L29120-LCD

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Automated World Health

Local Coverage Determination (LCD) for Computed Tomography of the Thorax (L29120)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29120

LCD Title Computed Tomography of the Thorax

Contractor's Determination Number 71250

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009 Original Determination Ending Date

Revision Effective Date

For services performed on or after 04/05/2011 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations, Chapter 1, Section 220.1

Indications and Limitations of Coverage and/or Medical Necessity

A computed tomographic (CT) image is a display of the anatomy of a thin slice of the body developed from multiple x-ray absorption measurements made around the body’s periphery. Unlike conventional tomography, where the image of a thin section is created by blurring out the information from unwanted regions, the CT image is constructed mathematically using data arising only from the section of interest. Generating such an image is confined to cross sections of the anatomy that are oriented essentially perpendicular to the axial dimensions of the body. Reconstruction of the final image can be accomplished in any plane. The CT of the thorax extends from the lung apices to the posterior costophrenic sulci and may extend inferiorly to image the adrenal glands.

Medicare will consider a CT of the thorax medically reasonable and necessary based on the American College of Radiology guidelines under the following circumstances:

• Evaluation of clinically suspected occult thoracic pathology (ACR)

• Evaluation of known or suspected thoracic vascular abnormalities (congenital or acquired)

• Evaluation and follow-up of pulmonary parenchymal and airway disease

• Assessment of cardiopulmonary failure or insufficiency

• Detection and determination of nature and extent of cardiovascular abnormalities such as but no tlimited to aneurysm, dissection, embolism, thrombosis, congenital anomalies, post-operative complications and sequelae of atherosclerotic disease

• For assessing and/or guiding drainage of pulmonary or pleural fluid collections such as abscess, empyema, effusion or pneumothorax

• For characterizing and follow-up evaluation of interstitial and alveolar lung disease due to idiopathic, allergic , collagen-vascular, environmental or other causes

• For evaluating thoracic sequelae of remote processes including but not limited to pancreatitis, gastrointestinal perforation and other processes

• For assessing injury, potential injury or thoracic sequelae after trauma, burn, surgery, transplantation, radiation therapy, chemotherapy or invasive procedure such as pacemaker placement, chest tube placement or mechanical ventilation

• Evaluation of the patient with symptoms that may be arising from the chest or be referred to the chest including but not limited to cough, hemoptysis, chest pain, abdominal pain and others

• Evaluation of abnormalities of the lungs, mediastinum, pleura and chest wall initially found on a standard chest radiographs.

• Evaluation, staging, and follow-up after therapy (e.g., surgery, radiation, and/or chemotherapy) of lung and other primary or secondary (ACR) thoracic malignancies.

• Evaluation of a patient who sustained trauma to the pleura, chest wall, mediastinum, and lung.

• Localization of a thoracic mass prior to biopsy.

• Evaluation of a patient with myasthenia gravis to rule out thymic tumors.

• CT of the Thorax is indicated for assessing the appropriateness and feasibility of percutaneous procedures such as biopsy and pleural/parenchymal drainage. CT of the thorax is also indicated for following for sequalae of, and response to treatment of these procedures. It is not expected that patients who have recently had CT scans of the thorax that documented treatable abnormalities, would undergo another CT scan of the chest at the time of the procedure. The procedure should be billed using the codes for the biopsy or drainage, with the appropriate code for CT guidance.

• Evaluation of a patient with signs and symptoms of pulmonary embolism or pulmonary emboli. (Should be performed with a multidector spiral scanner).

• Evaluation of a patient with any other condition/symptom when there is support in medical and scientific literature for the effective use of the scan for the condition being evaluated and the scan is reasonable and necessary for the individual patient.

A CT scan is reasonable and necessary for the individual patient if the use is found to be medically appropriate considering the patient’s symptoms and preliminary diagnosis.

NOTE: Posterior and lateral views of the chest represent the first line diagnostic tool in identifying abnormalities involving the thorax. It is expected that the chest x-ray is used to evaluate patients who present with signs and/or symptoms suggestive of chest pathology prior to proceeding to a CT scan. However, in limited circumstances, a CT of the Thorax may be used as a primary diagnostic tool if the documentation supports that the initial test was reasonable and necessary and the medical literature supports the CT scan as the primary diagnostic test for the condition being evaluated.

In addition to the medical necessity requirements, the CT scan must be performed on a model of CT equipment that meets the following criteria:

• The model must be known to the Food and Drug Administration; and

• Must be in the full market release phase of development.

The CT scan must be performed by qualified radiology personnel (radiology technicians), and interpretation of the films should be provided by qualified physicians (board-certified radiologists).

Limitations

• Follow up studies may be performed to assess response to treatment or change in clinical condition, and/or staging/restaging of neoplastic disease, or to follow the progression of a previously identified suspicious lesion using current published peer-reviewed protocols.

• The computerized tomography should be performed only when clinically appropriate for the patient’s symptoms or complaint. For non-specific signs and symptoms, CT is generally not the first imaging modality. When a CT scan is performed as a screening function it will not be covered.

• Scanning can be approved for abnormal signs; symptoms; known or strongly suspected, injury to disease for the area to be evaluated. In the case of a tumor, if supported in the medical literature, scanning is allowed for areas in which there is frequent or common metastasis and to define margins and effects on adjacent structures.

• CT scan of the heart (electron-beam or multislice (multidector) CT) used to demonstrate the presence of coronary calcification in patients with atherosclerotic heart disease is not a Medicare covered service. Currently the value of this test appears to be that of ‘screening’ for the presence of atherosclerosis. Medicare does not cover screening services in the absence of signs or symptoms unless Congress adds a specific benefit. Also, the

recent literature on cardiac CT for calcium score supports that the modality is ‘investigational’ in the management of symptomatic coronary artery disease and therefore not medically necessary.

• CT of the thorax for screening for lung cancer is not a Medicare covered service.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

71250 COMPUTED TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL

71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST MATERIAL(S)

71270 COMPUTED TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS

ICD-9 Codes that Support Medical Necessity N/A

XX000 Not Applicable

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, reason for the test, and interpretive report and copies of all images obtained. The computerized data with image reconstruction should also be maintained.

The medical record must contain documentation, including a written or electronic request for the procedure which fully supports the medical necessity of the procedure performed. This documentation includes, but is not limited

to relevant medical history, physical examination, diagnosis (if known), pertinent signs and symptoms and results of pertinent diagnostic tests and/or procedures. This entire documentation-not just the test report or the findings/diagnosis on the order, must be made available to Medicare upon request.

When a CT scan and MRI are performed on the same day for the same anatomical area, the medical record must clearly reflect the medical necessity for performing both tests.

Appendices

Utilization Guidelines

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Sources of Information and Basis for Decision

Aberle, D. R., Gamsu, G., & et al. (2001). A Consensus Statement of the Society of Thoracic Radiology: Screening for lung cancer with helical computed tomography. Journal of Thoracic Imaging. 16(1): 65-68.

American College of Radiology (2010). Practice guideline for communication of diagnostic imaging findings. Retreived from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx

American College of Radiology (2003). ACR Practice Guidelines for the performance of pediatric and adult Thoracic CT.

American College of Radiology. (2001). American College of Radiology Standards.

Brown, J (2003). Medical Encyclopedia: Thoracic CT. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/003788.htm on 5/25/05.

National Imaging Associates, Inc. (2005). Chest CT.

Payne, K. (2005) Computed Tomography (CT) Scan. Retrieved from http://www.webmd.com/hw/health_guide_atoz/hw233596.asp? on 5/25/05.

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which includes representatives from numerous specialties.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 05/01/2011

Revision History Number 1

Revision History Explanation Revision Number: 1 Start Date of Comment Period:N/A

Start Date of Notice Period:05/01/2011 Revision Effective Date 04/05/2011

LCR B2011-051

April 2011 Update

Explanation of Revision: Under the “Documentation Requirements” section of the LCD, verbiage was updated to be in line with the guidelines used to develop the LCD. In addition, references were updated under the “Sources of Information and Basis for Decision” section of the LCD. The effective date of this LCD revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29120) replaces LCD L6157 as the policy in notice. This document (L29120) is effective on 02/02/2009.

Reason for Change