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 Hemoptysis — High-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 Nodules — Solitary 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 Empyema — Contrast-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.

Policy  
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.

INDICATIONS FOR CHEST CT

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:¹

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

Nodule on Initial LDCT²

• If multiple nodules, the largest and type is used for decision
• Follow-up with LDCT as per Lung-RADS^® criteria^3,4 (Table 1)

Table 1: Lung-RADS Assessment Categories⁵

 
Incidental Lung Nodules⁶

• 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 three months to detect interval nodule growth)
    • Immunosuppression (may require a shorter follow-up, such as one month, if suspicion of fulminant infection)

Note: These should not be ordered as low-dose CT

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

Incidental pulmonary nodules on chest X-ray that are indeterminate (not typical of granulomatous disease) as noted by the radiologist. No time delay between the chest X-ray and the subsequent chest CT needed).
 
Table 2: 2017 Fleischner Society Guidelines for Management of Incidentally Detected Pulmonary Nodules⁶

Known Cancer^7,8,9

• For follow-up intervals for malignancies¹⁰
• Cancer staging (includes unknown primary)
• Cancer restaging
• Suspicious signs or symptoms of recurrence
• Suspected cancer based on prior imaging¹¹ 

Chest Mass (non-lung parenchymal)¹²
(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 patients¹³

Interstitial Lung Disease^14,15

• 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 disease¹⁶
• Guidance in selection of the most appropriate site for biopsy of diffuse lung disease¹⁷

Chronic Cough (> 8 weeks) and chest X-ray completed¹⁸

• 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)¹⁹
•    Known or suspected tuberculosis and initial chest X-ray done

Infection Follow-Up Imaging

• Abscess, empyema or pleural effusions on chest X-ray²⁰
• For evaluation of non-resolving pneumonia or inflammatory disease documented by at least two imaging studies:
• Unimproved with four weeks of antibiotic treatment; OR
• Unresolved at eight weeks^21,22

Pneumothorax on Chest X-ray²³

Vocal Cord Paralysis on Endoscopic Exam²⁴

• Neck and chest CT is an approvable combo.

Granulomatosis With Polyangiitis (Wegener’s Granulomatosis)²⁵

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)²⁶

• Chest CT not approvable for PE

Congenital Malformations

• Thoracic malformation on chest X-ray²⁷
• Congenital Heart Disease with pulmonary hypertension²⁸

Hemoptysis After X-ray Completed^29,30

Pre-operative/Procedural Evaluation

• Pre-operative evaluation for a planned surgery or procedure
• Pre-operative evaluation for electromagnetic navigation bronchoscopy³¹

Post-Operative/Procedural Evaluation

• Post-surgical follow-up when records document medical reason requiring additional imaging

Chest Wall Pain (after initial evaluation with chest X-ray and/or rib films)³²

• 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-19
  • 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-19 (See Overview.)
  • Prior history of COVID-19 with hypoxia or impaired lung function of follow-up³³
    • Restricted diffusion on pulmonary function test (would need a HRCT, or High Resolution CT)
    • Low oxygen saturation and a chest X-ray was done
  • Known fibrosis with continued symptoms

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
   

References  

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Coding Section 

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" 

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