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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.

04-70450-23

Original Effective Date: 09/15/09

Reviewed: 12/04/14

Revised: 01/01/15

Subject: Computerized Axial Tomography (CT) Spine (Cervical, Thoracic, Lumbar)

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 spine (cervical, thoracic, lumbar) for evaluation, diagnosis and management of spine related conditions in the outpatient setting.

POSITION STATEMENT:

NOTE: MRI is the imaging modality of choice for most spine (cervical, thoracic, lumbar) imaging indications, unless contraindicated or not tolerated by the member.

Documentation Requirements

Documentation containing the medical necessity of the computed tomography (CT) of the spine (cervical, thoracic, lumbar) 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 spine (cervical, thoracic, lumbar) meets the definition of medical necessity for the diagnosis and evaluation of the following:

Cervical Spine

NOTE: MRI is the preferred imaging modality for most cervical spine imaging indications, unless contraindicated or not tolerated by the member.

Fracture

Chronic or Degenerative Changes (e.g., osteoarthritis, degenerative disc disease)

Trauma or Acute Injury

Tumor, Cancer or Evidence of Metastasis (vertebrae, spinal canal, spinal cord)

Known or Suspected Infection, Abscess or Inflammatory Disease

Pre-Operative Evaluation

Pre-operative evaluation for:

Post-Evaluation

Neck Pain

New onset of neck pain with:

Other

Thoracic Spine

NOTE: MRI is the imaging modality of choice for most thoracic spine imaging indications, unless contraindicated or not tolerated by the patient.

Fracture

Chronic or Degenerative Changes (e.g., osteoarthritis, degenerative disc disease)

Back Pain (new onset) with:

Trauma or Acute Injury

Tumor, Cancer or Evidence of Metastasis

Known or Suspected Infection of Abscess

Pre-Operative Evaluation

Pre-operative evaluation for:

Post-Evaluation

Other

Lumbar Spine

NOTE: MRI is the imaging modality of choice for most lumbar spine imaging indications, unless contraindicated or not tolerated by the patient.

Fracture

Chronic or Degenerative Changes (e.g., osteoarthritis, degenerative disc disease)

Trauma or Acute Injury

Back Pain

Tumor, Cancer or Evidence of Metastasis

Known or Suspected Infection of Abscess

Pre-operative Evaluation

Post-Evaluation

Other

BILLING/CODING INFORMATION:

The following codes may be used to describe computed tomography of the spine (cervical, thoracic, and lumbar).

CPT Coding:

72125

Computed tomography, cervical spine; without contrast material

72126

Computed tomography, cervical spine; with contrast material(s)

72127

Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections

72128

Computed tomography, thoracic spine; without contrast material

72129

Computed tomography, thoracic spine; with contrast material(s)

72130

Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections

72131

Computed tomography, lumbar spine; without contrast material

72132

Computed tomography, lumbar spine; with contrast material(s)

72133

Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections

76380

Computed tomography, limited or localized follow-up study

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 spine (cervical, thoracic, lumbar).

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

REIMBURSEMENT INFORMATION:

Reimbursement for computed tomography (72125 – 72133, 76380) performed on the same anatomical area is limited to two (2) computed tomography (72125 – 72133, 76380) within a 6-month period. Computed tomography (72125 – 72133, 76380) in excess of two (2) computed tomography (72125 – 72133, 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 (7212572133, 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 (7212572133, 76380) within a 12-month period. Computed tomography (7212572133, 76380) for an oncologic condition in excess of four (4) computed tomography (7212572133, 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 spine (cervical, thoracic, lumbar) due to poor contrast enhanced exam or technically limited exam is the responsibility of the imaging provider.

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:

Acute: having a short and relatively severe course.

Arnold-Chiari syndrome (Chiari malformations): herniation of the cerebellar tonsils and vermis through the foramen magnum into the spinal canal. It is always associated with lumbosacral myelomeningocele, and hydrocephalus and mental defects are common.

Cauda Equine syndrome: dull aching pain of the perineum, bladder, and sacrum, generally radiating in a sciatic fashion, with associated paresthesias and areflexic paralysis, due to compression of the spinal nerve roots.

Chronic: persisting over a long period of time.

Neoplasm: any new and abnormal growth; specifically a new growth of tissue in which the growth is uncontrolled and progressive.

Osteoarthritis: a noninflammatory degenerative joint disease seen mainly in older persons, characterized by degeneration of the articular cartilage, hypertrophy of bone at the margins, and changes in the synovial membrane. It is accompanied by pain, usually after prolonged activity, and stiffness, particularly in the morning or with inactivity

Radiculitis: inflammation of the root of a spinal nerve, especially of that portion of the root, which lies between the spinal cord and the intervertebral canal. Also called radicular neuritis.

Radiculopathy: disease of the nerve roots.

Spondylolisthesis: forward displacement (olisthy) of one vertebra over another, usually of the fifth lumbar over the body of the sacrum, or of the fourth lumbar over the fifth, usually due to a developmental defect in the pars interarticularis.

Spondylolysis: dissolution of a vertebra; a condition marked by platyspondylia, aplasia of the vertebral arch, and separation of the pars interarticularis.

Syringomyelia: a chronic progressive disease of the spinal cord associated with sensory disturbances, muscle atrophy, and spasticity.

Syrinx: a pathological cavity in the brain or spinal cord especially in syringomyelia.

Tethered cord: a congenital anomaly resulting from defective closure of the neural tube; the conus medullaris is abnormally low and is tethered by one or more forms of intradural abnormality such as a short, thickened filum terminale, fibrous bands or adhesions, or an intraspinal lipoma.

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 and Pelvis 04-70450-22

Computerized Axial Tomography (CT), Extremity (Upper & Lower) 04-70450-24

Whole Body Computed Tomography (CT) Scanning, 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®-Suspected Spine Trauma, 2007.
  2. American College of Radiology (ACR) Practice Guideline for the Performance of Pediatric and Adult Thoracic Computed Tomography (CT), 2008.
  3. American College of Radiology (ACR), American Society of Neuroradiology (ASNR)and American Society of Spine Radiology (ASSR) Practice Guideline for the Performance of Computed Tomography (CT) of the Spine, 2011.
  4. Centers for Medicare & Medicaid Services NCD for Computed Tomography (220.1), 03/12/08.
  5. Brant-Zawadzki MN, Dennis SC, Gade GF et al. Low back pain. Radiology 2000; 217(2): 321-330.
  6. Bub LD, Blackmore CC, Mann FA et al. Cervical spine fractures in patients 65 years and older: a clinical prediction rule for blunt trauma. Radiology 2005; 234(1): 143-149.
  7. Deyo RA, Weinstein JN. Low back pain. The New England Journal of Medicine 2001; 344: 363-370.
  8. Gilbert FJ, Grant AM, Gillan MGC et al. Low back pain: Influence of early MR imaging or CT on treatment and outcome-multicenter randomized trial. Radiology 2004; 231: 43-351.
  9. Hanson JA, Blackmore CC, Mann FA et al. Cervical spine injury: a clinical decision rule to identify high-risk patients for helical CT screening. American Journal of Roentgenology 2000; 174: 713-717.
  10. Keenan HT, Hollingshead MC, Chung CJ et al. Using CT of the cervical spine for early evaluation of pediatric patients with head trauma. American Journal of Roentgenology 2001; 177: 1405-1409.
  11. Koeller KK, Rosenblum RS, Morrison AL. Neoplasms of the spinal cord and filum terminale: radiologic-pathologic correlation. Radiographics 2000; 20: 1721-1749.
  12. National Cancer Institute-Radiation risks and pediatric computed tomography (CT): A guide for health care providers, 12/12/08.
  13. National Imaging Associates, Inc. Cervical Spine CT, Thoracic Spine CT and Lumbar Spine CT Clinical Guidelines, 06/14
  14. National Institutes of Neurological Disorders and Stroke-Brain and Spinal Tumors, 05/15/09.
  15. Taylor BA, Casas-Ganem J, Vaccaro AR et al. Differences in the work-up and treatment of conditions associated with low back pain by patient gender and ethnic background. Spine 2005; 30(3): 359-399.
  16. Wintermark M, Mouhsine E, Theumann N et al. Thoracolumbar spine fractures in patients who have sustained severe trauma: depiction with multi-detector row CT. Radiology 2003; 227: 681-689.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 12/04/14.

GUIDELINE UPDATE INFORMATION:

09/15/09

New Medical Coverage Guideline.

01/01/10

Revised BCBSF Radiology Management program exception section.

09/15/11

Scheduled review: no change in position statements. 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 for: cervical spine; chronic or degenerative changes, trauma or acute injury (added abnormal EMG or nerve conduction study) and progression or worsening of symptoms and other (added neurological deficits and evaluation of immune system suppression. Revised and expanded position statement for: thoracic spine; added (fracture, back pain (new onset) and trauma or acute injury with criteria and other (added neurologic deficits and evaluation of immune system suppression) Revised and expanded position statement for: lumbar spine; tumor, cancer or evidence of metastasis-tumor evaluation (clarified covered indications) and other (added neurologic deficits and evaluation of immune system suppression. Deleted but is not limited to. Updated references.

10/15/13

Scheduled review; MCG subject changed to “Computed Tomography (CT) Spine (Cervical, Thoracic, Lumbar)”. Updated definitions, program exceptions and reference sections.

01/01/15

Scheduled review; added non-healing to fracture section (cervical, thoracic and lumbar), chronic, muscle weakness and abnormal reflexes to chronic or degenerative changes section (cervical and lumbar), exacerbation of chronic back pain, muscle weakness, abnormal reflexes, new extremity numbness or tingling and criteria to chronic or degenerative changes to thoracic spine section, when spine MRI is contraindicated to immune system suppression to other section (cervical, thoracic and lumbar), or new onset of abnormal sensory changes along a particular dermatome (nerve distribution) as documented on physical exam for neurologic deficits (other section: cervical, thoracic and lumbar), syrinx or syringomyelia to other section (cervical and thoracic), re-ordered fracture section (thoracic spine), and definition for syringomyelia and syrinx. Added limitation statement for an oncologic condition; limited to four (4) computed tomography within a 12-month period. Updated references.

Date Printed: June 28, 2017: 11:50 PM