ABBREVIATIONS for CHEST POLICY

Abbreviations for Chest Guidelines
AAA	abdominal aortic aneurysm
ACE	angiotensin-converting enzyme
AVM	arteriovenous malformation
BI-RADS	Breast Imaging Reporting and Database System
BP	blood pressure	BRCA	tumor suppressor gene
CAD	computer-aided detection	CBC	Complete blood count
COPD	chronic obstructive pulmonary disease
CT	computed tomography
CTA	computed tomography angiography
CTV	computed tomography venography
DCIS	ductal carcinoma in situ	DVT	deep venous thrombosis
ECG	electrocardiogram	EM	electromagnetic
EMG	electromyogram	FDA	Food and Drug Administration
FDG	fluorodeoxyglucose	FNA	fine needle aspiration
GERD	gastroesophageal reflux disease
GI	gastrointestinal
HRCT	high resolution computed tomography
IPF	idiopathic pulmonary fibrosis
LCIS	lobular carcinoma in situ
LFTP	localized fibrous tumor of the pleura
MRA	magnetic resonance angiography
MRI	magnetic resonance imaging
MRV	magnetic resonance venography
NCV	nerve conduction velocity
PE	pulmonary embolus
PEM	positron-emission mammography
PET	positron emission tomography
PFT	pulmonary function tests
PPD	purified protein derivative of tuberculin
RODEO	Rotating Delivery of Excitation Off-resonance MRI
SPN	solitary pulmonary nodule
SVC	superior vena cava

Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)

CH-1: GENERAL POLICIES

CH-1.0: General Guidelines

CH-1.1: General Guidelines – Chest X-Ray

CH-1.2: General Guidelines – Chest Ultrasound

CH-1.3: General Guidelines – CT Chest

CH-1.4: General Guidelines – CTA Chest (CPT® 71275)

CH-1.5: General Guidelines – MRI Chest without and with Contrast (CPT® 71552)

CH-1.6: General Guidelines – Nuclear Medicine

This General Policy section provides an overview of the basic criteria for which chest imaging may be medically necessary. Details regarding specific conditions or clinical presentations and the associated criteria for which imaging is medically necessary are described in subsequent sections.

CH-1: General Policies

For this condition imaging is medically necessary based on the following criteria:

† A current clinical evaluation (within 60 days) is required prior to considering advanced imaging.

® A clinical evaluation should include the following:
¡ A relevant history and physical examination.
¡ Appropriate laboratory studies and non-advanced imaging modalities, such as plain x-ray or ultrasound.
® Other meaningful contact (telephone call, electronic mail or messaging) by an established member can substitute for a face-to-face clinical evaluation.

For this condition imaging is medically necessary based on the following criteria:

† A recent chest x-ray (generally within the last 60 days) that has been over read by a radiologist would be performed in many of these cases prior to considering advanced imaging.^1,2

® Identify and compare with previous chest films to determine presence and stability.
® Chest x-ray can help identify previously unidentified disease and may direct proper advanced imaging for such conditions as:
¡ Pneumothorax, (See CH-19: Pneumothorax/Hemothorax).
¡ Pneumomediastinum, (See CH-19: Pneumothorax/Hemothorax).
¡ Fractured ribs, (See CH-22: Chest Wall Mass).
¡ Acute and chronic infections, and (See CH-13: Pneumonia and CH-14: Other Chest Infections).
¡ Malignancies.
® Exceptions to preliminary chest x-ray may include such conditions as:
¡ Supraclavicular lymphadenopathy (See CH-2.1: Supraclavicular Region).
¡ Known Bronchiectasis (See CH-7: Bronchiectasis).
¡ Suspected Interstitial lung disease (See CH-11: Interstitial Disease).
¡ Positive PPD or tuberculosis (See CH-14: Other Chest Infections).
¡ Suspected Pulmonary AVM (See CH-26: Pulmonary Hypertension).

For this condition imaging is medically necessary based on the following criteria:

† Chest ultrasound (CPT^® 76604) includes transverse, longitudinal, and oblique images of the chest wall with measurements of chest wall thickness, and also includes imaging of the mediastinum.

® Chest ultrasound: CPT^® 76604.
® Breast ultrasound.
¡ CPT^® 76641: unilateral, complete.
¡ CPT^® 76642: unilateral, limited.
® CPT^® 76641 and CPT^® 76642 should be reported only once per breast, per imaging session.
® Axillary ultrasound: CPT^® 76882 (unilateral); if bilateral, can be reported as CPT^® 76882 x 2.

For this condition imaging is medically necessary based on the following criteria:

† Intrathoracic abnormalities found on chest x-ray, fluoroscopy, CT Abdomen, or other imaging modalities may be further evaluated with CT Chest with contrast (CPT^® 71260).

® Abnormalities not addressed in these guidelines should be sent for Medical Director Review

® Member has contraindication to contrast.
® Follow-up of pulmonary nodule(s).
® High Resolution CT (HRCT).
® Low-dose CT Chest (CPT^® G0297) See CH-33: Lung Cancer Screening.

CT Chest Coding Notes:
† High resolution CT Chest should be reported only with an appropriate code from the set CPT^® 71250-CPT^® 71270.

® No additional CPT^® codes should be reported for the “high resolution” portion of the scan. The “high resolution” involves additional slices which are not separately billable.

For this condition imaging is medically necessary based on the following criteria:

† CTA Chest (CPT^® 71275) can be considered for suspected Pulmonary Embolism and Thoracic Aortic disease.

® CTA prior to minimally invasive or robotic surgery (See Adult Cardiac Imaging Policy (Policy #149 in the Radiology Section); CD-4.8: Transcatheter Aortic Valve Replacement (TAVR)).

For this condition imaging is medically necessary based on the following criteria:

† Indications for MRI Chest are infrequent and may relate to concerns about CT contrast such as renal insufficiency or contrast allergy. MRI may be indicated:

® Clarification of some equivocal findings on previous imaging studies, which are often in the thymic mediastinal region or determining margin (vascular/soft tissue) involvement with tumor and determined on a case-by-case basis.
¡ Certain conditions include:
§ Chest wall mass (CH-22: Chest Wall Mass).
§ Chest muscle tendon injuries (Adult Musculoskeletal Imaging Policy (Policy #152 in the Radiology Section); MS-11: Muscle/Tendon Unit Injuries/Diseases).
§ Brachial plexopathy (Adult Peripheral Nerve Disorders Imaging Policy (Policy #157 in the Radiology Section); PN-4: Brachial Plexus).
§ Thymoma (Adult Oncology Imaging Policy (Policy #155 in the Radiology Section); ONC-10.5: Thymoma and Thymic Carcinoma - Suspected/Diagnosis).

For this condition imaging is medically necessary based on the following criteria:

78597	Quantitative differential pulmonary perfusion, including imaging when performed
78598	Quantitative differential pulmonary perfusion and ventilation (e.g., aerosol or gas), including imaging when performed

Reference

1. Raoof, Suhail et al. Interpretation of Plain Chest Roentgenogram. CHEST, Volume 141, Issue 2, 545 – 558. February 2012.
2. Eisen et al., Competency in Chest Radiography. Journal of General Internal Medicine. Volume 21, Issue 5, Version of Record online: 25 APR 2006.
3. When to Order Contrast-Enhanced CT. https://www.aafp.org/afp/2013/0901/p312.pdf.



CH-2: LYMPHADENOPHATHY

CH-2.1: Supraclavicular Region

CH-2.2: Axillary Lymphadenopathy (and Mass)

CH-2.3: Mediastinal Lymphadenopathy

CH-2.1: Supraclavicular Region

For this condition imaging is medically necessary based on the following criteria:

† Ultrasound (CPT^® 76536) is the initial study for palpable or suspected lymphadenopathy.

® Allows simultaneous ultrasound-guided core needle biopsy (CPT^® 76942).
® CT Neck with contrast (CPT^® 70491) or CT Chest with contrast (CPT^® 71260) if ultrasound is indeterminate.
¡ See Adult Neck Imaging Policy (Policy #153 in the Radiology Section); Neck-1: General.

For this condition imaging is medically necessary based on the following criteria:

† There is no evidence-based support for advanced imaging of clinically evidenced axillary lymphadenopathy without biopsy.^2,3 Most axillary adenopathy is infectious in primary care settings. Metastatic axillary involvement from a lung or chest primary is highly unusual (CT Chest not often warranted).

† Localized axillary lymphadenopathy should prompt:

® Ultrasound directed core needle biopsy or surgical excisional biopsy of the most abnormal lymph node if condition persists or malignancy suspected.
® Search for adjacent hand or arm injury or infection, and
® 3-4 week observation if benign clinical picture, and
® Excisional or ultrasound directed core needle biopsy of most abnormal lymph node if condition persists or malignancy suspected.
® No advanced imaging indicated.

® Ultrasound directed core needle biopsy or surgical excisional biopsy of the most abnormal lymph node if condition persists or malignancy suspected.
® Diagnostic work-up, including serological tests, for systemic diseases, and
® Excisional biopsy of most abnormal lymph node if uncertainty persists.
® See Adult Oncology Imaging Policy (Policy #155 in the Radiology Section); ONC-27: Non-Hodgkin Lymphomas.

® See Adult Oncology Imaging Policy (Policy #155 in the Radiology Section); ONC-31: Metastatic Cancer, Carcinoma of Unknown Primary Site, and Other Types of Cancer.

CH-2.3: Mediastinal Lymphadenopathy

For this condition imaging is medically necessary based on the following criteria:

† CT Chest with contrast (CPT^® 71260) if mediastinal abnormalities are detected on a chest x-ray (over read by a radiologist) or other non-dedicated advanced chest imaging.

® Follow-up CT Chest (CPT^® 71260) after 4 weeks if:
¡ Enlarged lymph nodes are in the mediastinum with no other thoracic abnormalities; and
¡ Low risk or no clinical suspicion for malignancy.
¡ Thereafter, stability does not require further advanced imaging.
® Further evaluations
¡ Lymph node biopsy (see methods below) should be considered for:
§ Persistent lymphadenopathy on follow-up CT Chest; or
§ Suspected malignancy.

† Lymphadenopathy from neoplasms as well as from benign sources of inflammation can result in a positive PET scan. Therefore, the use of PET may not be helpful prior to histologic diagnosis.

† Less invasive methods of mediastinal biopsies are CT or ultrasound directed percutaneous biopsy, transbronchial biopsy, transbronchial biopsy using endobronchial ultrasound, and endoscopic ultrasound-guided FNA.

† More invasive and traditional methods are mediastinoscopy or thoracoscopy/thoracotomy.

References
1. Van Overhagen H, Brakel K, Heijenbrok MW, et al. Metastases in supraclavicular lymph nodes in lung cancer: assessment with palpation, US, and CT. Radiology 2004; 232: 75-8.
2. Lehman C, DeMartini W, Anderson B, et al. Indications for breast MRI in the patient with newly diagnosed breast cancer. J Natl Compr Canc Netw 2009; 7 (2): 193-201.
3. Yamaguchi H, Ishikawa M, Hatanaka K, et al. Occult breast cancer presenting as axillary metastases. The Breast 2006; 15: 259-262.
4. Stigt J, Boers J, Oostdijk A, et al. Mediastinal Incidentalomas, Journal of Thoracic Oncology: August 2011, Volume 6, Issue 8 pp 1345-1349.
5. English B, Ray C, Chang J, et al. Expert Panel on Interventional Radiology. ACR Appropriateness Criteria^® radiologic management of thoracic nodules and masses. Reston (VA): American College of Radiology (ACR); 2015. 14 p.



CH-3: COUGH

CH-3.1: Cough

CH-3.1: Cough

For this condition imaging is medically necessary based on the following criteria:

† Initial evaluation should include a recent chest x-ray after the current episode of cough started or changed.^1,2

® In addition all medications known to cause coughing (e.g. ACE inhibitors, Sitagliptin) should be discontinued.^1,2,3

® Non-Smoker cough after the following sequence for a total 3 week trial and investigation after ALL of the following:⁴
¡ Antihistamine and decongestant treatment.^1,2
¡ Bronchoprovocation challenge (e.g. methacholine challenge, exhaled nitric oxide test) and spirometry should be performed to rule out asthma.¹
¡ Empiric trial of corticosteroids.^1,2
¡ Treatment of gastroesophageal reflux disease (GERD).^1,2
§ See Adult Head Imaging Policy (Policy #151 in the Radiology Section); HD-29: Sinusitis.
® Current or past cigarette smokers with either⁴:
¡ New cough lasting greater than 2 weeks.
¡ Changed chronic cough in worsening frequency or character
§ See CH-6: Hemoptysis.
® CT Maxillofacial without contrast (CPT^® 70486) or CT Sinus, limited without contrast (CPT^® 76380) can be considered in those with suspicion of Upper Airway Cough Syndrome (UACS) secondary to rhinosinus disease.⁴
® For any abnormalities present on the initial chest x-ray, advanced chest imaging can be performed according to the relevant Chest Imaging Guidelines section.¹

† The resolution of cough usually will occur at a median time of 26 days of stopping use of the angiotensin-converting enzyme (ACE) inhibitor drug.² Smoking cessation is “almost always effective” in resolving cough in smoker.²

† It should be realized that cough after URI (Upper Respiratory Infection) can typically last beyond 2-3 weeks.

References

1. Gibson P, Wang G, McGarvey L, et al. CHEST Expert Cough Panel. Treatment of unexplained chronic cough: CHEST guideline and Expert Panel report. Online supplement. Chest. 2016 Jan; 149 (1): 27-44.
2. Pratter, M, et al. An Empiric Integrative Approach to the Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines. Chest. 2006; 129(1_suppl): 222S-231S.
3. Ebell MH, Lundgren J, Youngpairoi S, How long does a cough last? Comparing patients’ expectations with data from a systematic review of the literature. (2013). Ann Fam Med, 11, 15-13.
4. Irwin RS, French CL, Chang AB, et al. Classification of Cough as a Symptom in Adults and Management Algorithms. Chest. 2018;153(1):196-209. doi:10.1016/j.chest.2017.10.016.



CH-4: NON-CARDIAC CHEST PAIN

CH-4: Non-Cardiac Chest Pain

CH-4.1: Non-Cardiac Chest Pain – Imaging

CH-4.2: Costochondritis/Other Musculoskeletal Chest Wall Syndrome

CH-4.0: Non-Cardiac Chest Pain

For this condition imaging is medically necessary based on the following criteria:

† See the following guidelines:

® CH-25: Pulmonary Embolism (PE).
® CH-29.1: Aortic Dissection.
® Adult Cardiac Imaging Policy (Policy #149 in the Radiology Section); CD-1: General Guidelines.

† MRI is not supported in the evaluation of chest pain.

CH-4.1: Non-Cardiac Chest Pain – Imaging

For this condition imaging is medically necessary based on the following criteria:

† Initial evaluation should include a chest x-ray.^1,2

® CT Chest with contrast (CPT^® 71260) or CTA Chest with contrast (CPT^® 71275) if x-ray is abnormal.^1,2,3
® If x-ray is normal, member should undergo evaluation of other possible causes of pain prior to advanced imaging (CT Chest with contrast or CTA Chest with contrast) including:^1,2,3
¡ Cardiac evaluation^1,2 (See CD-1: General Guidelines in the Cardiac Imaging Guidelines)
¡ GI any ONE of the following:
§ Trial of anti-reflux medication, or pH probe, or esophageal manometry¹ or
§ Barium swallow or endoscopy
¡ Either a barium swallow, esophageal pH monitoring, manometry, or endoscopy should be done in all after cardiac causes have been ruled out since GERD is the cause in almost 60%
¡ Pulmonary Function Test (PFT’s)^1,2
® CT Chest with contrast (CPT^® 71260) if persistent:
¡ The initial chest x-ray reveals no abnormalities; and either
§ Sickle cell disease², or
§ Suspected lung mass in a member with chest pain, cough, and weight loss.²

For this condition imaging is medically necessary based on the following criteria:

† Costochondritis or other suggested musculoskeletal chest wall syndrome does not require advanced imaging (CT or MRI) unless it meets other criteria in these guidelines.

† Costochondritis can be readily diagnosed with palpation tenderness and/or hooking maneuver and imaging is non-specific.³

Practice Notes
Differential diagnosis of non-cardiac nonspecific chest pain includes aortic, pulmonary, gastrointestinal (GI), or musculoskeletal pathologies. Chest x-ray could identify pneumothorax, pneumomediastinum, fractured ribs, acute and chronic infections, and malignancies.¹

References

1. Hoffman U, Venkatesh V, White R, et al. Expert Panel on Cardiac Imaging. ACR Appropriateness Criteria^® acute nonspecific chest pain - low probability of coronary artery disease. American College of Radiology (ACR); 2015.
2. Woodard PK, White RD, Abbara S, Araoz PA, Cury RC, et al., Expert Panel on Cardiac Imaging. ACR Appropriateness Criteria^® chronic chest pain - low to intermediate probability of coronary artery disease. American College of Radiology (ACR); 2012.
3. Proulx A and Zryd T. Costochondritis: diagnosis and treatment. Am Fam Physician. 2009 Sep 15; 80 (6): 617.



CH-5: DYSPNEA/SHORTNESS OF BREATH

CH-5.1: Dyspnea/Shortness of Breath

CH-5.2: Pre-Operative Assessment

CH-5.1: Dyspnea/Shortness of Breath

For this condition imaging is medically necessary based on the following criteria:

† Dyspnea is the subjective experience of breathing discomfort. Initial evaluation should include a recent chest x-ray.^{1, 2}

® CT Chest without contrast (CPT^® 71250) if x-ray is abnormal.^1,2
® CT Chest without contrast (CPT^® 71250, including HRCT), or CT Chest with contrast (CPT^® 71260) if the initial chest x-ray is indeterminate and the following evaluations have been conducted and are indeterminate:²
¡ ECG, echocardiogram or stress testing,² and
¡ Pulse oximetry and pulmonary function studies (PFT’s)²

For this condition imaging is medically necessary based on the following criteria:

† “Split Function Studies” (CPT^® 78597-Quantitative Differential Pulmonary Perfusion, Including Imaging When Performed or CPT^® 78598-Quantitative Differential Pulmonary Perfusion and Ventilation (e.g., Aerosol or Gas), Including Imaging When Performed) can be considered for pre-operative assessment prior to planned segmental, lobar or lung removal.^{3, 4}

† If pulmonary embolus (PE) is suspected, See CH-25: Pulmonary Embolism (PE).


References
1. ACR Appropriateness Criteria^® Chronic Dyspnea - Noncardiovascular Origin. American College of Radiology (ACR); 2018
2. Abbara S, Ghoshhajra B, White R, et al, Expert Panel on Cardiac Imaging. ACR Appropriateness Criteria^® dyspnea -- suspected cardiac origin. American College of Radiology (ACR); Revised 2016.
3. Morton K, Clark P, et al. Diagnostic Imaging: Nuclear Medicine, Amursys, 2007; (4)2-15. Elvisier.
4. Thrall JH, Zeissman HA. Nuclear Medicine: The Requisites, Mosby, 2001, 145-165.



CH-6: HEMOPTYSIS

CH-6.1: Hemoptysis

CH-6.1 Hemoptysis

For this condition imaging is medically necessary based on the following criteria:

† CTA Chest (CPT^® 71275) may be performed after:

® Abnormal chest x-ray, or
® No chest x-ray needed if ANY of the following:
¡ High risk for malignancy with >40 years of age and >30 pack-year smoking history, or
¡ Persistent/recurrent with >40 years of age or >30 pack year smoking history, or
¡ Massive hemoptysis (≥30 cc per episode or unable protect airway).¹

CH-7.1: Bronchiectasis

For this condition imaging is medically necessary based on the following criteria:

† High resolution CT Chest (HRCT) without contrast (CPT^® 71250) for ANY of the following:^{4, 5}

® To confirm suspected diagnosis of bronchiectasis after an initial x-ray.^1,2
® For known bronchiectasis with worsening symptoms or worsening PFT’s.²
® For hemoptysis with known or suspected bronchiectasis.³

1. Schneebaum N, Blau H, Soferman R, et al. Use and yield of chest computed tomography in the diagnostic evaluation of pediatric lung disease. Pediatrics, 2009; 124:472-479.
2. Rosen M. Chronic cough due to bronchiectasis: ACCP evidence-based clinical practice guidelines. Chest, 2006; 129: 122S-131S.
3. Guidelines for Non-CF Bronchiectasis, British Thoracic Society, Bronchiectasis Guideline Group, Thorax, 65, Supplement 1, July 2010.
4. Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria^® hemoptysis. Reston (VA): American College of Radiology (ACR); 2010. (revised 2014).
5. Hansell D, Bronchiectasis. Radiologic Clinics of North America, (1998).36(1): 107-28.




CH-8: BRONCHITIS

CH-8.1: Bronchitis

CH-8.1 Bronchitis

For this condition imaging is medically necessary based on the following criteria:

† Advanced imaging is not needed for bronchitis.^1,2

† Chest x-ray to determine if any abnormality is present.

References

1. Braman S, Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines, Chest 2006,129, 95S-103S.
2. Michigan Quality Improvement Consortium. Management of uncomplicated acute bronchitis in adults. South-field (MI): Michigan Quality Improvement Consortium; 2016. http://www.mqic.org/pdf/mqic_management_of_uncomplicated_acute_bronchitis_in_adults_cpg.pdf.



CH-9: ASBESTOS EXPOSURE

CH-9.1: Asbestos Exposure

CH-9.1 Asbestos Exposure

For this condition imaging is medically necessary based on the following criteria:

† Chest x-ray as radiographic screening for asbestos exposure.^1,2

® Stable calcified pleural plaques on chest x-ray do not require advanced imaging of the chest.²

† High resolution CT Chest (HRCT) (CPT^® 71250) for ANY of the following:²

® Any change seen on chest x-ray.
® Progressive respiratory symptoms that may indicate the development or progression of asbestos related interstitial fibrosis.
® Send requests for additional follow-up imaging to Medical Director Review.

† Asbestosis and asbestos-related diseases include: pleural effusion, pleural plaques, lung cancer, and malignant mesothelioma. The risk of developing mesothelioma increases with increasing intensity and duration of exposure.

References

1. OSHA, Occupational Safety and Health Standards, Medical surveillance guidelines for asbestos, 1910.1001 App H. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=9995.
2. Daniel E. Banks, et al. American College of Chest Physicians Consensus Statement on the Respiratory Health Effects of Asbestos: Results of a Delphi Study, Chest. 2009; 135(6):1619-1627. doi:10.1378/chest.08-1345.
3. Agency for Toxic Substances and Disease Registry. Asbestos. Updated 2011. https://www.atsdr.cdc.gov/substances/toxsubstance.asp?toxid=4.




CH-10: CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

CH-10.1: COPD

CH-10.1: COPD

For this condition imaging is medically necessary based on the following criteria:

† Chest x-ray should be performed initially.

® CT Chest without contrast (CPT^® 71250) or CT Chest with contrast (CPT^® 71260)^1,2 can be performed if:
¡ Emphysema is known or suspected and a pre-operative study for Lung Volume Reduction Surgery (LVRS) is being requested.¹ OR
¡ Definitive diagnosis is not yet determined by laboratory studies and chest x-ray and ONE on the following is suspected:
§ Bronchiectasis
§ Sarcoidosis
§ Emphysema
§ Pneumoconiosis
§ Idiopathic pulmonary fibrosis
§ Langerhans cell histiocytosis
§ Hypersensitivity pneumonitis
§ Bronchiolitis obliterans
§ Lipoid pneumonia
§ Drug toxicity
§ Lymphangitic cancer²

® See “Screening Indications” in CH-33: Lung Cancer Screening

† COPD includes asthmatic bronchitis, chronic bronchitis, and emphysema. COPD is airflow reduction (FEV1/FVC ratio <0.7 or FEV1 <80% predicted) in the presence of respiratory symptoms, such as dyspnea. Advanced chest imaging is not typically indicated in COPD exacerbation, which is an acute change in baseline dyspnea, cough, and/or sputum beyond normal day-to-day variations.²

1. ACR Appropriateness Criteria^® Chronic Dyspnea - Noncardiovascular Origin. American College of Radiology (ACR); 2018.
2. Austin JHM. Pulmonary emphysema: Imaging assessment of lung volume reduction surgery. Radiology 1999; 212:1-3.


CH-11: INTERSTITIAL DISEASE

CH-11.1: Interstitial Disease

CH-11.1: Interstitial Disease

For this condition imaging is medically necessary based on the following criteria:

† High resolution CT Chest (HRCT) without contrast (CPT^® 71250) is the diagnostic modality of choice to evaluate for:

® Interstitial changes identified on other imaging (including chest x-ray) in members with pulmonary symptoms and abnormal pulmonary function studies (PFT’s) (See CH-5: Dyspnea/Shortness of Breath)^1-6
® Initial request to identify interstitial disease with a connective tissue disease diagnosis, including (chest x-ray not required):
¡ Rheumatoid arthritis
¡ Scleroderma
¡ Idiopathic inflammatory myopathies (polymyositis, dermatomyositis, inclusion body myositis)
¡ Asbestosis
¡ Silicosis
¡ Coal miner’s lung disease^1-6
® New or worsening pulmonary symptoms or worsening PFT’s in any type of interstitial disease, including connective tissue diseases^1-6
® Once a year in members with known idiopathic pulmonary fibrosis (IPF) if showing progression or regression of disease will change member management³

1. Bacchus L, Shah R, Chung H, et al., Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria^® occupational lung diseases [online publication]. Reston (VA): American College of Radiology (ACR); 2014.
2. Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria^® Chronic Dyspnea - Noncardiovascular Origin. American College of Radiology (ACR); 2018.
3. Misumi S and Lynch DA. Idiopathic pulmonary fibrosis/Usual interstitial pneumonia. Imaging diagnosis, spectrum of abnormalities, and temporal progression. Proceedings of the American Thoracic Society 2006; 3: 307-314.
4. Wells A, Hirani N, et al. Interstitial lung disease guideline: the British Thoracic Society in collaboration with the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society. Thorax, 2008; 63(Suppl V): v1-v58.
5. Dempsey O, Kerr K, Remmen H, et al. How to investigate a member with suspected interstitial lung disease. BMJ, 2010; 340:1294-1299.
6. Castelino F and Varga J. Interstitial lung disease in connective tissue diseases: evolving concepts of pathogenesis and management. Arthritis Research & Therapy. 2010. .



CH-12: MULTIPLE PULMONARY NODULES

CH-12.1: Multiple Pulmonary Nodules

CH-12.1 Multiple Pulmonary Nodules

For this condition imaging is medically necessary based on the following criteria:

† See CH-16: Solitary Pulmonary Nodule (SPN)¹

Practice Notes

† Increased risk of primary cancer as the total nodule count increased from 1 to 4 but decreased risk in members with 5 or more nodules, most of which likely resulted from prior granulomatous infection.¹

References
1. MacMahon H, et al. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017, Radiology.



CH-13: PNEUMONIA

For this condition imaging is medically necessary based on the following criteria:

† Chest x-ray would be performed initially in all patients with suspected pneumonia, prior to considering advanced imaging.^{1, 2}

® CT Chest with contrast (CPT^® 71260) if initial or repeat chest x-ray findings reveal:
¡ Complication of pneumonia (e.g. abscess, effusion, hypoxemia, respiratory distress, necrotizing pneumonia, pneumothorax).^1,2
¡ Possible lung mass associated with the infiltrate.²

For this condition imaging is medically necessary based on the following criteria:

† CT Chest without contrast (CPT^® 71250), or with contrast (CPT^® 71260) may be appropriate in the following clinical situations:

® Symptomatic COVID-19 positive patients with underlying comorbidities (including but not limited to age >65 years, asthma, COPD, cystic fibrosis, cardiovascular disease, malignancy, bronchopulmonary dysplasia, chronic infections, or immunocompromised state).

® Moderate to severe symptomatic patients with evidence of significant pulmonary dysfunction or damage (e.g., hypoxemia, moderate-to-severe dyspnea), suspected of having COVID-19, regardless of COVID-19 test results or when viral testing is not available.


¡ Thromboembolic complications including pulmonary embolism, stroke and mesenteric ischemia are recognized complications of COVID-19. See CH-25.1: Pulmonary Embolism, AB-6.1: Mesenteric Ischemia in the Adult Abdomen Imaging medical policy (Policy #148 in the Radiology Section), and HD-21.1: Stroke/TIA in the Adult Head Imaging medical policy (Policy #151 in the Radiology Section) for appropriate imaging guidance.

¡ Other systemic complications are being recognized as medical knowledge about this condition evolves. Requested imaging for possible COVID-19 complications should be managed by the appropriate advanced imaging medical policy.


® Repeat imaging may be appropriate in the following clinical circumstances:

¡ If there is significant worsening of symptoms in a COVID-19 positive patient and imaging will be used to modify patient management.

¡ A recovered COVID-19 positive patient with significant residual functional impairment and/or persistence hypoxemia.

Practice Notes

† The role of advanced imaging in the diagnosis and management of COVID-19 is very dynamic in this rapidly evolving condition.

† Findings on both Chest X-ray and CT Chest are non-specific. Chest X-rays may show patchy opacities with lower lung predominance. CT may show peripheral multifocal ground glass opacities with lower lung predominance. However, a significant portion of cases have opacities without a clear or specific distribution.^3,4,6

® Pediatric patients may have less pronounced imaging findings than adults.

® The American College of Radiology (ACR) recommends that CT Chest should not be used for screening or as a first-line test to diagnose COVID-19.³

® The Centers for Disease Control and Prevention (CDC) recommends viral testing as the only specific method of diagnosis.⁴

® The CDC has stated that symptoms may appear 2-14 days after exposure to the virus. These symptoms may include:⁵


¡ Fever or chills

¡ Cough

¡ Shortness of breath or difficulty breathing

¡ Fatigue

¡ Muscle or body aches

¡ Headache

¡ New loss of taste or smell

¡ Sore throat

¡ Congestion or runny nose

¡ Nausea or vomiting

¡ Diarrhea


® The Fleischner Society consensus statement published on April 7, 2020, recommends against the use of imaging in patients with suspected COVID-19 who are either asymptomatic or have only mild symptoms without evidence of significant pulmonary dysfunction or damage (e.g., absence of hypoxemia, no or mild dyspnea).⁶

® According to The American Society of Transplantation, screening donors is based on methods below. Screening donors encompasses three different methods.⁷


¡ Epidemiologic screening for travel and potential exposures

¡ Screening for symptoms suggestive of COVID-19

¡ Viral testing (Nucleic acid testing of specimens)

¡ There is no current indication for screening asymptomatic donors with advanced imaging.

1. Mandell L, Wunderink R, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007 Mar 1; 44 Suppl 2: S27-72.

2. ACR Appropriateness Criteria^® acute respiratory illness in immunocompetent patients. [online publication]. Reston (VA): American College of Radiology (ACR); 2018.

3. American College of Radiology. ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection. acr.org. Available at https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Recommendations-for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection. 3/22/2020

4. Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19). Centers for Disease Control and Prevention. National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. Page last reviewed: May 5, 2020. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html

5. Symptoms of Coronavirus. Centers for Disease Control and Prevention. National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. Page last reviewed: May 13, 2020. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html

6. AM Foust, et al. International Expert Consensus Statement on Chest Imaging in Pediatric COVID-19 Patient Management: Imaging Findings, Imaging Study Reporting and Imaging Study Recommendations. Radiology: Cardiothoracic Imaging. Published Online: Apr 23 2020 https://doi.org/10.1148/ryct.2020200214

7. GD Rubin, et al. The Role of Chest Imaging in Patient Management during the COVID-19 Pandemic: A Multinational Consensus Statement from the Fleischner Society. Radiology. Published Online: Apr 7 2020. https://doi.org/10.1148/radiol.2020201365

8. Scott Simpson, Fernando U. Kay, Suhny Abbara, Sanjeev Bhalla, Jonathan H. Chung, Michael Chung, Travis S. Henry, Jeffrey P. Kanne, Seth Kligerman, Jane P. Ko, and Harold Litt . Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA. Published online: March 25 2020 https://pubs.rsna.org/doi/10.1148/ryct.2020200152

9. American Society of Transplantation: COVID-19 (Coronavirus): FAQs for Organ Donation and Transplantation. Updated: March 11, 2020 https://www.myast.org/sites/default/files/COVID19%20FAQ%20Tx%20Centers%202020.03.11_FINAL.pdf

10. Grillet F, Behr J, Calame P, et al. Acute Pulmonary Embolism Associated with COVID-19 Pneumonia Detected by Pulmonary CT Angiography. Radiology 0 0:0 Published Online:Apr 23 2020

CH-14: OTHER CHEST INFECTIONS

CH-14.1: PPD or TB1,2 (Mycobacterium tuberculosis and Mycobacterium avium complex (MAC))

CH-14.2: Fungal Infections (Suspected or Known)

CH-14.3: Wegener's Granulomatosis/Granulomatosis with Polyangiitis

CH-14.4: Suspected Sternal Dehiscence

CH-14.1: PPD or TB^1,2 (Mycobacterium tuberculosis and Mycobacterium avium complex (MAC))

For this condition imaging is medically necessary based on the following criteria:

† CT Chest with contrast (CPT^® 71260) or CT Chest without contrast (CPT^® 71250) with ANY of the following:

® Positive PPD skin test or other positive tuberculin skin tests or suspected active (or reactivated) tuberculosis and a normal or equivocal chest x-ray¹
® Suspected complications or progression of tuberculosis (e.g. pleural tuberculosis, empyema, and mediastinitis).²

† Follow-up CT Chest with contrast (CPT^® 71260) with frequency at the discretion of the pulmonary specialist (not to exceed 3 studies in 3 months).

® Re-evaluate individuals undergoing active treatment for tuberculosis who had abnormalities seen only on CT Chest.

For this condition imaging is medically necessary based on the following criteria:

† CT Chest with contrast (CPT^® 71260) or High resolution CT Chest (HRCT) without contrast (CPT^® 71250):^3,4

® Initial diagnosis of any fungal pneumonia or chest infection.^3,4
® Suspected complications or progression of the fungal chest infection (e.g. worsening pneumonitis; pleural effusion, empyema, mediastinitis).

CH-14.3: Wegener's Granulomatosis/Granulomatosis with Polyangiitis

For this condition imaging is medically necessary based on the following criteria:

† CT Chest without contrast (CPT^® 71250)* should be done in all members who have pulmonary symptoms and are newly diagnosed or suspected of having an Antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitides (AAV) for a baseline prior to initiating immunosuppressive therapy.^5,6

† Selective use of additional imaging is useful in evaluating members who are suspected or known to have AAV, including CT Head (sinuses, orbits, mastoids) in members with visual or upper respiratory track symptoms or signs, and CT Neck (subglottic region) in members with symptoms or signs of subglottic stenosis.⁶

*In most situations, CT scans in members with AAV should be performed without an iodinated contrast agent administered.⁶

CH-14.4: Suspected Sternal Dehiscence

For this condition imaging is medically necessary based on the following criteria:

† Sternal wound dehiscence is primarily a clinical determination.

† Chest x-ray is performed prior to advanced imaging to identify abnormalities in the sternal wire integrity and/or a midsternal stripe. Other findings include rotated, shifted or ruptured wires.

† CT Chest without contrast can be considered if there is planned debridement and/or repair.

References

1. American College of Radiology (ACR) Appropriateness Criteria ^® Imaging of Possible Tuberculosis;2016.
2. Heitkamp DE, Albin MM, Chung JH, et al. ACR Appropriateness Criteria^® Acute Respiratory Illness in Immunocompromised Patients. Journal of Thoracic Imaging. 2015;30(3). doi:10.1097/rti.0000000000000153.
3. ACR Appropriateness Criteria: acute respiratory illness in immunocompetent patients. Last reviewed 2018.
4. Walker C, Abbott G, Greene R, et al. Imaging Pulmonary Infection: Classic Signs and Patterns. AJR; 2014; 202; 479-492.
5. Cordier J, Valeyre D, Guillevin L, et al. Pulmonary Wegener's granulomatosis. A clinical and imaging study of 77 cases. Chest 1990; 97:906.
6. Peivandi A, Vogel N, Opfermann U, et al. Early detection of sternal dehiscence by conventional chest X-ray. Thorac Cardiovasc Surg. 2006 Mar; 54 (2): 108-11.



CH-15: SARCOID

CH-15.1: Sarcoid

CH-15.1 Sarcoid

For this condition imaging is medically necessary based on the following criteria:

† Chest CT either with contrast (CPT^® 71260) or without contrast (CPT^® 71250) is appropriate for the following:¹

® Establish or rule out the diagnosis when suspected,
® Development of worsening symptoms,
® New symptoms appear after a period of being asymptomatic, or
® Treatment change is being considered in known sarcoid.

† There is currently no evidence-based data to support performing serial PET scans to monitor disease activity while tapering steroid therapy.^2,3,4

® See Adult Cardiac Imaging Policy (Policy #149 in the Radiology Section); CD-5.2: Cardiac MRI – Indication (excluding Stress MRI)
® See Adult Head Imaging Policy (Policy #151 in the Radiology Section); HD-22: Cerebral: Vasculitis.

1. Hantous-Zannad S, Charrada L, Zidi A, et al. Value of CT scanning in the investigation of thoracic sarcoidosis. Rev Mal Respir 2003 April; 20 (2 pt 1):207-213.
2. Okumura W, Iwasaki T, Toyama T, et al. Usefulness of fasting 18F-FDG PET in identification of cardiac sarcoidosis. J Nucl Med 2004; 45 (12): 1989-1998.
3. Barney J, Addrizzo-Harris D, Patel N, Sarcoidosis, Chest Foundation. Acquired 09182017.
4. Baughman R, Culver D, and Judson M, A Concise Review of Pulmonary Sarcoidosis, American Journal of Respiratory and Critical Care Medicine: Vol. 183, No. 5 | Mar 01, 2011.



CH-16: SOLITARY PULMONARY NODULE (SPN)

CH-16.0: Solitary Pulmonary Nodule

CH-16.1: Solitary Pulmonary Nodule – Imaging

CH-16.2: Incidental Pulmonary Nodules Detected on CT Images

CH-16.3: Interval Imaging Outcomes

CH-16.4: PET

CH-16.0: Solitary Pulmonary Nodule

For this condition imaging is medically necessary based on the following criteria:

† For Lung Cancer Screening (LDCT) including incidental findings from LDCT, See CH-33: Lung Cancer Screening.

CH-16.1: Solitary Pulmonary Nodule – Imaging

For this condition imaging is medically necessary based on the following criteria:

† CT Chest with contrast (CPT^® 71260) or CT Chest without contrast (CPT^® 71250) can be performed initially for discrete nodule(s) in the following scenarios:^1,2,3

® Lung nodule(s) seen on an imaging study other than a “dedicated” CT or MRI Chest. Examples of other studies:
¡ Chest x-ray
¡ CT Abdomen
¡ MRI Spine
¡ Coronary CTA¹
® But NOT in the following which are considered initial dedicated advanced chest imaging:
¡ CT Chest without and with contrast (CPT^® 71270).
¡ CTA Chest without and with contrast (CPT^® 71275).
¡ MRI Chest without contrast (CPT^® 71550).
¡ MRI Chest without and with contrast (CPT^® 71552).
¡ MRA Chest without and with contrast (CPT^® 71555).

¡ Similar-sized pleural nodule(s) is treated as a pulmonary nodule(s)

Abnormality examples include: mass, opacity, lesion, density, nodule, and calcification.

CH-16.2: Incidental Pulmonary Nodules Detected on CT Images

For this condition imaging is medically necessary based on the following criteria:

Incidentally Detected Solid Pulmonary Nodules Follow-up Recommendations*
Size
Nodule Type	<6 mm (<100 mm3)	6–8 mm	>8 mm	Comments
Single Nodule
	Follow-up (optional) CT at 12 months. No routine follow-up if stable at 12 months	CT at 6–12 months, then CT at 18–24 months if stable	CT at 3 months, then CT at 6-12 and then at 18-24 months if stable. Consider PET/CT** or biopsy	Certain members at high risk with suspicious nodule morphology, upper lobe location, or both may warrant 12-month follow-up
Multiple Nodules
	Follow-up (optional) CT at 12 months. *No routine follow-up if stable at 12 months	CT at 3–6 months, then at 18–24 months if stable	CT at 3–6 months, then at 18–24 months if stable. Consider PET/CT** or biopsy	Use most suspicious nodule as a guide to management. Follow-up intervals may vary according to size and risk.
Incidentally Detected Sub-Solid Pulmonary Nodules Follow-up Recommendations
Size
Nodule Type	<6 mm (<100 mm3)		≥6 mm (≥100 mm3)	Comments
Single Ground glass opacity (GGO)	Consider follow-up at 2 and 4 years. If solid component(s) or growth develops, consider resection.		CT at 6–12 months to confirm persistence, then follow-up with CT every 2 years until 5 years	In certain suspicious nodules, 6 mm, consider follow-up at 2 and 4 years. If solid component(s) or growth develops, consider resection.
Single Part-solid	Consider follow-up at 2 and 4 years. If growth develops, consider resection.		CT at 3–6 months to confirm persistence. If unchanged and solid component remains <6 mm, then annual CT should be performed for 5 years. If the solid component has suspicious morphology (i.e., lobulated margins or cystic components), is >8 mm or is growing: Consider PET/CT** or biopsy	In practice, part-solid nodules cannot be defined as such until >6 mm. Persistent part-solid nodules with solid components >6 mm should be considered highly suspicious.
Multiple Part-Solid	CT at 3–6 months. If stable, consider CT at 2 and 4 years.		CT at 3–6 months. Subsequent management based on the most suspicious nodule(s).	Multiple <6 mm pure ground-glass nodules are usually benign.

(*Following the Fleischner Society Guidelines for high risk which include American College of Chest Physicians intermediate and high risk categories.^1,2)

If a PET/CT was found to be negative, follow-up with CT at 6–12 months, then CT at 18–24 months if stable.

CH-16.3: Interval Imaging Outcomes

For this condition imaging is medically necessary based on the following criteria:

† No further advanced imaging is necessary if a nodule has been:

® Stable for 2 years
¡ Nodules(s) stable on chest x-ray.
¡ Nodule(s) ≥6mm stable on CT Chest.¹
® Stable for 1 year
¡ Nodule(s) <6mm.¹
® At any time, if:
¡ Classically benign characteristics by chest x-ray or previous CT (e.g. benign calcification pattern typical for a granuloma or hamartoma).
¡ Decreasing or disappearing nodule(s).³

® With an increase in nodule(s) size or number, PET (See CH-16.4: PET) as well as tissue sampling or other further diagnostic investigations should be considered.

For this condition imaging is medically necessary based on the following criteria:

† PET/CT (CPT^® 78815) is appropriate for a distinct lung nodule ≥8 mm on dedicated advanced chest imaging, as described in CH-16.1: Solitary Pulmonary Nodule – Imaging.

® If there is a history of malignancy, refer to the appropriate Oncology restaging/recurrence guideline for indications for PET imaging.
® Pleural nodule See CH-17.1: Pleural-Based Nodules and Other Abnormalities.
® Serial PET studies are not considered appropriate.
® Not appropriate for infiltrate, ground glass opacity, or hilar enlargement.

† A nodule is any pulmonary or pleural lesion that is a discrete, spherical opacity 2-30 mm in diameter surrounded by normal lung tissue. A larger nodule is called a mass. Entities that are not nodules, and are considered benign, include non-spherical linear, sheet-like, two-dimensional or scarring opacities.³

† Malignant nodule features can include spiculation, abnormal calcification, size greater than 7-10 mm, interval growth, history of a cancer that tends to metastasize to the lung or mediastinum, and/or smoking history.^1,3

® A nodule that grows at a rate consistent with cancer (doubling time 100 to 400 days) may be sampled for biopsy or resected.¹
® Less than 1% of <6 mm lung nodules are malignant.¹
® Three per cent of all 8 mm lung nodules are malignant.¹
® Only one follow-up at 6-12 months is sufficient for 6-8 mm nodules and not all require traditional 2 year follow-up.¹
® The larger the solid component of a subsolid nodule, the greater the risk of invasiveness and metastases.¹
® Increased risk of primary cancer as the total nodule count increased from 1 to 4 but decreased risk in members with 5 or more nodules, most of which likely resulted from prior granulomatous infection.¹
® A nodule that does not grow in 6 months has a risk of malignancy at <10%.

† Ground glass or subsolid opacities, which can harbor indolent adenocarcinoma with average doubling times of 3–5 years.¹

† Repeat PET is discouraged, since if the original PET is positive, biopsy may be performed. If the original PET is negative but subsequent CT Chest shows increase in size of the nodule, biopsy may be performed.

† False positive PET can occur with infection or inflammation; false negatives can occur with small size nodule, ground glass lesions and indolent cancers such as bronchoalvealor or carcinoid.

† False negative PET can be seen in members with adenocarcinoma in situ, carcinoid tumors, and mucinous adenocarcinomas. High pre-test likelihood of malignancy negative findings on the PET scan only reduce the likelihood of malignancy to 14%; while in a member with a low pre-test likelihood (20%), a negative FDG PET scan reduces the likelihood of malignancy to 1%.⁶

References

1. MacMahon H, et al. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017, Radiology.
2. Gould M, Donnington J, Lynch W, et al, Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3^rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143(5 Suppl): e93S–e120S.
3. Kanne J, Jensen L, Mohammed T, et al. Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria^® radiographically detected solitary pulmonary nodule. [Online publication]. Reston (VA): American College of Radiology (ACR); 2012
4. Tan B, Flaherty K, Kazerooni E, et al. The solitary pulmonary nodule. Chest 123(1 Suppl.), 89S–96S (2003).
5. Khandani, AH and Fielding, JR. PET in Management of Small Pulmonary Nodules, Communications, March 2007, Vol 242, Issue 3.
6. Truong MT, et al. Update in the evaluation of the solitary pulmonary nodule. Radiographics 2014; 34: 1658-1679.
7. Lung CT Screening Reporting and Data System (Lung-RADS™), American College of Radiology, Quality & Safety. https://www.acr.org/Quality-Safety/Resources/LungRADS.
8. National Comprehensive Cancer Network (NCCN) Guidelines, Lung Cancer Screening, Version 2.2019 – August 27,2018. Available at: https://www.nccn.org/professionals/physician_gls/pdf/lung_screening.pdf. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Lung Cancer Screening v2.2019 – August 27, 2018. ©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org.
9. National Comprehensive Cancer Network (NCCN) Guidelines, Non-Small Cell Lung Cancer, Version 3.2019 – January 18,2019. Available at: https://www.nccn.org/professionals/physician_gls/pdf/lung_screening.pdf Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Non-Small Cell Lung Cancer, Version 3.2019 – January 18, 2019. ^©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org.

CH-17: PLEURAL-BASED NODULES AND OTHER ABNORMALITIES

CH-17.1 Pleural-Based Nodules and Other Abnormalities

CH-17.1 Pleural-Based Nodules and Other Abnormalities

For this condition imaging is medically necessary based on the following criteria:

† CT Chest with contrast (CPT^® 71260) or CT Chest without contrast (CPT^® 71250) (with contrast is preferred for initial evaluation) for pleural nodule(s).¹

® Pleural nodule(s) seen on an imaging study other than a “dedicated” CT or MRI Chest.¹
® Pleural nodule(s) identified incidentally on any of the following dedicated chest studies can replace CT Chest as the initial dedicated study.¹
¡ CT Chest without and with contrast (CPT^® 71270).
¡ CTA Chest without and with contrast (CPT^® 71275).
¡ MRI Chest without contrast (CPT^® 71550).
¡ MRI Chest without and with contrast (CPT^® 71552).
¡ MRA Chest without and with contrast (CPT^® 71555).
® After preliminary comparison with any available previous chest films to determine presence and stability.
® Using largest measurement of multiple nodule(s). (See CH-16.1: Solitary Pulmonary Nodule – Imaging).
® Following the Fleischner Society Guidelines for high risk. (See CH-16.2: Incidental Pulmonary Nodules Detected on CT Images)¹

Practice Notes

Pleural nodule/mass or thickening without suggestion of malignancy would undergo surveillance or biopsy

1. Rivera M, et al. Establishing the diagnosis of lung cancer: diagnosis and management of lung cancer, 3^rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May; 143 (5 Suppl): e142S-65S.


CH-18: PLEURAL EFFUSION

CH-18.1: Pleural Effusion

CH-18.1 Pleural Effusion

For this condition imaging is medically necessary based on the following criteria:

† CT Chest with contrast (CPT^® 71260) after both:^1,2

® Chest x-ray including lateral decubitus films; and
® Thoracentesis to determine if fluid is exudative or transudative and remove as much as possible (this fluid can obscure the underlying lung parenchyma and possibly a mass).

Practice Notes

† Bilateral effusions are more often systemic related transudates (congestive heart failure, renal failure, liver insufficiency, etc.), and advanced imaging is rarely needed. Large unilateral effusions can be malignant. Analysis of fluid may include: cytology, culture, cell count, and biochemical studies.

References

1. Light R, MacGregor M, Luchsinger PC et al. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med 1972; 77:507-13.
2. British Thoracic Society Pleural Disease Guideline 2010: BTS Guidelines for the Management of Pleural Disease. Thorax 2010; 65; Suppl II.

CH-19.1 Pneumothorax/Hemothorax

For this condition imaging is medically necessary based on the following criteria:

† Chest x-ray initially.

® CT Chest with contrast (CPT^® 71260) or without contrast (CPT^® 71250) if:
¡ Diagnosis of a small pneumothorax is in doubt, and the presence of a pneumothorax will affect member treatment decisions.¹
¡ Preoperative study for treatment of pneumothorax.¹
¡ Pneumothorax associated with hemothorax.²
¡ Suspected complications from hemothorax (e.g. empyema).²
¡ Suspected Alpha-1-Antitrypsin Deficiency (even without pneumothorax).³

For this condition imaging is medically necessary based on the following criteria:

† Chest x-ray initially.

® CT Chest with contrast (CPT^® 71260) or without contrast (CPT^® 71250) if:
¡ Recent vomiting and/or suspected esophageal perforation.^4,5
¡ Associated pneumopericardium.^4,5
¡ Associated pneumothorax.^4,5
¡ Preoperative study for treatment.^4,5

† An expiration chest x-ray can enhance the evaluation of equivocal plain x-ray. There is no data supporting the use of serial CT Chest to follow members with a known pneumothorax or hemothorax who are asymptomatic or have stable symptoms. With the exception of the indications above, advanced imaging of the chest is rarely indicated in the diagnosis or management of pneumothorax. Inspiratory/expiratory chest x-rays are helpful in defining whether a pneumothorax is present.

References

1. Manes, N., et al. (2002). "Pneumothorax--guidelines of action." Chest 121(2): 669.
2. Mowery, N. T., et al. (2011). "Practice management guidelines for management of hemothorax and occult pneumothorax." J Trauma 70(2): 510-518.
3. Sandhaus R, Turino G, Brantly M, et al. The Diagnosis and Management of Alpha-1 Antitrypsin Deficiency in the Adult. Chronic Obst Pulm Dis 2016; 3:668.
4. Iyer V, Joshi A, Ryu J. Spontaneous pneumomediastinum: analysis of 62 consecutive adult patients; Mayo Clinic Proceedings; 84 (5) (2009), pp. 417-421.

For this condition imaging is medically necessary based on the following criteria:

† CT Chest with contrast (CPT^® 71260) to evaluate mediastinal abnormalities seen on chest x-ray or other non-dedicated chest imaging and can be done once initially if there is a concern for:^1,2,3

® Mediastinal cyst including bronchogenic, thymic, pericardial or esophageal in nature.
¡ CT Chest with contrast (CPT^® 71260) or MRI Chest without and with contrast (CPT^® 71552) for subsequent evaluations if:
§ New signs or symptoms, or
§ Preoperative assessment.

† For Goiter; See Adult Neck Imaging Policy (Policy #153 in the Radiology Section); NECK-8.1: Thyroid Nodule.

† For Myasthenia Gravis; See Adult Peripheral Nerve Disorders Imaging Policy (Policy #157 in the Radiology Section); PN-6.1: Neuromuscular Disease.

For this condition imaging is medically necessary based on the following criteria:

† Chest X-ray initially.

® CT Chest without contrast (CPT^® 71250) or with contrast (CPT^® 71260) for the following situations:¹
¡ Rib¹ or Sternal² Fracture:
§ With associated complications identified clinically or by other imaging, including pneumothorax, hemothorax, pulmonary contusion, atelectasis, flail chest, cardiovascular injury and/or injuries to solid or hollow abdominal organs.¹
§ Uncomplicated, single fractures, multiple fractures, non-acute fractures, or occult rib fractures are NOT an indication for CT Chest unless malignancy is suspected as the etiology.¹
¡ Routine follow-up advanced imaging of rib or sternal fractures is not indicated.¹

† Clavicle Fractures:

® CT Chest with contrast (CPT^® 71260) or CT Chest without contrast (CPT^® 71250) or MRI Chest without and with contrast (CPT^® 71552) or MRI Chest without contrast (CPT^® 71550) for proximal (medial) 1/3 fractures or sternoclavicular dislocations.³
® X-ray is adequate for evaluation of middle and distal 1/3 fractures.³

References

1. ACR Appropriateness Criteria^® Rib Fractures: American College of Radiology (ACR); 2018.

2. Clancy K, Velopulos C, Bilaniuk J, et al. Eastern Association for the Surgery of Trauma. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 Nov; 73 (5 Suppl 4): S301-6.
3. Throckmorton T, Kuhn JE. Fractures of the medial end of the clavicle. J Shoulder Elbow Surg 2007; 16:49.

† Chest x-ray is useful in the workup of a soft-tissue mass and are almost always indicated as the initial imaging study.¹

® Chest ultrasound (CPT^® 76604) may be useful as an initial imaging study in the setting of a suspected superficial or subcutaneous lipoma. This modality may also be valuable in differentiating cystic from solid lesions and has also been used to assess the vascularity of lesions.¹
® CT Chest with contrast (CPT^® 71260) or CT Chest without contrast (CPT^® 71250) or MRI Chest without and with contrast (CPT^® 71552) or MRI Chest without contrast (CPT^® 71550) can be considered unless chest x-ray or ultrasound demonstrate ONE of the following:^1,2
¡ Obvious lipomas¹ (See Adult Musculoskeletal Imaging Policy (Policy #152 in the Radiology Section); MS-10: Soft Tissue Mass or Lesion of Bone).
¡ Clearly benign entity¹ (See Adult Musculoskeletal Imaging Policy (Policy #152 in the Radiology Section); MS-10: Soft Tissue Mass or Lesion of Bone).

† Chest x-rays of chest wall masses can detect calcification, ossification, or bone destruction as well as location and size.³

References

1. ACR Appropriateness Criteria^® Soft-Tissue Masses. American College of Radiology (ACR); 2017.
2. ACR Appropriateness Criteria^® Primary Bone Tumors. American College of Radiology (ACR); 2013.


CH-23: PECTUS EXCAVATUM AND PECTUS CARINATUM

CH-23.1: Pectus Excavatum and Carinatum

CH-23.1 Pectus Excavatum and Carinatum

For this condition imaging is medically necessary based on the following criteria:

† CT Chest without contrast (CPT^® 71250) or MRI Chest without and with contrast (CPT^® 71552) and 3-D reconstruction (CPT^® 76377 or CPT^® 76376) if:

® Candidates for surgical correction.^1,2
¡ Cosmetic repairs requests without physiological disability or severe deformities may not meet certain payers policies.
® Cardiac or pulmonary dysfunction has been identified^1,2
¡ ECG and echocardiography if cardiac symptoms or evidence of cardiac function abnormalities.
¡ Chest x-ray and PFT’s if increasing shortness of breath.¹

® See Pediatric Chest Imaging Policy (Policy # 162 in the Radiology Section); PEDCH-11: Pectus Deformities.

References

1. Marcovici PA, LoSasso BE, Kruk P, Dwek J. MRI for the evaluation of pectus excavatum. Pediatr Radiol, 2011; 41:757-758.

2. Goretsky M, Kelly K, Croitoru D, et al. Chest wall anomalies: pectus excavatum and pectus carinatum. Adolesc Med Clin. 2004 Oct; 15(3):455-71.

For this condition imaging is medically necessary based on the following criteria:

† CT Chest with contrast (CPT^® 71260), CTA Chest (preferred modality) (CPT^® 71275), or MRA Chest (CPT^® 71555) for evaluation of:^1,2,3

® Suspected pulmonary AVM.
® First degree relatives of a member with a primary pulmonary AVM.
® Evaluation of members with paradoxical embolus/stroke and no evidence of patent foreman ovale on echocardiogram.

† Pulmonary AVMs are abnormal connections between pulmonary arteries and veins, usually found in the lower lobes, that can be either primary or acquired (such as trauma, bronchiectasis). They can be identified in up to 98% of chest x-rays by a peripheral, circumscribed, non-calcified lesion connected by blood vessels to the hilum of the lung. Treatment is often by surgery or embolization of the feeding artery using platinum coils or detachable balloons.

References
1. De Cillis E, Burdi N, Bortone A, et al. Endovascular treatment of pulmonary and cerebral arteriovenous malformations in patients affected by hereditary haemorrhagic teleangiectasia. Current Pharmaceutical Design 2006; 12 (10):1243-1248.
2. Gossage J and Kanj G. Pulmonary Arteriovenous Malformations a State of the Art Review, Am. J. Respir. Crit. Care Med. August 1, 1998 vol. 158 no. 2 643-661.
3. Lee E, Boiselle P, Cleveland R. Multidector CT evaluation of congenital lung anomalies. Radiology, 2008; 247: 632-648.



CH-25: PULMONARY EMBOLISM (PE)

CH-25.1: Pulmonary Embolism

CH-25.1 Pulmonary Embolism

For this condition imaging is medically necessary based on the following criteria:

† CT Chest with contrast with PE protocol (CPT^® 71260) or CTA Chest (CPT^® 71275) if at least one symptom, clinical/laboratory finding or risk factor from each of the lists below are present.

® With any ONE of the 3:^6,7,8
¡ Dyspnea, new onset and otherwise unexplained;
¡ Chest Pain, pleuritic;
¡ Tachypnea
® AND, with any ONE of the 3:^6,7,8
¡ Abnormal D-dimer test;
¡ Wells Criteria score* higher than 4 points;
¡ One Risk Factor** or Symptom** of new onset demonstrating high clinical probability of PE

RISK FACTORS**	SYMPTOMS ATTRIBUTED TO PE**
Immobilization at least 3 days or surgery in last 4 weeks or recent trauma	Signs or symptoms of DVT
Previous history of DVT or PE	Hemoptysis
Cancer actively treated in last 6 months or receiving palliative treatment	Right heart strain or failure
Recent history of a long airplane flight	Systolic BP <90
Use of estrogen-based contraceptives (birth control pills, the patch, and vaginal ring)/Oral estrogen1	Syncope
Advanced age (≥70)	Cough
Congestive heart failure	Heart Rate >100
Obesity (BMI ≥35)	Palpitations
Suspicion of COVID-19

Well’s Criteria for Clinical Probability of PE*
Clinical signs/symptoms of DVT (at minimum: leg swelling and pain with palpation of the deep veins)	3
PE is likely or equally likely diagnosis	3
Heart rate >100	1.5
Immobilization at least 3 days or surgery in last 4 weeks	1.5
Previous history of DVT or PE	1.5
Hemoptysis	1
Cancer actively treated in last 6 months or receiving palliative treatment	1
Calculate Probability: Low <2 Moderate 2 to 6 High >6
Using the above criteria, only 3% of members with a low pretest probability had PE versus 63% of those with a high pretest probability.

® Non-urgent cases which do not meet above 2-step criteria, should undergo prior to advanced imaging:⁹
¡ Chest x-ray (to rule out other causes of acute chest pain).
¡ Primary cardiac and pulmonary etiologies should be eliminated.
® Pregnant women with suspected PE are suggested to proceed with^1,9
¡ D-dimer and/or;
¡ Doppler studies of the lower extremities;
¡ V/Q preferred if Doppler negative; CTA Chest (CPT^® 71275) or MRA Chest (CPT^® 71555) can be performed if V/Q scanning is not available.
® Ventilation-perfusion scans, also called V/Q, scans (CPT^® 78580-Pulmonary Perfusion Imaging; CPT^® 78582-Pulmonary Ventilation (e.g., Aerosol or Gas) and Perfusion Imaging).
¡ Is not a replacement for CTA Chest⁹
¡ Can be considered in any of the following:
§ Suspected pulmonary embolism if there is a contraindication to CT or CTA Chest (ventilation-perfusion scans CPT^® 78582).
§ Suspected pulmonary embolism when a chest x-ray is negative and CTA Chest is not diagnostic (CPT^®78580 or CPT^® 78582).
§ Follow-up of an equivocal or positive recent ventilation-perfusion lung scan to evaluate for interval change (CPT^® 78580).
® Follow-up Imaging in Stable or Asymptomatic Members with Known PE is not warranted^2,3,4,10
® CT Chest with contrast with PE protocol (CPT^® 71260) or CTA Chest (CPT^® 71275) for ANY of the following indications:
¡ Recurrent signs or symptoms such as dyspnea, or
¡ Elevated d-dimer which is persistent or recurrently elevated, or
¡ Right heart strain or failure identified by EKG, ECHO or Heart catheterization.

† Pulmonary embolism is found in approximately 10% of all those that present with suspicion of PE. Dyspnea, pleuritic chest pain and tachypnea occur with about 50% incidence with leg swelling or pain just over 50%.

† D-dimer level has a high sensitivity and low specificity for diagnosing PE.

® A negative D-dimer in combination with low or moderate PE risk classification has a negative predictive value approaching 100%.
® D-dimer can be falsely elevated with recent surgery, injury, malignancy, sepsis, diabetes, pregnancy, or other conditions where fibrin products are likely to be present.

† The decision to terminate anticoagulation treatment after previous pulmonary embolism (PE) with absent or stable symptoms is based on clinical evaluation and risk factors.

† Repeat studies do not allow one the ability to distinguish new from residual clot, with luminal diameter and clot character poorly correlated to symptoms and ECHO findings.

† Two thirds after primary thromboembolism have residual pulmonary artery clot at 6 months and 50% remains at one year.

† Subsequent persistence or elevation of D-dimer is associated with increased risk of recurrent PE. ECHO and Right Heart Catheterization (RHC) can identify those with pulmonary hypertension. Yet, 1/2 of all have persistent or new pulmonary hypertension after primary thromboembolism and only half of this latter group has dyspnea at rest or exercise intolerance.

References
1. Canonico M, Plu-Bureau G, Lowe G, Scarabin, P. (2008). Hormone replacement therapy and risk of venous thromboembolism in postmenopausal women: systematic review and meta-analysis. BMJ 2008; 336: 1227.
2. Fedullo PF, Auger WR, Kerr KM, et al. Chronic thromboembolic pulmonary hypertension. N Engl J Med 2001; 345: 1465-1472.
3. Kline JA, Steuerwald MT, Marchick MR, et al. Prospective evaluation of right ventricular function and functional status 6 months after acute submassive pulmonary embolism: frequency of persistent or subsequent elevation in estimated pulmonary artery pressure. Chest 2009; 136: 1202-1210.
4. Nijkeuter M, Hovens M, Davidson BL, et al. Resolution of thromboemboli in patients with acute pulmonary embolism. A systematic review. 5. Chest 2006; 129: 192-197.
5. Palareti G, Cosmi B, Legnani C, et al. d-Dimer testing to determine the duration of anticoagulation therapy. N Engl J Med 2006; 355: 1780-1789.
6. Wells P. Anderson D. Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001 Jul 17: 135 (2): 98-107. PubMed PMID: 11453709.
7. Wolf S. McCubbin T, Feldhaus K, et al. Prospective validation of Wells Criteria in the evaluation of patients with suspected pulmonary embolism. Ann Emerg Med. 2001 Nov: 44 (5): 503-10.
8. van Belle, A., et al. (2006). "Effectiveness of managing suspected pulmonary embolism using an al-gorithm combining clinical probability, D-dimer testing, and computed tomography." JAMA 2006 Jan 295 (2): 172-179.
9. ACR Appropriateness Criteria^® Acute Chest Pain - Suspected Pulmonary Embolism. American College of Radiology (ACR); 2016.
10. Kearon C, Akl E, Ornelas J, et al., Antithrombotic therapy for VTE disease: CHEST guideline and ex-pert panel report. Chest. 2016 Feb; 149 (2): 315-52.

CH-26: PULMONARY HYPERTENSION

For this condition imaging is medically necessary based on the following criteria:

See Adult Peripheral Vascular Disease Imaging Policy (Policy #158 in the Radiology Section): PVD-5: Pulmonary Artery Hypertension in the Peripheral Vascular Disease Imaging Guidelines

CH-27: SUBCLAVIAN STEAL SYNDROME

CH-27: Subclavian Steal Syndrome – General

CH-27.1: Subclavian Steal Syndrome

CH-27 Subclavian Steal Syndrome - General

For this condition imaging is medically necessary based on the following criteria:

† Occurs from blood flowing up the contralateral vertebral artery to the basilar artery and retrograde down the ipsilateral vertebral artery (reversal of flow) to supply collateral circulation to the arm on the side and past the stenotic or occluded proximal subclavian or innominate artery to perfuse that arm.

CH-27.1 Subclavian Steal Syndrome

For this condition imaging is medically necessary based on the following criteria:

† Initial evaluation should include clinical findings satisfying the symptom complex and initial imaging with Carotid duplex study (CPT^® 93882).

® Satisfying the symptom complex.
¡ Physical examination findings suggestive of subclavian stenosis include a discrepancy of >15 mmHg in blood pressure readings taken in both upper extremities, delayed or decreased amplified pulses in the affected side, and a bruit in the supraclavicular area on the affected side.
¡ Symptoms include vertebral basilar artery insufficiency, vertigo, limb paresis, and paresthesias. Bilateral cortical visual disturbances, ataxia, syncope, and dysarthria occur less frequently.
¡ Symptoms of cerebral ischemia may be produced by exercise of the affected arm.
® Carotid duplex study (CPT^® 93882) is the initial and definitive imaging study
¡ Reversal of flow in the ipsilateral vertebral artery.
¡ If the carotid duplex is not diagnostic for reversal of flow in the ipsilateral vertebral artery, then neurological symptoms should be evaluated according to the Head guidelines.

† MRA Upper extremity (CPT^® 73225) or CTA Upper extremity (CPT^® 73206) can be performed in symptomatic members if needed to exclude pathology distal to the subclavian artery and if they will substitute for invasive angiography.

† See HD-21.1: Stroke/TIA (for vertebrobasilar stroke) in the Head Imaging Guidelines.

† Treatment options include ligation of the ipsilateral vertebral artery, aorta-subclavian artery bypass graft, or subclavian endarterectomy.

Practice Note
† While MRA does not expose the member to radiation, CTA should be considered the test of choice for subclavian steal syndrome given its superior spatial and temporal resolution.

References
1. Van Brimberge F, Dymarowski S, Budts W, et al. Role of magnetic resonance in the diagnosis of subclavian steal syndrome. J Magn Reson Imaging. 2000; 12 (2): 339.
2. Potter B and Pinto D. Subclavian steal syndrome. Circulation, 2014; 129: 2320-2323.



CH-28: SUPERIOR VENA CAVA (SVC) SYNDROME

CH-28.1 SVC Syndrome

CH-28.1 SVC Syndrome

For this condition imaging is medically necessary based on the following criteria:

† CT Chest with contrast (CPT^® 71260) for the evaluation of suspected SVC syndrome based on the facial cyanosis and upper extremity swelling without anasarca.^1,2

† MRV (CPT^® 71555) or CTV (CPT^® 71275) Chest may be indicated when stenting of the SVC is being considered.^1,2

Practice Notes
† SVC syndrome is caused by acute or subacute, intrinsic or extrinsic obstruction of the SVC, most commonly from lung cancer (80-85%) and less often benign (fibrosis, mediastinitis, indwelling devices). Other symptoms include dyspnea, headache and dizziness.

References

1. Wilson, et al. (2007). Superior Vena Cava Syndrome with Malignant Causes. New England Journal of Medicine, 356: 1862-1869.
2. Lepper P, Ott S, Hoppe H, et la. Superior vena cava syndrome in thoracic malignancies. Respir Care, 2011; 56: 653-666.


CH-29: THORACIC AORTA

CH-29.0: Thoracic Aorta

CH-29.1: Aortic Dissection

CH-29.2: Thoracic Aortic Aneurysm (TAA)

CH-29.3: Screening Guidelines for Familial Syndromes

CH-29.4: Thoracic Aorta in Individuals with Bicuspid Aortic Valve

CH-29.5: Calcified Ascending Aorta

CH-29 Thoracic Aorta

For this condition imaging is medically necessary based on the following criteria:

See Adult Peripheral Vascular Disease Imaging Policy (Policy #158 in the Radiology Section); PVD-6.2: Thoracic Aortic Aneurysm (TAA) and Adult Peripheral Vascular Disease Imaging Policy (Policy #158 in the Radiology Section); PVD-6.7: Aortic Dissection and Other Aortic Conditions

For this condition imaging is medically necessary based on the following criteria:

† See Adult Peripheral Vascular Disease Imaging Policy (Policy #158 in the Radiology Section); PVD-6.7: Aortic Dissection and Other Aortic Conditions

CH-29.2: Thoracic Aortic Aneurysm (TAA)

For this condition imaging is medically necessary based on the following criteria:

† See Adult Peripheral Vascular Disease Imaging Policy (Policy #158 in the Radiology Section); PVD-6.2: Thoracic Aortic Aneurysm (TAA)

CH-29.3: Screening Guidelines for Familial Syndromes

For this condition imaging is medically necessary based on the following criteria:

† See Adult Peripheral Vascular Disease Imaging Policy (Policy #158 in the Radiology Section); PVD-2.2: Screening for Vascular related genetic connective tissue Disorders (Familial Aneurysm Syndromes/Spontaneous Coronary Artery Dissection (SCAD)/Ehlers-Danlos/Marfan/Loeys-Dietz)

CH-29.4: Thoracic Aorta in Individuals with Bicuspid Aortic Valve

For this condition imaging is medically necessary based on the following criteria:

† See Adult Peripheral Vascular Disease Imaging Policy (Policy #158 in the Radiology Section); PVD-2.3: Screening for TAA in patients with bicuspid aortic valves

CH-29.5: Calcified Ascending Aorta

For this condition imaging is medically necessary based on the following criteria:

† Prior to open-heart operations.

® See Adult Cardiac Imaging Policy (Policy #149 in the Radiology Section); CD-13.1: Pre-Surgical Cardiac testing-General Information

® See CT and CTA in Adult Cardiac Imaging Policy (Policy #149 in the Radiology Section); CD-4.8: Transcatheter Aortic Valve Replacement (TAVR)

CH-30: ELEVATED HEMIDIAPHRAGM

CH-30.1: Elevated Hemidiaphragm

CH-30.1 Elevated Hemidiaphragm

For this condition imaging is medically necessary based on the following criteria:

† CT Chest with contrast (CPT^® 71260) and CT Neck with contrast (CPT^® 70491) (if requested) with new diaphragmatic paralysis after:^1,2

® Previous chest x-rays are available and reviewed to determine if the diaphragmatic elevation is a new finding, and/or
® Fluoroscopic examination (“sniff test”) to differentiate true paralysis from weakness.

† Repeat advanced imaging studies in the absence of new signs or symptoms are not indicated.

Practice Notes

† The right hemidiaphragm sits about 2 cm higher than the left.

† “Eventration” is thin membranous replacement of muscle, usually on the right, as the most common cause of elevation.

† Any injury to the phrenic nerve from neck to diaphragm can lead to paralysis.

† Common phrenic causes are traumatic or surgical injury or malignancy involving the mediastinum.

† Any loss of lung volume or increased abdominal pressure can lead to diaphragm elevation.

References
1. Ko MA, Darling GE. 2009. Acquired paralysis of the diaphragm. Thorac Surg Clin 19 (4): 501-510.
2. Qureshi A. 2009. Diaphragm paralysis. Semin Respir Crit Care Med 30(3): 315-320.


CH-31: THORACIC OUTLET SYNDROME (TOS)

CH-31.1: Thoracic Outlet Syndrome

CH-31.1 Thoracic Outlet Syndrome

For this condition imaging is medically necessary based on the following criteria:

† Chest x-ray should be performed initially in all cases, after the onset of symptoms or if there has been a change in symptoms, since it can identify boney abnormalities or other causes of right upper extremity pain.^1,2

† MR imaging is the preferred imaging modality in members with suspected TOS.^1,2

® MRI Chest (CPT^® 71550) or MRI Upper Extremity Other than Joint (CPT^® 73218).
® MRA Neck and Chest (CPT^® 70548 and CPT^® 71555) can be used in place of MRI with suspected arterial or venous TOS.
® CT Chest with contrast (CPT^® 71260) or CT Neck with contrast (CPT^® 70491) can be used in place of MRI for:
¡ Suspected anomalous ribs or fractures, as bone anatomy is more easily definable with CT.
¡ Postoperative members in whom there is a question regarding a remnant first rib.
¡ Dialysis-dependent renal failure, claustrophobia, or implanted device incompatibility.

Practice Notes
† TOS refers to compression of the subclavian vessels and/or brachial plexus at the thoracic outlet of the chest (the area bounded by the two scalene muscles and the first rib).
† There are 3 types, with neurogenic causes seen in 80%, venous causes (also called effort thrombosis) found in 15% and the remaining 5% being arterial in etiology.
† Since this is such a rare entity and diagnosis is difficult, specialist evaluation by a vascular surgeon or thoracic surgeon is helpful in determining the appropriate imaging pathway.

References
1. Raptis C, Sridhar S, Thompson R, et al. Imaging of the Patient with Thoracic Outlet Syndrome. RadioGraphics, 2016: 36: 984-1000.
2. ACR Appropriateness Criteria^® imaging in the diagnosis of thoracic outlet syndrome: American College of Radiology (ACR); 2014.



CH-32: LUNG TRANSPLANTATION

CH-32.1 Pre-Transplant Imaging Studies

CH-32.1 Pre-Transplant Imaging Studies

For this condition imaging is medically necessary based on the following criteria:

† Individuals on the waiting list or being considered for the lung transplant can undergo advanced imaging per that institution’s protocol as long as the studies do not exceed the following:

® CT Chest with and without contrast (CPT^® 71270), CT Chest with (CPT^® 71260), or CT Chest without contrast (CPT^® 71250)
® ECHO
® Imaging Stress Test (MPI, SE, MRI) or Heart Catheterization (Right and Left); Heart catheterization can also be done after a positive stress test.

† CT Chest with and without contrast (CPT^® 71270), CT Chest with contrast (CPT^® 71260), or CT Chest without contrast (CPT^® 71250) for initial post-transplant follow-up.

® Requests for subsequent follow-up imaging will go to Medical Director Review.

† Low-dose chest CT (CPT^® G0297) may be approved for lung cancer screening if all of the following criteria are met:

Screening Indications – Commercial and Medicaid

Imaging Study

† All criteria below must be met for approval: ® Member has not received a low-dose CT lung screening in less than 12 months; and ® Member has NO health problems that substantially limit life expectancy or the ability or willingness to have curative lung surgery*; and ® Member is between 55 and 80 years of age; and ® Member has at least a 30 pack-year history of cigarette smoking; and ® Currently smokes or quit within the past ≤15 years

Low-Dose Chest CT without contrast CPT® G0297

*This is based on a range of chest or other organ signs, symptoms or conditions which would question the member’s ability to undergo surgical or non-surgical treatment if a lung cancer was discovered. For example, congestive heart failure, advanced cancer from another site or a member with COPD who uses oxygen when ambulating, would be examples of conditions that would “substantially limit life expectancy.” Conversely, stable COPD and its symptoms, including cough, shortness of breath would not “substantially limit life expectancy.”

CH-33.2: National Coverage Determination (NCD) for Lung Cancer Screening with Low Dose Computed Tomography (LDCT) (210.14) (Medicare)
For this condition imaging is medically necessary based on the following criteria:

† Lung-RADS Assessment Categories

Screening Indications – Commercial and Medicaid

Imaging Study

† All criteria below must be met for approval: ® Member has not received a low-dose CT lung screening in less than 12 months; and ® Member has NO signs or symptoms suggestive of underlying lung cancer*; and ® Member is between 55 and 77 years of age; and ® Member has at least a 30 pack-year history of cigarette smoking; and ® Currently smokes or quit within the past ≤ 15 years ® A written order for LDCT lung cancer screening that includes counseling and shared decision making

Low-Dose Chest CT without contrast CPT® G0297

The Medicare Decision Memo and NCD 210.14

† ***A written order for LDCT lung cancer screening that meets the following criteria:

® For the initial LDCT lung cancer screening service: the beneficiary must receive a written order for LDCT lung cancer screening.
¡ *A written order for LDCT lung cancer screening that meets the following criteria:
■ For the initial LDCT lung cancer screening service: the beneficiary must receive a written order for LDCT lung cancer screening during a lung cancer screening counseling and shared decision making visit, furnished by a provider [as defined in Section 1861(r)(1) of the Social Security Act (the Act)] or qualified non-physician practitioner (physician assistant, nurse practitioner, or clinical nurse specialist as defined in §1861(aa)(5) of the Act).
® For subsequent LDCT lung cancer screenings: the beneficiary must receive a written order, which may be furnished during any appropriate visit (for example: during the Medicare annual wellness visit, tobacco cessation counseling services, or evaluation and management visit) with a provider (as defined in Section 1861(r)(1) of the Act) or qualified non-physician practitioner (physician assistant, nurse practitioner, or clinical nurse specialist as defined in Section 1861(aa)(5) of the Act).

® Determination of beneficiary eligibility including age, absence of signs or symptoms of lung disease, a specific calculation of cigarette smoking pack-years; and if a former smoker, the number of years since quitting;
® Shared decision making, including the use of one or more decision aids, to include benefits, harms, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure;
® Counseling on the importance of adherence to annual LDCT lung cancer screening, impact of comorbidities and ability or willingness to undergo diagnosis and treatment;
® Counseling on the importance of maintaining cigarette smoking abstinence if former smoker, or smoking cessation if current smoker and, if appropriate, offering additional Medicare-covered tobacco cessation counseling services; and
® If appropriate, the furnishing of a written order for lung cancer screening with LDCT. Written orders for both initial and subsequent LDCT lung cancer screenings must contain the following information, which must also be documented in the beneficiaries’ medical records:
¡ Beneficiary date of birth,
¡ Actual pack-year smoking history (number);
¡ Current smoking status, and for former smokers, the number of years since quitting smoking;
¡ Statement that the beneficiary is asymptomatic; and NPI of the ordering practitioner

For this condition imaging is medically necessary based on the following criteria:

† Any Lung-RADS less than 1 year interval follow-up is coded as Low-Dose CT Chest CPT^® 71250 (Not CPT^® G0297 which is ONLY the annual screen)

† For lung nodules, including incidental findings from studies other than screening LDCT, See CH-16.2: Incidental Pulmonary Nodules Detected on CT Images

Primary Category/Category Descriptor*	Management
3: Probably benign finding(s) - short term follow-up suggested; includes nodules with a low likelihood of becoming a clinically active cancer	6 month LDCT with a return to annual LDCT screening if unchanged.
4A: Suspicious - Findings for which additional diagnostic testing and/or tissue sampling is recommended	PET/CT may be used when there is a ≥8 mm solid component Follow-up with LDCT in 3 months with another LDCT in 6 months and a return to annual screening if stable and there is low suspicion of lung cancer.
4B or 4X: Suspicious - Findings for which additional diagnostic testing and/or tissue sampling is recommended	CT Chest with or without contrast, PET/CT and/or tissue sampling depending on the probability of malignancy and comorbidities. PET/CT may be used when there is a ≥8 mm solid component. If there is low suspicion of lung cancer, follow-up with LDCT in 3 months with another LDCT in 6 months and a return to annual screening if stable.

*The full description of the LUNG-RADS categories https://www.acr.org/-/media/ACR/Files/RADS/Lung-RADS/LungRADS_AssessmentCategories.pdf.

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.

________________________________________________________________________________________

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.

___________________________________________________________________________________________________________________________

Index:
Adult Chest Imaging Policy
Chest Imaging Policy, Adult
Computed Tomography, Chest, Adult
CT, Chest, Adult
Computed Tomography Angiography, Chest, Adult
CTA, Chest, Adult
Magnetic Resonance Imaging, Chest, Adult
MRI, Chest, Adult
Magnetic Resoance Angiography, Chest, Adult
MRA, Chest, Adult
Positron Emission Tomography, Chest, Adult
PET, Chest, Adult
Nuclear Medicine Imaging, Chest, Adult
Ultrasound, Chest, Adult
Radiopharmaceutical Nuclear Medicine Imaging, Chest, Adult

References:


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*