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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.

04-70450-21

Original Effective Date: 09/15/09

Reviewed: 02/25/16

Revised: 10/01/16

Next Review: No Longer Scheduled for Routine Review (NLR)

Subject: Computed Tomography (CT) Thorax (Chest)

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 or CT scan) is an imaging modality used for the detection and evaluation of diseases and conditions in the chest (e.g., tumor, inflammatory disease, vascular disease, congenital abnormalities, trauma, and hemoptysis). CT involves the exposure of patients to ionizing radiation. CT should be performed under the supervision of a physician with training in radiation protection to optimize examination safety.

POSITION STATEMENT:

Documentation Requirements

Documentation containing the medical necessity of the computed tomography (CT) of the thorax 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 thorax (chest) meets the definition of medical necessity for the following:

Tumor, Cancer or Mass

• Follow-up of known tumor or cancer of member undergoing active treatment with most recent follow-up study greater than 2 months (documentation to include, but not limited to type, timing and duration of recent treatment)

• Initial evaluation of diagnosed cancer

• Evaluation of known tumor or cancer, or history of prior cancer presenting with new signs (e.g., physical exam, lab findings, imaging findings) or new symptoms

• Cancer surveillance excluding small cell lung cancer: Every 6 months for the first 2 years then annually therafter

• Small cell lung cancer surveillance: Up to every 3 months for the first two years then annually thereafter

Evaluation of Suspicious Mass/Tumor (unconfirmed cancer diagnosis)

• Initial evaluation of suspicious mass/tumor found on an imaging study and needing clarification or found by physical exam and remains non-diagnostic after x-ray or ultrasound is completed

• Known distant cancer with suspected chest/lung metastasis based on a sign, symptom, imaging study or abnormal lab value

Follow-up evaluation of a pulmonary nodule with a previous CT (follow-up intervals approximately 3, 6, 12 and 24 months)

Interstitial Lung Disease

Known or suspected interstitial lung disease (e.g. idiopathic interstitial lung diseases, idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, pneumoconiosis, sarcoidosis, silicosis and asbestosis)

• Initial x-ray performed

Abnormal physical, laboratory, and/or imaging findings requiring further evaluation

Infection or Inflammatory Disease

Known or suspected infection or inflammatory disease (e.g., pneumonia not responding to treatment, lung abscess, empyema (pleural effusion, abscess), tuberculosis (TB), immunosuppression post-organ transplant with new symptoms or findings) and initial x-ray performed:

• Abnormal physical, laboratory and/or imaging findings requiring further evaluation

• Evaluation of known inflammatory disease (initial evaluation, during treatment, new signs and symptoms)

• Evaluation of pneumonia unresponsive to medical treatment (e.g., 4 weeks of antibiotic therapy) or not resolved at 8 weeks, documented by at least 2 imaging studies

• Evaluation of lung abscess, cavitary lesion, or empyema detected or suggested on prior imaging

Vascular Disease

• Evaluation of widened mediastinum on x-ray

• Evaluation of known or suspected superior vena cava (SVC) syndrome

• Suspected vascular disease (e.g., aneurysm, dissection)

• Suspected thoracic/thoracoabdominal aneurysm (documentation of clinical history may include, e.g., hypertension, reported “tearing or ripping type” chest pain)

Congenital Abnormalities

• Evaluation of congenital thoracic abnormalities (suspected or known)

• Vascular: (chest CTA or chest MRA may be performed, depending on age and radiation safety issues)

• Nonvascular: abnormal imaging and/or physical examination finding

Follow-Up Trauma

• Follow-up trauma for chest wall abnormality by physical exam or radiologic evidence

• Follow-up trauma for mediastinal widening with radiologic evidence

Hemoptysis

• Evaluation of hemoptysis and prior x-ray performed

Post-Operative/Procedural Evaluation

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 why additional imaging is needed for the type and area(s) requested.

Lung Cancer Screening

Annual screening for lung cancer with low-dose computed tomography (CT) meets the definition of medical necessity when ALL of the following criteria* are met:

• Member is between 55 and 80 years of age; AND

• There is at least a 30 pack-year smoking history; AND

• Member currently smokes or have quit within the past 15 years. 

* Member selection criteria are based on the U.S. Preventive Services Task Force recommendation and the National Lung Screening Trial (NLST). Screening should be discontinued once a member has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

Other

• Pre-operative evaluation

• For further evaluation after abnormal imaging within past 30-60 days and with no improvement on x-ray (not indicated with known rib fractures)

• Evaluation of other chest or thorax adenopathy

• Hoarseness, vocal cord lesion or vocal cord paralysis

• Evaluation of persistent unresolved cough of at least 4 weeks duration, unresponsive to medical treatment (e.g. pharmacologic therapy [antihistamines, corticosteroids, antibiotics]) and prior chest x-ray performed

• Evaluation of pneumothorax

• Evaluation of vocal cord paralysis

• Suspected thymoma with myasthenia gravis

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.

Combination of studies with Chest 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.

Combination of studies with Chest CT/Sinus CT:

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

• Granulomatosis with polyangiitis (GPA) (Wegener’s)

BILLING/CODING INFORMATION:

The following codes may be used to describe computed tomography of the thorax. There is no specific CPT or HCPCS code for low-dose computed tomography for lung cancer screening.

CPT Coding:

71250

Computed tomography, thorax; without contrast material

71260

Computed axial tomography, thorax; with contrast material(s)

71270

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

76380

Computed tomography, limited or localized follow-up study

HCPCS Coding:

G0297

Low dose CT scan (LDCT) for lung cancer screening

REIMBURSEMENT INFORMATION:

Reimbursement for computed tomography (71250 – 71270, 76380) performed on the same anatomical area is limited to two (2) computed tomography (71250 – 71270, 76380) within a 12-month period. Computed tomography (71250 – 71270, 76380) in excess of two (2) computed tomography (71250 – 71270, 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.

Reimbursement for computed tomography (71250 – 71270, 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 (71250 – 71270, 76380) within a 12-month period. Computed tomography (71250 – 71270, 76380) for an oncologic condition in excess of four (4) computed tomography (71250 – 71270, 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 thorax 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 thorax.

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 review date: Computed Tomography of the Thorax, (L29120) located at fcso.com.

The following Centers for Medicare & Medicaid Services (CMS) decision memo was reviewed on the last guideline review date: Decision Memo for Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439N) located at cms.gov.

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

DEFINITIONS:

Effusion: the escape of fluid into a part or tissue, as an exudation or a transudation.

Hemoptysis: the expectoration of blood or of blood-stained sputum.

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

Myasthenia gravis: an autoimmune disease of neuromuscular function; characteristics include muscle fatigue and exhaustion that fluctuates in severity, without sensory disturbance or atrophy. It may be restricted to one muscle group or become generalized with severe weakness and sometimes respiratory insufficiency. It may affect any muscle of the body, but especially those of the eyes, face, lips, tongue, throat, and neck. Called also Erb-Goldflam, Goldflam, or Goldflam-Erb disease.

Pulmonary embolism: the closure of the pulmonary artery or one of its branches by an embolus, sometimes associated with pulmonary infarction.

Sarcoidosis: a chronic, progressive, systemic granulomatous reticulosis of unknown etiology, characterized by hard tubercles. It can affect almost any organ or tissue, including the skin, lungs, lymph nodes, liver, spleen, eyes, and small bones of the hands and feet. Laboratory findings may include hypercalcemia and hypergammaglobulinemia. There is usually low or absent reactivity to tuberculin, and in active cases the Kveim test is positive. Called also sarcoid, Besnier-Boeck disease, Boeck disease or sarcoid, and Schaumann disease, sarcoid, or syndrome.

Thymoma: a tumor derived from the epithelial or lymphoid elements of the thymus.

Tuberculosis: any of the infectious diseases of humans or other animals caused by species of Mycobacterium and characterized by the formation of tubercles and caseous necrosis in the tissues.

Wegener’s disease (Wegener’s granulomatosis): a rare disorder in which blood vessels become inflamed, making it hard for blood to flow.

RELATED GUIDELINES:

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

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

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

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

Computed Tomography (CT) Abdomen and Pelvis 04-70450-22

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

Computed 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):

Note: 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.

CAT scanning

Helical CT

Low-dose CT

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® Follow-up of Malignant or Aggressive Musculoskeletal Tumors, 2011.
  2. American College of Radiology ACR Appropriateness Criteria®: Screening for Pulmonary Metastases, 2013.
  3. ACR–SCBT-MR–SPR Practice Guideline for the Performance of Thoracic Computed Tomography (CT), 2014.
  4. Bach PB, Mirkin JN, Oliver TK et al. Benefits and harms of CT screening for lung cancer: a systematic review. JAM 2012; 307(22): 2418-2429.
  5. Bach PB, Silvestri GA, Hanger M et al. Screening for lung cancer* ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition). Chest 2007; 132 (3): 69S-77S.
  6. Blue Cross Blue Association Screening for Lung Cancer Using CT Scanning Medical Policy 6.01.30, 02/2015.
  7. Bruzzi JF, Komaki R, Walsh GL et al. Imaging of non-small cell lung cancer of the superior sulcus: part 1: anatomy, clinical manifestations, and management. Radiographics 2008; 28:551-560.
  8. Bruzzi JF, Komaki R, Walsh GL et al. Imaging of non-small cell lung cancer of the superior sulcus: part 2: initial staging and assessment of respectability and therapeutic response. Radiographics 2008; 28:551-560.
  9. Centers for Medicare & Medicaid Services NCD for Computed Tomography (220.1), 03/12/08.
  10. Detterbeck FC, Lewis SZ, Diekemper R et al. Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, Chest 2013 supplement; 143(5): 7S-37S.
  11. Fedullo PF, Tapson VF. The evaluation of suspected pulmonary embolism. The New England Journal of Medicine 2003; 349 (13): 1247-1256.
  12. First Coast Service Options, Inc. LCD for Computed Tomography of the Thorax L29120, 04/05/11.
  13. Fultz PJ, Feins RH, Strang JG et al. Detection and diagnosis of nonpalpable supraclavicular lynph nodes in lung cancer at CT and US. Radiology 2002; 222: 245-251.
  14. Gilkeson RC, CiancibelloL, Zahka K. Pictorial essay. Multidetector CT evaluation of congenital heart disease in pediatric and adult patients. American Journal of Roentgenology 2003; 180: 973-980.
  15. Hocking WG, Hu P, Oken MM et al. Lung cancer screening in the randomized Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. Journal of the National Cancer Institute 2010; 102(10): 722-731.
  16. Humphrey LL, Deffebach M, Pappas M et al. Screening for lung cancer with low-dose computed tomography: a systematic review to update the U.S. Preventive Services Task Force Recommendation. Annals of Internal Medicine 2013; 159(6): 411-420.
  17. Irwin RS, Madison M. The diagnosis and treatment of cough. New England Journal of Medicine 2000; 343(23): 1715-1721.
  18. Jaklitsch MT, JacobsonFL, Austin JH et al. The American Association for Thoracic Surgery guidelines for lung cancer screening using low-dose computed tomography scans for lung cancer survivors and other high-risk groups. Journal of Thoracic and Cardiovascular Surgery 2012; 144(1): 33-38.
  19. Macura KJ, Cori FM, Fishman EK et al. Pathogenesis in acute aortic syndromes: aortic aneurysm leak and rupture and traumatic aortic transaction. American Journal of Roentgenology 2003; 181: 303-307.
  20. Munden RF, Swisher SS, Stevens CW et al. Imaging of the patient with non-small cell lung cancer. Radiology 2005; 327: 803-818.
  21. National Cancer Institute-Lung Cancer Screening (PDQ®), 02/13/15.
  22. National Cancer Institute-Radiation risks and pediatric computed tomography (CT): A guide for health care providers, 06/07/12.
  23. National Comprehensive Cancer Network® (NCCN) Guidelines™ Lung Cancer Screening, Version 1. 2015.
  24. National Comprehensive Cancer Network® (NCCN) Guidelines™ Non-Small Cell Lung Cancer, Version 4.2015.
  25. National Comprehensive Cancer Network® (NCCN) Guidelines™ Small Cell Lung Cancer, Version 1.2015.
  26. National Imaging Associates, Inc. Clinical Guidelines-Chest (Thorax) CT, 2015.
  27. National Imaging Associates, Inc. Clinical Guidelines Low Dose CT for Lung Cancer Screening, 2015.
  28. National Lung Screening Trial Research Team, Aberle DR, Adams AM et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. New England Journal of Medicine 2011; 365: 395-409.
  29. Ost D, Fein AM, Feinsilver SH. The solitary pulmonary nodule. The New England Journal of Medicine 2003; 348(25): 2535-2542.
  30. Swensen SJ, Jett JR, Hartman TE et al. CT screening for lung cancer: five-year prospective experience. Radiology 2005; 235: 259-265.
  31. Truong MT, Sabloff BS, Gladish GW et al. Invasive thymoma. American Journal of Roentgenology 2003; 181: 1504.
  32. U.S. Preventive Services Task Force. Screening for Lung Cancer, 12/13.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 02/25/16.

GUIDELINE UPDATE INFORMATION:

09/15/09

New Medical Coverage Guideline.

01/01/10

Revised BCBSF Radiology Management program exception section.

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.

02/15/12

Updated position statement and references.

06/15/13

Scheduled review; MCG subject changed to “Computed Tomography Thorax (Chest)”. Revised and updated tumor, cancer or mass: added restaging and periodic follow-up of documented malignancy (primary neoplasm and metastatic disease). Added evaluation of suspicious mass/tumor (unconfirmed cancer diagnosis). Added interstitial lung disease. Updated infection or inflammatory disease: added evaluation of known inflammatory disease (initial, during treatment, new signs and symptoms) and evaluation of lung abscess, cavitary lesion, or empyema detected or suggested on prior imaging. Revised congenital anomalies: added vascular and nonvascular. Updated other section: changed 2 weeks duration for persistent unresolved cough to 4 weeks and deleted “has been performed”, changed to “is indeterminate. Added Wegener’s disease. Updated code descriptor (71260, 71270). Revision; Program Exceptions section updated. Updated related guidelines section and references.

01/01/14

Revision; added “with polyangitis” to Wegener’s granulomatosis.

04/15/14

Scheduled review; added position statement for low-dose computed tomography (CT) for lung cancer screening, added limitation statement for an oncologic condition; limited to four (4) computed tomography within a 12-month period, added “evaluation of” to congenital anomalies and hemoptysis, added “helical CT’ and “low-dose CT” to other section, and updated references.

04/15/15

Revised description. Deleted pulmonary embolism and pre-operative evaluation. Revised: tumor, cancer or mass, infection or inflammatory disease, vascular disease, congenital abnormalities, hemoptysis, post-operative evaluation and add “procedural” to header, and other. Added: indication for combination studies for initial pre-therapy staging of cancer, or ongoing tumor/cancer surveillance, or evaluation of suspected metastases, combination studies with chest CT, and combination of studies with chest CT/sinus CT.

05/28/15

Updated Billing/Coding section; added HCPCS code S8032 .

03/15/16

Updated Billing/Coding section; added HCPCS code G0297.

10/01/16

Quarterly HCPCS update; deleted S8032.

Date Printed: October 23, 2017: 02:17 AM