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Date Printed: December 17, 2017: 10:09 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

04-70450-18

Original Effective Date: 09/15/09

Reviewed: 01/22/15

Revised: 02/15/15

Subject: Computed Tomography (CT) Head/Brain

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 Updates    
           

DESCRIPTION:

Computed tomography (CT) is a radiology 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 patients 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 head/brain for evaluation, diagnosis and management of head/brain related conditions in the outpatient setting.

POSITION STATEMENT:

NOTE: In the ambulatory setting, magnetic resonance imaging (MRI) is ordinarily the preferred exam. CT of the head is an alternative exam for patients when MRI is contraindicated or not tolerated by the member.

Documentation Requirements

Documentation containing the medical necessity of the computed tomography (CT) of the head/brain 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 head or brain meets the definition of medical necessity for the diagnosis and evaluation of the following:

Trauma (known or suspected)

NOTE: Trauma may be acute (less than 24 hours), recent (up to one week) or chronic (one week or longer).

Known or suspected trauma or injury to the head with documentation of one or more of the following (acute, new or fluctuating):

Headache

When any one of the following criteria is met:

Brain Tumor, Mass or Metastasis (known or suspected)

Cerebrovascular Accident (CVA)/Stroke (known or suspected)

Aneurysm/Arteriovenous Malformation (AVM) (known or suspected)

Inflammatory Disease or Infection (known or suspected)

Congenital Anomaly (congenital abnormality, congenital malformation)

Pre-operative Evaluation for Brain/Skull Surgery

Post-Operative/Procedural Evaluation

Other

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

Indication for Brain CT/Cervical CT combination studies:

BILLING/CODING INFORMATION:

The following codes may be used to describe computed tomography of the head/ brain.

CPT Coding:

70450

Computed tomography, head or brain; without contrast material

70460

Computerized axial tomography, head or brain; with contrast material(s)

70470

Computerized axial tomography, head or brain; without contrast material, followed by contrast material(s) and further sections

76380

Computed tomography, limited or localized follow-up study

REIMBURSEMENT INFORMATION:

Reimbursement for computed tomography (70450 – 70470, 76380) performed on the same anatomical area is limited to two (2) computed tomography (70450 – 70470, 76380) within a 6-month period. Computed tomography (70450 – 70470, 76380) in excess of two (2) computed tomography (70450 – 70470, 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 (70450 – 70470, 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 (70450 – 70470, 76380) within a 12-month period. Computed tomography (70450 – 70470, 76380) for an oncologic condition in excess of four (4) computed tomography (70450 – 70470, 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 head or brain 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 scan) of the head and brain.

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

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

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 Head or Brain, (L29121) 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:

Acute: having a short and relatively severe course.

Aneurysm: a sac formed by the dilatation of the wall of an artery, a vein, or the heart; it is filled with fluid or clotted blood, often forming a pulsating tumor.

Arteriovenous malformation: a congenital anomaly of the brain vasculature composed of arterial and venous channels with many interconnecting shunts without a capillary bed; clinical characteristics include hemorrhage, headache, and focal epileptic seizures.

Chiari: an inability to coordinate voluntary muscular movements that is symptomatic of some nervous disorders.

Cholesteatoma: a cyst-like mass or benign tumor lined with stratified squamous epithelium, usually keratinizing, and filled with desquamating debris often including cholesterol. Cholesteatomas are most common in the middle ear and mastoid region secondary to trauma or infection that heals improperly so that epithelium invaginates.

Chronic: persisting over a long period of time.

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

Hydrocephalus: a condition marked by dilatation of the cerebral ventricles, most often occurring secondarily to obstruction of the cerebrospinal fluid pathways and accompanied by an accumulation of cerebrospinal fluid within the skull.

Meningitis: inflammation of the meninges, usually by either a bacterium (bacterial) or a virus (viral).

Nystagmus: an involuntary, rapid, rhythmic movement of the eyeball, which may be horizontal, vertical, rotatory, or mixed.

Papilledema: edema of the optic disk (papilla), most commonly due to increased intracranial pressure, malignant hypertension, or thrombosis of the central retinal vein.

Thunderclap headaches: a severe headache with sudden onset similar to a clap of thunder, with maximum intensity within 1 minute.

RELATED GUIDELINES:

Computed Tomographic Angiography (CTA) Heart, 04-70450-03
Computed Tomography (CT) Abdomen and Pelvis 04-70450-22

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

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

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

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

Computed Tomography (CT), Thorax 04-70450-21

Computed Tomography to Detect Coronary Artery Calcification, 04-70450-02

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

OTHER:

Other name used to report computed tomography (CT):

CAT scanning
Computed tomography scanning
Computerized axial tomography

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. ACR-ASNR Practice Guideline for the Performance of Computed Tomography (CT) of the Brain, Revised 2010.
  2. American College of Radiology (ACR) Appropriateness Criteria®: Ataxia, 2012.
  3. American College of Radiology (ACR) Appropriateness Criteria® Cerebrovascular Disease, 2011.
  4. American College of Radiology (ACR) Appropriateness Criteria®: Cranial Neuropathy, 2012.
  5. American College of Radiology (ACR) Appropriateness Criteria®: Headache, 2009.
  6. American College of Radiology (ACR) Appropriateness Criteria®: Head Trauma, 2012.
  7. American College of Radiology (ACR) Appropriateness Criteria®: Orbits, Vision and Visual Loss, 2012.
  8. American College of Radiology (ACR) Appropriateness Criteria(r): Pre-Irradiation Evaluation and Management of Brain Metastasis, 2011.
  9. American College of Radiology (ACR) Appropriateness Criteria®: Seizures and Epilepsy, 2011.
  10. American College of Radiology (ACR) Appropriateness Criteria®: Vertigo and Hearing Loss, 2008.
  11. ACR-ASNR Practice Guideline for the Performance of Computed Tomography (CT) of the Brain, 2010.
  12. Centers for Medicare & Medicaid Services NCD for Computed Tomography (220.1), 03/12/08.
  13. First Coast Service Options, Inc. LCD for Computed Tomography of the Head or Brain L29121, 04/05/11.
  14. Karis JP, Seidenwurm DJ, Davis PC et al. American College of Radiology Appropriateness Criteria®-Epilepsy, 2006.
  15. National Cancer Institute-Adult brain tumors treatment (PDQ®), 05/22/09.
  16. National Imaging Associates, Inc. Brain (Head) CT Clinical Guidelines, 08/14.
  17. National Institutes of Neurological Disorders and Stroke-Brain and Spinal Tumors, 05/15/09.
  18. Smits M, Dippel DW, et al. Minor head injury: guidelines for the use of CT—a multicenter validation study. Radiology 2007; 245(3):831- 838.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 01/22/15.

GUIDELINE UPDATE INFORMATION:

09/15/09

New Medical Coverage Guideline.

01/01/10

Revised BCBSF Radiology Management program exception section.

07/15/11

Scheduled review; revised position statement for trauma-deleted with symptoms of neurological deficits (e.g., one sided weakness, paralysis, loss of muscle control, increased muscle tone, loss of muscle tone, gait disturbance, lack of coordination, ataxia, speech impairments, facial numbness, vision deficits), deleted headache and replaced with acute onset of headache, deleted criteria for headache: increased frequency or severity (progressively) gets worse over days or weeks), headache with fever, nuchal rigidity (stiff neck), headache with mental status changes, headache with nausea and vomiting, unexplained by physical findings, headache with focal neurological signs (e.g., ataxia, papilledema, visual field defects, nystagmus, gait disturbances), added 76380, revised limitation to two (2) within a 6-month period and updated the references.

10/01/11

Revision; formatting changes.

05/15/12

Revised and expanded position statement for; trauma, headache, brain, cerebrovascular accident, aneurysm/arteriovenous malformation, inflammatory disease or infection, post-operative evaluation and other section. Deleted but is not limited to. Updated references.

08/15/13

Scheduled review; MCG subject changed to “Computed Tomography Head/Brain”. Added indication to headache section: headache with a change in character/pattern (e.g., more frequent, increased severity or duration) to headache section. Added “symptom or” to Evaluation of Neurologic Deficits heading (Evaluation of Neurological Symptoms or Deficit). Updated definitions, program exceptions and reference sections.

05/15/14

Added limitation statement for an oncologic condition; limited to four (4) computed tomography within a 12-month period.

02/15/15

Annual review; indications revised (skull fracture, headache, aneurysm/AVM, inflammatory disease or infection, congenital anomaly, seizure). Added pre-operative evaluation for brain/skull surgery and combination studies. Deleted evaluation of neurological symptoms or deficits. Updated references.

Date Printed: December 17, 2017: 10:09 PM