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Date Printed: May 27, 2018: 07:28 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.

04-70450-19

Original Effective Date:09/15/09

Reviewed: 02/22/18

Revised: 03/15/18

Subject: Computed Tomography (CT) Temporal Bone/Mastoid and Maxillofacial

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    
           

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 temporal bone/mastoid and maxillofacial for evaluation, diagnosis and management of temporal bone/mastoid and maxillofacial related conditions in the outpatient setting.

POSITION STATEMENT:

Documentation Requirements

Documentation containing the medical necessity of the computed tomography (CT) of the temporal bone/mastoid and maxillofacial 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 temporal bone, mastoid, maxillofacial, sinus, orbits, sella, and internal auditory canal meets the definition of medical necessity for the following:

NOTE: For temporomandibular joint (TMJ) services and procedures, refer to member’s contract benefits.

Temporal Bone and Mastoid

Evaluation of cholesteatoma.

Evaluation of chronic otitis media, ear infections or drainage.

Evaluation of conductive hearing loss.

Evaluation of congenital hearing loss or deformity.

Evaluation of dehiscence of the jugular bulb or carotid canal.

Acoustic neuroma or other lesion of the 7th or 8th cranial nerve in member unable to undergo an MRI.

Evaluation of cochlear implant.

Evaluation of aberrant blood vessels or malformations.

Evaluation of mastoiditis.

A follow-up study may be needed to help evaluate a member’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that clearly indicated why additional imaging is needed for the type and area(s) requested.

Maxillofacial, Sinus, Orbits, and Sella

Maxillofacial & Sinus

Evaluation of known or suspected infections or inflammatory disease

Unresolved sinusitis after four (4) consecutive weeks of medication (e.g., antibiotics, steroids, antihistimines).

Immunocompromised member (including, but not limited to AIDS, transplant member or member with genetic or acquired deficiencies) or conditions predisposed to sinusitis (e.g., cystic fibrosis, immotile cilia syndrome/Kartagener’s syndrome).

Osteomyelitis of facial bone where imaging study (e.g., plain films, brain MRI) demonstrates an abnormality or is indeterminate.

Evaluation of known or suspected tumor

Known or suspected tumor with bony abnormality or opaque sinuses seen on imaging or for mucocele.

Evaluation of trauma

Suspected fracture AND prior imaging was non-diagnostic or equivocal,

Follow-up of trauma with fracture or opaque sinuses visualized on x-ray.

Pre-operative evaluation

Planned maxillofacial surgery.

For use as an adjunct to image guided sinus exploration or surgery such as functional endoscopic sinus surgery (FESS).

Post-operative evaluation

Complications (e.g., suspected CSF leak, post-operative bleeding as evidenced by persistent opaqueness on imaging).

Non-improvement, two (2) or more weeks after surgery.

Other indications for Sinus CT

For poorly controlled asthma associated with upper respiratory tract infections. May be performed without failing four (4) consecutive weeks of medical treatment with medication.

For presence of polyposis on imaging or direct visualization that may be causing significant airway obstruction.

• Deviated nasal septum or structural abnormality seen on imaging or direct visualization that may be causing significant airway obstruction.

New onset of anosmia (lack of sense of smell) or significant hyposmia (diminished sense of smell).

• Granulomatosis with polyangitis (Wegener’s granulomatosis) may be present as rhinosinusitis.

A follow-up study may be needed 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 for the type and area(s) requested.

Combination of studies with Sinus CT

Sinus CT/Chest CT

For poorly controlled asthma associated with upper respiratory tract infection. May be performed without failing four (4) consecutive weeks of medical treatment with medication.

Granulomatosis with polyangitis (Wegener’s granulomatosis) disease (GPA)

Orbit

Evaluation of decreased range of motion of the eyes.

Screening and assessment of suspected hyperthyroidism (such as Grave’s disease).

Screening and evaluation of ocular tumor,especially melanoma.

Screening and assessment of optic neuritis (known or suspected) if MRI is contraindicated or is unable to be performed.

Screening and evaluation of orbital pseudotumor.

Evaluation of progressive vision loss.

Assessment of proptosis (exophthalmos).

Assessment of trauma.

Evaluation of unilateral visual deficit.

Papilledema.

Orbital infection.

A follow-up study may be needed to help evaluate a member’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that clearly indicated why additional imaging is needed for the type and area(s) requested.

Combination of studies with orbit CT

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.

Sella

Evaluation of decreased range of motion of the eyes.

Screening and evaluation of parasellar bony structures for the evaluation of sellar tumors.

Screening and evaluation of ocular tumor.

Screening and assessment of optic neuritis (known or suspected) if MRI is contraindicated or is unable to be performed.

Screening and evaluation of suspected orbital pseudotumor.

Screening and evaluation of pituitary adenoma.

Evaluation of progressive vision loss/visual field deficit,

Assessment of proptosis (exophthalmos).

A follow-up study may be needed to help evaluate a member’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that clearly indicated why additional imaging is needed for the type and area(s) requested.

Internal Auditory Canal

Evaluation of acoustic neuroma or other lesion of the VIIth or VIIIth cranial nerve in patients unable to undergo an MRI.

Evaluation of documented conductive hearing loss.

Evaluation of chronic otitis media.

Evaluation of mastoiditis.

Evaluation of cholesteatoma.

Evaluation of congenital hearing loss.

Evaluation of cochlear implants.

A follow-up study may be needed 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 for the type and area(s) requested.

BILLING/CODING INFORMATION:

CPT Coding:

70480

Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material

70481

Computerized axial tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s)

70482

Computerized axial tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections

70486

Computed tomography, maxillofacial area; without contrast material

70487

Computerized axial tomography, maxillofacial area; with contrast material(s)

70488

Computerized axial tomography, maxillofacial area; 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 (70480 – 70488, 76380) performed on the same anatomical area is limited to two (2) computed tomography (70480 – 70488, 76380) within a 6-month period. Computed tomography (70480 – 70488, 76380) in excess of two (2) computed tomography (70480 – 70488, 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 (70480 – 70488, 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 (70480 – 70488, 76380) within a 12-month period. Computed tomography (70480 – 70488, 76380) for an oncologic condition in excess of four (4) computed tomography (70480 – 70488, 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) of the temporal bone/mastoid and maxillofacial.

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:

No Local Coverage Determination (LCD) was found at the time of the last guideline reviewed date.

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

DEFINITIONS:

Anosmia: absence of the sense of smell.

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.

Conductive hearing loss: hearing loss due to a defect of the sound conducting apparatus, i.e., of the external auditory canal or middle ear.

Hyposmia: diminished sensitivity of smell.

Mastoiditis: inflammation of the mastoid antrum and air cells.

Neuritis: inflammation of a nerve, with pain and tenderness, anesthesia and paresthesias, paralysis, wasting, and disappearance of the reflexes.

Osteomyelitis: inflammation of a bone caused by infection, usually by a pyogenic organism, although any infectious agent may be involved. It may remain localized or may spread through the bone to involve marrow, cortex, cancellous tissue, and periosteum.

Proptosis (exophthalmos): abnormal protrusion of the eyeball.

Pseudotumor: an enlargement that resembles a tumor; it may result from inflammation, accumulation of fluid, or other causes, and may or may not regress spontaneously.

Sella trucica: a saddle-shaped depression in the sphenoid bone at the base of the human skull which holds the pituitary gland.

Sinusitis: inflammation of a sinus, usually a paranasal sinus, it may be purulent or nonpurulent, acute or chronic.

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 04-70450-21

Computerized Axial Tomography (CT) Abdomen & Pelvis 04-70450-22

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), 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 Academy of Pediatrics Clinical Practice Guideline: Management of Sinusitis. Pediatrics 2001; 108: 798-808.
  2. ACR–ASNR–SPR Practice Guideline for the Performance of Computed Tomography (CT) of the Extracranial Head and Neck, Revised 2016.
  3. ACR-ASNR-SPR Practice Guideline for the Performance of Computed Tomography (CT) of the Extracranial Head and Neck in Adults and Children, 2011.
  4. American College of Radiology ACR Appropriateness Criteria® Neuroendocrine Imaging, 2012.
  5. American College of Radiology ACR Appropriateness Criteria® Orbits, Vision and Visual Loss, Revised 2017.
  6. Brem MH, Zamani AA, Riva R et al. Multidetector CT of the paranasal sinus: potential for radiation dose reduction. Radiology 2007; 243: 847-852.
  7. Caruso PA, Watkins LM, Suwansaard P et al. Odontogenic orbital inflammation: clinical and CT findings-initial observations. Radiology 2006; 239: 187-194.
  8. Lee CI, Haims AH, Monico EP et al. Diagnostic CT scans: assessment of patient, physician, and radiologist awareness of radiation dose and possible risks. Radiology 2004; 231: 393-398.
  9. National Cancer Institute-Radiation risks and pediatric computed tomography (CT): A guide for health care providers, 12/12/08.
  10. National Imaging Associates, Inc. CT Orbit (includes sella and posteria fossa) Clinical Guideline, 2018.
  11. National Imaging Associates, Inc. CT Internal Auditory Canal (Temporal Bone, Mastoid) Clinical Guideline, 2018.
  12. National Imaging Associates, Inc. CT Sella Clinical Guideline, 2018.
  13. National Imaging Associates, Inc. Maxillofacial Sinus CT Clinical Guideline, 2018.
  14. National Imaging Associates, Inc. CT Temporal Bone, Mastoid CT Clinical Guideline, 2018.
  15. Okuyemi KS, Tsue TT. Radiologic imaging in the management of sinusitis. American Family Physician 2002; 66(10): 1882-1886.
  16. Osguthorpe JD. Adult Rhinosinusitis: Diagnosis and management. American Family Physician 2001; 63(1): 69-76.
  17. Rosenfeld RM. Clinical practice guideline on adult sinusitis. Otolaryngology-Head and Neck Surgery 2007; 137: 365-377.
  18. Wald ER, Applegate KE, Bordley C et al. Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years Pediatrics 2013; e262-e280.
  19. Weissman JL, Hirsch BE. Imaging of Tinnitus: A review. Radiology 2000; 216:342-349.

COMMITTEE APPROVAL:

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

GUIDELINE UPDATE INFORMATION:

08/15/09

New Medical Coverage Guideline.

01/01/10

Revised BCBSF Radiology Management program exception section.

07/15/11

Annual review; revised course of treatment for sinusitis (added unresponsive to 3 documented courses), added 76380, revised limitation to two (2) within a 6-month period and updated references.

10/01/11

Revision; formatting changes.

05/15/12

Revised and expanded position statement for sinusitis; clarified documented courses of medical management, added immunocompromised conditions, adjunct to imaged guided sinus exploration surgery, follow-up after treatment, procedure, intervention or surgery and recurrent asthma. Deleted but is not limited to. Updated references.

09/15/13

Scheduled review; MCG subject changed to “Computed Tomography (CT) Temporal Bone/Mastoid and Maxillofacial”. Added chronic otitis media and evaluation of acoustic neuroma or other lesion of the 7th or 8th cranial nerve to temporal bone and mastoid section. Deleted “face” section; replaced with “maxillofacial, sinus and orbit”. Deleted heading “sinusitis”; replaced with “sinus”. Added deviated nasal septum or structural abnormality seen on imaging or direct visualization with airway obstruction and Wegener’s granulomatosis (suspected or known, may be present as rhinosinusitis) to sinus section. Added Medicare Advantage program exception and updated references.

01/01/14

Review/revision. Added if MRI is contraindicated or is unable to be performed to optic neuritis, pituitary adenoma and perisellar bony structures for evaluation of certain sellar tumors, and assessment of trauma (e.g., suspected facial bone fractures). Changed clouded sinuses to opaque sinuses and changed Wegener’s granulomatosis to Granulomatosis with polyangitis (Wegener’s). Deleted melanoma (ocular tumor).

01/01/15

Scheduled review; added indications for sella and definition for sella turica. Added limitation statement for an oncologic condition; limited to four (4) computed tomography within a 12-month period. Updated references.

11/15/15

Revised indications for temporal bone mastoid, maxillofacial and sinus, orbital and sella. Added indication for combination of studies with sinus CT. Updated references.

03/15/18

Revision; revised position statement (temporal bone and mastoid, maxillofacial & sinus, orbit and sella). Added position statement for combination studies and internal auditory canal. Updated references.

Date Printed: May 27, 2018: 07:28 PM