Subject:
Cone Beam Computed Tomography
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Cone Beam Computed Tomography (CBCT) provides opportunities for 3-dimensional cephalometrics in orthodontic assessment of bony landmarks and air-bounded surfaces such as the facial skin. Two-dimensional cephalogram simulation could facilitate the transfer of growth projections from existing data sets as a starting point for use of a new 3-dimensional paradigm. Three methods are described to simulate conventional 2-dimensional cephalograms from CBCT images and volumetric data sets. However, certain precautions are required to assure that selection criteria and imaging parameters guarantee a radiation dose that is as low as reasonably achievable.
Cone beam refers to a tomographic imaging beam that is concentrated to a narrow field of the body, as in the case of dental views. Multi-dimensional images of the hard tissue of the jaw are created to assist the oral surgeon in diagnosis and treatment planning for the patient. Cone beam CT provides an image of hard tissue that has no distortion and is anatomically correct. Views may include cross-sectional axial, coronal, sagittal, cephalometric, or panoramic.
This technology makes it possible to scan and reconstruct an object with cone beam x-rays in a spiral scan path with area detectors much shorter than the length of the object. The method is mathematically exact. If only a region of interest of the object is to be imaged, a top circle scan at the top level of the region of interest and a bottom circle scan at the bottom level of the region of interest are added. The height of the detector is required to cover only the distance between adjacent turns in the spiral projected at the detector. To reconstruct the object, the radon transform for each plane intersecting the object is computed from the totality of the cone beam data. This is achieved by suitably combining the cone beam data taken at different source positions on the scan path; the angular range of the cone beam data required at each source position can be determined easily with a mask which is the spiral scan path projected on the detector from the current source position. The spiral scan algorithm has been successfully validated with simulated cone beam data.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
Related Policies: Radiology 151: Adult Head Imaging
Radiology 163: Pediatric Head Imaging
I. Cone Beam CT is considered medically necessary as a diagnostic modality for the detection of the following specific maxillofacial conditions that may require surgery.
- Jaw Reconstruction- particularly atrophic maxillary or mandible reconstruction
- Facial Bone Fractures
- Temporal Mandibular Joint (TMJ) Disorders
- Cysts and tumors of the jaw
- Congenital Cleft Palate
II. Other uses of Cone Beam CT would be considered Dental procedures, except where explicitly stated in the contract.
Medicare Coverage:
Cone beam computed tomography (CBCT) for non-medically-related dental services is noncovered.
Medicare Advantage Products follow CMS National Coverage Determinations, Local Coverage Determinations and other CMS Guidance (eg, Medicare Benefit Policy Manual, Medicare Learning Network Articles (MLN Matters Articles), Medicare Claims Processing Manual)). If CMS does not have a coverage or noncoverage position on a service, Medicare Advantage Products will follow Horizon BCBSNJ Medical Policy. If there is no CMS Guidance and no Horizon BCBSNJ Medical Policy, then eviCore Diagnostic Advanced Imaging Guidelines will be applied.
NCDs available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx
LCDs available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/LcdSearch?_afrLoop=90769712476969#!%40%40%3F_afrLoop%3D90769712476969%26centerWidth%3D100%2525%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3D63y7eftob_46
DME LCDS available to be accessed at Noridian Healthcare Services, LLC, (DME MAC), Local Coverage Determinations (LCDs) search page: https://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=389&ContrVer=1&CntrctrSelected=389*1&s=38&DocType=All&bc=AggAAAAAAAAAAA%3d%3d&#ResultsAnchor.
Providers are responsible for reviewing CMS Medicare Coverage Center Guidance and in the event of a conflict between the Medicare Coverage section of the medical policy and the CMS Medicare Coverage Center Guidance, the CMS Medicare Coverage Center Guidance will control.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE-SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Cone Beam Computed Tomography
Cone Beam CT
Cone Beam
References:
1. Barghan S, Merrill R, Tetradis S. Cone beam computed tomography imaging in the evaluation of the temporomandibular joint.J Calif Dent Assoc, 2010 Jan;38(1):33-9.
2. Dawood A. Patel S. Brown J. Cone beam CT in dental practice. Br Dent J, 2009 Jul 11;207(1):23-8.
3. Ganz SD. Cone Beam Computed Tomography-assisted Treatment Planning Concepts.Dent Clin North Am, 2011 Jul;55(3):515-36.
4. Garib DG. Yatabe MS. Ozawa TO. da Silva Filho OG. Alveolar Bone Morphology In Patients With Bilateral Complete Cleft Lip And Palate In The Mixed Dentition: CBCT Evaluation.Cleft Palate Craniofac J, 2011 Jul 8
5. Hintze H. Wiese M. Wenzel A. Cone beam CT and conventional tomography for the detection of morphological temporomandibular joint changes.Dentomaxillofac Radiol, 2007 May;36(4):192-7.
6. ECRI. Hotline Report. Cone-beam Computed Tomography for Dental and Maxillofacial Imaging. Content current as of 12/31/2008.
7. Mah JK. Huang JC. Choo HR. Practical Applications of Cone-Beam Computed Tomography in Orthodontics.Journal of the American Dental Association. 2010 October;141 Suppl 3:7S-13S.
8. Miracle AC. Mukherji SK. Conebeam CT of the Head and Neck, Part 2: Clinical Applications.Am J Neuroradiol. 2009 Aug;30:1285-92
9. Orentlicher G. Abboud M. The use of 3-dimensional imaging in dentoalveolar surgery.Compend Cont Educ Dent. 2011 June;32(5):78-80, 82, 85-6.
10. Scarfe WC. Farman AG. What is cone-beam CT and how does it work?Dent Clin North Am.2008 Oct;52(4):707-30,v.
11. Shintaku WH. Venturin JS. Azevedo B. Noujeim M. Applications of cone-beam computed tomography in fractures of the maxillofacial complex.Dent Traumatol. 2009 Aug;24(4):358-66.
12. Wang P. Yan X. Lui D. Zhang W. Zhang Y. Ma X. Detection of dental root fractures by using cone-beam computed tomography.Dentomaxillofac Radiol 2011 Jul;40(5):290-8.
13. American Association of Endodontics and American Academy of Oral and Maxillofacial Radiography Joint Position Statement. Use of Cone-Beam-Computed Tomography in Endodontics.
14. Scarfe WC. Farman AG. Sukovic P. Clinical Applications of Cone-Beam Computed Tomography in Dental Practice.J Can Dent Assoc. 2006 February;72(1):75-80.
15. Querewby FA. Savell TA. Palomo JM. Applications of Cone Beam Computed Tomography in the Practice of Oral and Maxillofacial Surgery.J Oral Maxillofac Surg. 2008;66:791-796.
16. Tyndall DA, Rathore S. Cone-Beam CT Diagnostic Applications: Caries, Periodontal Bone Assessment, and Endodontic Applications. Den Clin N Am 2008; 825-841.
17. Anderson P, Yong R, Surman T, et al. Application of three-dimensional computed tomography in craniofacial clinical practice and research. Aust Den J 2014 Feb 24. [Epub ahead of print]
18. McTigue Dennis J. Evaluation and management of dental injuries in children. UpToDate. Mar 11, 2014
19. Whitesides Lee M., USA Cone Beam Computed Tomography: Is dentistry ready for a new standard of care? Dental Tribune Dec 23, 2014. Originally published in cone beam--international magazine of cone beam dentistry: No. 04/2014.
20. Berenson James R. Stopeck, Alison T. Medication-related osteonecrosis of the jaw in patients with cancer. UpToDate. Feb.18, 2015.
21. American Association of Dental Consultants. AADC Position Statement: Cone Beam Computer Tomography.
22. Ladeira DB, Cruz AD, Almeida SM. Digital panoramic radiography for diagnosis of the temporomandibular joint: CBCT as the gold standard. Braz Oral Res. 2015;29(1):1-7.
23. Leonardi Dutra K, Haas L, Porporatti AL, et al. Diagnostic Accuracy of Cone-Beam Computed Tomography and Conventional Radiography on Apical Periodontitis: A Systematic Review and Meta-analysis. J Endod. 2016 Mar;42(3):356-64.
24. Dabas J, Mohanty S, Chaudhary Z, et al. Assessment of Mandibular Distraction Regenerate Using Ultrasonography and Cone Beam Computed Tomography: A Clinical Study. Craniomaxillofac Trauma Reconstr. 2016 Mar;9(1):69-75.
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
D0364
D0365
D0366
D0367
D0368
D0380
D0381
D0382
D0383
D0384
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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