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Date Printed: October 20, 2017: 11:53 AM

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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.

04-70450-07

Original Effective Date: 06/15/15

Reviewed: 06/23/16

Revised: 07/15/16

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

Subject: Computed Tomography Angiography (CTA) Chest (non coronary)

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 angiography (CTA) is an imaging procedure performed for characterizing vascular anatomy, diagnosing vascular diseases, planning treatment for vascular disease and assessing the effectiveness of vascular treatment. CTA may be performed with or without contrast material.

POSITION STATEMENT:

Documentation Requirements

Documentation containing the medical necessity of the computed tomography angiography (CTA) of the chest (non coronary) 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 angiography (CTA) of the chest (non coronary) meets the definition of medical necessity for the following:

Evaluation of suspected or known pulmonary embolism (excludes low risk*):

Note: CTA and Pulmonary Embolism(PE) D-Dimer blood test in members at low risk for DVT is indicated prior to CTA imaging. Negative D-Dimer suggests alternative diagnosis in these members.

*Low risk defined as no to ALL of the following:

1. Evidence of current or prior DVT;

2. HR > 100;

3. Cancer diagnosis;

4. Recent surgery or prolonged immobilization;

5. Hemoptysis;

6. History of PE; AND

7. Other diagnosis is more likely than PE

CTA has high sensitivity and specificity and is the primary imaging modality to evaluate patients suspected of having acute pulmonary embolism. When high suspicion of pulmonary embolism on clinical assessment is combined with a positive CTA, there is a strong indication of pulmonary embolism. Likewise, a low clinical suspicion and a negative CTA can be used to rule out pulmonary embolism.

Evaluation of known vascular abnormalities:

• Thoracic aortic aneurysm or thoracic aortic dissection

• Congenital thoracic vascular anomaly, (e.g., coarctation of the aorta or evaluation of a vascular ring suggested by gastrointestinal (GI) study)

• Signs or symptoms of vascular insufficiency of the neck or arms (e.g., subclavian steal syndrome with abnormal ultrasound)

• Follow-up evaluation of progressive vascular disease when new signs or symptoms are present

• Pulmonary hypertension

Note: CTA and Thoracic Aortic Aneurysms Computed tomographic angiography (CTA) allows the examination of the precise 3-D anatomy of the aneurysm from all angles and shows its relationship to branch vessels. This information is very important in determining the treatment: endovascular stent grafting or open surgical repair.

CTA and Coarctation of the Aorta Coarctation of the aorta is a common vascular anomaly characterized by a constriction of the lumen of the aorta distal to the origin of the left subclavian artery near the insertion of the ligamentum arteriosum. The clinical sign of coarctation of the aorta is a disparity in the pulsations and blood pressures in the legs and arms. Chest CTA may be used to evaluate either suspected or known aortic coarctation and patients with significant coarctation should be treated surgically or interventionally.

Preoperative evaluation:

• Known vascular abnormalities and member has not had a catheter angiogram within the last month.

• Proposed ablation procedure for atrial fibrillation

Postoperative or post procedural evaluation:

• Known vascular abnormalities with physical evidence of post-operative bleeding complication or re-stenosis

• Request for a follow-up study: 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 indicates why additional imaging is needed for the type and area(s) requested

BILLING/CODING INFORMATION:

CPT Coding:

71275

Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

Re-imaging or additional imaging 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 angiography (CTA) of the chest.

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 BCBSF Radiology Management program for select products. The National Imaging Associates (NIA) will determine coverage for these services for select products. Refer to the 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 National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Computed Tomography Angiography (CTA) Abdomen and Pelvis, 04-70450-04
Computed Tomography Angiography (CTA) Brain (Head), 04-70450-05

Computed Tomography Angiography (CTA) Lower Extremity, 04-70450-09

Computed Tomography Angiography (CTA) Neck, 04-70450-06

Computed Tomography Angiography (CTA) Upper Extremity, 04-70450-08

OTHER:

None

REFERENCES:

  1. ACR-NASCI-SIR-SPR Practice Guideline for the Performance and Interpretation of Body Computed Tomography Angiography (CTA), 2014.
  2. American College of Radiology (ACR) Appropriateness Criteria® Acute Chest Pain-Suspected Pulmonary Embolism, 2011.
  3. Anderson DR, Kahn SR, Rodger MA et al. Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. JAMA 2007; 298(23): 2743-1753.
  4. National Imaging Associates, Inc. CTA Chest Clinical Guideline, 2016.
  5. Stein PD, Fowler SE, Goodman LR et al. Multidetector computed tomography for acute pulmonary embolism. New England Journal of Medicine 2006; 354(22): 17-27.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 06/23/16.

GUIDELINE UPDATE INFORMATION:

06/15/15

New Medical Coverage Guideline.

07/15/16

Revision; added information related to: chest CTA and pulmonary embolism (PE), CTA and thoracic aortic aneurysms and CTA and coarctation of the aorta. Updated references.

Date Printed: October 20, 2017: 11:53 AM