Procedure Codes Associated with Chest Imaging

Procedure Codes Associated with Chest Imaging
MRI	CPT®
MRI Chest without contrast	71550
MRI Chest with contrast (rarely used)	71551
MRI Chest without and with contrast	71552
Unlisted MRI procedure (for radiation planning or surgical software)	76498
MRA	CPT®
MRA Chest (non-cardiac)	71555
CT	CPT®
CT Chest without contrast	71250
CT Chest with contrast	71260
CT Chest without and with contrast (rarely used)	71270
CT Guidance for Placement of Radiation Therapy Fields	77014
Unlisted CT procedure (for radiation planning or surgical software)	76497
CTA	CPT®
CTA Chest (non-coronary)	71275
Nuclear Medicine	CPT®
PET Imaging; limited area (this code not used in pediatrics)	78811
PET Imaging: skull base to mid-thigh (this code not used in pediatrics)	78812
PET Imaging: whole body (this code not used in pediatrics)	78813
PET with concurrently acquired CT; limited area (this code rarely used in pediatrics)	78814
PET with concurrently acquired CT; skull base to mid-thigh	78815
PET with concurrently acquired CT; whole body	78816
Pulmonary Ventilation (e.g., Aerosol or Gas) Imaging	78579
Pulmonary Perfusion Imaging	78580
Pulmonary Ventilation (e.g., Aerosol or Gas) and Perfusion Imaging	78582
Quantitative Differential Pulmonary Perfusion, Including Imaging When Performed	78597
Quantitative Differential Pulmonary Perfusion and Ventilation (e.g., Aerosol or Gas), Including Imaging When Performed	78598
Ultrasound	CPT®
Ultrasound, chest (includes mediastinum, chest wall, and upper back)	76604
Ultrasound, axilla	76882
Ultrasound, breast; unilateral, including axilla when performed; complete	76641
Ultrasound, breast; unilateral, including axilla when performed; limited	76642

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

PEDCH-1: General Policies

PEDCH-1.1: Pediatric Chest Imaging Age Considerations

PEDCH-1.2: Pediatric Chest Imaging Appropriate Clinical Evaluation

PEDCH-1.3: Pediatric Chest Imaging Modality General Considerations

This General Policy section provides an overview of the basic criteria for which Pediatric 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.

PEDCH-1.1: Pediatric Chest Imaging Age Considerations

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

† Many conditions affecting the chest in the pediatric population are different diagnoses than those occurring in the adult population. For those diseases which occur in both pediatric and adult populations, differences may exist in management due to member age, comorbidities, and differences in disease natural history between children and adults.

† Members who are <18 years old should be imaged according to the Pediatric Chest Imaging Guidelines, and members who are ≥18 years old should be imaged according to the Adult Chest Imaging Guidelines, except where directed otherwise by a specific guideline section.

PEDCH-1.2: Pediatric Chest Imaging Appropriate Clinical Evaluation

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

† A recent (within 60 days) face to face evaluation including a detailed history, physical examination, and appropriate laboratory studies should be performed prior to considering advanced imaging (CT, MRI, Nuclear Medicine), unless the member is undergoing guideline-supported scheduled follow-up imaging evaluation.

† Unless otherwise stated in a specific guideline section, the use of advanced imaging to screen asymptomatic members for disorders involving the chest is not supported. Advanced imaging of the chest should only be approved in members who have documented active clinical signs or symptoms of disease involving the chest.

† Unless otherwise stated in a specific guideline section, repeat imaging studies of the chest are not necessary unless there is evidence for progression of disease, new onset of disease, and/or documentation of how repeat imaging will affect member management or treatment decisions.

PEDCH-1.3: Pediatric Chest Imaging Modality General Considerations

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

† MRI

® MRI Chest is generally performed without and with contrast (CPT^® 71552) unless the member has a documented contraindication to gadolinium or otherwise stated in a specific guideline section.
® Due to the length of time required for MRI acquisition and the need to minimize member movement, anesthesia is usually required for almost all infants (except neonate) and young children (age <7 years), as well as older children with delays in development or maturity. This anesthesia may be administered via oral or intravenous routes. In this member population, MRI sessions should be planned with a goal of minimizing anesthesia exposure by adhering to the following considerations:
¡ MRI procedures can be performed without and/or with contrast use as supported by these condition-based guidelines. If intravenous access will already be present for anesthesia administration and there is no contraindication for using contrast, imaging without and with contrast may be appropriate if requested. By doing so, the requesting provider may avoid repetitive anesthesia administration to perform an MRI with contrast if the initial study without contrast is inconclusive.
§ Recent evidence-based literature demonstrates the potential for gadolinium deposition in various organs including the brain, after the use of MRI contrast.
§ The U.S. Food and Drug Administration (FDA) has noted that there is currently no evidence to suggest that gadolinium retention in the brain is harmful and restricting gadolinium-based contrast agents (GBCAs) use is not warranted at this time. It has been recommended that GBCA use should be limited to circumstances in which additional information provided by the contrast agent is necessary and the necessity of repetitive MRIs with GBCAs should be assessed.
® If multiple body areas are supported by Horizon BCBSNJ guidelines for the clinical condition being evaluated, MRI of all necessary body areas should be obtained concurrently.
® The presence of surgical hardware or implanted devices may preclude MRI.
® The selection of best examination may require coordination between the provider and the imaging service.

® CT Chest is generally performed either with contrast (CPT^® 71260) or without contrast (CPT^® 71250).
¡ There are no generally accepted pediatric indications for CT Chest without and with contrast (CPT^® 71270).
® CT should not be used to replace MRI in an attempt to avoid sedation unless listed as a recommended study in a specific guideline section.
® The selection of best examination may require coordination between the provider and the imaging service.

® Ultrasound chest (CPT^® 76604) or axilla (CPT^® 76882) is indicated as an initial study for evaluating adenopathy, palpable chest wall lesions, pleural effusion or thickening, patency of thoracic vasculature, and diaphragm motion abnormalities.
® For those members who do require advanced imaging, ultrasound can be very beneficial in selecting the proper modality, body area, image sequences, and contrast level that will provide the most definitive information for the member.

® Nuclear medicine studies other than PET/CT are rarely used in evaluation of the pediatric chest.
® Pulmonary Ventilation-Perfusion Imaging (CPT^® 78582) has been replaced by CTA Chest (CPT^® 71275) or CT Chest with contrast (CPT^® 71260), but can be approved for evaluation of suspected pulmonary embolism if CT is unavailable.
¡ See Adult Chest Imaging Policy (Policy #150 in the Radiology Section); CH-25: Pulmonary Embolism (PE).
® Pulmonary Perfusion Imaging (CPT^® 78580) should generally not be approved in lieu of CPT^® 78582 for initial evaluation of suspected pulmonary embolism, but can be approved for follow up of an equivocal or positive recent ventilation-perfusion lung scan (CPT^® 78582) to evaluate for interval change.
® Pulmonary Ventilation Imaging (CPT^® 78579) should not be approved in lieu of CPT^® 78582 for evaluation of suspected pulmonary embolism, but can be approved for additional evaluation of an abnormal perfusion-only scan (CPT^® 78580).
® Pulmonary split crystal function study (CPT^® 78597 or CPT^® 78598), also known as Quantitative Differential Pulmonary Perfusion, is indicated for preoperative planning of segmental, lobar, or lung resection.
® Quantitative Differential Pulmonary Perfusion Lung Scan (CPT^® 78597 or CPT^® 78598), can be performed for post lung transplant members to detect regional perfusion abnormalities.
® Radiopharmaceutical nuclear medicine imaging of an inflammatory process (CPT^® 78800, CPT^® 78801, CPT^® 78802, or CPT^® 78803) is rarely performed, but is indicated for evaluation of sarcoidosis or toxicity from drug toxicity (cyclophosphamide, busulfan, bleomycin, amiodarone, or nitrofurantoin).

References

1. Siegel MJ. Chest. In: Pediatric Sonography. Philadelphia. Wolters Kluwer, 2018. pp 156-195.
2. ACR Practice parameter for performing and interpretating of magnetic resonance imaging (MRI) Revised 2017 (Resolution 10).
3. ACR–ASER–SCBT-MR–SPR Practice parameter for the performance of pediatric computed tomography (CT) Revised 2014 (Resolution 3).
4. Trinavarat P and Riccabonna M. Potential of ultrasound in the pediatric chest. Eur J Radiol. 2014 Sep; 83 (9):1507-1518.
5. Goh Y, Kapur J. Sonography of the pediatric chest. J Ultrasound Med. 2016 May; 35 (5):1067-1080.
6. Ing C, DiMaggio C, Whitehouse A, et al. Long-term differences in language and cognitive function after childhood exposure to anesthesia. Pediatrics. 2012 Sep; 130 (3): e476-e485.
7. Monteleone M, Khandji A, Cappell J, et al. Anesthesia in children: perspectives from nonsurgical pediatric specialists. J Neurosurg Anesthesiol. 2014 Oct; 26 (4):396-398.
8. DiMaggio C, Sun LS, and Li G. Early childhood exposure to anesthesia and risk of developmental and behavioral disorders in a sibling birth cohort. Anesth Analg. 2011 Nov; 113 (5):1143-1151.
9. Nevin MA. Pulmonary embolism, infarction, and hemorrhage. Nelson Textbook of Pediatrics, Chapter 407. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp 2123-2128.
10. Kirsch J, Brown KJ, Henry TS, et al. Suspected pulmonary embolism. ACR Appropriateness Criteria^®. Revised 2016.
11. Fesmire FM, Kline JA, Wolf SJ, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected pulmonary embolism. Ann Emerg Med 2003 Feb; 41 (2):257-270.
12. Parker JA, Coleman RE, Grady E, et al. Society of Nuclear Medicine practice guideline for lung scintigraphy. J Nuc Med Tech. 2012 Mar; 40 (1)57-65.
13. Wells PS, Anderson DR, Rodger M, et al. Derivation of a simple clinical model to categorize patient’s probability of pulmonary embolism: Increasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 2000 Mar; 83 (3):416-420.
14. Drescher FS, Chandrika S, Weir ID, et al. Effectiveness and acceptability of a computerized decision support system using modified wells criteria for evaluation of suspected pulmonary embolism. Ann Emerg Med. 2011 Jun; 57 (6):613-621.
15. Morton KA, Clark PB, et al. Diagnostic imaging: nuclear medicine. Amirsys. 2013; (4) 2-15.
16. Thrall JH and Zeissman HA. Nuclear medicine: the requisites. Mosby. 2001, 145-165.
17. Palestro CJ, Brown ML, Forstrom LA, et al. Society of Nuclear Medicine procedure guideline for ¹¹¹in-leukocyte scintigraphy for suspected infection /inflammation, Version 3.0, approved June 2, 2004.
18. De Vries EFJ, Roca M, Jamar F et al. Guidelines for the labelling of leucocytes with ^99mTc-HMPAO. Eur J Nucl Med Mol Imaging. 2010 Apr; 37 (4):842-848.
19. ACR–SPR–STR PRACTICE PARAMETER FOR THE PERFORMANCE OF PULMONARY SCINTIGRAPHY, Revised 2018 (Resolution 30)
20. Blumfield E, Swenson DW, Iyer RS, Stanescu AL. Gadolinium-based contrast agents — review of recent literature on magnetic resonance imaging signal intensity changes and tissue deposits, with emphasis on pediatric patients. Pediatric Radiology. 2019;49(4):448-457. doi:10.1007/s00247-018-4304-8.


PEDCH-2: Lymphadenopathy

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

† Axillary lymphadenopathy imaging indications in pediatric members are identical to those for adult members. See Adult Chest Imaging Policy (Policy #150 in the Radiology Section); CH-2.2: Axillary Lymphadenopathy (and Mass).

† Supraclavicular adenopathy in pediatric members is almost always pathologic, and advanced imaging is indicated prior to excisional biopsy. Fine needle aspiration, while common in adults prior to advanced imaging, is inappropriate for evaluating lymphadenopathy in pediatric members. Any of the following studies may be approved for evaluation of supraclavicular adenopathy in children:

® CT Chest with contrast (CPT^® 71260).
® MRI Chest without and with contrast (CPT^® 71552).
® Ultrasound chest (CPT^® 76604).

® Lymphoma: Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-5: Pediatric Lymphomas.
® Soft tissue sarcoma: Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-8: Pediatric Soft Tissue Sarcomas.
® Neuroblastoma: Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-6: Neuroblastoma.

1. Allen-Rhoades W and Steuber CP. Clinical assessment and differential diagnosis of the child with suspected cancer. Principles and Practice of Pediatric Oncology. eds Pizzo PA and Poplack DG. 7^th edition. 2015, pp 101-111.

PEDCH-3: Mediastinal Mass

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

The causes of mediastinal masses in children are generally different than those in adults, and the imaging considerations are different.

† Chest x-ray is indicated as an initial study for all members with suspected mediastinal mass.

† CT Chest with contrast (CPT^® 71260) is indicated for any pediatric member with a mediastinal mass identified on Chest x-ray.

® Masses can be very large and anterior masses frequently cause compression of the trachea and/or mediastinal blood vessels.

® A posterior (paravertebral) mediastinal mass on CT Chest that invades the spinal canal.
® CT findings are inconclusive regarding specific anatomy.
® MRI should not be used for members with large anterior mediastinal masses if anesthesia is necessary to complete the study.

† MIBG (CPT^® 78800, CPT^® 78802, CPT^® 78803, or CPT^® 78804) is indicated and can be approved prior to biopsy in pediatric members if neuroblastoma is known or strongly suspected. See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-6: Neuroblastoma

† Ultrasound (CPT^® 76604) can be approved in children younger than 5 years old to distinguish prominent but otherwise normal thymus from true mediastinal mass.

† A single repeat CT Chest with contrast (CPT^® 71260) can be approved to confirm stability and avoid biopsy for members with NONE of the following features:

® Anterior mediastinal mass.
® Enlarged lymph nodes anywhere in the imaging field.
® Lymphopenia.
® Pleural effusion.

1. Thacker PG, Mahani MG, Heider A, et al. Imaging evaluation of mediastinal masses in children and adults. J Thorac Imaging, 2015 Jul; 30(4):247-264.
2. Mullen EA and Gratias EJ. Oncologic emergencies, Nathan and Oski’s Hematology and Oncology of Infancy and Childhood. eds Orkin SH, Fisher DE, Ginsburg D, et al. 8^th edition. 2015, pp 2267-2291.
3. Trinavarat P and Riccabonna M. Potential of ultrasound in the pediatric chest. Eur J Radiol. 2014 Sep; 83(9):1507-1518.
4. Naeem F, Metzger ML, Arnold SR, et al. Distinguishing benign mediastinal masses from malignancy in a histoplasmosis-endemic region. J Pediatr. 2015 Aug; 167(2):409-415.
5. Manson DE. Magnetic resonance imaging of the mediastinum, chest wall and pleura in children. Pediatr Radiol. 2016 May; 46 (6):902-915.

PEDCH-4: Hemoptysis

PEDCH-4.1: Hemoptysis – Imaging

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

† True hemoptysis is rare in pediatric members, and a detailed history, physical examination, and appropriate laboratory studies should be performed prior to considering advanced imaging.

® Aspirated blood from epistaxis or emesis frequently presents as hemoptysis, and history and physical examination will aid in this assessment.

® Advanced imaging is not indicated for members with epistaxis and a normal chest radiograph and no personal or family history of underlying lung disease or bleeding disorder.
® CT Chest with contrast (CPT^® 71260) is indicated for all other pediatric members with hemoptysis.
¡ CT Chest without contrast (CPT^® 71250) can be approved for members with a documented allergy to CT contrast or significant renal dysfunction.

References
1. Singh D, Bhalla AS, Veedu PT, et al. Imaging evaluation of hemoptysis in children. World J. Clin Pediatr. 2013 Nov 8; 2 (4):54-64.
2. Nevin MA. Pulmonary embolism, infarction, and hemorrhage, Nelson Textbook of Pediatrics Chapter 407. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp 2123-2128.



PEDCH-5: Cystic Fibrosis and Bronchiectasis

PEDCH-5.1: Cystic Fibrosis

PEDCH-5.2: Bronchiectasis Not Associated with Cystic Fibrosis

PEDCH-5.1: Cystic Fibrosis

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

† Chest x-ray is the primary study for initial evaluation of acute clinical symptoms in members with cystic fibrosis.

† CT Chest without contrast (CPT^® 71250) or with contrast (CPT^® 71260) is indicated for the following (without initial Chest x-ray):

® Hemoptysis.
® Pneumonia worsening despite antibiotic therapy.
® Pleural effusion or empyema.
® Suspected fungal pneumonia.
® Monitoring treatment changes on bronchiectasis.
® Expiratory CT for evaluating small airways disease.
® Pre- and post-lung transplant evaluation.

PEDCH-5.2: Bronchiectasis Not Associated with Cystic Fibrosis

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

† Bronchiectasis not associated with cystic fibrosis is rare in pediatric members, and imaging indications are identical to those for adult members. See Adult Chest Imaging Policy (Policy #150 in the Radiology Section); CH-7: Bronchiectasis.

References
1. Egan M., Green DM, Voynow JA. Cystic fibrosis. Nelson Textbook of Pediatrics, Chapter 403. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp 2098-2113.
2. Szczesniak R, Turkovic L, Andrinopoulou E-R, Tiddens HA. Chest imaging in cystic fibrosis studies: What counts, and can be counted? Journal of Cystic Fibrosis. 2017;16(2):175-185. doi:10.1016/j.jcf.2016.12.008
3. Paranjape SM and Mogayzel Jr PJ. Cystic fibrosis. Pediatr Rev. 2014 May; 35 (5):194-205.
4. Tiddens HAM, Stick SM, and Davis S. Multi-modality monitoring of cystic fibrosis lung disease: the role of chest computed tomography. Paediatr Resp Rev. 2014 Mar; 15(1):92-97.
5. Murphy KP, Maher MM, Oconnor OJ. Imaging of Cystic Fibrosis and Pediatric Bronchiectasis. American Journal of Roentgenology. 2016;206(3):448-454. doi:10.2214/ajr.15.14437.

PEDCH-6: Bronchiolitis

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

Bronchiolitis is a self-limiting viral infection causing inflammation of the small airways, most common in infants under 12 months of age.

† Chest x-rays are indicated when there is a clinical suspicion of pneumonia or other complications.

† Advanced imaging is not indicated for routine evaluation or monitoring of bronchiolitis, but CT Chest with contrast (CPT^® 71260) can be approved for the following:

® Pleural effusion or empyema on recent Chest x-ray.
® Immunocompromised member with acute pulmonary symptoms.
® Abnormality on recent Chest x-ray suggesting condition other than bronchiolitis.

Reference
1. Coates BM, Carmada LE, and Goodman DM. Wheezing in infants: bronchiolitis. Nelson Textbook of Pediatrics Chapter 391.1. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp 2044-2048.
2. Chang AB, Bush A, Grimwood K. Bronchiectasis in children: diagnosis and treatment. The Lancet. 2018;392(10150):866-879. doi:10.1016/s0140-6736(18)31554-x.
3. Darras KE, Roston AT, Yewchuk LK. Imaging Acute Airway Obstruction in Infants and Children. RadioGraphics. 2015;35(7):2064-2079. doi:10.1148/rg.2015150096.



PEDCH-7: Pneumonia

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

† Pneumonia imaging indications in pediatric members are very similar to those for adult members. See Adult Chest Imaging Policy (Policy #150 in the Radiology Section); CH-13: Pneumonia in the Chest Imaging Guidelines.

† Pediatric-specific imaging considerations include the following:

® CT Chest with contrast (CPT^® 71260) for immunocompromised members with acute pulmonary symptoms.
® CT Chest without contrast (CPT^® 71250) or with contrast (CPT^® 71260) for members with recurrent lower respiratory tract infections.
® Ultrasound chest (CPT^® 76604) can be approved for evaluation of complicated or recurrent childhood pneumonia.

1. Kelly MS and Sandora TJ. Community-acquired pneumonia. Nelson Textbook of Pediatrics, Chapter 400. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp 2088-2094.
2. O'Grady K-AF, Torzillo PJ, Frawley K, Chang AB. The radiological diagnosis of pneumonia in children. Pneumonia. 2014;5(S1):38-51. doi:10.15172/pneu.2014.5/482.
3. Andronikou S, Goussard P, Sorantin E. Computed tomography in children with community-acquired pneumonia. Pediatric Radiology. 2017;47(11):1431-1440. doi:10.1007/s00247-017-3891-0.
4. Stadler JAM, Andronikou S, Zar HJ. Lung ultrasound for the diagnosis of community-acquired pneumonia in children. Pediatric Radiology. 2017;47(11):1412-1419. doi:10.1007/s00247-017-3910-1.
5. Patria MF and Esposito S. Recurrent lower respiratory tract infections in children: a practical approach to diagnosis. Paediatr Resp Rev. 2013 Mar; 14(1):53-60.
6. Pereda MA, Chavez MA, Hooper-Miele CC, et al. Lung ultrasound for the diagnosis of pneumonia in children: a meta-analysis. Pediatrics. 2015 Apr; 135 (4):714-722.
7. Goh Y and Kapur J. Sonography of the pediatric chest. J Ultrasound Med. 2016 May; 35 (5):1067-1080.


PEDCH-8: Solitary Pulmonary Nodule

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

The Fleischner Society guidelines for solitary pulmonary nodule management do not apply to pediatric members. An incidental solitary pulmonary nodule in a child representing a primary lung carcinoma has never been reported in the literature. Similarly, an extrathoracic malignancy presenting with an incidental solitary pulmonary nodule in an otherwise healthy child is very rare.

† CT Chest with contrast (CPT^® 71260) as a one-time evaluation for all children with a pulmonary nodule incidentally discovered on other imaging.

† Follow up imaging of incidental solitary pulmonary nodules in asymptomatic healthy children is not necessary.

® Follow up imaging is indicated for the following:
¡ Immunocompromised members.
¡ Malignancy (see below).
¡ Invasive infection.
¡ New or worsening pulmonary symptoms.

† This guideline section does not apply to multiple pulmonary nodules, which are imaged according to the underlying disorder in pediatric members.

Practice Notes
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.

References
1. Assefa D and Atlas A. Natural history of incidental pulmonary nodules in children. Pediatr Pulmonol. 2015 May; 50 (5):456-459.
2. Westra SJ, Broday AS, Mahani MG, et al. The incidental pulmonary nodule in a child, Part 1; recommendations from the SPR Thoracic Imaging Committee regarding characterization, significance, and follow up. Pediatr Radiol. 2015 May 45 (5): 628-633.
3. Westra SJ, Thacker PG, Podberesky DJ, et al. The incidental pulmonary nodule in a child, Part 2; commentary and suggestions for clinical management, risk communication and prevention. Pediatr Radiol. 2015 May; 45 (5): 634-639.
4. Strouse PJ. The incidental pulmonary nodule in a child: a conundrum. Pediatr Radiol. 2015 May; 45 (5): 627.
5. 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

PEDCH-9: Positive PPD or Tuberculosis

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

† Positive PPD and tuberculosis imaging indications in pediatric members are similar to those for adult members. See Adult Chest Imaging Policy (Policy #150 in the Radiology Section); CH-14.1: PPD or TB (Mycobacterium tuberculosis and Mycobacterium avium complex (MAC).

† Pediatric-specific imaging considerations include the following:

® MRI Spine with and without contrast can be approved at symptomatic levels in members with concern for spinal involvement of tuberculosis.

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

† Chest x-ray is indicated when the member’s condition does not respond to standard therapy, to identify complications, such as pneumonia or to rule out other causes of respiratory distress.

† Advanced imaging is not indicated for routine evaluation or monitoring of asthma, but CT Chest without (CPT^® 71250) or with (CPT^® 71260) contrast can be approved for the following:

® Pleural effusion or empyema on recent Chest x-ray.
® Immunocompromised member with acute pulmonary symptoms.
® Abnormality on recent Chest x-ray suggesting condition other than asthma, including suspected foreign body.
® Asthma and poor response to bronchodilators or conventional inhaled corticosteroid therapy in whom associated conditions, such as allergic bronchopulmonary aspergillosis and eosinophilic pneumonia can mimic asthma.

PEDCH-11: Pectus Deformities

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

† CT Chest without contrast (CPT^® 71250), MRI Chest with and without contrast (CPT^® 71552), or MRI Chest without contrast (CPT^® 71550) is indicated in members with a pectus deformity for:

® Preoperative planning.
® Significant cardiac displacement after Chest x-ray and echocardiography (CPT^® 93306).
® Evidence of pulmonary impingement after Chest x-ray and pulmonary function tests (PFTs) if there is increasing shortness of breath. Note: It may not be possible to obtain PFTs in children younger than 9 years old.
® Evaluation of congenital heart disease or Marfan’s syndrome when suspected in those members with pectus deformities.

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

See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-17: Pediatric Breast Masses.

PEDCH-13: Vascular Malformations

PEDCH-13.1: Vascular Ring

PEDCH-13.2: Other Vascular Malformations

PEDCH-13.1: Vascular Ring

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

Vascular rings generally present with either respiratory symptoms (stridor, wheezing, tachypnea, cough) or feeding difficulties (dysphagia, slow feeding, hyperextension of the head while feeding, weight loss, failure to thrive) but can also be discovered incidentally on imaging obtained for other purposes.

† Chest x-ray is the recommended initial study in members with respiratory symptoms.

† Barium esophagram is the recommended initial study in members with feeding difficulties.

† CT Chest with contrast (CPT^® 71260), CTA Chest (CPT^® 71275) or MRA Chest (CPT^® 71555) can be approved in members with known or suspected vascular ring after Chest x-ray or barium esophagram.

† Echocardiogram can be approved to rule out associated congenital heart disease.

® CPT^® 93303, CPT^® 93306, CPT^® 93320, and CPT^® 93325 can be approved for initial evaluation of members with vascular ring and no prior echocardiograms.

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

See PEDCH-14.2: Pulmonary Arteriovenous Malformations for Pulmonary AVMs.

See Pediatric Peripheral Vascular Disease Imaging Policy (Policy # 169 in the Radiology Section); PEDPVD-2: Vascular Anomalies.

References
1. Licari A, Manca E, Rispoli GA, et al. Congenital vascular rings: a clinical challenge for the pediatrician. Pediatr Pulmonol. 2015 May; 50 (5): 511-524.
2. Poletto E, Mallon MG, Stevens RM, et al. Imaging review of aortic vascular rings and pulmonary sling. J Am Osteopath Coll Radiol. 2017; 6 (2): 5-14.
3. Hanneman K, Newman B, Chan F. Congenital Variants and Anomalies of the Aortic Arch. RadioGraphics. 2017;37(1):32-51. doi:10.1148/rg.2017160033.
4. Etesami M, Ashwath R, Kanne J, Gilkeson RC, Rajiah P. Computed tomography in the evaluation of vascular rings and slings. Insights into Imaging. 2014;5(4):507-521. doi:10.1007/s13244-014-0343-3.
5. Backer CL, Mongé MC, Popescu AR, Eltayeb OM, Rastatter JC, Rigsby CK. Vascular rings. Seminars in Pediatric Surgery. 2016;25(3):165-175. doi:10.1053/j.sempedsurg.2016.02.009.
.


PEDCH-14: Congenital Lung Diseases

PEDCH-14.1: Congenital Cystic Lung Diseases

PEDCH-14.2: Pulmonary Arteriovenous Malformations

PEDCH-14.1: Congenital Cystic Lung Diseases

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

† This section includes common congenital cystic lung lesions such as:

® Bronchogenic cyst
® Congenital pulmonary airway malformation (congenital cystic adenomatoid malformation)
® Congenital lobar overinflation

† Chest x-ray is indicated before considering advanced imaging.

† CT Chest with contrast (CPT^® 72160) may be approved when Chest x-ray suggests a cystic lung lesion.

† MRI Chest with and without contrast (CPT^® 71552) can be approved if CT is inconclusive or if requested for pre-operative planning

PEDCH-14.2: Pulmonary Arteriovenous Malformations

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

† Pulmonary arteriovenous malformations (PAVMs) are vascular structures that most commonly result from abnormal communication between pulmonary arteries and pulmonary veins.

® Chest x-ray are indicated as an initial imaging modality for members with known AVMs, or members presenting with hypoxemia and/or hemoptysis

® CTA or MRA may be approved in members with known AVM or abnormal Chest x-ray suggesting AVM for treatment planning.

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

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*