TEMPORAL BONE, MASTOID, ORBITS CT - CAM 745
Computed tomography’s use of thin sections with multi-planar reconstruction (e.g., axial, coronal, and sagittal planes), along with its three-dimensional rendering, permits thorough diagnosis and management of ocular and orbital disorders. Brain CT is often ordered along with CT of the orbit for head injury with orbital trauma. MRI Orbits is preferred over CT Orbits except in the case of orbital trauma, infection, or bone abnormalities.
Temporal bone, mastoid, and internal auditory canal computed tomography (CT) is a unique study performed for problems, such as conductive hearing loss, chronic otitis media, mastoiditis, cholesteatoma, congenital hearing loss and cochlear implants. It is a modality of choice because it provides 3D positional information and offers a high degree of anatomic detail. It is rarely used for evaluation of VIIth or VIIIth nerve tumors.
CT is preferred for visualizing bony detail and calcifications., MRI is superior for the evaluation of the visual pathways, globe, and soft tissues is considered MEDICALLY NECESSARY for the following indications:
- Abnormal external or direct eye exam (Hande, 2012):
- Exophthalmos (proptosis) or enophthalmos
- Ophthalmoplegia with concern for orbital pathology (Stalcup, 2013)
- Unilateral optic disk swelling if MRI is contraindicated or cannot be performed (Hata, 2017; Margolin, 2019; Passi, 2013)
- Documented visual defect if MRI is contraindicated or cannot be performed (Fadzil, 2013; Kedar, 2011; Prasad, 2012; Sadun, 2011)
- Unilateral or with abnormal optic disc(s) (i.e., optic disc blurring, edema, or pallor); AND
- Not explained by an underlying diagnosis, glaucoma, or macular degeneration
- Optic Neuritis if MRI is contraindicated or cannot be performed
- With an atypical presentation, severe visual impairment or poor recovery following initial onset or treatment onset (CMSC, 2018; Voss, 2011)
- If needed to confirm optic neuritis and rule out compressive lesions
- Orbital trauma
- Physical findings of direct eye injury
- Suspected orbital trauma with indeterminate x-ray
- For further evaluation of a fracture seen on x-ray for treatment or surgical planning
- Orbital or ocular mass/tumor, suspected, or known (Hande, 2012; Kedar, 2011)
- Clinical suspicion of orbital infection (Gavito-Higuera, 2016; Kirsch, 2017)
- Clinical suspicion of osteomyelitis (Arunkumar, 2011; Lee, 2016)
- Direct visualization of bony deformity OR
- Abnormal x-rays
- Clinical suspicion of Orbital Inflammatory Disease (e.g., eye pain and restricted eye movement with suspected orbital pseudotumor) (Pakdaman, 2014)
- Congenital orbital anomalies (Tawfik, 2012)
- Complex strabismus to aid in diagnosis, treatment and/or surgical planning (Demer; 2002; Kadom, 2008)
Combination Studies with Orbit CT
- Brain CT/Orbit CT if MRI is contraindicated or cannot be performed
- Optic neuropathy or unilateral optic disk swelling of unclear etiology to distinguish between a compressive lesion of the optic nerve, optic neuritis, ischemic optic neuropathy (arteritic or non-arteritic), central retinal vein occlusion, or optic nerve infiltrative disorders (Behbehani, 2007)
- Bilateral optic disk swelling (papilledema) with vision loss (Margolin, 2019)
- Approved indications as noted above and being performed in high-risk populations and will need anesthesia for the procedure and there is a suspicion of concurrent intracranial pathology (Lawson, 2000)
INDICATIONS FOR SELLA CT
MRI is contraindicated or cannot be performed (ACR NE, 2018; Chaudhary, 2011)
- For further evaluation of known sellar and parasellar masses
- Suspected pituitary gland disorder (Wu, 2014) based on:
- Documented visual field defect suggesting compression of the optic chiasm; OR
- Laboratory findings suggesting pituitary dysfunction (Freda, 2011); OR
- Pituitary apoplexy with sudden onset of neurological and hormonal symptoms
- Follow-up to other imaging suggesting sella (pituitary) mass
INDICATIONS FOR TEMPORAL/MASTOID/INTERNAL AUDITORY CANAL CT
Hearing loss (documented on audiogram) (Cunnane, 2019; Sharma, 2018)
- Asymmetric sensorineural when MRI is contraindicated (Krause, 2010; Verbist, 2012)
- Conductive or mixed (Trojanowska, 2012)
- Congenital (Trojanowska, 2012)
- Cochlear implant evaluation (Juliano, 2015)
Tinnitus (Kessler, 2017; Pegge, 2017; Yew, 2014)
- Pulsatile tinnitus
- Unilateral non-pulsatile tinnitus and MRI is contraindicated or cannot be performed
- Clinical suspicion of acute mastoiditis as a complication of acute otitis media (Kann, 2016; Luntz, 2012; Patel, 2014; Platzek, 2014)
- Systemic illness or toxic appearance
- Signs of extracranial complications (e.g., postauricular swelling/erythema, auricular protrusion, retro-orbital pain, hearing loss, tinnitus, vertigo, nystagmus)
- Not responding to treatment
Note: MRI is also indicated if there are signs of intracranial complications (e.g., meningeal signs, cranial nerve deficits, focal neurological findings, altered mental status).
This is most common in the pediatric population
- Chronic Otitis Media (with or without cholesteatoma on exam) (Gomaa, 2013; Patel, 2014)
- Failed treatment for acute otitis media
Cholesteatoma (Barath, 2011; Chen, 2018)
CSF Otorrhea (Hiremath, 2019; Vemuri, 2017)
- When looking to characterize a bony defect (for intermittent leaks and complex cases consider CT/MR/Nuclear Cisternography). CSF fluid should always be confirmed with laboratory testing (Beta-2 transferrin assay.)
Temporal Bone Fracture (Collins, 2012; Kennedy, 2014; Lantos, 2019)
- Suspected based on mechanism of injury OR
- Indeterminate findings on initial imaging OR
- For further evaluation of a known fracture for treatment or surgical planning
Vascular Indications (Bozek, 2016; Muderris, 2011)
- Suspected or known with need for further evaluation
- Dehiscence of the jugular bulb or carotid canal OR
- Other vascular anomalies of the temporal bone (i.e., aberrant internal carotid artery, high jugular bulb, persistent stapedial artery, aberrant petrosal sinus)
Peripheral vertigo (Muncie, 2017; Sharma, 2018; Strupp, 2013)
- Based on clinical exam (Head-Impulse with saccade, Spontaneous unidirectional horizontal nystagmus, Dix-Hallpike maneuver); AND
- Persistent symptoms after a trial of medication and four weeks of vestibular therapy (e.g., Epley’s maneuvers)
Bell’s Palsy/hemifacial spasm if MRI is contraindicated or cannot be performed (for evaluation of the extracranial nerve course)
- If atypical signs, slow resolution beyond three weeks, no improvement at four months, or facial twitching/spasms prior to onset (Quesnel, 2010)
OTHER INDICATIONS FOR TEMPORAL BONE, MASTOID, ORBITS, SELLA, INTERNAL AUDITORY CANAL CT
- Pre-operative evaluation for a planned surgery or procedure
Post- operative/procedural evaluation
- When imaging, physical, or laboratory findings indicate surgical or procedural complications
- 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.
All other uses of this technology are investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY.
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Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material
|70481||Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s)|
|70482||Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; 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 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
Annual review, adding policy verbiage related to complex strabismus, temporal bone fracture, optic neuritis, visual defect, osteomyelitis, optic neuropathy and csf otorrhea. Also updating description and references.
Annual review, clarifying policy verbiage and updating references and description.