GENERAL INFORMATION

• It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted. 
• Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Policy
INDICATIONS FOR UPPER EXTREMITY CT (HAND, WRIST, ARM, ELBOW, OR SHOULDER) (Plain radiographs must precede CT evaluation)

Some indications are for MRI, CT, or MR or CT arthrogram. More than one should not be approved at the same time.

If a CT arthrogram fits approvable criteria below, approve as CT.

Joint or muscle pain without positive findings on an orthopedic exam as listed above, after X-ray completed^1,2 (does not apply to young children). If MRI contraindicated or cannot be performed or requested as a CT arthrogram.

• Persistent joint or musculotendinous pain unresponsive to conservative treatment*, within the last 6 months which includes active medical therapy (physical therapy, chiropractic treatments, and/or physician-supervised exercise**), of at least four (4) weeks, OR
• With progression or worsening of symptoms during the course of conservative treatment

Joint-specific provocative orthopedic examination and MRI is contraindicated or cannot be performed or requested as a CT arthrogram.

Note: With a positive orthopedic sign, an initial X-ray is always preferred. However, it is not required to approve advanced imaging. Any test that suggests joint instability requires further imaging (list is not all inconclusive).

Shoulder^3,4,5,6

• Rotator cuff weakness on exam
• Subscapularis tendon tear
  • Belly press off test
  • Napoleon test
  • Bear Hug test
  • Internal rotation lag
  • Lift-off test
• Supraspinatus tendon tear
  • Drop arm
  • Full can test
  • Empty can (aka Jobe or Supraspinatus test)
  • Hawkins or Neer test⁷ (only when ordered by an orthopedic surgeon if there is clear documentation in the records that an actual rotator cuff tear is suspected, and NOT just for the evaluation of impingement)
• Infraspinatus/Teres Minor/Biceps tendon tear
  • External rotation lag sign at 0 and 90 degrees
  • Pain or weakness with resisted external rotation testing
  • Hornblower test
  • Popeye sign (if acute finding or for evaluation of surgical correction)
• Labral tear/instability
  • Grind test
  • Clunk test
  • Crank test, compression-rotation test
  • O’Brien’s test
  • Anterior load and shift
  • Apprehension test
  • Posterior load and shift test
  • Jerk test
  • Sulcus sign

Elbow^8,9

• Biceps tendon
  • Bicipital aponeurosis (BA) flex test
  • Biceps squeeze test
  • Hook test
  • Passive forearm pronation test
  • Reverse Popeye sign (if acute finding or for evaluation of surgical correction)
• Instability
• Posterolateral rotatory drawer test
• Tabletop relocation test
  • Valgus stress
  • Varus stress
  • Milking maneuver
  • Push-up test

Wrist^10,11

• Lunotriquetral ligament
  • Derby Relocation test
  • Reagan test (lunotriquetral ballottement test)
• TFCC tear
  • Press test
  • Ulnar foveal sign/test
  • Ulnocarpal stress test
• Scaphoid ligament 
  • Watson test (scaphoid shift test)
  • Scapholunate ballottement test

Tendon or Muscle Rupture After X-ray^12,13,14 (not listed above) If MRI contraindicated or cannot be performed.

• High clinical suspicion of a specific tendon rupture based on mechanism of injury and physical findings (i.e., triceps or pectorals tendon rupture)

Shoulder Dislocations^15,16 If MRI contraindicated or cannot be performed unless requested as CT arthrogram or to evaluate glenoid bone stock or size of Hill-Sachs lesion.

• Recurrent
• First time in any of the situations below that increase the risk or repeated dislocation
  • Glenoid or humeral bone loss on X-ray
  • Bankart lesion on radiographs
  • 14- to 40-year-old
  • > 40 with exam findings concerning for rotator cuff tear (i.e., weakness on exam)

Bone Fracture (If MRI contraindicated or cannot be performed)

• Suspected occult scaphoid fracture with snuffbox pain after initial X-ray
• Non scaphoid suspected occult, stress or insufficiency fracture with a negative initial X-ray^17,18,19
  • Repeat X-rays in 10-14 days if negative or non-diagnostic
• Pathologic fracture on X-ray or CT²⁰
• Suspected ligamentous/tendon injury with known fractures on x-ray/CT that may require surgery 

Fracture Nonunion

• Nonunion or delayed union as demonstrated by no healing between two sets of X-rays. If a fracture has not healed by 4 – 6 months, there is delayed union. Incomplete healing by 6 – 8 months is nonunion.²¹

Osteochondral Lesions (defects, fractures, osteochondritis dissecans) and X-ray completed^22,23,24,25

• Clinical suspicion based on mechanism of injury and physical findings

Loose bodies or synovial chondromatosis and after X-ray or ultrasound completed

• In the setting of joint pain or mechanical symptoms ²⁶

Osteonecrosis (e.g., Avascular necrosis [AVN]^27,28,29 when MRI is contraindicated or cannot be preformed)

• To further characterize a prior abnormal X-ray
• Normal X-rays but symptomatic and high-risk (e.g., glucocorticosteroid use, renal transplant recipient, glycogen storage disease, alcohol abuse,²⁷ sickle cell anemia²⁸)
• Known osteonecrosis to evaluate a contralateral joint after initial X-rays

Joint prosthesis/replacement

• Suspected joint prosthesis loosening or dysfunction, (i.e., pseudotumor formation) after initial X-rays^30,31

Extremity Mass³²

• Mass or lesion after non-diagnostic X-ray or ultrasound33 MRI preferred. CT is better than MRI to evaluate mass calcification or bone involvement and may complement or replace MRI:³⁴
  • If superficial mass, then ultrasound is the initial study.
  • If deep mass, then X-ray is the initial study.
• Vascular malformations
  • After initial evaluation with ultrasound and results will change management or for preoperative planning:³⁵
    • CTA is also approvable for initial evaluation.
    • Follow up after treatment/embolization.

Known Primary Cancer of the Extremity^{36,37,38,39,40}

• Initial staging primary extremity tumor
• Follow-up of known primary cancer of patient undergoing active treatment within the past year or as per surveillance imaging guidance for that cancer
• Signs or symptoms or imaging findings suspicious for recurrence
• Suspected metastatic disease with signs/symptoms and after initial imaging with radiographs

Further evaluation of indeterminate or questionable findings on prior imaging and MRI cannot be performed or CT is preferred (i.e., tumor matrix)

• For initial evaluation of an inconclusive finding on a prior imaging report (i.e., X-ray, ultrasound or MRI) that requires further clarification.
• One follow-up exam of a prior indeterminate MR/CT finding to ensure no suspicious interval change has occurred. (No further surveillance unless specified as highly suspicious or change was found on last follow-up exam).

Infection of Bone, Joint or Soft tissue Abscess^41,42
MRI and nuclear medicine studies are recommended for acute infection as they are more sensitive in detecting early changes of osteomyelitis.⁴³ CT is better at demonstrating findings of chronic osteomyelitis (sequestra, involucrum, cloaca, sinus tracts) as well as detecting soft tissue gas and foreign bodies.⁴⁴

• Abnormal X-ray or ultrasound
• Negative X-ray but with a clinical suspicion of infection
  • Signs and symptoms of joint or bone infection include:
    • Pain and swelling
    • Decrease range of motion
    • Fever
  • Laboratory findings of infection include any of the following:
    • Elevated ESR or CRP
    • Elevated white blood cell count
    • Positive joint aspiration
• Ulcer (diabetic, pressure, ischemic, traumatic) with signs of infection (redness, warm, swelling, pain, discharge which may range from white to serosanguineous) that is not improving despite treatment and bone, or deep infection is suspected
  • Increased suspicion if size or temperature increases, bone is exposed/positive probe-to-bone test, new areas of breakdown, new smell⁴⁵

Pre-operative/procedural evaluation:

• Pre-operative evaluation for a planned surgery or procedure

Post-operative/procedural evaluation: 

• When imaging, physical, or laboratory findings indicate joint infection, delayed or non-healing, or other surgical/procedural complications

Inflammatory Arthropathy (e.g., rheumatoid arthritis) and MRI is contraindicated or cannot be performed^46,47

• Further evaluation of an abnormality or non-diagnostic findings on prior imaging 
• Initial imaging of a single joint for diagnosis or response to therapy after plain films and appropriate lab tests (e.g., RF, ANA, CRP, ESR) 
• To determine change in treatment or when diagnosis is uncertain prior to start of treatment 
• Follow-up to determine treatment efficacy in the following:
  • Early rheumatoid arthritis
  • Advanced rheumatoid arthritis if X-ray and ultrasound are equivocal or noncontributory

Known or suspected inflammatory myopathies (If MRI contraindicated or cannot be performed): (Includes polymyositis, dermatomyositis, immune-mediated necrotizing  myopathy, inclusion body myositis)^48,49

• For diagnosis
• For biopsy planning

Crystalline Arthropathy

• Dual-energy CT can be used to characterize crystal deposition disease (i.e., gout) after
  • Appropriate rheumatological work up and initial X-rays AND 
  • After inconclusive joint aspiration or when joint aspiration cannot be performed OR⁵⁰
  • In the setting of extra-articular crystal deposits (i.e., tendons or bursa) 

Foreign Body⁵¹

• Indeterminate X-ray and ultrasound

Peripheral Nerve Entrapment (e.g., carpal tunnel) and MRI is contraindicated or cannot be performed, including any of the following:^{52,53,54,55,56}

• Abnormal electromyogram or nerve conduction study
• Abnormal X-ray or ultrasound
• Clinical suspicion and failed 4 weeks conservative treatment including at least two of the following (active treatment with physical therapy is not required):
  • Activity modification
  • Rest, ice, or heat
  • Splinting or orthotics
  • Medication

Brachial Plexopathy and MRI is contraindicated or cannot be performed^57,58

• If mechanism of injury or EMG/NCV studies are suggestive 
• Chest CT is preferred study, but neck and/or shoulder (upper extremity) CT can be approved depending on the suspected location of injury

Pediatrics

• Osteoid Osteoma after an x-ray is done⁵⁹

Rationale 
Computed tomography (CT) may be used for the diagnosis, evaluation, and management of conditions of the hand, wrist, elbow, and shoulder. CT is not usually the initial imaging test, but it is performed after standard radiographs. CT is used for preoperative evaluation or to evaluate specific abnormalities of the bones, joints, and soft tissues of the upper extremities. 

OVERVIEW
*Conservative Therapy — (Musculoskeletal) should include a multimodality approach consisting of a combination of active and inactive components. Inactive components, such as rest, ice, heat, modified activities, medical devices (including crutches, immobilizer, metal braces, orthotics, rigid stabilizer, or splints, etc. and not to include neoprene sleeves), medications, injections (bursal, and/or joint, not including trigger point), and diathermy, can be utilized. Active modalities may consist of physical therapy, a physician-supervised home exercise program**, and/or chiropractic care. 

**Home Exercise Program (HEP) — The following two elements are required to meet guidelines for completion of conservative therapy:

• Information provided on exercise prescription/plan AND
• Follow-up with member with information provided regarding completion of HEP (after suitable 4-week period), or inability to complete HEP due to physical reason- i.e., increased pain, inability to physically perform exercises. (Patient inconvenience or noncompliance without explanation does not constitute “inability to complete” HEP).

Shoulder Dislocation — Glenoid bone loss occurs in anterior shoulder dislocation. Severe degrees of glenoid bone loss are shown on axial radiography, but it can be quantified more definitively using CT. This information is important as it helps to predict the likelihood of further dislocation and the need for bone augmentation surgery. The number of dislocations cannot reliably predict the degree of glenoid bone loss; it is important to quantify glenoid bone loss, initially by arthroscopy and later by CT. 

American Academy of Pediatrics “Choosing Wisely” Guidelines advise against ordering advanced imaging studies (MRI or CT) for most musculoskeletal conditions in a child until all appropriate clinical, laboratory and plain radiographic examinations have been completed. “History, physical examination, and appropriate radiographs remain the primary diagnostic modalities in pediatric orthopedics, as they are both diagnostic and prognostic for the great majority of pediatric musculoskeletal conditions. Examples of such conditions would include, but not be limited to, the work up of injury or pain (spine, knees, and ankles), possible infection, and deformity. MRI examinations and other advanced imaging studies frequently require sedation in the young child (5 years old or less) and may not result in appropriate interpretation if clinical correlations cannot be made. Many conditions require specific MRI sequences or protocols best ordered by the specialist who will be treating the patient … if you believe findings warrant additional advanced imaging, discuss with the consulting orthopedic surgeon to make sure the optimal studies are ordered.”⁶⁰

References  

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60. American Academy of Pediatrics. Five things physicians and patients should question: Do not order advanced imaging studies (MRI or CT) for most musculoskeletal conditions in a child until all appropriate clinical, laboratory and plain radiographic examinations have been completed. Choosing Wisely Initiative ABIM Foundation. Updated February 12, 2018. Accessed November 20, 2022. https://www.choosingwisely.org/clinician-lists/aap-posna-mri-or-ct-for-musculoskeletal-conditions-in-children/

Coding Section 

Code	Number	Description
CPT	73200	Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections
	73201	Computed tomography, upper extremity; with contrast material(s)
	73202	Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections

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 nonaffiliated 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     

11/15/2023	Annual review, updating entire policy for clarity. Adding verbiage regarding updated orthopedic signs, dual energy CT, known AVN, vascular malformations, indeterminate findings, Popeye and reverse Popeye sign.
11/11/2022	Annual review, removing table one and updating coverage criteria for clarity.
11/01/2021	Annual review, adding additional information about rotator cuff tear, impingement, non traumatic should instability and glenoid labral tears. Also adding detail regarding shoulder dislocation and medical necessity for suspected bone infection. Also updating description/ overview and references.
11/01/2020	Annual review, updating policy for clarity, adding table 1 and updating references.
11/18/2019	New Policy