2016 NIA Clinical Guidelines for Medical Necessity Review AETNA MEDICARE HMO NIA Clinical Guidelines © 2016 Magellan Health, Inc. Proprietary Page 1 of 270 Guidelines for Clinical Review Determination Preamble NIA is committed to the philosophy of supporting safe and effective treatment for patients. The medical necessity criteria that follow are guidelines for the provision of diagnostic imaging. These criteria are designed to guide both providers and reviewers to the most appropriate diagnostic tests based on a patient’s unique circumstances. In all cases, clinical judgment consistent with the standards of good medical practice will be used when applying the guidelines. Guideline determinations are made based on the information provided at the time of the request. It is expected that medical necessity decisions may change as new information is provided or based on unique aspects of the patient’s condition. The treating clinician has final authority and responsibility for treatment decisions regarding the care of the patient. Guideline Development Process These medical necessity criteria were developed by NIA for the purpose of making clinical review determinations for requests for diagnostic tests. The developers of the criteria sets included representatives from the disciplines of radiology, internal medicine, nursing, and cardiology. They were developed following a literature search pertaining to established clinical guidelines and accepted diagnostic imaging practices. All inquiries should be directed to: National Imaging Associates, Inc. 6950 Columbia Gateway Drive Columbia, MD 21046 Attn: NIA Associate Chief Medical Officer _______________________________________________________________ NIA Clinical Guidelines © 2016 Magellan Health, Inc. Proprietary Page 2 of 270 TABLE OF CONTENTS TOC 70336 – MRI Temporomandibular Joint (TMJ) _________________________________________ 5 70450 – CT Head/Brain ______________________________________________________________ 7 70480 – CT Orbit (Includes Sella and Posterior Fossa) ________________________________ 13 70480 – CT Internal Auditory Canal ________________________________________________ 15 70480 – CT Sella __________________________________________________________________ 18 70486 – Face CT __________________________________________________________________ 20 70486 – Maxillofacial/Sinus CT _____________________________________________________ 22 70490 – CT Soft Tissue Neck _______________________________________________________ 25 70496 – CT Angiography, Head/Brain _______________________________________________ 28 70498 – CT Angiography, Neck _____________________________________________________ 31 70540 – MRI Orbit ________________________________________________________________ 33 70540 – MRI Face _________________________________________________________________ 36 70540 – MRI Neck _________________________________________________________________ 37 70540 – MRI Sinus ________________________________________________________________ 40 70544 – MR Angiography Head/Brain _______________________________________________ 41 70547 – MR Angiography Neck _____________________________________________________ 44 70551 – MRI Brain (includes Internal Auditory Canal) _______________________________ 46 70554 – Functional MRI Brain _____________________________________________________ 53 71250 – CT Chest (Thorax) _________________________________________________________ 55 71275 – CT Angiography, Chest (non coronary) ______________________________________ 60 71550 – MRI Chest (Thorax) _______________________________________________________ 62 71555 – MR Angiography Chest (excluding myocardium)______________________________ 65 72125 – CT Cervical Spine _________________________________________________________ 68 72128 – CT Thoracic Spine _________________________________________________________ 72 72131 – CT Lumbar Spine _________________________________________________________ 76 72141 – MRI Cervical Spine ________________________________________________________ 81 72146 – MRI Thoracic Spine ________________________________________________________ 86 72148 – MRI Lumbar Spine ________________________________________________________ 90 72159 – MR Angiography Spinal Canal ______________________________________________ 95 72191 – CT Angiography, Pelvis ____________________________________________________ 97 72192 – CT Pelvis ________________________________________________________________ 100 72196 – MRI Pelvis _______________________________________________________________ 107 72198 – MR Angiography, Pelvis ___________________________________________________ 113 73200 – CT Upper Extremity (Hand, Wrist, Elbow, Long Bone or Shoulder) ___________ 116 73206 – CT Angiography, Upper Extremity _________________________________________ 122 73220 – MRI Upper Extremity _____________________________________________________ 124 73225 – MR Angiography Upper Extremity _________________________________________ 129 73700 – CT Lower Extremity (Ankle, Foot, Hip or Knee) _____________________________ 131 73706 – CT Angiography, Lower Extremity _________________________________________ 136 73720 – MRI Lower Extremity (Ankle, Foot, Knee, Hip, Leg) _________________________ 138 73725 – MR Angiography, Lower Extremity ________________________________________ 143 NIA Clinical Guidelines © 2016 Magellan Health, Inc. Proprietary Page 3 of 270 74150 – CT Abdomen _____________________________________________________________ 145 74174 – CT Angiography, Abdomen and Pelvis ______________________________________ 153 74175 – CT Angiography, Abdomen ________________________________________________ 156 74176 – CT Abdomen and Pelvis Combo ____________________________________________ 159 74181 – MRI Abdomen ____________________________________________________________ 167 74185 – MR Angiography, Abdomen _______________________________________________ 172 74261 – CT Colonoscopy Diagnostic (Virtual) _______________________________________ 176 75557 – MRI Heart _______________________________________________________________ 178 75571 – Electron Beam Tomography (EBCT) ________________________________________ 187 75572 – CT Heart ________________________________________________________________ 188 75574 – CTA Coronary Arteries (CCTA) ____________________________________________ 197 75635 – CT Angiography, Abdominal Arteries _______________________________________ 208 76497 – Unlisted CT Procedure ____________________________________________________ 210 76498 – Unlisted MRI Procedure __________________________________________________ 211 77058 – MRI Breast ______________________________________________________________ 212 77078 – CT Bone Density Study ___________________________________________________ 216 78205 – Liver SPECT _____________________________________________________________ 219 78320 – Bone and/or Joint SPECT _________________________________________________ 221 77084 – MRI Bone Marrow ________________________________________________________ 223 78451 – Myocardial Perfusion Imaging (Nuc Card) __________________________________ 225 78459 – PET Scan, Heart (Cardiac) ________________________________________________ 237 78472 – MUGA Scan______________________________________________________________ 244 78607 – Brain SPECT ____________________________________________________________ 247 78608 – PET Scan, Brain__________________________________________________________ 250 78647 – Cerebrospinal Fluid Flow SPECT __________________________________________ 254 78710 - Kidney SPECT____________________________________________________________ 256 78813 – PET Scan ________________________________________________________________ 258 +0159T – CAD Breast MRI ________________________________________________________ 264 G0235 - PET imaging, any site, not otherwise specified ______________________________ 265 S8037 – MR Cholangiopancreatography (MRCP) ____________________________________ 266 S8032 – Low Dose CT for Lung Cancer Screening ___________________________________ 269 S8042 – Low Field MRI ___________________________________________________________ 270 _______________________________________________________________ NIA Clinical Guidelines © 2016 Magellan Health, Inc. Proprietary Page 4 of 270 TOC 70336 – MRI Temporomandibular Joint (TMJ) CPT Code: 70336 INTRODUCTION: Temporomandibular joint (TMJ) dysfunction causes pain and dysfunction in the jaw joint and muscles controlling jaw movement. Symptoms may include: jaw pain, jaw muscle stiffness, limited movement or locking of the jaw, clicking or popping in jaw joint when opening or closing the mouth, and a change in how the upper and lower teeth fit together. The cause of the condition is not always clear but may include trauma to the jaw or temporomandibular joint, e.g., grinding of teeth, clenching of jaw, or impact in an accident. Osteoarthritis or rheumatoid arthritic may also contribute to the condition. The modality of choice for the evaluation of temporomandibular joint dysfunction is magnetic resonance imaging (MRI) which provides tissue contrast for visualizing the soft tissue and periarticular structures of the TMJ. INDICATIONS FOR TEMPOROMANDIBULAR JOINT (TMJ) MRI:  For evaluation of dysfunctional temporomandibular joint after unsuccessful conservative therapy for at least four (4) weeks with bite block or splint and anti-inflammatory medicine.  For pre-operative evaluation of dysfunctional temporomandibular joint in candidates for orthognathic surgery.  For evaluation of locked or frozen jaw.  For persistent temporomandibular joint dysfunction after surgical repair. ADDITIONAL INFORMATION RELATED TO TEMPOROMANDIBULAR JOINT (TMJ) MRI: Request for a follow-up study - A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested. MRI imaging – Metal devices or foreign body fragments within the body, such as indwelling pacemakers and intracranial aneurysm surgical clips that are not compatible with the use of MRI, may be contraindicated. Other implanted metal devices in the patient as well as external devices such as portable O tanks may also be contraindicated. 2 MRI Imaging of Temporomandibular Joint – Imaging of the temporomandibular joint has been difficult as the mandibular condyle is small and located close to dense and complex anatomic structures. MRI produces cross-sectional multiplanar images that document both soft and osseous tissue abnormalities of the joint and the surrounding structures and may help in determining the pathology around the joint. _______________________________________________________________ NIA Clinical Guidelines © 2016 Magellan Health, Inc. Proprietary Page 5 of 270 REFERENCES: American Society of Temporomandibular Joint Surgeons. (2001). Guidelines for diagnosis and management of disorders involving the temporomandibular joint and related musculoskeletal structures. American Society of Temporomandibular Joint Surgeon, Retrieved from http://astmjs.org/final%20guidelines-04-27-2005.pdf. Arvidsson, L.Z., Smith, H.J., Flato, B., & Larheim, T.A. (2010, July). Temporomandibular joint findings in adults with long-standing juvenile idiopathic arthritis: CT and MR imaging assessment. Radiology, 256(1), 191-200. doi: 10.1148/radiol.10091810. Larheim, T.A. (2005). Role of magnetic resonance imaging in the clinical diagnosis of the temporomandibular joint. Cells, Tissues, Organs, 180(1), 6-21. doi: 10.1159/000086194 Shaefer, J.R., Riley, C.J., Caruso, P. & Keith, D. (2012). Analysis of Criteria for MRI Diagnosis of TMJ Disc Displacement and Arthralgia. Int J Dent. 283163. doi: 10.1155/2012/283163. Wadhwa, S., & Kapila, S. (2008). TMJ disorders: Future innovations in diagnostics and therapeutics. Journal of Dental Education, 72(8), 930-947. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2547984/pdf/nihms66136.pdf. _______________________________________________________________ NIA Clinical Guidelines © 2016 Magellan Health, Inc. Proprietary Page 6 of 270 TOC 70450 – CT Head/Brain CPT Codes: 70450 70460 70470 INTRODUCTION: Computed tomography (CT) is an imaging technique used to view the structures of the brain and is useful in evaluating pathologies in the brain. It provides more detailed information on head trauma, brain tumors, stroke, and other pathologies in the brain than regular radiographs. INDICATIONS FOR BRAIN CT: For evaluation of neurological symptoms or deficits:  Acute, new or fluctuating neurologic symptoms or deficits such as tingling (paresthesia), numbness of one side, spastic weakness (hemiparesis) of one side, paralysis, loss of muscle control, inability to speak, lack of coordination or mental status changes. For evaluation of known or suspected trauma:  Known or suspected trauma or injury to the head with documentation of one or more of the following acute, new or fluctuating: o Focal neurologic findings o Motor changes o Mental status changes o Amnesia o Vomiting o Seizures o Headache o Signs of increased intracranial pressure  Known or suspected skull fracture by physical exam and/positive x-ray For evaluation of cognitive assessment:  Change in mental status with a mental status score of either MMSE or MoCA of less than 26 or other similar mental status exams showing at least mild cognitive impairment AND a completed basic metabolic workup (such as thyroid function testing, liver function testing, complete blood count, etc). For evaluation of headache:  Chronic headache with a change in character/pattern (e.g. more frequent, increased severity or duration) and MRI is contraindicated or cannot be performed.  New onset (< 48 hours) of “worst headache in my life” or “thunderclap” headache. Note: The duration of a thunderclap type headache lasts more than 5 minutes. Sudden onset new headache reaching maximum intensity within 2-3 minutes.  New headache in occipitonuchal region in individual > 55 years old and MRI is contraindicated or cannot be performed.  New temporal headache in person > 55, with Sedimentation Rate (ESR) > 55 and tenderness over the temporal artery and MRI is contraindicated or cannot be performed.  Patient with history of cancer, HIV, or immunocompromised with new onset headache and MRI is contraindicated or cannot be performed. _______________________________________________________________ NIA Clinical Guidelines © 2016 Magellan Health, Inc. Proprietary Page 7 of 270 For evaluation of known or suspected brain tumor, mass, or metastasis:  For patient with history of cancer with suspected recurrence or metastasis [based on symptoms or examination findings (may include new or changing lymph nodes)].  Evaluation of patient with history of cancer that had a recent course of chemotherapy, radiation therapy (to the brain), or has been treated surgically within the last two (2) years.  Evaluation for a bone tumor or abnormality of the skull Indication for combination studies for the initial pre-therapy staging of cancer, OR ongoing tumor/cancer surveillance OR evaluation of suspected metastases:  < 5 concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: Neck, Abdomen, Pelvis, Chest, Brain, Cervical Spine, Thoracic Spine or Lumbar Spine. o Cancer surveillance excluding small cell lung cancer: Every six (6) months for the first two (2) years then annually thereafter. o Cancer surveillance – small cell lung cancer: Up to every 3 months for the first two years then annually thereafter. For evaluation of known or suspected stroke:  To evaluate patient with history of a known stroke with new and sudden onset of severe headache.  To evaluate patient with a suspected stroke or history of a known stroke with a family history (brother, sister, parent or child) of stroke or aneurysm. For evaluation of known or suspected aneurysm or arteriovenous malformation (AVM) and MRI is contraindicated or cannot be performed:  With history of known aneurysm or AVM with new onset headache.  With history or suspicion of aneurysm or AVM with family history (brother, sister, parent or child) of aneurysm or AVM. For evaluation of known or suspected inflammatory disease or infection, (e.g., meningitis, or abscesses) and MRI is contraindicated or cannot be performed:  Intracranial abscess or brain infection with acute altered mental status OR positive lab findings (such as elevated WBC’s) OR follow up assessment during or after treatment completed.  Inflammatory disease (i.e. vasculitis), sarcoid or infection for patient presenting with a fever, stiff neck and positive lab findings (such as elevated white blood cells or abnormal lumbar puncture fluid exam).  Meningitis with positive physical findings (such as fever, stiff neck and positive lab findings (such as elevated white blood cells or abnormal lumbar puncture fluid exam.)  Suspected encephalitis with a severe headache, altered mental status OR positive lab finding, (such as elevated WBC’s).  Endocarditis with suspected septic emboli. For evaluation of known or suspected congenital abnormality (such as hydrocephalus, craniosynostosis):  Treatment planned within four (4) weeks for congenital abnormality (such as placement of shunt or problems with shunt; surgery).  Known or rule out congenital abnormality with any acute, new or fluctuating neurologic, motor or mental status changes.  Evaluation of macrocephaly with child >6 months of age or microcephaly. _______________________________________________________________ NIA Clinical Guidelines © 2016 Magellan Health, Inc. Proprietary Page 8 of 270  Follow up shunt evaluation within six (6) months of placement or one (1) year follow up and/or with neurological symptoms. Suspected normal pressure hydrocephalus (NPH) with symptoms. Pre-operative evaluation for brain/skull surgery. Post-operative/procedural evaluation:  A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested. Other indications for a Brain CT:  Evaluation of suspected acute Subarachnoid Hemorrhage (SAH).  For the evaluation of a single study related to new onset of seizures or newly identified change in seizure activity/pattern AND cannot have a Brain MRI.  Initial evaluation of a cholesteatoma.  Follow up for known hemorrhage, hematoma or vascular abnormalities.  Developmental delay where MRI cannot be performed.  Vertigo associated with headache, blurred or double vision, or a change in sensation after full neurologic examination and initial work-up.  Abnormal eye findings on physical or neurologic examination (papilledema, nystagmus, ocular nerve palsies, visual field deficit etc).  Anosmia (loss of smell) (documented by objective testing). .  For evaluation of known or suspected cerebrospinal fluid (CSF) leakage.  Immunocompromised patient (e.g. transplant recipients, HIV, primary immunodeficiency syndromes, hematologic malignancies) with focal neurological symptoms, headaches, behavioral, cognitive or personality changes. Indication for Brain CT/Cervical CT combination studies:  For evaluation of Arnold Chiari malformation where MRI cannot be performed. Brain CT/Orbit CT:  For approved indications as noted above and being performed in a child under 3 years of age who will need anesthesia for the procedure and there is a suspicion of concurrent intracranial tumor (e.g. “trilateral retinoblastoma”)*  Unilateral papilledema: to distinguish a compressive lesion on the optic nerve or optic disc swelling associated with acute demyelinating optic neuritis in multiple sclerosis from nonarteritic anterior ischemic optic neuropathy (NAION), central retinal vein occlusion or optic nerve infiltrative disorders. Brain CT/Neck CTA:  Confirmed carotid stenosis >60%, surgery or angioplasty candidate (significant lesion can flip off emboli, looking for stroke). ADDITIONAL INFORMATION RELATED TO BRAIN CT: CT scan for Head Trauma – Most types of head injury are minor injuries; clinical signs and symptoms help predict the need for brain CT following injury. A patient who presents with certain clinical risk factors may be more likely to benefit from CT imaging. Some of the clinical risk factors that may be used as a guide to predict the probability of abnormal CT following minor head injury _______________________________________________________________ NIA Clinical Guidelines © 2016 Magellan Health, Inc. Proprietary Page 9 of 270 are vomiting, skull fracture and age greater than 60 years. Patients with a Glasgow Coma Scale of 15 or less who also have vomiting or suspected skull fracture are likely to show abnormal results on CT scan. CT scan for Headache - Generally, magnetic resonance imaging is the preferred imaging technique for evaluating the brain parenchyma and CT is preferable for evaluating subarachnoid hemorrhage. CT is faster and more readily available than MRI and is often used in urgent clinical situations. Neurologic imaging is warranted in patients with headache disorders along with abnormal neurologic examination results or predisposing factors for brain pathology. CT scan for Head Trauma – CT has advantages in evaluating head injury due to its sensitivity for demonstrating mass effect, ventricular size and configuration, bone injuries and acute hemorrhage. CT has been used routinely as a screening tool to evaluate minor or mild head trauma in patients who are admitted to a hospital or for surgical intervention. CT is useful in detecting delayed hematoma, hypoxic-ischemic lesions or cerebral edema in the first 72 hours after head injury. CT scan for Stroke – Patients presenting with symptoms of acute stroke should receive prompt imaging to determine whether they are candidates for treatment with tissue plasminogen activator. Non-contrast CT can evaluate for hemorrhage that would exclude the patient from reperfusion therapy. Functional imaging can be used to select patients for thrombolytic therapy by measuring the mismatch between “infarct core” and “ischemic penumbra” which is a target for therapy. Contrast enhanced CT angiography (CTA) may follow the non-contrast CT imaging and may define ischemic areas of the brain with the potential to respond positively to reperfusion therapy. CT scan and Meningitis – In suspected bacterial meningitis, contrast CT may be performed before lumbar puncture to show beginning meningeal enhancement. It may rule out causes for swelling. CT may be used to define the pathology of the base of the skull and that may require therapeutic intervention and surgical consultation. Some causes of the infection include fractures of the paranasal sinus and inner ear infection. REDUCING RADIATION EXPOSURE: Brain MRI is preferred to Brain CT in most circumstances where the patient can tolerate MRI and sufficient time is available to schedule the MRI examination. Assessment of subarachnoid hemorrhage, acute trauma or bone abnormalities of the calvarium (fracture, etc) may be better imaged with CT. REFERENCES American College of Radiology. (2014). ACR Appropriateness Criteria® Retrieved from https://acsearch.acr.org/list. Brown, C., Weng, J., Oh, D., Sallim, A., Kasotakis, G., Demetriades, D., . . . Rhee, P. (2004). Does routine serial computed tomography of the head influence management of traumatic brain injury? A Prospective Evaluation. Journal of Trauma-Injury Infection & Critical Care, 57(5), 939-943. Retrieved from http://journals.lww.com/jtrauma/pages/articleviewer.aspx?year=2004&issue=11000&article=000 03&type=abstract _______________________________________________________________ NIA Clinical Guidelines © 2016 Magellan Health, Inc. 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