FOR CMS (MEDICARE) MEMBERS ONLY NATIONAL COVERAGE DETERMINATION (NCD) FOR COMPUTED TOMOGRAPHY:

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1 National Imaging Associates, Inc. Clinical guidelines CHEST CTA Original Date: September 1997 Page 1 of 5 CPT Codes: Last Review Date: August 2014 NCD Last Effective Date: March 2008 Guideline Number: NIA_CG_022-1 Last Revised Date: August 2014 Responsible Department: Clinical Operations Implementation Date: January 2015 FOR CMS (MEDICARE) MEMBERS ONLY NATIONAL COVERAGE DETERMINATION (NCD) FOR COMPUTED TOMOGRAPHY: Item/Service Description A. General Diagnostic examinations of the head (head scans) and of other parts of the body (body scans) performed by computerized tomography (CT) scanners are covered if medical and scientific literature and opinion support the effective use of a scan for the condition, and the scan is: (1) reasonable and necessary for the individual patient; and (2) performed on a model of CT equipment that meets the criteria in C below. CT scans have become the primary diagnostic tool for many conditions and symptoms. CT scanning used as the primary diagnostic tool can be cost effective because it can eliminate the need for a series of other tests, is non-invasive and thus virtually eliminates complications, and does not require hospitalization. Indications and Limitations of Coverage for NCD B. Determining Whether a CT Scan Is Reasonable and Necessary Sufficient information must be provided with claims to differentiate CT scans from other radiology services and to make coverage determinations. Carefully review claims to insure that a scan is reasonable and necessary for the individual patient; i.e., the use must be found to be medically appropriate considering the patient's symptoms and preliminary diagnosis. There is no general rule that requires other diagnostic tests to be tried before CT scanning is used. However, in an individual case the contractor's medical staff may determine that use of a CT scan as the initial diagnostic test was not reasonable and necessary because it was not supported by the patient's symptoms or complaints stated on the claim form; e.g., "periodic headaches." Claims for CT scans are reviewed for evidence of abuse which might include the absence of reasonable indications for the scans, an excessive number of scans or unnecessarily expensive types of scans considering the facts in the particular cases. 1 NCD/NIA Chest CTA 2015 Proprietary

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3 NIA CLINICAL GUIDELINE FOR CHEST CTA: INTRODUCTION: Computed tomography angiography (CTA) is a non-invasive imaging modality that may be used in the evaluation of thoracic vascular problems. Chest CTA (non-coronary) may be used to evaluate vascular conditions, e.g., pulmonary embolism, thoracic aneurysm, thoracic aortic dissection, aortic coarctation. CTA depicts the vascular structures as well as the surrounding anatomical structures. INDICATIONS FOR CHEST CTA: For evaluation of suspected or known pulmonary embolism (excludes low risk*) For evaluation of suspected or known vascular abnormalities: Thoracic aortic aneurysm or thoracic aortic dissection. Congenital thoracic vascular anomaly, (e.g., coarctation of the aorta or evaluation of a vascular ring suggested by GI study). Signs or symptoms of vascular insufficiency of the neck or arms (e.g., subclavian steal syndrome with abnormal ultrasound). Follow-up evaluation of progressive vascular disease when new signs or symptoms are present. Pulmonary hypertension. Preoperative evaluation Known vascular abnormalitiesand patient has not had a catheter angiogram within the last month. Proposed ablation procedure for atrial fibrillation. Postoperative or post-procedural evaluation Known vascular abnormalities with physical evidence of post-operative bleeding complication or re-stenosis. 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. ADDITIONAL INFORMATION RELATED TO CHEST CTA: CTA and Coarctation of the Aorta Coarctation of the aorta is a common vascular anomaly characterized by a constriction of the lumen of the aorta distal to the origin of the left subclavian artery near the insertion of the ligamentum arteriosum. The clinical sign of coarctation of the aorta is a disparity in the pulsations and blood pressures in the legs and arms. Chest CTA may be used to evaluate either suspected or known aortic coarctation and patients with significant coarctation should be treated surgically or interventionally. CTA and Pulmonary Embolism (PE) Note: D-Dimer blood test in patients at low risk* for DVT is indicated to prior to CTA imaging. Negative D-Dimer suggests alternative diagnosis in these patients. 3 NCD/NIA Chest CTA 2015 Proprietary

4 *Low risk defined as NO to any of the following questions: 1) evidence of current or prior DVT; 2) HR > 100; 3) cancer diagnosis; 4) recent surgery or prolonged immobilization; 5) hemoptysis; 6) history of PE; 7) other diagnosis more likely. CTA has high sensitivity and specificity and is the primary imaging modality to evaluate patients suspected of having acute pulmonary embolism. When high suspicion of pulmonary embolism on clinical assessment is combined with a positive CTA, there is a strong indication of pulmonary embolism. Likewise, a low clinical suspicion and a negative CTA can be used to rule out pulmonary embolism. CTA and Thoracic Aortic Aneurysms Computed tomographic angiography (CTA) allows the examination of the precise 3-D anatomy of the aneurysm from all angles and shows its relationship to branch vessels. This information is very important in determining the treatment: endovascular stent grafting or open surgical repair. 4 NCD/NIA Chest CTA 2015 Proprietary

5 REFERENCES American College of Radiology. (2014). ACR Appropriateness Criteria Retrieved from Anderson, E.R., Kahn, S.R., Rodger, M.A., Kovacs, M.J., Morris, T., Hirsch, A.,... Wells, P.S. (2007). Computed tomographic pulmonary angiography vs. ventilation-perfusion lung scanning in patients with suspected pulmonary embolism. JAMA, 298(23), doi: /jama Miller, J.C., Greenfield, A.J., Cambria, R.P., & Lee, S.I. (2008). Aortic aneurysms. Journal of the American College of Radiology, 5(5), doi: /j.jacr Romano, M., Mainenti, P.P., Imbriaco, M., Amato, B., Markabaowi, K., Tamburrini, O., & Salvatore, M. (2004). Multidetector row CT angiography of the abdominal aorta and lower extremities in patients with peripheral arterial occlusive disease: Diagnostic accuracy and interobserver agreement. Radiology, 50(3), doi: /S X(03) Stein, P.D., Fowler, S.E., Goodman, L.R., et al. (2006). Multidetector computed tomography for acute pulmonary embolism. The New England Journal of Medicine, 354(22), doi: /NEJMoa NCD/NIA Chest CTA 2015 Proprietary