Prior Authorization Review Panel MCO Policy Submission · New Policy Revised Policy* ......
Transcript of Prior Authorization Review Panel MCO Policy Submission · New Policy Revised Policy* ......
Prior Authorization Review Panel MCO Policy Submission
A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.
Plan: Aetna Better Health Submission Date:11/01/2019
Policy Number: 0029 Effective Date: Revision Date: 03/18/2019
Policy Name: Thermography
Type of Submission – Check all that apply:
New Policy Revised Policy*
Annual Review – NoRevisions Statewide PDL
*All revisions to the pol icy must be highlighted using track changes throughout the document.
Please prov ide a ny clarifying information for the p olicy below:
CPB 0029 Th ermography
Clinical content waslast revisedon 03/18/2019. No additional non-clinical updates were made by Corporate since the last PARPsubmission.
Name of Authorized Individual (Please t ype or print):
Dr. Bernard Lewin, M.D.
Signature o f Authorized Individual:
Revised July 22, 2019
Proprietary
(https://www.aetna.com/)
Thermography
Clinical Policy Bulletins Medical Clinical Policy Bulletins
Number: 0029
*Please see amendment for Pennsylvania Medicaid at the end of this CPB.
Aetna considers thermography (including digital infrared thermal imaging, magnetic resonance (MR)
thermography and temperature gradient studies) experimental and investigational for all indications including the
following (not an all-inclusive list) because available medical literature indicates thermography to be an ineffective
diagnostic technique:
Assessment of myofascial trigger points
Detection and screening for breast cancer
Detection of rupture-prone vulnerable coronary plaque
Determination of the efficacy of stroke rehabilitation
Diagnosis of complex regional pain syndrome
Diagnosis of musculoskeletal injuries
Diagnosis and management of vasculitis
Early identification of skin neoplasms
Esophageal monitoring
Evaluation of acute skin toxicity of breast radiotherapy
Evaluation of burn wounds
Evaluation of dry eye disease
Evaluation of leprosy
Evaluation and monitoring of individuals with Emery-Dreifuss muscular dystrophy
Joint assessment in individuals with inflammatory arthritis
Management of infantile hemangioma
Monitoring of diabetes mellitus
Pre- and peri-operative management of hidradenitis suppurativa
Prediction and detection of pressure ulcers
Prognosis of post-herpetic neuralgia
Screening for adolescent idiopathic scoliosis.
Last Review
03/18/2019
Effective: 07/21/1995
Next
Review: 01/09/2020
Review History
Definitions
Clinical Policy
Bulletin Notes
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Aetna considers dynamic infrared blood perfusion imaging (DIRI) for intra-operative and post-operative perfusion
assessment (e.g., assessment of skin blood perfusion in cranioplasty and flap evaluation) experimental and
investigational because of insufficient evidence regarding its clinical effectiveness.
Thermography
Thermography is the measurement of temperature variations at the body surface. The scientific evidence
suggests that thermography may only confirm the presence of a temperature difference, and that other
procedures are needed to reach a specific diagnosis. Thermography may add little to what doctors already know
based on history, physical examination, and other studies.
Thermography studies are non-invasive imaging techniques that are intended to measure the skin surface
temperature distribution of various organs and tissues. The infrared radiation from the tissues reveals
temperature variations by producing brightly colored patterns on a liquid crystal display. Interpretation of the color
pattern is thought to contribute to the diagnosis of many disorders including breast cancer, Raynaud's
phenomenon, digital artery vasospasm, impaired spermatogenesis in infertile men, deep vein thrombosis, reflex
sympathetic dystrophy/complex regional pain syndrome, vertebral subluxation, and others.
In contrast to the skin surface thermography techniques used by some chiropractors and other providers, a newer
invasive test called a temperature gradient study involves an intravenous catheter. The catheter is threaded into
the coronary arteries to directly measure temperature differences on the inner artery walls. Researchers believe
this information may be related to the presence of unstable coronary artery plaques and could be useful in
diagnosing vulnerable patients. Madjid et al (2006) have shown that inflamed atherosclerotic plaques are hot and
their surface temperature correlates with an increased number of macrophages and decreased fibrous-cap
thickness. Multiple animal and human experiments have shown that temperature heterogeneity correlates with
arterial inflammation in vivo. Several coronary temperature mapping catheters are currently being developed and
studied. These thermography methods can be used in the future to detect vulnerable plaques, potentially to
determine patients' prognosis, and to study the plaque-stabilizing effects of different medications.
A number of medical authorities have concluded that thermography has no proven medical value, including the
American Medical Association, the Office of Health Technology Assessment (OHTA), and the American Academy
of Neurology. Based on a study by the OHTA, the Health Care Financing Administration (now the Center for
Medicare and Medicaid Services) withdrew Medicare coverage of thermography.
Devices that have been used for thermography skin temperature differential analysis include the Nervoscope, the
Temp-O-Scope, and the Neurocalometer.
There is insufficient evidence for the use of thermography for detection of breast cancer. A structured evidence
review of thermography for breast cancer (Kerr, 2004) reached the following conclusions: "The evidence that is
currently available does not provide enough support for the role of infrared thermography for either population
screening or adjuvant diagnostic testing of breast cancer. The major gaps in knowledge at this time can only be
addressed by large-scale, prospective randomised trials. More robust research on the effectiveness and costs of
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technologically advanced infrared thermography devices for population screening and diagnostic testing of breast
cancer is needed, and the conclusions of this review should be revisited in the face of additional reliable
evidence".
Other reviews have also found a need for additional research on thermography. Kennedy et al (2009) noted that
thermography was first introduced as a screening tool for breast cancer in mid-1950s. However, after a 1977
study found thermography to lag behind other screening tools, the medical community lost interest in this
diagnostic approach. These researchers discussed each screening tool with a focus brought to thermography.
They stated that no single diagnostic tool provides excellent predictability; however, a combination that
incorporates thermography may boost both sensitivity as well as specificity. The authors concluded that in light of
technological advances and maturation of the thermographical industry, more research is needed to confirm the
potential of thermography in providing an effective non-invasive, low-risk adjunctive tool for the early detection of
breast cancer.
Mammography is currently the gold standard for breast cancer screening. Thus, sensitivities, specificities, as well
as positive and negative predictive values of thermography need to be compared with those of mammography in
order to ascertain if thermography is equivalent or superior to mammography. Presently, there is a lack of
scientific data comparing the 2 screening techniques. In addition, there are no published evidence-based
practice guidelines and/or position statements that recommend thermography as the appropriate method of
screening for early detection of breast cancer.
Arora et al (2008) examined the effectiveness of a non-invasive digital infrared thermal imaging (DITI) system in
the detection of breast cancer. A total of 92 patients for whom a breast biopsy was recommended based on prior
mammogram or ultrasound underwent DITI. Three scores were generated: (i) an overall risk score in the
screening mode, (ii) a clinical score based on patient i nformation, and (iii) assessment by artificial neural
network. Sixty of 94 biopsies were malignant and 34 were benign. Digital infrared thermal imaging identified 58
of 60 malignancies, with 97 % sensitivity, 44 % specificity, and 82 % negative predictive value depending on the
mode used. Compared to an overall risk score of 0, a score of 3 or greater was significantly more likely to be
associated with malignancy (30 % versus 90 %, p < 0.03). The author concluded that DITI is a valuable adjunct
to mammography and ultrasound, especially in women with dense breast parenchyma. Moreover, the authors
reported a high negative predictive value for thermography where "the location of the lesion under question based
on prior imaging was assessed to generate a positive or negative clinical assessment", i.e., where they were
unblinded to the results of the prior mammography or ultrasound. The specificity was only 11 % and the negative
predictive value of thermography was only 66 % in the blinded screening mode. Furthermore, the authors stated
that DITI is not currently recommended or approved as a substitute for screening mammography, and correlation
of findings on DITI should be made with alternative imaging techniques. They stated that further studies are
needed using a representative screening population of persons who have not been selected for biopsy based
upon prior imaging results.
An American Cancer Society report Mammograms and Other Breast Imaging Procedures (2010) stated that "
[t]hermography is a way to measure and map the heat on the surface of the breast using a special heat-sensing
camera. It is based on the idea that the temperature rises in areas with increased blood flow and metabolism,
which could be a sign of a tumor. Thermography has been around for many years, and some scientists are still
trying to improve the technology to use it in breast imaging. But no study has ever shown that it is an effective
screening tool for finding breast cancer early. It should not be used as a substitute for mammograms. Newer
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versions of this test are better able to find very small temperature differences. They may prove to be more
accurate than older versions, and are now being studied to find out if they might be useful in finding cancer".
Thermography is listed under "newer and experimental breast imaging methods" in this report.
Additionally, the United Kingdom's NHS Cancer Screening Programmes (2010) stated that "thermography is nota
replacement for mammography. It is a relatively new test and isn't reliable enough to use either to diagnose or
screen for cancer. Mammography is still the best test and is used as a world wide standard for breast screening
in women over 50".
The Food and Drug Administration (FDA, 2011) stated that breast thermography should not be used instead of
mammography, noting that thermography has not been approved as a stand-alone tool for breast cancer
screening or diagnosis. Telethermographic devices produce infrared images and do not require exposure to
radiation or breast compression, which some healthcare providers claim make them superior to mammographic
devices. However, the FDA stated that "there is simply no evidence" that breast thermography can take the place
of mammography. The agency has sent warning letters to manufacturers and practitioners who have made
misleading claims about breast thermography use.
Currently, there is insufficient evidence to support the use of thermography for the diagnosis of complex regional
pain syndrome (CRPS). The use of thermography in the diagnosis of CRPS type 1 (CRPS1) is based on the
presence of temperature asymmetries between the involved area of the extremity and the corresponding area of
the uninvolved extremity. However, the interpretation of thermographical images is subjective and not validated
for routine use. Huygen et al (2004) developed a sensitive, specific and reproducible arithmetical model as the
result of computer-assisted infra-red thermography in patients with early stage CRPS1 in one hand. Eighteen
patients with CRPS1 on one hand and 13 healthy volunteers were included in the study. The severity of the
disease was determined by means of pain questionnaires [visual analogue scale (VAS) pain and McGill Pain
Questionnaire], measurements of mobility (active range of motion) and edema volume. Asymmetry between the
involved and the uninvolved extremities was calculated by means of the asymmetry factor, the ratio and the
average temperature differences. The discrimination power of the 3 methods was determined by the receiver-
operating curve (ROC). The regression between the determined temperature distributions of both extremities
was plotted. Subsequently the correlation of the data was calculated. In normal healthy individuals the
asymmetry factor was 0.91 (0.01) (SD), whereas in CRPS1 patients this factor was 0.45 (0.07) (SD). The
performance of the arithmetic model based on the ROC curve was excellent. The area under the curve was 0.97
(p < 0.001), the sensitivity and specificity was 9 2% and 94 %, respectively. Furthermore, the temperature
asymmetry factor was correlated with the duration of the disease and VAS pain.
Gradl and colleagues (2003) stated that CRPS1 represents a frequent complication following distal radial
fractures. These investigators studied the value of clinical evaluation, radiography and thermography in the early
diagnosis of CRPS1. A total of 158 patients with distal radial fractures were followed-up for 16 weeks after
trauma. Apart from a detailed clinical examination 8 and 16 weeks after trauma, thermography and bilateral
radiographs of both hands were carried out. At the end of the observation period 18 patients (11 %) were
clinically identified as CRPS1. The severity of the preceding trauma and the chosen therapy did not influence the
process of the disease. Sixteen weeks after trauma easy differentiation between normal fracture patients and
CRPS1 patients was possible. Eight weeks after distal radial fracture clinical evaluation showed a sensitivity of
78 % and a specificity of 94 %. On the other hand, thermography (58 %) and bilateral radiography (33 %)
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revealed poor sensitivities. The specificity was high for radiography (91 %) and again poor for thermography (66
%). These authors concluded that the results of the study support the importance of clinical evaluation in the
early diagnosis of CRPS1. Plain radiographs facilitate the diagnosis as soon as bony changes develop.
Arterial wall thermography has also been used to identify rupture-prone vulnerable coronary plaque. However,
the clinical value of arterial thermography in interventional cardiology has not been established.
Schaar and colleagues (2007) noted that rupture of vulnerable plaques is the principal cause of acute coronary
syndrome and myocardial infarction. Identification of vulnerable plaques is therefore essential to enable the
development of treatment modalities to stabilize such plaques. Thermography is one of the several novel
methods being examined for detecting vulnerable plaques. It evaluates the temperature heterogeneity as an
indicator of the metabolic state of the plaque. The authors concluded that while several invasive and non
invasive techniques are currently under development to assess vulnerable plaques, none has proven its value in
an extensive in-vivo validation and all have a lack of prospective data.
García-García and colleagues (2008) stated that thin-capped fibroatheroma is the morphology that most
resembles plaque rupture. Detection of these vulnerable plaques in-vivo is essential to being able to study their
natural history and evaluate potential treatment modalities and, therefore, may ultimately have an important
impact on the prevention of acute myocardial infarction and death. The investigators reported that, currently,
conventional grayscale intra-vascular ultrasound, virtual histology and palpography data are being collected with
the same catheter during the same pullback. A combination of this catheter with either thermography capability
or additional imaging, such as optical coherence tomography or spectroscopy, would be an exciting
development. Intra-vascular magnetic resonance imaging also holds much promise. The investigators stated
that, to date, none of the techniques described above has been sufficiently validated and, most importantly, their
predictive value for adverse cardiac events remains elusive. The investigators concluded that very rigorous and
well-designed studies are needed for defining the role of each diagnostic modality. Until researchers are able to
detect in-vivo vulnerable plaques accurately, no specific treatment is warranted.
Madjid and colleagues (2006) stated that up to 2/3 of acute myocardial infarctions develop at sites of culprit
lesions without a significant stenosis. New imaging techniques are needed to identify those lesions with an
increased risk of developing an acute complication in the near future. Inflammation is a hallmark feature of these
vulnerable/high-risk plaques. These investigators have demonstrated that inflamed atherosclerotic plaques are
hot and their surface temperature correlates with an increased number of macrophages and reduced fibrous-cap
thickness. They noted that animal and human studies have reported that temperature heterogeneity correlates
with arterial inflammation in-vivo. Several coronary temperature mapping catheters are currently being
developed. These thermographic methods can be used in the future to detect vulnerable plaques, potentially to
ascertain patients' prognosis, and to examine the plaque-stabilizing effects of various pharmacotherapies.
Sharif and Murphy (2010) noted that critical coronary stenoses have been shown to contribute to only a minority
of acute coronary syndromes and sudden cardiac death. Autopsy studies have identified a subgroup of high-risk
patients with disrupted vulnerable plaque and modest stenosis. Consequently, a clinical need exists to develop
methods to identify these plaques prospectively before disruption and clinical expression of disease. Recent
advances in invasive as well as non-invasive imaging techniques have shown the potential to identify these high-
risk plaques. The anatomical characteristics of the vulnerable plaque such as thin cap fibro-atheroma and lipid
pool can be identified with angioscopy, high frequency intra-vascular ultrasound, intra-vascular magnetic
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resonance imaging (MRI), and optical coherence tomography. Efforts have also been made to recognize active
inflammation in high-risk plaques using intra-vascular thermography. Plaque chemical composition by measuring
electro-magnetic radiation using spectroscopy is also an emerging technology to detect vulnerable plaques. Non
invasive imaging with MRI, computed tomography, and positron emission tomography also holds the potential to
differentiate between low-risk and high-risk plaques. However, at present none of these imaging modalities is
able to detect vulnerable plaque nor have they been shown to definitively predict outcome. Nevertheless in
contrast, there has been a parallel development in the physiological assessment of advanced athero-sclerotic
coronary artery disease. Thus, recent trials using fractional flow reserve in patients with modest non flow-limiting
stenoses have shown that deferral of percutaneous coronary intervention with optimal medical therapy in these
patients is superior to coronary intervention. The authors concluded that further trials are needed to provide more
information regarding the natural history of high-risk but non flow-limiting plaque to establish patient-specific
targeted therapy and to refine plaque stabilizing strategies in the future.
There is insufficient evidence to support the use of thermography in post-herpetic neuralgia. Han and
associates (2010) examined the usefulness of infrared thermography as a predictor of post-herpetic neuralgia
(PHN). Infrared thermography was performed on the affected body regions of 110 patients who had been
diagnosed with acute herpes zoster (HZ). Demographical data collected included age, gender, time of skin
lesions onset, development of PHN, and co-morbidities. The temperature differences between the unaffected
and affected dermatome were calculated. Differences greater than 0.6 degrees C for the mean temperature
across the face and trunk were considered abnormal. The affected side was warmer in 35 patients and cooler in
33 patients than the contralateral side. A patient's age and disease duration affected treatment outcomes.
However, the temperature differences were not correlated with pain severity, disease duration, allodynia,
development of PHN, and use of anti-viral agents (p > 0.05). The authors concluded that a patient's age and
disease duration are the most important factors predicting PHN progression, irrespective of thermal findings, and
PHN can not be predicted by infrared thermal imaging.
An Agency for Healthcare Research and Quality's report on non-invasive diagnostic techniques for thedetection
of skin cancers (Parsons et al, 2011) listed thermography as one of the investigational diagnostic techniques for
the detection of skin cancers.
Kontos et al (2011) determined the sensitivity and specificity of DITI in a series of women who underwent surgical
excision or core biopsy of benign and malignant breast lesions presenting through the symptomatic clinic. Digital
infrared thermal imaging was evaluated in 63 symptomatic patients attending a 1-stop diagnostic breast clinic.
Thermography had 90 true-negative, 16 false-positive, 15 false-negative and 5 true-positive results. The
sensitivity was 25 %, specificity 85 %, positive-predictive value 24 %, and negative-predictive value 86 %. The
authors concluded that despite being non-invasive and painless, because of the low sensitivity for breast cancer,
DITI is not indicated for the primary evaluation of symptomatic patients nor should it be used on a routine basis as
a screening test for breast cancer.
The Canadian Agency for Drugs and Technologies in Health’s technology assessment on Infrared thermography
for population screening and diagnostic testing for breast cancer” (Morrison, 2012) states that “No randomized
controlled trials have been conducted that compare the effectiveness of thermography with mammography for
screening in well women, and there is no evidence regarding the cost-effectiveness of thermography used for
screening. Prospective cohort studies of symptomatic patients or patients with abnormal mammograms or
ultrasounds do not provide the type of evidence needed to justify the use of thermography for breast screening.
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Results indicate that thermography performance is worse than mammography in terms of sensitivity, specificity,
and predictive values; however, some of the studies’ authors have suggested there may be a role for
thermography as an adjunct diagnostic test in some cases”.
Kim et al (2012) evaluated the accuracy of the size and location of the ablation zone produced by volumetric MRI-
guided high-intensity focused ultrasound (HIFU) ablation of uterine fibroids on the basis of MR thermometric
analysis and assessed the effects of a feedback control technique. A total of 33 women with 38 uterine fibroids
were treated with an MR imaging-guided HIFU system capable of volumetric feedback ablation. Size (diameter
times length) and location (3-D displacements) of each ablation zone induced by 527 sonications (with [n = 471]
and without [n = 56] feedback) were analyzed according to the thermal dose obtained with MR thermometry.
Prospectively defined acceptance ranges of targeting accuracy were ± 5 mm in left-right (LR) and cranio-caudal
(CC) directions and ± 12 mm in antero-posterior (AP) direction. Effects of feedback control in 8- and 12-mm
treatment cells were evaluated by using a mixed model with repeated observations within patients. Overall mean
sizes of ablation zones produced by 4-, 8-, 12-, and 16-mm treatment cells (with and without feedback) were 4.6
mm ± 1.4 (standard deviation) × 4.4 mm ± 4.8 (n = 13), 8.9 mm ± 1.9 × 20.2 mm ± 6.5 (n = 248), 13.0 mm ± 1.2 ×
29.1 mm ± 5.6 (n = 234), and 18.1 mm ± 1.4 × 38.2 mm ± 7.6 (n = 32), respectively. Targeting accuracy values
(displacements in absolute values) were 0.9 mm ± 0.7, 1.2 mm ± 0.9, and 2.8 mm ± 2.2 in LR, CC, and AP
directions, respectively. Of 527 sonications, 99.8 % (526 of 527) were within acceptance ranges. Feedback
control had no statistically significant effect on targeting accuracy or ablation zone size. However, variations in
ablation zone size were smaller in the feedback control group. The authors concluded that sonication accuracy of
volumetric MRI-guided HIFU ablation of uterine fibroids appears clinically acceptable and may be further
improved by feedback control to produce more consistent ablation zones.
Brkljacic et al (2013) noted that breast cancer is a common malignancy causing high mortality in women
especially in developed countries. Due to the contribution of mammographic screening and improvements in
therapy, the mortality rate from breast cancer has decreased considerably. An imaging-based early detection of
breast cancer improves the treatment outcome. Mammography is generally established not only as diagnostic
but also as screening tool, while breast ultrasound plays a major role in the diagnostic setting in distinguishing
solid lesions from cysts and in guiding tissue sampling. Several indications are established for contrast-enhanced
MRI. Thermography was not validated as a screening tool and the only study performed long ago for evaluating
this technology in the screening setting demonstrated very poor results. The conclusion that thermography might
be feasible for screening cannot be derived from studies with small sample size, unclear selection of patients, and
in which mammography and thermography were not blindly compared as screening modalities. Thermography
cannot be used to aspirate, biopsy or localize lesions pre-operatively since no method so far was described to
accurately transpose the thermographic location of the lesion to the mammogram or ultrasound and to surgical
specimen. The authors concluded that thermography cannot be proclaimed as a screening method, without any
evidence whatsoever.
The Work Loss Data Institute’s guideline on “Low back -- lumbar & thoracic (acute & chronic)” (2013) listed
thermography (infrared stress thermography) as one of the interventions/procedures that was considered, but is
not recommended.
Sanchis-Sanchez et al (2014) noted that musculoskeletal injuries occur frequently. Diagnostic tests using ionizing
radiation can lead to problems for patients, and infra-red thermal imaging could be useful when diagnosing these
injuries. A systematic review was performed to determine the diagnostic accuracy of infra-red thermal imaging in
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patients with musculoskeletal injuries. A meta-analysis of 3 studies evaluating stress fractures was performed
and found a lack of support for the usefulness of infra-red thermal imaging (including thermography) in
musculoskeletal injuries diagnosis.
Dibai-Filho and Guirro (2015) reviewed recent studies published on the use of infra-red thermography (IRT) for
the assessment of myofascial trigger points (MTrPs). A search of the MEDLINE, CINAHL, PEDro, and SciELO
databases was carried out between November 2012 and January 2013 for articles published in English,
Portuguese, or Spanish from the year 2000 to 2012. Because of the nature of the included studies and the
purpose of this review, the analysis of methodological quality was assessed using the Quality Assessment of
Diagnostic Accuracy Studies tool. The search retrieved 11 articles, 2 of which were excluded based on language
(German and Chinese); 3 were duplicated in different databases, 1 did not use IRT for diagnostic purposes, and
the other did not use IRT to measure the skin temperature. Thus, the final sample was made up of 4
observational investigations: 3 comparative studies and 1 accuracy study. The authors concluded that at present,
there are few studies evaluating the accuracy and reliability of IRT for the diagnosis and assessment of MTrPs.
Of the few studies present, there is no agreement on skin temperature patterns in the presence of MTrPs.
Burke-smith et al (2015) states that currently the only evidence-based adjunct to clinical evaluation of burn depth
is laser Doppler imaging (LDI), although preliminary studies of alternative imaging modalities with instant image
acquisition are promising. These researchers investigated the accuracy of IRT and spectrophotometric
intracutaneous analysis (SIA) for burn depth assessment, and compared this to the current gold standard: LDI.
They included a comparison of the 3 modalities in terms of cost, reliability and usability. These investigators
recruited 20 patients with burns presenting to the Chelsea and Westminster Adult Burns Service. Between 48
hours and 5 days after burn, these researchers recorded imaging using (i) moorLDI2-BI-VR (LDI), (ii) FLIR E60
(IRT) and (iii) Scanoskin (SIA). Subsequent clinical management and outcome was as normal, and not affected
by the extra images taken. A total of 24 burn regions were grouped according to burn wound healing: group A
healed within 14 days, group B within 14 to 21 days, and group C took more than 21 days or underwent grafting.
Both LDI and IRT accurately determined healing potential in groups A and C, but failed to distinguish between
groups B and C (p > 0.05). Scanoskin interpretation of SIA was 100 % consistent with clinical outcome. The
authors concluded that FLIR E60 and Scanoskin both presented advantages to moorLDI2-BI-VR in terms of cost,
ease-of-use and acceptability to patients. Infra-red thermography is unlikely to challenge LDI as the gold
standard as it is subject to the systematic bias of evaporative cooling. At present, the LDI color-coded palette is
the easiest method for image interpretation, whereas Scanoskin monochrome color-palettes are more difficult to
interpret. However the additional analyses of pigment available using SIA may help more accurately indicate the
depth of burn compared with perfusion alone. The authors suggested development of Scanoskin software to
include a simplified color-palette similar to LDI and additional work to further investigate the potential of SIA as an
alternative to the current gold standard.
Evaluation of Burn Wounds
Prindeze and associates (2015) noted that despite advances in perfusion imaging, burn wound imaging
technology continues to lag behind that of other fields. Quantification of blood flow is able to predict time for
healing, but clear assessment of burn depth is still questionable. Active dynamic thermography (ADT) is a non-
contact imaging modality capable of distinguishing tissue of different thermal conductivities. Utilizing the
abnormal heat transfer properties of the burn zones, these researchers examined if ADT was useful in the
determination of burn depth in a model of early burn wound evaluation. Duroc pigs (castrated male; n = 3) were
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anesthetized, and 2 burns were created with an aluminum billet at 3 and 12 seconds. These contact times
resulted in superficial partial and deep partial thickness burn wounds, respectively. Active dynamic thermography
and laser Doppler imaging (LDI) imaging were performed every 30 minutes post-burn for a total of 5 imaging
sessions ending 150 minutes post-burn. For ADT, imaging excitation was performed for 42 to 120 seconds with
dual quartz-infrared lamps, and subsequent infrared image capture was performed for 300 seconds; MATLAB-
assisted image analysis was performed to determine burn zone region of interest thermal relaxation and
characteristic patterns. Laser Doppler imaging was performed with a moorLDI system, and biopsies were
captured for histology following the 150-minute imaging session. Both ADT and LDI imaging modalities were able
to detect different physical properties at 30, 60, 90, 120, and 150 minutes post-burn with statistical significance (p
< 0.05). Resultant ADT cooling curves characterized greater differences with greater stimulation and a potentially
more identifiable differential cooling characteristic. Histological analysis confirmed burn depth. The authors
concluded that this preliminary work confirmed that ADT can measure burn depth and is deserving of further
research either as a stand-alone imaging technology or in combination with a device to assess perfusion.
Burke-Smith and colleagues (2015) stated that the only evidence-based adjunct to clinical evaluation of burn
depth is LDI, although preliminary studies of alternative imaging modalities with instant image acquisition are
promising. These investigators examined the accuracy of IRT and spectrophotometric intracutaneous analysis
(SIA) for burn depth assessment, and compared this to the current gold standard: LDI. They included a
comparison of the 3 modalities in terms of cost, reliability and usability. These investigators recruited 20 patients
with burns presenting to the Chelsea and Westminster Adult Burns Service. Between 48 hours and 5 days post-
burn, these researchers recorded imaging using moorLDI2-BI-VR (LDI), FLIR E60 (IRT) and Scanoskin (SIA).
Subsequent clinical management and outcome was as normal, and not affected by the extra images taken. A
total of 24 burn regions were grouped according to burn wound healing: group A healed within 14 days, group B
within 14 to 21 days, and group C took more than 21 days or underwent grafting. Both LDI and IRT accurately
determined healing potential in groups A and C, but failed to distinguish between groups B and C (p > 0.05).
Scanoskin interpretation of SIA was 100 % consistent with clinical outcome. The authors concluded that FLIR
E60 and Scanoskin both presented advantages to moorLDI2-BI-VR in terms of cost, ease-of-use and
acceptability to patients. Infrared thermography is unlikely to challenge LDI as the gold standard as it is subject to
the systematic bias of evaporative cooling. At present, the LDI color-coded palette is the easiest method for
image interpretation, whereas Scanoskin monochrome color-palettes are more difficult to interpret. However the
additional analyses of pigment available using SIA may help more accurately indicate the depth of burncompared
with perfusion alone. The authors suggested development of Scanoskin software to include a simplified color-
palette similar to LDI, and additional work to further investigate the potential of SIA as an alternative to the current
gold standard.
Evaluation of Dry Eye Disease
Tan and colleagues (2016) evaluated the effectiveness of IR ocular thermography in screening for dry eye
disease (DED); IR ocular thermography was performed on 62 dry eye and 63 age- and sex-matched control
subjects. Marking of ocular surface and temperature acquisition was done using a novel “diamond” demarcation
method. A total of 30 static- and 30 dynamic-metrics were studied and receiver operating characteristic curves
were plotted. Effectiveness of the temperature metrics in detecting DED were evaluated singly and in
combination in terms of their area under the curve (AUC), Youden's index and discrimination power (DP).
Absolute temperature of the extreme nasal conjunctiva 5s and 10s after eye opening were best detectors for
DED. With threshold value for the first metric set at 34.7° C, sensitivity and specificity was 87.1 % (95 % CI: 76.2
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to 94.3 %) and 50.8 % (95 % CI: 37.9 to 63.6 %), respectively. With threshold value for the second metric set at
34.5°C, sensitivity and specificity was 77.6 % (95 % CI: 64.7 to 87.5 %) and 61.9 % (95 % CI: 48.8 to 73.9 %),
respectively. The 2 metrics had moderate accuracy and limited performances with AUC of 72 % (95 % CI: 63 to
81 %) and 73 % (95 % CI: 64 to 82 %); Youden index of about 0.4 and DP of 1.07 and 1.05, respectively. None
of the dynamic metrics was good detector for DED. Combining metrics was not able to increase the AUC. The
authors concluded that the findings of this study suggested some utility for the application of IR ocular
thermography for evaluation of patients with DED.
Evaluation of Leprosy
Cavalheiro and associates (2016) examined if IRT would be able to measure the change in temperature in the
hands of people with leprosy. The study assessed 17 leprosy patients who were under treatment at the National
Reference Center for Sanitary Dermatology and Leprosy, and 15 people without leprosy for the control group.
The infrared camera FLIR A325 and Therma CAM Researcher Professional 2.9 software were used to measure
the temperature. The room was air-conditioned, maintaining the temperature at 25° C; the distance between the
camera and the limb was 70 cm. The vasomotor reflex of patients was tested by a cold stress on the palm. The
study showed a significant interaction between the clinical form of leprosy and temperature, where the control
group and the borderline-borderline form revealed a higher initial temperature, while borderline-lepromatous and
lepromatous leprosy showed a lower temperature. Regarding vasomotor reflex, lepromatous leprosy patients
were unable to recover the initial temperature after cold stress, while those with the borderline-tuberculoid form
not only recovered but exceeded the initial temperature. The authors concluded that IRT proved a potential tool
to assist in the early detection of neuropathies, helping in the prevention of major nerve damage and the
installation of deformities and disabilities that are characteristic of leprosy.
Management of Infantile Hemangioma
In a preliminary, prospective, observational study, Burkes et al (2016) applied a functional imaging method,
dynamic IRT, to investigate infantile hemangiomas (IH) status versus control skin and over time. A total of 25
subjects with superficial or mixed IHs (age of less than 19 months) over 59 clinic visits were included in this
study. Infrared images of IHs and control sites, standardized color images, and three-dimensional (3D) images
were obtained. Tissue responses following application and removal of a cold stress were recorded with video
IRT. Outcomes included areas under the curve during cooling (AUCcool ) and rewarming (AUCrw ) and thermal
intensity distribution maps. AUCcool and AUCrw were significantly higher and cooling rate slower for IHs versus
uninvolved tissue indicating greater heat, presumably due to greater perfusion and metabolism for the IH. Infra
red distribution maps showed specific areas of high and low temperature. Significant changes in IH thermal
activity were reflected in the difference (AUCcool - AUCrw ), with 6.2 at 2.2 months increasing to 37.6 at 12.8
months; IH cooling rate increased with age, indicating slower recovery, and interpreted as reduced proliferation
and/or involution. The authors concluded that dynamic IRT was a well-tolerated, quantitative functional imaging
modality appropriate for the clinic, particularly when structural changes, i.e., height, volume, color, were not
readily observed. They stated that dynamic IRT may aid in monitoring progress, individualizing treatment, and
evaluating therapies.
Monitoring of Diabetes Mellitus
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Staffa et al (2016) stated that foot complications in persons with diabetes mellitus (DM) are associated with
substantial costs and loss of quality of life. Increasing evidence suggests changes in skin temperature, measured
using an IRT system, may be a predictor of foot ulcer development in patients with DM. In a case study, these
researchers described the long-term IRT findings and overall clinical outcomes of a patient with DM and
peripheral vascular disease (PVD). Foot temperature measurements using IRT were obtained slightly more than
1 year before and immediately following endovascular treatment of a 76-year old man, a non-smoker with type 2
DM, hypertension, and ischemic heart disease with cardiac arrhythmia. Although he was otherwise
asymptomatic, the infrared measurement showed an average temperature difference of 2.3˚ C between the left
and right foot until he developed a small, trauma-induced wound on the left foot, at which time left foot
temperature increased. He was diagnosed with recto-sigmoid adenocarcinoma, underwent surgery and
chemotherapy, and subsequently was evaluated for PVD. Before undergoing peripheral angiography and
percutaneous transluminal angioplasty, IRT evaluation showed a hot spot on the left heel. Immediately following
endovascular treatment, the mean temperature difference between the right and left foot was low (0.2˚ C), but a
Stage I pressure ulcer was visible on the left heel. Skin breakdown in that area was observed 2 months later, and
the wound continued to increase in size and depth. The patient died shortly thereafter due to complications of
cancer. In this case study, a series of infrared images of foot skin temperatures appeared to show a relationship
with blood circulation and wound/ulcer development and presentation. The authors concluded that IRT has the
ability to instantaneously measure the absolute temperature of the skin surface over a large area without direct
skin contact. However, they stated that these devices are very sensitive; and prospective clinical studies are
needed to determine the validity, reliability, sensitivity, and specificity of these measurements for routine use in
patients who are at risk for vascular disease and/or foot ulcers.
Predicting Pressure Ulcers
In a systematic review, Oliveira and colleagues (2017) examined the clinical significance of ultrasound (US),
thermography, photography and sub-epidermal moisture (SEM) measurement in detecting skin/tissue damage
and thus predicting the presence of pressure ulcers (PUs); determined the relative accuracy of one of these
assessment methods over another; and made recommendations for practice pertaining to assessment of early
skin/tissue damage. The following databases, Cochrane Wounds Group Specialized Register, the Cochrane
Central Register of Controlled Trials, Ovid Medline, Ovid Embase, Elsevier version, Ebsco CINAHL,
ClinicalTrials.gov , WHO International Clinical Trials Registry (ICTR) and The EU Clinical Trials Register were
searched for terms including; thermography, ultrasound, sub-epidermal moisture, photograph and pressure ulcer.
These investigators identified 4 SEM, 1 thermography and 5 ultrasound studies for inclusion in this review. Data
analysis indicated that photography was not a method that allowed for the early prediction of PU presence; SEM
values increased with increasing tissue damage, with the sacrum and the heels being the most common
anatomical locations for the development of erythema and stage I PUs. Thermography identified temperature
changes in tissues and skin that may give an indication of early PU development; however the data were not
sufficiently robust; US detected pockets of fluid/edema at different levels of the skin that were comparable with
tissue damage. Thus, SEM and US were the best methods for allowing a more accurate assessment of early
skin/tissue damage. Using the EBL Critical Appraisal Tool, the validities of the studies varied between 33.3 to
55.6 %, meaning that there is potential for bias within all the included studies. All of the studies were situated at
level IV, V and VII of the evidence pyramid. These researchers noted that although the methodological quality of
the studies warrants consideration, these studies showed the potential that SEM and US have in early PU
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detection. The authors concluded that SEM and US are promising in the detection and prediction of early tissue
damage and PU presence. However, they stated that these methods should be further studied to clarify their
potential for use more widely in PU prevention strategies.
Determining the Efficacy of Stroke Rehabilitation
Hegedus (2018) stated that maintaining good physiological circulation in the extremities requires an optimally
functioning muscle pump. Stroke symptoms indicate a change in venous circulation. In this study, these
researchers measured changes in joint function and microcirculation, and the correlation between them. A total
of 16 randomly selected post-stroke patients with hemiparesis affecting mainly the upper extremities began
undergoing rehabilitation 13 ± 4 days following stroke. Thermograms were taken with a Fluke Ti 20 (Fluke
Corporation, WA) pre-treatment and post-treatment, and a physiotherapy documentation form was completed.
Treatment comprised 15 physiotherapy, massage, and galvanic therapy sessions per patient, with the side
exhibiting no neurological symptoms as a control. Joint function showed significant improvement on the affected
side (p < 0.05). Thermographic examinations revealed microcirculatory dysfunction in the affected extremities in
100 % of the cases. Following treatment, temperature increased significantly (p ≥ 0.5°C) on the affected side. A
strong correlation (r) was observed between joint function and temperature change (p < 0.05). The authors
concluded that thermography was shown to be a reliable method for monitoring the effects of stroke rehabilitation
treatment. They stated that thermographic testing may enable clinicians to predict the course of the trauma and
the effectiveness of treatment even at the acute stage.
Thermography for Evaluating Acute Skin Toxicity of Breast Radiotherapy
Maillot and associates (2018) stated that radiotherapy is a common adjuvant treatment of breast cancer. Acute
radiation-induced dermatitis is a frequent side effect. These researchers hypothesized whether it is possible to
capture the increase of local temperature as a surrogate of the inflammatory state induced by radiotherapy. They
designed a prospective, observational, single-center study to acquire data on temperature rise in the treated
breast during the course of radiotherapy, establish a possible association with the occurrence of dermatitis and
examine the predictive value of temperature increase in future occurrences of radiation-induced dermatitis. All
patients presenting for neoadjuvant or adjuvant radiotherapy during the course of breast cancer treatment at the
university hospital of Martinique were considered for inclusion. Every week, patients were examined by 2 trained
investigators for the occurrence of radiation-induced dermatitis, graded based on Radiotherapy Oncology Group,
Common Terminology Criteria for Adverse Events v.4.0 and Wright scales. A frontal thermal image of torso was
taken in strictly controlled conditions, with a calibrated TE-Q1 camera (Thermal Expert, i3systems, Daejeon,
Korea). These investigators studied temperature differences between the irradiated breast or thoracic wall and
the contralateral area. For each thermal picture, these researchers measured the difference in maximum
temperature as well as the difference in minimum temperature and the difference in the average temperature in
the considered area. They studied the evolution of these parameters over time (week after week), measuring the
maximum recorded difference and its correlation to acute radiation dermatitis intensity. A total of 64 consecutive
patients were included. For all patients, these investigators noticed an increase of temperature during the course
of radiotherapy. Difference in maximum, minimum and average temperature was higher between the 2 breasts of
patients with a radiation-induced dermatitis grade 2 or above compared to patients with no or mild dermatitis.
Higher temperatures were also significantly associated with an increased sensation of discomfort, as recorded by
questionnaire (p < 0.05). The authors concluded that as expected from the inflammatory phenomena involved in
radiation-induced dermatitis, a noticeable increase in temperature during the course of radiotherapy was
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observed in all patients. Furthermore, high-grade radiation-induced dermatitis was strongly associated with an
additional increase in local temperature, which was probably linked to the intense inflammatory reaction. Lastly,
with a 1.4°C threshold set beforehand, it was possible to anticipate the occurrence of radiation-induced
dermatitis, with interesting positive and negative predictive values (PPV and NPV) of 70 % and 77 %, respectively
in this population. Moreover, these researchers stated that these findings need to be confirmed in a dedicated
study.
Thermography for Evaluating and Monitoring of Individuals Emery-Dreifuss Muscular Dystrophy
Cabizosu and colleagues (2018) noted that Emery-Dreifuss muscular dystrophy (EDMD) is a clinical condition
characterized by neuro-skeletal and cardiac impairments. By means of thermography, new insights could be
obtained regarding the evaluation and follow-up of this disease. Actually, musculoskeletal disorders are a major
cause of counseling and access to rehabilitation services and are some of the most important problems that
affect the quality of life of many people. There are urgent clinical and research needs for the assessment and
follow-up of patients with EDMD. These researchers offered a new possible hypothesis of validating
thermographic techniques that support the evaluation and clinical follow-up of the EDMD. They relied on
evidence of existing bibliography. These investigators performed a systematic review; and after the application of
an automatic and manual filter, inclusion and exclusion criteria, no study was obtained. There is a lack of
evidence on the use of thermography in EDMD. Due to a lack of information, these researchers expanded the
search to studies concerning the use of thermography in relation to alterations of the musculoskeletal system
compatible with those of EDMD, genetic diseases related to the X chromosome and more generally muscular
atrophy. Based on other studies performed in diseases that showed signs and symptoms similar to EDMD, the
authors believed that a new line of translational research could be opened with novel findings and they thought
thermography could be an optimal tool for the clinical monitoring of this pathology. These researchers believed
that it would be of a great importance to carry out an observational study, to lay the foundations for future work,
that relate thermography to EDMD.
Thermography for Joint Assessment in Individuals with Inflammatory Arthritis
Jones and associates (2018) noted that rheumatoid arthritis (RA) is a common inflammatory disease that causes
destruction of joints. Accurate recognition of active disease has significant implications in determining
appropriate treatment; however, there is significant inter-rater variability in clinical joint assessment. In a cross-
sectional study, these researchers evaluated the use of thermographic imaging in the evaluation of inflammatory
arthritis activity as an adjunct to clinical assessment. This trial included 79 subjects recruited from the University
of Alberta out-patient rheumatology clinic. These investigators compared the hand joints of 49 patients with RA
diagnosed by American College of Rheumatology (ACR) criteria to 30 healthy volunteers. Convenience sampling
of consecutive RA patients was undertaken. The effect of clinical assessment (HAQ and DAS-28) on joint
temperature was evaluated using a linear mixed effect model. A thermography camera, FLIR T300 model, 30
Hz, was used to obtain both thermographic and digital images on subjects. Pearson's correlation coefficient was
used to assess the correlation of clinical assessments and average joint temperature averaged over all joints.
Thermographic analysis did not associate with clinical measures of disease activity. In RA patients, there was no
statistically significant relationship between joint temperature and clinical assessment of disease activity including
Health Assessment Questionnaire (coefficient estimate - 0.54, p = 0.056), swollen joints (coefficient estimate - 0.09,
p = 0.238), or serologic markers of inflammation such as C-reactive protein (CRP; coefficient estimate - 0.006,
p = 0.602) and erythrocyte sedimentation rate (ESR; coefficient estimate - 0.01, p = 0.503). The authors
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concluded that evaluation of disease activity requires a multi-faceted approach that includes clinical assessment
and appropriate imaging. They stated that there may be a role for thermography in assessment of larger joints;
however, it does not appear to be an effective modality for the small joints of the hand.
Thermography for Pre- and Peri-Operative Management of Hidradenitis Suppurativa
Derruau and co-workers (2018) stated that hidradenitis suppurativa (HS) is a chronic, inflammatory, and recurrent
skin disease. Surgical excision of wounds appears to be the only curative treatment for the prevention of
recurrence of moderate-to-severe stages; MRI is a standard reference examination for the detection of HS peri
anal inflammatory fistula. In this case study, the use of real-time medical infrared thermography (MIT), in
combination with MRI as appropriate imaging, was proposed. The objective was to assist surgeons in the pre
and peri-surgical management of severe perianal HS with the intent to ensure that all diseased lesions were
removed during surgery and therefore to limit recurrence. The results showed that MIT, combined with MRI,
could be a highly effective strategy to address thermally distinguished health tissues and inflammatory sites
during excision, as characterized by differential increases in temperature. Medical infrared thermography could
be used to check the total excision of inflammatory lesions as a non-invasive method that is not painful, not
radiant, and is easily transportable during surgery. The authors concluded that this method could be
complementary with MRI in providing clinicians with objective data on the status of tissues below the perianal skin
surface in the pre- and peri-operating management of severe HS. This was a single-case study; its findings need
to be validated by well-designed studies.
Infrared Thermography for Diagnosis and Management of Vasculitis, Early Identification of Skin Neoplasms, Esophageal Monitoring, and Screening for Adolescent Idiopathic Scoliosis
Lin and colleagues (2018) noted that vasculitis is a clinical condition with associated diagnostic challenges due to
non-specific symptoms and lack of a confirmatory imaging modality. These investigators reported a case of a 39
year old woman who developed generalized malaise, lethargy, and headache. Laboratory evaluation showed
elevated inflammatory markers. Conventional imaging studies including computed tomography (CT) and carotid
duplex ultrasound (US) were unremarkable. Infrared thermography revealed enhanced thermographic signals in
the left carotid artery and aortic arch. Corticosteroid therapy was commenced, and the patient responded well.
Follow-up infrared thermography at 6 months showed complete resolution of the thermographic pattern, and the
patient remained symptom-free. The authors concluded that this case highlighted the potential clinical utility of
using infrared thermography in patients with vasculitis. The enhanced thermal signals in the aortic arch and
carotid artery provided valuable information in the diagnosis and treatment of arteritis in this patient. This
technology was similarly beneficial in subsequent surveillance evaluation once the patient completed the
prescribed treatment. Moreover, they stated that further studies are needed to determine the clinical sensitivity
and diagnostic accuracy of this imaging modality in vasculitis.
Magalhaes and associates (2018) stated that infrared thermal imaging captures the infrared radiation emitted by
the skin surface. The thermograms contain valuable information, since the temperature distribution can be used
to characterize physiological anomalies. Thus, the use of infrared thermal imaging (IRT) has been studied as a
possible tool to aid in the diagnosis of skin oncological lesions. These researchers evaluated the current state of
the applications of IRT in skin neoplasm identification and characterization. They carried out a literature survey
using the reference bibliographic databases: Scopus, PubMed and ISI Web of Science. Keywords
(thermography, infrared imaging, thermal imaging and skin cancer) were combined and its presence was verified
at the title and abstract of the article or as a main topic. Only articles published after 2013 were considered
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during this search. A total of 55 articles were encountered, resulting in 14 publications for revision after applying
the exclusion criteria. It was denoted that IRT have been used to characterize and distinguish between malignant
and benign neoplasms and different skin cancer types; IRT has also been successfully applied in the treatment
evaluation of these types of lesions. The authors concluded that trends and future challenges have been
established to improve the application of IRT in this field, disclosing that dynamic infrared thermography is a
promising tool for early identification of oncological skin conditions.
Daly and co-workers (2018) noted that catheter ablation for atrial fibrillation (AF) has potential to cause
esophageal thermal injury. Esophageal temperature monitoring during ablation is commonly used; however, it
has not eliminated thermal injuries, possibly because conventional sensors have poor spatial sampling and
response characteristics. To enhance understanding of temperature dynamics that may underlie esophageal
injury, these researchers tested a high-resolution, intra-body, infrared thermography catheter to continuously
image esophageal temperatures during ablation. Patients undergoing AF ablation were instrumented with a
flexible, 9F infrared temperature catheter inserted nasally (n = 8) or orally (n = 8) into the esophagus adjacent to
the left atrium. Ablation was performed while the infrared catheter continuously recorded surface temperatures
from 7,680 points/sec circumferentially over a 6-cm length of esophagus. Physicians were blinded to temperature
data. Endoscopy was performed within 24 hours to document esophageal injury. Thermal imaging showed that
most patients (10/16) experienced greater than or equal to 1 events where peak esophageal temperature was
over 40° C; 3 patients experienced temperatures over 50° C; and 1 experienced over 60 °C. Analysis of
temperature data for each subject's maximum thermal event revealed high gradients (2.3 ± 1.4° C/mm) and rates
of change (1.5 ± 1.3° C/sec) with an average length of esophageal involvement of 11.0 ± 5.4 mm. Endoscopy
identified 3 distinct thermal lesions, all in patients with temperatures over 50° C; all resolved within 2 weeks. The
authors concluded that infrared thermography provided dynamic, high-resolution mapping of esophageal
temperatures during cardiac ablation. Esophageal thermal injury occurred with temperatures of over 50° C and
was associated with large spatiotemporal gradients. Moreover ,they stated that additional studies are needed to
determine the relationships between thermal parameters and esophageal injury.
In an editorial that accompanied the afore-mentioned study by Daly et al (2018), Borne and Nguyen (2018) stated
that “it is important to note the multiple limitations of esophageal temperature monitoring. First, to be effective,
esophageal monitoring must accurately reflect the esophageal temperature. The esophagus is a broad and
patulous structure, and the position of a temperature probe might not align with the ablation catheter such that
monitoring might provide a false sense of security. In a prior investigation in which 2 commercially available
probes (9F esophageal probe and an 18F esophageal stethoscope) were used among patients undergoing
ablation, there were significant differences in the peak temperature and rise in temperature between the probes,
suggesting that significant temperature variation exists among frequently used temperature probes. Second,
there is evidence to suggest that the use of a temperature probe can be potentially harmful. In an ex vivo model,
ablation near a non-insulated multi-sensor esophageal probe significantly increased temperatures in the tissues
adjacent to the ablation lesion compared with lesions without a nearby temperature probe. This was echoed in
clinical work in which patients undergoing AF ablation were enrolled prospectively to receive an esophageal
temperature probe-guided ablation strategy versus no temperature monitoring … The study has some notable
limitations. First, there is limited validation of this technology for esophageal temperature monitoring. A previous
report described the use of infrared probes to monitor esophageal temperatures in a swine model, which were
significantly higher than conventional probes. The current authors reported their experience with the first-in
human use of the IRTC in a patient undergoing PVI. Rigorous ex vivo and in vivo experiments need to be
performed, establishing best practices and limitations of this technology, including how distance and location of
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the IRTC and ablation catheter affect temperature readings, if interactions between radiofrequency ablation and
the probe exist and correlations to multiple different conventional temperature probes. Second, lesions identified
on endoscopy were not correlated to specific ablation lesions and their characteristics (i.e., contact force, force-
time integral). To best define risk for esophageal injury and thereby allow for risk modification, ablation
characteristics and IRTC esophageal temperatures need to be analyzed. For instance, is the risk of esophageal
injury related to a time-temperature phenomenon, is it a structural/anatomic phenomenon, or is it related other
factors that result in visible injury in some but not other ablation lesions causing temperatures >50° C? If lesions
identified on endoscopy did not correlate to higher esophageal temperatures, it is hard to know how temperature
monitoring would guide ablation … Although further work needs to be performed in establishing the use of
infrared thermography, the authors should be commended on their work for developing a system that has the
potential to provide useful temperature monitoring data to improve the safety of AF catheter ablation. Although
the question remains as to what the optimal approach to avoid esophageal injury is, this study provides evidence
to suggest that more accurate esophageal temperature monitoring is possible. Until then, we should remain on
red alert for risks of esophageal injury, in order to keep catheter ablation safe”.
Kwok and colleagues (2017) stated that adolescent idiopathic scoliosis (AIS) is a multi-factorial, 3-D deformity of
the spine and trunk. School scoliosis screening (SSS) is recommended by researchers as a means of early
detection of AIS to prevent its progression in school-aged children. The traditional screening technique for AIS is
the forward-bending test because it is simple, non-invasive and inexpensive. Other tests, such as the use of
Moiré topography, have reduced the high false referral rates. These researchers examined the use of infrared
(IR) thermography for screening purposes based on the findings of previous studies on the asymmetrical para
spinal muscle activity of scoliotic patients compared with non-scoliotic subjects; IR thermography was performed
with an IR camera to determine the temperature differences in para-spinal muscle activity. A statistical analysis
showed that scoliotic subjects demonstrated a statistically significant difference between the left and right sides of
the regions of interest. This difference could be due to the higher IR emission of the convex side of the observed
area, thereby creating a higher temperature distribution. The authors concluded that the findings of this study
suggested the feasibility of incorporating IR thermography as part of SSS. Moreover, they stated that future
studies could also consider a larger sample of both non-scoliotic and scoliotic subjects to further validate the
findings.
Intraoperative Infra-Red Thermography in Surgery of Glioblastoma Multiforme
Naydenov and colleagues (2017) noted that IRT is a real-time non-contact diagnostic tool with a broad potential
for neurosurgical applications. These researchers described the intraoperative use of this technique in a single
patient with newly diagnosed glioblastoma multiforme (GBM). An 86-year old woman was admitted in the clinic
with a 2-month history of slowly progressing left-sided paresis. Neuroimaging studies demonstrated an irregular
space-occupying process consistent with a malignant glioma in the right fronto-temporo-insular region. An
elective surgical intervention was performed by using 5-aminolevulinic acid fluorescence (BLUE 400, OPMI) and
intraoperative IRT brain mapping (LWIR, 1.25 mRad IFOV, 0.05°C NETD). After dura opening, the cerebral
surface appeared inconspicuous. However, IRT revealed a significantly colder area (Δt° 1.01°C), well
corresponding to the cortical epicenter of the lesion. The underlying tumor was partially excised and the
histological result was GBM. The authors concluded that intraoperative IRT appeared to be a useful technique
for subcortical convexity brain tumor localization. Moreover, they stated that further studies with a large number
of patients are needed to prove the reliability of this method in GBM surgery.
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Dynamic Infrared Blood Perfusion Imaging
Dynamic infrared blood perfusion imaging (DIRI) is a new infrared imaging technique that is intended to detect
changes in blood flow in tissue and organs by sensing passively emitted infrared radiation from tissues. Potential
clinical applications of DIRI include: use as an adjunctive screening tool for breast cancer and other cancers;
evaluation of response to cancer chemotherapy; monitoring response to therapy in diabetic peripheral vascular
disease; identifying perforator vessels during pre-surgical planning; assessing post-operative perfusion of pedicle
flaps following reconstructive surgery (i.e., of the breast); mapping of functional cortex in patients undergoing
tumor surgery; and determining cardiac bypass graft patency and perfusion of the myocardium in cardiac
surgery. Agostini and colleagues (2009) stated that dynamic infrared imaging is a promising technique in breast
oncology. Currently available evidence, however, is limited to evaluations of DIRI's technical feasibility. There is
an absence of evidence of the impact of DIRI on health outcomes. The BioScanIR System (OmniCorder
Technologies, Inc., Bohemia, NY) is an example of a DIRI device that is commercially available.
Lohman et al (2015) stated that over the last decade, microsurgeons have used a greater variety of more
complex flaps. At the same time, microsurgeons have also become more interested in technology, such as indo
cyanine green (ICG) angiography, dynamic infra-red thermography (DIRT), and photo-spectrometry, for pre
operative planning and post-operative monitoring. These technologies are now migrating into the operating room,
and are used to optimize flap design and to identify areas of hypo-perfusion or problems with the anastomoses.
Although relatively more has been published about ICG angiography, information is generally lacking about the
intra-operative role of these techniques. A systematic analysis of articles discussing intra-operative ICG
angiography, DIRT, and photo-spectrometry was performed to better define the sensitivity, specificity, expected
outcomes, and potential complications associated with these techniques. For intra-operative ICG angiography,
the sensitivity was 90.9 % (95 % confidence interval [CI]: 77.5 to 100) and the accuracy was 98.6 % (95 % CI:
97.6 to 99.7). The sensitivity of DIRT was 33 % (95 % CI: 11.3 to 64.6), the specificity was 100 % (95 % CI: 84.9
to 100), and the accuracy was 80 % (95 % CI: 71.2 to 89.7). The sensitivity of intra-operative photo-spectrometry
was 92 % (95 % CI: 72.4 to 98.6), the specificity was 100 % (95 % CI: 98.8 to 100), and the accuracy was also
100 % (95 % CI: 98.7 to 100). The authors concluded that these technologies for intra-operative perfusion
assessment have the potential to provide objective data that may improve decisions about flap design and the
quality of microvascular anastomoses. However, more work is needed to clearly document their value.
Just and colleagues (2016) investigated static IRT and DIRT for intra- and post-operative free-flap monitoring
following oropharyngeal reconstruction. A total of 16 patients with oropharyngeal reconstruction by free radial
forearm flap were included in this prospective, clinical study. Prior ("intraop_pre") and following ("intraop_post")
completion of the microvascular anastomoses, IRT was performed for intra-operative flap monitoring. Further IR
images were acquired 1 day ("postop_1") and 10 days ("postop_10") after surgery for post-operative flap
monitoring. Of the 16, 15 transferred free radial forearm flaps did not show any perfusion failure. A significant
decreasing mean temperature difference (∆T: temperature difference between the flap surface and the
surrounding tissue in Kelvin) was measured at all investigation points in comparison with the temperature
difference at "intraop_pre" (mean values on all patients: ∆T intraop_pre = -2.64 K; ∆T intraop_post = -1.22 K, p <
0.0015; ∆T postop_1 = -0.54 K, p < 0.0001; ∆T postop_10 = -0.58 K, p < 0.0001). Intra-operative DIRT showed
typical pattern of non-pathological rewarming due to re-established flap perfusion after completion of the
microvascular anastomoses. The authors concluded that static and dynamic IRT is a promising, objective method
for intra-operative and post-operative monitoring of free-flap reconstructions in head and neck surgery and to
detect perfusion failure, before macroscopic changes in the tissue surface are obvious. They noted that a lack of
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significant decrease of the temperature difference compared to surrounding tissue following completion of
microvascular anastomoses and an atypical re-warming following a thermal challenge are suggestive of flap
perfusion failure.
Dynamic Infrared Blood Perfusion Imaging (DIRI) for Assessment of Skin Blood Perfusion in Cranioplasty
Rathmann and colleagues (2018) noted that complications in wound healing after neurosurgical operations occur
often due to scarred dehiscence with skin blood perfusion disturbance. The standard imaging method for intra-
operative skin perfusion assessment is the invasive indocyanine green video angiography (ICGA). The non
invasive dynamic infrared thermography (DIRT) is a promising alternative modality that was evaluated by
comparison with ICGA. These researchers performed a proof-of-concept study for qualitative comparison of
DIRT with the standard ICGA. This trial was carried out in 2 parts: investigation of technical conditions for intra-
operative use of DIRT for its comparison with ICGA, and visual and quantitative comparison of both modalities in
9 patients. Time-temperature curves in DIRT and time-intensity curves in ICGA for defined regions of interest
were analyzed. New perfusion parameters were defined in DIRT and compared with the usual perfusion
parameters in ICGA. The visual observation of the image data in DIRT and ICGA showed that operation material,
anatomical structures and skin perfusion were represented similarly in both modalities. Although the analysis of
the curves and perfusion parameter values showed differences between patients, no complications were
observed clinically. These differences were represented in DIRT and ICGA equivalently. The authors concluded
that DIRT has shown a great potential for intra-operative use, with several advantages over ICGA. The technique
is passive, contactless and non-invasive. The practicability of the intra-operative recording of the same operation
field section with ICGA and DIRT has been demonstrated. These researchers stated that the promising results of
this proof-of-concept provided a basis for a trial with a larger number of patients.
Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":
Code Code Description
CPT codes not covered for indications listed in the CPB:
93740 Temperature gradient studies
ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
A30.0 - A30.9 Leprosy [Hansen's disease]
B02.22 Postherpetic trigeminal neuralgia
B02.29 Other postherpetic nervous system involvement
C00.0 - C96.9 Malignant neoplasms
D18.00 - D18.09 Hemangioma and lymphangioma, any site
E08.3211 - E13.37x9 Diabetes mellitus
E10.51 - E10.59
E11.51 - E11.59
Diabetes mellitus with circulatory complications [Type 1 or 2]
www.aetna.com/cpb/medical/data/1_99/0029.html Proprietary 18/24
Code Code Description
G71.09 Other specified muscular dystrophies
G90.50 - G90.59 Complex regional pain syndrome
H04.121 - H04.129 Dry eye syndrome
I25.10 - I25.9 Coronary atherosclerosis
I73.9 Peripheral vascular disease, unspecified
I77.6 Arteritis, unspecified
L73.2 Hidradenitis suppurativa
L89.000 - L89.95 Pressure ulcer
M06.4 Inflammatory polyarthropathy
M79.601 -M79.609 Pain in limb
M84.421S - M84.429S
M84.431S - M84.439S
S42.209S - S42.496S
S49.001S - S49.199S
S52.001S - S52.92xS
S59.001S - S59.299S
S62.90xS - S62.92xS
Fracture of upper extremity, sequela
S52.501+ - S52.509+
S52.531+ - S52.539+
Fracture of radius [open or closed]
T20.00xA - T32.99 Burns
Y84.2 Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of
later complication, without mention of misadventure at the time of the procedure
Z01.810 Encounter for preprocedural cardiovascular examination
Z01.818 Encounter for other preprocedural examination
Z01.89 Encounter for other specified special examinations [not covered for intra-operative and
post-operative perfusion assessment]
Z12.0 - Z12.9 Encounter for screening for malignant neoplasms
Z13.89 Encounter for screening for other disorder
Z51.11 - Z51.12 Encounter for antineoplastic chemotherapy or immunotherapy
Z95.1 Presence of aortocoronary bypass graft
1. U.S. Department of Health and Human Services (DHHS), Public Health Service, Office of Health Technology
Assessment. Thermography for indications other than breast lesions. Health Technology Assessment
Reports. DHHS Pub. No. PHS 89-3438. Washington, DC: DHHS; August 1989.
www.aetna.com/cpb/medical/data/1_99/0029.html Proprietary 19/24
2. So YT, Olney RK, Aminoff MJ. Evaluation of thermography in the diagnosis of selectedentrapment
neuropathies. Neurology. 1989;39:1-5.
3. So YT, Minoff JF, Olney RK. The role of thermography in the evaluation of lumbosacralradiculopathy.
Neurology. 1989;349:1154-1158.
4. Harper CM, Low PA, Realey RD, et al. Utility of thermography in the diagnosis oflumbosacral
radiculopathy. Neurology. 1991;41:1010-1014.
5. American Academy of Neurology, Therapeutics and Technology Assessment Subcommittee.
Thermography in neurologic practice. Assessment. Neurology. 1990;40:523-525.
6. Ilowite NT, Walco GA, Pochaczevsky R. Assessment of pain in patients with juvenile rheumatoid
arthritis: Relation between pain intensity and degree of joint inflammation. Ann RheumaticDiseases.
1992;51(3):343-346.
7. Ben-Eliyahu DJ. Infrared thermographic imaging in the detection of sympathetic dysfunction in patients
with patellofemoral pain syndrome. J Manipulative Physiol Ther. 1992;15:164-170.
8. Leclaire R, Esdaile JM, Jequier JC, et al. Diagnostic accuracy of techniques used in low back pain
assessment. Thermography, triaxial dynamometry, spinoscopy, and clinical examination. Spine.
1996;21(11):1325-1330, discussion 1331.
9. Devulder J, Dumoulin K, De Laat M, Rolly G. Infra-red thermographic evaluation of spinal cord
electrostimulation in patients with chronic pain after failed back surgery. Br J Neurosurg.
1996;10(4):379-383.
10. Mackin GA. Medical and pharmacologic management of upper extremity neuropathic painsyndromes.
J Hand Ther. 1997;10(20):96-109.
11. Stefanadis C, Toutouzas K, Tsiamis E, et al. Thermography of human arterial system by means of new
thermography catheters. Catheter Cardiovasc Interv. 2001;54(1):51-58.
12. Radhakrishna M, Burnham R. Infrared skin temperature measurement cannot be used to detect
myofascial tender spots. Arch Phys Med Rehabil. 2001;82(7):902-905.
13. Barrett S. The Nervo-Scope. Chirobase. Plymouth Meeting, PA: Chirobase; October 13, 2000.Available
at: http://www.chirobase.org/06DD/nervoscope.html. Accessed May 17, 2002.
14. Madjid M, Naghavi M, Malik BA, et al. Thermal detection of vulnerable plaque. Am J Cardiol.
2002;90(10C):36L-39L.
15. Diamantopoulos L. Arterial wall thermography. J Interv Cardiol. 2003;16(3):261-266.
16. Stefanadis C, Vavuranakis M, Toutouzas P. Vulnerable plaque: The challenge to identify and treat it. J
Interv Cardiol. 2003;16(3):273-280.
17. Conseil d'Evaluation des Technologies de la Sante du Quebec (CETS). Thermography - nonsystematic
review. CETS 98-5 NE. Montreal, QC: CETS; 1999.
18. Kerr J. Review of the effectiveness of infrared thermal imaging (thermography) for population
screening and diagnostic testing of breast cancer. New Zealand Health TechnologyAssessment
(NZHTA). NZHTA Tech Brief Series. 2004;3(3):1-60.
19. Hall A, Girkin JM. A review of potential new diagnostic modalities for caries lesions. J Dent Res. 2004;83
Spec No C:C89-C94.
20. Ecker RD, Goerss SJ, Meyer FB, et al. Vision of the future: Initial experience with intraoperativereal-time
high-resolution dynamic infrared imaging. Technical note. J Neurosurg. 2002;97(6):1460-1471.
21. Button TM, Haifang L, Fisher P, et al. Dynamic infrared imaging for the detection of malignancy. Phys
Med Biol. 2004;49:3105-3116.
22. Anbar M. Assessment of physiologic and pathologic radiative heat dissipation using dynamicinfrared
imaging. Ann N Y Acad Sci. 2002;972:111-118.
www.aetna.com/cpb/medical/data/1_99/0029.html Proprietary 20/24
23. Binzoni T, Leung T, Delpy DT, et al. Mapping human skeletal muscle perforator vessels using a
quantum well infrared photodetector (QWIP) might explain the variability of NIRS and LDF
measurements. Phys Med Biol. 2004;49(12):N165-N173.
24. Janicek MJ, Demetri G, Janicek MR, et al. Dynamic infrared imaging of newly diagnosed malignant
lymphoma compared with Gallium-67 and Fluorine-18 fluorodeoxyglucose (FDG) positron emission
tomography. Technol Cancer Res Treat. 2003;2(6):571-578.
25. Parisky YR, Sardi A, Hamm R, et al. Efficacy of computerized infrared imaging analysis to evaluate
mammographically suspicious lesions. AJR Am J Roentgenol. 2003;180(1):263-269.
26. OmniCorder Technologies, Inc. BioScanIR System [website]. Bohemia, NY: OmniCorder Technologies;
2005. Available at: http://www.omnicorder.com/default.aspx?pageid=21. Accessed April 6, 2005.
27. Huygen FJ, Niehof S, Klein J, Zijlstra FJ. Computer-assisted skin videothermography is a highlysensitive
quality tool in the diagnosis and monitoring of complex regional pain syndrome type I. Eur J Appl
Physiol. 2004;91(5-6):516-524.
28. Gradl G, Steinborn M, Wizgall I, et al. Acute CRPS I (morbus sudeck) following distal radialfractures-
methods for early diagnosis. Zentralbl Chir. 2003;128(12):1020-1026.
29. Madjid M, Willerson JT, Casscells SW. Intracoronary thermography for detection of high-riskvulnerable
plaques. J Am Coll Cardiol. 2006;47(8 Suppl):C80-C85.
30. Schaar JA, Mastik F, Regar E, et al. Current diagnostic modalities for vulnerable plaque detection. Curr
Pharm Des. 2007;13(10):995-1001.
31. García-García HM, Gonzalo N, Granada JF, et al. Diagnosis and treatment of coronaryvulnerable
plaques. Expert Rev Cardiovasc Ther. 2008;6(2):209-222.
32. Kennedy DA, Lee T, Seely D. A comparative review of thermography as a breast cancerscreening
technique. Integr Cancer Ther. 2009;8(1):9-16.
33. Agostini V, Knaflitz M, Molinari F. Motion artifact reduction in breast dynamic infrared imaging. IEEE
Trans Biomed Eng. 2009;56(3):903-906.
34. Arora N, Martins D, Ruggerio D, et al. Effectiveness of a noninvasive digital infrared thermal imaging
system in the detection of breast cancer. Am J Surg. 2008;196(4):523-526.
35. American Cancer Society (ACS). Mammograms and other breast imaging procedures. CancerReference
Information. Washington, DC: ACS; July 7. 2010. Available at:
http://www.cancer.org/Healthy/FindCancerEarly/ExamandTestDescriptions/MammogramsandOtherBreastImagingProcedures/mammograms- and
other-breast-imaging-procedures-newer-br-imaging-tests. Accessed October 21, 2010.
36. National Health Service (NHS). FAQ 15. Could I have thermography for breast cancer screening instead
of mammography? I am worried about the radiation I will be exposed to. NHS Breast CancerScreening
Programme. Sheffield, UK: NHS Cancer Screening Programmes; 2010. Available at:
http://www.cancerscreening.nhs.uk/breastscreen/faq15.html. Accessed October 21, 2010.
37. Han SS, Jung CH, Lee SC, et al. Does skin temperature difference as measured by infrared
thermography within 6 months of acute herpes zoster infection correlate with pain level? Skin Res
Technol. 2010;16(2):198-201.
38. Sharif F, Murphy RT. Current status of vulnerable plaque detection. Catheter Cardiovasc Interv.
2010;75(1):135-144.
39. U.S. Food and Drug Administration (FDA). Breast thermography not a substitute for mammography.
Silver Spring, MD: FDA; June 2, 2011. Available at:
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm257633.htm. Accessed January
4, 2012.
www.aetna.com/cpb/medical/data/1_99/0029.html Proprietary 21/24
40. Parsons SK, Chan JA, Yu WW, et al. Noninvasive diagnostic techniques for the detection of skin cancers.
Technical Brief No. 11 (Prepared by the Tufts University Evidence-based Practice Center under Contract
No. 290-2007-1055-1). AHRQ Publication No. 11-EHC085-EF. Rockville, MD: Agency for Healthcare
Research and Quality. September 2011.
41. Kontos M, Wilson R, Fentiman I. Digital infrared thermal imaging (DITI) of breast lesions: Sensitivity and
specificity of detection of primary breast cancers. Clin Radiol. 2011;66(6):536-539.
42. Morrison, A. Infrared thermography for population screening and diagnostic testing for breast cancer.
Issues in Emerging Health Technologies, Issue 118. Ottawa, ON: Canadian Agency for Drugs and
Technologies in Health (CADTH); March 2012.
43. Fitzgerald A, Berentson-Shaw J. Thermography as a screening and diagnostic tool: A systematic review.
N Z Med J. 2012;125(1351):80-91.
44. Pauling JD, Shipley JA, Harris ND, McHugh NJ. Use of infrared thermography as an endpoint in
therapeutic trials of Raynaud's phenomenon and systemic sclerosis. Clin Exp Rheumatol.2012;30(2
Suppl 71):S103-S115.
45. Kim YS, Trillaud H, Rhim H, et al. MR thermometry analysis of sonication accuracy and safety margin of
volumetric MR imaging-guided high-intensity focused ultrasound ablation of symptomatic uterine
fibroids. Radiology. 2012;265(2):627-637.
46. Brkljacic B, Miletic D, Sardanelli F. Thermography is not a feasible method for breast cancerscreening.
Coll Antropol. 2013;37(2):589-593.
47. Work Loss Data Institute. Low back -- lumbar & thoracic (acute & chronic). Encinitas, CA: Work Loss
Data Institute; December 4, 2013.
48. Sanchis-Sanchez E, Vergara-Hernandez C, Cibrian RM, et al. Infrared thermal imaging in thediagnosis
of musculoskeletal injuries: A systematic review and meta-analysis. AJR Am J Roentgenol.
2014;203(4):875-882.
49. Lohman RF, Ozturk CN, Ozturk C, et al. An analysis of current techniques used for intraoperative flap
evaluation. Ann Plast Surg. 2015;75(6):679-685.
50. Dibai-Filho AV, Guirro RR. Evaluation of myofascial trigger points using infrared thermography: A
critical review of the literature. J Manipulative Physiol Ther. 2015;38(1):86-92.
51. Burke-Smith A, Collier J, Jones I. A comparison of non-invasive imaging modalities: Infrared
thermography, spectrophotometric intracutaneous analysis and laser Doppler imaging for the
assessment of adult burns. Burns. 2015;41(8):1695-1707.
52. Just M, Chalopin C, Unger M, et al. Monitoring of microvascular free flaps following oropharyngeal
reconstruction using infrared thermography: First clinical experiences. Eur ArchOtorhinolaryngol.
2016;273(9):2659-2567.
53. Curkovic S, Antabak A, Haluzan D, et al. Medical thermography (digital infrared thermal imaging - DITI)
in paediatric forearm fractures - A pilot study. Injury. 2015;46(Suppl 6):S36-S39.
54. Prindeze NJ, Fathi P, Mino MJ, et al. Examination of the early diagnostic applicability of active dynamic
thermography for burn wound depth assessment and concept analysis. J Burn Care Res.
2015;36(6):626-635.
55. Burke-Smith A, Collier J, Jones I. A comparison of non-invasive imaging modalities: Infrared
thermography, spectrophotometric intracutaneous analysis and laser Doppler imaging for the
assessment of adult burns. Burns. 2015;41(8):1695-1707.
56. Childs C, Siraj MR, Fair FJ, et al. Thermal territories of the abdomen after caesarean section birth:
Infrared thermography and analysis. J Wound Care. 2016;25(9):499-512.
www.aetna.com/cpb/medical/data/1_99/0029.html Proprietary 22/24
57. Cavalheiro AL, Costa DT, Menezes AL, et al. Thermographic analysis and autonomic response in the
hands of patients with leprosy. An Bras Dermatol. 2016;91(3):274-283.
58. Burkes SA, Patel M, Adams DM, et al. Infantile hemangioma status by dynamic infrared thermography:
A preliminary study. Int J Dermatol. 2016;55(10):e522-e532.
59. Staffa E, Bernard V, Kubicek L, et al. Using noncontact infrared thermography for long-termmonitoring
of foot temperatures in a patient with diabetes mellitus. Ostomy Wound Manage. 2016 ;62(4):54-61.
60. Tan LL, Sanjay S, Morgan PB. Screening for dry eye disease using infrared ocular thermography. Cont
Lens Anterior Eye. 2016;39(6):442-449.
61. Ramirez-Elías MG, Kolosovas-Machuca ES, Kershenobich D, et al. Evaluation of liver fibrosis using
Raman spectroscopy and infrared thermography: A pilot study. Photodiagnosis Photodyn Ther.
2017;19:278-283.
62. Oliveira AL, Moore Z, O Connor T, Patton D. Accuracy of ultrasound, thermography and subepidermal
moisture in predicting pressure ulcers: A systematic review. J Wound Care. 2017;26(5):199-215.
63. Naydenov E, Minkin K, Penkov M, et al. Infrared thermography in surgery of newlydiagnosed
glioblastoma multiforme: A technical case report. Case Rep Oncol. 2017;10(1):350-355.
64. Hegedus B. The potential role of thermography in determining the efficacy of stroke rehabilitation. J
Stroke Cerebrovasc Dis. 2018;27(2):309-314.
65. Kwok G, Yip J, Yick KL, et al. Postural screening for adolescent idiopathic scoliosis with infrared
thermography. Sci Rep. 2017;7(1):14431.
66. Polidori G, Kinne M, Mereu T, et al. Medical infrared thermography in back painosteopathic
management. Complement Ther Med. 2018;39:19-23.
67. Gatt A, Cassar K, Falzon O, et al. The identification of higher forefoot temperatures associated with
peripheral arterial disease in type 2 diabetes mellitus as detected by thermography. Prim Care
Diabetes. 2018;12(4):312-318.
68. Rathmann P, Chalopin C, Halama D, et al. Dynamic infrared thermography (DIRT) for assessment of
skin blood perfusion in cranioplasty: A proof of concept for qualitative comparison with the standard
indocyanine green video angiography (ICGA). Int J Comput Assist Radiol Surg. 2018;13(3):479-490.
69. Maillot O, Leduc N, Atallah V, et al. Evaluation of acute skin toxicity of breast radiotherapy using
thermography: Results of a prospective single-centre trial. Cancer Radiother.2018;22(3):205-210.
70. Cabizosu A, Carboni N, Martinez-Almagro Andreo A, et al. Theoretical basis for a new approach of
studying Emery-Dreifuss muscular dystrophy by means of thermography. Med Hypotheses.
2018;118:103-106.
71. Jones B, Hassan I, Tsuyuki RT, et al. Hot joints: Myth or reality? A thermographic joint assessment of
inflammatory arthritis patients. Clin Rheumatol. 2018;37(9):2567-2571.
72. Derruau S, Renard Y, Pron H, et al. Combining magnetic resonance imaging (MRI) and medical Infrared
thermography (MIT) in the pre- and peri-operating management of severe hidradenitis suppurativa
(HS). Photodiagnosis Photodyn Ther. 2018;23:9-11.
73. Lin PH, Echeverria A, Poi MJ. Infrared thermography in the diagnosis and management of vasculitis. J
Vasc Surg Cases Innov Tech. 2017;3(3):112-114.
74. Daly MG, Melton I, Roper G, et al. High-resolution infrared thermography of esophageal temperature
during radiofrequency ablation of atrial fibrillation. Circ Arrhythm Electrophysiol.2018;11(2):e005667.
75. Borne RT, Nguyen DT. Red alert: Infrared thermography for esophageal monitoring. CircArrhythm
Electrophysiol. 2018;11(2):e006113.
76. Magalhaes C, Vardasca R, Mendes J. Recent use of medical infrared thermography in skinneoplasms.
Skin Res Technol. 2018;24(4):587-591.
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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a
contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent
contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and
treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
Copyright © 2001-2019 Aetna Inc.
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AETNA BETTER HEALTH® OF PENNSYLVANIA
Amendment to Aetna Clinical PolicyBulletin Number: 0029
Thermography
There are no amendments for Medicaid.
www.aetnabetterhealth.com/pennsylvania annual 11/01/2019
Proprietary