CT Chest (Thorax) - CAM 750

Description
Computed tomography (CT) scans provide greater clarity than regular x-rays and are used to further examine abnormalities found on chest x-rays. They may be used for detection and evaluation of various disease and conditions in the chest, e.g., tumor, inflammatory disease, vascular disease, congenital abnormalities, trauma, and symptoms such as hemoptysis.

OVERVIEW
LDCT for Lung Cancer Screening - Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

CT and Aneurysm  

  • Initial evaluation of aneurysm (Erbel, 2014; Hannuksela, 2015; Hiratzka, 2010)
    • Echocardiogram shows aneurysm
    • Echocardiogram inconclusive of proximal aorta and first-degree relative with thoracic aneurysm
    • Chest x-ray shows possible aneurysm
  • Follow-up after established Thoracic Aneurysm (above these sizes surgery is usually recommended) (Erbel, 2014; Hannuksela 2015; Hiratzka, 2010)
    • Aortic Root or Ascending Aorta
      • 3.5 to 4.5 Annual
      • 4.5 to 5.4 Every 6 months
    • Genetically mediated (Marfans syndrome, Aortic Root or Ascending Aorta
      • 3.5 to 4.0 Annual
      • 4.0 to 5.0 Every 6 months
    • Descending Aorta
      • 4.0 to 5.0 Annual
      • 5.0 to 6.0 Every 6 months

CT and Interstitial Lung Disease (ACR, 2019) - Radiography of the chest is usually appropriate for the initial imaging of patients who undergo screening and surveillance for lung disease when occupational exposure is present.

Costochondritis (Proulx, 2009) - If physical exam findings are suggestive of costochondritis but the pain is persistent despite conservative care, it should be kept in mind that costochondritis can be recurrent and persistent. It is associated with fibromyalgia. Chest CT should be considered if the findings are not consistent with typical costochondritis, such as fever or elevated inflammatory markers, suggestive of infection or a suspicion of cancer based on history or current findings.

CT for Management of HemoptysisHigh-resolution CT (HRCT) is useful for estimating the severity of hemoptysis, localizing the bleeding site and determining the cause of the bleeding. Its results can be related to the severity of bleeding. The volume of expectorated blood and the amount of blood that may be retained within the lungs without being coughed up are important. HRCT is a way to evaluate the amount of bleeding and its severity. It may also help in the localization of bleeding sites and help in detecting the cause of bleeding.

CT and Solitary Pulmonary NodulesSolitary Pulmonary nodules are abnormalities that are solid, semisolid and non-solid; another term to describe a nodule is focal opacity. CT makes it possible to find smaller nodules and contrast-enhanced CT is used to differentiate benign from malignant pulmonary modules. When a nodule is increasing in size or has spiculated margins or mixed solid and ground-glass attenuation, malignancy should be expected. Patients who have pulmonary nodules and who are immunocompromised may be subject to inflammatory processes.

CT and EmpyemaContrast-enhanced CT used in the evaluation of the chest wall may detect pleural effusion and differentiate a peripheral pulmonary abscess from a thoracic empyema. CT may also detect pleural space infections and help in the diagnosis and staging of thoracic empyema.

CT and Rib fractures (ACR, 2018) - Chest CT may be useful for characterizing a pathologic fracture, and some features may be helpful in differentiating a primary malignant tumor of bone from metastasis. CT may also be helpful to search for a primary malignancy in patients with a suspected pathologic fracture; however, there is no strong indication that CT serves a significant use as the initial imaging modality to detect pathologic rib fractures.

CT and Occupational Lung Disease (ACR, 2019) - The chest radiograph and CT are complementary in the initial workup of suspected occupational lung disease. When patients with occupational exposures present with respiratory symptoms, chest radiography serves as the primary function of excluding alternative diagnoses, such as infectious pneumonia or pulmonary edema, with HRCT findings offering the best characterization of lung disease.

CT and Tuberculosis - "The chest radiograph is usually the first study performed in patients suspected of having TB. Although frontal and lateral radiographs are often performed in this setting, it has been shown that the lateral radiograph does not improve the detection of findings related to TB. In those with signs or symptoms of disease, the radiographic pattern of upper-lobe or superior-segment lower-lobe fibrocavitary disease in the appropriate clinical setting is sufficient to warrant respiratory isolation and sputum culture for definitive diagnosis. Using radiographs in combination with clinical evaluation results in a high sensitivity for the diagnosis but a relatively low specificity for both latent and active TB. In addition, radiographs may reveal ancillary findings of TB such as pleural effusion or spondylitis. For immunocompromised hosts, particularly those with a low CD4 count, computed tomography (CT) should be considered (ACR, 2016)." CT may be of value in the severely immunocompromised patient with a normal or near-normal radiograph by revealing abnormal lymph nodes or subtle parenchymal disease. Finally, CT may also have a role in identifying patients with latent TB who will be at risk for reactivation disease.

CT and Superior Vena Cava (SVC) Syndrome – SVC is associated with cancer, e.g., lung, breast and mediastinal neoplasms. These malignant diseases cause invasion of the venous intima or an extrinsic mass effect. Adenocarcinoma of the lung is the most common cause of SVC. SVC is a clinical diagnosis with typical symptoms of shortness of breath along with facial and upper extremity edema. Computed tomography (CT), often the most readily available technology, may be used as confirmation and may provide information including possible causes.

CT and Family History of Lung Cancer (Loverdos, 2019) - Family history is equally important. Individuals with a family history of lung cancer among first-degree relatives have been consistently shown to have a two-fold higher risk of developing lung cancer themselves. Those with multiple affected family members diagnosed at younger age appear to be at greater risk.

This Chest CT Guideline covers CPT codes 71250 (CT chest without contrast), CT chest with contrast (71260), CT chest without and with contrast (71270) and Low dose CT scan (LDCT) for lung cancer screening (71271).  When the case is listed as CT chest in BBI and the clinical scenario or request for LDCT in the office notes meets appropriate use criteria for a LDCT, the LDCT is approvable due to these overlapping CPT codes. Reprocessing of the case to a separate LDCT request is not required.

Policy  
For Annual Lung Cancer Screening:
The use of low-dose, non-contrast spiral (helical) multi-detector CT imaging as an annual screening technique for lung cancer is considered MEDICALLY NECESSARY ONLY when used to screen for lung cancer for certain high-risk asymptomatic individuals when ALL of the following criteria are met (USPSTF, 2021):   

  • Individual is between 50-80 years of age; AND
  • There is at least a 20 pack-year history of cigarette smoking; AND
  • If the individual is a former smoker, that individual had quit smoking within the previous 15 years

Nodule on Initial LDCT (Wood, 2018) 

  • If multiple nodules, the largest and type is used for decision
  • Follow-up with LDCT as per Lung-Rads criteria (Table 1)

Table 1: Lung-RADS® Assessment Categories (ACR, 2019) 

Category Descriptor  Lung-RADS Score  Findings  Management 
 Incomplete 

 Prior chest CT examination(s) being located for comparison

Part or all lungs cannot be evaluated

 

 Additional lung cancer screening CT images and/or comparison to prior chest CT examinations is nedded 
 

Negative

No nodules and definitely benign nodules

 1

No lung Nodules

Nodule(s) with specific calcifications: complete, central, popcorn, concentric rings and fat containing nodules

 

 Continue annual screening with LDCT in 12 months

Benign Appearance or Behavior

Nodules with a very low likelihood of becoming a clinically active cancer due to size or lack of growth 

 2

Perifissural nodel(s) (See Footnote 11) <10 mm (524 mm3

Solid nodule(s): <6 mm (<113 mm3); new <4 mm  (34 mm3

Part solid nodule(s): <6 mm total diameter (133 mm3) on baseline screening

Non solid nodule(s) (GGN): <30 mm (<14137 mm3OR ≥ 30 mm (≥14137 mm3) and unchanged or slowly growing

Category 3 or 4 nodules unchanged for ≥3 months

 

Continue annual screening with LDCT in 12 months 

Probably Benign

Probably benign finding(s) - short term follow-up suggested; includes nodules with a low likelihood of becoming a clinically active cancer

 3

Solid nodule(s): ≥6 mm to <8 mm (≥113 to <268 mm3) at baseline OR  new 4 mm to <6 mm (<34 to <113 mm3)

Part solid nodule(s): ≥6 mm total diameter (≥113 mm3) with solid component <6 mm (<113 mm3) OR new <6 mm total diameter (<113 mm3)

Non solid nodule(s): (GGN) ≥30 mm (≥14137 mm3) on baseline CT or new

 

6 month LDCT

 Suspicious

Findings for which additional diagnostic testing is recommended

 4A

Solid nodule(s): ≥8 mm to <15 mm (≥268 to <1767 mm3) at baseline OR  growing <8 mm (<268 mm3) OR new 6 mm to <8 mm (113 to <268 mm3)

Part solid nodule(s): ≥6 mm (≥113 mm3) with solid component ≥6 mm to <8 mm (≥113 to <268 mm3) OR with a new or growing <4 mm (<34 mm3) solid component

Endobronichial nodule

 

3 month LDCT; PET/CT may be used when there is a ≥ 8 mm (≥268 mm3) solid component 

 Very Suspicious

Findings for which additional diagnostic testing and/or tissue sampling is recommended

4B

Solid nodule(s): ≥15 mm (≥1767 mm3) OR new or growing, and ≥8mm (≥268 mm3)

Part solid nodule(s) with: a solid component ≥8 mm (≥268 mm3) OR a new or growing ≥4 mm  (≥34 mm3) solid component

 

Chest CT 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 (≥268 mm3) solid component. For new large nodules that develop on an annual repeat screening CT, a 1 month LDCT may be recommended to address potentially infectious or inflammatory conditions

 

4X

Category 3 or 4 nodules with additional features or imaging findings that increase the suspicion of malignancy

 

 Other

Clinically Significant or Potentially Clinically Significant Findings (non lung cancer)

S Modifier - may add on to category 0-4 coding As appropriate to the specific findings

Incidental Lung Nodules(Bueno, 2018) 

  • Incidental pulmonary nodules detected on a nonscreening Chest CT (use Fleischner Table)
    • Age ≥ 35 years old – use Fleischner table
    • Excludes
      • Lung cancer screening (see lung cancer screening guidelines above)
      • History of primary cancer (imaging follow-up for surveillance is 3 months to detect interval nodule growth)
      • Immunosuppression (may require a shorter follow-up, such as 1 month, if suspicion of fulminant infection)

Note: These should not be ordered as Low Dose CT 

  • Incidental pulmonary nodules on non-chest CT
    • Nodules >8mm or those with very suspicious features need further Chest CT as early as possible
    • Nodules ≤ 8mm should follow the Fleischner table 

Table 2: 2017 Fleischner Society Guidelines for Management of Incidentally Detected Pulmonary Nodules (Bueno, 2018) 

A: Solid Nodules•
Nodule Type Nodules <6 mm (<100 mm3) Nodules 6-8 mm (100-250 mm3) Nodules >8 mm (>250 mm3) Comments
Single
Low risk No routine follow-up CT at 6-12 mo, then consider CT at 18-24 mo Consider CT at 3 mo, PET/CT, or tissue sampling Nodules <6 mm do not require routine follow-up in low-risk patients (recommendation 1A)
High risk Optional CT at 12 mo CT at 6-12 mo, then at 18-24 mo Consider CT at 3 mo, PET/CT, or tissue sampling Certain patients at high risk with suspicious nodule morphology, upper lobe location, or both may warrant 12-mo follow-up (recommendation 1A)
Multiple
Low risk No routine follow-up CT at 3-6 mo, then consider CT at 18-24 mo CT at 3-6 mo, then consider Ct at 18-24 mo Use most suspicious nodule as guide to management; follow-up intervals may vary according to size and risk (recommendation 2A)
High risk Optional CT at 12 mo CT at 3-6 mo, then at 18-24 mo CT at 3-6 mo, then consider Ct at 18-24 mo Use most suspicious nodule as guide to management; follow-up intervals may vary according to size and risk (recommendation 2A)
B: Subslid Nodules•
Nodule Type Nodules <6 mm (<100 mm) Nodules >6 mm (>100 mm) Comments
Single
Ground glass No routine follow-up CT at 6-12 mo to confirm persistence; the CT every 2 y until 5 y For certain unspicious nodules <6 mm, consider follow-up at 2y and 4 y; if solid component(s) develops or growth occurs, consider resection (recommendations 3A and 4A)
Partly solid No routine follow-up CT at 6-12 mo to confirm persistence; if lesion is unchanged and solid component remains <6 mm, annual CT should be performed for 5 y In practice, partly solid nodules cannot be defined as such until they are ≥6 mm, and nodules <6 mm usually do not require follow-up; persistent partly solid nodules with a solid component ≥6 mm should be considered highly suspicious (recommendations 4A-4C) 
Multiple CT at 3-6 mo; if lesion is stable, consider CT at 2 y and 4 y CT at 3-6 mo; subsequent management based on the most supicious nodule(s) Multiple <6 mm pure GGNs' usually are benign, but consider follow-up at 2 y and 4 y in select patients at high risk (recommendation 5A) 

Known Cancer (Carter, 2018; Hong, 2014; Lee, 2014)  

  • For follow-up intervals for malignancies (NCCN, 2019)
  • Cancer staging (includes unknown primary)
  • Cancer restaging
  • Suspicious signs or symptoms of recurrence
  • Suspected cancer based on prior imaging (Greco, 2012)

Chest Mass (non-lung parenchymal) (Mullan, 2011) (Preference should be given to MRI over chest CT for chest wall mass)  

  • Mass or lesion, including lymphadenopathy, after non-diagnostic initial imaging
  • Thymoma screening in Myasthenia Gravis patients (Kumar, 2015)

Interstitial Lung Disease (ACR, 2019; Vij, 2013) 

  • Suspected or known based on restrictive pattern pulmonary function test or signs or symptoms after initial chest x-ray
  • Signs or symptoms unresponsive to treatment such as:
    • Shortness of breath
    • Persistent dyspnea
    • Persistent cough
  • Monitoring treatment response of known interstitial lung disease
  • Patients with known collagen vascular disease (Antoniou, 2009)
  • Guidance in selection of the most appropriate site for biopsy of diffuse lung disease (ACR, 2015)

Chronic Cough (> 8 weeks) and chest x-ray completed (Turner, 2016) 

  • After evaluation for other causes and failed treatment for those diagnosed with:
    • Asthma
    • Gastroesophageal Reflux Disease
    • Discontinuation of ACE inhibitors
    • Postnasal drip
  • Clinical concern for bronchiectasis

Tuberculosis (TB) (Ko, 2018) 

  • Known or suspected tuberculosis and initial chest x-ray done

Infection Follow-up Imaging

  • Abscess, empyema, or pleural effusions on chest x-ray (Dean, 2016)
  • For evaluation of non-resolving pneumonia or inflammatory disease documented by at least two imaging studies:
    • Unimproved with 4 weeks of antibiotic treatment; OR
    • Unresolved at 8 weeks (Bryl, 2018; Little, 2014)

Pneumothorax on Chest X-ray (Melamed, 2017)

Vocal Cord Paralysis on Endoscopic Exam (Paquette, 2012) 

  • Neck and Chest CT is an approvable combo

Granulomatosis with Polyangiitis (Wegener’s Granulomatosis) (Li, 2018)

Vascular Disease  

  • CT chest is not preferred study for vascular disease, CTA should be considered. See Chest CTA guideline.
  • Chest CT can be used to detect and follow-up thoracic aortic aneurysms. See Background section.

Suspected Pulmonary Embolism (PE) 

  • Chest CT not approvable for PE

Congenital Malformations 

  • Thoracic malformation on chest x-ray (Ferreira, 2015)
  • Congenital Heart Disease with pulmonary hypertension (Pascall, 2018)

Hemoptysis after x-ray completed (ACR, 2019; Ketai, 2014)

Pre-operative/procedural evaluation  

  • Pre-operative evaluation for a planned surgery or procedure

Post-operative/procedural evaluation 

  • Post-surgical follow-up when records document medical reason requiring additional imaging
  • Pre-operative evaluation for Electromagnetic Navigation Bronchoscopy (Khan, 2016)

Chest Wall Pain (after initial evaluation with chest x-ray and/or rib films) (Winzenberg, 2015)

  • History of known or suspected cancer
  • Signs and symptoms of infection, such as:
    • Accompanying fever
    • Elevated inflammatory markers
    • Known infection at other sites

Chest CT and COVID-19 (Coronavirus)

  • Acute COVID
    • Imaging is not indicated in patients suspected of having coronavirus disease (COVID-19) and mild clinical features unless they are at risk for disease progression
    • Imaging is indicated in a patient with COVID-19 and worsening respiratory status
    • In a resource-constrained environment, imaging is indicated for medical triage of patients suspected of having COVID-19 who present with moderate-to-severe clinical features and a high pretest probability of disease
  • Long (Chronic) COVID:
    • Prior history of Covid with hypoxia or impaired lung function of follow-up (Rubin, 2020)
    • Restricted diffusion on Pulmonary Function Test (would need a HRCT – High Resolution CT)
    • Low oxygen saturation and a Chest x-ray was done

Combination of studies with Chest CT

  • Abdomen CT/Pelvis CT/Chest CT/Neck MRI/Neck CT with MUGA – known tumor/cancer for initial staging or evaluation before starting chemotherapy or radiation treatment
  • Neck and Chest CT - Neck and Chest CT is an approvable combo with vocal cord paralysis and concern for recurrent laryngeal nerve lesion

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  62. Yoo S, Lee MH, White C. MDCT evaluation of acute aortic syndrome. Radiol Clin North Am. 2010; 48(1):67-83. doi: 10.1016/j.rcl.2009.09.006.

Coding Section 

Code Number Description
CPT 71250 Computed tomography, thorax; without contrast material
  71260 Computed tomography, thorax; with contrast material(s)
  71270 Computed tomography, thorax; without contrast material, followed by contrast material(s) and further sections
  71271 (effective 01/01/2021)  Computed tomography, thorax; low dose for lung cancer screening; without contrast material(s) 
  G0297 Low dose ct scan (ldct) for lung cancer screening

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 and 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     

12/15/2021 

Annual review updating existing information regarding Fleischner criteria and Lung Rads. Also adding section related to COVID 19. Updating description and references. 

12/10/2020 

Updated coding with 2021 codes. No other changes. 

12/01/2020 

Annual review, policy updated for clarity and also adding verbiage regarding low dose CT scanning previously in CAM 60130. Entire policy updated to encompass that addition. 

12/03/2019

New Policy

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