CT Angiography, Pelvis - CAM 703

Description
Computed tomographic angiography (CTA) is used in the evaluation of many conditions affecting the veins and arteries of the pelvis or lower extremities. It is not appropriate as a screening tool for asymptomatic patients without a previous diagnosis.

OVERVIEW
CT/MRI and acute hemorrhage: MRI is not indicated and MRA/MRV (MR Angiography/Venography) is rarely indicated for evaluation of intraperitoneal or retroperitoneal hemorrhage, particularly in the acute setting. CT is the study of choice due to its availability, speed of the study and less susceptibility to artifact from patient motion. Advances in technology have allowed conventional CT to not just detect hematomas but also the source of acute vascular extravasation. In special cases finer vascular detail to assess the specific source vessel responsible for hemorrhage may require the use of CTA. CTA in diagnosis of lower gastrointestinal bleeding is such an example.

Follow-up of asymptomatic, incidentally-detected iliac artery aneurysms: -The definition of an iliac artery aneurysm (IAA) is dilitation to more than 1.5 times its normal diameter; in general a common iliac artery 18 mmin men and 15 mm in women; an internal iliac argery (IIA) > 8 mm is considered aneurysmal. There are four types of isolated iliac aneurysms classified by Reber. Suggested surveillance is extrapolated from AAA surveillance and can be done by Doppler ultrasound or CTA if hard to visualize by ultrasound.

Policy
PELVIS CT Angiography/CT Venography - (Abdominal CTA can be added when indicated) is considered MEDICALLY NECESSARY for the following indications:

For evaluation of known or suspected vascular disease 

  • For pelvic extent of known large vessel diseases (abdominal aorta, inferior vena cava, superior/inferior mesenteric, celiac, splenic, renal or iliac arteries/veins), e.g., aneurysm, dissection, arteriovenous malformations (AVMs), and fistulas, intramural hematoma, and vasculitis.
  • Evidence of vascular abnormality seen on prior imaging studies.
  • For suspected pelvic extent of aortic dissection.
  • Evaluation of known or suspected aneurysms limited to the pelvis or in evaluating pelvic extent of aortic aneurysm Known or suspected iliac artery aneurysm AND equivocal or indeterminate Doppler ultrasound results
    • If repeat Doppler ultrasound is indeterminate
    • Suspected complications of known aneurysm as evidenced by clinical findings such as new onset of pelvic pain.
  • Follow-up of iliac artery aneurysm:
    • Every three years for diameter 2.0 – 2.9 cm.
    • Annually for 3.0-3.5 cm if Doppler ultrasound is inconclusive
    • If > 3.5 cm, < six month follow up (and consider intervention).
  • Suspected retroperitoneal hematoma or hemorrhage (to determine a vascular source of hemorrhage in the setting of trauma, tumor invasion, fistula or vasculitis; otherwise CT (rather than CTA) is sufficient and the modality of choice for diagnosing hemorrhage.
  • For evaluation of suspected pelvic vascular disease or pelvic congestive syndrome when findings on ultrasound are indeterminate (MR or CT venography may be used as the initial study for pelvic thrombosis or thrombophlebitis).
  • For evaluation of venous thrombosis in the inferior vena cava.
  • Venous thrombosis if previous studies have not resulted in a clear diagnosis.
  • Vascular invasion or displacement by tumor (Conventional CT or MRI also appropriate).
  • For known and/or suspected mesenteric ischemia/ ischemic colitis (can include abdomen CTA)
  • Other vascular indications
  • For suspected May-Thurner Syndrome (iliac vein compression syndrome) (can include abdomen CTA)
  • For known and/or suspected mesenteric ischemia/ ischemic colitis.
  • Lower gastrointestinal hemorrhage: Active bleeding in a hemodynamically stable patient or non-localized intermittent bleeding as an alternative to Tc-99m RBC scan when colonoscopy did not localize the bleeding, is contraindicated or unavailable.
  • For evaluation of erectile dysfunction when a vascular cause is suspected and Doppler ultrasound is inconclusive.
  • For patient with fibromuscular dysplasia (FMD), a one-time vascular study of the abdomen and pelvis
  • For patients  with vascular Ehlers-Danlos syndrome or Marfan syndrome recommend a one-time vascular study of the abdomen and pelvis.
  • For Loeys Dietz vascular imaging every two years (include abdomen CTA)
  • For spontaneous coronary artery dissection (SCAT) at time of coronary arteriography (includes CTA abdomen)

Pre-operative evaluation  

  • Evaluation of interventional vascular procedures prior to endovascular aneurysm repair (EVAR), or for luminal patency versus restenosis due to conditions such as atherosclerosis, thromboembolism, and intimal hyperplasia.
  • Imaging of the deep inferior epigastric arteries for surgical planning (breast reconstruction surgery) include abdomen CTA/MRA
  • Prior to uterine artery embolization for fibroids (MRA preferred)

Post-operative or post-procedural evaluation 

  • Evaluation of post-operative complications of renal transplant allograft.
  • Evaluation of endovascular/interventional vascular procedures for luminal patency versus restenosis due to conditions such as atherosclerosis, thromboembolism, and intimal hyperplasia.
  • Evaluation of post-operative complications, e.g., pseudoaneurysms, related to surgical bypass grafts, vascular stents and stent-grafts in the pelvis.
  • Follow-up for post-endovascular repair (EVAR) or open repair of abdominal aortic aneurysm (AAA) and iliac artery aneurysms.
    • Routine, baseline study (post-op/intervention) is warranted within 1 – 3 months.
    • Asymptomatic at six (6) month intervals, for one (1) year, then annually.
    • Symptomatic/complications related to stent graft — more frequent imaging may be needed
  • 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.

Chest CTA and Abdomen CTA or Abdomen/Pelvis CTA combo 

  • For preoperative or preprocedural evaluation such as TAVR (transcatheter aortic valve replacement) or transcatheter venous ablation
  • Acute aortic dissection
  • Takayasu’s arteritis
  • Marfan syndrome
  • Loeys Dietz syndrome
  • Spontaneous coronary artery dissection (SCAD)
  • Vascular Ehlers-Danlos syndrome
  • Post-operative complications

All other uses of this technology are investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY.

References 

  1. Abe T, Kai M, Miyoshi O, et al. Idiopathic retroperitoneal hematoma. Case Rep Gastroenterol. September-December 2010; 4(3):318-322. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2974992/. Retrieved February 12, 2018.
  2. Al-Nouri O, Milner R. May-Thurner Syndrome. Clin Rev. 2011; 8(3). https://www.vasculardiseasemanagement.com/content/may-thurner-syndrome. Accessed May 9, 2019.
  3. American College of Radiology (ACR). ACR Appropriateness Criteria®. https://acsearch.acr.org/list. Published 2018.
  4. Aw-Zoretic J, Collins JD. Considerations for imaging the inferior vena cava (IVC) with/without IVC Filters. Semin Intervent Radiol. 2016; 33(2):109-21.
  5. Barman M. Acute aortic dissection. Euro Society Cardiol. 2014; 12(25).
  6. Bennet KM, Kent KC, Schumacher J, et al. Targeting the most important complications in vascular surgery. J Vasc Surg. 2017; 65(3):793-803.
  7. Bookwalter, CA., Van Buren, WM,. et. al. Imaging Appearance and Nonsurgical Management of Pelvic Venous Congestion Syndrome. Radiographics. 2019; 39(2).
  8. Bultman EM, Klaers J, Johnson KM, et al. Non-contrast enhanced 3D SSFP MRA of the renal allograft vasculature: A comparison between radial linear combination and cartesian inflow-weighted acquisitions. Magn Reson Imaging. 2014; 32(2):190–195.
  9. Certik B, Treska V, Molacek J, et al. Cardiovascular Surgery. How to proceed in the case of a tumor thrombus in the inferior vena cava with renal cell carcinoma. Cor et Vasa. April 2015; 57(2):e95-e100. https://www.sciencedirect.com/science/article/pii/S0010865015000260. Retrieved February 12, 2018.
  10. Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. January 2018; 67(1):2- 77.e2. http://www.jvascsurg.org/article/S0741-5214(17)32369-8/fulltext#sec1.3. Retrieved February 15, 2018.
  11. Choudhury, M. Postoperative Management of Vascular Surgery Patients: A Brief Review. Clin Surg. 2017; 2:1584.
  12. Chu, LC., Johnson, PT., Dietz HC, et. al. CT Angiographic Evaluation of Genetic Vascular Disease: Role in Detection, Staging, and Management of Complex Vascular Pathologic Conditions. AJR Am J Roentgenol. 2014 May; 202(5):1120-9.
  13. Clerc D, Grass F, Schafer M, et al. Lower gastrointestinal bleeding—Computed tomographic angiography, colonoscopy or both? World J Emerg Surg. 2017; 12:1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5215140/. Retrieved February 12, 2018.
  14. Crousillat, DR., Wood, MJ., et. al. Spontaneous Coronary Artery Dissection: An Update for the Interventionalist. Cath Lab Digest. March; 2020:28(3).
  15. Eren S. Multi-detector row computed tomography findings of pelvic congestion syndrome caused by dilated ovarian veins. Eurasian J Med. 2010 Dec; 42(3):128-31.
  16. Henes FO, Pickhardt PJ, Herzyk A, et al. CT angiography in the setting of suspected acute mesenteric ischemia: prevalence of ischemic and alternative diagnoses. Abdom Radiol (NY). 2017 Apr; 42(4):1152-1161. doi: 10.1007/s00261-016-0988-0.
  17. Kadian-Dodov, D., Gornik, HL,. et. al. Diissection and Aneurysm in Patients w ith Fibromuscular Dysplasia: Findings from the US Registry for FMD. Journal of the Am Coll of Cardiology. 2016; 68(2).
  18. Kalu S, Shah P, Natarajan A, et al. May-thurner syndrome: A case report and review of the literature. Case Rep Vasc Med. 2013; 2013:740182. Epub 2013 Feb 20.
  19. Keser G, Direskeneli H, Aksu K, et al. Management of Takayasu Arteritis: A systematic review. Rheumatology. 2014; 53(5):793-801.
  20. Khalil H, Avruch L, Olivier A, et al. The natural history of pelvic vein thrombosis on magnetic resonance venography after vaginal delivery. Am J Obstet Gynecol. 2012; 206(4):356.
  21. Khosa F, Krinsky G, Macari M, et al. Managing incidental findings on abdominal and pelvic CT and MRI, Part 2: White paper of the ACR Incidental Findings Committee II on vascular findings. J Am Coll Radiol. 2013; 10(10):789-794. doi:10.1016/j.jacr.2013.05.021.
  22. Knuttinen, M-G., Xie, K., et. al. Pelvic Venous Insufficiency: Imaging, Diagnosis, Treatment Approaches and Therapeutic Issues. AJR. 2015; 204(2).
  23. Liu PS, Platt JF. CT angiography of the renal circulation. Radiol Clin North Am. 2010; 48(2):347-365. doi: 10.1016/j.rcl.2010.02.005.
  24. Maciel, C., Tang, YZ, et. al. Preprocedural MRI and MRA in planning fibroid embolization. Diagn Interv Radiol. 2017; 23(2): 163-171.
  25. Ohana M, Bakouboula B, Labani A, et al. Imaging before and after catheter ablation of atrial fibrillation. Diagn Interv Imaging. 2015 Nov; 96(11):1113-23.
  26. Seitz M, Waggershauser T, Khoder W. Congenital intrarenal arteriovenous malformation presenting with gross hematuria after endoscopic intervention: A case report. J Med Case Rep. 2008; 2:326. doi: 10.1186/1752-1947-2-326.
  27. Shindel AW, Brandt WO, Bochinski D, et al. Medical and Surgical Therapy of Erectile Dysfunction. In: Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc. 2018 Jul 10. https://www.ncbi.nim.nih.gov/books. July 10, 2018.
  28. Smillie R, Shetty M, Boyer AC, et al. Imaging Evaluation of the inferior vena cava. RadioGraphics. 2015; 35(2). https://pubs.rsna.org/doi/full/10.1148/rg.352140136.
  29. Sommer WH, Becker CR, Haack M, et al. Time-resolved CT Angiography for the Detection and Classification of Endoleaks. Radiol. 2012; 263(3):917-26. https://pubs.rsna.org/doi/full/10.1148/radiol.12111217.
  30. Thakur V, Inampudi P, Pena CS. Imaging of mesenteric ischemia. Applied Radiology. 2018; 47(2):13-18.
  31. Uberoi R, Tsetis D, Shrivastava V, et al. Standard of practice for the interventional management of isolated iliac artery aneurysms. Cardiovasc Intervent Radiol. 2011; 34(1):3-13. doi:10.1007/s00270-010-0055-0.
  32. Wanhainen A, Verzini F, Van Herzeele I, et al. Editor's Choice - European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg. 2019; 57(1):8-93.

Coding Section

Codes Number Description
CPT 72191

Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing.

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association.  All Rights Reserved" 

History From 2019 Forward 

11/01/2021  Annual review, no change to policy intent. 
11/01/2020  Annual review, adding verbiage regarding runoff requests, iliac artery aneurysm size removed, adding multiple new diagnoses with medical necessity. Also updating background and references. 
11/21/2019                 NEW POLICY  
Complementary Content
${loading}