Print

Date Printed: August 18, 2017: 08:00 PM

Private Property of Blue Cross and Blue Shield of Florida.
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.

04-70450-09

Original Effective Date: 06/15/15

Reviewed: 05/28/15

Revised: 00/00/00

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

Subject: Computed Tomography Angiography (CTA) Lower Extremity

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 lower extremity 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 lower extremity meets the definition of medical necessity for the following:

For assessment/evaluation of suspected or known vascular disease/condition:

• Significant ischemia in the presence of ulcers/gangrene

• Large vessel diseases (e.g. aneurysm, dissection, arteriovenous malformations (AVMs), and fistulas, intramural hematoma, and vasculitis)

• Arterial entrapment syndrome (e.g. Peripheral artery disease (PAD))

• Venous thrombosis if previous studies have not resulted in a clear diagnosis

• Vascular invasion or displacement by tumor

• Pelvic vein thrombosis or thrombophlebitis

• Abnormal preliminary testing (Ankle/Brachial index, ultrasound/doppler arterial evaluation) associated with significant symptoms of claudication with exercise

Pre-operative evaluation:

• Evaluation of known aortoiliac occlusion or peripheral vascular disease of the leg and ultrasound indicates significant disease and an indeterminate conclusion about whether the condition would be amenable to surgery

Post- operative/procedural evaluation:

• Post-operative or interventional vascular procedure for luminal patency versus re-stenosis (due to atherosclerosis, thromboembolism, intimal hyperplasia and other causes) as well as complications such as pseudoaneurysms related to surgical bypass grafts and vascular stents and stent-grafts.

• 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:

73706

Computed tomographic angiography, lower extremity, 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 neck.

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) Chest (non coronary), 04-70450-07

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

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

OTHER:

None applicable.

REFERENCES:

  1. ACR-NASCI-SIR-SPR Practice Guideline for the Performance and Interpretation of Body Computed Tomography Angiography (CTA), 2014.
  2. Kock MC, Dijkshoorn ML, Pattynama PM et al. Multi-detector row computed tomography angiography of peripheral arterial disease. European Radiology 2007; 17(12): 208-222.
  3. Lopera JE, Trimmer CK, Josephs SG et al. Multidetector CT angiography of infrainguinal arterial bypass. Radiographics 2008; 28(2): 529-548.
  4. National Imaging Associates, Inc. CT Angiography, Lower Extremity Clinical Guideline, 2015.
  5. Met R, Bipat S, Legemate DA et al. Diagnostic performance of computed tomography angiography in peripheral arterial disease: a systematic review and meta-analysis. JAMA 2009; 301(4): 415-424.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/28/15.

GUIDELINE UPDATE INFORMATION:

06/15/15

New Medical Coverage Guideline.

Date Printed: August 18, 2017: 08:00 PM