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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.

04-70450-20

Original Effective Date: 09/15/09

Reviewed: 02/22/18

Revised: 03/15/18

Subject: Computed Tomography (CT) of the Neck for Soft Tissue Evaluation

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 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 neck for soft tissue evaluation, diagnosis and management of neck (soft tissue) related conditions in the outpatient setting.

POSITION STATEMENT:

Documentation Requirements

Documentation containing the medical necessity of the computed tomography (CT) of the neck for soft tissue evaluation 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 neck meets the definition of medical necessity for the following:

Evaluation of known tumor, cancer or mass

Evaluation of neck tumor/mass, or history of cancer with suspected recurrence or metastasis [based on symptoms or examination findings (may include new or changing lymph nodes)].

Evaluation of skull base tumor, mass or cancer.

Evaluation of tumors of the tongue, larynx, nasopharynx, pharynx, or salivary glands.

Evaluation of parathyroid tumor when:

o CA (calcium) normal [>10.6 mg/dL] and PTH > normal [55 pg/mL]; WITH

o Previous non-diagnostic ultrasound or nuclear medicine scan; AND

o Surgery is planned.

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.

For evaluation of suspected tumor, cancer or mass

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.

Evaluation of palpable suspicious lesions in mouth or throat.

Evaluation of non-thyroid masses in the neck when present greater than one month, noted to be >/= to 1 cm or associated with generalized lymphadenopathy.

For evaluation of known or suspected inflammatory disease or infection

Evaluation of deep space infections or abscesses of the pharynx and neck.

Evaluation of lymphadenopathy in the neck when present for greater than one month, noted to be >/= to 1 cm or associated with generalized lymphadenopathy.

Pre-operative evaluation

Post-operative/procedural evaluation (e.g. post neck dissection)

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.

Other indications for a Neck CT

Evaluation of vocal cord lesions or vocal cord paralysis.

Evaluation of stones of the salivary glands and ducts.

Evaluation of tracheal stenosis.

Indications for combination studies

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.

BILLING/CODING INFORMATION:

CPT Coding:

70490

Computed tomography, soft tissue neck; without contrast material

70491

Computerized axial tomography, soft tissue neck; with contrast material(s)

70492

Computerized axial tomography, soft tissue neck; 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 (70490 – 70492, 76380) performed on the same anatomical area is limited to two (2) computed tomography (70490 – 70492, 76380) within a 6-month period. Computed tomography (70490 – 70492, 76380) in excess of two (2) computed tomography (70490 – 70492, 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 (70490 – 70492, 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 (70490 – 70492, 76380) within a 12-month period. Computed tomography (70490 – 70492, 76380) for an oncologic condition in excess of four (4) computed tomography (70490 – 70492, 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 soft tissue neck, 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 neck for soft tissue evaluation.

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:

Lymphadenopathy: disease of the lymph nodes, usually with swelling.

Stenosis: an abnormal narrowing of a duct or canal.

Vascular malformation: an abnormal vascular formation resulting from a developmental anomaly rather than from neoplastic growth; common types include arteriovenous fistulas, some types of hemangiomas and lymphangiomas, nevus anemicus, and nevus flammeus.

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), Thorax (Chest) 04-70450-21

Computerized Axial Tomography (CT) Abdomen and 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 College of Radiology ACR Appropriateness Criteria®-Chronic Neck Pain, Last review date: 2013.
  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. Chin SC, Edelstein S, Chen CY et al. Using CT to localize side and level of vocal cord paralysis. American Journal of Roentgenology 2003; 180: 1165-1170.
  5. King AD, Tse GM, Ahuja AT et al. Necrosis in metastatic neck nodes: diagnostic accuracy of CT, MR imaging, and US. Radiology 2004; 230: 720-726.
  6. National Cancer Institute-Radiation risks and pediatric computed tomography (CT): A guide for health care providers, 12/12/08.
  7. National Imaging Associates, Inc. Clinical Guidelines-CT Soft Tissue Neck, 2018.
  8. Som PM, Curtin HD, Mancuso AA. Imaging-based nodal classification for evaluation of neck metastatic adenopathy. American Journal of Roentgenology 2000; 174: 837-844.
  9. Sumi M, Ohki M, Nakamura T et al. Comparison of sonography and CT for differentiating benign from malignant cervical lymph nodes in patients with squamous cell carcinoma of the head and neck. American Journal of Roentgenology 2001; 176: 1019-1024.

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.

08/15/11

Scheduled review. Updated position statement. Added general consideration statement for magnetic resonance imaging (MRI). 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: added neck to lymphadenopathy and duration, added tumor or cancer to skull base mass, added neck (tumor, mass, cancer), parathyroid tumor and nasopharyngeal tumor. Deleted but is not limited to. Updated references.

09/15/13

Scheduled review; MCG subject changed to “Computed Tomography (CT) of the Neck for Soft Tissue Evaluation”. Deleted hoarseness. Added pre-operative evaluation. Updated Medicare Advantage program exception and references.

05/15/14

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

01/01/15

Scheduled review; maintain position statement. Updated references.

03/15/18

Revision; revised position statement. Added position statement for tumor, cancer, mass, combination studies, inflammatory disease or infection, and pre/post-operative evaluation. Updated references.

Date Printed: May 24, 2018: 11:59 AM