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Date Printed: May 27, 2018: 07:33 PM

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04-70450-18

Original Effective Date: 09/15/09

Reviewed: 02/22/18

Revised: 03/15/18

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 following:

Evaluation of known or suspected seizure disorder

Evaluation of a single study related to new onset of seizures or newly identified change in seizure activity/pattern AND cannot have a brain MRI.

Evaluation of neurologic symptoms or deficits

Acute, new or fluctuating neurologic symptoms or deficits such as sensory deficits, limb weakness, speech difficulties, lack of coordination or mental status changes.

Evaluation of clinical assessment documenting cognitive impairment of unclear cause

Change in mental status with a mental status score of either MMSE or MoCA of less than 26 or other similar mental status instruments showing at least mild cognitive impairment AND a completed basic metabolic workup ( such as thyroid function testing, liver function testing, complete blood count, electrolytes, and B12).

Evaluation of known or suspected trauma

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):

• Focal neurologic findings (e.g., ataxia, papilledema, visual field defects, nystagmus, gait disturbances) and brain MRI is contraindicated

• Motor changes

• Mental status changes

• Amnesia

• Vomiting

• Seizures

Headache

• Signs of increased intracranial pressure (e.g., headaches, seizures, nausea, vomiting, blurred vision).

Known coagulopathy

• Known or suspected skull fracture by physical exam and positive x-ray findings (e.g., plain skull x-ray).

Repeat scan 24 hours post head trauma for anticoagulated members with suspected diagnosis of delayed subdural hematoma.

Evaluation of headache

• Chronic headache with a change in character/pattern (e.g., more frequent, increased severity or duration) and MRI is contraindicated or cannot be performed.

• New onset (< 48 hours) of “worst headache in my life” or “thunderclap” headache. Note: The duration of a thunderclap type headache lasts more than 5 minutes. Sudden onset new headache reaching maximum intensity within 2-3 minutes.

New onset of headache with any acute, new or fluctuating neurologic deficits such as sensory deficits, limb weakness, speech difficulties, lack of coordination or mental status changes.

CT is indicated once in membrs with cluster headaches to eliminated secondary causes.

Member with history of cancer, or significantly immunocompromised, with new onset headache.

• New onset of headache in member > 55 years of age

• New temporal headache in member > 55 years of age with erythrocyte sedimentation rate (ESR) > 55 and tenderness over the temporal artery and brain MRI is contraindicated or cannot be performed

History of suspicion of aneurysm of arterious venous malformation (AVM) with new onset of headache.

Evaluation of known of suspected brain tumor, mass, or metastasis

• Evaluation of bone tumor or abnormality of the skull.

• Evaluation of member with history of cancer with recent course of chemotherapy, radiation therapy (to the brain), or treated surgically within the last two years.

• Member with history of cancer with suspected recurrence or metastasis, based on symptoms (e.g., headaches (new onset, increase in frequency and severity), nausea, vomiting, vision problems (blurred, double, loss of peripheral vision) or examination findings (e.g., new or changing lymph nodes).

Follow up for known tumor.

Evaluation of suspected tumor with any acute, new or fluctuating neurologic symptoms or deficits such as sensory deficits, limb weakness, speech difficulties, lack of coordination or mental status changes.

Known lung cancer, or rule out metastasis and/or preoperative evaluation.

Evaluation of metastatic melanoma (not all melanomas).

Evaluation of known or suspected cerebrovascular accident (CVA)/ stroke

Evaluation of member with history of a known stroke with new and sudden onset of severe headache.

Known or suspected stroke with any acute, new or fluctuating symptoms or deficits such as sensory deficits, limb weakness, speech difficulties, lack of coordination or mental status changes or with a family history (brother, sister, parent or child) of aneurysm.

Symptoms of transient ischemic attack (TIA) (episodic neurologic symptoms).

Evaluation of known or suspected inflammatory disease or infection (e.g., meningitis, or abscess) and MRI is contraindicated or cannot be performed

Member with suspected increased intracranial pressure or meningitis.

Intracranial abscess or brain infection with acute altered mental status OR positive lab findings (such as elevated WBC’s) OR follow up assessment during or after treatment completed.

Meningitis with positive physical findings (such as fever, stiff neck) and positive lab findings (such as elevated white blood cells or abnormal lumbar puncture fluid exam).

Suspected encephalitis with a severe headache, altered mental status OR positive lab finding, (such as elevated WBC’s).

Endocarditis with suspected septic emboli.

Evaluation for central nervous system (CNS) involvement in members with known or suspected vasculitis or autoimmune disease with positive lab findings.

Evaluation of known or suspected congenital abnormality (such as hydrocephalus, craniosynostosis)

• Evaluation of member for congenital anomaly (known or suspected) with any acute, nes or fluctuating neurologic, motor or mental status changes.

• Evaluation of member for hydrocephalus (known or suspected).

• Evaluation of member for prior treatment or treatment planned for congenital abnormality.

Evaluation of macrocephaly with child >6 months of age.

Evaluation of microcephaly and MRI is contraindicated or cannot be performed

Follow up shunt evaluation within six (6) months of placement or one (1) year follow up and/or with neurologic symptoms.

Evaluation of craniosynostosis and other head deformities.

Suspected normal pressure hydrocephalus, (NPH) with symptoms

Pre-operative evaluation for brain/skull surgery

Post-operative/procedural evaluation

• Follow-up study for evaluation of member’s progress after treatment, procedure, intervention or surgery. Documentation should include a medical reason why additional imaging is needed for the type and area(s) requested for evaluation.

Other indications for a brain CT

Suspected Cholesteatoma.

• Follow-up for known hemorrhage, hematoma or vascular abnormalities.

Evaluation of suspected acute subarachnoid hemorrhage (SAH).

Developmental delay where MRI cannot be performed.

Vertigo associated with headache, blurred or double vision, or a change in sensation after full neurologic examination and initial work-up and MRI is contraindicated or cannot be performed.

Abnormal eye findings on physical or neurologic examination (e.g., papilledema, nystagmus, ocular nerve palsies, visual field deficit).

Anosmia (loss of smell) (documented by objective testing).

Evaluation of known or suspected cerebrospinal fluid (CSF) leakage.

Immunocompromised patient (e.g., transplant recipients, HIV with CD4<200, primary immunodeficiency syndromes, hematologic malignancies) with focal neurologic symptoms, headaches, behavioral, cognitive or personality changes.

Suspected central venous thrombosis.

Evaluation of neurological findings in sickle cell disease.

Prior to lumbar puncture in members with suspected increased intracranial pressure or at risk for herniation.

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, or spine (cervical, thoracic, or lumbar).

Cancer surveillance: active monitoring for recurrence as clinically indicated.

Indication for brain CT/cervical CT combination studies

• Evaluation of Arnold Chiari malformation where MRI cannot be performed.

Brain CT/Orbit CT

For approved indications as noted above and being performed in a child under 3 years of age who will need anesthesia for the procedure and there is a suspicion of concurrent intracranial tumor (e.g. “trilateral retinoblastoma”).

Unilateral papilledema: to distinguish a compressive lesion on the optic nerve or optic disc swelling associated with acute demyelinating optic neuritis in multiple sclerosis from nonarteritic anterior ischemic optic neuropathy (NAION), central retinal vein occlusion or optic nerve infiltrative disorders.

Brain CT/Neck CTA

Confirmed carotid stenosis >60%, surgery or angioplasty candidate.

BILLING/CODING INFORMATION:

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. Karis JP, Seidenwurm DJ, Davis PC et al. American College of Radiology Appropriateness Criteria®-Epilepsy, 2006.
  13. National Cancer Institute-Adult brain tumors treatment (PDQ®), 05/22/09.
  14. National Imaging Associates, Inc. Brain (Head) CT Clinical Guidelines, 2018.
  15. National Institutes of Neurological Disorders and Stroke-Brain and Spinal Tumors, 05/15/09.
  16. 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 02/22/18.

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.

03/15/18

Revision; revised position statement. Added position statement for seizure disorder, neurologic symptoms or deficits, cognitive impairment, inflammatory disease or infection, normal pressure hydrocephalus, combination CT. Updated references.

Date Printed: May 27, 2018: 07:33 PM