2016 NIA Clinical Guidelines for Medical Necessity Review ... · NIA is committed to the philosophy...

NIA Clinical Guidelines

© 2016 Magellan Health, Inc. Proprietary of 200

2016 NIA Clinical Guidelines for Medical Necessity Review

FLORIDA BLUE

_______________________________________________________________



Guidelines for Clinical Review Determination

Preamble

NIA is committed to the philosophy of supporting safe and effective treatment for patients. The

medical necessity criteria that follow are guidelines for the provision of diagnostic imaging. These

criteria are designed to guide both providers and reviewers to the most appropriate diagnostic

tests based on a patient’s unique circumstances. In all cases, clinical judgment consistent with the

standards of good medical practice will be used when applying the guidelines. Guideline

determinations are made based on the information provided at the time of the request. It is

expected that medical necessity decisions may change as new information is provided or based on

unique aspects of the patient’s condition. The treating clinician has final authority and

responsibility for treatment decisions regarding the care of the patient.

Guideline Development Process

These medical necessity criteria were developed by NIA for the purpose of making clinical review

determinations for requests for diagnostic tests. The developers of the criteria sets included

representatives from the disciplines of radiology, internal medicine, nursing, and cardiology. They

were developed following a literature search pertaining to established clinical guidelines and

accepted diagnostic imaging practices.

All inquiries should be directed to:

National Imaging Associates, Inc.

6950 Columbia Gateway Drive

Columbia, MD 21046

Attn: NIA Associate Chief Medical Officer



TABLE OF CONTENTS

TOC

70450 – CT Head/Brain ______________________________________________________________ 5

70486 – Face CT ____________________________________________________________________ 9

70486 – Maxillofacial/Sinus CT _______________________________________________________ 9

70480 – CT Orbit (Includes Sella and Posterior Fossa) __________________________________ 9

70480 – CT Internal Auditory Canal __________________________________________________ 9

70480 – CT Sella ____________________________________________________________________ 9

70490 – CT Soft Tissue Neck _______________________________________________________ 13

70496 – CT Angiography, Head/Brain _______________________________________________ 15

70498 – CT Angiography, Neck _____________________________________________________ 17

70540 – MRI Orbit ________________________________________________________________ 19

70540 – MRI Face _________________________________________________________________ 19

70540 – MRI Neck _________________________________________________________________ 19

70540 – MRI Sinus ________________________________________________________________ 19

70336 – MRI Temporomandibular Joint (TMJ) _______________________________________ 19

70544 – MR Angiography Head/Brain _______________________________________________ 23

70547 – MR Angiography Neck _____________________________________________________ 25

70551 – MRI Brain (includes Internal Auditory Canal) _______________________________ 27

70554 – Functional MRI Brain _____________________________________________________ 32

71250 – CT Chest (Thorax) _________________________________________________________ 33

71275 – CT Angiography, Chest (non coronary) ______________________________________ 37

71550 – MRI Chest (Thorax) _______________________________________________________ 39

71555 – MR Angiography Chest (excluding myocardium)______________________________ 40

72125 – CT Cervical Spine _________________________________________________________ 41

72128 – CT Thoracic Spine _________________________________________________________ 41

72131 – CT Lumbar Spine _________________________________________________________ 41

72141 – MRI Cervical Spine ________________________________________________________ 51

72146 – MRI Thoracic Spine ________________________________________________________ 51

72148 – MRI Lumbar Spine ________________________________________________________ 51

72159 – MR Angiography Spinal Canal ______________________________________________ 60

72192 – CT Pelvis _________________________________________________________________ 61

74150 – CT Abdomen ______________________________________________________________ 61

74176 – CT Abdomen and Pelvis Combo _____________________________________________ 61

72196 – MRI Pelvis ________________________________________________________________ 69

74181 – MRI Abdomen _____________________________________________________________ 69

72198 – MR Angiography, Pelvis ____________________________________________________ 75

74185 – MR Angiography, Abdomen ________________________________________________ 75

73200 – CT Upper Extremity (Hand, Wrist, Elbow, Long Bone or Shoulder) ____________ 78

73700 – CT Lower Extremity (Ankle, Foot, Hip or Knee) ______________________________ 78

73206 – CT Angiography, Upper Extremity __________________________________________ 81

73220 – MRI Upper Extremity ______________________________________________________ 82

73225 – MR Angiography Upper Extremity __________________________________________ 85

73725 – MR Angiography, Lower Extremity _________________________________________ 85

73706 – CT Angiography, Lower Extremity __________________________________________ 87

_______________________________________________________________



73720 – MRI Lower Extremity (Ankle, Foot, Knee, Hip, Leg) __________________________ 88

74175 – CT Angiography, Abdomen _________________________________________________ 91

74174 – CT Angiography, Abdomen and Pelvis _______________________________________ 91

72191 – CT Angiography, Pelvis ____________________________________________________ 91

75635 – CT Angiography, Abdominal Arteries ________________________________________ 91

74261 – CT Colonoscopy (Virtual) ___________________________________________________ 95

75557 – MRI Heart ________________________________________________________________ 96

75571 – Electron Beam Tomography (EBCT) ________________________________________ 104

75572 – CT Heart ________________________________________________________________ 105

75574 – CTA Coronary Arteries (CCTA) ____________________________________________ 105

76390 – MR Spectroscopy _________________________________________________________ 108

77058 – MRI Breast ______________________________________________________________ 109

77084 – MRI Bone Marrow ________________________________________________________ 111

78451 – Myocardial Perfusion Imaging (Nuc Card) __________________________________ 112

78472 – MUGA Scan______________________________________________________________ 112

78459 – PET Scan, Heart (Cardiac) ________________________________________________ 118

78608 – PET Scan, Brain__________________________________________________________ 121

78813 – PET Scan ________________________________________________________________ 129

S8037 – MR Cholangiopancreatography (MRCP) ____________________________________ 137

S8032 – Low Dose CT for Lung Cancer Screening ___________________________________ 138

MUSCULOSKELETAL_SPINE SURGERY GUIDELINES ___________________________ 139

22600/63001 – Cervical Spinal Surgery _____________________________________________ 139

22612/63030 – Lumbar Spinal Surgery _____________________________________________ 147

62310-62311 – Spinal Epidural Injections __________________________________________ 153

64490-64493 – Paravertebral Facet Joint Injections/Blocks ___________________________ 158

64633-64635 – Paravertebral Facet Joint Neurolysis ________________________________ 162

27132 – Hip Arthroplasty _________________________________________________________ 168

27130 – Hip Arthroscopy __________________________________________________________ 175

27446 – Knee Arthroplasty ________________________________________________________ 182

27332 – Knee Arthroscopy ________________________________________________________ 188

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TOC

70450 – CT Head/Brain

“FOR FLORIDA BLUE MEMBERS ONLY”

In the ambulatory setting, magnetic resonance imaging (MRI) is ordinarily the preferred exam. CT

of the head is an alternative exam for patients when MRI is contraindicated or not tolerated by the

member.

INDICATIONS FOR BRAIN (HEAD) CT:

Trauma (known or suspected):

NOTE: Trauma may be acute (less than 24 hours), recent (up to one week) or chronic (one week or

longer).

Known or suspected trauma or injury to the head with documentation of one or more of the

following (acute, new or fluctuating):

Focal neurologic sign(s) (e.g., ataxia, papilledema, visual field defects, nystagmus, gait

disturbances) and brain MRI is contraindicated

Motor changes

Mental status changes

Amnesia

Vomiting

Seizures

Signs of increased intracranial pressure (e.g., headaches, seizures, nausea, vomiting, blurred

vision)

Know or suspected skull fracture by physical exam and positive x-ray findings (e.g., plain

skull x-ray).

Headache

When any one of the following criteria is met:

Chronic headache with a change in character/pattern (e.g., more frequent, increased severity

or duration) and MRI is contraindicated or cannot be performed.

New onset (< 48 hours) or “worst headache in my life” or “thunderclap” headache. Note: The

duration of a thunderclap type headache lasts more than 5 minutes. Sudden onset new

headache reaching maximum intensity within 2-3minutes

New onset of headache in occipitonuchal region in member > 55 years of age and brain MRI

is contraindicated or cannot be performed.

New onset of temporal headache in member > 55 years of age with erythrocyte

sedimentation rate (ESR) > 55 and tenderness over the temporal artery and brain MRI is

contraindicated or cannot be performed.

New onset of headache in member with history of cancer or HIV and brain MRI is


Brain Tumor, Mass or Metastasis (known or suspected):

Evaluation of bone tumor or abnormality of the skull.

Evaluation of member with history of cancer with recent course of chemotherapy, radiation

therapy (to the brain), or treated surgically within the last two years

Member with history of cancer with suspected recurrence or metastasis, based on symptoms

(e.g., headaches (new onset, increase in frequency and severity), nausea, vomiting, vision

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problems (blurred, double, loss of peripheral vision) or examination findings (e.g., new or

changing lymph nodes).

Cerebrovascular Accident (CVA)/Stroke (known or suspected):

Evaluation of member with history of a known stroke with new and sudden onset of severe

headache.

Evaluation of member with suspected stroke or history of known stroke with a family history

(parent, child, brother, or sister) of stroke or aneurysm.

Aneurysm/Arteriovenous Malformation (AVM) (known or suspected):

History of known aneurysm or AVM with new onset of headache and brain MRI is


History or suspicion of aneurysm or AVM or AVM with family history (parent, child, borther,

or sister) of aneurysm or AVM and brain MRI is contraindicated or cannot be performed.

Inflammatory Disease or Infection (known or suspected):

Known or suspected inflammatory disease or infection (e.g., meningitis, abscess) with

positive lab findings (e.g., cerebrospinal spinal fluid culture, blood culture) and brain MRI is


Congenital Anomaly (congenital abnormality, congenital malformation):

Evaluation of member for congenital anomaly (known or suspected) and MRI is


Evaluation of member for hydrocephalus (known or suspected) and MRI is contraindicated

or cannot be performed.

Evaluation of member for prior treatment or treatment planned for congenital abnormality

and MRI is contraindicated or cannot be performed.

Post-Operative/Procedural Evaluation:

Follow-up study for evaluation of member’s progress after treatment, procedure,

intervention or surgery. Documentation should include a medical reason why additional

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

Other :

Initial evaluation of a Cholesteatoma

Follow-up for known hemorrhage, hematoma or vascular abnormalities

Evaluation of a single study related to new onset of seizures or newly identified change in

seizure activity/pattern and MRI is contraindictiond or cannot be performed.

CT of the head or brain is an alternative exam for members when MRI is contraindicated or

not tolerated by the member.

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, or spine (cervical, thoracic

lumbar).

Indication for Brain CT/Cervical CT combination studies:

For evaluation of Arnold Chiari malformation.





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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).

Definitions

Acute: having a short and relatively severe course.

Aneurysm: a sac formed by the dilatation of the wall of an artery, a vein, or the heart; it is filled

with fluid or clotted blood, often forming a pulsating tumor.

Arteriovenous malformation: a congenital anomaly of the brain vasculature composed of arterial

and venous channels with many interconnecting shunts without a capillary bed; clinical

characteristics include hemorrhage, headache, and focal epileptic seizures.

Ataxia: an inability to coordinate voluntary muscular movements that is symptomatic of some

nervous disorders.

Cholesteatoma: a cyst-like mass or benign tumor lined with stratified squamous epithelium, usually

keratinizing, and filled with desquamating debris often including cholesterol. Cholesteatoma are

most common in the middle ear and mastoid region secondary to trauma or infection that heals

improperly so that epithelium invaginates.

Chronic: persisting over a long period of time.

Congenital anomaly: congenital anomaly present at birth; it may be a malformation, disruption,

deformation, or dysplasia.

Hydrocephalus: a condition marked by dilatation of the cerebral ventricles, most often occurring

secondarily to obstruction of the cerebrospinal fluid pathways and accompanied by an accumulation

of cerebrospinal fluid within the skull.

Meningitis: inflammation of the meninges, usually by either a bacterium (bacterial) or a virus

(viral).

Nystagmus: an involuntary, rapid, rhythmic movement of the eyeball, which may be horizontal,

vertical, rotatory, or mixed.

Papilledema: edema of the optic disk (papilla), most commonly due to increased intracranial

pressure, malignant hypertension, or thrombosis of the central retinal vein.

Thunderclap headaches: a severe headache with sudden onset similar to a clap of thunder, with

maximum intensity within 1 minute.

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REIMBURSEMENT INFORMATION:

Reimbursement for computed tomography (70450 – 70470, 76380) performed on the same

anatomical area is limited to two (2) computed tomography (70450 – 70470, 76380) within a 6-

month period. Computed tomography (70450 – 70470, 76380) in excess of two (2) computed

tomography (70450 – 70470, 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 (70450 – 70470, 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 (70450 – 70470, 76380) within a

12-month period. Computed tomography 70450 – 70470, 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.

_______________________________________________________________



TOC

70486 – Face CT

70486 – Maxillofacial/Sinus CT

70480 – CT Orbit (Includes Sella and Posterior Fossa)

70480 – CT Internal Auditory Canal

(Temporal Bone, Mastoid)

70480 – CT Sella


Computed tomography (CT) of the temporal bone, mastoid, maxillofacial, sinus, and orbits meets

the definition of medical necessity for the diagnosis and evaluation of the following.

Temporal Bone and Mastoid

Computed tomography (CT) of the temporal bone and mastoid meets the definition of medical

necessity for the following:

Cholesteatoma

Chronic otitis media, ear infections or drainage

Conductive hearing loss

Congenital hearing loss (deformity)

Dehiscence of the jugular bulb or carotid canal

Acoustic neuroma or other lesion of the 7th or 8th cranial nerve in member unable to undergo

an MRI

Cochlear implant

Follow-up exam to evaluate progress after treatment, procedure, intervention, and surgery

Malformation of blood vessels or aberrant blood vessels

Mastoiditis

Temporomandibular joint (TMJ) disease/dysfunction if MRI is contraindicated (documentation

should include why MRI is contraindicated)

Maxillofacial, Sinus, Orbits, and Sella

Computed tomography (CT) of the maxillofacial, sinus, and orbits meets the definition of medical


Maxillofacial & Sinus

Evaluation of known or suspected infections or inflammatory disease

Unresolved sinusitis after four (4) consecutive weeks of medication (e.g., antibiotics, steroids,

antihistimines)

Immunocompromised member (including, but not limited to AIDS, transplant member or

member with genetic or acquired deficiencies) or conditions predisposed to sinusitis (e.g.,

cystic fibrosis, immotile cilia syndrome)

_______________________________________________________________



Osteomyelitis of facial bone where imaging study (e.g., plain films, brain MRI) demonstrates

an abnormality or is indeterminate

Evaluation of known or suspected tumorKnown or suspected tumor with bony abnormality

or opaque sinuses seen on imaging or for mucocele (unusual benign tumor)

Evaluation of trauma

Suspected fracture AND prior imaging was non-diagnostic or equivocal

For follow-up of trauma with fracture or opaque sinuses visualized on x-ray

Post-operative evaluation

Complications (e.g., suspected CSF leak, post-operative bleeding as evidenced by persistent

opaqueness on imaging)

Non-improvement, two (2) or more weeks after surgery

Other indications for Sinus CT

For poorly controlled asthma associated with upper respiratory tract infections. (May be

performed without failing four (4) consectuve weeks of medical treatment with medication).

Deviated nasal septum or structural abnormality seen on imaging or direct visualization that

may be causing significant airway obstruction

New onset of anosmia (lack of sense of smell) or significant hyposmia (disminished sense of

smell

Granulomatosis with polyangitis (Wegener’s) may be present as rhinosinusitis

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.

Combination of studies with Sinus CT

Sinus CT/Chest CT

For poorly controlled asthma associated with upper respiratory tract infection. (May be

performed without failing four (4) consecutive weeks of medical treatment with medication.)

Granulomatosis with polyangitis (Wegener’s) disease (GPA)

Orbit

Decreased range of motion of the eyes

Follow-up exam to evaluate progress after treatment, procedure and surgery

Known or suspected hyperthyroidism (e.g., Grave’s disease)

Ocular tumor (melanoma)

Optic neuritis (known or suspected) if MRI is contraindicated or is unable to be performed

Orbital pseudotumor

Progressive vision

Proptosis (exophthalmos)

Trauma (eye)

Unilateral visual deficit

Sella

_______________________________________________________________



Decreased range of motion of the eyes

Parasellarbony structures for the evaluation of sellar tumors

Ocular tumor

Optic neuritis (known or suspected) if MRI is contraindicated or is unable to be performed

Orbital pseudotumor (suspected)

Pituitary adenoma

Progressive vision loss/visual field deficit













12-month period. Computed tomography (70480 – 70488, 76380) for an oncologic condition in excess





Re-imaging or additional imaging of the head or brain due to poor contrast enhanced exam or

technically limited exam is the responsibility of the imaging provider.

Documentation Requirements

Documentation containing the medical necessity of the computed tomography (CT) of the temporal

bone/mastoid and maxillofacial 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.

DEFINITIONS:

Anosmia: absence of the sense of smell.

Cholesteatoma: a cyst-like mass or benign tumor lined with stratified squamous epithelium, usually

keratinizing, and filled with desquamating debris often including cholesterol. Cholesteatomas are

most common in the middle ear and mastoid region secondary to trauma or infection that heals

improperly.

Conductive hearing loss: hearing loss due to a defect of the sound conducting apparatus, i.e., of the

external auditory canal or middle ear.

_______________________________________________________________



Hyposmia: diminished sensitivity of smell.

Mastoiditis: inflammation of the mastoid antrum and air cells.

Neuritis: inflammation of a nerve, with pain and tenderness, anesthesia and paresthesias,

paralysis, wasting, and disappearance of the reflexes.

Osteomyelitis: inflammation of a bone caused by infection, usually by a pyogenic organism,

although any infectious agent may be involved. It may remain localized or may spread through the

bone to involve marrow, cortex, cancellous tissue, and periosteum.

Proptosis (exophthalmos): abnormal protrusion of the eyeball.

Pseudotumor: an enlargement that resembles a tumor; it may result from inflammation,

accumulation of fluid, or other causes, and may or may not regress spontaneously.

Sella turcica: a saddle-shaped depression in the sphenoid bone at the base of the human skull which

holds the pituitary gland.

Sinusitis: inflammation of a sinus, usually a paranasal sinus, it may be purulent or nonpurulent,

acute or chronic.








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TOC

70490 – CT Soft Tissue Neck


INDICATIONS FOR NECK CT:

Computed tomography (CT) of the soft tissue of the neck meets the definition of medical necessity

for the diagnosis and evaluation of the following if MRI is contraindicated:

Abscess (pharynx, neck)

Lymphadenopathy of the neck (persistent), greater than one month, noted to be >/= to 1 cm

and/or associated with generalized lymphadenopathy

Palpable lesion (e.g., mouth, throat)

Skull base mass, tumor or cancer

Tracheal stenosis

Stones (parotid gland, submandibular gland, parotid duct, submandibular duct)

Tumor of larynx, pharynx, nasopharynx, or salivary glands (suspected or known);

Vascular malformation

Vocal cord lesion

Vocal cord paralysis

Known or suspected neck tumor, mass, or cancer in member with history of cancer (with

signs/symptoms or physical examination findings, may include new or change in lymph nodes)

Known or suspected recurrence or metastasis of neck tumor, mass, or cancer in member with

history of cancer (based on symptoms or physical examination findings, may include new or

change in lymph nodes)

Known or suspected parathyroid tumor when:

o Ca > 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

Known or suspected nasopharyngeal tumor

Known or suspected persistent non-thyroid mass in the neck greater than one month (noted to

be >/= to 1 cm and/or associated with generalized lymphadenopathy

Pre-operative evaluation

Follow-up study to evaluate progress after treatment, procedure and surgery.


Reimbursement for computed tomography (70490, 70491, 70492) performed on the same anatomical

area is limited to two (2) computed tomography (70490, 70491, 70492) within a 6-month period.

Computed tomography (70490, 70491, 70492) in excess of two (2) computed tomography (70490,

70491, 70492) 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, 70491, 70492) for an oncologic condition


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same anatomical area is limited to four (4) computed tomography (70490, 70491, 70492) within a

12-month period. Computed tomography (70490, 70491, 70492) for an oncologic condition in excess

of four (4) computed tomography (70490, 70491, 70492) within a 12-month period are subject to






General Considerations

The development of magnetic resonance imaging (MRI) capability to provide highly detailed

visualization of soft tissue structures makes MRI the preferred technology for evaluation of soft-

tissue structures of the neck. MRI should always be the study of choice unless there is a

contraindication.


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.

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TOC

70496 – CT Angiography, Head/Brain


INTRODUCTION

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. This guideline addresses the use of CTA of the brain (head) in the outpatient setting.


Documentation containing the medical necessity of the computed tomography angiography (CTA) of

the brain (head) 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.

INDICATIONS FOR BRAIN (HEAD) CTA:

Evaluation of known intracranial vascular disease:

Evaluation of known intracranial aneurysm or arteriovenous malformation (AVM)

Evaluation of known vertebral basilar insufficiency (VBI).

Re-evaluation of vascular abnormality visualized on prior brain MRI

Evaluation of known vasculitis

Evaluation for suspected intracranial vascular disease:

Screening for suspected intracranial aneurysm in member whose parent or sibling has history of

intracranial aneurysm. Note: If there is a first degree familial history, repeat study is

recommended every 5 years.

Screening for aneurysm in polycystic kidney disease, Ehlers-Danlos syndrome, fibromuscular

dysplasia, neurofibromatosis, or known aortic coarctation

Evaluation of suspected vertebral basilar insufficiency (VBI)

Evaluation of suspected arteriovenous malformation (AVM)

Evaluation of suspected venous thrombosis

Evaluation of pulsatile tinnitus for vascular etiology

Evaluation of suspected vasculitis with abnormal lab results suggesting acute inflammation or

autoimmune antibodies

Pre-operative evaluation:

Pre-operative evaluation for surgery (e.g., brain/skull)

Post-operative/procedural evaluation:



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

_______________________________________________________________



Indications for Brain CTA/Neck CTA combination studies:

Evaluation of members who have had a stroke or transient ischemic attack (TIA) within the

past 2 weeks

Evaluation of members with a sudden onset of one-sided weakness, inability to speak, vision

defects or severe dizziness

Evaluation of head trauma in a member with closed head injury for suspected carotid or

vertebral artery dissection

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TOC

70498 – CT Angiography, Neck


INTRODUCTION




material.

DOCUMENTATION REQUIREMENTS


the neck 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.

INDICATIONS FOR NECK CTA:

Evaluation of vascular disease:

Evaluation of abnormal ultrasound of the neck or carotid duplex imaging



Evaluation of known or suspected tumor/mass:

Evaluation of carotid body tumors (also called paragangliomas)

Evaluation of pulsatile neck mass


Pre-operative evaluation for surgery (e.g., carotid endarterectomy)



procedure, intervention or surgery (e.g., carotid endarterectomy). Documentation requires a

medical reason that clearly indicates why additional imaging is needed for the type and area(s)

requested.

Indications for Neck CTA/Brain CTA combination studies:

For evaluation of members who have had a stroke or transient ischemic attack (TIA) within the

past 2 weeks.

For evaluation of members with a sudden onset of one-sided weakness, inability to speak, vision

defects or severe dizziness.

_______________________________________________________________



For suspected vertebral basilar insufficiency with symptoms such as vision changes, vertigo, or

abnormal speech.

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TOC

70540 – MRI Orbit

70540 – MRI Face

70540 – MRI Neck

70540 – MRI Sinus

70336 – MRI Temporomandibular Joint (TMJ)


Orbit

Decrease range of motion of eyes

Hyperthyroidism (e.g., Graves disease)

Infection (orbital cellulitis, abscess)

Nystagmus

Optic neuritis

Progressive vision loss


Orbital Pseudotumor

Strabismus

Trauma (assessment)

Ocular tumor (e.g., melanoma)

Visual loss unexplained by ophthalmic evaluation

Unilateral visual deficit

Tumors or malignancy (known or suspected)

o Diagnosis or staging;

o Evaluation or response to treatment;

o Preoperative evaluation.

Face

Osteomyelitis

Parotid tumors

Trauma

Tumor (sinonasal, facial)

Tumors or malignancy (known or suspected)

o Diagnosis or staging;

o Evaluation or response to treatment;

o Preoperative evaluation.

Neck

Brachial plexus dysfunction (brachial plexopathy, thoracic outlet syndrome)

Neck lymphadenopathy when greater than one month, noted to be >/= to 1 cm or associated

with generalized lymphadenopathy

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Neck tumor, mass or cancer (known or suspected) with suspected recurrence or metastasis

(based on symptoms or examination findings (may include new or changing lymph nodes)

Obstructive thyroid nodule

Palpable lesion in mouth or throat

Palpable neck mass

Persistent hoarseness

Skull base tumor, mass or cancer

Suspected or know tumor of: larynx, pharynx, nasopharynx, parathyroid, salivary glands

Tracheal stenosis

Vocal cord lesion

Vocal cord paralysis

Non-thyroid mass in neck when persistent, greater than one month, and >/= to 1cm

Parotid and submandibular glands and ducts stones

Pre-operative evlauation

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

o A follow-up study may be needed for evaluation of 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

Evaluation of parathyroid tumor when:

o Ca > 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

Temporomandibular Joint (TMJ)

Failed conservative therapy (e.g., TMJ splint, bite block, anti-inflammatory medication) for

TMJ disease for at least four (4) weeks

Frozen or locked jaw

Suspected TMJ joint disease/TMJ dysfunction (difficulty in the ability to open mouth, pain

with chewing, etc)

Other:

Preoperative evaluation of dysfunctional TMJ for orthognathic surgery

Sinus

Evidence of tumor from a physical exam, plain sinus x-ray or previous CT

Cerebrospinal fluid (CSF) leak

Sinusitis (rhinosinusitis) unresponsive to 3 documented courses of 4 weeks of medical

management (each documented course of treatment must be 4 weeks long) (e.g., antibiotics,

nasal steroids, decongestants, anti-histamines)

Osteomyelitis.

MRI Field Strength

MRI field strength, including intermediate and low field strength MRI units are considered an

acceptable alternative to standard closed MRI units.

MRI imaging, when used as a screening tool in the absence of signs or symptoms of a disease or

condition, without a diagnosis, or specific clinical indication does not meet the definition of medical

_______________________________________________________________



necessity as there is insufficient clinical evidence to support the use of MRI imaging as a screening

tool.


Reimbursement for MRI imaging (70336, 70540-70543) performed on the same anatomical area is

limited to one (1) MRI imaging (70336, 70540-70543) within a 6-month period. MRI imaging in

excess of one (1) within a 6-month period is subject to medical review for 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.

Additional MRI imaging of the same anatomical area may be appropriate for the following,

including, but not limited to: diagnosis, staging or follow-up of cancer, follow-up assessment during

or after therapy for known metastases, follow-up or evaluation after treatment, procedure,

intervention or surgery, reevaluation due to change in clinical status, new or worsening clinical

findings, medical intervention which warrants reassessment, reevaluation for treatment planning,

and follow-up during and after completion of therapy or treatment to assess effectiveness.

Reimbursement for MRI imaging (70336, 70540-70543) 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) MRI imaging (70336, 70540-70543) within a 12-month period. MRI

imaging (70336, 70540-70543) for an oncologic condition in excess of four (4) 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 due to poor contrast enhanced exam or technically limited exam

is the responsibility of the imaging provider.

Open MRI Units (Stand-Up MRI/Sitting MRI-Positional MRI)

Open MRI units of any configuration, including MRI units that allow imaging when standing

(Stand-up MRI) or when sitting (Sitting MRI), are considered to be an acceptable standard

alternative to standard “closed” MRI units. Stand-up MRI and sitting MRI may be reported like a

standard MRI. No additional payment will be made for stand-up MRI or sitting MRI.

DEFINITIONS:

Hyperthyroidism: a condition caused by excessive production of iodinated thyroid hormones;

characteristics include goiter, tachycardia or atrial fibrillation, widened pulse pressure,

palpitations, fatigability, nervousness and tremor, heat intolerance and excessive sweating, warm,

smooth, moist skin, weight loss, muscular weakness, excessive defecation, emotional liability, and

ocular signs such as stare, slowing of eyelid movements, photophobia, and sometimes

exophthalmos.

Lymphadenopathy: disease of the lymph nodes.

_______________________________________________________________



Nystagmus: Involuntary usually rapid movement of the eyeballs (as from side to side) occurring

normally with dizziness during and after bodily rotation or abnormally following head injury or as a

symptom of disease.

Proptosis: Abnormal protrusion of the eyeball.

_______________________________________________________________



TOC

70544 – MR Angiography Head/Brain


INTRODUCTION

Magnetic resonance angiography (MRA) is a noninvasive imaging technology used for the

evaluation and imaging of vessels in the head and neck. Magnetic resonance angiography (MRA) or

magnetic resonance venography (MRV) may be used as a first line investigation of intracranial

vascular disease. It is an alternative to invasive intracatheter angiography. A contrast agent

(gadolinium) may be used with MRA/MRV for better visualization and may be used in individuals

who have a history of contrast allergy and who are at high risk of kidney failure.


Documentation containing the medical necessity of the magnetic resonance angiography

(MRA)/magnetic resonance venography (MRV) of the brain (head) 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.

INDICATIONS FOR BRAIN (HEAD) MRA:

Evaluation of known intracranial vascular disease:

Evaluate known intracranial aneurysm or arteriovenous malformation (AVM)

Evaluate known vertebral basilar insufficiency (VBI)

Re-evaluate vascular abnormality visualized on prior brain MRI

Evaluation of known vasculitis

Evaluation for suspected intracranial vascular disease:

Screening for suspected intracranial aneurysm in patient whose parent or sibling has history of

intracranial aneurysm. Note: If there is a first degree familial history, repeat study is

recommended every 5 years

Screening for aneurysm in polycystic kidney disease, Ehlers-Danlos syndrome, fibromuscular

dysplasia, neurofibromatosis, or known aortic coarctation

Evaluate suspected vertebral basilar insufficiency (VBI)

Evaluation of suspected arteriovenous malformation (AVM)

Evaluation of suspected venous thrombosis

Evaluation of pulsatile tinnitus for vascular etiology

Evaluation of suspected vasculitis with abnormal lab results suggesting acute inflammation or

autoimmune antibodies


Pre-operative evaluation for brain/skull surgery


_______________________________________________________________






Indications for Brain MRA/Neck MRA combination studies:


past 2 weeks





_______________________________________________________________



TOC

70547 – MR Angiography Neck


INTRODUCTION

Magnetic resonance angiography (MRA) is a noninvasive imaging technology used for the

evaluation and imaging of vessels in the head and neck. MRA may be performed after abnormal

results are found on carotid duplex imaging. MRA may be performed with or without contrast

material.


Documentation containing the medical necessity of the magnetic resonance angiography (MRA) of

the neck and imaging results (e.g., images, clinical reports) should be maintained in the member’s


INDICATIONS FOR NECK MRA:

Evaluation of vascular disease:

Evaluation of members with an abnormal ultrasound of the neck or carotid duplex imaging



Evaluation of known or suspected tumor/mass:

Evaluation of carotid body tumors (also called paragangliomas)

Evaluation of pulsatile neck mass


Pre-operative evaluation for surgery (e.g., carotid endarterectomy)

Post-operative/procedural evaluation (e.g., carotid endarterectomy:




Indications for combination studies:

Neck MRA/Brain MRA:


past 2 weeks

_______________________________________________________________





Evaluate suspected vertebral basilar insufficiency (VBI) with symptoms such as vision changes,

vertigo, or abnormal speech.


vertebral artery dissection.

Neck MRA/Brain MRI:

Confirmed carotid occlusion of greater than 60%, surgery or angioplasty candidate (significant

lesion can flip off emboli, looking for stroke).

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TOC

70551 – MRI Brain (includes Internal Auditory Canal)


INDICATIONS FOR BRAIN (HEAD) MRI:

Aneurysm or Arteriovenous Malformation (AVM) (known or suspected):

New onset of headache or any acute neurologic, motor or mental status changes (recent, acute,

new or fluctuating) e.g., one sided weakness, paralysis, loss of muscle control, increased muscle

tone, loss of muscle tone, gait disturbance, lack of coordination, ataxia, speech impairment,

facial numbness, visual deficit

Brain Tumor/Metastasis (known or suspected):

Tumor with new onset of headache

Follow-up for tumor without any acute, new or fluctuating neurologic, motor or mental status

changes

Follow-up for tumor with acute, new or fluctuating neurologic, motor or mental status changes

Pituitary tumor with clinical findings on physical exam (e.g., galactorrhea), neurologic findings

(e.g., headaches, visual problems (loss, double), confusion, facial numbness, facial pain,

dizziness) and/or lab abnormalities (e.g., elevated prolactin levels, low testosterone levels,

growth hormone levels)

Lung cancer (rule out metastasis and/or preoperative evaluation)

As part of metastatic work-up

Congenital Abnormality (e.g., hydrocephalus, craniosynostosis) (known or suspected):

Evaluation of macrocephaly or microcephaly in child >6 months of age

Known or rule out congenital abnormality with acute, new or fluctuating neurologic, motor or

mental status changes (e.g., one sided weakness, paralysis, loss of muscle control, increased

muscle tone, loss of muscle tone, gait disturbance, lack of coordination, ataxia, speech

impairment, facial numbness, visual deficit, delayed speech, enlarged head circumference,

developmental delay)

Surgical treatment for shunt placement (improve the flow of cerebrospinal fluid)

Surgical treatment for shunt malfunction or blockage

Follow-up shunt evaluation within 6 months or 1 year after placement and/or neurological

symptoms

Evaluation of neurological symptoms of shunt malfunction or blockage (e.g., headache, vomiting,

drowsiness, seizures)

Evaluation of Neurological Deficits:

Acute, new or fluctuating neurologic deficits including, but not limited to tingling (paresthesia),

numbness of one side, spastic weakness (hemiparesis) of one side, paralysis, loss of muscle

control, inability to speak, lack of coordination or mental status changes

Headache (Evaluation):

_______________________________________________________________



Sudden onset of a headache described as the worst headache of life or “thunderclap” type

headache (concerned with aneurysm). Note: The duration of a thunderclap type headache lasts

more than 5 minutes. A headache that lasts less than 5 seconds in duration is not neurological

New, severe unilateral headache with radiation to or from the neck, associated with suspicion of

carotid or vertebral artery dissection

Acute, sudden onset of headache with personal or family history (parent, sibling or child of

patient) of stroke, brain aneurysm or arteriovenous malformation (AVM)

History of cancer or HIV with new onset of headache

New onset of headache in pregnancy

Recurring or chronic headache with new presenting symptoms of change in character, severity

or frequency associated with mental status change, seizure, syncope or focal neurological signs

(e.g., ataxia, papilledema, visual field defects, nystagmus, gait disturbances, tingling

(paresthesia), numbness of one side, one sided spastic weakness (hemiparesis), paralysis, loss of

muscle control, gait disturbance, inability to speak, lack of coordination)

Recurring or chronic headache with recent symptoms of neurological deficits (e.g., one sided

weakness, paralysis, loss of muscle control, increased muscle tone, loss of muscle tone, gait

disturbance, lack of coordination, ataxia, speech impairments, facial numbness, visual deficit,

tingling (paresthesia), numbness of one side, one sided spastic weakness (hemiparesis), inability

to speak, lack of coordination)

Inflammatory Disease or Infection (known or suspected):

Endocarditis with suspected septic emboli

Intracranial abscess or brain infection with acute altered mental status or positive lab findings

(e.g., elevated WBC’s) or follow-up assessment during or after treatment is completed

Inflammatory disease (e.g., vasculitis), sarcoid or infection associated with fever, stiff neck and

positive lab findings (e.g., elevated white blood cells or abnormal lumbar puncture fluid exam)

Meningitis with positive physical findings (e.g., fever, stiff neck, positive lab findings (e.g.,

elevated white blood cells or abnormal lumbar puncture fluid exam))

Encephalitis with severe headache, altered mental status or positive lab finding (e.g., elevated

WBCs)

Multiple Sclerosis (MS) (known or suspected):

Evaluation of changes in neurological symptoms or deficits (e.g., one sided weakness, paralysis,

loss of muscle control, increased muscle tone, loss of muscle tone, gait disturbance, lack of

coordination, ataxia, speech impairment, facial numbness, visual deficit)

Periodic scans to assess asymptomatic progression in multiple sclerosis during the course of

disease

Exacerbation of symptoms

Monitoring the progress of MS to establish a prognosis or evaluation of response to treatment

(e.g., Tysabri (Natalizumab)

Parkinson’s disease:

Baseline study evaluation of Parkinson’s disease

Evaluation of new onset of non-Parkinson’s symptoms complicating the evaluation of the

current condition

_______________________________________________________________



Seizure Disorder (known or suspected):

Seizure with new onset

Seizure with increasing frequency and severity

Epilepsy refractory to medical management

Stroke (known or suspected):

Symptoms of transient ischemic attack (TIA), episodic symptoms with normal carotid studies

(may be tumor or Multiple Sclerosis (MS))

Known or rule out stroke with acute, new or fluctuating neurologic motor or mental status

changes (e.g., one sided weakness, paralysis, ataxia, speech impairment, facial numbness, visual

deficit)

Trauma (known or suspected):

Trauma or injury to the head with documentation of one or more of the following (acute, new or

fluctuating):

Focal neurologic findings (e.g., ataxia, papilledema, visual field defects,

nystagmus, gait disturbances)

Motor changes

Mental status changes

Amnesia

Vomiting

Seizures

Signs of increasing intracranial pressure (e.g., headaches, seizures, nausea,

vomiting, blurred vision)

Skull fracture by physical exam and positive x-ray findings (magnetic resonance (CT))

Tumor or Rule out Metastasis:

Tumor or Rule Out Metastasis

Known tumor and new onset of headache

Follow-up for known tumor without acute, new or fluctuating neurologic, motor or mental status

changes (adult low-grade infiltrative supratentorial astrocytoma, oligodendroglioma (excluding

pilocystic astrocytoma), anaplastic gliomas/glioblastoma, intracranial ependymomas,

medulloblastoma and supratentorial primitive neuroectodermal tumors (PNET), meningiomas,

brain metastases)

Known or suspected tumor or rule out metastasis with acute, new or fluctuating neurologic,

motor or mental status change (e.g., one sided weakness, paralysis, loss of muscle control,

increased muscle tone, gait disturbance, lack of coordination, ataxia, speech impairment, facial

numbness, visual deficit)

Known or suspected pituitary tumor with clinical findings on physical exam (e.g., galactorrhea),

neurologic findings (e.g., headaches, visual problems (loss, double), confusion, facial numbness,

facial pain, dizziness) and/or lab abnormalities (e.g., elevated prolactin levels, low testosterone

levels, growth hormone levels)

Known lung cancer, rule out metastasis and/or preoperative evaluation

(related to neurosurgical procedures)

Initial follow-up of suspected or known post-operative complications

_______________________________________________________________



Follow-up study for evaluation of progress after treatment, procedure, intervention or

surgery (documented medical reason for additional imaging, including type or MRI and

area for evaluation)


Other indications for a Brain MRI:

Evaluation of suspected acute subarachnoid hemorrhage (SAH)

Initial evaluation of a cholesteatoma

Initial imaging of a suspected or known Arnold Chiari Malformation

Optic neuritis

Initial brain evaluation for known syrinx or syringomyelia

Tinnitus (constant ringing in one or both ears), hearing loss and an abnormal audiogram

(concerned with tumor or Menieres disease)

Vertigo associated with headache, blurred or double vision or change in sensation after full

neurologic examination and initial work-up

Change in mental status, with a mini-mental status score (MMSE) of less than 25 and a

complete metabolic workup (e.g., urinalysis, thyroid function testing, complete blood count)

Abnormal eye findings on physical neurologic examination (e.g., papilledema, nystagmus, ocular

nerve palsies, visual field deficit)

Anosmia (loss of smell), documented by objective testing

Follow-up for known hemorrhage, hematoma or vascular abnormalities related to the

head/brain

For evaluation of known or suspected cerebrospinal (CSF) leakage

Developmental delay

Evaluation of headache with suspected intracranial complication of sinusitis and/or mastoiditis

Evaluation of child 24 months of age or younger, with suspected head trauma by history and/or

injury

Suspected acoustic neuroma (Schwannoma) or cerebellar pontine angle tumor with any of the

following signs and symptoms: unilateral hearing loss by audiometry, headache, disturbed

balance or gait, tinnitus, facial weakness, altered sense of taste

Suspected glomus tumor

Acute onset or asymmetrical sensory neurological hearing loss

DEFINITIONS:

Acoustic neuroma: a progressively enlarging, benign tumor, usually within the internal auditory

canal arising from Schwann cells of the vestibular division of the eighth cranial nerve; the

symptoms, which vary with the size and location of the tumor, may include hearing loss, headache,

disturbances of balance and gait, facial numbness or pain, and tinnitus. It may be unilateral or

bilateral (neurofibromatosis).

Arnold Chiari malformation: 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 (also called Arnold-Chiari deformity or syndrome).

Encephalopathy: any degenerative disease of the brain.

Galactorrhea: productions of breast milk in men or in women who are not breast feeding.

_______________________________________________________________



Nystagmus: an involuntary, rapid, rhythmic movement of the eyeball, which may be horizontal,

vertical, rotatory, or mixed.

Syringomyelia: a rare disorder that causes a cyst (syrinx) to form in the spinal cord.

Syrinx: an abnormal cavity in the spinal cord in syringomyelia.


Reimbursement for magnetic resonance (70551, 70552, 70553, 70540, 70542, 70543) performed on

the same anatomical area is limited to two (2) magnetic resonance (70551, 70552, 70553, 70540,

70542, 70543) within a 6-month period. Magnetic resonance (70551, 70552, 70553, 70540, 70542,

70543) in excess of two (2) magnetic resonance (70551, 70552, 70553, 70540, 70542, 70543) within a

6-month period are subject to medical review of documentation to support medical necessity.



recommendation.

Reimbursement for magnetic resonance (70551, 70552, 70553, 70540, 70542, 70543) 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) magnetic resonance (70551, 70552,

70553, 70540, 70542, 70543) within a 12-month period. Magnetic resonance (70551, 70552, 70553,

70540, 70542, 70543) for an oncologic condition in excess of four (4) magnetic resonance (70551,

70552, 70553, 70540, 70542, 70543) within a 12-month period are subject to medical review of






_______________________________________________________________



TOC

70554 – Functional MRI Brain


INTRODUCTION:

Before neurological surgery for seizure disorders or resection of brain tumors, localization of certain

areas of the brain, such as language and motor centers (referred to as “eloquent areas”), it is

important to minimize or avoid damage or disruption to these areas. There is increased potential

for damage or disruption of structures adjacent to the area of surgical interest. There are several

methods that may be used to identify eloquent areas of the brain, including Wada test and direct

electrical stimulation. Both of these tests are invasive and require involvement of various

specialists.

Functional magnetic resonance imaging (fMRI) is proposed as a noninvasive alternative method for

location of eloquent brain areas. Functional MRI allows regional mapping of human cognitive

functions such as motor skills, vision, language, and memory function. Functional MRI is

accomplished by imaging the active patient during the performance of specific tasks. Functional

MRI uses sequences based on T2-weighted blood oxygen. Images are collected as various activities

are conducted. Laterality indices are calculated, reflecting the interhemispheric difference between

activated volumes in the left and right hemispheric regions of interest. These studies are often done

on MR scanners with field strengths of 1.5 Tesla or greater. The functional MRI images are

processed by computer and interpreted by a physician. The information from the fMRI may be used

in neurosurgical planning.

INDICATIONS FOR FUNCTIONAL MRI:

Functional MRI meets the definition of medical necessity

In the preoperative evaluation of members with seizures or

Member with brain tumors who are candidates for neurosurgery when the lesion is in close

proximity to an eloquent area of the brain (e.g., controlling verbal or motor function) and testing

is expected to have an important role in assessing the spatial relationship between the lesion

(mapping lesion) and eloquent brain area.

Functional MRI is considered investigational or experimental for all other applications as there is

insufficient clinical evidence to support the use of functional MRI (fMRI) for all other applications.

There is a lack of clinical data to permit conclusions on efficacy and net health outcomes

_______________________________________________________________



TOC

71250 – CT Chest (Thorax)


INTRODUCTION:

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.

Auto-approve all requests for a Chest (Thorax) CT for pre-cancerous screening when ALL three

indications are met:

1. Plan name for member is: St. John’s County Blue Choice PPO or

St. Johns County Blue Options PPO 2. Imaging Provider is: St.Augustine Imaging Center (provider number V2739),

AND

3. Member is: 35 years of age or older.

INDICATIONS FOR CHEST CT:


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.

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:

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

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

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

*Patient 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.

Tumor, cancer or mass:

Follow-up of known tumor or cancer of patient 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 thereafter.

_______________________________________________________________



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.

For the 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):

o Initial x-ray performed

o 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:

o 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:

For evaluation of hemoptysis and prior x-ray performed.

_______________________________________________________________



Post-operative/Procedural evaluation:


procedure, intervention or surgery. Documentation requires a medical reason why additional

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

Other indications for Chest CT:


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.

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:


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

preformed without failing 4 consecutive weeks of treatment with medication.

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









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





_______________________________________________________________



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.








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TOC

71275 – CT Angiography, Chest (non coronary)


INTRODUCTION:




material.

INDICATIONS FOR CHEST CTA:

For evaluation of suspected or known pulmonary embolism (excludes low risk*)

For evaluation of suspected or 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 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.

Preoperative evaluation

Known vascular abnormalities and patient 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.

A follow-up study may be needed to help evaluate a patient’s progress after treatment,



Documentation Requirements:


the Chest (non coronary) and imaging results (e.g., images, clinical reports) should be maintained in


Definition:

*Low risk is defined as NO to any of the following questions:

(1) Evidence of current or prior deep vein thrombosis (DVT);

(2) Heart rate (HR) > 100;

(3) Cancer diagnosis;

(4) Recent surgery or prolonged immobilization;

(5) Hemoptysis;

(6) History of pulmonary embolism (PE);

_______________________________________________________________



(7) Other diagnosis more likely.

_______________________________________________________________



TOC

71550 – MRI Chest (Thorax)


INDICATIONS FOR CHEST MRI:

Magnetic resonance imaging (MRI) of the chest and heart meets the definition of medical necessity

for the following:

For evaluation of mediastinal or hilar mass of patient with renal failure or allergy to contrast

material.

For evaluation of myasthenia gravis with suspected thymoma.

For evaluation of brachial plexus dysfunction (brachial plexopathy/thoracic outlet syndrome).

For evaluation of an aneurysm or dissection of the thoracic aorta.

For evaluation of congenital heart disease and malformations, (e.g., aortic arch anomalies and

patent ductus arteriosus (PDA)).

For evaluating whether masses invade into specific thoracic structures (e.g., aorta, pulmonary

artery, brachial plexus, subclavian vessels, thoracic spine).

To determine the consistency of thoracic masses (cystic vs. solid vs. mixed).

_______________________________________________________________



TOC

71555 – MR Angiography Chest (excluding myocardium)


INTRODUCTION

Magnetic resonance angiography (MRA) is a noninvasive imaging technology used to provide cross-

sectional and projection images of the thoracic vascular, including large and medium size vessels

(e.g., thoracic aorta). MRA provides images of normal as well as diseased blood vessels and

quantifies blood flow through these blood vessels. A contrast agent (gadolinium) may be used to

enable visualization of a body system or body structure and may be used in individuals who have a

history of contrast allergy and who are at high risk of kidney failure.



the chest and imaging results (e.g., images, clinical reports) should be maintained in the member’s


INDICATIONS FOR CHEST MRA:

Evaluation of suspicious mass and CTA is contraindicated due to allergy to iodinated contrast or

member is at high risk for contrast induced renal failure.

Evaluation of suspected or known pulmonary embolism

For evaluation of suspected or 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 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.


Known vascular abnormalities and patient 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 clearly indicates why additional imaging is needed for the type and area(s)

requested.

_______________________________________________________________



TOC

72125 – CT Cervical Spine

72128 – CT Thoracic Spine

72131 – CT Lumbar Spine


NOTE: MRI is the imaging modality of choice for most spine (cervical, thoracic, lumbar) imaging

indications, unless contraindicated or not tolerated by the member.

INDICATIONS FOR CERVICAL SPINE CT:

Fracture

Assess position of known fracture fragments

Assess union of a known fracture (physical exam or X-ray findings suggest delayed or failed

healing

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

Chronic or degenerative changes with abnormal electromyography (EMG) or nerve conduction

study cervical spine MRI is contraindicated

Chronic or degenerative changes with changing or new onset of radiculopathy or radiculitis

unresponsive to 6 weeks of conservative treatment (e.g., pharmacologic intervention

[nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxant], physical therapy, home

exercise program) and cervical spine MRI is contraindicated

Chronic or degenerative changes with extremity numbness or tingling and 6 weeks of

conservative treatment (e.g., pharmacologic intervention [nonsteroidal anti-inflammatory drugs

(NSAIDs), muscle relaxant], physical therapy, home exercise program) and cervical spine MRI is

contraindicated

Chronic or degenerative changes with neurological deficits (e.g., extremity weakness, abnormal

gait, asymmetric reflexes) and cervical spine MRI is contraindicated

Exacerbation of chronic neck pain, muscle weakness, abnormal reflexes, new extremity

numbness or tingling unresponsive to 6 weeks of conservative therapy and no improvement with

treatment (e.g., pharmacologic intervention [nonsteroidal anti-inflammatory drugs (NSAIDs),

muscle relaxant], physical therapy, home exercise program) and the patient cannot have

cervical spine MRI is contraindicated

Trauma or Acute Injury

Trauma or acute injury with neurologic deficits (e.g., extremity weakness, abnormal gait,

asymmetric reflexes)

Trauma or acute injury with radiculopathy or radiculitis

Abnormal electromyography (EMG) or nerve conduction study

Progression or worsening of symptoms during the course of conservative treatment (e.g.,

pharmacologic intervention [analgesic, nonsteroidal anti-inflammatory drugs (NSAIDs))

_______________________________________________________________



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

Follow-up of known tumor or cancer of patient undergoing active treatment

Known tumor and evidence of metastasis on bone scan or imaging study

Known tumor or cancer with abnormal electromyography (EMG) or nerve conduction study

Known tumor or cancer with neurological deficits (e.g., extremity weakness, abnormal gait,


Known tumor or cancer with new signs (e.g., new tumor, change in tumor) per lab findings or

imaging

Known tumor or cancer with radiculopathy or radiculitis

Staging of known tumor

Suspected tumor on bone scan or imaging study requiring evaluation

Tumor evaluation (suspected or known), including but not limited to the following neoplasms:

o Primary or metastatic neoplasm involving the vertebrae

o Tumor spread in the spinal canal

o Spinal cord neoplasm

Known or Suspected Infection, Abscess or Inflammatory Disease

Clinical evidence (e.g., physical findings, laboratory, x-ray) of an infectious process (e.g.,

paraspinal abscess, meningitis, osteomyelitis, discitis, septic arthritis, meningitis) and the

member cannot have cervical spine MRI

Pre-Operative Evaluation

Infection and cervical spine MRI is contraindicated

Tumor

Pre-operative evaluation of member with neurological deficits (e.g., extremity weakness,

abnormal gait, asymmetric reflexes) and cervical spine MRI is contraindicated

Pre-operative evaluation of member with radiculopathy or radiculitis and cervical spine MRI is

contraindicated

Post-Operative Evaluation

Follow-up to surgery (or fracture) occurring with the past 6 months with physical or X-ray

findings of delayed or failed healing

Follow-up to surgery occurring within the past 6 months with physical or laboratory findings of

a post surgical infection

Follow-up to surgery or fracture occurring with the past 6 months with new abnormal

electromyography (EMG) (not paraspinal EMG) or nerve conduction study

Follow-up to surgery or fracture occurring within the past 6 months

Follow-up to surgery or fracture occurring within the past 6 months with new, persistent or

recurring neurological deficits (e.g., extremity weakness, asymmetric reflex, abnormal gait)

_______________________________________________________________



Follow-up to surgery or fracture occurring within the past 6 months with changing

radiculopathy or radiculitis

Neck Pain (new onset of neck pain with)

Abnormal electromyography (EMG) or nerve conduction study and cervical spine MRI is

contraindicated

Failed physical therapy and cervical spine MRI is contraindicated

Neurological deficits ((e.g., extremity weakness, abnormal gait, asymmetric reflexes) and



pharmacologic intervention [nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxant],

physical therapy, home exercise program) and cervical spine MRI is contraindicated

Radiculopathy or radiculitis unresponsive to 6 weeks of conservative treatment (e.g.,

pharmacologic intervention [nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxant],

physical therapy, home exercise program) and cervical spine MRI is contraindicated

Other

Arnold-Chiari syndrome (Chiari malformation) and have cervical spine MRI is contraindicated

Follow-up imaging to evaluate progress after treatment, procedure and surgery

Immune system suppression (e.g., HIV, chemotherapy, leukemia, lymphoma) when cervical

spine MRI is contraindicated

Neck pain is due to or a symptom of documented clinical findings of immune suppression and


Neurologic deficits (e.g., extremity weakness, asymmetric reflexes) or new onset of abnormal

sensory changes along a particular dermatome (nerve distribution) as documented on physical

exam

Spondylosis with neurological deficits (e.g., extremity weakness, abnormal gait, asymmetric

reflexes)

Suspected cord compression with neurological deficits (e.g., extremity weakness, abnormal gait,

asymmetric reflexes) and cervical spine MRI is contraindicated

Evaluation of immune system suppression (e.g., HIV, chemotherapy, leukemia, lymphoma)

when cervical spine MRI is contraindicated, presents with neck pain as a symptom of

documented clinical findings (e.g., signs, symptoms, laboratory, prior imaging findings) of

immune system suppression

Syrinx or syringomyelia and cervical spine MRI is contraindicated

INDICATIONS FOR THORACIC SPINE CT:

Fracture



healing

_______________________________________________________________




Chronic back pain unresponsive to 6 weeks of conservative treatment (e.g., pharmacologic

intervention [nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxant], physical

therapy, home exercise program) and thoracic spine MRI is contraindicated

Chronic or degenerative changes unresponsive to 4 months or less conservative therapy (e.g.,

physical therapy, home exercise program)

Chronic or degenerative changes with abnormal electromyography (EMG) (not paraspinal EMG)

or nerve conduction study and thoracic spine MRI is contraindicated

Chronic or degenerative changes with acute onset of tenderness in the area of the point of a

localized area of the spine and thoracic spine MRI is contraindicated

Chronic or degenerative changes with neurological deficits (e.g., lower extremity weakness,

lower extremity asymmetric reflexes, abnormal gait) and thoracic spine MRI is contraindicated

Back Pain (new onset) with:

Radiculopathy and unresponsive to 6 weeks of conservative therapy (e.g., physical therapy,

home exercise program) and no improvement with conservative treatment (e.g., pharmacologic

intervention [nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxant] and thoracic

MRI is contraindicated


pharmacologic intervention [nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxant]

and thoracic MRI is contraindicated

An abnormal electromyography (EMG) or nerve conduction study and thoracic MRI is

contraindicated


Trauma or acute injury with neurologic deficits (e.g., extremity weakness, abnormal gait,



Abnormal electromyography (EMG) or nerve conduction study


pharmacologic intervention [analgesic, nonsteroidal anti-inflammatory drugs (NSAIDs))

Tumor, Cancer or Evidence of Metastasis







imaging

_______________________________________________________________









o Spinal cord neoplasm.

Known or Suspected Infection of Abscess


paraspinal abscess, meningitis, osteomyelitis, discitis, septic arthritis) and thoracic spine MRI is

contraindicated

Immunocompromised (e.g., HIV, chemotherapy, leukemia, lymphoma) with rule out infection

and thoracic spine MRI is contraindicated

Pre-Operative Evaluation

Infection and thoracic spine MRI is contraindicated

Tumor


Follow-up to surgery occurring with the past 6 months with physical or X-ray findings of

delayed or failed healing




electromyography (EMG) or nerve conduction study



recurring neurological deficits (e.g., lower extremity weakness, lower extremity asymmetric

reflexes, abnormal gait)



Thoracic back pain post thoracic surgery.

Other


Immune system suppression (e.g., HIV, chemotherapy, leukemia, lymphoma) when thoracic


Neurologic deficits (e.g., extremity weakness, asymmetric reflexes); or new onset of abnormal


exam

_______________________________________________________________





documented clinical findings (e.g., signs, symptoms, laboratory, prior imaging findings) of

immune system suppression

Syrinx or syringomyelia and thoracic spine MRI is contraindicated

INDICATIONS FOR LUMBAR SPINE CT

NOTE: MRI is the imaging modality of choice for most lumbar spine imaging indications, unless

contraindicated or not tolerated by the patient

Fracture



healing)


Chronic or degenerative changes with abnormal electromyography (EMG) or nerve conduction

study and lumbar spine MRI is contraindicated

Chronic or degenerative changes with changing or new onset of radiculopathy or radiculitis and

lumbar spine MRI is contraindicated

Chronic or degenerative changes with extremity numbness or tingling and 6 weeks of

conservative treatment (e.g., pharmacologic intervention [nonsteroidal anti-inflammatory drugs

(NSAIDs), muscle relaxant], physical therapy, home exercise program) and lumbar spine MRI is

contraindicated

Chronic or degenerative changes with neurological deficits (e.g., lower extremity weakness,

lower extremity asymmetric reflexes, abnormal gait, Cauda Equina syndrome, bowel

dysfunction, bladder dysfunction, foot drop) and lumbar spine MRI is contraindicated

Exacerbation of chronic back pain, muscle weakness, abnormal reflexes, new extremity

numbness or tingling and unresponsive to 6 weeks of conservative therapy and no improvement

with treatment (e.g., pharmacologic intervention [nonsteroidal anti-inflammatory drugs

(NSAIDs), muscle relaxant], physical therapy, home exercise program) and lumbar spine MRI is

contraindicated


Trauma or acute injury with abnormal electromyography (EMG) or nerve conduction study

Trauma or acute injury with neurologic deficits (e.g., lower extremity weakness, abnormal gait,

asymmetric reflexes Cauda Equina syndrome, bowel dysfunction, bladder dysfunction, foot drop)


Back Pain

_______________________________________________________________



New onset of back pain radiculopathy or radiculitis unresponsive to 6 weeks of conservative

treatment (e.g., pharmacologic intervention [nonsteroidal anti-inflammatory drugs (NSAIDs),

muscle relaxant], physical therapy, home exercise program) and lumbar spine MRI is

contraindicated

New onset of back pain unresponsive (includes persisting, progression or worsening of

symptoms) to 6 weeks of conservative treatment (e.g., pharmacologic intervention [nonsteroidal

anti-inflammatory drugs (NSAIDs), muscle relaxant], physical therapy, home exercise program)

and lumbar spine MRI is contraindicated

New onset of back pain with an abnormal electromyography (EMG) or nerve conduction study

and lumbar spine MRI is contraindicated

New onset on back pain with neurological deficits (e.g., lower extremity weakness, abnormal

gait, asymmetric reflexes, Cauda Equina syndrome, bowel dysfunction, bladder dysfunction, foot

drop) and lumbar spine MRI is contraindicated

Tumor, Cancer or Evidence of Metastasis







imaging


Primary or metastatic neoplasm involving the vertebrae

Spinal cord neoplasm






o Spinal cord neoplasm

Known or Suspected Infection of Abscess


paraspinal abscess, meningitis, osteomyelitis, discitis, septic arthritis) and lumbar spine MRI is

contraindicated

Pre-operative Evaluation

Abnormal electromyography (EMG) or nerve conduction study and lumbar spine MRI is

contraindicated

Infection and the patient cannot have thoracic spine MRI

_______________________________________________________________



Neurological deficits (e.g., lower extremity weakness, abnormal gait, asymmetric reflexes,

Cauda Equina syndrome, bowel dysfunction, bladder dysfunction, foot drop) and lumbar spine

MRI is contraindicated

Placement of pedicle screw

Radiculopathy or radiculitis and lumbar spine MRI is contraindicated

Tumor


Follow-up to surgery occurring with the past 6 months with physical or X-ray findings of

delayed or failed healing




electromyography (EMG) or nerve conduction study



recurring neurological deficits (e.g., lower extremity weakness, abnormal gait, asymmetric

reflexes, Cauda Equina syndrome, bowel dysfunction, bladder dysfunction, foot drop)



Other


Immune system suppression (e.g., HIV, chemotherapy, leukemia, lymphoma) when lumbar


Back pain is due to or a symptom of documented clinical findings of immune suppression and

lumbar spine MRI is contraindicated

Lumbar back pain associated with abdominal pain

Spinal dysraphism and lumbar spine MRI is contraindicated

Spondylosis with neurological deficits (e.g., lower extremity weakness, abnormal gait,

asymmetric reflexes, Cauda Equina syndrome, bowel dysfunction, bladder dysfunction, foot

drop)

Tethered cord and lumbar spine MRI is contraindicated

Neurologic deficits (e.g., extremity weakness, asymmetric reflexes); or new onset of abnormal


exam



documented clinical findings of immune system suppression

ADDITIONAL INFORMATION RELATED TO SPINE CT: 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.


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.

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.












12-month period. Computed tomography (72125 – 72133, 76380) for an oncologic condition in excess


_______________________________________________________________






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.








_______________________________________________________________



TOC

72141 – MRI Cervical Spine

72146 – MRI Thoracic Spine

72148 – MRI Lumbar Spine

“FLORIDA BLUE MEMBERS ONLY”

MRI of the spine (cervical, thoracic and lumbar) meets the definition of medical necessity for the

following:

INDICATIONS FOR CERVICAL SPINE MRI:

For evaluation of known or suspected multiple sclerosis (MS)

Evidence of MS on recent baseline Brain MRI

Follow up to known MS with changing signs or symptoms

Follow up to the initiation or change in medication for member with known Multiple Sclerosis

For evaluation of neurologic deficits

With any of the following new neurological deficits: extremity weakness; abnormal reflexes; or

new onset of abnormal sensory changes along a particular dermatome (nerve distribution) as

documented on physical examination

For evaluation of chronic or degenerative changes (e.g., osteoarthritis, degenerative disc disease)

Failure of conservative treatment for at least six (6) weeks within the last six (6) months

With progression or worsening of symptoms during the course of conservative treatment

With an abnormal electromyography (EMG) or nerve conduction study if radicular symptoms

are present

For evaluation of new onset of neck pain

With radiculopathy and failure of conservative treatment for at least six (6) weeks


With an abnormal electromyography (EMG) or nerve conduction study

For evaluation of trauma or acute injury within past 72 hours

Presents with radiculopathy muscle weakness, abnormal reflexes, and/or sensory changes along

a particular dermatome (nerve distribution)



For evaluation of known tumor, cancer, or evidence of metastasis

_______________________________________________________________




For follow-up evaluation of patient undergoing active treatment

Presents with new signs (e.g., laboratory and/or imaging findings) of new tumor or change in

tumor

Presents with radiculopathy

With an abnormal electromyography (EMG) or nerve conduction if radicular symptoms are

present

With evidence of metastasis on bone scan or previous imaging study

With no imaging/restaging within the past ten (10) months

For evaluation of suspected tumor

Prior abnormal or indeterminate imaging that requires further clarification

Indication for combination studies for the initial pre-therapy staging of cancer, or ongoing

tumor/cancer surveillance or evaluation of suspected metastases:


depending on the cancer: neck, abdomen, pelvis, chest, brain, cervical spine, thoracic spine or

lumbar spine

For evaluation of known or suspected infection, abscess, or inflammatory disease

Paraspinal abscess as evidenced by neck pain, or laboratory or x-ray findings

Osteomyelitis as evidenced on physical exam or laboratory x-ray findings

Meningitis as evidenced by positive physical exam findings or history

Septic arthritis or discitis as evidenced by physical exam or laboratory x-ray findings

As evidenced by signs/symptoms, laboratory or prior imaging findings

For evaluation of immune system suppression (e.g., HIV, chemotherapy, leukemia, lymphoma)

Presents with neck pain as a symptom of documented clinical findings of immune system

suppression as evidenced by signs/symptoms, laboratory or prior imaging findings


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 that clearly indicates why additional imaging is needed for the type and

area(s) requested

Changing neurologic status post-operatively


are present

Surgical infection as evidence by signs/symptoms, laboratory or prior imaging findings

Delayed or non-healing as evidence by signs/symptoms, laboratory or prior imaging findings

Continuing or recurring symptoms of any of the following neurological deficits: lower extremity

weakness, lower extremity asymmetric reflexes

For preoperative evaluation [if surgery scheduled within the next thirty (30) days]

Known tumor and meets one of the tumor guideline criteria above

_______________________________________________________________



Known infection and meets one of the infection guideline criteria above

Known radiculopathy and failure of conservative treatment for at least six (6) weeks


For pre-surgical Scoliosis survey in infant or child

For post-operative/procedural evaluation for surgery or fracture occurring within the past six (6)

months:






are present





Other indications for a Cervical Spine MRI


Suspected cord compression with any of the following neurological deficits: (e.g., extremity

weakness; abnormal gait; asymmetric reflexes)

Known Arnold-Chiari Syndrome

Known Syrinx or syringomyelia

Combination of Studies with Cervical Spine MRI:

Cervical/Thoracic/Lumbar MRI

Any combination of these for scoliosis survey in infant/child

Any combination of these for spinal survey in patient with metastases

Cervical MRI/CT

Unstable craniocervical junction

Brain MRI/Cervical MRI

Evaluation of Arnold Chiari malformation

Follow-up of known Multiple Sclerosis (MS)

INDICATIONS FOR THORACIC SPINE MRI:


With any of the following new neurological deficits: lower extremity weakness, abnormal

reflexes; or new onset of abnormal sensory changes along a particular dermatome (nerve

distribution) as documented on physical examination

_______________________________________________________________




Failure of conservative treatment for at least six (6) weeks within the last six (6) months



are present

For evaluation of new onset of back pain

Failure of conservative treatment for at least six (6) weeks




Presents with radiculopathy muscle weakness, abnormal reflexes, and/or sensory changes along



For evaluation of known tumor, cancer or evidence of metastasis



Presents with new signs (e.g., laboratory and/or or imaging findings) of new tumor or change in

tumor

Presents with radiculopathy, muscle weakness, abnormal reflexes, and/or sensory changes along


With an abnormal electromyogram (EMG) or nerve conduction study if radicular symptoms are

present


With no imaging/restaging within the past ten (10) months


Prior abnormal or indeterminate imaging that requires further clarification





lumbar spine



For evaluation of immune system suppression (e.g., HIV, chemotherapy, leukemia, or lymphoma)

_______________________________________________________________





months:






are present





Other indications for a Thoracic Spine MRI


Suspected cord compression with any of the following neurogical deficits (e.g., extremity

weakness, abnormal gait, asymmetric reflexes)

Known or suspected Syrinx or syringomyelia.

Combination of Studies with Thoracic Spine MRI:

Cervical/Thoracic/Lumbar MRI:


Any combination of these for spinal survey in patient with metastases

INDICATIONS FOR LUMBAR SPINE MRI:


With any of the following new neurological deficits: lower extremity weakness; abnormal

reflexes; or new onset of abnormal sensory changes along a particular dermatome (nerve

distribution) as documented on physical examination; evidence of Cauda Equina Syndrome;

bowel or bladder dysfunction; new foot drop



With progression or worsening of synptoms during the course of conservative treatment


are present

For evaluation of new onset of back pain


_______________________________________________________________





are present


Presents with radiculopathy, muscle weakness, abnormal reflexes, and/or sensory changes along



For evaluation of known tumor, cancer or evidence of metastasis

For staging of known tumor


Presents with new signs (e.g., laboratory and/or imaging findings) of new tumor or change in

tumor

Presents with radiculopathy



With no imaging/restaging within the past ten (10) month


Prior abnormal or indeterminate imaging that requires further clarification.





lumbar spine



For evaluation of immune system suppression (e.g., HIV, chemotherapy, leukemia, or lymphoma)



months:





_______________________________________________________________




are present





Other indications for a Lumbar Spine MRI


Suspected cord compression with any of the following neurologic deficits (e.g., extremity

weakness, abnormal gait, asymmetric reflexes)

Tethered cord or known/suspected spinal dysraphism

Ankylosing Spondylitis- For diagnosis when suspected as a cause of back or sacroiliac pain and

completion of the following initial evaluation:

History of back pain associated with morning stiffness

Sedimentation rate and/or C-reactive protein

HLA B27

Non-diagnostic or indeterminate x-ray

Combination of Studies with Lumbar Spine MRI:

Cervical/Thoracic/Lumbar MRI:


Any combination of these for spinal survey in patient with metastasis


Reimbursement for MRI imaging (72141-72158) of the same anatomical area is limited to one (1)

MRI imaging within a 6-month period. MRI imaging (72141-72158) in excess of one (1) within a 6-

month period is subject to medical review for medical necessity. Documentation should include





or after therapy for known metastases, follow-up of member who have had an operative,

interventional or therapeutic procedure (e.g., surgery, embolization), reevaluation due to change in

clinical status (e.g., deterioration), new or worsening clinical findings, (e.g., neurologic signs,

symptoms), medical intervention which warrants reassessment, reevaluation for treatment

planning, follow-up during and after completion of therapy or treatment to assess effectiveness, and

evaluation after intervention or surgery.

Reimbursement for MRI imaging (72141-72158) for an oncologic condition undergoing active


area is limited to four (4) MRI imaging (72141-72158) within a 12-month period. MRI imaging

(72141-72158) for an oncologic condition in excess of four (4) within a 12-month period are subject to


_______________________________________________________________












DEFINITIONS:

Abscess: a localized collection of pus buried in tissues, organs, or confined spaces.

Arnold Chiari malformation: 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 (also called Arnold-Chaiari deformity or syndrome).

Arthritis: inflammation of a joint. Acute arthritis: arthritis marked by pain, heat, redness, and

swelling, due to inflammation, infection, or trauma. Chronic inflammatory arthritis: inflammation

of joints in chronic disorders such as rheumatoid arthritis. Rheumatoid arthritis: a chronic systemic

disease primarily of the joints, usually polyarticular, marked by inflammatory changes in the

synovial membranes and articular structures and by muscle atrophy and rarefaction o the bones. In

late stages deformity and ankylosis develop.

Cauda equine syndrome: dull aching pain of the perineum, bladder, and sacrum, generally

radiating in a sciatic fashion, with associated paresthesias and areflexic parlysis, due to

compression of the spinal nerve roots.

Discitis: inflammation of a disk, particularly of an interarticular disk.

Dysraphism: incomplete closure of a raphe (a seam; anatomic terminology for the line of union of

the halves of any of various symmetrical parts); defective fusion, particularly of the neural tube.

Osteomyelitis: inflammation of bone caused by infection, usually by a pyogenic organism, although

any infectious agent may be involved. It may remain localized or may spread through the bone to

involve the marrow, cortex, cancellous tissue, and periosteum.

Spondylitis: inflammation of the vertebrae, also called rachitis.

Syringomyelia: a slowly progressive syndrome of cavitation in the central segments of the spinal

cord, generally in the cervical region, but sometimes extending up into the medulla oblonga

(syringobulbia) or down into the thoracic region; it may be of developmental origin, arise secondary

to tumor, trauma, infarction, or hemorrhage, or be of unknown cause. It results in neurologic

deficits, usually segmental muscular weakness and atrophy with a dissociated sensory loss (loss of

_______________________________________________________________



pain and temperature sensation, with preservation of the sense of touch), and thoracic scoliosis is

often present.

Syrinx: an abnormal cavity in the spinal cord in syringomyelia.

_______________________________________________________________



TOC

72159 – MR Angiography Spinal Canal


INTRODUCTION:

Magnetic resonance angiography (MRA) is a noninvasive imaging technology. Application of spinal

magnetic resonance angiography (MRA) allows for more effective and noninvasive screening for

vascular lesions than magnetic resonance imaging (MRI) alone. It may improve characterization of

normal and abnormal intradural vessels while maintaining good spatial resolution. Spinal MRA is

used for the evaluation of spinal arteriovenous malformations, cervical spine fractures and

vertebral artery injuries. A contrast agent (gadolinium) may be used with MRA for better

visualization and may be used in individuals who have a history of contrast allergy and who are at

high risk of kidney failure.



the spinal canal and imaging results (e.g., images, clinical reports) should be maintained in the


INDICATIONS FOR SPINAL CANAL MRA:

Evaluation of spinal arteriovenous malformation (AVM)

Evaluation of a cervical spine fracture

Evaluation of known or suspected vertebral artery injury

_______________________________________________________________



TOC

72192 – CT Pelvis

74150 – CT Abdomen

74176 – CT Abdomen and Pelvis


Computed tomography (CT) of the abdomen and pelvis meets the definition of medical necessity for

the diagnosis and evaluation of the following:

Indications for an Abdomen CT:

Abdominal pain (persistent) unexplained by clinical findings, including physical examination

and other imaging studies (e.g., ultrasonography, plain film radiography, endoscopy, capsule

endoscopy (colonoscopy), intravenous pyelogram (IVP))

Abnormalities noted on other imaging studies (e.g., ultrasonography, radiography), which

require further evaluation

Abnormalities of abdominal vascular structures

Adrenal gland mass (pheochromocytoma)

Aorta aneurysm limited to the abdomen: suspected or known < four (4) cm and equivocal or

indeterminate ultrasound results; or prior imaging demonstrated aneurysm ≥ four (4) cm in

diameter; or suspected complications of known aneurysm as evidenced by physical exam such as

new onset of abdominal pain

Appendicitis (acute) (suspected) evidenced by physical exam (e.g., abdominal pain, tenderness)

with at least one of the following: elevated white blood count (WBC), fever, anorexia or nausea

and vomiting

Cancer (known) with suspected abdominal metastasis based on signs, symptoms or an abnormal

lab value

Cancer: Initial staging of known cancer, excluding the following:

o Basel cell carcinoma of the skin

o Melanoma without symptoms of signs of metastasis

Cancer follow-up: Three (3) month follow-up of known abdominal cancer undergoing active

treatment within the past year

Cancer follow-up: Six (6) month follow-up of known abdominal cancer undergoing active


Cancer follow-up: Cancer (known) of member undergoing active treatment with the past year

Cancer (known); Surveillance once per year (previous CT must be over ten (10) months ago)

Cholecystitis (suspected) with equivocal ultrasound

Congenital anomaly of abdominal organs (known or suspected)

Diverticulitis (suspected or known) with at least one of the following: elevated white blood count

(WBC), fever, anorexia or nausea and vomiting

Diverticulitis (complications) with abdominal pain or tenderness not responding to antibiotic

treatment

Fistula; history of fistula limited to the abdomen that requires re-evaluation, or is suspected to

have recurred

Hematoma

Hematuria (e.g., renal stones/urinary tract calculi, renal tumors, urothelial tumors)

http://mcgs.bcbsfl.com/index.cfm?fuseaction=main.main&stage=pub&format=cfm&doc=Computed%20Tomography%20(CT)%20Abdomen%20and%20Pelvis#P292_23517


_______________________________________________________________



Hemorrhage

Hepatitis C/hepatoma with elevated alpha-fetoprotein (AFP) and equivocal ultrasound results

Hepatomegaly (physical findings, laboratory studies, intravenous pyelogram or ultrasound)

Hernia (suspected): Spigelian hernia (ventral hernia) or incisional hernia evidenced by a

surgical abdominal scar)

Hydronephrosis (evidenced by physical exam or confirmed on imaging study e.g., intravenous

pyelogram, renal scan, ultrasound abdomen/kidney)

Infection in the abdomen (known)

Infection (suspected)

Infection that is suspected to have created an abscess in the abdomen

Inflammatory bowel disease (known or suspected) (e.g., Crohn’s disease, ulcerative colitis) with

abdominal pain and diarrhea or bloody diarrhea

Inflammatory bowel disease (e.g., Crohn’s, ulcerative colitis) with recurrence or worsening

signs/symptoms (e.g., abdominal pain) requiring re-evaluation

Ischemic bowel

Mass/tumor

o Initial evaluation of suspicious mass/tumor found in the abdomen by physical exam or

imaging study (e.g., ultrasound).

o Surveillance: One (1) follow-up exam to ensure no suspicious change has occurred in

tumor(s) in the abdomen. No further surveillance CT unless tumor(s) are specified as

highly suspicious, or a change was found on previous follow-up CT (new or changing

signs/symptoms) or abnormal lab values(e.g., blood, urea, nitrogen (BUN), creatinine,

liver function tests)

Pancreatitis (known), including pancreatic pseudocyst with recurrence or worsening

signs/symptoms requiring re-evaluation

Pancreatitis (suspected) with abnormal elevation of serum amylase or lipase

Pancreatic mass

Peritonitis (follow-up) if abdominal pain and tenderness to palpation is present, and at least one

of the following: rebound, rigid abdomen, or tenderness to palpation present over entire

abdomen

Primary or metastatic malignancies of the abdomen

Renal colic

Renal mass

Retroperitoneal hematoma or hemorrhage (suspected)

Splenomegaly (physical exam, prior ultrasound results equivocal and further imaging required)

Trauma with physical or lab (e.g., complete blood count (CBC)) findings of intra-abdominal

bleeding

Unexplained weight loss (more than 10% of body weight in two months) unexplained by clinical

findings, including physical examination

Urinary calculus (kidney, ureteral) (known or suspected) and or flank pain

Vascular abnormality (known or suspected) (e.g., aneurysm, hematoma, retroperitoneal

hematoma or hemorrhage) evidenced by imaging study (e.g., x-ray, ultrasound, Doppler)

Other indications for an Abdomen CT:

Abnormal fluid collection (ascites) seen on prior imaging (e.g., ultrasonography, plain film

radiography) that require follow-up evaluation

Evaluation after treatment, procedure, intervention or surgery involving the abdomen

Follow-up tumor evaluation (to ensure no suspicious changes has occurred in a tumor in the

abdomen)

_______________________________________________________________



Post-operative evaluation for complications (suspected or known) involving the abdomen

Pre-operative evaluation for abdominal surgery or procedure

Persistent abdominal pain unexplained by physical findings or imaging studies (e.g., x-ray,

abdominal ultrasound, endoscopy (including capsule endoscopy), colonoscopy, sigmoidoscopy,

intravenous pyelogram)

Completed or high-grade partial small bowel obstruction (suspected)

Follow-up evaluation of aortoiliac endograft

Indications for a Pelvis CT:

Abnormalities noted on other imaging studies, which require further evaluation (e.g., urinary

calculus)

Abnormalities of pelvic vascular structure

Aorta aneurysm limited to the abdomen: suspected or known < four (4) cm and equivocal or

indeterminate ultrasound results; or prior imaging demonstrated aneurysm ≥ four (4) cm in

diameter; or suspected complications of known aneurysm as evidenced by physical exam such as

new onset of abdominal pain



and vomiting

Aseptic/avascular necrosis of hips (MRI is contraindicated)

Bowel obstruction of unknown etiology

Cancer (known) with suspected pelvic metastasis based on signs, symptoms or an abnormal lab

value

Cancer: Initial staging of known cancer, excluding the following:

o Basel cell carcinoma of the skin

o Melanoma without symptoms of signs of metastasis

Cancer follow-up: Three (3) month follow-up of known pelvic cancer undergoing active treatment

within the past year

Cancer follow-up: Six (6) month follow-up of known pelvic cancer undergoing active treatment

within the past year



Congenital anomaly of pelvic organs (known or suspected)



Diverticulitis (complications) with abdominal pain or tenderness, not responding to antibiotic

treatment

Fistula; history of fistula limited to the abdomen that requires re-evaluation, or is suspected to

have recurred

Follow-up tumor evaluation (to ensure no suspicious changes has occurred in a tumor in the

pelvis)

Hematoma


Hemorrhage

Hepatomegaly (seen on ultrasonography or x-ray)



Hydronephrosis when ultrasound is abnormal or unexplained, further evaluation required

Infection in the pelvis (known)



_______________________________________________________________



Infection that is suspected to have created an abscess in the pelvis



Inguinal hernia suspect incarceration

Ischemic bowel (known or suspected)

Lymphadenopathy (for initial detection and follow-up)

Mass/tumor

o Initial evaluation of suspicious mass/tumor found in the pelvis by physical exam or

imaging study (e.g., ultrasound).

o Surveillance: One (1) follow-up exam to ensure no suspicious change has occurred in

tumor(s) in the pelvis. No further surveillance CT unless tumor(s) are specified as highly

suspicious, or a change was found on previous follow-up CT (new or changing

signs/symptoms) or abnormal lab values

Organ enlargement (e.g., uterus, ovaries, prostate) evidenced by physical exam or confirmed on

imaging study (e.g., ultrasonography)

Pelvic fracture

Pelvic mass (palpable)

Pelvic pain (persistent) unexplained by clinical findings, physical examination or other imaging

studies (e.g., ultrasound, barium examination or endoscopy)

Pelvic vein thrombosis

Prostate cancer recurrence work-up with:

o PSA greater than twenty (20)

o Gleason score of seven (7) or greater

Prostate cancer; Failure of PSA to fall to undetectable after radical prostatectomy or PSA

detectable and rising on 2 or more subsequent determinations

Renal Colic

Renal mass


Septic arthritis, osteomyelitis of pelvic bones (suspected)

Splenomegaly (palpated on exam or seen on ultrasonography or x-ray)

Trauma with physical or lab findings of pelvic bleeding

Urinary tract calculus (kidney, ureter, urethra)



Other indications for a Pelvis CT:



Evaluation of known cancer with suspected pelvis metastasis (based on signs and symptoms

(e.g., weight loss, ascites, anorexia) or an abnormal lab value (e.g., elevated BUN or creatinine))

Evaluation after treatment, procedure, intervention or surgery

Evaluation of physical or radiological evidence of pelvic fracture


Post-operative evaluation for complications (suspected or known) involving the pelvis

Pre-operative evaluation for pelvic infection, pelvic surgery or procedure.

Suspected complications of diverticulitis (known to be limited to pelvis by prior imaging) with

pelvic pain or severe tenderness, not responding to antibiotic treatment

Unexplained abdominal pain in members seventy-five (75) years or older



_______________________________________________________________



Indications for an Abdomen and Pelvis CT Combination:

Abdomen and pelvic trauma (blunt or penetrating)

Abdomen/pelvic pain not explained by clinical findings, physical examination and imaging

studies (e.g., ultrasound, abdominal radiography)

Abdominal/pelvic mass (palpable), known or suspected

Abnormalities noted on other imaging studies, which require further evaluation

Adrenal mass (pheochromocytoma) suspected based on clinical presentation (e.g., hypertension),

diagnostic testing/ imaging (e.g., 24-our blood and urine test (catecholamines), CT scan, MRI,

MIBG scan)

Aorta aneurysm: suspected or known < four (4) cm and equivocal or indeterminate ultrasound

results; or prior imaging demonstrated aneurysm ≥ four (4) cm in diameter; or suspected

complications of known aneurysm as evidenced by physical exam such as new onset of

abdominal or pelvic pain



and vomiting

Ascites

Bowel obstruction of unknown etiology

Cancer (known) with suspected abdominal/pelvic metastasis based on signs, symptoms or an

abnormal lab value

Cancer: Initial staging of known cancer, excluding the following: Basel cell carcinoma of the skin

Melanoma without symptoms of signs of metastasis

Prostate cancer unless Gleason score is seven plus (7+) or PSA over twenty (20)

Cancer follow-up: Three (3) month follow-up of known abdominal/pelvic cancer undergoing

active treatment within the past year

Cancer follow-up: Six (6) month follow-up of known abdominal/pelvic cancer undergoing active




Congenital anomaly (known or suspected)



Diverticulitis (complications) with abdominal/ pelvic pain or tenderness not responding to

antibiotic treatment

Fistula; history of fistula that requires re-evaluation, or is suspected to have recurred in the

abdomen or pelvis

Gastroparesis (diabetic)

Hematoma


Hemorrhage



Hydronephrosis when ultrasound is abnormal or unexplained, further evaluation required

Infection (known) in the abdomen/pelvis area

_______________________________________________________________



Infection that is suspected to have created an abscess in the abdomen or pelvis

Infectious or inflammatory process-known or suspected (e.g., abscess, diffuse inflammation,

pelvic inflammatory disease, Crohn’s disease, ulcerative colitis acute non-ulcerative colitis,

diverticulitis, retroperitoneal abscess)



Ischemic bowel

Lymphadenopathy unexplained by clinical history and imaging (chest radiography,

ultrasonography and physical exam)

Mass/tumor

Initial evaluation of suspicious mass/tumor found in the abdomen/pelvis by physical

exam or imaging study (e.g., ultrasound).

Surveillance: One (1) follow-up exam to ensure no suspicious change has occurred in

tumor(s) in the abdomen/pelvis. No further surveillance CT unless tumor(s) are specified

as highly suspicious, or a change was found on previous follow-up CT (new or changing

signs/symptoms) or abnormal lab values

Organ enlargement (e.g., splenomegaly, hepatomegaly, uterus, ovaries, prostate) evidenced by

physical exam or confirmed on imaging study e.g., ultrasonography)

Pancreatic mass

Pancreatic pseudocyst (seen on ultrasound)

Pancreatitis (suspected) with abnormal elevation of amylase or lipase

Pancreatitis (known), including pancreatic pseudocyst with recurrence or worsening


Peritonitis (follow-up) if abdominal pain and tenderness to palpation is present, and at least one

of the following: rebound, rigid abdomen, or tenderness to palpation present over entire

abdomen

Renal colic

Renal mass


Cholecystitis (suspected) with equivocal ultrasound

Inflammatory bowel disease (suspected) (Crohn’s or ulcerative colitis) with abdominal pain and

persistent diarrhea or bloody diarrhea

Trauma

Unexplained weight loss of 10% if body weight in two months unexplained by clinical findings,

including physical examination

Unexplained weight loss of 5% if body weight in six months confirmed by documentation to

include (related member history, chest x-ray, abdominal ultrasound, lab tests (TSH),

colonoscopy (if member is 50+ years old)

Unexplained abdominal pain in members 75 years or older



Other indications for an Abdomen and Pelvis CT Combination:



_______________________________________________________________



Delineation of known or suspected renal calculi or ureteral calculi with completion of initial

work-up

Evaluation of suspicious mass/tumor found on physical findings or imaging study and both the

abdomen and pelvis are likely affected

Evaluation after treatment, procedure, intervention or surgery


Follow-up study for known diagnosis/condition (e.g., mass, abscess)

Post-operative evaluation for complications

Pre-operative evaluation for infection

Suspected complications of diverticulitis (known to be limited to the abdomen/pelvis by prior

imaging)

Definitions:

Ascites: effusion and accumulation of serous fluid in the abdominal cavity.

Congenital anomaly: congenital anomaly present at birth; it may be a malformation, disruption,

deformation, or dysplasia.

Diverticulitis: inflammation of a diverticulum, especially inflammation related to colonic

diverticula, which may undergo perforation with abscess formation.

Gastroparesis: paralysis of the stomach, usually from damage to its nerve supply, so that food

empties out much more slowly, if at all.

Hematoma: a localized collection of blood, usually clotted, in an organ, space, or tissue, usually due

to a break in the wall of a blood vessel.

Hematuria: blood (erythrocytes) in the urine; called also erythrocyturia.

Hepatitis C: a viral disease caused by the hepatitis C virus. Although the chronic infection is

usually mild and asymptomatic, cirrhosis may occur.

Hepatomegaly: enlargement of the liver.

Hydronephrosis: distention of the pelvis and calices of the kidney with urine, as a result of

obstruction of the ureter.

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

Pancreatitis (acute): pancreatitis with sudden onset, fever, abdominal pain, nausea, vomiting,

tachycardia, and often increased blood levels of pancreatic enzymes. It may be accompanied by

complications such as hemorrhaging or necrosis.

Pancreatic pseudocyst: a cystic collection of fluid and necrotic debris whose walls are formed by the

pancreas and nearby organs. It occurs as a complication of acute pancreatitis and may subside

spontaneously or become secondarily infected and develops into an abscess.

_______________________________________________________________



Septic arthritis: infectious arthritis, usually acute, characterized by inflammation of synovial

membranes with purulent effusion into a joint or joints, most often due to Staphylococcus aureus,

Streptococcus pyogenes, S. pneumoniae, or Neisseria gonorrhea, usually caused by hematogenous

spread from a primary site of infection although joints may also become infected by direct

inoculation or local extension. Called also bacterial, pyogenic, or suppurative.

Splenomegaly: enlargement of the spleen.


Reimbursement for computed tomography (72192 – 72194, 74150 – 74170, and 74176 – 74178,

76380) performed on the same anatomical area is limited to two (2) computed tomography (72192 –

72194, 74150 – 74170, and 74176 – 74178, 76380) within a 6-month period. Computed tomography

(72192 – 72194, 74150 – 74170, and 74176 – 74178, 76380) in excess of two (2) computed

tomography (72192 – 72194, 74150 – 74170, and 74176 – 74178, 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 (72192 – 72194, 74150 – 74170, and 74176 – 74178,

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

(72192 – 72194, 74150 – 74170, and 74176 – 74178, 76380) within a 12-month period. Computed

tomography (72192 – 72194, 74150 – 74170, and 74176 – 74178, 76380) for an oncologic condition in

excess of four (4) computed tomography (72192 – 72194, 74150 – 74170, and 74176 – 74178, 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.



_______________________________________________________________



TOC

72196 – MRI Pelvis

74181 – MRI Abdomen


INDICATIONS FOR PELVIC MRI:

Evaluation of suspicious/known mass/tumors (unconfirmed diagnosis of cancer) for further

evaluation of indeterminate or questionable findings:

Initial evaluation of suspicious pelvic masses/tumors found only in the pelvis by physical exam

or imaging study, such as ultrasound (US)

Surveillance: One follow-up exam to ensure no suspicious change has occurred in a tumor in the

pelvic. No further surveillance unless tumor(s) are specified as highly suspicious, or change was

found on last follow-up, or new/changing signs/symptoms or abnormal lab values

Evaluation of known cancer for further evaluation of indeterminate or questionable findings,

identified by physical examination or imaging exams such as ultrasound (US) and computed

tomography (CT):

Initial staging of known cancer:

o All cancers, excluding the following:

Excluding Basal Cell Carcinoma of the skin

Excluding Melanoma without symptoms or signs of metastasis

Three (3) month follow-up of known abdomen/pelvic cancer undergoing active treatment within

the past year

Six (6) month follow-up of known abdominal/pelvic cancer undergoing active treatment within

the past year

Follow-up of known cancer of patient undergoing active treatment within the past year

Known cancer with suspected abdominal/pelvic metastasis based on a sign, symptom or an

abnormal lab value

Cancer surveillance: Once per year (last test must be over ten (10) months ago before new

approval) for surveillance of known cancer

For evaluation of suspected infection or inflammatory disease:

Suspected acute appendicitis (or severe acute diverticulitis) if pelvic pain and tenderness to

palpation is present, with AT LEAST ONE of the following:

o WBC elevated;

o Fever;

o Anorexia; OR

o Nausea and vomiting

Suspected complications of diverticulitis (known to be limited to the pelvis by prior imaging)

with pelvic pain or severe tenderness, not responding to antibiotics treatment

Suspected infection in the pelvis

For evaluation of known infection or inflammatory disease follow up:

_______________________________________________________________



Complications of diverticulitis with severe abdominal pain or severe tenderness, not responding

to antibiotic treatment, (prior imaging study is not required for diverticulitis diagnosis)

Known inflammatory bowel disease (Crohn’s or ulcerative colitis) with recurrence or worsening


Known infection that is clinically suspected to have created an abscess in the pelvis.

History of fistula limited to the pelvis that requires re-evaluation, or is suspected to have

recurred

Abnormal fluid collection seen on prior imaging that needs follow-up evaluation

Known infection in the pelvis

For evaluation of known or suspected vascular disease (e.g., aneurysms, hematomas):

Evidence of vascular abnormality identified on imaging studies.

Evaluation of suspected or known aortic aneurysm limited to the pelvis:

o Suspected or known aneurysm < four (4) cm AND equivocal or indeterminate ultrasound

results; OR

o Prior imaging demonstrated aneurysm ≥ four (4) cm in diameter; OR

o Suspected complications of known aneurysm as evidenced clinical findings such as new

onset of pelvic pain

Scheduled follow-up evaluation of aorto/ilial endograft

o Asymptomatic at six (6) month intervals, for two (2) years;

o Asymptomatic/complications related to stent graft, more frequent imaging may be

needed

Suspected retroperitoneal hematoma or hemorrhage

For known or suspected prostate cancer for recurrence workup:

Initial treatment by radical prostatectomy:

o Failure of PSA to fall to undetectable levels or PSA detectable and rising on at least 2

subsequent determinations

Initial treatment radiation therapy (RT):

o Post-RT rising PSA or positive digital exam and is candidate for local therapy

In members without confirmed diagnosis of prostate cancer (previous negative biopsy) with

persistent elevation or rising PSA

Indications for Musculoskeletal Pelvic MRI:

Initial evaluation of suspicious mass/tumor of the bones, muscles or soft tissues of the pelvis

found on an imaging study, and needing clarification, or found by physical exam and remains

non-diagnostic after x-ray or ultrasound

Evaluation of suspected fracture and/or injury when initial imaging is inconclusive or needs

further evaluation

For evaluation of known or suspected aseptic/avascular necrosis of hip(s)

Sacroiliitis (infectious or inflammatory)

Sacroiliac Joint Dysfunction:

o Persistent back and/or sacral pain after failure of four (4) weeks conservative treatment

within the recent six (6) months, including physical therapy or physician supervised

home exercise plan (HEP), for at least six (6) weeks

Persistent Pain:

_______________________________________________________________



o For evaluation of persistent pain unresponsive to four (4) weeks of conservative

treatment within the recent six (6) months

Pelvic floor failure:

o For evaluation of incontinence and anatomical derangements including, but not limited

to uterine prolapse, rectocele, cystocele

o For further evaluation of congenital anomalies of the sacrum and pelvis and initial

imaging has been performed


For pelvic surgery or procedure

For post-operative/procedural evaluation:

Follow-up of known or suspected post-operative complication involving the hips or the pelvis

Follow-up study 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.

Other Indications for a Pelvic MRI:

For location or evaluation of undescended testes in adults and in children, including

determination of location of testes, where ultrasound has been done previously

To provide an alternative to follow-up of an indeterminate pelvic CT when previous

CT/ultrasound was equivocal and needed to clarify a finding a CT could not

For evaluation and characterization of uterine and adnexal masses, (e.g., fibroids, ovaries, tubes

and uterine ligaments), or congenital anomaly where ultrasound has been done previously

For evaluation of uterus prior to embolization

For evaluation of endometriosis

Prior to uterine surgery if there is abnormality suspected on prior US (e.g., bicornuate uterus)

For evaluation of known or suspected aseptic/avascular necrosis of hip(s)

For evaluation of known or suspected abnormality of the fetus noted on prior imaging and no

prior pelvis MRI

INDICATIONS FOR ABDOMINAL MRI:

Evaluation of suspicious known mass/tumors (unconfirmed diagnosis of cancer) for further

evaluation of indeterminate or questionable findings:

Initial evaluation of suspicious abdomen masses/tumors found only in the abdomen by physical

exam or imaging study, such as ultrasound (US)

Surveillance: One follow-up exam to ensure no suspicious change has occurred in a tumor in the

abdomen. No further surveillance unless tumor(s) are specified as highly suspicious, or change

was found on last follow-up

Evaluation of known cancer for further evaluation of indeterminate or questionable findings

identified by physical examination or imaging exams such as ultrasound (US) and computed

tomography (CT):

_______________________________________________________________



Initial staging of known cancer:

o All cancers, excluding the following:

Excluding Basal Cell Carcinoma of the skin,

Excluding Melanoma without symptoms or signs of metastasis.

Three (3) month follow-up of known abdominal cancer undergoing active treatment within the

past year.

Six (6) month follow-up of known abdominal cancer undergoing active treatment within the past

year.

Follow-up of known cancer of patient undergoing active treatment within the past year.

Known cancer with suspected abdominal metastasis based on a sign, symptom or an abnormal

lab value.

Cancer surveillance: Once per year (last test must be over ten (10) months ago before new

approval) for surveillance of known cancer.

For evaluation of suspected infection or inflammatory disease:

Suspected acute appendicitis (or severe acute diverticulitis) if abdominal pain and tenderness to

palpation is present, with at LEAST one of the following:

o WBC elevated;

o Fever;

o Anorexia; OR

o Nausea and vomiting

Suspected peritonitis (from any cause) if abdominal pain and tenderness to palpation is present,

and at LEAST one of the following:

o Rebound, rigid abdomen; OR

o Severe tenderness to palpation present over entire abdomen

Suspected pancreatitis with abnormal elevation of amylase or lipase results

Suspected inflammatory bowel disease (Crohn’s disease or Ulcerative colitis) with abdominal

pain, and persistent diarrhea, or bloody diarrhea

Suspected cholecystitis with recent equivocal ultrasound

Suspected infection in the abdomen

For evaluation of known infection or inflammatory disease follow up:

Complications of diverticulitis with severe abdominal pain or severe tenderness, not responding

to antibiotic treatment, (prior imaging study is not required for diverticulitis diagnosis

Pancreatitis by history, (including pancreatic pseudocyst) with abdominal pain suspicious for

worsening, or re-exacerbation

Known inflammatory bowel disease (Crohn’s disease or Ulcerative colitis) with recurrence or

worsening signs/symptoms requiring re-evaluation

Known infection that is clinically suspected to have created an abscess in the abdomen

History of fistula limited to the abdomen that requires re-evaluation or is suspected to have

recurred.

Abnormal fluid collection seen on prior imaging that needs follow-up evaluation

Hepatitis C/hepatoma evaluation with elevated alpha-fetoprotein (AFP) and equivocal

ultrasound results

Known infection

Evaluation of suspected or known vascular disease (e.g., aneurysms, hematomas):

_______________________________________________________________



Evidence of vascular abnormality seen on imaging studies

Evaluation of suspected or known aortic aneurysm limited to abdomen

Suspected or known aneurysm < four (4) cm AND equivocal or indeterminate ultrasound

results; OR

Prior imaging demonstrated aneurysm ≥ four (4) cm in diameter; OR

Suspected complications of known aneurysm as evidenced clinical findings such as new onset of

abdominal pain

Scheduled follow-up evaluation of aorto/ilial endograft

Asymptomatic at six (6) month intervals, for two (2) years

Symptomatic/complications related to stent graft-more frequent imaging may be needed



For abdominal surgery or procedure


Follow-up of suspected or known post-operative complication involving only the abdomen

A follow-up study to help evaluate a patient’s progress after treatment, procedure, intervention

or surgery. Documentation requires a medical reason that clearly indicates why additional

imaging is needed

Other Indications for an Abdominal MRI:

To provide an alternative to abdominal CT when CT would be limited due to allergy to

radiographic contrast material

To provide an alternative to follow-up of an indeterminate abdomen CT when previous

CT/ultrasound was equivocal

Suspected adrenal mass or pheochromocytoma based on diagnostic testing/imaging results,

and/or a suspicious clinical presentation


Reimbursement for MRI imaging (72195-72197, 74181-74183) performed on the same anatomical

area is limited to one (1) MRI imaging within a 6-month period. MRI imaging (72195-72197, 74181-

74183) in excess of one (1) within a 6-month period is subject to medical review for medical



recommendation.









_______________________________________________________________





Reimbursement for MRI imaging (72195-72197, 74181-74183) 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) MRI imaging (72195-72197, 74181-74183) within a 12-month

period. MRI imaging (72195-72197, 74181-74183) for an oncologic condition in excess of four (4)

within a 12-month period are subject to medical review of documentation to support medical



recommendation.






_______________________________________________________________



TOC

72198 – MR Angiography, Pelvis

74185 – MR Angiography, Abdomen


INTRODUCTION

Magnetic resonance angiography (MRA) is a noninvasive imaging technology, which generates

images of the arteries that can be evaluated for evidence of stenosis, occlusion or aneurysms. MRA

is used to evaluate the arteries of the abdominal aorta and the renal arteries. A contrast agent

(gadolinium) may be used with MRA for better visualization and may be used in individuals who

have a history of contrast allergy and who are at high risk of kidney failure.



the abdomen and pelvis and imaging results (e.g., images, clinical reports) should be maintained in


Indications for Abdomen MRA:

For evaluation of known or suspected abdominal vascular disease:

Known large vessel diseases (abdominal aorta, inferior vena cava, superior/inferior mesenteric,

celiac, splenic, renal or iliac arteries/veins), e.g., aneurysm, dissection, arteriovenous

malformations (AVMs), and fistulas, intramural hematoma, and vasculitis

Evidence of vascular abnormality seen on prior imaging studies

Evaluation of suspected or known aortic aneurysm:


results; OR


Suspected complications of known aneurysm as evidenced by signs/symptoms such as new onset

of abdominal or pelvic pain


Suspected renal vein thrombosis in patient with known renal mass

Evaluation of mesenteric ischemia/ischemic colitis

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

Vascular invasion or displacement by tumor

Evaluation of hepatic blood vessel abnormalities (e.g., aneurysm, hepatic vein thrombosis,

stenosis post-transplant)

Evaluation of splenic artery aneurysm

Kidney failure or renal insufficiency if initial evaluation performed with Ultrasound is

inconclusive

Evaluation of known or suspected renal artery stenosis or resistant hypertension demonstrated

by any of the following:

o Unsuccessful control after treatment with three (3) or more anti-hypertensive medication

at optimal dosing

_______________________________________________________________



o Acute elevation of creatinine after initiation of an Angiotension Converting Enzyme

inhibitor (ACE inhibitor) or Angiotension receptor blocker (ARB)

o Asymmetric kidney size noted on ultrasound

o Onset of hypertension in a person younger than age 30 without any other risk factors or

family history of hypertension

o New onset of hypertension after age 55 (>160/100)

o Acute rise in blood pressure in a person with previously stable blood pressures

o Flash pulmonary edema without identifiable causes

o Malignant hypertension


Evaluation of interventional vascular procedures for luminal patency versus restenosis due to

conditions such as atherosclerosis, thromboembolism, and intimal hyperplasia

Pretransplant evaluation of either liver or kidney

Post-operative or post-procedural evaluation:

Evaluation of endovascular/interventional abdominal vascular procedures for luminal patency

versus restenosis due to conditions such as atherosclerosis, thromboembolism, and intimal

hyperplasia

Evaluation of post-operative complications (e.g., pseudoaneurysms) related to surgical bypass

grafts, vascular stents and stent-grafts in the peritoneal cavity

Follow-up for post-endovascular repair (EVAR) or open repair of abdominal aortic aneurysm

(AAA). Routine baseline study (post-op/intervention) is warranted within 1-3 months


Symptomatic/complications related to stent graft – more frequent imaging may be needed

Follow-up study may be needed to help evaluate a patient’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

Indications for Pelvis MRA:

For evaluation of known or suspected pelvic vascular disease:


celiac, splenic, renal or iliac arteries/veins), e.g., aneurysm, dissection, arteriovenous

malformations (AVMs), and fistulas, intramural hematoma, and vasculitis


Suspected aortic dissection

Evaluation of suspected or known aortic aneurysm:


results; OR


Suspected complications of known aneurysm as evidenced by signs/symptoms such as new onset

of abdominal or pelvic pain


For evaluation of suspected pelvic vascular disease when findings on ultrasound are

indeterminate

_______________________________________________________________





Pelvic vein thrombosis or thrombophlebitis



conditions such as atherosclerosis, thromboembolism, and intimal hyperplasia

Post- operative or post-procedural evaluation:

Evaluation of endovascular/ interventional vascular procedures for luminal patency versus

restenosis due to conditions such as atherosclerosis, thromboembolism, and intimal hyperplasia

Evaluation of post-operative complications (e.g. pseudoaneurysms, related to surgical bypass

grafts, vascular stents and stent-grafts in peritoneal cavity)


(AAA). Routine, baseline study (post-op/intervention) is warranted within 1-3 months

o Asymptomatic at six (6) month intervals, for two (2) years

o Symptomatic/complications related to stent graft – more frequent imaging may be

needed

Follow-up study may be needed to help evaluate a patient’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.

_______________________________________________________________



TOC

73200 – CT Upper Extremity (Hand, Wrist, Elbow, Long Bone or Shoulder)

73700 – CT Lower Extremity (Ankle, Foot, Hip or Knee)


INDICATIONS FOR UPPER OR LOWER EXTREMITY CT:

Computed tomography (CT) of the extremity (upper or lower) meets the definition of medical

necessity for the diagnosis and evaluation of the following:

Tumor evaluation (Bone): primary neoplasm or metastatic disease (known or suspected)

Palpable mass on physical exam

Mass/lesion noted on imaging study (e.g., ultrasound, MRI, x-ray)

When MRI is contraindicated

Fracture evaluation

Rule out suspected fracture or subluxation with trauma when plain x-rays are normal

Determine position of known fracture or subluxation

Assessment of fracture healing for delayed union or non-union when physical or plain x-

ray findings suggest delayed or failed healing

To confirm a suspected (occult) fracture when MRI is contraindicated

To determine the extent of an acute fracture, position of fracture fragments and subluxation

To assess union or status of healing fracture.

Infectious and inflammatory process (e.g., abscess, septic arthritis, osteomyelitis) when MRI is

contraindicated

Intra or extra articular abnormality (e.g., loose body)

Mass (palpable)

Neoplasms (benign, malignant) when MRI is contraindicated

Occult fracture (suspected) when MRI is contraindicated

Osteonecrosis (avascular necrosis, aseptic necrosis, ischemic necrosis) when MRI is

contraindicated

Pain (chronic) unresponsive to conservative treatment (e.g., physical therapy)

Pain (persistent) unresponsive to 4 weeks of conservative treatment (e.g. pharmacologic

intervention [nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants], steroids,

physical therapeutic modalities (e.g., physical therapy, exercise)

Tendonitis when MRI is contraindicated

Trauma (with prior x-ray to rule out fracture)

Tumor-known or suspected when MRI is contraindicated

Evaluation of auto immune disease (e.g., rheumatoid arthritis, scleroderma) (Known or

suspected) and MRI is contraindicated

Evaluation of shoulder impingement when MRI is contraindicated

Evaluation of rotator cuff tear when MRI is contraindicated

Evaluation of labral tear ((SLAP (superior labrum from anterior to posterior) lesion/tear),

Bankart lesion) when MRI is contraindicated

OTHER INDICATIONS FOR THE UPPER OR LOWER EXTREMITY:

_______________________________________________________________



Assess status of loose body in the presence of joint effusion

Assess status of osteochondral abnormalities including osteochondral fractures, osteochondritis

dissecans, treated osteochondral defects when physical or imaging findings suggest its presence

and MRI is contraindicated or is unable to be performed

Documented physical exam or x-ray findings of prosthetic device dislocation

Follow-up evaluation after treatment, procedure or surgery

Follow-up for primary or metastatic bone tumor when MRI is contraindicated

Hemarthrosis (bloody joint effusion) seen on x-ray when MRI is contraindicated

Postoperative evaluation with physical exam or laboratory findings of joint infection when MRI

is contraindicated

Post-operative evaluation with physical exam or x-ray findings of delayed or failed healing

Preoperative evaluation prior to open surgery (e.g., joint replacement)

When MRI is contraindicated and when guideline criteria are met

Evaluation of abnormal physical findings or imaging results that require further imaging

Evaluation of brachial plexus dysfunction (brachial plexopathy/thoracic outlet syndrome)

Evaluation of recurrent dislocation (painful and non-painful)

INDICATIONS FOR LOWER EXTREMITY CT:

In addition to the above indications, the following indications for lower extremity CT meet the

definition of medical necessity for the diagnosis and evaluation of the following:

Anterior cruciate ligament (ACL), posterior cruciate ligament (PCL) or medial collateral

ligament (MCL) injury documented by physical findings (Drawer or Lackman’s sign) when MRI

is contraindicated

Meniscal injury documented by physical findings for torn meniscus (McMurray’s, Apley’s tests

or laxity on varus or valgus stress) when MRI is contraindicated

Slipped femoral capital epiphysis (rule out)

Tarsal coalition when MRI is contraindicated

ADDITIONAL INFORMATION RELATED TO EXTREMITY CT:

PEDIATRIC EXAMINATIONS







DEFINITIONS:


Laxity: slackness or looseness; a lack of tautness, firmness, or rigidity. Slackness or displacement

(whether normal or abnormal) in the motion of a joint.

Legg-Calve-Perthes disease: osteochondrosis of the capitular epiphysis of the femur.

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

uncontrolled and progressive.

_______________________________________________________________



Occult: obscure; concealed from observation; difficult to understand.

Osteoarthropathy: any disease of the joints and bones.

Osteochondritis dissecans (OCD): osteochondritis resulting in the splitting of pieces of cartilage into

the joint, particularly the knee joint or shoulder joint. A term for osteochondral fracture.

Osteochondritis: inflammation of both bone and cartilage.

Osteochondrosis: a disease of the growth or ossification centers in children that begins as

degeneration or necrosis and is followed by regeneration or recalcification.

Osteonecrosis: necrosis of bone due to obstruction of its blood supply (avascular, ischemic necrosis

or the bone).

Scleroderma (localized): scleroderma confined to the skin and subcutaneous tissue or secondarily

involving the musculoskeletal system.

Slipped femoral capital epiphysis: dislocation of the epiphysis of a bone, as of the epiphysis of the

head of the femur.

Tarsal coalition: the fibrous, cartilaginous, or bony fusion of two or more of the tarsal bones, often

resulting in talipes planovalgus, although other deformities occur and some patients are

asymptomatic; it may be congenital or acquired as a response to trauma, infection, or joint disease.

Tendonitis: inflammation of tendons and of tendon-muscle attachments.

Union: the process of healing; the renewal of continuity in a broken bone or between the edges of a

wound.

Valgus stress: a pressure applied to the leg that tires to bend the lower leg sideways at the knee,

away from the other leg.

Varus stress: a pressure applied to the leg that tires to bend the lower leg sideways at the knee,

toward the other leg.


Reimbursement for computed tomography (73200 – 73202 and 73700 – 73702, 76380) performed on

the same anatomical area is limited to two (2) computed tomography (73200 – 73202 and 73700 –

73702, 76380) within a 6-month period. Computed tomography (73200 – 73202 and 73700 – 73702,

76380) in excess of two (2) computed tomography (73200 – 73202 and 73700 – 73702, 76380) within

a 6-month period are subject to medical review of documentation to support medical necessity.



recommendation.

Reimbursement for computed tomography (73200 – 73202 and 73700 – 73702, 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 (73200 – 73202

and 73700 – 73702, 76380) within a 12-month period. Computed tomography (73200 – 73202 and

73700 – 73702, 76380) for an oncologic condition in excess of four (4) computed tomography (73200

– 73202 and 73700 – 73702, 76380) within a 12-month period are subject to medical review of




Re-imaging or additional imaging of the extremity (upper and lower) due to poor contrast enhanced

exam or technically limited exam is the responsibility of the imaging provider.

_______________________________________________________________



TOC

73206 – CT Angiography, Upper Extremity


INTRODUCTION:




material.

INDICATIONS FOR UPPER EXTREMITY CTA:

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

For evaluation of suspected vascular disease aneurysm, arteriovenous malformation, fistula,

vasculitis, or intramural hematoma.

For evaluation of Raynaud's syndrome.

For evaluation of vascular invasion or displacement by tumor.

For evaluation of complications of interventional vascular procedures, e.g., pseudoaneurysms

related to surgical bypass grafts, vascular stents, or stent-grafts.

Preoperative evaluations:

For preoperative evaluation from known vascular disease/condition.

Post-operative/ procedural evaluations:




Other indications for Upper Extremity CTA:

For evaluation of a dialysis graft.



the upper extremity and imaging results (e.g., images, clinical reports) should be maintained in


_______________________________________________________________



TOC

73220 – MRI Upper Extremity


Indications for upper extremity MRI (hand, wrist, arm, elbow or shoulder) (plain radiographs must

precede MRI evaluation):

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

Suspected tumor size increase or recurrence based on a sign, symptom, imaging study or

abnormal lab value

Surveillance: One follow-up exam if initial evaluation is indeterminate and lesion remains

suspicious for cancer. No further surveillance unless tumor is specified as highly suspicious, or

change was found on last imaging.

Evaluation of known cancer:

Initial staging of known cancer in the upper extremity

Follow-up of known cancer of patient undergoing active treatment within the past year

Known cancer with suspected upper extremity metastasis based on a sign, symptom, imaging

study or abnormal lab value

Prior cancer surveillance: Once per year (last test must be over 10 months ago before new

approval) for surveillance of known cancer.

For evaluation of known or suspected infection or inflammatory disease (e.g. osteomyelitis):

Further evaluation of an abnormality or non-diagnostic findings on prior imaging

With abnormal physical, laboratory, and/or imaging findings

Known or suspected (based upon initial workup including x-ray) of septic arthritis or

osteomyelitis.

For evaluation of suspected avascular necrosis (AVN) (e.g., aseptic necrosis, Legg-Calve-Perthes

disease in children):

Further evaluation of an abnormality or non-diagnostic findings on prior imaging.

For evaluation of known or suspected Auto Immune Disease, (e.g., Rheumatoid arthritis):

Known or suspected auto immune disease and non-diagnostic findings on prior imaging.

For evaluation of known or suspected fracture and/or injury:

Further evaluation of an abnormality or non-diagnostic findings on prior imaging

Suspected fracture when imaging is negative or equivocal

http://mcgs.bcbsfl.com/index.cfm?fuseaction=main.main&format=cfm&doc=Magnetic%20Resonance%20Imaging%20(MRI)%20Upper%20Extremity#P147_12079

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_______________________________________________________________



Determine position of known fracture fragments/dislocation.

For evaluation of persistent pain and initial imaging (e.g. x-ray) has been performed:

Chronic pain and/or persistent tendonitis unresponsive to conservative treatment, which

include - medical therapy (may include physical therapy or chiropractic treatments) and/or -

physician supervised home exercise of at least four (4) weeks.

Pre-operative/pre-procedural evaluation


When imaging, physical or laboratory findings indicate joint infection, delayed or non-healing or

other surgical/procedural complications




Other indications for an upper extremity (hand, wrist, arm, elbow, or shoulder) MRI:

Abnormal bone scan and x-ray is non-diagnostic or requires further evaluation

MR arthrogram

To assess status of osteochondral abnormalities including osteochondral fractures,

osteochondritis dissecans treated osteochondral defects where physical or imaging findings

suggest its presence.

Additional indications for shoulder MRI:

For evaluation of known or suspected impingement, rotator cuff tear, or labral tear (superior

labral anterior-posterior (SLAP) lesion, Bankart lesion).

Known or suspected impingement or when impingement test is positive

Impingement or rotator cuff tear indicated by positive Neer’s sign, Hawkin’s sign or drop sign.

Status post prior rotator cuff repair with suspected re-tear and findings on prior imaging are

indeterminate

For evaluation of brachial plexus dysfunction (brachial plexopathy/thoracic outlet syndrome)

For evaluation of recurrent dislocation.

Additional indications for wrist MRI:

For evaluation of suspected ligament injury with evidence of wrist instability on examination or

evidence of joint space widening on x-ray

For suspected triangular fibrocartilage complex (TFCC) injury.


Reimbursement for MRI imaging (73218-73223) performed on the same anatomical area is limited

to one (1) MRI imaging within a 6-month period. MRI imaging (73218-73223) in excess of one (1)

within a 6-month period is subject to medical review for medical necessity. Documentation should

_______________________________________________________________



























DEFINITIONS:

Aseptic necrosis: increasing sclerosis and cystic changes in the head of the femur, which sometimes

follow traumatic dislocation of the hip. A similar condition sometimes develops in the head of the

humerus after shoulder dislocation.

Osteomyelitis: inflammation of bone caused by infection, usually by a pyogenic organism, although

any infectious agent may be involved. It may remain localized or may spread through the bone to

involve the marrow, cortex, cancellous tissue, and periosteum.

Septic arthritis: infectious arthritis, usually acute, characterized by inflammation of synovial

membranes with purulent effusion into a joint or joints, most often due to Staphylococcus aureus.

Streptococcus pyogenes, S. pneumoniae, or Neisseria gonorrhoeae, usually caused by hematogenous

spread from a primary site of infection although joints may also become infected by direct

inoculation or local extension. Also called bacterial, pyogenic, or suppurative arthritis.

_______________________________________________________________



TOC

73225 – MR Angiography Upper Extremity

73725 – MR Angiography, Lower Extremity


INTRODUCTION:

Magnetic resonance angiography (MRA) is a noninvasive imaging alternative to catheter

angiography for evaluation of vascular structures in the upper extremity and for imaging arterial

obstructive disease in the lower extremity. In the upper extremity, magnetic resonance venography

(MRV) may be used to image veins instead of arteries. MRA and MRV are less invasive than

conventional x-ray digital subtraction angiography. In the lower extremity, MRA may be used to

image tibia and pedal arteries and evaluate symptoms that occur after angiography. A contrast

material (gadolinium) may be used to enable visualization of a body system or body structure and

may be used in individuals who have a history of contrast allergy and who are at high risk of kidney

failure.



the extremity (upper and lower) and imaging results (e.g., images, clinical reports) should be


process.

Indications for Upper Extremity MRA

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

For evaluation of suspected vascular disease aneurysm, arteriovenous malformation, fistula,

vasculitis, or intramural hematoma.

For evaluation of vascular invasion or displacement by tumor.

For evaluation of complications of interventional vascular procedures, e.g., pseudoaneurysms

related to surgical bypass grafts, vascular stents, or stent-grafts.

For evaluation of suspected upper extremity embolism or venous thrombosis.

Preoperative evaluations:

• For preoperative evaluation from known vascular disease/condition.

Post-operative/ procedural evaluations:




Indications for Lower Extremity MRA

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.


Abnormal preliminary testing (Ankle/Brachial index, ultrasound/doppler arterial evaluation)

associated with significant symptoms of claudication with exercise.


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




_______________________________________________________________



TOC

73706 – CT Angiography, Lower Extremity


INTRODUCTION:




material.

INDICATIONS FOR LOWER EXTREMITY CTA:

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.


Abnormal preliminary testing (Ankle/Brachial index, ultrasound/doppler arterial evaluation)

associated with significant symptoms of claudication with exercise.


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 patient’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.



the lower extremity and imaging results (e.g., images, clinical reports) should be maintained in the


_______________________________________________________________



TOC

73720 – MRI Lower Extremity (Ankle, Foot, Knee, Hip, Leg)

(Joint and other than joint)


MRI of the lower extremity (foot, ankle, knee, leg, hip) meets the definition of medical necessity for

the following:

INDICATIONS FOR LOWER EXTREMITY MRI (FOOT, ANKLE, KNEE, LEG or HIP):

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.

Suspected tumor size increase or recurrence based on a sign, symptom, imaging study or

abnormal lab value.

Surveillance: One follow-up exam if initial evaluation is indeterminant and lesion remains

suspicious for cancer. No further surveillance unless tumor is specified as highly suspicious, or

change was found on last imaging.

Evaluation of known cancer:

Initial staging of known cancer in the lower extremity.

Follow-up of known cancer of patient undergoing active treatment within the past year.

Known cancer with suspected lower extremity metastasis based on a sign, symptom, imaging

study or abnormal lab value.

Cancer surveillance: Once per year (last test must be over 10 months ago before new approval)

for surveillance of known cancer.

For evaluation of known or suspected infection or inflammatory disease (e.g., osteomyelitis):


With abnormal physical, laboratory, and/or imaging findings.

Known or suspected (based upon initial workup including x-ray) of septic arthritis or

osteomyelitis.

For evaluation of suspected avascular necrosis (AVN) (e.g., aseptic necrosis, Legg-Calve-Perthes

disease in children):


For evaluation of suspected or known Auto Immune Disease (e.g., Rheumatoid arthritis):

Known or suspected auto immune disease and ordered by an orthopedist or rheumatologist and

non-diagnostic findings on prior imaging.

For evaluation of known or suspected fracture and/or injury:

_______________________________________________________________




Suspected fracture when imaging is negative or equivocal.

Determine position of known fracture fragments/dislocation.

For evaluation of persistent pain and initial imaging (e.g. x-ray) has been performed:

Chronic pain and/or persistent tendonitis unresponsive to conservative treatment, which

include - medical therapy (may include physical therapy or chiropractic treatments) and/or -

physician supervised home exercise of at least four (4) weeks.

Pre-operative/pre-procedural evaluation


When imaging, physical or laboratory findings indicate joint infection, delayed or non-healing or

other surgical/procedural complications.




Other indications for a Lower Extremity (Foot, Ankle, Knee, Leg or Hip) MRI:

Abnormal bone scan and x-ray is non-diagnostic or requires further evaluation.

MR arthrogram when ordered by orthopedic specialist, surgeon or primary care provider on

behalf of specialist.

To assess status of osteochondral abnormalities including osteochondral fractures,

osteochondritis dissecans, treated osteochondral defects where physical or imaging findings

suggest its presence.

Additional indication specific for FOOT or ANKLE MRI

Chronic pain in a child or adolescent with painful rigid flat foot where imaging is unremarkable

or equivocal or on clinician’s decision to evaluate for known or suspected tarsal coalition.

Accompanied by physical findings of ligament damage such as an abnormal drawer test of the

ankle or significant laxity on valgus or varus stress testing and/or joint space widening on x-

rays.

Additional indications specific for KNEE MRI:

Accompanied by blood in the joint (hemarthrosis) demonstrated by aspiration.

Presence of a joint effusion.

For evaluation of suspected Baker’s cyst or posterior knee swelling with ultrasound requiring

further evaluation.

Accompanied by physical findings of a meniscal injury determined by physical examination tests

(McMurray’s, Apley’s) or significant laxity on varus or valgus stress tests.

Accompanied by physical findings of anterior cruciate ligament (ACL) or posterior cruciate

ligament (PCL) ligamental injury determined by the drawer test or the Lachman test.

Additional indications specific for HIP MRI:

_______________________________________________________________



For evaluation of suspected slipped capital femoral epiphysis with non-diagnostic imaging.

For any evaluation of patient with hip prosthesis or other implanted metallic hardware where

prosthetic loosening or dysfunction is suspected on physical examination or imaging.

Suspected labral tear of the hip with signs of clicking and pain with hip motion especially with

hip flexion, internal rotation and adduction.


Reimbursement for MRI imaging (73718-73723) performed on the same anatomical area is limited

to one (1) MRI imaging within a 6-month period. MRI imaging (73718-73723) in excess of one (1)

within a 6-month period is subject to medical review for medical necessity. Documentation should

























_______________________________________________________________



TOC

74175 – CT Angiography, Abdomen

74174 – CT Angiography, Abdomen and Pelvis

72191 – CT Angiography, Pelvis

75635 – CT Angiography, Abdominal Arteries





material.

Abdomen and pelvis CTA is used in the evaluation of the arteries and veins in the peritoneal cavity

(abdominal aorta, iliac arteries). Abdomen CTA is used in the evaluation of the arteries of the

abdominal aorta and renal arteries. Pelvis CTA is used in the evaluation of veins and arteries of the

pelvis or lower extremities. Abdominal arteries CTA are used in the evaluation of the abdominal

aorta and vascular supply to the lower extremities.



the (abdomen and pelvis, abdomen, pelvis, and abdominal arteries) 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.

Indications for Abdomen/Pelvis CTA:

Evaluation of known or suspected abdominal vascular disease:

Known large vessel diseases (e.g., abdominal aorta, inferior vena cava, superior/inferior

mesenteric, celiac, splenic, renal or iliac arteries/veins) (e.g., aneurysm, dissection,

arteriovenous malformations (AVMs), fistulas, intramural hematoma, and vasculitis)

o Evidence of vascular abnormality seen on prior imaging studies

o Suspected retroperitoneal hematoma or hemorrhage

o Venous thrombosis (for CT venogram) if previous studies have not resulted in a clear

diagnosis

o Vascular invasion or displacement by tumor

o Suspected aortic dissection

o Evaluation of suspected or known aortic aneurysm

Suspected or known aneurysm < four (4) cm AND equivocal or indeterminate

ultrasound results; OR

Prior imaging demonstrated aneurysm equal or greater to four (4) cm in diameter;

OR

Suspected complications of known aneurysm as evidenced by signs/symptoms,

such as new onset of abdominal or pelvic pain.

_______________________________________________________________





conditions (e.g., atherosclerosis, thromboembolism, and intimal hyperplasia)

Post- operative evaluation:

Evaluation of endovascular/interventional abdominal vascular procedures for luminal patency

versus restenosis due to conditions (e.g., atherosclerosis, thromboembolism, intimal hyperplasia)

Evaluation of post-operative complications (e.g., pseudoaneurysms, related to surgical bypass

grafts, vascular stents and stent-grafts in the peritoneal cavity)


(AAA):

o Routine, baseline study (post-op/intervention) is warranted within 1-3 months


o Symptomatic/complications related to stent graft (more frequent imaging may be needed)

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

Abdomen CTA

Indications for Abdomen CTA:



celiac, splenic, renal or iliac arteries/veins) (e.g., aneurysm, dissection, arteriovenous

malformations (AVMs), fistulas, intramural hematoma, and vasculitis)


Suspected aortic dissection

Evaluation of suspected or known aortic aneurysm


results; OR

Prior imaging demonstrated aneurysm equal or greater to four (4) cm in diameter;

OR

Suspected complications of known aneurysm as evidenced by signs/symptoms,

such as new onset of abdominal or pelvic pain.


Suspected renal vein thrombosis in member with known renal mass

Evaluation of suspected chronic mesenteric ischemia

Venous thrombosis (if studies (e.g., Doppler study/ultrasound) have not resulted in a clear

diagnosis)


Evaluation of portal venous system (hepatic portal system)

Evaluation of known or suspected renal artery stenosis or resistant hypertension demonstrated

by any of the following:

o Unsuccessful control after treatment with three (3) or more anti-hypertensive

medications at optimal dosing

_______________________________________________________________



o Acute elevation of creatine after initiation of an angiotensin-converting-enzyme inhibitor

(ACE) or angiotensin II receptor blockers (ARB)

o Asymmetric kidney size noted on ultrasound

o Onset of hypertension in a member younger than age 30 without any other risk factors or

family history of hypertension

o New onset of hypertension after age 55 (>160/100)

o Acute rise in blood pressure in a member with previously stable blood pressure

o Flash (rapid/acute) pulmonary edema without identifiable causes

o Malignant hypertension

Post-operative evaluation:



Post-operative or post-procedure evaluation:

Evaluation of endovascular/interventional vascular procedures for luminal patency versus




Follow-up for post-endovascular aortic repair (EVAR) or open repair of abdominal aortic

aneurysm (AAA):

o Routine, baseline study (post-op/intervention) is warranted within 1-3 months


o Symptomatic/complications related to stent graft (more frequent imaging may be needed)



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

Pelvis CTA

Indications for Pelvis CTA:

Evaluation of known or suspected vascular disease:


celiac, splenic, renal or iliac arteries/veins) (e.g., aneurysm, dissection, arteriovenous

malformations (AVMs), fistulas, intramural hematoma, and vasculitis)





Evaluation of pelvic vascular disease when findings on ultrasound are indeterminate

Evaluation of suspected or known aortic aneurysm


results; OR

o Prior imaging demonstrated aneurysm equal or greater to four (4) cm in diameter; OR

_______________________________________________________________



o Suspected complications of known aneurysm as evidenced by signs/symptoms, such as

new onset of abdominal or pelvic pain.




Post-procedural evaluation:

Evaluation of endovascular/interventional vascular procedures for luminal patency versus


Evaluation of post-operative complications (e.g. pseudoaneurysms, related to surgical bypass



(AAA):

Routine baseline study (post-operative/intervention) is warranted within 1-3 months


Symptomatic/complications related to stent graft (more frequent imaging may be needed)




Abdominal Arteries CTA

Indications for abdominal arteries CTA:


Known or suspected peripheral arterial disease

Significant ischemia that could be related to the presence of an ulcer, gangrene or significant

claudication




Post-operative or post-procedural evaluation:


grafts, vascular stents and stent grafts)




_______________________________________________________________



TOC

74261 – CT Colonoscopy (Virtual)


INTRODUCTION:

Computed tomographic colonography (CTC), also known as “virtual colonoscopy”, is minimally

invasive imaging examination of the colon and rectum. CTC uses CT acquired images and

advanced 2-dimensional (2D) and 3-dimensional (3D) image display techniques for interpretation.

These images are interpreted by a radiologist to determine the presence of abnormalities of the

colon.

INDICATIONS FOR CT COLONOSCOPY (VIRTUAL COLONOSCOPY):

CT colonography meets the definition of medical necessity for diagnostic evaluation for the

following when conventional colonoscopy incomplete or contraindicated:

o Failed colonoscopy due to medical condition (e.g., hypotension secondary to the sedation,

adhesions from prior surgery, excessive colonic tortuosity.

o Member is unable to undergo sedation.

o Member has a medial condition (e.g., recent myocardial infarction, recent colonic surgery,

bleeding disorders, severe lung and/or heart disease, obstructive colorectal cancer.

CT colonography for the purpose of routine colon cancer screening that does not meet the above

criteria for coverage is considered experimental or investigation because the clinical outcomes of CT

colonography for screening have not been shown to be superior to other approaches (e.g., optical

colonoscopy, fecal occult blood testing, or sigmoidoscopy).

Magnetic resonance colonography (MRC) is considered experimental or investigational, as there is

insufficient clinical evidence to support the use of this technology for routine colorectal cancer

screening.


Reimbursement for computer-aided detection used in the interpretation of computed tomographic

(CT) colonography (virtual colonoscopy, CT colonography, CTC) is included in the allowance of the

computed tomographic (CT) colonography (virtual olonoscopy, CT colonography, CTC).

_______________________________________________________________



TOC

75557 – MRI Heart


INDICATIONS FOR HEART (CARDIAC) MRI:

Where stress echocardiography (SE) is noted as an appropriate substitute according to the

American College of Cardiology Foundation (ACCF) Appropriateness Criteria for cardiac magnetic

resonance imaging (MRI) for indications (2, 3, 4, 12, and 13) in Table 1a, 2a and 3a AND at least

one of the following contraindications to SE must be documented in the member’s medical record:

Stress echocardiography is not indicated; OR

Stress echocardiography has been performed, however findings were inadequate;

there were technical difficulties with interpretation, or results were discordant with

previous clinical data

OR

Cardiac MRI is the preferred diagnostic imaging to stress echocardiography for the following,

including, but not limited to following conditions:

Ventricular paced rhythm

Evidence of ventricular tachycardia

Severe aortic valve dysfunction

Severe chronic obstructive pulmonary disease, (COPD) as defined as FEV1 < 30%

predicted or FEV1 < 50% predicted plus respiratory failure or clinical signs of right

heart failure. (GOLD classification of COPD)

Congestive heart failure (CHF) with current ejection fraction (EF), 40%

Inability to get an echo window for imaging

Prior thoracotomy, CABG, other surgery

Obesity BMI>40

Poorly controlled hypertension (generally above 180 mm Hg systolic (both physical

stress and dobutamine stress may exacerbate hypertension during stress echo))

Poorly controlled atrial fibrillation (resting heart rate > 100 bpm on medication)

Inability to exercise requiring pharmacological stress test

Segmental wall motion abnormalities at rest (e.g., due to cardiomyopathy, recent

MI, or pulmonary hypertension)

OR

Arrhythmias with stress echocardiography- any member on a type 1C anti-

arrhythmic drug (e.g., Flecainide or Propafenone) or considered for treatment with a

type 1C anti-arrhythmic drug.

All other requests for cardiac MRI, the member must meet the ACCF cardiac magnetic resonance

imaging Appropriateness Criteria Score (4-9) in Table 1a, 2a and 3a.

_______________________________________________________________



Indications in the American College of Cardiology Foundation (ACCF) Appropriateness Criteria for

cardiac magnetic resonance imaging with an Appropriate Use Score (1-3; Inappropriate (I)) noted in

Table 4a OR any one of the following do not meet the definition of medically necessity:

For any combination imaging study

For same imaging tests less than six weeks part unless specific guideline criteria

states otherwise.

For different imaging tests, such as CTA and MRA, of same anatomical structure

less than six weeks apart without high level review to evaluate for medical

necessity.

For re-imaging of repeat or poor quality study.

ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2010 APPROPRIATE USE CRITERIA for

CARDIAC MRI:

Where there is other ACCF reviewed imaging modalities, a crosswalk shows the relative appropriate use score between the two equivalent elements.

TABLE 1A DETECTION OF CAD: SYMPTOMATIC

Heart MRI

(Appropriate

ACCF/ASNC/ACR/AHA

/ASE/SCCT/SCMR/SNM

Criteria

# with Use Score

A= Appropriate (7-9)

U= Uncertain (4-6)

Indications

(*Refer to additional

information section

Other imaging modality cross-

walk: stress echocardiography

(SE) and chest CTA (CCTA)

(Appropriate

ACCF/ASNC/ACR/AHA

/ASE/SCCT/SCMR/SNM

Criteria

# with Use Score

Evaluation of Chest Pain Syndrome (Use of Vasodilator Perfusion CMR or Dobutamine

Stress Function CMR)

2 U (4) Intermediate pre-test

probability of CAD*

ECG interpretable

AND able to exercise

SE 116 A (7)

3 A (7) Intermediate pre-test

probability of CAD*

ECG interpretable

OR unable to exercise

SE 117 A (9)

4 U (5) High pre-test

probability of CAD*

SE 118 A (7)

_______________________________________________________________



Evaluation of Intra-Cardiac Structures (Use of MR Coronary Angiography)

8 A (8) Evaluation of

suspected coronary

anomalies

CCTA 46 A (9)

Acute Chest Pain (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)

9 U (6) Intermediate pre-test

probability of CAD

No ECG changes and

serial cardiac

enzymes negative

CCTA 6 A (7)

Risk Assessment With Prior Test Results (Use of Vasodilator Perfusion CMR or

Dobutamine Stress Function CMR)

12 U (6) Intermediate CHD

risk (Framingham)

Equivocal stress test

(exercise, stress

SPECT, or stress

echo)

SE 153 A (8)

13 A (7) Coronary

angiography

(catheterization or

CT)

Stenosis of unclear

significance

SE 141 A (8)

Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery – Intermediate or High

Risk Surgery (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)

15 U (6) Intermediate

perioperative risk

predictor

TABLE 2A STRUCTURE AND FUNCTION

Cardiac MRI

(Appropriate

ACCF/ASNC/ACR/AHA

/ASE/SCCT/SCMR/SNM

Criteria

# with Use Score

Indications


information section)




(Appropriate

ACCF/ASNC/ACR/AHA

/ASE/SCCT/SCMR/SNM

Criteria

# with Use Score

_______________________________________________________________




U= Uncertain (4-6)

Evaluation of Ventricular and Valvular Function

Procedures may include LV/RV mass and volumes, MR angiography, quantification of

valvular disease and delayed contrast enhancement

18 A (9) Assessment of

complex congenital

heart disease

including anomalies

of coronary

circulation, great

vessels, and cardiac

chambers and valves

Procedures may

include LV/RV mass

and volumes, MR

angiography,

quantification of

valvular disease, and

contrast

enhancement

CCTA 47 A (8)

19 U (6) Evaluation of LV

function following

myocardial infarction

OR in heart failure

members

20 A (8) Evaluation of LV

function following


OR in heart failure

members

Members with

technically limited

images from

echocardiogram

21 A (8) Quantification of LV

function

Discordant

information that is

clinically significant

from prior tests

_______________________________________________________________



22 A (8) Evaluation of specific

cardiomyopathies

(infiltrative (amyloid,

sarcoid), HCM, or due

to cardiotoxic

therapies)

Use of delayed

enhancement

23 A (8) Characterization of

native and prosthetic

cardiac valves—

including planimetry

of stenotic disease

and quantification of

regurgitant disease

Members with

technically limited

images from

echocardiogram or

TEE

24 A (9) Evaluation for

arrythmogenic right

ventricular

cardiomyopathy

(ARVC)

Members presenting

with syncope or

ventricular

arrhythmia

25 A (8) Evaluation of

myocarditis or


with normal coronary

arteries

Positive cardiac

enzymes without

obstructive

atherosclerosis on

angiography

Evaluation of Intra- and Extra-Cardiac Structures

26 A (9) Evaluation of cardiac mass

(suspected tumor or

_______________________________________________________________



thrombus)

Use of contrast for perfusion

and enhancement

27 A (8) Evaluation of pericardial

conditions (pericardial mass,

constrictive pericarditis)

28 A (8) Evaluation for aortic

dissection

29 A (8) Evaluation of pulmonary

veins prior to radiofrequency

ablation for atrial fibrillation

Left atrial and pulmonary

venous anatomy including

dimensions of veins for

mapping purposes

Chest CTA 38 A (8)

TABLE 3A DETECTION OF MYOCARDIAL SCAR AND VIABILITY

Cardiac MRI

(Appropriate

ACCF/ASNC/ACR/AHA

/ASE/SCCT/SCMR/SNM

Criteria

# with Use Score


U= Uncertain (4-6)

Indications

(*Refer to reimbursement

information section)




(Appropriate

ACCF/ASNC/ACR/AHA

/ASE/SCCT/SCMR/SNM

Criteria

# with Use Score

Evaluation of Myocardial Scar (Use of Late Gadolinium Enhancement)

30 A (7) • To determine the location,

and extent of myocardial

necrosis including ‗no reflow‘

regions

• Post-acute myocardial

infarction

31 U (4) • To detect post PCI

myocardial necrosis

32 A (9) • To determine viability

prior to revascularization

• Establish likelihood of

recovery of function with

revascularization (PCI or

_______________________________________________________________



CABG) or medical therapy

33 A (9) • To determine viability

prior to revascularization

• Viability assessment by

SPECT or dobutamine echo

has provided "equivocal or

indeterminate" results

INAPPROPRIATE USE INDICATIONS

TABLE 4A DETECTION OF CAD: SYMPTOMATIC

Cardiac MRI

(Appropriate

ACCF/ASNC/ACR/AHA

/ASE/SCCT/SCMR/SNM

Criteria

# with Use Score)

Indications


information section

Appropriate Use Score (1-3)

I= Inappropriate

Evaluation of Chest Pain Syndrome (Use of Vasodilator Perfusion CMR or Dobutamine

Stress Function CMR)

1 • Low pre-test probability of

CAD

ECG interpretable

AND able to exercise

I (2)

Evaluation of Chest Pain Syndrome (Use of MR Coronary Angiography)

5 • Intermediate pre-test

probability of CAD

• ECG interpretable AND

able to exercise

I (2)

6 • Intermediate pre-test

probability of CAD

• ECG uninterpretable OR

unable to exercise

I (2)

7 • High pre-test probability of

CAD

I (1)

Acute Chest Pain (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)

10 • High pre-test probability of

CAD

• ECG - ST segment

elevation and/or positive

I (1)

_______________________________________________________________



cardiac enzymes

Risk Assessment With Prior Test Results (Use of Vasodilator Perfusion CMR or

Dobutamine Stress Function CMR)

11 • Normal prior stress test

(exercise, nuclear, echo, MRI)

• High CHD risk

(Framingham)

• Within 1 year of prior

stress test

I (2)

Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery – Low Risk Surgery

(Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)

14 • Intermediate perioperative

risk predictor

I (2)

TABLE 5A DETECTION OF CAD: POST-REVASCULARIZATION (PCI OR CABG)

Cardiac MRI

(Appropriate

ACCF/ASNC/ACR/AHA

/ASE/SCCT/SCMR/SNM

Criteria

# with Use Score)

Indications


information section.)

Appropriate Use Score (1-3)

I= Inappropriate

Evaluation of Chest Pain Syndrome (Use of MR Coronary Angiography)

16 Evaluation of bypass

grafts

I (2)

17 History of

percutaneous

revascularization with

stents

I (1)

_______________________________________________________________



TOC

75571 – Electron Beam Tomography (EBCT)

CPT Codes: 75571, S8092


POSITION STATEMENT:

Electron beam computed tomography (EBCT) and spiral computed tomography to detect coronary

artery calcification (e.g., evaluation of coronary artery disease, diagnosing coronary artery disease,

screening for coronary artery disease) is considered experimental or investigational, as there is

insufficient evidence in the published peer-reviewed scientific literature to support conclusions

regarding the effects of EBCT and spiral CT on health outcomes. Available published clinical

studies fail to establish a clear screening role for EBCT in asymptomatic patients, nor have any

studies shown that clinical outcomes can be favorably altered by the use of screening EBCT.

The U.S. Preventive Services Task Force recommends against routine screening with EBCT

scanning for coronary calcium for either the presence of severe coronary artery stenosis or the

prediction of coronary heart disease events in adults at low risk for coronary heart disease events.

_______________________________________________________________



TOC

75572 – CT Heart

75574 – CTA Coronary Arteries (CCTA)


INTRODUCTION:

Computed tomographic angiography (CTA) is a noninvasive imaging test that requires the use of

intravenously administered contrast material and high-resolution, high-speed CT machinery to

obtain detailed volumetric images of blood vessels. CTA can be applied to image blood vessels

throughout the body; however, to apply CTA in the coronary arteries, several technical challenges

must be overcome to obtain high-quality diagnostic images. First, very short image acquisition

times are necessary to avoid blurring artifacts from the rapid motion of the beating heart. In some

cases, premedication with beta-blocking agents is used to slow down the heart rate below about 60 –

65 beats per minute to facilitate adequate scanning, and electrocardiographic triggering or

retrospective gating is used to obtain images during diastole when motion is reduced. Second, rapid

scanning is also helpful so that the volume of cardiac images can be obtained during breath-holding.

Third, very thin sections (< = 1mm) are important to provide adequate spatial resolution and high-

quality 3D reconstruction images.

CTA has several limitations. The presence of dense arterial calcification or an intracoronary stent

can produce significant beam-hardening artifacts that may preclude a satisfactory study. The

presence of an uncontrolled rapid heart rate or arrhythmia hinders the ability to obtain

diagnostically satisfactory images. Evaluation of the distal coronary arteries is generally more

difficult than visualization of the proximal and mid segment coronary arteries due to greater

cardiac motion and the smaller caliber of coronary vessels in distal locations.

CTA may contribute to refined risk assessment in certain subsets of the population, there are

currently no clinical data to support its use or upon which to base therapeutic recommendations.

Current scientific evidence to justify widespread use of this rapidly evolving technology in broad

clinical populations remains undefined. Therefore, it is currently not recommended to use CTA for

routine screening. Scientific evidence to justify widespread use of CTA in broad clinical populations

remains undefined (Gibbons et al. 2006). Exposure to radiation and contrast agents are concerns

with CTA. Radiation exposure (quantified at 3 – 4 times the radiation exposure compared to

diagnostic invasive angiography) and the use of iodinated contrast can be nephrotoxic for certain

individuals (Patel et al. 2007).

INDICATIONS FOR CCTA:

Computed tomographic angiography (CTA) performed for the evaluation of the heart and coronary

arteries using a 64-slice scanner or greater meets the definition of medical necessity for the

following indications:

Evaluation of chest pain in individuals with an intermediate pre-test probability of coronary

artery disease (CAD) by the American College of Cardiology criteria for pretest probability of

coronary artery disease (CAD) (see Table 1, Reimbursement Information) or the Framingham

_______________________________________________________________



risk scoring for coronary heart disease (CHD) (see Table 2, Reimbursement Information), with

any of the following:

Electrocardiogram (ECG) uninterpretable and contraindications to exercise and

pharmacological stress test; OR

Uninterpretable, inconclusive, or equivocal stress test (e.g., exercise treadmill, stress echo,

nuclear stress test [myocardial perfusion imaging], CTA will be performed in lieu of an

angiography or there is a suspicion that the results are falsely positive.

Evaluation of acute chest pain for Intermediate pre-test probability of coronary artery disease

(see Table 1, Reimbursement Information).

Evaluation of anomalous coronary arteries when conventional angiography is unsuccessful or

equivocal and when the results of CTA will impact treatment.

Assessment of complex congenital heart disease, including, but not limited to anomalies of great

vessels, cardiac chambers and valves.

Evaluation of coronary arteries in members with new onset heart failure to assess etiology.

Evaluation of suspected aortic dissection or thoracic aortic aneurysm.

The following indications meet the definition of medical necessity for new or changing signs or

symptoms:

Evaluation of bypass grafts

Evaluation of coronary anatomy

Evaluation of stent occlusion or in-stent restenosis

Evaluation of coronary anatomy after percutaneous coronary intervention (e.g., angioplasty,

percutaneous transluminal coronary angioplasty [PTCA], balloon angioplasty)

Detection of coronary artery disease post-revascularization procedures (e.g., percutaneous

coronary intervention, coronary artery bypass grafting surgery).

INDICATIONS FOR HEART CT:

Computed tomographic angiography (CTA) of the heart and coronary arteries is considered

experimental or investigational for the following indications, including but not limited to:

Screening for coronary artery disease

Screening asymptomatic members for coronary artery disease

Screening members at low risk for coronary artery disease.

Computed tomography, heart meets the definition of medical necessity for the following indications:

Assessment of complex congenital heart disease (e.g., anomalies of great vessels, cardiac

chambers and valves)

Evaluation of coronary arteries in patients with new onset heart failure to assess etiology

Evaluation of suspected aortic dissection or thoracic aortic aneurysm.

Table 1: Determination of Pretest Probability for Coronary Disease Based on Age, Gender, and

Symptoms (Source: American College of Cardiology Criteria for Pretest Probability of Coronary

Artery Disease (CAD).

The following risk assessment may be used to determine pre-test probability of coronary artery

disease.

_______________________________________________________________



Table 1:

Age

(years)

Gender Typical/Definite

Angina Pectoris

Atypical/Probable

Angina Pectoris

Nonanginal

Chest Pain

Asymptomatic

30 – 39 Men Intermediate Intermediate Low Very low

Women Intermediate Very low Very low Very low

40 – 49 Men High Intermediate Intermediate Low

Women Intermediate Low Very low Very low


Women Intermediate Intermediate Low Very low


Women High Intermediate Intermediate Low

High: Greater than

90% pre-test

probability

Intermediate: Between

10% and 90% pre-test

probability

Low: Between 5% and

10% pre-test

probability

Very low: Less

than 5% pre-test

probability

Angina: As defined by the American College of Cardiology (ACC)/American Heart

Association (AHA)

Typical Angina (Definite): 1.) Substernal chest pain or discomfort that is 2.) Provoked by

exertion or emotional stress and 3.) Relieved by rest and/or nitroglycerine.

Atypical Angina (Probable): Chest pain or discomfort that lacks one of the

characteristics of definite or typical angina.

Non-Anginal Chest Pain: Chest pain or discomfort that meets one or none of the typical

angina characteristics.

Table 2: Framingham Risk Assessment for Coronary Heart Disease (CHD) Risk

Framingham risk assessment is a calculation to predict the 10-year risk of heart disease. The

calculation is based on the individual’s age, sex, most recent lipid values, blood pressure,

smoking history, and presence of diabetes.

Table 2:

CHD Risk Level Framingham Score

CHD Risk-Low Defined by the age-specific

risk level that is below average. In general,

low risk will correlate with a 10-year

absolute CHD risk.

Less than 10%

CHD Risk-Moderate Defined by the age-

specific risk level that is average or above

average.

Between 10% and 20%

CHD Risk-High Defined as the presence of

diabetes mellitus.

Greater than 20%

_______________________________________________________________



TOC

76390 – MR Spectroscopy


INTRODUCTION:

Magnetic resonance spectroscopy (MRS) is a noninvasive technique that can be used to measure the

concentrations of different chemical components within tissues. The technique is based on the same

physical principles as magnetic resonance imaging (MRI) and the detection of energy exchange

between external magnetic fields and specific nuclei within atoms. The information produced by

MRS is displayed graphically as a spectrum with peaks consistent with the various chemicals

detected. MRS may be performed as an adjunct to MRI. An MRI image is first generated, and then

MRS spectra are developed at the site of interest, termed the voxel. While an MRI provides an

anatomic image of the brain, MRS provides a functional image related to underlying dynamic

physiology. The information produced by MRS is used to assist in planning a course of treatment.

MRS can be performed with existing MRI equipment, modified with additional software and

hardware. Multiple software packages for performing proton MRS have received clearance by the

U.S. Food and Drug Administration (FDA) through the 510(k) process.

INDICATION FOR MAGNETIC RESONANCE SPECTROSCOPY (MRS):

Magnetic resonance spectroscopy (MRS) meets the definition of medical necessity when used to:

Differentiate recurrent or residual brain tumor from post-therapy changes (e.g., delayed

radiation necrosis); OR

Differentiate brain tumor from other non-tumor diagnoses (e.g., abscesses or other infectious or

inflammatory processes).

Magnetic resonance spectroscopy (MRS) is considered experimental or investigational, as there is

insufficient clinical evidence data regarding the clinical utility to support the use of MRS for all

other indications, and specifically for the following conditions:

Epilepsy

Alzheimer’s disease

Parkinson’s disease

Multiple sclerosis

Bipolar disorder

Prostate cancer

Diagnosing unexplained chest pain

Detection and monitoring of neurometabolic diseases

Disorders of muscle

Breast lesions.

_______________________________________________________________



TOC

77058 – MRI Breast


INTRODUCTION:

Magnetic resonance imaging (MRI) of the breast is an imaging modality for the detection and

characterization of breast disease, assessment of local extent of disease, evaluation of treatment

response, and guidance for biopsy and localization. MRI findings should be correlated with clinical

history, physical examination results, and findings of other imaging modalities (e.g.,

mammography, ultrasound). Breast MRI should be bilateral except for women with a history of

mastectomy or when the MRI is being performed expressly to further evaluate or follow findings in

one breast. MRI findings should be correlated with clinical history, physical examination results,

and the results of mammography and any other prior breast imaging. MRI of the breast is

performed using MR scanners and intravenous magnetic resonance contrast agents. MRI

examinations should be performed with a dedicated breast MRI coil unless obesity or other patient

consideration requires modification of the imaging procedure.

Magnetic resonance imaging (MRI) of the breast for women meets the definition of medical

necessity for the following indications:

Silicone Implants:

Confirmation of silicone gel-filled breast implant ruptures, when this diagnosis cannot be

confirmed by mammography or breast ultrasound.

For postoperative evaluation of silicone breast implant complications.

No History of Known Breast Cancer

For screening examination to detect breast cancer in any of the following:

A Breast Cancer Risk Assessment (by the Gail risk or other validated breast cancer risk

assessment models) that identifies the member as having a lifetime risk of 20% or greater of

developing breast cancer (approve annually).

Two or more first degree relatives (parents, siblings, and children) with history of breast cancer.

History of chest irradiation (usually as treatment for Hodgkin’s or other lymphoma) annually

starting at age 30.

Known BRCA mutation, annually starting at age 30.

Member not yet tested for BRCA gene, but with known BRCA mutation in first degree relative,

annually starting at age 30.

For evaluation of identified lesion, mass or abnormality in breast for any of the following:

Two or more first degree relatives (parents, siblings, and children) with history of breast cancer.

Evaluation of suspected breast cancer when other imaging examinations, such as ultrasound

and mammography, and physical examination are inconclusive for the presence of breast

cancer, and biopsy could not be performed (e.g. seen only in single view mammogram without

ultrasound correlation).

Previous positive breast biopsy within the previous four (4) months and no previous breast MRI.

Inconclusive mammogram due to breast characteristics limiting the sensitivity of

mammography (e.g., dense breasts, breast implants).

Evaluation of palpable lesion on physical examination not visualized on ultrasound or

mammogram and MRI guided biopsy considered.

Evaluation of axillary node metastasis or adenocarcinoma with normal physical examination

and normal breast mammogram.

_______________________________________________________________



Member diagnosed with biopsy-proven lobular neoplasia or ADH (atypical ductal hyperplasia).

Personal history of or first-degree relative with Le-Fraumeni syndrome (TP53 mutation),

Cowden syndrome (PTEN) or Bannayan-Riley-Ruvalcaba syndrome (BRRS).

History of Known Breast Cancer

For screening examination to detect breast cancer for any of the following:

Known history of breast cancer: Initial staging, with treatment [within three (3) months], and

yearly surveillance for detection of recurrence or a new cancer.

For evaluation of identified lesion, mass or abnormality in breast in any of the following:

Evaluation of breast lesion, identifying whether single or multi-focal, in patient with diagnosed

breast cancer.

Evaluation of suspicious mass, lesion, distortion or abnormality of breast in member with

history of breast cancer.

Pre-operative:

For evaluation for known breast cancer when surgery planned within thirty (30) days.

Evaluation of more than two (2) lesions to optimize surgical planning when requested by

surgeon or primary care provider on behalf of surgeon who has seen the patient.

Computer-Aided Detection (CAD)

No proven indications for use of CAD with MRI of the breast.


Reimbursement for computer=aided detection (0159T) is included in the allowance of the magnetic

resonance imaging breast (77058, and 77059).

Follow-up study




DEFINITIONS:

Bannayan-Riley-Ruvalcaba syndrome: a rare congenital inherited disorder characterized by

excessive growth before and after birth; an abnormally large head (macrocephaly) that is often long

and narrow (scaphocephaly); normal intelligence or mild mental retardation; and/or benign tumor-

like growths (hamartomas) that, in most cases, occur below the surface of the skin

(subcutaneously). The symptoms of this disorder vary greatly from case to case.

Cowden syndrome: (also known as multiple hamartoma syndrome) is a genetic disorder

characterized by the development of multiple benign tumor-like malformations (hamartomas) in

various areas of the body. Affected individuals also have a predisposition to developing certain

cancers, especially cancer of the breast, thyroid or mucous membrane lining the uterus

(endometrium). The specific symptoms of Cowden syndrome vary from case to case.

Li-Fraumeni syndrome (LFS): a familial syndrome of early breast carcinoma associated with soft

tissue sarcomas and other tumors.

_______________________________________________________________



TOC

77084 – MRI Bone Marrow


Magnetic resonance imaging (MRI) of the bone marrow meets the definition of medical necessity for

the following:

For vertebral fractures with suspected bone metastasis

For the diagnosis, staging and follow-up of members with multiple myeloma and related

disorders

_______________________________________________________________



TOC

78451 – Myocardial Perfusion Imaging (Nuc Card)

78472 – MUGA Scan


Myocardial perfusion imaging (MPI) and cardiac blood pool imaging meets the definition of medical


Evaluation for Suspected Coronary Artery Disease (CAD) /Asymptomatic: Without Ischemic

Equivalent

Testing is medically necessary when any one of the following conditions is met:

For the detection of asymptomatic CAD (without ischemic equivalent)

o High coronary heart disease (CHD) risk (Adult Treatment Panel (ATP) III Risk Criteria,

see Table 2 and Framingham Risk Factors, see Table 3)

o Intermediate CHD risk (ATP III risk criteria (see Table 2) or Framingham Risk Factors

(see Table 3)), and an uninterpretable electrocardiogram (ECG) (defined as an ECG with

resting ST-segment depression (greater than 0.10V), complete left bundle-branch block

(LLB), pre-excitation Wolff-Parkinson-White syndrome (WPW) or paced rhythm)

Physical limitation prohibiting exercise treadmill testing due to any one of the following:

o Contraindications (e.g., morbid obesity [body mass index (BMI) greater than 40]),

o Inability to ambulate one block due to dyspnea/emphysema,

o Orthopedic conditions that restricts ambulation more than one block)

Known regional wall motion abnormalities noted on prior studies (e.g., echocardiography,

ultrasound, myocardial perfusion imaging (MPI), multi-gated acquisition (MUGA))

New onset or newly diagnosed heart failure with left ventricular (LV) systolic dysfunction

without ischemic equivalent and no prior CAD evaluation and no planned coronary angiography

New onset atrial fibrillation (part of evaluation when etiology is unclear)

Ventricular tachycardia, regardless of level of CHD risk

Syncope and either one of the following:

o Intermediate CHD risk

o High CHD risk

Troponin elevation without additional evidence of acute coronary syndrome (ACS) (clinical

presentation of ACS may include: unstable angina, myocardial infarction with ST-segment

elevation (NSTEMI) and myocardial infarction with ST-segment elevation (STEMI))

Detection of Coronary Artery Disease (CAD)/Risk Assessment Symptomatic: Evaluation of Ischemic

Equivalent (Non-Acute)

Low pre-test probability of CAD (Determination of pretest probability for CAD, see Table 1), and

an uninterpretable electrocardiogram (ECG) (defined as an ECG with resting ST-segment

depression (greater than 0.10V), complete left bundle-branch block (LLB), pre-excitation Wolff-

Parkinson-White syndrome (WPW) or paced rhythm)

Low pre-test probability of CAD (Determination of pretest probability for CAD, see Table 1), and

unable to exercise

http://mcgs.bcbsfl.com/index.cfm?fuseaction=main.main&stage=pub&format=cfm&doc=Cardiac%20Nuclear%20Imaging#P247_14660






_______________________________________________________________



Intermediate pre-test probability of CAD, and an uninterpretable electrocardiogram (ECG)

(defined as an ECG with resting ST-segment depression (greater than 0.10V), complete left

bundle-branch block (LLB), pre-excitation Wolff-Parkinson-White syndrome (WPW) or paced

rhythm)

Intermediate pre-test probability of CAD and unable to exercise

High pre-test probability of CAD

Evaluation for Known Coronary Artery Disease (CAD) with New or Changing Symptoms

Evaluation of known coronary artery disease with new or changing cardiac symptoms and one of

the following:

o Abnormal prior coronary angiography

o Abnormal prior stress imaging study

Evaluation for Known Coronary Artery Disease (CAD) with Asymptomatic OR with No New or

Changing Symptoms. The test may be medically necessary if any one of the following conditions is

met:

Intermediate to high CHD risk (ATP III risk criteria, see Table 2 and Framingham Risk

Factors, see Table 3), and last cardiac stress imaging study done more than or equal to 3 years

ago

Equivocal, borderline or discordant stress testing where obstructive CAD remains a concern,

and last cardiac stress imaging study done more than or equal to 3 years ago

Intermediate Duke treadmill score, see Table 4

High risk Duke treadmill score, see Table 4

Risk Assessment: Preoperative Evaluation of Noncardiac Surgery without Active Cardiac

Conditions:

Intermediate risk surgery and when all of the following criteria are met:

Greater than or equal to 1 clinical risk factor (Framingham) AND

Poor or unknown functional capacity (less than 4 estimated metabolic equivalent of exercise

(METS))

Vascular surgery and when all of the following criteria are met:

Greater than or equal to 1 clinical risk factor (Framingham)

Poor or unknown functional capacity (less than 4 METS)

Risk Assessment: Within 3 months of an Acute Coronary Syndrome

Member who has had a ST-elevation myocardial infarction (STEMI) and when all of the following

criteria are met:

Hemodynamically stable, no recurrent chest pain syndrome or no signs of heart failure (HF)

The test will be used to evaluate for inducible ischemia

No prior coronary angiography





_______________________________________________________________



Member who has Non ST-elevation myocardial infarction (NSTEMI) and when all of the following

criteria are met:

Normal exercise tolerance (greater than or equal to 4 METS)

Hemodynamically stable with no recurrent chest pain or no signs of Heart Failure

The test will be used to evaluate for inducible ischemia

No prior coronary angiography

Other

Evaluation of known or suspected congenital coronary anomalies

Patient scheduled to receive or receiving chemotherapeutic drugs (nuclear cardiac imaging/MPI

performed before or after treatment)

Risk Assessment: Post Revascularization (Percutaneous Transluminal Coronary Angioplasty

(PTCA) or Coronary Artery bypass Graft (CABG)

Evaluation of ischemic equivalent (symptomatic)

Incomplete revascularization (asymptomatic) and additional revascularization feasible

Prior CABG with no myocardial perfusion imaging (MPI) for 2 years or more unless most recent

MPI showed reversible ischemia (asymptomatic)

Greater than or equal to 2 years after percutaneous coronary intervention (PCI) (asymptomatic)

Assessment of Viability/Ischemia-Ischemic Cardiomyopathy/Assessment of Viability and both of the

following criteria are met:

Known severe left ventricular (LV) dysfunction AND

Patient eligible for revascularization

Multi-Gated Acquisition (MUGA)/Gated Wall Motion Study (Cardiac Blood Pool Imaging)

Primary Indications for MUGA

In chemotherapy patients: Evaluation of heart function before treatment and monitoring of

cardiotoxic effects during and after chemotherapy

Evaluation of ejection fraction in patients with congestive heart failure (CHF)

Evaluation of coronary artery disease in obese patients who has chronic obstructive pulmonary

disease (COPD)

Establishment of a quantitative measure of left ventricular ejection fraction (LVEF); in cases

where the resulting patient therapy, such as automatic implantable cardioverter defibrillator

(AICD) is contingent on the test outcome or exact number

Evaluation of ventricular function when an echocardiogram is not feasible due to physical

limitations

The following indications for MUGA meets the definition of medical necessity when other imaging

modalities (e.g., echocardiogram, heart PET) cannot be obtained or are equivocal.

_______________________________________________________________



Evaluation of valvular heart disease: Initial assessment of left ventricular (LV) and right

ventricular (RV) function. Routine serial (every other year) assessment of left ventricular (LV)

and right ventricular (RV) function

Evaluation of congenital heart disease

o Shunt detection and quantification

o Initial assessment of LV and RV function

o Routine serial (every other year assessment of LV and RV function

Assessment of myocardial viability

Heart failure: Functional assessment

o Initial assessment of LV and RV function at rest and with exercise

o Routine serial (every other year) assessment of LV and RV function

Determination of Pretest Probability for Coronary Artery Disease (CAD)

Table 1: Determination of Pretest Probability for Coronary Artery Disease Based on Age, Gender,

and Symptoms (Source: American College of Cardiology Criteria for Pretest Probability of Coronary

Artery Disease (CAD).

The following risk assessment may be used to determine pre-test probability of coronary artery

disease.

Table 1:

Age

(years)

Gender Typical/Definite

Angina Pectoris

Atypical/Probable

Angina Pectoris

Nonanginal

Chest Pain

Asymptomatic

30 – 39 Men Intermediate Intermediate Low Very low

Women Intermediate Very low Very low Very low


Women Intermediate Low Very low Very low


Women Intermediate Intermediate Low Very low


Women High Intermediate Intermediate Low

High: Greater than

90% pre-test

probability of CAD

Intermediate:

Between 10% and

90% pre-test

probability of CAD

Low: Between 5%

and 10% pre-test

probability of CAD

Very low: Less than 5% pre-

test probability of CAD

Angina: As defined by the American College of Cardiology (ACC)/American Heart Association

(AHA)

Typical Angina (Definite): 1.) Substernal chest pain or discomfort that is 2.) Provoked by

exertion or emotional stress and 3.) Relieved by rest and/or nitroglycerine.

Atypical Angina (Probable): Chest pain or discomfort that lacks one of the characteristics of

definite or typical angina.

_______________________________________________________________



Non-Anginal Chest Pain: Chest pain or discomfort that meets one or none of the typical

angina characteristics.

Adult Treatment Panel III (ATP III)

Table 2: Adult Treatment Panel III (ATP III)

The National Heart, Lung and Blood Institute report on Detection, Evaluation and Treatment of

High Blood Cholesterol in Adults (Adult Treatment Panel III (ATP III)

Coronary heart disease (CHD) risk is based on the American College of Cardiology (ACC)/American

Heart Association (AHA) Scientific Statement on Cardiovascular Risk Assessment. Absolute risk is

defined as the probability of developing CHD, including myocardial infarction or CHD death over a

given time period. The ATP III report specifies absolute risk for coronary heart disease (CHD) over

the next 10 years. CHD risk refers to 10-year risk for any hard cardiac event.

Table 2:

Coronary Heart Disease (CHD) Risk

Low Defined by the age-specific risk level that is below average. In general, low risk will

correlate with a 10-year absolute CHD risk less than 10%.

Moderate Defined by the age-specific risk level that is average or above average. In general,

moderate risk will correlate with a 10-year absolute CHD risk between 10% and

20%.

High Defined as the presence of diabetes mellitus in a patient 40 years of age or older,

peripheral arterial disease or other coronary risk equivalents or a 10-year absolute

CHD risk of greater than 20%.

Framingham Risk Factors

Table 3: Framingham Risk Factors

Patient is considered to be at:

High risk for CAD if they have three (3) of the

following risk factors;

Intermediate risk for CAD if they have two

(2) of the following risk factors

Low risk for CAD if they have zero (0) to one

(1) of the following risk factors:

Age 55 and/or older

Diabetic

Hypertension

Active history of smoking

History of low-density lipoprotein

(LDL) cholesterol greater than 130

History of high-density lipoprotein

(HDL) cholesterol less than 35

Obesity with body mass index (BMI)

greater than 30

Family history of premature or early

onset of CAD:

Father below age 55

Mother below age 65

_______________________________________________________________



Duke Treadmill Score (DTS)

Table 4: Duke Treadmill Score (DTS)

The equation for calculating the Duke treadmill score (DTS) is, DTS= exercise time–(5 X ST

deviation)-(4X exercise angina), with 0= none, 1=non-limiting and 2=exercise limiting.

The score typically ranges from -25 to +15. These values correspond to low-risk (with a score

of greater or equal to+5), moderate-risk (with scores ranging from -10 to +4) and high-risk

(with a score of less than or equal to 11) categories.


Reimbursement for myocardial perfusion imaging (78451, 78452, 78453, 78454, 78466, 78468, and

76469) and cardiac blood pool imaging (78472, 78473, 78481, 78483, 78494, and 78496) is limited to

two (2) of each type of study in a 6-month period. Services in excess of two (2) of each type of study

in a 6-month period are subject to medical review of documentation to support medical necessity.



recommendation.

Re-imaging due to technically limited exam is the responsibility of the imaging provider.

_______________________________________________________________



TOC

78459 – PET Scan, Heart (Cardiac)


INTRODUCTION:

Positron emission tomography (PET) scans are based on the use of positron emitting radionuclide

tracers, which simultaneously emit 2 high energy photons in opposite directions. These photons can

be simultaneously detected (referred to as coincidence detection) by a PET scanner, consisting of

multiple stationary detectors that encircle the thorax. Compared to SPECT scans (single photon

emission computed tomography), coincidence detection offers greater spatial resolution.

A variety of radiopharmaceuticals (tracers, radiotracers) are used for PET scanning, (e.g., e.g.,

ammonia N-13, Fluorodeoxyglucose F-18 FDG, Rubidium Rb-82). Because of their short half-life,

radiopharmaceuticals must be made locally. With the exception of fluorine and rubidium,

radiopharmaceuticals must be manufactured with an on-site cyclotron. The radiopharmaceutical

may be coupled to a variety of physiologically active molecules. For example, fluorine-18 is often

coupled with fluorodeoxyglucose as a means of detecting glucose metabolism, which in turn reflects

the metabolic activity, and thus viability, of the target tissue.

In terms of cardiac applications, PET scanning has focused on the following clinical situations:

myocardial perfusion scanning as a technique of identifying perfusion defects, which in turn reflect

coronary artery disease; and assessment of myocardial viability in patients with left ventricular

dysfunction as a technique to determine candidacy for a revascularization procedure.

INDICATIONS FOR MYOCARDIAL PERFUSION PET IMAGING:

Myocardial perfusion PET imaging may be considered when a member has undergone prior

nuclear stress testing (e.g., thallium stress test) or stress echocardiography with equivocal

results.

Myocardial perfusion PET imaging is performed in lieu of, but not in addition to a single

photon emission computed tomography (SPECT).

In extreme obese members (*BMI > 40kg/m2) or silicone breast implants, myocardial

perfusion PET imaging may be considered as the initial test (because of a higher likelihood

of technically suboptimal image quality on nuclear stress testing and stress

echocardiography in this population). As defined by the National Heart Lung and Blood

Institute Classification of Overweight and Obesity by BMI.

http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf

Myocardial perfusion PET imaging (rest and or stress) meets the definition of medically necessity

for the following indications for:

Members who are at least 65 years old or

Have a body mass index (BMI) greater than 40 or

Have other conditions for which a SPECT may have attenuation problems because of the

likelihood of technically suboptimal image quality on nuclear stress testing and stress

echocardiography in this member population (e.g., large breasts, left mastectomy, breast

http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf

_______________________________________________________________



implant, chest wall deformity) and when the results are expected to influence the clinical

management of the member for any of the following conditions:

o Evaluation of symptoms (such as chest discomfort, shortness of breath, palpitations,

dizziness) consistent with myocardial ischemia to diagnose or exclude coronary artery

disease.

o Coronary artery disease with recurrent atypical symptoms (such as chest pain

(atypical or typical), angina, shortness of breath).

o Evaluation of regional myocardial blood flow in the member with multiple vessel

coronary artery disease for identification of a lesion for revascularization (e.g.,

coronary artery bypass graft surgery (CABG), percutaneous transluminal coronary

angioplasty (PTCA)).

o Evaluation of asymptomatic members with the presence of intermediate risk factors

or high risk factors for coronary artery disease. (**see table with coronary artery disease risk factors/clinical predictors section)

o Evaluation of members who have had an equivocal nuclear stress test or stress

echocardiography within the past 60 days.

Myocardial perfusion PET imaging (rest and or stress) does not meet the definition of medical

necessity for screening for coronary artery disease.

INDICATIONS FOR METABOLIC PET IMAGING:

For the evaluation of myocardial viability when ALL of the following conditions are met and

when the results are expected to influence the clinical management of the member.

o Has established (known) coronary artery disease; AND

o Has left ventricular systolic dysfunction; AND

o The myocardial viability status is not defined by other cardiac nuclear imaging studies;

AND

o Coronary revascularization is being considered.

Myocardial metabolic PET imaging does not meet the definition of medical necessity for

screening for coronary artery disease.

**American College of Cardiology (ACC) and American Heart Association (AHA) (2002)

defines coronary artery disease risk factors/clinical predictors as:

High risk factors/Major

clinical predictors

unstable coronary syndromes, decompensated congestive

heart failure (CHF), significant arrhythmias, severe

valvular disease

Intermediate risk

factors/Intermediate

clinical predictors

mild angina pectoris, prior myocardial infarction (MI),

compensated or prior CHF, diabetes mellitus, renal

insufficiency

Low risk factors/minor

clinical predictors

advanced age, abnormal electrocardiogram (ECG),

rhythm other than sinus, low functional capacity, history

stroke, uncontrolled systemic hypertension

DEFINITIONS:

Asymptomatic: showing or causing no symptoms.

_______________________________________________________________



Attenuation: attenuation is the decrease in intensity of a photon signal along its path to the

detector. During nuclear cardiac imaging, non-uniform attenuation occurs as photons pass through

tissues of varying densities, such as the subdiaphragmatic tissues, chest wall, spine, and breasts.

This results in an attenuation artifact whose extent varies with location of soft tissue, overall

patient body size, and depth of target organ (heart).

Attenuation artifact: attenuation artifact leads to loss of diagnostic accuracy as artifacts may be

confused with true perfusion abnormalities, resulting in an increase in false-positives.

Equivocal: of uncertain nature or classification.

Habitus: posture or position of the body. Physique; body build and constitution.

Myocardial metabolic PET imaging: the cardiac muscle is imaged using data received from

positron-emitting radionuclides administered to the patient. The collision of the positrons emitted

by the radionuclide with the negatively charged electrons normally present in tissue is then

computer synthesized to produce an image, usually in color. This image will show the presence or

absence of ischemic cardiac tissue.

Myocardial perfusion PET imaging: imaging of the cardiac muscle is performed using data received

from positron-emitting radionuclides administered to the patient. Collision of the positrons emitted

by the radionuclide with the negatively charged electrons normally present in tissue is then

computer synthesized to produce an image, usually in color. The procedure may be performed at

rest or stress.

Symptomatic: indicative (of a particular disease or disorder).


Documentation containing the medical necessity of the myocardial perfusion PET imaging and

myocardial metabolic PET imaging, imaging results (e.g., images, clinical reports) should be


process.

Reimbursement Information:

PET scans are performed using a camera that has either been approved or cleared for marketing by

the Food and Drug Administration (FDA) to image positron annihilation gamma photons in the

body.

PET scans are performed using FDA approved or radiopharmaceutical (tracer, radiotracer) (e.g.,

ammonia N-13, Fluorodeoxyglucose F-18 FDG, Rubidium Rb-82). The radiopharmaceutical may

be manufactured on site, or manufactured at a regional delivery center with delivery to the

institution performing the PET scan. When the radiopharmaceutical is provided by an outside

distribution center, there may be a separate charge for both the radiopharmaceutical and

transportation of the radiopharmaceutical.

_______________________________________________________________



TOC

78608 – PET Scan, Brain


INTRODUCTION:

Positron emission tomography (PET) is an imaging technique that uses radioactive substances

injected into individuals to provide images of the body using specialized scanners. These PET

images provide information about the function and metabolism of the body’s organs, in contrast to

computed tomography (CT) or magnetic resonance imaging (MRI), which show the body’s anatomy

and structure.

INDICATIONS FOR BRAIN PET SCAN:

Brain tumor or cancer:

Positron emission tomography (PET) using 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) meets

the definition of medical necessity for the following:

Evaluation of known brain tumor or cancer with new signs or symptoms indicative of a

reoccurrence of cancer.

Follow-up of brain tumor after surgery

Follow-up of brain tumor after treatment (radiation therapy or chemotherapy)

Epileptic Seizures:


the definition of medical necessity in the assessment of individuals with epileptic seizures who are

candidates for surgery (pre-surgical evaluation) and who meet ALL of the following criteria:

Complex partial seizures have failed to respond to medical therapy; AND

Who have been advised to have a resection of a suspected epileptogenic focus located in a region

of the brain accessible to surgery; AND

Conventional techniques (e.g., electroencephalography (EEG)) for seizure localization must have

been tried and provided data that suggested a seizure focus, but were not conclusive to permit

surgery.

Post-operative/procedural evaluation (brain PET imaging):

A follow-up study may be needed to help evaluate of a member’s progress after treatment,


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

Dementia:


the definition of medical necessity in the evaluation of dementia when ALL of the following criteria

have been met (medical records, including the date of onset of symptoms may be required to be

submitted to the health plan for review):

1. The member has a recent diagnosis of dementia or fronto-temporal dementia (FTD) AND

documented cognitive decline of at least six months and

2. The member has a change in mental status and has had more than one assessment of

mental status, documented by neuro-diagnostic testing, such as:

_______________________________________________________________



o Mini-mental status exam (MMSE) or Montreal Cognitive Assessment (MoCA,

Mini-Cog) score of less than 26 or similar mental status exam showing at least

mild cognitive impairment:

o Electroencephalogram (EEG) and long-term EEG monitoring

o Transcranial Dopplers studies

o Evoked potentials

o Intraoperative neurophysiological monitoring

o AND

o Metabolic workup (e.g., thyroid function testing, liver function testing, complete

blood count) for treatable causes; AND

o Appropriate medication restriction or reduction to test for reversibility

INDICATIONS FOR PET MISCELLANEOUS APPLICATIONS:

Chronic Osteomyelitis


the definition of medical necessity in the diagnosis of chronic osteomyelitis if the diagnosis cannot

be determined by a bone scan.

OTHER INDICATIONS:

The use of PET imaging for ALL other miscellaneous indications is considered experimental or

investigational, including, but not limited to the following. There is insufficient evidence to

determine the role of PET imaging for all other indications including screening.

Central Nervous System (CNS) Diseases

Alzheimer’s disease

Autoimmune disorders with CNS manifestations, including:

o Behcet’s syndrome

o Lupus erythematosus

Cerebrovascular diseases, including:

o Arterial occlusive disease (arteriosclerosis, atherosclerosis)

o Carotid artery disease

o Cerebral aneurysm

o Cerebrovascular malformations (AVM and Moya Moya disease)

o Hemorrhage

o Infarct

o Ischemia

Degenerative motor neuron diseases, including:

o Amyotrophic lateral sclerosis

o Friedreich’s ataxia

o Olivopontocerebellar atrophy

o Parkinson’s disease

o Progressive supranuclear palsy

o Shy-Drager syndrome

o Spinocerebellar degeneration

o Steele-Richardson-Ollszewski disease

o Tourette’s syndrome

Demyelinating diseases, such as multiple sclerosis

Developmental, congenital, or inherited disorders, including:

_______________________________________________________________



o Adrenoleukodystrophy

o Down’s syndrome

o Huntington’s chorea

o Kinky-hair disease (Menkes’ syndrome)

o Sturge-Weber syndrome (encephalofacial angiomatosis) and the phakomatoses

Nutritional or metabolic diseases and disorders, including:

o Acanthocytes

o Hepatic encephalopathy

o Hepatolenticular degeneration

o Metachromatic leukodystrophy

o Mitochondrial disease

o Subacute necrotizing encephalomyelopathy

Psychiatric diseases and disorders, including:

o Affective disorders

o Depression

o Obsessive-compulsive disorder

o Psychomotor disorders

o Schizophrenia

Pyogenic infections, including:

o Aspergillosis

o Encephalitis

Substance abuse, including the CNS effects of alcohol, cocaine, and heroin

Trauma, including brain injury and carbon monoxide poisoning

Viral infections, including:

o Acquired immune deficiency syndrome (AIDS)

o AIDS dementia complex

o Creutzfeldt-Jakob syndrome

o Progressive multifocal leukoencephalopathy

o Progressive rubella encephalopathy

o Subacute sclerosing panencephalitis

Pulmonary diseases

o Adult respiratory distress syndrome

o Diffuse panbronchiolitis

o Emphysema

o Obstructive lung disease

o Pneumonia

Musculoskeletal diseases

o Spondylodiscitis

o Joint replacement follow-up

Other

o Anorexia nervosa

o Cerebral blood flow in newborns

o Chronic fatigue syndrome

o Giant cell arteritis

o Inflammatory bowel disease

o Migraine

o Mycobacterium infection

o Post-traumatic stress disorder

o Sick building syndrome

o Vegetative versus “locked-in” state

_______________________________________________________________



o Vasculitis

Definitions:

Acquired immune deficiency syndrome (AIDS): An epidemic, transmissible retroviral disease due to

infection with human immunodeficiency virus (HIV), which attacks the subset of T lymphocytes

known as the CD4 cells or CD4+ T lymphocytes.

Adrenoleukodystrophy: An X-linked recessive disease of childhood, closely related to Schilder

disease, marked by diffuse abnormality of the cerebral white matter and adrenal atrophy and

characterized by mental deterioration progressing to dementia, with aphasia, apraxia, dysarthria,

and loss of vision in about a third of the patients. Almost all show abnormal adrenal functioning

when tested.

Adult respiratory distress syndrome: Fulminant pulmonary interstitial and alveolar edema; also

called acute respiratory distress syndrome.

Affective disorder: Mental disorders whose essential feature is a disturbance of mood manifested as

one or more episodes of mania, hypomania, depression, or some combination.

AIDS dementia complex: A progressive primary encephalopathy caused by infection with human

immunodeficiency virus type 1; it involves principally the subcortical white matter and deep gray

nuclei and is manifested by a variety of cognitive, motor, and behavioral abnormalities; called also

AIDS dementia complex, AIDS e., HIV encephalitis, HIV encephalopathy, and HIV-related

encephalopathy.

Alzheimer’s disease: A progressive central neurodegenerative disorder.

Amyotrophic lateral sclerosis: A motor neuron disease marked by progressive degeneration of the

neurons that give rise to the corticospinal tract and of the motor cells of the brain stem and spinal

cord, resulting in a deficit of upper and lower motor neurons; it usually ends fatally within two to

three years.

Anorexia nervosa: An eating disorder primarily affecting females, usually with onset in

adolescence, characterized by refusal to maintain a normal minimal body weight, intense fear of

gaining weight or becoming obese, and a disturbance of body image resulting in a feeling of being

fat or having fat in certain areas even when extremely emaciated, undue reliance on body weight or

shape for self-evaluation, and amenorrhea.

Aspergillosis: Infection of humans or other animals by species of Aspergillus, marked by

inflammatory granulomatous lesions in the skin, ear, orbit, nasal sinuses, lungs, and sometimes the

bones and meninges.

Behcet syndrome: A variant of neutrophilic dermatosis of unknown etiology, involving the small

blood vessels, characterized by recurrent aphthous ulceration of oral and pharyngeal mucous

membranes and genitalia, with skin lesions, severe uveitis, retinal vasculitis, optic atrophy, and

often involvement of the joints, gastrointestinal system, and central nervous system.

Chronic fatigue syndrome: Persistent debilitating fatigue lasting longer than six months, with other

known medical conditions having been ruled out by clinical diagnosis, accompanied by at least four

_______________________________________________________________



of the following: significantly impaired short-term memory or concentration, muscle weakness, pain

in multiple joints without swelling or redness, sore throat, tender lymph nodes, headaches,

unrefreshing sleep, and malaise that lasts more than 24 hours following exertion.

Creutzfeldt-Jakob syndrome: A rare, degenerative, invariably fatal brain disorder.

Dementia with Lewy-Bodies: A general loss of cognitive abilities, including impairment of memory

as well as one or more of the following: aphasia, apraxia, agnosia, or disturbed planning,

organizing, and abstract thinking abilities with concentrically laminated, round bodies found in

vacuoles in the cytoplasm of some neurons of the midbrain in Parkinson disease.

Depression: A mental state of depressed mood characterized by feelings of sadness, despair, and

discouragement.

Diffuse panbronchiolitis: A chronic type of infectious inflammation of the airways limited to the

bronchioles, seen mainly in East Asia and nearby island countries.

Down’s syndrome: A chromosome disorder characterized by a small, anteroposteriorly flattened

skull, short, flat-bridge nose, epicanthal fold, short phalanges, widened spaces between the first and

second digits of hands and feet, and moderate to severe mental retardation, with Alzheimer disease

developing in the fourth or fifth decade.

Emphysema: Pathological accumulation of air in tissues or organs.

Encephalitis: Inflammation of the brain.

Epilepsy: Any of a group of syndromes characterized by paroxysmal transient disturbances of the

brain function that may be manifested as episodic impairment or loss of consciousness, abnormal

motor phenomena, psychic or sensory disturbances, or perturbation of the autonomic nervous

system.

Friedreich’s ataxia: An autosomal recessive disorder, usually beginning before adolescence, with

sclerosis of the posterior and lateral columns of the spinal cord. It is attended by ataxia, speech

impairment, lateral curvature of the spinal column, and peculiar swaying and irregular

movements, with paralysis of the muscles, especially of the lower limbs, and a high-arched foot. It is

often associated with hypertrophic cardiomyopathy.

Frontotemporal dementia: Any of several degenerative conditions of the frontal and anterior

temporal lobes that cause personality and behavioral changes; they may eventually progress to

immobility and loss of speech.

Giant cell arteritis: A chronic vascular disease in the elderly, of unknown origin, often associated

with polymyalgia rheumatica, seen usually in the external carotid arteries but sometimes in other

arteries. Characteristics include proliferative inflammation, often with giant cells and granulomas;

headache, pain with chewing; weight loss; fever; sometimes ocular symptoms; and increased

erythrocyte sedimentation rate.

Hepatic encephalopathy: A condition usually seen secondary to advanced disease of the liver but

also seen with other severe diseases and in patients with portacaval shunts. It is marked by

_______________________________________________________________



disturbances of consciousness that may progress to deep coma (hepatic coma), psychiatric changes

of varying degree, flapping tremor, and fetor hepaticus.

Hepatolenticular degeneration: A rare, progressive, autosomal recessive disease due to a defect in

metabolism of copper.

Huntington’s chorea: A disorder characterized by chronic progressive chorea and mental

deterioration terminating in dementia; the age of onset is variable but usually in the fourth decade

of life, with death within 15 years.

Kinky-hair disease: Hereditary, X-linked recessive abnormality in copper absorption; the resultant

copper poisoning causes symptoms such as sparse, brittle, twisted scalp hair, severe cerebral

degeneration, and arterial changes with death in infancy.

Lupus erythematosus: A group of connective tissue disorders primarily affecting women aged 20 to

40 years, comprising a spectrum of clinical forms in which cutaneous disease may occur with or

without systemic involvement.

Metachromatic leukodystrophy: An autosomal recessive disorder due to deficiency of cerebroside-

sulfatase or saposin B, characterized by accumulation of sulfatide in neural and nonneural tissues,

with a diffuse loss of myelin in the central nervous system. There are three forms due to deficiency

of cerebroside sulfatase, with variable age of onset, all initially presenting as mental regression and

motor disturbances (infantile, juvenile, adult). The infantile form usually begins in the second year

of life and is additionally characterized by developmental delay, seizures, optic atrophy, ataxia,

weakness, loss of speech, and progressive spastic quadriparesis. The juvenile form is clinically

similar, but presents between the ages of 4 and 12 years and progresses more slowly; a variant of

the juvenile form is caused by deficiency of saposin B. The adult form begins after 16 years of age,

generally presenting initially as dementia and disturbances in behavior and progressing more

slowly to motor and posture disturbances.

Migraine: A symptom complex of periodic attacks of vascular headache, usually temporal and

unilateral in onset, commonly associated with irritability, nausea, vomiting, constipation or

diarrhea, and often photophobia.

Multi-infarct dementia: Dementia with a stepwise deteriorating course (a series of small strokes)

and a patchy distribution of neurologic deficits (affecting some functions and not others) caused by

cerebrovascular disease. It may be classified as uncomplicated or as occurring with delusions,

delirium, or depressed mood; called also vascular dementia.

Obsessive-compulsive disorder: An anxiety disorder characterized by recurrent obsessions or

compulsions, which are severe enough to interfere significantly with personal or social functioning.

Obstructive lung disease: Is a category of respiratory disease characterized by airway obstruction.

Olivopontocerebellar atrophy: Any of a group of progressive hereditary disorders involving

degeneration of the cerebellar cortex, middle peduncles, ventral pontine surface, and olivary nuclei.

They occur in the young to middle-aged and are characterized by ataxia, dysarthria, and tremors

similar to those of parkinsonism.

_______________________________________________________________



Pick’s disease: Rare progressive degenerative disease of the brain, similar in clinical manifestations

and course to Alzheimer disease but having a distinctive histopathology; cortical atrophy is confined

to the frontal and temporal lobes; degenerating neurons contain globular intracytoplasmic

filamentous inclusions (Pick bodies).

Parkinson’s disease: A slowly progressive disease (usually occurring in late life) characterized by

masklike facies, resting tremor, slowing of voluntary movements, festinating gait, peculiar posture,

and muscle weakness, sometimes with excessive sweating and feelings of heat. Pathologically, there

is neurodegeneration within the nuclear masses of the extrapyramidal system and loss of melanin-

containing cells from the substantia nigra and a corresponding reduction in dopamine levels in the

corpus striatum.

Pneumonia: Inflammation of the lungs with consolidation.

Post-traumatic stress syndrome: An anxiety disorder caused by exposure to an intensely traumatic

event; characterized by re-experiencing the traumatic event in recurrent intrusive recollections,

nightmares, or flashbacks, by avoidance of trauma-associated stimuli, by generalized numbing of

emotional responsiveness, and by hyper-alertness and difficulty in sleeping, remembering, or

concentrating.

Presenile dementia: Usually occurs in persons age 65 or younger; since most cases are due to

Alzheimer disease, the term is sometimes used as a synonym of dementia of the Alzheimer type,

early onset, and has also been used to denote Alzheimer’s disease.

Progressive multifocal leukoencephalopathy: An opportunistic infection of the central nervous

system by the JC virus, seen in immunocompromised persons and sometimes secondary to

neoplastic conditions such as lymphosarcoma, lymphoblastic leukemia, or myelogenous leukemia.

Progressive supranuclear palsy: A progressive neurological disorder, having onset during the sixth

decade, characterized by supranuclear ophthalmoplegia, especially paralysis of the downward gaze,

pseudobulbar paralysis, dysarthria, dystonic rigidity of the neck and trunk, and dementia; also

called Steele-Richardson-Olszewski syndrome.

Psychomotor disorder: Pertaining to motor effects of cerebral or psychic activity.

Schizophrenia: A mental disorder or heterogeneous group of disorders (the schizophrenias or

schizophrenic disorders) comprising most major psychotic disorders and characterized by

disturbances in form and content of thought (loosening of associations, delusions, and

hallucinations), mood (blunted, flattened, or inappropriate affect), sense of self and relationship to

the external world (loss of ego boundaries, dereistic thinking, and autistic withdrawal), and

behavior (bizarre, apparently purposeless, and stereotyped activity or inactivity).

Shy-Drager syndrome: A progressive disorder of unknown etiology that begins with symptoms of

autonomic insufficiency including orthostatic hypotension, impotence in males, constipation,

urinary urgency or retention, and anhidrosis; these are followed by signs of generalized neurologic

dysfunction such as parkinsonian-like disturbances, cerebellar incoordination, muscle wasting and

fasciculations, and coarse tremors of the legs.

Sick building syndrome: This term is used to describe situations in which building occupants

experience acute health and comfort effects that appear to be linked to time spent in a building, but

_______________________________________________________________



no specific illness or cause can be identified. The complaints may be localized in a particular room

or zone, or may be widespread throughout the building.

Spinocerebellar degeneration: Pertaining to the spinal cord and the cerebellum.

Spondylodiscitis: An inflammation of the base and upper plates of the vertebra as well as the

adjoining intervertebral disc and is frequently accompanied by spondylitis (inflammation of the

vertebral body).

Steele-Richardson-Olszewski syndrome: See progressive supranuclear palsy.

Sturge-Weber syndrome: A congenital syndrome of unknown etiology consisting of a port-wine stain

distributed over the trigeminal nerve, usually unilaterally, with a similar vascular disorder of

underlying meninges and cerebral cortex.

Subacute necrotizing encephalomyelopathy: A type of encephalopathy of unclear clinical and

pathological criteria, causing neuro-pathologic damage. It occurs in two forms (infantile, adult). The

infantile form is characterized by degeneration of gray matter with necrosis and capillary

proliferation in the brain stem; hypotonia, seizures, and dementia; anorexia and vomiting; slow or

arrested development; and ocular and respiratory disorders, with death usually before age 3. The

adult form usually first manifests as bilateral optic atrophy with central scotoma and

colorblindness, followed by a quiescent period of up to 30 years and then late symptoms such as

ataxia, spastic paresis, clonic jerks, grand mal seizures, psychic lability, and mild dementia.

Subacute sclerosing panencephalitis: A rare and devastating form of leukoencephalitis usually

affecting children and adolescents. Insidious in onset, it characteristically produces progressive

cerebral dysfunction over several weeks or months and death within a year.

Tourette’s syndrome: A syndrome comprising both multiple motor and one or more vocal tics,

occurring over a period of at least one year, at least intermittently but sometimes as frequently as

many times daily. Obsessions, compulsions, hyperactivity, distractibility, and impulsivity are often

associated. Onset is in childhood and tics often lessen in severity and frequency and may even remit

during adolescence and adulthood.

Vasculitis: Inflammation of a blood or lymph vessel.

Vegetative versus “locked-in” state: A condition of profound non-responsiveness in the wakeful state

caused by brain damage. Locked-in state is a condition in which a patient is aware and awake but

cannot move or communicate verballydue to complete paralysis of nearly all voluntary muscles in

the body except for the eyes.

_______________________________________________________________



TOC

78813 – PET Scan


INTRODUCTION:

Positron emission tomography (PET), also known as PET imaging, PET scan, positron emission

transverse tomography (PETT), or positron emission coincident imaging (PECI), is a noninvasive

diagnostic imaging procedure that assesses the level of metabolic activity and perfusion in various

organ systems of the human body. Images are obtained from positron emitting radioactive tracer

substances (radiopharmaceuticals). A variety of radiotracers are used for PET imaging, including

oxygen-15, nitrogen-13, carbon-11, and fluorine-18. Because of their short half-life, some tracers

must be made locally using an onsite cyclotron. The radiotracer most commonly used in oncology

imaging has been fluorine-18 coupled with fluorodeoxyglucose (FDG), which has a metabolism

related to glucose metabolism. FDG has been considered useful in cancer imaging, since tumor cells

show increased metabolism of glucose.

The efficacy, sensitivity and specificity of PET vary with the type of cancer. The medical indication

of PET imaging for oncologic applications depends in part on what imaging techniques are used

either before or after PET imaging. PET imaging is typically considered after other techniques

provide inconclusive or discordant results, such as computed tomography (CT), magnetic resonance

imaging (MRI), or ultrasonography.

Combined positron emission tomography (PET) computed tomography (CT) systems merge PET

and CT imaging technology into one system to produce an image that provides both functional and

anatomic information. CT uses x-rays to produce cross-sectional anatomic views of the area of

interest.

The following applications in oncology apply for PET imaging:

Diagnosis: Diagnosis refers to use of PET imaging as part of the testing used in establishing

whether or not an individual has cancer.

Staging: Staging refers to use of PET imaging to determine the stage (extent) of the cancer at the

time of diagnosis, before any treatment is given. Imaging at this time is generally to determine

whether or not the cancer is localized. This may also be referred to as initial staging.

Restaging: Restaging refers to PET imaging following treatment; evaluation of an individual in

which a disease recurrence is suspected based on signs and/or symptoms and in determining the

extent of malignancy following completion of a full course of treatment.

Surveillance: Surveillance refers to use of PET imaging in asymptomatic individuals (individuals

without objective signs or symptoms of recurrent disease). PET imaging is completed 6 months or

more following completion of treatment for cancer and 12 months or more for lymphoma following

completion of treatment.

Initial Treatment Management

_______________________________________________________________



Diagnosis: PET meets the definition of medical necessity only in clinical situations in which the

PET results may assist in avoiding an invasive diagnostic procedure, or in which the PET results

may assist in determining the optimal anatomic location to perform an invasive diagnostic

procedure. In general, for most solid tumors, a tissue diagnosis is made prior to the performance of

PET imaging. PET scans following a tissue diagnosis are performed for the purpose of staging,

rather than diagnosis.

Staging: PET meets the definition of medical necessity for staging in clinical situations in which the

stage of the cancer remains in doubt after completion of a standard diagnostic workup, including

conventional imaging (computed tomography (CT), magnetic resonance imaging (MRI), or

ultrasound), or the PET could potentially replace one or more conventional imaging studies when it

is expected that conventional study information is insufficient for the clinical management of the

patient, and clinical management of the patient would differ depending on the stage of the cancer

identified.

Subsequent Treatment Management

Restaging: PET meets the definition of medical necessity for restaging after completion of

treatment for the purpose of detecting residual disease, for detecting suspected recurrence or

metastasis, to determine the extent of a known recurrence, or if it could potentially replace one or

more conventional imaging studies when it is expected that conventional study information is

insufficient for the clinical management of the patient. Restaging apples to testing after a course of

treatment is completed.

Monitoring: Refers to the use of PET to monitor tumor response to treatment during the planned

course of therapy (e.g., when a change in therapy is anticipated).

Positron emission tomography (PET) imaging with or without combined positron emission

tomography/computed tomography (PET/CT) with an FDA approved radiopharmaceutical and

radiotracer meets the definition of medical necessity for the following indications.

INDICATIONS FOR AN ONCOLOGICAL PET SCAN:

Bone Cancer

PET imaging of the bone meets the definition of medical necessity in the staging of Ewing

sarcoma and osteosarcoma.

PET imaging of the bone is considered experimental or investigational for all other applications,

including but not limited to staging of chondrosarcoma. There is limited evidence in the published

peer-reviewed medical literature to support PET imaging in all other applications, including but not

limited to staging of chondrosarcoma

Brain

PET imaging of the brain meets the definition of medical necessity for any one of the following:

When used to differentiate between treatment induced (radiation) tumor necrosis and brain

tumor recurrence

New signs and symptoms indicative of a brain tumor recurrence

Evidence of a brain mass on a brain CT or MRI scan

When used to distinguish a benign lesion from a malignant tumor.

_______________________________________________________________



PET imaging of the brain is considered experimental or investigational as the initial study in the

diagnosis of brain tumors. There is limited evidence in the published peer-reviewed medical

literature to support PET imaging in the diagnosis of brain tumors.

Breast Cancer

PET imaging of the breast meets the definition of medical necessity for any one of the following:

As an adjunct to standard imaging modalities for staging distant metastasis

Restaging locoregional recurrence (local recurrence) or metastasis

As an adjunct to standard imaging modalities for monitoring locally advanced and

metastatic breast cancer when a change in therapy is contemplated

Staging and restaging for detection of locoregional or distant recurrence or metastasis

(except axillary lymph nodes) when suspicion of disease is high and other imaging is

inconclusive.

PET imaging of the breast is considered experimental or investigational in the diagnostic

evaluation of breast cancer for all other applications, including but not limited to any of the

following. There is limited evidence in the published peer-reviewed medical literature to support

PET imaging for the following:

Initial diagnosis of breast cancer

Differential diagnosis in members with suspicious breast lesions or an indeterminate/low

suspicion finding on mammography

Staging of axillary lymph nodes

Predicting pathologic response to neoadjuvant therapy for locally advanced disease.

Cervical Cancer

PET imaging for cervical cancer meets the definition of medical necessity for any one of the

following:

For initial diagnostic evaluation of cervical cancer as an adjunct to conventional imaging in

members with a negative CT or MRI for extra-pelvic metastatic disease

For initial staging of locally advanced cervical cancer

For detection and diagnostic evaluation of residual or recurrent disease after treatment or

restaging (post cancer surgery, chemotherapy, or radiation therapy).

Chronic Lymphocytic Leukemia (CLL)

PET imaging for chronic lymphocytic leukemia (CLL) meets the definition of medical

necessity as the initial study with biopsy proven cancer or for detecting suspected cancer

based on diagnostic testing (e.g., bone marrow aspiration and biopsy, CBC).

Colorectal Cancer

PET imaging for colorectal cancer meets the definition of medical necessity for any one of the

following:

Staging and restaging to detect and assess resectability of hepatic or extrahepatic

metastases of colorectal cancer;

To determine the location of recurrent colorectal tumors (indicated by rising levels of

carcinoembryonic antigen (CEA) (the primary purpose for determining the location of

colorectal tumors is for making a decision as to whether surgical intervention is warranted

Diagnostic evaluation of rising and persistently elevated carcinoembryonic antigen (CEA)

level when imaging (e.g., CT scan) is negative

Tumor staging and re-staging

_______________________________________________________________



For detection and diagnostic evaluation of residual or recurrent disease after treatment (post

cancer surgery, chemotherapy, or radiation therapy).

PET imaging is considered experimental or investigational for the following. There is limited

evidence in the published peer-reviewed medical literature to support PET imaging for the

following:

Assessment of the presence of scarring versus local bowel recurrence in patients with

previously resected colorectal cancer

Radiotherapy treatment planning.

Esophageal Cancer

PET imaging for esophagus cancer meets the definition of medical necessity for any one of the

following:

Tumor staging and restaging

For detection and diagnostic evaluation of residual or recurrent disease after treatment (post

cancer surgery, chemotherapy, or radiation therapy)

Determining response to preoperative induction therapy.

PET imaging is considered experimental or investigational in the detection of primary esophageal

cancer. There is limited evidence in the published peer-reviewed medical literature to support PET

imaging in the evaluation of esophageal cancer.

Head and Neck Cancer

PET imaging of head and neck cancer meets the definition of medical necessity for any one of the

following:

Diagnosis, staging, and restaging of head and neck cancer

Diagnosis of suspected head and neck cancer

Initial staging of head and neck cancer

Identification of a head or neck tumor as a suspected but unknown “primary”

Staging of known head or neck tumor and assessing resectability of the tumor

Restaging of residual or recurrent disease after treatment (post cancer surgery,

chemotherapy, or radiation therapy).

Lung

PET imaging of the lung meets the definition of medical necessity for any one of the following:

Diagnosis, staging and restaging of known non-small cell lung cancer

Characterization of solitary pulmonary nodule or single pulmonary nodules (SPN’s) (to

determine the likelihood of malignancy in order to plan future management and treatment

As a technique to distinguish between benign and malignant disease when prior CT scan

and chest x-ray are inconclusive or discordant


restaging (post cancer surgery, chemotherapy, or radiation therapy)

To determine resectability for presumed solitary metastatic lesion from non-small cell lung

cancer

Restaging and monitoring lung cancer (small cell) if other imaging modalities (ultrasound,

CT, MRI) are inconclusive in determining a treatment plan or if unable to perform imaging

modalities (ultrasound, CT, MRI).

_______________________________________________________________



PET imaging is considered experimental or investigational in staging and restaging of small cell

lung cancer. There is limited evidence in the published peer-reviewed medical literature to support

PET imaging in the staging of small cell lung cancer.

Lymphoma (including Hodgkin’s disease)

PET imaging for lymphoma meets the definition of medical necessity for any one of the following:

Diagnosis of lymphoma

Tumor staging and restaging



Melanoma

PET imaging for melanoma meets the definition of medical necessity for any one of the following:

Diagnosis, staging, and restaging of malignant melanoma

As a technique for assessing extranodal spread of malignant melanoma at initial staging or

during follow-up treatment



PET imaging is considered experimental or investigational as a technique to detect regional lymph

node metastases in patients with clinically localized melanoma who are candidates to undergo

sentinel node biopsy. There is limited evidence in the published peer-reviewed medical literature to

support PET imaging as a technique to detect regional lymph node metastases in patients with

clinically localized melanoma who are candidates to undergo sentinel node biopsy.

Multiple Myeloma

PET imaging for multiple myeloma meets the definition of medical necessity for any one of the

following:

Diagnosis and initial staging of multiple myeloma

Restaging after completion of therapy

Monitoring response to treatment.

Neuroendocrine Cancer

PET imaging for restaging and monitoring neuroendocrine cancer (e.g., carcinoid,

pheochromocytoma) meets the definition of medical necessity if other imaging (ultrasound, CT,

MRI) is inconclusive in determining a treatment plan or if unable to perform imaging modalities.

Ovarian Cancer

PET imaging for ovarian cancer meets the definition of medical necessity for the following:

Diagnostic evaluation of signs and symptoms of suspected ovarian cancer recurrence

(restaging) when imaging (e.g., CT scan) is inconclusive.

PET imaging is considered experimental or investigational in the initial diagnostic evaluation of

known or suspected ovarian cancer. There is limited evidence in the published peer-reviewed

medical literature to support PET imaging in the initial diagnostic evaluation of known or

suspected ovarian cancer.

Pancreatic Cancer

_______________________________________________________________



PET imaging for pancreatic cancer meets the definition of medical necessity in the initial diagnosis

and staging of pancreatic cancer when other imaging (e.g., ultrasound, CT, or MRI) and biopsy are

inconclusive.

PET imaging for subsequent (post-treatment) for pancreatic cancer meets the definition of medical

necessity only if other imaging (e.g., ultrasound, CT, or MRI) is inconclusive in determining a

treatment plan or if unable to perform imaging modalities.

PET imaging is considered experimental or investigational including, but not limited to PET

imaging as a technique for evaluation of other aspects of pancreatic cancer. There is limited

evidence in the published peer-reviewed medical literature to support PET imaging for other

applications, including but not limited to PET imaging as a technique for evaluation of other

aspects of pancreatic cancer.

Prostate Cancer

PET imaging of prostate meets the definition of medical necessity for any one of the following:

To determine the anatomic extent of tumor when the recommended anti-tumor treatment

depends on the extent of the tumor

To determine if member is an appropriate candidate for an invasive diagnostic or

therapeutic procedure

To determine the optimal anatomic location for an invasive procedure.

PET imaging for prostate cancer is considered experimental or investigational for restaging or

monitoring response to active treatment.

Soft Tissue Sarcoma

PET imaging for subsequent (post-treatment) for soft tissue sarcoma meets the definition of medical

necessity only if other imaging (e.g., ultrasound, CT, or MRI) is inconclusive in determining a

treatment plan or if unable to perform imaging modalities.

PET imaging is considered experimental or investigational in the diagnostic evaluation of soft

tissue sarcoma, including but not limited to the following applications. There is limited evidence in

the published peer-reviewed medical literature to support PET imaging for the following:

Distinguishing between low grade and high grades of soft tissue sarcoma

Diagnostic evaluation of response to imatinib and other treatments for gastrointestinal

stromal tumors.

Testicular Cancer

PET imaging meets the definition of medical necessity in the diagnostic evaluation of residual mass

following chemotherapy of stage IIB and III seminomas (the PET imaging should be completed not

sooner than 6 weeks following chemotherapy) and initial staging.

PET imaging is considered experimental or investigational in the diagnostic evaluation of testicular

cancer, including but not limited to the following. There is limited evidence in the published peer-

reviewed medical literature to support PET imaging for the following:

Distinguishing between viable tumor and necrosis/fibrosis after treatment of testicular

cancer

Detection of recurrent disease after treatment of testicular cancer, except where noted above

Thyroid Cancer

_______________________________________________________________



PET imaging for thyroid cancer meets the definition of medical necessity for the following:

Restaging of recurrent or residual thyroid cancers of follicular cell origin that have been

previously treated by thyroidectomy and radioiodine ablation and the member has a serum

thyroglobulin greater than 10ng/ml and negative I-131 whole body scan.

Restaging of differentiated thyroid cancer when thyroglobulin (Tg) levels are elevated

(greater than 10ng/ml) and whole-body I-131 imaging is negative

Medullary thyroid cancer when calcitonin levels are elevated post operatively (greater than

150pg/mL).

PET imaging is considered experimental or investigational in the diagnostic evaluation of known or

suspected differentiated or poorly differentiated thyroid cancer. There is limited evidence in the

published peer-reviewed medical literature to support PET imaging in the evaluation of known or

suspected differentiated or poorly differentiated thyroid cancer.

Unknown Primary (occult primary tumors/cancers of unknown site)

PET imaging of unknown primary meets the definition of medical necessity when ALL of the


For a single site of disease outside the cervical lymph nodes; AND

Local or regional treatment for a single site of metastatic disease is being considered; AND

After a negative work up for an occult primary tumor; AND

PET imaging will be used to rule out or detect additional sites of disease that would

eliminate the rationale for local or regional treatment.

PET imaging is considered experimental or investigational for other unknown primary including,

but not limited to the following indications. There is limited evidence in the published peer-

reviewed medical literature to support PET imaging for the following:

Initial work-up of an unknown primary

Work-up for multiple sites of diseases

Other

PET imaging for multiple myeloma, and vulvar cancer requires Physician Clinical review of the

general criteria; refer to initial treatment management (diagnosis, staging) and subsequent

treatment management (restaging, monitoring).

INDICATIONS FOR PET MISCELLANEOUS APPLICATIONS:

Chronic Osteomyelitis


the definition of medical necessity in the diagnosis of chronic osteomyelitis if the diagnosis cannot

be determined by a bone scan.

PET imaging is considered experimental or investigational for all other indications, including, but

not limited to the following indications/applications. There is limited evidence in the published

peer-reviewed medical literature to support PET imaging for the following:

PET mammography (PEM)

PET magnetic resonance imaging (PET/MR, PET/MRI)

Diagnostic evaluation of neuroendocrine tumors

Staging inguinal lymph nodes in patients with squamous cell carcinoma of the penis

_______________________________________________________________



Cancer Surveillance

PET imaging is considered experimental or investigational when used as a surveillance tool for

patients with cancer or with a history of cancer. PET imaging is considered surveillance if

performed more than 6 months after completion of cancer therapy (12 months for lymphoma) in

patients without objective signs or symptoms suggestive of cancer recurrence. There is limited

evidence in the published peer-reviewed medical literature to support PET imaging in surveillance.

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TOC

S8037 – MR Cholangiopancreatography (MRCP)


INTRODUCTION:

Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive magnetic resonance

imaging radiologic technique that produces detailed images of the hepatobiliary and pancreatic

system, including the liver, gall bladder, bile ducts, pancreas and pancreatic duct.

INDICATIONS FOR MRCP:

Magnetic resonance cholangiopancreatography (MRCP) meets the definition of medical necessity

for the following:

Evaluation of suspected congenital anomaly of the pancreaticobiliary tract (e.g., aberrant ducts,

choledochal cysts, pancreas divisum or related complications)

Evaluation of complications of chronic pancreatitis pancreatitis or the complications related to

such (pseudocysts and bile duct strictures)

Pre-operative evaluation: Prior to surgery or other invasive procedure

Post-operative evaluation: Evaluation of suspected biliary abnormalities after surgery or

invasive procedure.

Further evaluation of inconclusive abnormalities identified on other imaging (ultrasound, CT, or

MRI)

Evaluation of abnormality related to the biliary tree based on symptoms or laboratory findings

and initial imaging has been performed


Documentation containing the medical necessity of the magnetic resonance

cholangiopancreatography (MRCP) and imaging results (e.g., images, clinical reports) should be


process.

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TOC

S8032 – Low Dose CT for Lung Cancer Screening


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:

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

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

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

*Patient 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.

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TOC

MUSCULOSKELETAL_SPINE SURGERY GUIDELINES

22600/63001 – Cervical Spinal Surgery


INTRODUCTION:

Degenerative cervical spine disorders, while often benign and episodic in nature, can become

debilitating, resulting in axial pain and neurological damage to the spinal cord. Compression on the

nerve root and / or spinal cord may be caused by (1) a herniated disc with or without extrusion of

disc fragments and/or (2) degenerative cervical spondylosis.

Spine surgery is a complex area of medicine. Operative treatment is indicated only when the

natural history of an operatively treatable problem is better than the natural history of the problem

without operative treatment. Choice of surgical approach is based on anatomy, the candidate’s

pathology, and the surgeon's experience and preference. All operative interventions must be based

on a positive correlation with clinical findings, the natural history of the disease, the clinical course,

and diagnostic tests or imaging results.

Anterior surgical approaches

Anterior surgical approaches to cervical spine decompression emerged in the 1950s in response to

technical limitations experienced with posterior approaches, including restricted access to and

exposure of midline bony spurs and disc fragments. Anterior approaches include anterior cervical

discectomy and fusion. Discectomy is removal of all or part of a herniated or ruptured disc or

spondolytic bony spur to alleviate pressure on the nerve roots or on the spinal cord in individuals

with symptomatic radiculopathy. Discectomy is most often combined with fusion to stabilize the

spine.

Posterior surgical approaches

Posterior surgical approaches include laminectomy, laminoplasty, and laminoforaminotomy (also

known as posterior discectomy). Laminectomy is the removal of the bone between the spinal process

and facet pedicle junction to expose the neural elements of the spine. This allows for the inspection

of the spinal canal, identification and removal of pathological tissue, and decompression of the cord

and roots. Laminoplasty is the opening of the lamina to enlarge the spinal canal. There are several

laminoplasty techniques; all aim to alleviate cord compression by reconstructing the spinal canal.

Laminoplasty is commonly performed to decompress the spinal cord in those with degenerative

spinal stenosis.

Laminoforaminotomy (also known as posterior discectomy) is the creation of a small window in the

lamina to facilitate removal of arthritic bone spurs and herniated disc material pressing on the

nerve root as it exits through the foramen. The opening of the foramen is widened so that the nerve

exits without being compressed.

Cervical Artificial Disc

Artificial total disc replacement refers to the insertion of a prosthetic device into the intervertebral

space. The goal is to maintain physiologic motion in adults with degenerative disc disease (DDD).

_______________________________________________________________



An artificial disc is intended to preserve range of motion (ROM) and reduce pain. These prostheses

replace the degenerated disc and have been proposed as a means of improving flexibility,

maintaining spinal curvature and providing an equalized weight-bearing surface, while reducing or

possibly eliminating pain. Several prosthetic devices are currently available for artificial total disc

replacement.

CLINICAL INDICATIONS:

Anterior Cervical Decompression with Fusion (ACDF) (Single Level or Multiple Levels)

Anterior cervical discectomy and fusion at a single or multiple levels, with either a bone bank

allograft or autograft with or without plating, meets the definition of medical necessity when:

There are positive clinical findings of myelopathy with evidence of progressive neurologic

deficits consistent with worsening spinal cord compression (immediate surgical evaluation is

indicated, no conservative treatment required); symptoms may include:

Upper extremity weakness

Unsteady gait related to myelopathy, balance or generalized lower extremity

weakness

Disturbance with coordination

Hyperreflexia

Hoffmann sign

Positive Babinski sign

OR

There is progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with

evidence of spinal cord or nerve root compression on Magnetic Resonance Imaging (MRI) or

Computed Tomography (CT) imaging (immediate surgical evaluation is indicated, no

conservative treatment required)

OR

When all of the following are met:

Cervical radiculopathy or myelopathy from ruptured disc, spondylosis, spinal

instability, or deformity, AND

Persistent or recurrent symptoms/pain with functional limitations that are

unresponsive to at least 6 weeks of conservative treatment, AND

Imaging studies (MRI or CT with or without myelography) confirm the presence of

spinal cord or spinal nerve root compression (disc herniation or foraminal stenosis) at

the level(s) corresponding with the clinical findings

OR

As first-line treatment without conservative treatment in the following clinical scenarios:

Significant spinal cord or nerve root compression due to tumor, infection or trauma

Fracture or instability on radiographic films measuring:

Sagittal plan angulation of greater than 11 degrees at a single interspace, OR

Greater than 3.5mm anterior subluxation in association with radicular / cord

dysfunction, OR

Subluxation at the (C1) level of the atlantodental interval of more than 3 mm

in an adult and 5 mm in a child

NOTE: ACDF at a single level or at multiple levels is not recommended for the following:

_______________________________________________________________



In asymptomatic or mildly symptomatic cases of cervical spinal stenosis

In cases of neck pain alone, without neurological deficits, and no evidence of significant

spinal nerve root or cord compression on MRI or CT

Posterior Cervical Decompression with Fusion (Single Level or Multiple Levels)

Posterior cervical decompression with fusion at a single level or multiple levels meets the definition

of medical necessity for cervical spine stenosis and/or cervical spondylotic myelopathy (CSM) when:





Unsteady gait related to myelopathy/balance or generalized lower extremity

weakness


Hyperreflexia

Hoffmann sign


OR





OR


Cervical radiculopathy or myelopathy from ruptured disc, spondylosis, spinal

instability, or deformity, AND




spinal cord or spinal nerve root compression (disc herniation or foraminal stenosis) at

the level(s) corresponding with the clinical findings, AND

Symptomatic cervical disease at a single or multiple levels as evidenced by:

Cervical spinal stenosis due to cervical spondylotic myelopathy (CSM), OR

Cervical spinal stenosis due to ossification of the posterior longitudinal

ligament (OPLL), OR

Spinal cord or nerve root compression due to herniated disc at a single level or

multiple levels

OR

As first-line treatment without conservative treatment in the following clinical scenarios:

Significant spinal cord or nerve root compression due to tumor, infection or trauma

Fracture or instability on radiographic films measuring:

Sagittal plan angulation of greater than 11 degrees at a single interspace, OR

Greater than 3.5mm anterior subluxation in association with radicular / cord

dysfunction, OR

Subluxation at the (C1) level of the atlantodental interval of more than 3 mm

in an adult and 5 mm in a child

_______________________________________________________________



NOTE: Posterior cervical decompression with fusion at a single level or at multiple levels is not

recommended for the following:

In asymptomatic or mildly symptomatic cases of cervical spinal stenosis

In cases of neck pain alone, without neurological deficits, and no evidence of significant

spinal nerve root or cord compression on MRI or CT

In individuals with kyphosis or at risk for development of postoperative kyphosis

Cervical Fusion for Treatment of Axial Neck Pain

Cervical fusion for the treatment of axial neck pain meets the definition of medical necessity when:

There is non-radicular cervical pain, AND

Improvement of symptoms has failed or plateaued, AND

Residual symptoms of pain and functional disability are unacceptable after 6 to 12

consecutive months of active non-operative treatment, or after longer duration of non-

operative treatment for debilitated individuals with complex problems, AND

All pain generators are adequately defined and treated, AND

All physical medicine and manual therapy interventions are completed, AND

X-ray, MRI, or CT demonstrates disc pathology or spinal instability, AND

Spine pathology is limited to one or two levels unless other complicating factors are involved,

AND

Psychosocial evaluation for confounding issues, if any, have been addressed

NOTE: The effectiveness of three-level or greater cervical fusion for non-radicular pain has not been

established.

Posterior Cervical Decompression

Posterior cervical nerve root decompression meets the definition of medical necessity to treat

radiculopathy, disc herniation or foraminal stenosis when:





Unsteady gait related to myelopathy/balance or generalized lower extremity

weakness


Hyperreflexia

Hoffmann sign


OR





OR

_______________________________________________________________




Cervical radiculopathy from ruptured disc, spondylosis, or deformity, AND




spinal cord or spinal nerve root compression at the level(s) corresponding with the

clinical findings

OR

As first-line treatment without conservative treatment for significant spinal cord or nerve

root compression due to tumor, infection or trauma

NOTE: Posterior cervical decompression is not recommended for the following:

In asymptomatic or mildly symptomatic cases

In cases of pain alone, without neurological deficits, and abnormal imaging findings

Cervical Artificial Disc

Artificial cervical disc replacement at a single level meets the definition of medical necessity when

all of the following are met:

The artificial disc is FDA-approved, AND

Skeletally mature, AND

Intractable radiculopathy caused by single level herniated disc located at C3-C7, AND

Symptoms are not responsive to 6 weeks of conservative treatment, AND

Imaging studies confirm the presence of compression at the level corresponding with the

clinical findings (MRI or CT), AND

No prior neck surgery

Artificial cervical disc replacement at multiple levels is considered experimental or investigational.

There is a lack of clinical data to permit conclusions on net health outcomes.

NOTE: Artificial cervical disc replacement is NOT indicated when any of the following clinical

scenarios exist:

Symptomatic multiple level disease

Adjacent level disease: degenerative disease adjacent to a previous cervical fusion

Infection (at site of implantation or systemic)

Osteoporosis or osteopenia

Instability:

Translation greater than 3mm difference between lateral flexion-extension views at

the symptomatic levels;

11 degrees of angular difference between lateral flexion-extension views at the

symptomatic levels

Sensitivity or allergy to implant materials

Severe spondylosis defined as:

>50% disc height loss compared to minimally or non-degenerated levels, OR

Bridging osteophytes, OR

Absence of motion on lateral flexion-extension views at the symptomatic site

Severe facet arthropathy

Ankylosing spondylitis

_______________________________________________________________



Rheumatoid arthritis

Previous fracture with anatomical deformity

Ossification of the posterior longitudinal ligament (OPLL)

Active cervical spine malignancy

Cervical Fusion without Decompression

Cervical fusion without decompression is reviewed on a case-by-case basis. Atraumatic instability

due to Down Syndrome-related spinal deformity, rheumatoid arthritis, or basilar invagination is

uncommon, but may require cervical fusion.

Cervical Anterior Decompression without Fusion

Anterior decompression without fusion is reviewed on a case-by-case basis.

Conservative treatment

Musculoskeletal conservative treatment includes a combination of modalities, such as rest, ice,

heat, modified activities, medical devices (crutches, immobilizer, metal braces, orthotics, rigid

stabilizer or splints, not to include neoprene sleeves), medications, diathermy, chiropractic

treatments, or physician supervised home exercise program. Part of this combination may include

the physician instructing member to rest the area or stay off the injured part.

Home Exercise Program

A home exercise program must include both of the following elements:

Member is provided an exercise prescription/plan

Follow up with member is conducted regarding completion of HEP (after suitable 4-6 week

period), or inability to complete HEP due to a physical reason (e.g., increased pain, inability

to physically perform exercises; member inconvenience or noncompliance without

explanation does not constitute an inability to complete HEP)

Contraindications to spine surgery:

Medical contraindications (e.g., severe osteoporosis; infection of soft tissue adjacent to the

spine, whether or not it has spread to the spine; severe cardiopulmonary disease; anemia;

malnutrition; systemic infection)

Non-physiologic modifiers of pain presentation or non-operative conditions mimicking

radiculopathy or instability (e.g., peripheral neuropathy, piriformis syndrome, myofascial

pain, sympathetically mediated pain syndromes, sacroiliac dysfunction, psychological

conditions)

Active tobacco use prior to fusion surgery (stopping smoking for at least six weeks prior to

surgery and during the period of fusion healing is generally recommended)

Morbid obesity (significant risk and concern for improper post-operative healing, post-

operative complications related to morbid obesity, and/or an inability to participate in post-

operative rehabilitation)

BILLING/CODING INFORMATION:

CPT Coding:

0095T Removal of total disc arthroplasty (artificial disc), anterior approach, each

additional interspace, cervical (List separately in addition to code for primary

procedure) (investigational)

0098T Revision including replacement of total disc arthroplasty (artificial disc),

_______________________________________________________________



anterior approach, each additional interspace, cervical (List separately in

addition to code for primary procedure) (investigational)

0375T Total disc arthroplasty (artificial disc), anterior approach, including discectomy

with end plate preparation (includes osteophytectomy for nerve root or spinal

cord decompression and microdissection), cervical, three or more levels

(investigational)

22548 Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-

axis), with or without excision of odontoid process

22551 Arthrodesis, anterior interbody, including disc space preparation, discectomy,

osteophytectomy and decompression of spinal cord and/or nerve roots; cervical

below C2

22552 Arthrodesis, anterior interbody, including disc space preparation, discectomy,

osteophytectomy and decompression of spinal cord and/or nerve roots; cervical

below C2, each additional interspace (List separately in addition to code for

separate procedure)

22554 Arthrodesis, anterior interbody technique, including minimal discectomy to

prepare interspace (other than for decompression); cervical below C2


prepare interspace (other than for decompression); each additional interspace

(List separately in addition to code for primary procedure)

22590 Arthrodesis, posterior technique, craniocervical (occiput-C2)

22595 Arthrodesis, posterior technique, atlas-axis (C1-C2)

22600 Arthrodesis, posterior or posterolateral technique, single level; cervical below

C2 segment

22614 Arthrodesis, posterior or posterolateral technique, single level; each additional

vertebral segment (List separately in addition to code for primary procedure)

22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy


cord decompression and microdissection); single interspace, cervical



cord decompression and microdissection); second level, cervical (List separately

in addition to code for primary procedure) (investigational)

22861 Revision including replacement of total disc arthroplasty (artificial disc),

anterior approach, single interspace; cervical

22864 Removal of total disc arthroplasty (artificial disc), anterior approach, single

interspace; cervical

63001 Laminectomy with exploration and/or decompression of spinal cord and/or

cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal

stenosis), 1 or 2 vertebral segments; cervical


_______________________________________________________________




stenosis), more than 2 vertebral segments; cervical

63020 Laminotomy (hemilaminectomy), with decompression of nerve root(s),

including partial facetectomy, foraminotomy and/or excision of herniated

intervertebral disc; 1 interspace, cervical



intervertebral disc; each additional interspace, cervical or lumbar (List

separately in addition to code for primary procedure)



intervertebral disc, reexploration, single interspace; cervical



intervertebral disc, reexploration, single interspace; each additional cervical

interspace (List separately in addition to code for primary procedure)

63045 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with

decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or

lateral recess stenosis]), single vertebral segment; cervical



lateral recess stenosis]), single vertebral segment; each additional segment,

cervical, thoracic, or lumbar (List separately in addition to code for primary

procedure)

63050 Laminoplasty, cervical, with decompression of the spinal cord, 2 or more

vertebral segments;

63051 Laminoplasty, cervical, with decompression of the spinal cord, 2 or more

vertebral segments; with reconstruction of the posterior bony elements

(including the application of bridging bone graft and non-segmental fixation

devices [eg, wire, suture, mini-plates], when performed)

63075 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s),

including osteophytectomy; cervical, single interspace

63076 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s),

including osteophytectomy; cervical, each additional interspace (List separately

in addition to code for primary procedure)

_______________________________________________________________



TOC

22612/63030 – Lumbar Spinal Surgery


INTRODUCTION:

Lumbar spinal stenosis is narrowing of the spinal column or of the neural foramina where spinal

nerves leave the spinal column, causing pressure on the spinal cord. The most common cause is

degenerative changes in the lumbar spine. Neurogenic claudication is the most common symptom,

referring to leg symptoms encompassing the buttock, groin and anterior thigh, as well as radiation

down the posterior part of the leg to the feet.

Degenerative lumbar spondylolisthesis is the displacement of a vertebra in the lower part of the

spine; one lumbar vertebra slips forward on another with an intact neural arch and begins to press

on nerves. The slippage occurs at the L4-L5 level most commonly. The most common cause, in

adults, is degenerative disease although it may also result from bone diseases and fractures.

Spondylosis is an umbrella term describing age-related degeneration of the spine. Lumbar

degenerative disease without stenosis or spondylolisthesis is characterized by disabling low back

pain and spondylosis at L4-5, L5-S1, or both levels.

Spine surgery is a complex area of medicine. Operative treatment is indicated only when the

natural history of an operatively treatable problem is better than the natural history of the problem

without operative treatment. Choice of surgical approach is based on anatomy, the candidate’s

pathology, and the surgeon's experience and preference. All operative interventions must be based

on a positive correlation with clinical findings, the natural history of the disease, the clinical course,

and diagnostic tests or imaging results. In general, operative treatment is indicated if the program

of non-operative treatment fails.

Lumbar microdiscectomy is a surgical procedure to remove part of the damaged spinal disc. The

damaged spinal disc herniates into the spinal canal and irritates the nerve roots. Nerve root

compression leads to symptoms like low back pain, radicular pain, numbness and tingling,

muscular weakness, and paresthesia. Typical disc herniation pain is exacerbated with any

movement that causes the disc to increase pressure on the nerve roots.

Lumbar laminectomy, facetectomy and foraminotomy are common decompression surgeries. The

most common indication for decompression surgery is spinal stenosis. Spondylolisthesis and

herniated disk are also frequent indications. Decompression surgery is usually performed as part of

lumbar fusion surgery.

Lumbar spinal fusion (arthrodesis) is a surgical procedure used to treat spinal conditions of the

lumbar spine, e.g., degenerative disc disease, spinal stenosis, injuries/fractures of the spine, spinal

instability, and spondylolisthesis. Spinal fusion is a “welding” process that permanently fuses or

joins together two or more adjacent bones in the spine, immobilizing the vertebrae and restricting

motion at a painful joint. It is usually performed after other surgical procedures of the spine, such

as discectomy or laminectomy. Fusions can be performed either anteriorly, laterally, or posteriorly,

or via a combined approach.

_______________________________________________________________




Lumbar Microdiscectomy

Lumbar microdiscectomy meets the definition of medical necessity for the following:

Inter-vertebral disc herniation when all of the following are met:

o Primary radicular symptoms that hinder daily activities noted on clinical exam, AND

o Failure to improve with at least six consecutive weeks of conservative treatment,

AND

o Imaging studies show evidence of inter-vertebral disc herniation

As the first line of treatment (no conservative treatment required) in the following clinical

scenarios:

o Progressive nerve compression resulting in an acute neurologic deficit (sensory or

motor) due to herniated disc, OR

o Cauda equina syndrome (loss of bowel or bladder control)

Lumbar Decompression (Laminectomy, Facetectomy and Foraminotomy)

Lumbar spinal canal decompression using laminectomy, facetectomy or foraminotomy meets the

definition of medical necessity for the following:

Lumbar spinal stenosis when all of the following are met:

o Low back pain, neurogenic claudication, and/or radicular leg pain that impairs daily

activities for at least twelve (12) weeks, AND

o Failure to improve with at least 6 weeks of conservative treatment, AND

o Imaging findings are consistent with clinical signs/symptoms, AND

o Imaging studies do not show evidence of spinal instability

OR


scenarios:

o Progressive nerve compression resulting in an acute neurologic (sensory or motor)

deficit


o Spinal stenosis due to tumor, infection, or trauma

Lumbar Spine Fusion (single level with or without decompression)

Lumbar spine fusion at a single level, with or without decompression, meets the definition of

medical necessity for the following:

Lumbar back pain, neurogenic claudication, and/or radicular leg pain without sensory or

motor deficit that impairs daily activities for at least 6 months, AND

Failure to improve with least 6-12 weeks of conservative treatment, AND

Imaging studies correspond to the clinical findings, AND

At least one of the following clinical conditions exists:

o Spondylolisthesis (neural arch defect: spondylolytic spondylolisthesis, degenerative

spondylolisthesis, or congenital unilateral neural arch hypoplasia), OR

o Evidence of segmental instability (excessive motion, as in degenerative

spondylolisthesis, segmental instability, and surgically induced segmental

instability), OR

o Revision of previous failed surgery for pseudoarthrosis at the same level, at least 6-12

months after initial surgery, if significant functional gains are anticipated, OR

_______________________________________________________________



o Revision of previous failed surgery for disc herniations if significant functional gains

are anticipated, OR

o Fusion for the treatment of spinal tumor, cancer, or infection, OR

o Chronic low back pain or degenerative disc disease must have failed at least 6

months of appropriate non-operative treatment (comprehensive rehabilitation) (will

be evaluated on a case-by-case basis).

OR


scenarios:

o Progressive nerve compression resulting in an acute neurologic deficit (sensory or

motor)


Repeat Lumbar Spine Fusion

Repeat lumbar fusion surgeries are reviewed on a case-by-case basis upon submission of medical

records and imaging studies that demonstrate remediable pathology. The items below will also be

required:

Rationale as to why fusion is preferred over other non-invasive or less invasive treatment

procedures

Signed documentation that the has participated in the decision-making process and

understands the high rate of failure and complications

Lumbar Spine Fusion (multi-level with or without decompression)

NOTE*: All multi-level fusion surgeries are reviewed on a case-by-case basis.

Lumbar spine fusion at multiple levels, with or without decompression, meets the definition of

medical necessity for the following:

Lumbar back pain, neurogenic claudication, and/or radicular leg pain (without sensory or

motor deficit) that impairs daily activities for at least 6 months, AND

Failure to improve with least 6-12 weeks of conservative treatment, AND

Imaging studies correspond to the clinical findings, AND

o At least one of the following clinical conditions:

o Multiple level spondylolisthesis, OR

o Fusion for the treatment of spinal tumor, trauma, cancer, or infection affecting

multiple levels, OR

o Intra-operative segmental instability

As the first line of treatment (no conservative treatment required) for progressive nerve

compression resulting in an acute neurologic deficit (sensory or motor), AND one of the

aforementioned clinical conditions

NOTE**: Instrumentation, bone formation or grafting materials, including biologics, should be

limited to FDA approved devices or biologics and indications.

Lumbar Artificial Disc

Artificial lumbar disc replacement is considered experimental or investigational. There is a lack of

clinical data to permit conclusions on net health outcomes.

Conservative treatment

_______________________________________________________________



Musculoskeletal conservative treatment includes a combination of modalities, such as rest, ice,

heat, modified activities, medical devices (crutches, immobilizer, metal braces, orthotics, rigid

stabilizer or splints, not to include neoprene sleeves), medications, diathermy, chiropractic

treatments, or physician supervised home exercise program. Part of this combination may include

the physician instructing member to rest the area or stay off the injured part.

Home Exercise Program

A home exercise program must include both of the following elements:

1. Member is provided an exercise prescription/plan

2. Follow up with member is conducted regarding completion of HEP (after suitable 4-6 week

period), or inability to complete HEP due to a physical reason (e.g., increased pain, inability

to physically perform exercises; member inconvenience or noncompliance without

explanation does not constitute an inability to complete HEP)

Contraindications to spine surgery:

Medical contraindications (e.g., severe osteoporosis; infection of soft tissue adjacent to the

spine, whether or not it has spread to the spine; severe cardiopulmonary disease; anemia;

malnutrition; systemic infection)

Non-physiologic modifiers of pain presentation or non-operative conditions mimicking

radiculopathy or instability (e.g., peripheral neuropathy, piriformis syndrome, myofascial

pain, sympathetically mediated pain syndromes, sacroiliac dysfunction, psychological

conditions)

Active tobacco use prior to fusion surgery (stopping smoking for at least six weeks prior to

surgery and during the period of fusion healing is generally recommended)

Morbid obesity (significant risk and concern for improper post-operative healing, post-

operative complications related to morbid obesity, and/or an inability to participate in post-

operative rehabilitation

BILLING/CODING INFORMATION: CPT Coding:

0163T Total disc arthroplasty (artificial disc), anterior approach, including discectomy

to prepare interspace (other than for decompression), each additional

interspace, lumbar (List separately in addition to code for primary procedure)

(investigational)

0164T Removal of total disc arthroplasty, (artificial disc), anterior approach, each

additional interspace, lumbar (List separately in addition to code for primary

procedure) (investigational)

0165T Revision including replacement of total disc arthroplasty (artificial disc),

anterior approach, each additional interspace, lumbar (List separately in

addition to code for primary procedure) (investigational)

22533 Arthrodesis, lateral extracavitary technique, including minimal discectomy to

prepare interspace (other than for decompression); lumbar

22534 Arthrodesis, lateral extracavitary technique, including minimal discectomy to

prepare interspace (other than for decompression); thoracic or lumbar, each

additional vertebral segment (List separately in addition to code for primary

procedure)


prepare interspace (other than for decompression); lumbar


_______________________________________________________________



prepare interspace (other than for decompression); each additional interspace

(List separately in addition to code for primary procedure)

22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with

lateral transverse technique, when performed)

22614 Arthrodesis, posterior or posterolateral technique, single level; each additional

vertebral segment (List separately in addition to code for primary procedure)

22630 Arthrodesis, posterior interbody technique, including laminectomy and/or

discectomy to prepare interspace (other than for decompression), single

interspace; lumbar

22632 Arthrodesis, posterior interbody technique, including laminectomy and/or

discectomy to prepare interspace (other than for decompression), single

interspace; each additional interspace (List separately in addition to code for

primary procedure)

22633 Arthrodesis, combined posterior or posterolateral technique with posterior

interbody technique including laminectomy and/or discectomy sufficient to

prepare interspace (other than for decompression), single interspace and

segment; lumbar

22634 Arthrodesis, combined posterior or posterolateral technique with posterior

interbody technique including laminectomy and/or discectomy sufficient to

prepare interspace (other than for decompression), single interspace and

segment; each additional interspace and segment (List separately in addition

to code for primary procedure)


to prepare interspace (other than for decompression), single interspace, lumbar

(investigational)

22862 Revision including replacement of total disc arthroplasty (artificial disc),

anterior approach, single interspace; lumbar (investigational)

22865 Removal of total disc arthroplasty (artificial disc), anterior approach, single

interspace; lumbar (investigational)



stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis

63012 Laminectomy with removal of abnormal facets and/or pars inter-articularis

with decompression of cauda equina and nerve roots for spondylolisthesis,

lumbar (Gill type procedure)



stenosis), more than 2 vertebral segments; lumbar



intervertebral disc; 1 interspace, lumbar



intervertebral disc; each additional interspace, cervical or lumbar (List




intervertebral disc, reexploration, single interspace; lumbar

_______________________________________________________________





intervertebral disc, reexploration, single interspace; each additional lumbar

interspace (List separately in addition to code for primary procedure)



lateral recess stenosis]), single vertebral segment; lumbar



lateral recess stenosis]), single vertebral segment; each additional segment,

cervical, thoracic, or lumbar (List separately in addition to code for primary

procedure)

63056 Transpedicular approach with decompression of spinal cord, equina and/or

nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar

(including transfacet, or lateral extraforaminal approach) (eg, far lateral

herniated intervertebral disc)

63057 Transpedicular approach with decompression of spinal cord, equina and/or

nerve root(s) (eg, herniated intervertebral disc), single segment; each

additional segment, thoracic or lumbar (List separately in addition to code for

primary procedure)

_______________________________________________________________



TOC

62310-62311 – Spinal Epidural Injections


INTRODUCTION

Therapeutic spinal epidural injections, or select nerve root blocks (transforaminal), are types of

interventional pain management procedures. The therapeutic use of epidural injections is for short-

term pain relief associated with acute back pain or exacerbation of chronic back pain. With

therapeutic injections a corticosteroid is injected close to the target area with the goal of pain

reduction. Epidural injections should be used in combination with other conservative therapy*

modalities and not as stand alone treatment for long-term back pain relief. There are different

approaches used when administering spinal epidural injections, described below.

Interlaminar epidural injections, with steroids, access the epidural space between two vertebrae

(interlaminar) to treat cervical, lumbar or thoracic radicular pain. These procedures should be

performed using fluoroscopic guidance. Interlaminar epidural injections are the most common type

of epidural injection.

Transforaminal epidural injections (also called selective nerve root blocks) access the epidural space

via the intervertebral foramen where the spinal nerves exit (cervical, lumbar or thoracic region). It

is used both diagnostically and therapeutically. These procedures are always aided with

fluoroscopic guidance.

Caudal epidural injections, with steroids, are used to treat back and lower extremity pain, accessing

the epidural space through the sacral hiatus, providing access to the lower nerve roots of the spine.

These procedures should be performed using fluoroscopic guidance. Failed back surgery syndrome

is the most common reason for the caudal approach.


Epidural injections (caudal, interlaminar, and transforaminal) with local anesthetics and

corticosteroids meet the definition of medical necessity for the following indications:

Acute radicular neck or back pain

Two (2) weeks or more of acute radicular pain that has failed to respond or poorly responded

to conservative non-operative therapy*, AND

Average pain levels of ≥ 6 on a scale of 0 to 10, or intermittent or continuous pain causing

functional disability

Failed back surgery syndrome or epidural fibrosis

No sooner than 6 months post surgery, AND

Engaged in some form of conservative non-operative therapy* for a minimum of 6 weeks

prior to epidural injections, AND



Spinal stenosis or chronic neck or low back pain

_______________________________________________________________



Engaged in some form of other conservative non-operative therapy* for a minimum of 6

weeks prior to epidural injections, AND



Frequency of repeat therapeutic epidural injection

Documented proof that the prior injection had a positive response by significantly decreasing

pain (at least 30- 50% reduction in pain after initial injections), or significant documented

functional improvement; AND

Continues to have ongoing pain or documented functional disability (≥ 6 on a scale of 0 to

10); AND

Is actively engaged in other forms of conservative non-operative therapy* (unless pain

prevents participation in conservative therapy*); AND

Injections meet all of the following criteria:

o There must be at least 14 days between injections

o No more than 3 procedures in a 12-week period of time per region (cervical and

thoracic regions are considered as one region and lumbar and sacral are considered as

one region)

o Limited to a maximum total of 6 procedures per region per 12 months

Course of treatment, up to three epidural injections, regardless of approach must provide:

At least 50% or more cumulative pain relief obtained for a minimum of 6 weeks to be

considered a positive and effective response

If different regions are treated, injections may be administered at intervals of no sooner than

14 days

Epidurography is limited to one (1) test in six (6) months

Injecting multiple regions or performing multiple procedures during the same visit do not meet the

definition of medical necessity, unless documentation of an unusual situation is provided.

Epidural injection with ultrasound guidance (0228T-0231T) for any indication is considered

experimental or investigational, as the available published clinical evidence does not support

safety, effectiveness or clinical value.

*Conservative non-operative therapy (spine) should include a multimodality approach consisting of

a combination of active and inactive components. Inactive components, such as rest, ice, heat,

modified activities, medical devices, acupuncture and/or stimulators, medications, injections (facet,

not including trigger point), and diathermy can be utilized. Active modalities may consist of

physical therapy, a physician supervised home exercise program**, and/or chiropractic care.

** A home exercise program (HEP) must consist of the following two elements:

1. Information on an exercise prescription/plan is provided to the member

2. Follow up is conducted (after 4-6 weeks), regarding completion of HEP or inability to

complete HEP due to a physical reason (e.g., increased pain, inability to physically perform

exercises). NOTE: member inconvenience or noncompliance without explanation does not

constitute inability to complete a HEP.

Contraindications for epidural injections include:

Bleeding diathesis and full anticoagulation (risk of epidural hematoma)

Severe spinal stenosis resulting in intraspinal obstruction

Local infection at injection site

Predominantly psychogenic pain

Sepsis

_______________________________________________________________



Hypovolemia

Pregnancy

Uncontrolled diabetes

Uncontrolled glaucoma

High concentrations of local anesthetics in persons with multiple sclerosis

For diagnosis or treatment of facet mediated pain

Known or suspected allergic reaction to steroid medications

Spinal infection

Malignancy

Acute fracture


CPT Coding:

62310 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic,

antispasmodic, opioid, steroid, other solution), not including neurolytic

substances, including needle or catheter placement, includes contrast for

localization when performed, epidural or subarachnoid, cervical or thoracic

62311 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic,

antispasmodic, opioid, steroid, other solution), not including neurolytic

substances, including needle or catheter placement, includes contrast for

localization when performed, epidural or subarachnoid; lumbar or sacral

(caudal)

64479 Injection(s), anesthetic agent AND/OR steroid, transforaminal epidural, with

imaging guidance (fluoroscopy or CT); cervical or thoracic, single level


imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level

(list separately in addition to code for primary procedure)


imaging guidance (fluoroscopy or CT); lumbar or sacral, single level


imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level

(list separately in addition to code for primary procedure)

72275 Epidurography, radiological supervision and interpretation

77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or

paraspinous diagnostic or therapeutic injection procedures (epidural,

subarachnoid)

0228T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with

ultrasound guidance, cervical or thoracic, single level (investigational)


ultrasound guidance, cervical or thoracic, each additional level (investigational)


ultrasound guidance, lumbar or sacral, single level (investigational)


ultrasound guidance, lumbar or sacral, each additional level (investigational)

ICD-9 Diagnoses Codes That Support Medical Necessity (if Position Statement criteria are met):

053.10 Herpes zoster with unspecified nervous system complication

053.13 Postherpetic polyneuropathy

053.14 Herpes zoster myelitis

_______________________________________________________________



053.19 Herpes zoster with other nervous system complications

353.2 Cervical root lesions

353.3 Thoracic root lesions

353.4 Lumbosacral root lesions

722.4 Degeneration of cervical intervertebral disc

722.51 Degeneration of thoracic or thoracolumbar intervertebral disc

722.52 Degeneration of lumbar or lumbosacral intervertebral disc

722.71 Intervertebral disc disorder with myelopathy, cervical region

722.72 Intervertebral disc disorder with myelopathy, thoracic region

722.73 Intervertebral disc disorder with myelopathy, lumbar region

722.81 Postlaminectomy syndrome, cervical region

722.82 Postlaminectomy syndrome, thoracic region

722.83 Postlaminectomy syndrome, lumbar region

723.4 Brachial neuritis or radiculitis NOS

724.00 –

724.09

Spinal stenosis, other than cervical

724.3 Sciatica

724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified

V58.61 Encounter for long-term (current) use of anticoagulants (use only as a

supplemental code in addition to the primary diagnosis, when anticoagulant

therapy has been temporarily discontinued to facilitate therapeutic injections

for pain management)

ICD-10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

B02.23 Postherpetic polyneuropathy

B02.24 Postherpetic myelitis

B02.29 Other postherpetic nervous system involvement

G54.2 Cervical root disorders

G54.3 Thoracic root disorders

G54.4 Lumbosacral root disorders

M48.00 Spinal stenosis

M48.06 Spinal stenosis, lumbar region

M48.04-

M48.08

Spinal stenosis, thoracic region; thoracolumbar region; lumbar region;

lumbosacral region; sacral and sacrococcygeal region

M50.00-

M50.03

Cervical disc disorder with myelopathy; unspecified; high, mid cervical region;

cerviothoracic region

M50.30-

M50.33

Other cervical disc degeneration

M51.04-

M51.05

Intervertebral disc disorders with myelopathy, thoracic region; thoracolumbar

region

M51.06-

M51.07

Intervertebral disc disorders with myelopathy, lumbar region; lumbosacral

region

M51.14-

M54.17

Intervertebral disc disorders with radiculopathy, thoracic region;

thoracolumbar region; lumbar region; lumbosacral region

M51.34-

M51.35

Other intervertebral disc degeneration, thoracic region; thoracolumbar region

M51.36-

M51.37

Other intervertebral disc degeneration, lumbar region; lumbosacral region

_______________________________________________________________



M54.14-

M54.17

Radiculopathy, thoracic region; thoracolumbar region; lumbar region;

lumbosacral region

M54.30-

M54.32

Sciatica, unspecified side; right side; left side

M54.40-

M54.42

Lumbago with sciatica, unspecified side; right side; left side

M96.1 Postlaminectomy syndrome

M99.22-

M99.25

Subluxation stenosis of neural canal of thoracic region; lumbar region; sacral

region; pelvic region

M99.32-

M99.35

Osseous stenosis of neural canal of thoracic region; lumbar region; sacral

region; pelvic region

M99.42-

M99.45

Connective tissue stenosis of neural canal of thoracic region; lumbar region;

sacral region; pelvic region

M99.52-

M99.55

Intervertebral disc stenosis of neural canal of thoracic region; lumbar region;

sacral region; pelvic region

M99.62-

M99.65

Osseous and subluxation stenosis of intervertebral foramina of thoracic region;

lumbar region; sacral region; pelvic region

M99.72-

M99.75

Connective tissue and disc stenosis of intervertebral foramina of thoracic

region; lumbar region; sacral region; pelvic region

Z79.01 Long term (current) use of anticoagulants

DEFINITIONS:

Failed back surgery syndrome: characterized by persistent or recurring low back pain, with or

without sciatica, following lumbar surgery; the most common cause is epidural fibrosis.

Radicular pain: a type of pain that radiates into an extremity directly along the course of a spinal

nerve root; caused by compression, inflammation and/or injury to a spinal nerve root arising from

common conditions such as herniated disc and spinal stenosis.

_______________________________________________________________



TOC

64490-64493 – Paravertebral Facet Joint Injections/Blocks


INTRODUCTION

Facet joints (also called zygapophysial joints or z-joints), are posterior to the vertebral bodies in the

spinal column and connect the vertebral bodies to each other. They are located at the junction of

the inferior articular process of a more cephalad vertebra, and the superior articular process of a

more caudal vertebra. These joints provide stability and enable movement, allowing the spine to

bend, twist, and extend in different directions. They also restrict hyperextension and hyperflexion.

Facet joints are clinically important spinal pain generators in those with chronic spinal pain. Facet

joints may refer pain to adjacent structures, making the underlying diagnosis difficult, as referred

pain may assume a pseudoradicular pattern. Lumbar facet joints may refer pain to the back,

buttocks, and lower extremities while cervical facet joints may refer pain to the head, neck and

shoulders.

Imaging findings are of little value in determining the source and location of ‘facet joint syndrome’,

a term referring to back pain caused by pathology at the facet joints. Imaging studies may detect

changes in facet joint architecture, but correlation between radiologic findings and symptoms is

unreliable. Although clinical signs are also unsuitable for diagnosing facet joint-mediated pain, they

may be of value in selecting candidates for controlled local anesthetic blocks of either the medial

branches or the facet joint itself. This is an established tool in diagnosing facet joint syndrome.

Facet joint interventions are used in the treatment of pain in certain individuals with a confirmed

diagnosis of facet joint pain. Interventions include intra-articular injections and medial branch

nerve blocks in the affected region. Facet joint injections or medial branch nerve blocks require

guidance imaging.


Facet joint injection meets the definition of medical necessity when ALL of the following are met:

Disabling, non-radicular low back (lumbosacral) or neck (cervical) pain*, suggestive of facet

joint origin as documented in the medical record based upon:

o History, consisting of mainly axial or non-radicular pain, AND

o Physical examination, with positive provocative signs of facet disease (pain

exacerbated by extension and rotation, or associated with lumbar rigidity)

Lack of evidence for discogenic or sacroiliac joint pain

Lack of disc herniation or evidence of radiculitis

Intermittent or continuous pain with average pain levels of ≥ 6 on a scale of 0 to 10, or


Duration of pain of at least 2 months

Failure to respond to conservative non-operative therapy*

Injection is performed with fluoroscopic or CT guidance

_______________________________________________________________



*Thoracic facet joint injection is considered experimental or investigational. Data in published

medical literature are inadequate to permit scientific conclusions on long-term and net health

outcomes.

Facet joint injection performed with ultrasound guidance is considered experimental or

investigational. The evidence is insufficient to permit conclusions on efficacy and net health

outcomes.

Frequency of facet joint injections:

There must be a minimum of 14 days between injections

There must be a positive response of ≥ 50% pain relief and improved ability to perform

previously painful movements

Maximum of 3 procedures per region every 6 months (lumbar and sacral are considered as

one region)

If the procedures are applied for different regions, they may be performed at intervals of no

sooner than 2 weeks for most types of procedures

Maximum of 3 levels injected on same date of service

Radiofrequency neurolysis procedures should be considered in those with positive facet blocks (with

at least 50% pain relief and ability to perform prior painful movements without any significant

pain)



modified activities, medical devices, acupuncture and/or stimulators, medications, injections

(epidural, facet, bursal and/or joint, not including trigger point), and diathermy can be utilized.

Active modalities may consist of physical therapy, a physician supervised home exercise program**,

and/or chiropractic care.







Contraindications for facet joint injections include: History of allergy to contrast administration, local anesthetics, steroids, or other drugs

potentially utilized

Hypovolemia

Infection over puncture site

Bleeding disorders or coagulopathy

Inability to obtain percutaneous access to the target facet joint

Progressive neurological disorder which may be masked by the procedure

Pregnancy

Spinal infection

Acute Fracture


_______________________________________________________________



CPT Coding:

64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet

(zygapophyseal) joint (or nerves innervating that joint) with image

guidance (fluoroscopy or CT), cervical or thoracic; single level



guidance (fluoroscopy or CT), cervical or thoracic; second level (List




guidance (fluoroscopy or CT), cervical or thoracic; third and any

additional level(s) (List separately in addition to code for primary

procedure)



guidance (fluoroscopy or CT), lumbar or sacral; single level



guidance (fluoroscopy or CT), lumbar or sacral; second level (List




guidance (fluoroscopy or CT), lumbar or sacral; third and any additional

level(s) (List separately in addition to code for primary procedure)

0213T Injection(s), diagnostic or therapeutic agent, paravertebral facet

(zygapophyseal) joint (or nerves innervating that joint) with ultrasound

guidance, cervical or thoracic, single level (investigational)



guidance, cervical or thoracic; second level (investigational)



guidance, cervical or thoracic; third and any additional level (s) (list

separately in addition to code for primary procedure) (investigational)



guidance, lumbar or sacral; single level (investigational)



guidance, lumbar or sacral; second level (List separately in addition to

code for primary procedure) (investigational)



guidance, lumbar or sacral; third and any additional level(s) (List

separately in addition to code for primary procedure) (investigational)

ICD-9 Diagnoses Codes That Support Medical Necessity: (if position statement criteria are met)

719.48 Pain in joint involving other specified sites

721.0 Cervical spondylosis without myelopathy

721.2 Thoracic spondylosis without myelopathy

_______________________________________________________________



721.3 Lumbosacral spondylosis without myelopathy

721.41 Spondylosis with myelopathy, thoracic region

721.42 Spondylosis with myelopathy, lumbar region

722.81 Post-laminectomy syndrome of cervical region

722.82 Post-laminectomy syndrome of thoracic region

722.83 Post-laminectomy syndrome of lumbar region

723.1 Cervicalgia

724.1 Pain in thoracic spine

724.2 Lumbago

724.8 Other symptoms referable to back

V58.61 Long-term (current) use of anticoagulants (Use only as a supplemental

code in addition to primary diagnosis, when anticoagulant therapy has

been discontinued to facilitate therapeutic injections for pain

management)


M25.50 – M25.579 Pain in unspecified joint

M47.14 – M47.18 Other spondylosis with myelopathy

M47.812 – M47.817 Spondylosis without myelopathy or radiculopathy

M47.892 – M47.897 Other spondylosis

M47.9 Spondylosis, unspecified

M54.2 Cervicalgia

M54.5 Low back pain

M54.6 Pain in thoracic spine

M96.1 Postlaminectomy syndrome, not elsewhere classified

Z79.01 Long-term (current) use of anticoagulants

_______________________________________________________________



TOC

64633-64635 – Paravertebral Facet Joint Neurolysis


INTRODUCTION

Radiofrequency neurolysis for facet joint pain

Facet joints (also called zygapophysial joints or z-joints), are posterior to the vertebral bodies in the

spinal column and connect the vertebral bodies to each other. They are located at the junction of

the inferior articular process of a more cephalad vertebra, and the superior articular process of a

more caudal vertebra. These joints provide stability and enable movement, allowing the spine to

bend, twist, and extend in different directions. They also restrict hyperextension and hyperflexion.

Facet joints are clinically important spinal pain generators in those with chronic spinal pain. Facet

joints may refer pain to adjacent structures, making the underlying diagnosis difficult, as referred

pain may assume a pseudoradicular pattern. Lumbar facet joints may refer pain to the back,

buttocks, and lower extremities while cervical facet joints may refer pain to the head, neck and

shoulders.

Imaging findings are of little value in determining the source and location of ‘facet joint syndrome’,

a term referring to back pain caused by pathology at the facet joints. Imaging studies may detect

changes in facet joint architecture, but correlation between radiologic findings and symptoms is

unreliable. Although clinical signs are also unsuitable for diagnosing facet joint-mediated pain, they

may be of value in selecting candidates for controlled local anesthetic blocks of either the medial

branches or the facet joint itself. This is an established tool in diagnosing facet joint syndrome.

Radiofrequency neurolysis is a minimally invasive treatment for facet joint pain. It involves using

energy in the radiofrequency range to cause necrosis of specific nerves (medial branches of the

dorsal rami), preventing the neural transmission of pain. The objective of radiofrequency neurolysis

is to both provide relief of pain and reduce the likelihood of recurrence. Radiofrequency neurolysis

has been employed for over 30 years to treat facet joint pain.

Chemical neurolysis

Chemical neurolysis may be performed to provide pain relief for peripheral nerve pain. A chemical

ablating agent (e.g., diluted phenol or alcohol) is injected into the nerve, with the intent of

destroying the internal contents of the nerve while preserving its outer sheath.

NOTE: Peripheral nerve blocks, anti-inflammatory injections and local anesthetic injections into

the soft tissue surrounding the nerve do not represent neurolysis.

Peripheral nerve pain may occur in the foot, as described below:

Morton’s neuroma

According to the National Institutes of Health National Library of Medicine, a neuroma is a

thickening of nerve tissue that may develop in various parts of the body. The most common

neuroma in the foot is a Morton’s neuroma, which occurs between the third and fourth toes. It

is sometimes referred to as an intermetatarsal neuroma. “Intermetatarsal” describes its

_______________________________________________________________



location in the ball of the foot between the metatarsal bones. Neuromas may also occur in other

locations in the foot.

Symptoms of Morton’s neuroma include tingling, burning, or numbness; pain, a feeling that

something is inside the ball of the foot, or a feeling that there’s something in the shoe or a sock

is bunched up.

Ultrasound testing has been shown to be very effective in diagnosing neuromas. Because nerve

tissue is not seen on an x-ray, the x-ray will not show the neuroma. A skilled foot specialist will

be able to actually feel the neuroma on examination of the foot. Special studies such as MRI

and CT scan have little value in the diagnosis of a neuroma.

Plantar Fasciitis

Plantar fasciitis is one of the most common complaints related to the foot. Plantar fasciitis is

irritation and swelling of the thick tissue on the bottom of the foot. The plantar fascia is a very

thick band of tissue that connects the heel bone to the toes. This band of tissue is what creates

the arch of the foot. When the fascia is overstretched or overused, it can become inflamed.

When the fascia is inflamed, it can be painful and can make walking more difficult.

The most common symptom is pain in the bottom of the heel, which is usually worse in the

morning and may improve throughout the day. By the end of the day the pain may be replaced

by a dull ache that improves with rest.

Other neuritis of the foot

Neuritis is the inflammation of a nerve. Other neuritic foot conditions include but are not

limited to Tarsal Tunnel Syndrome, Medial Plantar Neuritis, Digital Neuritis, Deep Peroneal

Neuritis, and Baxter’s nerve neuritis.


Paravertebral facet joint denervation (non-pulsed radiofrequency neurolysis)

Facet joint pain

Paravertebral facet joint radiofrequency neurolysis (denervation) meets the definition of medical


Pain suggestive of facet joint origin in the cervical region or lumbar region only, AND

Positive response to controlled local anesthetic blocks of the facet joint, with at least 50%

pain relief and ability to perform prior painful movements without significant pain, but with

insufficient sustained relief (less than 2-3 months relief); OR

Positive response to prior radiofrequency neurolysis procedures with at least 50% pain

improvement for up to 6 months of relief in past 12 months; AND

The presence of the following:

o Lack of evidence that the primary source of pain is discogenic pain, sacroiliac joint

pain, disc herniation or radiculitis, AND

o Intermittent or continuous facet-mediated pain [average pain levels of ≥ 6 on a scale

of 0 to 10] causing functional disability, AND

o Duration of pain of at least 3 months, AND

o Failure to respond to more conservative non-operative therapy*

Frequency of treatment

_______________________________________________________________



Relief typically lasts between 6 and 12 months and sometimes provides relief for greater

than 2 years; repeat radiofrequency denervation is performed for sustained relief up to two

and three times

Limit to 2 facet neurolysis procedures every 12 months, per region (cervical is considered one

region, and lumbar and sacral are considered as one region)



modified activities, medical devices, acupuncture and/or stimulators, medications, injections

(epidural, facet, not including trigger point), and diathermy can be utilized. Active modalities may

consist of physical therapy, a physician supervised home exercise program**, and/or chiropractic

care.







Contraindications to facet joint denervation (radiofrequency neurolysis) include:

History of allergy to local anesthetics or other drugs potentially utilized

Lumbosacral radicular pain (dorsal root ganglion)

Conditions/diagnosis for which procedure is used are other than those listed above

Absence of positive diagnostic blocks

For any nerve other than the medial branch nerve

Radiofrequency neurolysis is considered experimental or investigational for all other conditions, as

the available scientific evidence does not support conclusions regarding safety and effectiveness.

These conditions include but are not limited to pain associated with the thoracic facet joints or the

sacroiliac joint (SI) joints, or conditions of the foot (e.g., Morton’s neuroma, plantar fasciitis, and

other foot pain).

All other methods of facet neurolysis are considered experimental or investigational, including but

not limited to pulsed radiofrequency neurolysis, laser neurolysis, chemical neurolysis and

cryoneurolysis.

Chemical neurolysis

Chemical neurolysis for foot pain meets the definition of medical necessity when ALL of the


Morton’s neuroma:

A thorough history and physical is performed to accurately diagnose the neuroma, AND

Diagnostic tests have ruled out other bony pathology, AND

There is documentation of attempt and failure of at least ONE physical/mechanical treatment:

Padding

Strapping

Icing

Orthotic devices

Activity modification

Changes in shoe wear

_______________________________________________________________



Physical therapy, AND

There is documentation of attempt and failure of at least ONE pharmacological treatment:

Medications (e.g. NSAIDS, unless contraindicated)

Nerve block

Anti-inflammatory injections (e.g., corticosteroids)

Local anesthetic injection.

Plantar fasciitis and other neuritis of the foot:

A thorough history and physical is performed to accurately diagnose plantar fasciitis/neuritis,

AND

There is documentation of attempt and failure of at least ONE physical/mechanical treatment:

Stretching

Strapping

Icing

Orthotic devices

Activity modification

Changes in shoe wear

Physical therapy, AND

There is documentation of attempt and failure of at least ONE pharmacological treatment:

Medications (e.g. NSAIDS, unless contraindicated)

Anti-inflammatory injections (e.g., corticosteroids).

All other methods of neurolysis for conditions of the foot are considered experimental or

investigational, as the published clinical evidence does not support conclusions regarding effects on

health outcomes.

Documentation should clearly indicate the agent used for neurolytic destruction.

Medical necessity for imaging (fluoroscopic or ultrasound) performed with chemical neurolysis for

conditions of the foot has not been established.


The following codes may be used to describe neurolysis:

CPT Coding:

64632 Destruction by neurolytic agent; plantar common digital nerve

64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s) with

imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet

joint


imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional

facet joint (list separately in addition to code for primary procedure)


imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint


imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional

facet joint (list separately in addition to code for primary procedure)

64640 Destruction by neurolytic agent, other peripheral nerve or branch

Coding Notes:

According to CPT guidelines:

_______________________________________________________________



CPT code 64632 is the correct code for reporting destruction by neurolytic agent of the

plantar common digital nerve(s) (e.g., Morton’s neuroma).

CPT code 64640 is not appropriate for reporting destruction by neurolytic agent for

Morton’s neuroma.

CPT code 64640 may be used to report chemical neurolysis for plantar fasciitis and other

neuritis of the foot.

ICD-9 Diagnoses Codes That Support Medical Necessity:

355.5 Tarsal tunnel syndrome

355.6 Lesion of plantar nerve

355.79 Other mononeuritis of lower limb

355.8 Mononeuritis of lower limb, unspecified

721.0 Cervical spondylosis without myelopathy

721.1 Cervical spondylosis with myelopathy

721.3 Lumbosacral spondylosis without myelopathy

721.42 Spondylosis with myelopathy lumbar region

722.81 Postlaminectomy syndrome of cervical region

722.82 Post-laminectomy syndrome of thoracic region

722.83 Post-laminectomy syndrome of lumbar region

723.1 Cervicalgia

724.2 Lumbago

724.3 Sciatica

728.71 Plantar fascial fibromatosis


G57.50 – G57.52 Tarsal tunnel syndrome

G57.60 – G57.62 Lesion of plantar nerve

G57.80 – G57.82 Other mononeuropathies of lower limb

G57.90 – G57.92 Mononeuropathy of lower limb

M47.011 – 47.012 Anterior spinal artery compression syndromes, occipital and cervical

regions

M47.016 Anterior spinal artery compression syndromes, lumbar region

M47.021 – M47.022 Vertebral artery compression syndromes, occipital and cervical regions

M47.11 – M47.12 Other spondylosis with myelopathy, occipital and cervical regions

M47.16 Other spondylosis with myelopathy, lumbar region

M47.21 – M47.22 Other spondylosis with radiculopathy, occipital and cervical regions

M47.26 Other spondylosis with radiculopathy, lumbar region

M47.811 – M47.812 Spondylosis without myelopathy or radiculopathy, occipital and cervical

regions

M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region

M47.891 – M47.892 Other spondylosis, occipital and cervical regions

M47.896 Other spondylosis, lumbar region

M54.2 Cervicalgia

M54.30 – M54.32 Sciatica

_______________________________________________________________



M54.40 – M54.42 Lumbago with sciatica

M54.5 Low back pain

M72.2 Plantar fascial fibromatosis

M96.1 Post-laminectomy syndrome, not elsewhere classified


Chemical neurolysis for Morton’s neuroma: Total number of procedures (64632) is limited to five (5)

in three (3) months. Each injection should be at least one (1) week apart.

Chemical neurolysis for plantar fasciitis and other neuritis of the foot: Total number of procedures

(64640) is limited to five (5) in three (3) months. Each injection should be at least one (1) week

apart.

NOTE: Services in excess of the limitations shown above are subject to medical review of

documentation. The following information is required documentation to support medical necessity:

physician history and physical, radiology study reports, physician progress notes with

documentation of conservative treatment, treatment plan including narrative, physician operative

report. Documentation must support “Position Statement” criteria and provide rationale for

additional procedures.

DEFINITIONS:

Chemical neurolysis: destruction of a nerve by injection of agent directly into the nerve.

Cryoneurolysis: destruction of a nerve with the use of extreme cold

Facet joint: each of four joints formed above and below and on either side of a vertebra by bony

projections (articular processes). The smooth surface at the end of the bony projections is called a

facet. Each vertebra has a bony projection on either side which angles downward on its lower side

and a bony projection that angles upward on either side. The lower projections of one vertebra meet

the upper projections of the vertebra below it, forming facet joints.

Medial branch block: injection of local anesthetic near the very small nerve branches that control

sensation to the facet joints.

Morton’s neuroma: a thickening of the nerve present in the space between the third and fourth

toes.

Neurolysis, denervation or neuro-ablation: destruction of a nerve.

Plantar fasciitis: inflammation of the band of tissue that connects the heel bone to the toes.

Radiofrequency neurolysis (radiofrequency lesioning): destruction of a nerve with the use of heat.

_______________________________________________________________



TOC

27132 – Hip Arthroplasty

CPT Codes: 27132, 27134, 27137, 27138

INTRODUCTION:

This guideline outlines the indications for four hip arthroplasty categories: total hip, partial/hemi-

arthroplasty, resurfacing, and revision/conversion. Arthroplasty describes the surgical replacement

or reconstruction of a joint with implanted devices when the joint has been damaged by an arthritic,

traumatic, or malignant process.

This guideline is structured with clinical indications outlined for each of the following hip

arthroplasty applications:

a) Total Hip Arthroplasty (THA)/Hip Resurfacing THA describes the reconstruction of the entire joint articular surfaces, including the femoral head and acetabular sides. Hip resurfacing arthroplasty replaces the articular surface of the femoral head with limited removal of femoral bone and the entire surface of the acetabulum.

b) Revision/Conversion Arthroplasty

Revision/Conversion hip arthroplasty describes surgical reconstruction due to failure or complication of a previous arthroplasty or reconstruction.

c) Hemiarthroplasty (Partial Arthroplasty)

Hemiarthroplasty is reconstruction of the femoral head but not the acetabulum and is indicated for the treatment of trauma (no additional clinical guidelines included)

Elective arthroplasty surgery may be considered when pain and documented loss of function

(deviation from normal hip function which may include painful weight bearing; painful or

inadequate range of motion to accomplish activities of daily living (ADLs) and/or employment; and

mechanical catching, locking, popping):

1. Cause a diminished quality of life

2. Symptoms have been present for at least 6 months and have not responded to non-

operative care, including rest, activity modification, weight reduction, oral anti-

inflammatory medications, physical therapy, gait aides (cane, walking stick, walker,

crutches), and injections (corticosteroid, viscosupplementation, PRP [platelet-rich

plasma]).

3. Are associated with typical objective findings on physical exam, including reduced hip

flexion and rotation, positive impingement testing, crepitus, hip flexion contracture,

antalgic gait limp.

4. Are associated with radiographic or chondral changes consistent with significant

arthritis, including joint space narrowing, subchondral sclerosis, subchondral cysts, and

osteophytes (radiographs); joint space narrowing, subchondral bone marrow edema, loss

of articular cartilage, effusion, subchondral and paralabral cysts, and osteophytes (MRI).


A. Total Hip Arthroplasty (THA)/Resurfacing

_______________________________________________________________



This guideline breaks out the criteria for total hip arthroplasty (THA) and hip resurfacing

procedures.

Total Hip Arthroplasty (THA):

THA may be considered medically necessary when the following criteria are met:

Hip pathology is due to rheumatoid arthritis, femoral neck fracture in the setting of

pre-existing arthritis, malignancy, or failure of previous surgery, dysplasia, or

avascular necrosis with collapse, confirmed by imaging.

OR

When ALL of the following criteria are met:

○ Pain and documented loss of function (deviation from normal hip function

which may include painful weight bearing; painful or inadequate range of

motion to accomplish activities of daily living (ADLs) and/or employment; and

mechanical catching, locking, popping); are present for at least 6 months; AND

○ 6 months of non-operative treatment* have failed to improve symptoms; AND

○ Physical exam has typical findings of hip pathology as evidenced by one or

more of the following:

a. Painful, limited range of motion or antalgic gait, or

b. Contracture, or

c. Crepitus, or

d. Leg length difference; AND

○ Imaging demonstrates advanced hip joint arthritis of at least **Kellgren-

Lawrence grade 3-4 or ***Tönnis grade 2 or 3;

Relative Contraindications:

○ Metal allergy (dependent upon implant choice)

○ Chronic renal insufficiency (due to metal ions circulating and potential renal

toxicity)

Absolute Contraindications:

○ Local or remove active infection

○ Female of child-bearing age (due to metal ions circulating in blood with

potential risk to fetus) (metal on metal replacements) **Kellgren-Lawrence Grading System:

Grade 0: No radiographic features of osteoarthritis

Grade I: Possible joint space narrowing and osteophyte formation

Grade II: Definite osteophyte formation with possible joint space narrowing

Grade III: Moderate multiple osteophytes, definite narrowing of joint space, some

sclerosis and possible deformity of bone contour (some sclerosis and cyst formation and deformity of femoral head and acetabulum)

Grade IV: Large osteophytes, marked narrowing of joint space, severe sclerosis and

definite deformity of bone contour (increased deformity of the femoral head and acetabulum)

***Tönnis Classification of Osteoarthritis by Radiographic Changes

0 No signs of osteoarthritis

1 Mild: Increased sclerosis, slight narrowing of the joint space, no or slight loss

of head sphericity

_______________________________________________________________



2 Moderate: Small cysts, moderate narrowing of the joint space, moderate loss

of head sphericity

3 Severe: Large cysts, severe narrowing or obliteration of the joint space, severe

deformity of the head

Hip Resurfacing Arthroplasty:

Hip resurfacing procedures will be reviewed on a case by case basis.

Hip resurfacing arthroplasty may be considered medically necessary when the following

criteria are met:

Pain and documented loss of function (deviation from normal hip function which may

include painful weight bearing; painful or inadequate range of motion to accomplish

activities of daily living (ADLs) and/or employment; and mechanical catching,

locking, popping); are present for at least 6 months; AND

6 months of non-operative treatment* have failed to improve symptoms; AND

Physical exam has typical findings of hip pathology as evidenced by one or more of

the following:

○ Painful, limited range of motion or antalgic gait, or

○ Contracture, or

○ Crepitus, or

○ Leg length difference; AND

Imaging demonstrates advanced hip joint pathology of at least **Kellgren-Lawrence

grade 3-4 or ***Tönnis grade 2 or 3 or avascular necrosis involving less than 50% of

the femoral head; AND

Male patient is less than 65 years old, or female patient is less than 55 years old;

AND

BMI less than 40; AND

Patient does not have evidence of any of the following contraindications:

o Osteoporosis or osteopenia (DEXA scan bone mineral density evaluation)

o Other co-morbidity (including medications that contribute to decreased

bone mineral density (glucocorticoid steroids, heparin, aromatase

inhibitors, thiazolidinediones, proton pump inhibitors, loop diuretics,

cyclosporine, anti-retrovirals, anti-psychotics, anti-seizures, certain breast

cancer drugs, certain prostate cancer drugs, depo-provera, aluminum-

containing antacids) that may contribute to active bone demineralization

o Cystic degeneration at the junction of the femoral head and neck on

radiographs or MRI or CT

o Malignancy at the proximal femur

o Current or recent hip infection, or sepsis

o Female of child-bearing age (due to metal ions circulating in blood with

potential risk to fetus)

o Chronic renal insufficiency (due to metal ions circulating and potential

renal toxicity)

o Metal allergy

Relative Contraindications:

○ Osteoporosis or osteopenia (DEXA scan bone mineral density evaluation)

Absolute Contraindications:

○ Local or remove active infection

_______________________________________________________________



○ Female of child-bearing age (due to metal ions circulating in blood with

potential risk to fetus)

**Kellgren-Lawrence Grading System:




Grade III: Moderate multiple osteophytes, definite narrowing of joint space, some

sclerosis and possible deformity of bone contour (some sclerosis and cyst formation and deformity of femoral head and acetabulum)


definite deformity of bone contour (increased deformity of the femoral head and acetabulum)

***Tönnis Classification of Osteoarthritis by Radiographic Changes

0 No signs of osteoarthritis

1 Mild: Increased sclerosis, slight narrowing of the joint space, no or slight loss

of head sphericity

2 Moderate: Small cysts, moderate narrowing of the joint space, moderate loss

of head sphericity

3 Severe: Large cysts, severe narrowing or obliteration of the joint space, severe

deformity of the head

B. Hip Revision/Conversion Arthroplasty

Hip Revision/Conversion Arthroplasty may be considered medically necessary when a

previous hip reconstruction meets the following criteria:

Extensive disease or damage due to fracture, malignancy, osteolysis, or other bone or

soft-tissue reactive or destructive process confirmed by MRI or other advanced

imaging. NOTE: MRI is used less often in these circumstances unless it is a metal-on-metal and looking for soft-tissue lesions; x-ray, CT, nuclear studies are used more frequently; OR

Infected joint confirmed by synovial fluid aspiration (cell count and/or culture); OR

When all of the following are present:

○ Symptomatic hip arthroplasty where patient has persistent, severe disabling

pain and loss of function for > 6 months; AND

○ Unstable joint upon physical exam; AND

○ Aseptic loosening, osteolysis, other bone or soft-tissue reactive or destructive

process, inappropriate positioning of components, or other failure of fixation of

components confirmed on imaging

Additional Information:

*Non-operative management may include one or more of the following modalities:

o Rest or activity modifications/limitations;

o Weight reduction for patient with elevated BMI;

o Protected weight-bearing with cane, walker or crutches;

o Physical therapy modalities;

o Supervised home exercise;

o Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics;

_______________________________________________________________



o Injections: cortisone, viscosupplementation, PRP (platelet-rich plasma)

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Ollivere, B., et al. "Early clinical failure of the Birmingham metal-on-metal hip resurfacing is

associated with metallosis and soft-tissue necrosis." Journal of Bone & Joint Surgery, British Volume 91.8 (2009): 1025-1030.

Ong, Kevin L., et al. "Risk of subsequent revision after primary and revision total joint

arthroplasty." Clinical Orthopaedics and Related Research® 468.11 (2010): 3070-3076.

Pisters, M. F., et al. "Long-term effectiveness of exercise therapy in patients with osteoarthritis of

the hip or knee: a randomized controlled trial comparing two different physical therapy

interventions." Osteoarthritis and Cartilage 18.8 (2010): 1019-1026.

_______________________________________________________________



Prokopetz, Julian JZ, et al. "Risk factors for revision of primary total hip arthroplasty: a systematic

review." BMC musculoskeletal disorders 13.1 (2012): 251.

Sansom, Anna, et al. "Routes to total joint replacement surgery: patients' and clinicians' perceptions

of need." Arthritis care & research 62.9 (2010): 1252-1257.

Shears, E., et al. "Outcime of Revision of metal on hip resurfacing. Journal of Bone & Joint Surgery, British Volume 93.SUPP IV (2011): 548-548.

Stephens, Byron F., G. Andrew Murphy, and William M. Mihalko. "The effects of nutritional

deficiencies, smoking, and systemic disease on orthopaedic outcomes." The Journal of Bone & Joint Surgery 95.23 (2013): 2152-2157.

Wetters, Nathan G., et al. "Risk factors for dislocation after revision total hip arthroplasty." Clinical Orthopaedics and Related Research® 471.2 (2013): 410-416.

Zhang, W., et al. "OARSI recommendations for the management of hip and knee osteoarthritis: part

III: Changes in evidence following systematic cumulative update of research published through

January 2009." Osteoarthritis and Cartilage 18.4 (2010): 476-499.

_______________________________________________________________



TOC

27130 – Hip Arthroscopy

CPT Codes: 27130, S2118, 29860, 29861, 29862, 29863

INTRODUCTION:

This guideline describes the indications for, and surgical uses of arthroscopy in the hip as well as

open, non-arthroplasty hip repair procedures.

Arthroscopy introduces a fiberoptic camera into the hip joint (arthroscopy) and surrounding extra-

articular areas (endoscopy) through a small incision for diagnostic purposes. Other tools may then

be introduced to remove, repair, or reconstruct intra-articular and extra-articular pathology.

Surgical indications are based on relevant clinical symptoms, physical exam, radiologic findings,

and response to non-operative, conservative management when medically appropriate.

This guideline is structured with clinical indications outlined for each of the following

applications: Arthroscopic; Open, non-arthroplasty;

d) Diagnostic arthroscopy

e) Femoroacetabular Impingement (FAI)

Labral Repair Only

CAM, Pincer, CAM & Pincer combined

f) Synovectomy, Biopsy, or Removal of Loose or Foreign Body

g) Chondroplasty or abrasion for Chondral injuries, chondromalacia

h) Extra-articular (Endoscopic) Hip Surgery


C. Diagnostic Hip Arthroscopy

All requests for diagnostic hip arthroscopy will be considered and decided on a case-by-case

basis.

D. Femoroacetabular Impingement (FAI)

FAI is a condition characterized by a mechanical conflict between the femur (cam) and/or

acetabulum (pincer) that may result in labral injury (labral tear) or articular cartilage injury

(chondral defect, arthritis). Up to 95% of labral tears are observed in the presence of FAI.

Thus, “isolated” labral tears are very uncommon. Labral tears are infrequently traumatic

(<5%). There is no evidence to support hip arthroscopy for FAI and/or labral tear in an

asymptomatic subject.

Labral Repair

Arthroscopic labral repair may be medically necessary when ALL of the following criteria

are met:

Hip or groin pain in positions of flexion and rotation that may be associated with

mechanical symptoms of locking, popping, or catching; AND

Positive provocative test on physical exam with pain at the hip joint with flexion,

adduction, and internal rotation; AND

Acetabular labral tear by MRI, with or without intra-articular contrast; AND

Symptoms not improved with at least 6 weeks of conservative, non-operative care*, AND

_______________________________________________________________



No evidence of hip joint arthritis, defined as a Tönnis Grade 2 or 3 (joint space less than

2 millimeters) on weight-bearing AP radiograph; AND

Patient is less than age 50.

NOTE: Arthroscopy of the hip for acetabular labral or repair is considered not medically necessary in the presence of significant hip joint arthritis (Tonnis grade II or greater)**, dysplasia*** or other structural abnormality that would require skeletal correction.

***Dysplasia defined as:

o Lateral center edge angle <20 degrees; OR

o Anterior center edge angle <20 degrees; OR

o Tonnis angle >15 degrees; OR

o Femoral head extrusion index >25%

CAM, Pincer, Combined CAM & Pincer Repair

Technically not a repair, this procedure involves bony decompression, shaving, osteoplasty,

femoroplasty, acetabuloplasty, and/or osteochondroplasty. Greater than 95% of labral repairs should be performed with at least a femoral osteoplasty or an acetabuloplasty.

Arthroscopic CAM, Pincer or combined CAM and Pincer repair may be medically necessary

when ALL of the following criteria are met:

Positional hip pain for at least 6 weeks not improved with conservative, non-operative

care*; AND

Positive impingement sign on physical exam (hip or groin pain with flexion, adduction

and internal rotation; or extension and external rotation); AND

One of the following radiograph, CT and/or MRI findings of FAI:

○ Nonspherical femoral head or prominent head-neck junction (pistol-grip

deformity) with alpha angle >55 degrees indicating CAM impingement; OR

○ Overhang of the anterolateral rim of the acetabulum, posterior wall sign,

prominent ischial spine sign, acetabular protrusion, or retroversion with a

center edge (CE) angle >35° and/or cross-over sign indicating pincer deformity;

OR

○ Combination of CAM and pincer criteria; AND

No evidence of significant hip joint arthritis; AND

Skeletally mature patient, AND

Under age < 50 years old; AND

BMI < 40; AND

Radiographic images show no evidence of ANY of the following indicators for hip

dysplasia:

○ Lateral center edge angle <20°; OR

○ Anterior center edge angle <20°; OR

○ Tonnis angle >15°; OR

○ Femoral head extrusion index >25%

NOTE: arthroscopy of the hip for FAI is considered not medically necessary or contraindicated in the presence of significant hip joint arthritis (Tonnis grade II or greater)**, the skeletally immature patient (open proximal femoral physis), age > 50 years, or BMI >40. Requests meeting any of these criteria will be reviewed on a case by case basis.

_______________________________________________________________



E. Arthroscopy for Synovectomy, Biopsy, or Removal of Loose or Foreign Body

Arthroscopic synovectomy, biopsy, removal of loose or foreign body, or a combination of

these procedures may be medically necessary when the following criteria are met:

Radiographic evidence of acute post-traumatic intra-articular foreign body or displaced

fracture fragment;

OR


○ Hip pain associated with grinding, catching, locking, or popping for at least 12

weeks not improved with conservative, non-operative care*; AND

○ Physical exam finding confirms painful hip with limited range of hip motion;

AND

○ Radiographs, CT and/or MRI with synovial proliferation, calcifications,

nodularity, inflammation, pannus, loose body

F. Shaving or debridement of articular cartilage (chondroplasty), and/or abrasion

arthroplasty

There are no clinical indications for performing an independent debridement procedure

within the hip. Debridement should always be combined or secondary to another

procedure, and is primary performed within FAI procedures.

All requests will be considered and decided on a case-by-case basis.

G. Extra-articular (Endoscopic) Hip Surgery

Arthroscopy for extra-articular hip pathology is recognized as a less invasive adjunctive tool to

correct or minimize symptoms of structural pathology, but is not supported in current high

level evidence-based literature.

Use of this technology for these applications will be decided on a case-by-case basis.

Extra-articular hip applications may be used to minimize symptoms of internal snapping hip

(internal coxa saltans, iliopsoas tendonitis, snapping iliopsoas), iliopsoas tendon at

iliopectineal eminence or anterior inferior iliac spine, external snapping hip (external coxa

saltans, snapping iliotibial band, iliotibial band at greater trochanter). May also include

proximal hamstring endoscopy for partial tear of proximal hamstring with or without bursitis

or proximal hamstring, sciatic neurolysis, ischiofemoral decompression (for ischiofemoral

impingement), or anterior inferior iliac spine (subspine) decompression for subspine

impingement (3 types of anterior inferior iliac spine:

Type 1: small, tip does not extend to sourcil;

Type 2: medium, tip extends down to sourcil;

Type 3: large, tip extends down below sourcil.

Type 3 should have surgical decompression. Most type 2 should have surgical decompression. Type 1 should never need surgical decompression.)

Activity related painful snapping sensation around the hip joint caused by the iliotibial

tract over the greater trochanter or bursa (external snapping hip) and/or the iliopsoas

tendon over medial bony prominence or bursa (internal snapping hip) unresponsive to

non-operative care;

OR

_______________________________________________________________



Activity related pain and tenderness at the greater or lesser trochanter due to bursal

inflammation, tendinosis and/or tendinitis, or tear of the tendon (gluteus medius or

minimus) unresponsive to non-operative care; AND

At least 6 months of non-operative care* that may include activity modification,

supervised physical therapy, NSAIDS, and/or corticosteroid injection; AND

Physical exam findings align with patient symptoms and have at least one or more of the

following:

o Limp or painful ambulation

o Tenderness and/or crepitus to palpation

o Visible, audible, or palpable snapping at the greater trochanter or pelvic brim

o Pain and/or weakness with active or resisted motion of the hip

o Pain relief with diagnostic local anesthetic injection

Additional Information:

*Non-Operative Treatment:

Throughout this document, conservative, non-operative care* is defined as a combination of

two or more of the following:

Rest or activity modifications/limitations;

Ice/heat;

Protected weight bearing;

Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics;

Brace/orthosis;

Physical therapy modalities;

Supervised home exercise;

Weight optimization;

Injections: cortisone/viscosupplementation/PRP (Platelet-rich plasma)

**Tönnis Classification of Osteoarthritis by Radiographic Changes

Grade 0 No signs of osteoarthritis

Grade 1 Mild: Increased sclerosis, slight narrowing of the joint space, no or

slight loss of head sphericity

Grade 2 Moderate: Small cysts, moderate narrowing of the joint space,

moderate loss of head sphericity

Grade 3 Severe: Large cysts, severe narrowing or obliteration of the joint

space, severe deformity of the head

Additional Notes:

A very high prevalence of abnormal radiographs is found in asymptomatic patients.

o 33% of asymptomatic hips have a cam

o 66% of asymptomatic hips have a pincer

o 68% of asymptomatic hips have a labral tear

FAI and labral tears are precursors to hip arthritis

Dysplasia is precursor to hip arthritis

Arthroscopy is never indicated for treatment of osteoarthritis within the hip

Rarely (if ever) arthroscopy for dysplasia

REFERENCES

_______________________________________________________________



Ayeni, Olufemi R., et al. "Current state-of-the-art of hip arthroscopy." Knee Surgery, Sports Traumatology, Arthroscopy 22.4 (2014): 711-713.

Bardakos, N. V., J. C. Vasconcelos, and R. N. Villar. "Early outcome of hip arthroscopy for

femoroacetabular impingement The role of femoral osteoplasty in symptomatic improvement."

Journal of Bone & Joint Surgery, British Volume 90.12 (2008): 1570-1575.

Bozic, Kevin J., et al. "Trends in hip arthroscopy utilization in the United States." The Journal of arthroplasty 28.8 (2013): 140-143.

Byrd, J. W., and Kay S. Jones. "Hip arthroscopy for labral pathology: prospective analysis with 10-

year follow-up." Arthroscopy: The Journal of Arthroscopic & Related Surgery 25.4 (2009): 365-

368.

Colvin, Alexis Chiang, John Harrast, and Christopher Harner. "Trends in hip arthroscopy." The Journal of Bone & Joint Surgery 94.4 (2012): e23-1.

Egerton, Thorlene, et al. "Intraoperative cartilage degeneration predicts outcome 12 months after

hip arthroscopy." Clinical Orthopaedics and Related Research® 471.2 (2013): 593-599.

Fabricant, Peter D., Benton E. Heyworth, and Bryan T. Kelly. "Hip arthroscopy improves symptoms

associated with FAI in selected adolescent athletes." Clinical Orthopaedics and Related Research® 470.1 (2012): 261-269.

Glick, James M., Frank Valone III, and Marc R. Safran. "Hip arthroscopy: from the beginning to the

future—an innovator’s perspective." Knee Surgery, Sports Traumatology, Arthroscopy 22.4

(2014): 714-721.

Heyworth, Benton E., et al. "Radiologic and intraoperative findings in revision hip arthroscopy."

Arthroscopy: The Journal of Arthroscopic & Related Surgery 23.12 (2007): 1295-1302.

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in patients with early osteoarthritis." Clinical orthopaedics and related research 456 (2007):

128-132.

Kocher, Mininder S., et al. "Hip arthroscopy in children and adolescents." Journal of Pediatric Orthopaedics 25.5 (2005): 680-686.

Lynch, T. Sean, et al. "Hip Arthroscopic Surgery Patient Evaluation, Current Indications, and

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Malviya, A., G. H. Stafford, and R. N. Villar. "Impact of arthroscopy of the hip for femoroacetabular

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examination in determining intra-articular hip pain for potential hip arthroscopy candidates."


_______________________________________________________________



Mascarenhas, Randy; Frank, Rachel M.; Lee, Simon; Salata, Michael J.; Bush-Joseph, Charles;

Nho, Shane J. “Endoscopic Treatment of Greater Trochanteric Pain Syndrome of the Hip.”

JBJS REVIEWS 2014;2(12):e2 · http://dx.doi.org/10.2106/JBJS.RVW.N.00026 1

McCarthy, Joseph C., and Joann Lee. "Hip arthroscopy: indications, outcomes, and complications."

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_______________________________________________________________



Wilkin, Geoffrey, Gerard March, and Paul E. Beaulé. "Arthroscopic Acetabular Labral Debridement

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_______________________________________________________________



TOC

27446 – Knee Arthroplasty

CPT Codes: 27446, 27447, 27486, 27487, 27488, 27438

INTRODUCTION:

Arthroplasty describes the surgical replacement or reconstruction of a joint with implanted devices

when the joint has been damaged by an arthritic or traumatic process. This guideline outlines the

clinical indications for three types of knee arthroplasty procedures: total, partial/unicompartmental,

and revision arthroplasty.


applications: Total Knee Arthroplasty (TKA), Unilateral Knee Arthroplasty (UKA), and

Revision Arthroplasty.

a) Total Knee Arthroplasty (TKA)

b) Unicompartmental Knee Arthroplasty (UKA)

c) Revision Arthroplasty

A. Total Knee Arthroplasty (TKA)

Total Knee Arthroplasty (TKA) describes reconstruction of all articular joint surfaces.

TKA may be considered medically necessary for treatment of the following knee joint

pathology:

Extensive disease or damage due to rheumatoid arthritis, fracture, or avascular

necrosis confirmed by imaging (radiographs, MRI or other advanced imaging); AND

Patient has pain and documented loss of function (no indication to perform TKA in

patient with severe disease and no symptoms);

OR


Pain that is persistent and severe and/or patient has documented loss of function that

has been present for at least 6 months resulting in a diminished quality of life; AND

At least 6 months of non-operative care* that has failed to improve symptoms. Non-

operative care should include at least two or more of the following:

a) Rest or activity modifications/limitations;

b) Weight reduction for patient with elevated BMI;

c) Protected weight-bearing with cane, walker or crutches;

d) Physical therapy modalities;

e) Supervised home exercise;

f) Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics;

g) Brace/orthosis;

h) Injections: cortisone/viscosupplementation/PRP (platelet rich plasma); AND

Physical exam findings demonstrate one or more of the following: tenderness,

swelling/effusion, limited range of motion (decreased from uninvolved side or as

compared to a normal joint), flexion contracture, palpable or audible crepitus, instability

and/or angular deformity; AND

_______________________________________________________________



Radiographic findings show evidence of bicompartmental or tricompartmental advanced

arthritic changes, documented by weight-bearing radiographs described as Kellgren-

Lawrence (K-L)** stage III or stage IV degeneration

NOTE:

All requests for simultaneous bilateral total knee replacements will be reviewed on a

case by case basis.

All requests for TKA in patients with chronic, painless effusion and extensive

radiographic arthritis will be evaluated on a case-by-case basis.





Grade III: Moderate multiple osteophytes, definite narrowing of joint space,

some sclerosis and possible deformity of bone contour

Grade IV: Large osteophytes, marked narrowing of joint space, severe

sclerosis and definite deformity of bone contour;

Contraindications:

Absolute contraindication:

o Active infection (local or remote)

Relative contraindication: Any of the following:

o Prior infection at site (unless aspiration with cultures and serology [CBC with

differential, ESR, CRP] demonstrates no infection). If prior infection at site, tissue

biopsies should be sent intra-operatively to exclude latent/dormant infection.

o Extreme morbid obesity (BMI > 40)

o Extensor mechanism deficiency

o Neuropathic joint

o Severe peripheral vascular disease

o Compromised soft tissue envelope

o Uncontrolled comorbidities

B. Unicompartmental Knee Arthroplasty (UKA)/Partial Knee Replacement (PKA)

Unicompartmental knee arthroplasty (UKA) is also called partial, hemi- or unicondylar knee,

bicondylar knee arthroplasty, and involves reconstruction of either the medial (more common

than lateral) or lateral weight bearing compartment of the knee and/or patellofemoral joint

UKA/PKA may be medically necessary when ALL of the following criteria are met:

Pain localized to the medial or lateral compartment is present for at least 6 months;

AND

At least 6 months of non-operative care that has failed to improve symptoms. *Non-

operative care should include at least two or more of the following:

a) Rest or activity modifications/limitations;

b) Weight optimization;

c) Protected weight-bearing with cane, walker or crutches;

d) Physical therapy modalities;

e) Supervised home exercise;

f) Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics;

_______________________________________________________________



g) Brace/orthosis;

h) Injections: cortisone/viscosupplementation/PRP (platelet rich plasma); AND

Total arc of motion (goniometer) > 90 degrees; AND

Normal ACL or stable reconstructed ACL per physical exam test; AND

Age > 50 years; AND

Radiographic findings demonstrate only unicompartmental disease (with or without

patellofemoral involvement) with evidence of degeneration equal to K-L* Grade 3 or 4;

AND

Contracture < 5-10 degrees upon physical exam (goniometer); AND

Angular deformity < 10 passively correctable to neutral upon physical exam

(goniometer); AND

BMI < 40

NOTE:

All requests for UKA in patients with chronic, painless effusion and extensive

radiographic arthritis will be evaluated on a case-by-case basis.





Grade III: Moderate multiple osteophytes, definite narrowing of joint space,

some sclerosis and possible deformity of bone contour

Grade IV: Large osteophytes, marked narrowing of joint space, severe

sclerosis and definite deformity of bone contour

Outerbridge Arthroscopic Grading System

Grade 0 Normal cartilage

Grade I Softening and swelling

Grade II Partial thickness defect, fissures < 1.5cm diameter

Grade III Fissures down to subchondral bone, diameter > 1.5cm

Grade IV Exposed subchondral bone

Contraindications:

o Local or systemic active infection

o Inflammatory arthritis

o Angular deformity or contracture greater than indicated range

o Significant arthritic involvement of other knee compartments

o Ligamentous instability (at least ACL [anterior cruciate ligament])

o Poor bone quality or significant osteoporosis or osteopenia

o Meniscectomy of the opposite compartment

o Stiffness greater than indicated range of motion

C. Revision Arthroplasty

Revision describes surgical reconstruction due to failure or complication of a previous

arthroplasty.

Revision TKA may be considered medically necessary when the following criteria are met:

Previous UKA/PKA or TKA joint; AND

_______________________________________________________________



Infection ruled out by synovial fluid aspiration/biospy (cell count and/or culture) AND off

antibiotics; OR


o Symptomatic UKA/PKA or TKA as evidence by persistent, severe disabling pain

and loss of function; AND

o Any of the following upon physical exam: tenderness to palpation objectively

attributable to the implant, swelling or effusion, pain on weight-bearing or

motion, instability on stress-testing, abnormal or limited motion compared to

usual function), palpable or audible crepitus associated with reproducible pain;

AND

o Aseptic loosening, osteolysis confirmed on radiographic or advanced imaging

(nuclear medicine bone scan, CT scan, MRI)

Contraindications:

Absolute contraindication:

o Local or systemic active infection

Relative contraindication: Any of the following:

o Deficiency of the extensor mechanism

o Neuropathic joint

o Unstable or poorly controlled comorbidities

o Severe peripheral vascular disease

o Compromised soft-tissue envelope (revision may be performed in conjunction with

plastic surgical consultation for soft tissue coverage via pedicle flaps or other

acceptable procedure)

Non-Covered Services:

The following procedures are not considered a covered service and are not reimbursable based

on lack of current scientific evidence for clinically important improvement, safety or efficacy;

or based on scientific evidence of increased risk of serious complications:

Procedures utilizing computer-navigated or patient-specific or gender-specific

instrumentation

Bicompartmental arthroplasty (investigational at this time)

Robot-assisted TKA (Makoplasty)

Other issues:

Manipulation following total knee arthroplasty:

o Nonsurgical treatment is initial treatment

o However, manipulation is indicated if within 3 months from time of primary

arthroplasty if physical therapy is unable to improve motion to satisfactory degree

If cause of arthrofibrosis/stiffness is due to technical error (component

malpositioning or inappropriate sizing), then surgical revision arthroplasty is

indicated

If cause of arthrofibrosis/stiffness is due to adhesions/capsular contraction,

then either arthroscopic or open lysis of adhesions is indicated

Poor dental hygiene (e.g. tooth extraction should be performed prior to arthroplasty). Major

dental work within 2 year after a joint replacement MAY lead to seeding of the implant and

possible revision surgery. If possible, all dental work must be completed prior to shoulder

arthroplasty as these procedures increase risk for infection. Following surgery, patients

should receive antibiotics for routine dental check-ups for a minimum of two years.

_______________________________________________________________



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_______________________________________________________________



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III: Changes in evidence following systematic cumulative update of research published through

January 2009." Osteoarthritis and Cartilage 18.4 (2010): 476-499.

_______________________________________________________________



TOC

27332 – Knee Arthroscopy

CPT Codes: 27332, 27333, 27403, 29868, 29880, 29881, 29882, 29883, 27405, 27407, 27409, 27427,

27428, 27429, 29888, 29889, 27412, 27415, 27416, 27418, 27420, 27422, 27424, 27425, 29866,

29867, 29870, 29873, 29874, 29875, 29876, 29877, 29879, G0289, 27570, 29884

INTRODUCTION:

This guideline describes surgical indications of both arthroscopy as well as open, non-arthroplasty

knee surgery. Also included are indications for knee manipulation. Arthroscopy introduces a fiber-

optic camera into the knee joint through a small incision for diagnostic visualization purposes.

Other instruments may then be introduced to remove, repair, or reconstruct intra- and extra-

articular joint pathology. Surgical indications are based on relevant subjective clinical symptoms,

objective physical exam and radiologic findings, and response to previous non-operative treatments

when medically appropriate. Open, non-arthroplasty knee surgeries are performed instead of an

arthroscopy as dictated by the type and severity of injury and/or disease and surgeon

skill/experience.


applications: Arthroscopic; Open, non-arthroplasty; Manipulation:

d) Diagnostic knee arthroscopy

e) Debridement with or without chondroplasty

f) Meniscectomy/meniscal repair

g) Ligament reconstruction/repair

i. Anterior cruciate ligament (ACL) reconstruction

ii. Posterior cruciate ligament (PCL) reconstruction

iii. Collateral ligament repair

h) Articular cartilage restoration/repair:

i. Marrow stimulating techniques (microfracture, drilling, abrasion

chondroplasty, augmented marrow-stimulation [BioCartilage])

ii. Restorative techniques (osteochondral autograft transfer system (OATS),

mosaicplasty, autologous chondrocyte implantation (ACI), osteochondral

allograft implantation, minced articular cartilage allograft transplantation

[DeNovo NT])

i) Synovectomy (major [2+ compartments], minor [1 compartment])

j) Loose body removal

k) Lateral release\patellar realignment

l) Manipulation under anesthesia (MUA)

m) Lysis of adhesions for arthrofibrosis of the knee

*Non-operative Treatment:

Throughout this document non-operative care* is defined as a combination of two or more of the

following:

Rest or activity modifications/limitations;

Ice/heat;

Protected weight bearing;

Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol

_______________________________________________________________



Brace/orthosis;

Physical therapy modalities;

Supervised home exercise;

Weight optimization;

Injections: cortisone, viscosupplementation, platelet rich plasma (PRP)



Grade I: Doubtful joint space narrowing and possible osteophytic lipping

Grade II: Definite osteophyte formation with possible joint space narrowing on

anteroposterior weight-bearing radiograph

Grade III: Multiple osteophytes, definite narrowing of joint space, some sclerosis and

possible bony deformity


definite bony deformity

***Outerbridge Arthroscopic Grading System


Grade I Softening and swelling/blistering

Grade II Partial thickness defect, fissures < 1.5cm diameter/wide

Grade III Fissures /defects down to subchondral bone with intact calcified cartilage layer,

diameter > 1.5cm

Grade IV Exposed subchondral bone

****The International Cartilage Research Society (ICRS)


Grade I Nearly normal. Superficial lesions.

A. Soft indentation

B. And/or superficial fissures and cracks

Grade II Abnormal. Lesions extending down to <50% of cartilage depth

Grade III Severely abnormal

A. Cartilage defects extending down >50% of cartilage depth

B. And down to calcified layer

C. And down to, but not through the subchondral bone

D. And blisters

Grade IV Severely abnormal (through the subchondral bone)

A. Penetration of subchondral bone but not across entire diameter of

defect

B. Penetration of subchondral bone across the full diameter of the

defect


A. Diagnostic Knee Arthroscopy

Diagnostic knee arthroscopy may be medically necessary when ALL of the following

criteria are met:

At least 3 months of knee pain with documented loss of function (deviation from

normal knee function which may include painful weight bearing, unstable

articulation, and/or inadequate range of motion (>10 degrees flexion contracture or

<90 degrees flexion or both) to accomplish activities of daily living (ADLs),

_______________________________________________________________



recreational activity, and/or employment (documentation of missed days of work or

modifications of work status due to injury/pain)); AND

At least 12 weeks of non-operative care* that has failed to improve symptoms; AND Clinical documentation of painful weight bearing, joint line tenderness, effusion

and/or limited motion compared to presymptomatic joint range; AND

Indeterminate radiographs AND MRI findings.

B. Debridement with or without Chondroplasty

Debridement may be medically necessary when ALL of the following criteria are met:

Knee pain with documented loss of function (deviation from normal knee function

which may include painful weight bearing, unstable articulation, and/or inadequate

range of motion (>10 degrees flexion contracture or <90 degrees flexion or both) to

accomplish activities of daily living (ADLs) and/or employment (documentation of

missed days of work or modifications of work status due to injury/pain)); AND

At least 12 weeks of non-operative care* that has failed to improve symptoms; AND

MRI results showing evidence of unstable chondral flap; AND

Recurrent (more than 2) or persistent effusion(s)

OR

Arthrofibrosis as evidence by physical exam findings of painful stiffness and loss of

motion due to proliferation of scar tissue in and around the joint. NOTE: Imaging is not necessary, but historically has been used to determine the diagnosis; AND

At least 6 weeks of supervised or self-directed physical therapy that has failed to

improve symptoms.

OR

Debridement chondroplasty for patellofemoral chondrosis when ALL of the following

criteria are met:

o Anterior knee pain and loss of function (deviation from normal pain-free

weight bearing, stable articulation, and/or range of motion to accomplish

activities of daily living (ADLs) and/or employment); AND

o Other extra-articular or intra-articular sources of pain or dysfunction have

been excluded (referred pain, radicular pain, tendinitis, bursitis, neuroma);

AND

o Physical exam localizes tenderness to the patellofemoral joint with pain

aggravated by activities that load the joint (single leg squat, ascending

>descending stairs, and being in seated position for extended periods of time

with knee flexed); AND

o Imaging (radiographs, MRI, or CT to measure tibial tubercle—trochlear

groove distance)

o At least 12 weeks of non-operative care has failed to improve symptoms; AND

o No evidence of osteoarthritis (Kellgren-Lawrence** Grade 3-4 based on

standing or weight-bearing radiographs and patellofemoral views))

NOTE: arthroscopic debridement with or without chondroplasty for osteoarthritis of the

knee is considered NOT MEDICALLY NECESSARY unless above criteria noted.

C. Meniscectomy/Meniscal Repair

Meniscectomy and/or meniscal repair may be medically necessary when the following

criteria are met:

_______________________________________________________________



Symptomatic meniscal tear confirmed by MRI results that show a peripheral

longitudinal tear in a vascular zone, associated with pain and mechanical symptoms

upon physical exam;

OR

Pediatric or adolescent patient has pain and mechanical symptoms upon physical

exam; AND

MRI results show unstable tear;

OR

When at least 3 of the following 5 criteria are met::

1. History of "catching" or "locking" as reported by the patient;

2. Knee joint line pain with forced hyperextension upon physical exam;

3. Knee joint line pain with maximum flexion upon physical exam;

4. Knee pain or an audible click with McMurray's maneuver upon physical exam;

5. Joint line tenderness to palpation upon physical exam; AND


One of the following radiographic findings:

o Radiographic findings without moderate or severe osteoarthritic changes; OR

o MRI results confirm meniscal tear in patients < 30 years of age; OR

o MRI results confirm displaced tear (any age);

OR

Meniscus tear encountered during other medically necessary arthroscopic procedure

Absolute Contraindications

Arthroscopic meniscectomy or meniscal repair is never medically necessary in the

presence of Kellgren-Lawrence Grade 4 osteoarthritis.

Relative Contraindications

Meniscectomy or repair is considered NOT MEDICALLY NECESSARY in the

presence of Kellgren-Lawrence Grade 3 osteoarthritis unless acute onset with

effusion, locking (note: locking only. This does not include catching, popping,

cracking), and MRI evidence of bucket-handle or displaced meniscal fragment that

correlates with the correct compartment (i.e. medial tenderness and locking for a

medial tear).

If grade 3 changes are present, only a meniscectomy may be indicated, not repair. If

evidence of meniscal extrusion on coronal MRI with/without subchondral edema,

arthroscopy is relatively contraindicated, even if tear is present.

BMI > 35

D. Ligament Reconstruction/Repair

Anterior Cruciate Ligament (ACL) Reconstruction with Allograft or Autograft:

ACL reconstruction or repair may be medically necessary when ALL of the following

criteria are met:

Knee instability (as defined subjectively as "giving way", "giving out", "buckling", two-

fist sign) with clinical findings of instability: Lachman’s 1A, 1B, 2A, 2B, 3A, 3B,

Anterior Drawer, or Pivot Shift, instrumented (KT-1000 or KT-2000) laxity of greater

than 3 mm side-side difference; AND

MRI results confirm complete ACL tear; AND

_______________________________________________________________



Patient has no evidence of severe arthritis (Kellgren-Lawrence** Grade 3 or 4)

OR

When ONE of the following criteria are met:

o MRI results confirm ACL tear associated with other ligamentous instability or

repairable meniscus; OR

o MRI results confirm partial or complete ACL tear AND patient has persistent

symptoms despite at least 12 weeks of non-operative care*; OR

o Acute ACL tear confirmed by MRI in high demand occupation or competitive

athlete (as quantified by Marx activity score for athletics (any score greater

than 4) and Tegner activity score for athletics and/or occupation (score greater

than 2)); AND

o Patient has no evidence of severe arthritis (Kellgren-Lawrence** Grade 3 or 4)

Tears in patients less than age 13 will be reviewed on a case by case basis.

Posterior Cruciate Ligament (PCL) Reconstruction:

PCL reconstruction or repair may be medically necessary when ALL of the following criteria

are met:

Knee instability (as defined subjectively as "giving way", "giving out", "buckling", two-

fist sign) with clinical findings of positive Posterior Drawer, posterior Sag, or

quadriceps active, or Dial test at 90 degrees knee flexion, reverse pivot shift test;

AND

MRI results confirm complete PCL tear; AND

Failed non-operative care (bracing in full extension successful in acute PCL tears);

AND

Absence of medial and patellofemoral K-L grade 3-4 changes in chronic tears;

OR

The following clinical scenarios will be considered and decided on a case-by-case

basis:

o pediatric and adolescent tears in patients with open physes or open growth

plates

o symptomatic partial tears with persistent instability despite non-operative

care

o incidental Kellgren-Lawrence Grade 2-3 osteoarthritis in acute/subacute tears

with unstable joint

Tears in patients less than age 13 will be reviewed on a case by case basis.

Collateral Ligament Repair or Reconstruction:

Collateral ligament repair or reconstruction should rarely occur independent of

additional repair or reconstruction surgery. All non-traumatic collateral ligament

repair/reconstruction requests will be reviewed on a case by case basis.

E. Articular Cartilage Restoration/Repair

Skeletally Immature Indications:


o Skeletally immature patient; AND

_______________________________________________________________



o Patient is symptomatic (pain, swelling, mechanical symptoms of popping,

locking, catching, or limited range of motion); AND

o radiographic findings (any radiograph and MRI) of a displaced lesion;

OR


o Skeletally immature patient; AND



o At least 12 weeks of non-operative care* has failed to improve symptoms; AND

o Radiographic findings (any radiograph and MRI) results finding of a stable

osteochondral lesion

OR


o Skeletally immature; AND

o Asymptomatic; AND

o At least 12 weeks of non-operative care has failed to improve lesion stability or

size; AND

o Radiographic findings (any radiograph and MRI) results finding of an

unstable osteochondral lesion

AND

Exclude patients with evidence of meniscal deficiency and/or malalignment IF these are

not being addressed (meniscal transplant and/or lateral release/patellar realignment

procedure) at the same time as the cartilage restoration procedure.

Skeletally Mature Indications, Listed By Surgical Approach:

Reparative marrow stimulation techniques (microfracture & drilling. Abrasion

arthroplasty is including in coding but is not indicated) may be medically necessary

when ALL of the following criteria are met:

o Skeletally mature adult; AND

o MRI confirms a full-thickness weight-bearing lesion that is < 2.5 sq.cm; AND



o Patient is less than 50 years of age; AND

o BMI < 35 (optimal outcomes if patient BMI <30); AND

o Physical exam findings and/or (imaging) results confirm knee has stable

ligaments; AND

o No evidence of prior meniscectomy in same compartment (medial femoral

condyle full thickness lesion and prior medial meniscectomy) unless

concurrent meniscal transplant performed.

OR

Restorative techniques (abrasion arthroplasty, osteochondral autograft transfer or

transplantation (OATS), mosaicplasty, autologous chondrocyte implantation (ACI),

osteochondral allograft implantation, minced articular cartilage allograft

transplantation [DeNovo NT])) may be medically necessary when ALL of the


o Skeletally mature adult; AND

_______________________________________________________________



o MRI results confirm a full thickness chondral or osteochondral lesion of the

femoral condyles or trochlea > 2.5 cm; AND

o Patient is less than 50 years of age; AND

o Patient has been symptomatic (pain, swelling, mechanical symptoms of

popping, locking, catching, or limited range of motion) for at least 6 months;

AND

o At least 6 months of non-operative care* has failed to improve symptoms;

AND

o MRI and/or physical findings confirm knee has normal alignment as defined

as +/- 3 degrees from neutral on full-length mechanical axis long-leg x-ray

(unless concurrent or staged tibial or femoral osteotomy performed) and

stability (unless concurrent ligamentous repair or reconstruction performed);

AND

o BMI < 35 (optimal outcomes if patient BMI <30); AND

o MRI shows no evidence of significant osteoarthritis (greater than Kellgren-

Lawrence Grade 2); AND

o No prior meniscectomy in same compartment (unless concurrent or staged

meniscal transplant performed)

OR

Surgical intervention for the treatment of patellofemoral chondrosis (osteochondral

autograft transfer or transplantation (OATS), microfracture, autologous chondrocyte

implantation (ACI), osteochondral allograft implantation, minced articular cartilage

allograft transplantation [DeNovo NT], debridement chondroplasty, tibial tubercle

osteotomy) may be medically necessary when ALL of the following criteria are met:

o Anterior knee pain and loss of function (deviation from normal knee function

which may include painful weight bearing, unstable articulation, and/or

inadequate range of motion (>10 degrees flexion contracture or <90 degrees

flexion or both) to accomplish activities of daily living (ADLs), recreational

activity, and/or employment (documentation of missed days of work or

modifications of work status due to injury/pain)); AND

o Other extra-articular or intra-articular sources of pain or dysfunction have

been excluded (referred pain, radicular pain, tendinitis, bursitis, neuroma);

AND

o Physical exam localizes tenderness to the patellofemoral joint with pain

aggravated by activities that load the joint (single leg squat, descending >

ascending stairs or stair climbing, and being in seated position for extended

periods of time with knee flexed); AND

o Radiologic imaging shows patellofemoral chondrosis graded 3 or 4 by the

Outerbridge Classification*** or ICRS**** (grade 3-4) classification

o At least 6 months of non-operative care has failed to improve symptoms; AND

o No evidence of osteoarthritis (Kellgren-Lawrence** Grade 3-4 based on

standing or weight-bearing radiographs )) in the medial/lateral compartments

F. Synovectomy (major [2+ compartments], minor [1 compartment])

Synovectomy may be medically necessary when ALL of the following criteria are met:

Proliferative rheumatoid synovium (in patients with established rheumatoid arthritis

according to the American College of Rheumatology Guidelines); AND

Not responsive to disease modifying drug (DMARD) therapy for at least 6 months and

at least 6 weeks of non-operative care that has failed to improve symptoms; AND

_______________________________________________________________



At least one instance of aspiration of joint effusion and cortisone injection (if no

evidence of infection);

OR

Hemarthrosis from injury, coagulopathy or bleeding disorder confirmed by physical

exam, joint aspiration, and/or MRI;

OR

Proliferative pigmented villonodular synovitis, synovial chondromatosis, sarcoid

synovitis, or similar proliferative synovial disease, traumatic hypertrophic synovitis

confirmed by history, MRI or biopsy; AND


At least one instance of aspiration of joint effusion and injection of cortisone (if no

evidence of infection);

OR

Detection of painful plica confirmed by physical exam and MRI findings; AND

At least 12 weeks of non-operative care* that has failed to improve symptoms.

At least one instance of aspiration of joint effusion OR single injection of cortisone

(effusion may not be present with symptomatic plica);

G. Loose Body Removal

Loose body removal may be medically necessary when the following criteria are met:

Removal of loose body or foreign object that causes limitation or loss of function

(deviation from normal knee function which may include painful weight bearing,

unstable articulation, and/or inadequate range of motion (>10 degrees flexion

contracture or <90 degrees flexion or both) to accomplish activities of daily living

(ADLs), recreational activity, and/or employment (documentation of missed days of

work or modifications of work status due to injury/pain)).

H. Lateral Release/Patellar Realignment:

This guideline describes indications for surgical procedures to address patellofemoral pain

disorders and abnormal alignment of the extensor mechanism of the knee by arthroscopic

and/or open surgical techniques. Surgical indications are based on relevant clinical

symptoms, physical exam, radiologic findings, and response to non-operative management

when medically appropriate.

Surgical intervention for the treatment of lateral patellar compression syndrome is

indicated when the following criteria are met:

o Evidence of lateral patellar tilt from radiologic images (patellofemoral view:

mercer merchant (45-60 degrees flexion); skyline (60-90 degrees flexion); sunrise

(60-90 degrees flexion); AND

o Associated lateral patella facet K-L changes grade 1, 2, or 3; AND

o Reproducible isolated lateral patellofemoral pain with patellar tile test; AND

o At least 6 months of non-operative care* has failed to improve symptoms

including appropriate hamstring/IT band stretching and patellar mobilization

techniques; AND

o No evidence of patellar dislocation without documented patellar tilt; AND

o No evidence of medial patellofemoral changes (Kellgren-Lawrence Grade 2

osteoarthritis or higher);

_______________________________________________________________



Surgical intervention for the treatment of patellar malalignment and/or patellar instability

is indicated when the following criteria are met:

o Acute traumatic patellar dislocation is associated with an osteochondral fracture,

loose body, vastus medialus obliquus/Medial patellofemoral ligament muscle

avulsion, or other intra-articular injury that requires urgent operative

management; OR

o Repeat (greater than 2) patellar dislocations or subluxations have occurred

despite 6 months of non-operative care* with radiologic confirmation of MPFL

(medial patellofemoral ligament) deficiency; OR

o Physical exam has patellofemoral tenderness and abnormal articulation of the

patella in the femoral trochlear groove (patellar apprehension with positive J

sign); AND

o Radiologic images rule out fracture or loose body, and show abnormal

articulation, trochlear dysplasia, or other abnormality related to malalignment;

AND

o CT scan or MRI rules out other abnormality to malalignment (tibial tubercle-

trochlear groove (TT-TG) distance > 20 millimeters); AND

o At least 6 months of non-operative care* has failed to improve symptoms

I. Manipulation under Anesthesia (MUA)

Manipulation under anesthesia (MUA) may be indicated when the following criteria are

met:

Physical exam findings demonstrate inadequate range of motion of the knee defined

as less than 105 degrees of flexion; AND

Failure to improve range of motion of the knee despite 6 weeks (12 visits) of

documented physical therapy; AND

Patient is less than 12 weeks after ligamentous or joint reconstruction.

J. Lysis of Adhesions for Arthrofibrosis of the knee

Surgical indications are based on relevant clinical symptoms, physical exam, radiologic

findings, time from primary surgery, and response to conservative management when

medically appropriate. Improved range of motion may be accomplished through

arthroscopically-assisted or open lysis of adhesions with general anesthesia, regional

anesthesia, or sedation.

Physical exam findings demonstrate inadequate range of motion of the knee, defined

as less than 105 degrees of flexion; AND

Failure to improve range of motion of the knee despite 6 weeks (12 visits) of

documented physical therapy; AND

Patient is more than 12 weeks after ligamentous or joint reconstruction, or resolved

infection; OR

Patient is more than 12 weeks after trauma, or resolved infection; AND

Patient has native knee; AND

Manipulation under anesthesia is also performed

_______________________________________________________________



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