pain and tenderness to palpation is present, and at LEAST one of the following:

o Rebound, rigid abdomen; OR

o Severe tenderness to palpation present over entire abdomen.

Suspected pancreatitis; can have pancreatitis without abnormally elevated amylase and lipase.

Suspected complications of diverticulitis (known to be limited to the abdomen/pelvis by prior imaging) with abdominal/pelvic pain or severe tenderness, not responding to antibiotics treatment.

Suspected inflammatory bowel disease (Crohn’s or ulcerative colitis) with abdominal pain, and persistent diarrhea, or bloody diarrhea.

Suspected cholecystitis or retained gallstones with recent equivocal ultrasound.

Suspected infection in abdomen/pelvis.

For evaluation of known infection or inflammatory disease follow up

Complications of diverticulitis with severe abdominal/pelvic pain or severe tenderness or mass not responding to antibiotic treatment (prior imaging study is not required for diverticulitis diagnosis).

Pancreatitis by history (including pancreatic pseudocyst) with abdominal pain suspicious for worsening, or re-exacerbation.

Known inflammatory bowel disease, (Crohn’s or Ulcerative colitis) with recurrence or worsening signs/symptoms requiring re-evaluation.

Any known infection that is clinically suspected to have created an abscess in the abdomen or pelvis.

Any history of fistula that requires re-evaluation, or is suspected to have recurred in the abdomen or pelvis.

Abnormal fluid collection seen on prior imaging that needs follow-up evaluation.

Follow up for peritonitis (from any cause) if abdominal/pelvic pain and tenderness to palpation is present, and at LEAST one of the following:

o Rebound, rigid abdomen; OR

o Severe tenderness to palpation present over entire abdomen.

Hepatitis/hepatoma screening after ultrasound and alpha-fetoprotein (AFP) have been obtained and either elevated alpha-fetoprotein (AFP) is elevated or ultrasound is abnormal, equivocal or non-diagnostic.

Known infection in the abdomen/pelvis region.

For evaluation of known or suspected vascular disease (e.g., aneurysms or hematomas)*

Evidence of vascular abnormality seen on imaging studies.

Evaluation of suspected or known aortic aneurysm limited to the abdomen/pelvis or in evaluating abdominal /pelvic extent of aortic aneurysm**:

o Suspected or known aneurysm > 2.5 cm AND equivocal or indeterminate ultrasound results; OR

o Prior imaging (e.g. ultrasound) demonstrating aneurysm > 2.5 cm in diameter; OR

o Suspected complications of known aneurysm as evidenced by clinical findings such as new onset of abdominal or pelvic pain.

Scheduled follow-up evaluation of aorto/iliac endograft or stent (Abd/Pelvis CTA is preferred)

o Asymptomatic at six (6) month intervals, for two (2) years

o Symptomatic/complications related to stent graft (more frequent imaging may be needed).

Suspected retroperitoneal hematoma or hemorrhage.

For evaluation of trauma

For evaluation of trauma with lab or physical findings of intra-abdominal/pelvic bleeding.

Suspected retroperitoneal hematoma or hemorrhage.

Pre-operative evaluation

For abdominal/pelvic surgery or procedure.

Post-operative/procedural evaluation

Follow-up of known or suspected post-operative complication.

A follow-up study to help evaluate a patient’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed.

Indication for combination studies for the initial pre-therapy staging of cancer, OR ongoing tumor/cancer surveillance OR evaluation of suspected metastases

≤5 concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: neck, abdomen, pelvis, chest, brain, cervical spine, thoracic spine or lumbar spine.

Cancer surveillance: Active monitoring for recurrence as clinically indicated.

Other indications for abdomen/pelvic CT Combo

Suspected adrenal mass or pheochromocytoma based on diagnostic testing/imaging results, and/or a suspicious clinical presentation.

Persistent abdomen/pelvic pain not explained by previous imaging/procedure.

Unexplained weight loss of 10% of body weight in two months (member history); with a second MD visit documenting further decline in weight.

Unexplained weight loss of 5% of body weight in six months confirmed by documentation to include the following:

o Related history and abdominal exam

o Chest x-ray

o Abdominal ultrasound

o Lab tests, must include TSH

o Colonoscopy if patient fifty plus (50+) years old.

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

Suspected spigelian hernia (ventral hernia) or incisional hernia (evidenced by a surgical abdominal scar) when ordered as a pre-operative study.

Hernia with suspected complications (e.g., bowel obstruction, strangulation) or prior to surgical repair.

Ischemic bowel.

*Abdominal aneurysms and general guidelines for follow-up

The normal diameter of the suprarenal abdominal aorta is 3.0 cm and that of the infrarenal is 2.0cm. Aneurysmal dilatation of the infrarenal aorta is defined as diameter >/= 3.0 cm or dilatation of the aorta >/= 1.5x the normal diameter. Initial evaluation of abdominal aortic aneurysm (AAA) is accurately made by ultrasound. Ultrasound can detect and size AAA, with the advantage of being relatively inexpensive, noninvasive and not require iodinate contrast1. The limitations are that overlying bowel gas can obscure findings and the technique is operator dependent.

BILLING/CODING INFORMATION:

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:

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

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.

Hepatomegaly: enlargement of the liver.

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.

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, Revised 2016.
  2. American College of Radiology (ACR) Appropriateness Criteria® Stress/Insufficiency Fracture, Including Sacrum, Excluding Other Vertebrae, Revised 2016.
  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, Revised 2016.
  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. Grazioli L, Federle MP, Brancatelli G et al. Hepatic adenomas: imaging and pathologic findings. Radiographics 2001; 21: 877-892.
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  10. Jeong YY, Kang HK, Chung TW et al. Uterine cervical carcinoma after therapy: CT and MR imaging findings. Radiographics 2003; 23: 969-981.
  11. 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.
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  13. Macedo TA. Stanson AW, Oderich GS et al. Infected aortic aneurysms: imaging findings. Radiology 2004; 231: 250-257.
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COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 02/22/18.

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.

03/15/18

Revision; revised position statements (abdomen, pelvis, abdomen and pelvis). Updated definitions and references.

Date Printed: May 21, 2018: 02:46 PM