CHEST IMAGING GUIDELINES 2011 MedSolutions, Inc

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1 MedSolutions, Inc. Clinical Decision Support Tool Diagnostic Strategies This tool addresses common symptoms and symptom complexes. Imaging requests for patients with atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician, specialist and/or patient s Primary Care Physician (PCP) may provide additional insight. CHEST IMAGING GUIDELINES 2011 MedSolutions, Inc MedSolutions, Inc. Clinical Decision Support Tool for Advanced Diagnostic Imaging Common symptoms and symptom complexes are addressed by this tool. Imaging requests for patients with atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician may provide additional insight. This version incorporates MSI accepted revisions prior to 7/22/ MedSolutions, Inc. Chest Imaging Guidelines Page 1 of 62

2 2011 CHEST IMAGING GUIDELINES 2011 CHEST IMAGING GUIDELINE NUMBER and TITLE ABBREVIATIONS 4 BI-RADS Categories Chart 5 CH-1~GENERAL GUIDELINES 6 CH-2~LYMPHADENOPATHY 8 CH-3~CHRONIC COUGH 11 CH-4~NON-CARDIAC CHEST PAIN 11 CH-5~DYSPNEA/Shortness of Breath 12 CH-6~HEMOPTYSIS 13 BRONCHIAL TREE CH-7~BRONCHIECTASIS 14 CH-8~BRONCHITIS 14 LUNG PARENCHYMA (Alphabetical Order) CH-9~ASBESTOS EXPOSURE 15 CH-10~CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) 15 CH-11~INTERSTITIAL DISEASE 16 CH-12~MULTIPLE PULMONARY NODULES 16 CH-13~PNEUMONIA 17 CH-14~POSITIVE PPD or TUBERCULOSIS (TB) 17 CH-15~SARCOID 17 CH-16~SOLITARY PULMONARY NODULE (SPN) 18 PLEURA (Alphabetical Order) CH-17~PLEURAL-BASED NODULES and OTHER ABNORMALITIES 21 CH-18~PLEURAL THICKENING 21 DISORDERS INVOLVING the PLEURAL SPACE (Alphabetical Order) CH-19~PLEURAL EFFUSION 22 CH-20~PNEUMOTHORAX-HEMOTHORAX 22 MEDIASTINUM CH-21~MEDIASTINAL LYMPHADENOPATHY 24 CH-22~MEDIASTINAL MASS 24 CHEST WALL and RIBS (Alphabetical Order) CH-23~CHEST TRAUMA 24 CH-24~COSTOCHONDRITIS 25 CH-25~CHEST WALL MASS 26 CH-26~PECTUS EXCAVATUM/CARINATUM 26 CH-27~BREAST ABNORMALITIES 27 THORACIC VASCULAR DISORDERS (Alphabetical Order) CH-28~PULMONARY ARTERIOVENOUS FISTULA (AVM) 36 CH-29~PULMONARY EMBOLISM 36 CH-30~SUBCLAVIAN STEAL SYNDROME 39 CH-31~SUPERIOR VENA CAVA (SVC) SYNDROME 39 CH-32~THORACIC AORTA 40 CH-33~ELEVATED HEMIDIAPHRAGM 44 CH-34~THORACIC OUTLET SYNDROME 45 NEWER IMAGING TECHNIQUES CH-35~Virtual Bronchoscopy 46 CH-36~EM-Guided Peripheral Bronchoscopy 46 CH-37~Positron-Emission Mammography 46 CH-38~Breast MR Spectroscopy 47 END Chest Imaging Guidelines For Evidence Based Clinical Support, See NEXT PAGE 2011 MedSolutions, Inc. RETURN Page 2 of 62

3 2011 CHEST IMAGING GUIDELINES EVIDENCE BASED CLINICAL SUPPORT CH-3~Chronic Cough 48 CH-9~Asbestos Exposure 48 CH-15~Sarcoid 49 CH-16~Solitary Pulmonary Nodule (SPN) 49 CH-22~Mediastinal Mass 50 CH-27~Breast Abnormalities 50 CH-29~Pulmonary Embolism (PE) 52 CH-31~Superior Vena Cava (SVC) Syndrome 54 CH-32~Thoracic Aortic Dissection or Aneurysm 55 CHEST IMAGING GUIDELINE REFERENCES MedSolutions, Inc. RETURN Page 3 of 62

4 ABBREVIATIONS for CHEST GUIDELINES AAA abdominal aortic aneurysm ACE angiotensin-converting enzyme AIDS acquired immune deficiency syndrome AVM arteriovenous malformation BI-RADS Breast Imaging Reporting and Database System BP blood pressure BRCA tumor suppressor gene CAD computer-aided detection CBC Complete blood count COPD chronic obstructive pulmonary disease CT computed tomography CTA computed tomography angiography CTV computed tomography venography DCIS ductal carcinoma in situ DVT deep venous thrombosis ECG electrocardiogram EM electromagnetic EMG electromyogram FDA Food and Drug Administration FDG fluorodeoxyglucose FNA fine needle aspiration GERD gastroesophageal reflux disease GI gastrointestinal HRCT high resolution computed tomography IPF idiopathic pulmonary fibrosis LCIS lobular carcinoma in situ LFTP localized fibrous tumor of the pleura MRA magnetic resonance angiography MRI magnetic resonance imaging MRV magnetic resonance venography NCV nerve conduction velocity PE pulmonary embolus PEM positron-emission mammography PET positron emission tomography PFT pulmonary function tests PPD purified protein derivative of tuberculin RODEO Rotating Delivery of Excitation Off-resonance MRI SPN solitary pulmonary nodule SVC superior vena cava 2011 MedSolutions, Inc. RETURN Page 4 of 62

5 BI-RADS Categories Chart Category 1: Negative There is nothing to comment on. The breasts are symmetrical and no masses, architectural disturbances or suspicious calcifications are present. Category 2: Benign Finding This is also a negative mammogram, but the interpreter may wish to describe a finding. Involuting, calcified fibroadenomas, multiple secretory calcifications, fat containing lesions such as oil cysts, lipomas, galactoceles, and mixed density hamartomas all have characteristic appearances, and may be labeled with confidence. The interpreter might wish to describe intramammary lymph nodes, implants, etc. while still concluding that there is no mammographic evidence of malignancy. Category 3: Probably Benign Finding Short Interval Follow-up Suggested A finding placed in this category should have a very high probability of being benign. It is not expected to change over the follow-up interval, but the radiologist would prefer to establish its stability. Data is becoming available that sheds light on the efficacy of short interval follow-up. At the present time, most approaches are intuitive. These will likely undergo future modification as more data accrue as to the validity of an approach, the interval required, and the type of findings that should be followed. Category 4: Suspicious Abnormality Biopsy Should Be Considered There are lesions that do not have the characteristic morphologies of breast cancer but have a definite probability of being malignant. The radiologist has sufficient concern to urge a biopsy. If possible, the relevant possibilities should be cited so that the patient and her physician can make the decision on the ultimate course of action. Category 5: Highly Suggestive of Malignancy-Appropriate Action Should Be Taken These lesions have a high probability of being cancer. RETURN TO: CH-27~BREAST ABNORMALITIES 2011 MedSolutions, Inc. RETURN Page 5 of 62

6 2011 CHEST IMAGING GUIDELINES CH-1~GENERAL GUIDELINES A recent complete history and physical examination should be performed prior to considering advanced imaging of the chest. Chest X-ray o A recent chest x-ray (generally within the last 30 days) that has been overread by a radiologist should be performed prior to considering advanced imaging. Chest Ultrasound o Chest ultrasound (CPT 76604) includes transverse, longitudinal, and oblique images of the chest wall with measurements of chest wall thickness, and also includes imaging of the mediastinum. o Chest x-ray should be performed prior to chest ultrasound o Indications for chest ultrasound (CPT 76604) include: Evaluate presence of fluid within the pleural spaces Evaluate mediastinal masses Measure the distance between the anterior surface to chest wall prior to radiation therapy Evaluate other masses suspected within the chest or chest wall o Coding Notes Chest ultrasound--cpt Breast ultrasound--cpt (unilateral or bilateral) Axillary ultrasound--cpt (unilateral) If bilateral axillary ultrasounds are being performed, this should be coded as CPT x 2. Chest CT o Intrathoracic abnormalities found on chest x-ray, fluoroscopy, abdominal CT scan, or other imaging modalities can be further evaluated with chest CT with contrast (CPT 71260). o Non-contrast chest CT (CPT 71250) can be used for the following: Patient has contraindication to contrast Follow-up of pulmonary nodule(s) High Resolution CT (HRCT) Noncontrast CT is specifically requested by pulmonary specialist Other circumstances as specified in the guidelines o Chest CT without and with contrast (CPT 71270) does not add significant diagnostic information above and beyond that provided by chest CT with contrast, unless a question regarding calcification needs to be resolved. o Coding notes: High resolution chest CT should be reported only with an appropriate CPT code from the set No additional CPT codes should be used for the high resolution portion of the scan. The high resolution involves additional slices which are not separately billable. Chest CTA o Pre-op evaluation for minimally invasive or robotic surgery: 2011 MedSolutions, Inc. RETURN Page 6 of 62

7 There is insufficient data to support the routine use of CTA for the routine evaluation of peripheral arteries, iliac arteries, and/or aorta prior to minimally invasive or robotic surgery. Chest MRI o Chest CT is indicated in the majority of cases to evaluate pathology in the chest when advanced imaging is appropriate. Indications for chest MRI are much less common. o MRI chest is appropriate when there are concerns about CT contrast such as renal insufficiency or contrast allergy. o MRI chest may be appropriate in order to clarify equivocal findings on previous imaging studies. Appropriateness will need to be determined on a case by case basis MedSolutions, Inc. RETURN Page 7 of 62

8 CH-2 LYMPHADENOPATHY 2011 CHEST IMAGING GUIDELINES 2.1 Supraclavicular Region Axillary Lymphadenopathy Mediastinal Lymphadenopathy 9 CH-2~LYMPHADENOPATHY CH-2.1 Supraclavicular Region o Also see NECK-1 General Guidelines in the Neck Imaging Guidelines o A complete history and physical examination, including palpation of the supraclavicular region, should be performed initially in the evaluation of a suspected supraclavicular mass or abnormality. The sensitivity of palpation, CT, and ultrasound for detecting supraclavicular metastases were 33%, 83%, and 100%, respectively. 1 In one study, lymph nodes had to have a diameter of 22.3 mm or greater to be palpated in 50% of cases. 1 1 Radiology 2004;232:75-80 o Given the high false positive and false negative results of palpation alone, ultrasound (CPT 76536) should be performed in order to confirm the presence of enlarged lymph nodes or other mass prior to considering advanced imaging. Ultrasound has the added advantage of allowing ultrasound-guided fine needle aspiration (FNA) (CPT 76942) for histologic diagnosis of a suspicious lymph node or mass.* *Radiology 2004;232:75-80 o If ultrasound is indeterminate, soft tissue neck CT with contrast (CPT 70491) or chest CT with contrast (CPT 71260) can be performed. Either study images the supraclavicular region equally well if done correctly.* *Eliot Fishman. Ask the Fish communication. Johns Hopkins Medicine, Accessed July 2, 2007 o Definitive diagnosis of a supraclavicular abnormality requires biopsy (FNA or open biopsy). CH-2.2 Axillary Lymphadenopathy o In the primary care setting, lymphadenopathy is usually due to benign infectious causes. o Most patients can be diagnosed on the basis of a careful history and physical examination. o Localized axillary lymphadenopathy should prompt a search for an adjacent precipitating lesion such as a hand or arm injury or infection, and an examination of other nodal areas to rule out generalized lymphadenopathy. In individuals with localized axillary lymphadenopathy and a benign clinical picture, a 3 to 4 week period of observation is appropriate. If the adenopathy persists, excisional biopsy of the most abnormal lymph node is indicated. Advanced imaging is generally not indicated. In individuals with generalized lymphadenopathy, a more extensive 2011 MedSolutions, Inc. RETURN Page 8 of 62

9 diagnostic work-up including serological tests to rule out systemic infectious diseases, and lymph node biopsy is indicated. o Reference: American Family Physician 1998 Oct. Accessed June 6, 2011 o Axillary Lymphadenopathy from an Occult Primary Cancer Axillary lymph node metastasis, without identification of a primary cancer, is an uncommon finding. Adenocarcinoma is the most common histology, with breast cancer being the most common cancer (although non-palpable breast cancer presenting as axillary metastases accounts for less than 0.5% of all breast cancers). Breast MRI (CPT 77059) can be performed if breast cancer is suspected and physical exam and mammography are negative. Carcinomas of the lung, thyroid, stomach, colon, rectum, and pancreas have the potential to spread to axillary lymph nodes, but these metastases are rarely the first manifestations of disease. Symptomatology, risk factors, and clinical suspicion should lead to imaging of these possible primary sites. Also see ONC-29 Metastatic Cancer and Carcinomas of Unknown Primary Site in the Oncology and PET Imaging Guidelines Immunohistochemical markers have proven useful for differentiating metastatic breast carcinoma from adenocarcinoma arising in other primary sites. References: J Natl Compr Canc Netw 2009;7(2): The Breast 2006;15: CH-2.3 Mediastinal Lymphadenopathy o Mediastinal abnormalities detected on chest x-ray (overread by a radiologist) can be further evaluated by chest CT with contrast (CPT 71260). o Mediastinal masses identified on screening chest CT scans should be approached conservatively. In the I-ELCAP study which involved almost 30,000 individuals who received screening chest CT scans, 123 (1%) had a mediastinal lesion, but only 4 were cancers.* *Imaging Economics 2005 Feb, p.37 o If chest CT shows enlarged lymph nodes in the mediastinum with no other abnormalities in a patient at low risk for malignancy and with no clinical suspicion for malignancy, one follow-up chest CT (CPT 71260) at 4 to 8 weeks can be performed. Requests for additional CT scans or for PET should be sent for Medical Director review. Lymph node biopsy should be considered in cases of persistent lymphadenopathy in order to obtain a histologic diagnosis. o Lymphadenopathy from neoplasms as well as from benign sources of inflammation can result in a positive PET scan. Therefore, the use of PET may not be helpful prior to histologic diagnosis. o If biopsy can only be accomplished by mediastinoscopy or thoracoscopy/thoracotomy (i.e. percutaneous biopsy, transbronchial biopsy, 2011 MedSolutions, Inc. RETURN Page 9 of 62

10 transbronchial biopsy using endobronchial ultrasound, and endoscopic ultrasound-guided FNA cannot be performed), and a negative PET scan will allow the patient to be observed, then PET can be considered to confirm the likelihood of yielding a pathologic diagnosis and to determine if a more favorable site for biopsy exists. o PET may be helpful in characterizing anterior mediastinal abnormalities, especially since the thymus gland has a characteristic uptake pattern on most PET scans, and the study may differentiate normal or benign hypertrophic thymus tissue from pathologic mediastinal lesions MedSolutions, Inc. RETURN Page 10 of 62

11 SYMPTOM-BASED GUIDELINES (ALPHABETICAL ORDER) CH-3~CHRONIC COUGH Chronic cough is defined as a cough that lasts at least eight weeks. Information provided for patients with chronic cough should include a complete list of current medications, smoking history, history of recent upper respiratory infection, and history of cancer. All patients must first be evaluated with a recent (within last 30 days) chest x-ray (overread by a radiologist). Current or past cigarette smokers with a history of chronic smoker's cough should be asked if the cough has changed. If no change in cough and chest x-ray is unremarkable, no further imaging is indicated. Chest CT with contrast (CPT 71260) is indicated in a current or past smoker with a change in cough (other than improvement) or a new onset cough lasting greater than 4 weeks. Patients taking medications known to cause coughing (e.g. ACE inhibitors) should have medication discontinued. If cough persists > 4 weeks, chest CT with contrast (CPT 71260) or without contrast (CPT 71250) is indicated. Patients with no history of smoking and clear chest x-ray should undergo the following algorithm: 1,2 o A 3 week trial of antihistamine and decongestant treatment should be performed initially. o If chronic cough persists after treatment of upper airway cough syndrome, asthma should be ruled out with bronchoprovocation challenge (e.g. methacholine challenge, exhaled nitric oxide test) and spirometry should be performed. o If bronchoprovocation challenge is not available, an empiric trial of corticosteroids should be performed. o If cough persists, treatment of gastroesophageal reflux disease should be started and referral to a cough specialist is helpful. o If cough persists, chest CT (either with contrast [CPT 71260] or without contrast [CPT 71250] can be performed. 1 Can Fam Physician 2002 Aug;48: Chest 2006;129:1S-23S CH-4~NON-CARDIAC CHEST PAIN Defined as recurrent episodes of unexplained retrosternal pain in patients lacking a cardiac abnormality after a reasonable evaluation.* *Chiropractic and Osteopathy 2005;13:18 This guideline addresses all types of non-cardiac chest pain (chest wall pain, pleuritic pain, retrosternal pain, etc.). Chronic chest pain is generally defined as pain that persists for 6 months or more. More than half of patients with no organic cause for chest pain continue to experience chest pain one year after discharge from the hospital.* *European J of Emergency Medicine 1997;4: MedSolutions, Inc. RETURN Page 11 of 62

12 Etiology: o Studies have found that the most common etiologies include idiopathic (60%), musculoskeletal chest pain (esp. costochondritis) (36%), and reflux disease (GERD) (13%).* *J Fam Pract 1994;38(4): o Esophageal angina: Approximately 10%-20% of patients with GERD present with symptoms that are clinically indistinguishable from angina pectoris. Clinical features that may suggest the esophagus as the source of the atypical pain include: posturally aggravated symptoms, history of dysphagia, substernal pain limited to the midline and radiating to the interscapular area. Reference: Hiebert CA. Clinical Features.In Pearson FG, Deslauriers J, Ginsberg RJ, et al. (Eds.). Thoracic Surgery. New York, Churchill Livingstone, Inc., 1995, pp %-50% of chest pain presentations in ambulatory settings may be musculoskeletal. o Musculoskeletal pain is a diagnosis of exclusion. o Some patients with Thoracic Outlet Syndrome can present with anterior chest wall or parascapular pain.* o Also see CH-34 Thoracic Outlet Syndrome *Mackinnon S, Patterson GA, Urschel HC, Jr. Thoracic Outlet Syndromes. Pearson FG, Deslauriers J, Ginsberg RJ, et. al. (Eds.). Thoracic Surgery. New York, Churchill Livingstone, Inc.,1995, p.1221 Chest x-ray should be performed initially and overread by a radiologist. Abnormalities present on chest x-ray that were not present on previous imaging studies (if available) can be further evaluated with chest CT with contrast (CPT 71260). If chest x-ray is unremarkable, a thorough cardiac (ECG, echocardiogram, stress test), GI (trial of anti-reflux medication, possible upper endoscopy, ph probe, esophageal manometry), and pulmonary (PFT s) evaluation should be performed at least once. If the above evaluations have not yielded an explanation for the chest pain, symptoms have not improved after a 6 to 8 week trial of rest, analgesics, and anti-inflammatory treatment under the direction of a physician, and a recent chest x-ray (within 2 to 4 weeks) has been performed, then chest CT with contrast (C P T 71260) can be performed. There is no evidence to support MRI for the evaluation of chest pain. Repeat advanced imaging of the chest in patients with unchanged or improving symptoms is not appropriate. CH-5~DYSPNEA/SHORTNESS OF BREATH Dyspnea is the subjective experience of breathing discomfort Evaluation of dyspnea/shortness of breath is aimed at determining whether the cause is cardiac, pulmonary, mixture of cardiac and pulmonary, or noncardiac/nonpulmonary o Most cases are due to cardiac or pulmonary disease 2011 MedSolutions, Inc. RETURN Page 12 of 62

13 If pulmonary embolus (PE) is suspected, see CH-29 Pulmonary Embolism Prior to considering advanced imaging of the chest, work up should include the following: o Thorough history and physical examination o Recent (within past 30 days) chest x-ray that has been overread by a radiologist o ECG o Pulse oximetry o Pulmonary function studies (PFT s) o Blood work including CBC and thyroid function tests Intrathoracic abnormalities found on chest x-ray that were not present on previous imaging studies and do not have benign features such as a benign calcification pattern typical of granuloma or hamartoma can be evaluated with chest CT without (CPT 71250) or with (CPT 71260) contrast. High resolution chest CT scan (HRCT) without contrast (CPT 71250) can be performed if PFT s are consistent with interstitial lung disease such as idiopathic pulmonary fibrosis. If chest x-ray, ECG, and PFT s do not yield a diagnosis, then arterial blood gas measurement, echocardiography, and cardiac stress testing should be performed prior to considering advanced imaging of the chest. o See the following in the Cardiac Imaging Guidelines for the appropriate cardiac stress test: CD-1.3 Stress Testing CD-2.4 Stress Echocardiography CD-3.2 Indications for MPI CD-6.3 Indications for Stress MRI Chest CT without (CPT 72150) or with (CPT 71260) contrast can be performed if the above work up has been completed and dyspnea/shortness of breath that is not cardiac in origin persists for greater than 6 to 8 weeks. CH-6~HEMOPTYSIS A careful history should help determine the amount of blood and differentiate between hemoptysis, pseudohemoptysis, and hematemesis. Most common etiologies for hemoptysis: o Adults: Bronchitis, bronchogenic carcinoma, pneumonia Work up: o Careful history and physical examination and chest x-ray. o Low risk patient with normal chest x-ray: treat on an outpatient basis with close monitoring and antibiotics if indicated. o Patients with risk factors for malignancy (e.g. male sex, age >40, smoking, duration of hemoptysis >1 week): chest CT with contrast (CPT 71260) should be performed even if chest x-ray is normal. Reference: o Am Fam Physician 2005;72(7): In the non-trauma patient with a history of clinically documented hemoptysis, chest CT (either with contrast [CPT 71260] or without contrast [CPT 71250] 2011 MedSolutions, Inc. RETURN Page 13 of 62

14 depending on physician preference) is indicated prior to bronchoscopy.* *AJR 2002;179: BRONCHIAL TREE CH-7~BRONCHIECTASIS Bronchiectasis is defined as localized, irreversible dilatation of bronchi >2 mm in diameter. Patients have excessive mucus production. Bronchiectasis is associated with a wide range of disorders, including cystic fibrosis, AIDS, alpha1-antitrypsin deficiency, rheumatoid arthritis, obstruction of the bronchi, and necrotizing bacterial infections. Chest x-ray and PFT s should be performed initially in patients with known or suspected bronchiectasis, but may be normal. High resolution chest CT scan (HRCT) without contrast (CPT 71250) is the advanced imaging study of choice to confirm the diagnosis of bronchiectasis and/or evaluate patients with known bronchiectasis who have worsening symptoms or worsening PFT s. There is no published data to support performing routine follow-up advanced imaging of the chest in the absence of new or worsening symptoms or worsening lung function studies in patients with known bronchiectasis. MRI is not used to evaluate patients with bronchiectasis. Patients with bronchiectasis who present with hemoptysis should undergo chest CTA (CPT 71275) or chest MRA (CPT 71555). Reference: o Emmons EE. Bronchiectasis. emedicine, May 13, 2011, Accessed May 23, 2011 CH-8~BRONCHITIS Acute inflammation of trachea and/or large and small bronchi due to infection or other causes. The majority of cases of bronchitis are due to viral infections. Symptoms can include coughing, wheezing, shortness of breath, fever o Acute bronchitis usually improves within a few days but the cough may continue for weeks. Imaging Studies: o Chest x-ray to rule out pneumonia if symptoms do not improve after a trial of conservative therapy (rest, analgesics, fluids, humidifier, etc.) 2011 MedSolutions, Inc. RETURN Page 14 of 62

15 LUNG PARENCHYMA (ALPHABETICAL ORDER) CH-9~ASBESTOS EXPOSURE Chest x-ray must be performed initially in patients with suspected asbestosrelated lung disease. In patients with stable calcified pleural plaques seen on chest x-ray, no advanced imaging of the chest is indicated. If a change is seen on chest x-ray, high resolution chest CT (HRCT) (CPT 71250) can be performed. Patients with progressive pleural and parenchymal changes are at particularly high risk of developing malignant mesothelioma and should have HRCT (CPT 71250) every 3 to 6 months. CH-10~CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) COPD includes a spectrum of diseases: asthmatic bronchitis, chronic bronchitis, and emphysema. Typical presenting symptoms include cough, excess mucus, dyspnea on exertion, and/or wheezing. Diagnosis is best made by performing spirometry (PFT s). 1 o In addition, chest x-ray and arterial blood gas measurement should be performed. 1 1 Swierzewski SJ. COPD diagnosis.healthcommunities.com,, June 1, 2000, updated May 3, 2011, Accessed May 24, 2011 o Chest CT without contrast (CPT 71250), high resolution chest CT without contrast (CPT 71250), or chest CT with contrast (CPT 71260) can be performed if emphysema is suspected and the above initial studies are indeterminate. o Chest MRI is generally not indicated in the evaluation of COPD. o Patients with a family history of emphysema or chronic bronchitis should have a spirometry test as part of their initial evaluation.* *Making the Diagnosis of COPD. National Lung Health Education Program, Accessed October 31, 2007 An exacerbation of COPD is characterized by a change in baseline dyspnea, cough, and/or sputum that is acute in onset and beyond normal day-to-day variations. o Advanced imaging of the chest is not typically indicated in the evaluation of COPD exacerbation. o Evaluation of COPD exacerbation should include arterial blood gas measurement, chest x-ray, ECG, sputum culture, and blood work to measure electrolytes and complete blood count.* *Buist AS, Rodriguez-Roisin R, Anzueto A, et al. Global Initiative for Chronic Obstructive Lung Disease: Pocket guide to COPD diagnosis, management, and prevention. National Institutes of Health, National Heart, Lung, and Blood Institute; April 2001 (updated December 2010 ), 2011 MedSolutions, Inc. RETURN Page 15 of 62

16 Accessed May 24, 2011 There is no published data to support performing routine follow-up advanced imaging of the chest in patients with COPD. Lung Volume Reduction Surgery o Chest CT either without contrast (CPT 71250) or with contrast (CPT 71260) can be performed for preoperative evaluation in patients who are being considered for lung volume reduction surgery.* *Radiology 1999;212:1-3 o There is insufficient data to support obtaining routine follow-up advanced imaging of the chest in patients who have had lung volume reduction surgery. o New or worsening signs/symptoms in patients who have had lung volume reduction surgery should be evaluated with chest x-ray prior to considering advanced imaging of the chest CH-11~INTERSTITIAL DISEASE High resolution chest CT scan (HRCT) without contrast (CPT 71250) is the diagnostic modality of choice to evaluate for interstitial changes in patients with pulmonary symptoms and abnormal pulmonary function studies (PFT S). Chest x-ray may be normal in some cases of interstitial lung disease and PFT s are the best indicator of the need for HRCT. Evaluation by a Pulmonologist is helpful in determining the need for advanced imaging. HRCT can be performed in patients with known interstitial pneumonia, idiopathic pulmonary fibrosis, or other interstitial lung disease if there are new or worsening pulmonary symptoms or worsening PFT s. HRCT can be performed once a year in patients with known idiopathic pulmonary fibrosis (IPF) who are asymptomatic or have stable symptoms and stable PFT s, if imaging results showing progression or regression of disease will change patient management.* *Proceedings of the American Thoracic Society 2006;3: CH-12~MULTIPLE PULMONARY NODULES More than 6 nodules usually indicates inflammatory lung disease, and this has been confirmed after years of follow-up.* *Chest 2004;125: Clustering of multiple nodules in a single location in the lung tends to favor an infectious process, although a dominant nodule with adjacent small satellite nodules can be seen in primary lung cancer.* *Radiology 2005:237: In patients with multiple pulmonary nodules, the largest nodule should be imaged based on CH-16 Solitary Pulmonary Nodule Imaging Guidelines. If infection is highly suspected in a patient with multiple pulmonary nodules, the first follow-up chest CT (CPT or 71260) can be performed sooner than 3 months MedSolutions, Inc. RETURN Page 16 of 62

17 CH-13~PNEUMONIA Chest x-ray (overread by a radiologist) must be performed initially in all patients with suspected pneumonia prior to considering advanced imaging. Chest CT with contrast (CPT 71260) may be helpful in evaluating a patient with pneumonia that has shown no improvement by chest x-ray after two weeks or has not cleared by chest x-ray after four weeks. Chest CT with contrast (CPT 71260) is indicated when chest x-ray shows a possible complication of pneumonia (e.g. abscess, effusion) or possible lung mass associated with the infiltrate. CH-14~POSITIVE PPD or TUBERCULOSIS (TB) Chest CT with contrast (CPT 71260) can be performed in patients with positive PPD skin test or other positive tuberculin skin tests and normal chest x-ray who have not had a previous normal chest CT. Chest CT can show evidence of tuberculosis (e.g. primary complexes, mediastinal or hilar lymphadenopathy) in up to 20% of patients with unremarkable chest x-rays.* *AJR 1997 Apr;168(4): *Eur J Radiol 2003 Dec;48(3): o Evidence of tuberculosis on chest CT will alter clinical management and result in full multi-drug treatment for these patients rather than single drug treatment for positive PPD. If chest CT is unremarkable, there is insufficient data to support performing subsequent chest CT scans unless symptoms develop or chest x-ray shows a new abnormality. Follow-up chest CT with contrast (CPT 71260) can be used to re-evaluate patients undergoing active treatment for tuberculosis who had abnormalities seen only on chest CT. o The frequency of the follow-up chest CT scans should be at the discretion of the pulmonary specialist following the patient, as there are no published guidelines or evidence-based data addressing this issue. Patients with suspected complications or progression of tuberculosis (e.g. pleural tuberculosis, empyema, mediastinitis) can be evaluated with chest CT with contrast (CPT 71260). CH-15~SARCOID Also see ONC-30.5 Sarcoidosis in the Oncology Imaging Guidelines and HD Sarcoidosis in the Head Imaging Guidelines. CT of the chest either with contrast (CPT 71260) or without contrast (CPT 71250) is superior to chest x-ray in establishing the diagnosis of sarcoid. CT scan helps differentiate sarcoid from other granulomatous disorders, especially tuberculosis, and allows follow-up for the detection of complications, especially fibrosis.* *Rev Mal Respir 2003;20 (2 pt 1): MedSolutions, Inc. RETURN Page 17 of 62

18 Patients with suspected sarcoid should have chest CT either with contrast (CPT 71260) or without contrast (CPT 71250) to establish or rule out the diagnosis. Bronchoscopy with biopsy is indicated to make a definitive diagnosis; if positive for sarcoidosis, no further imaging is necessary. PET can also be useful in making the diagnosis of sarcoid, as sarcoid has a distinctive appearance on PET. However, definitive diagnosis can only be made by biopsy. o There is currently no evidence-based data to support performing serial PET scans to monitor disease activity while tapering steroid therapy. Cardiac PET (CPT 78459) is useful for identifying and monitoring response to therapy for cardiac sarcoid. The diagnosis should be established or strongly suspected prior to imaging.* *J Nucl Med 2004;45(12): Chest CT (either with or without contrast) is indicated in patients with worsening symptoms, new symptoms after a period of being asymptomatic, or if a treatment change is being considered. CH-16~SOLITARY PULMONARY NODULE (SPN) A nodule is any pulmonary or pleural lesion represented in a radiograph by a sharply defined, discrete, nearly circular opacity 2-30 mm in diameter which is surrounded by normal lung tissue. o A linear or essentially two-dimensional opacity that does not have an approximately spherical component is not a nodule. o Purely linear or sheet like lung opacities are unlikely to represent neoplasms and do not require follow-up, even when the maximum dimension exceeds 8 mm (0.8 cm).* *Radiology 2005;237: o Nodular opacities and/or thickening that are typical of scarring do not require follow-up advanced imaging and do not require imaging with contrast for further delineation.* *Radiology 2005;237: o Malignant features can include spiculation, abnormal calcification, size greater than 7-10 mm, ground glass opacity, interval growth, history of a cancer that tends to metastasize to the lung or mediastinum, and/or smoking history. o Benign features can include benign calcification (granuloma, hamartoma), multiple areas of calcification, small size, multiple nodules, linear/streaking/sheet-like opacities, negative PET, and stability of size over 2 years. A pulmonary nodule seen on an imaging study other than a dedicated chest CT (e.g. nodule seen on abdominal CT, spine MRI, chest or coronary artery CTA, etc.) can be further evaluated with one chest CT without contrast (CPT 71250) or with contrast (CPT 71260). Follow-up imaging should proceed based upon the Modified Fleischner Society Criteria (next page) and other guidelines below. A solitary pulmonary nodule (SPN) can be imaged by chest CT without contrast (CPT 71250) or with contrast 2011 MedSolutions, Inc. RETURN Page 18 of 62

19 (CPT 71260) (depending on physician preference) if there has been an increase in size on chest x-ray, if there are no old films for comparison, or if the lesion does not have classically benign characteristics by chest x-ray or previous CT (e.g. benign calcification pattern typical for a granuloma or hamartoma). If the SPN was identified on a prior CT or there has been a negative PET scan, then CT without contrast (CPT 71250) or with contrast (CPT 71260) (with thin cuts through the nodule) can be performed as follows: 1,2 1 Radiology 2005;237: Radiology 2004;231: Modified Fleischner Society Criteria Nodule Size (mm) Low-Risk Patient+ High-Risk Patient± 4 No follow-up needed Follow-up CT at 12 months; if unchanged, no further follow-up > 4 6 Follow-up CT at 12 months; if One follow-up CT at 6-12 months unchanged, no further follow-up then repeat CT at 18 months and 24 months >6 7 One follow-up CT at 6-12 months One follow-up CT at 3-6 months, one then repeat CT at 18 months and CT at 9-12 months, and one CT at 24 months 24 months > 7 Follow-up CT at 3, 9, and 24 months Same as for low-risk patient Note Newly detected indeterminate nodule in persons 35 years of age or old. *Average of length and width + Minimal or absent history of smoking and of other known risk factors. ± History of smoking or of other known risk factors. The risk of malignancy in this category (<1%) is substantially less than that in a baseline CT scan of an asymptomatic smoker. Nonsolid (ground-glass) or partly solid nodules may require longer follow-up to exclude indolent adenocarcinoma. o High risk patients include those with smoking history, significant second hand smoke exposure, asbestos exposure, or history of cancer other than ordinary skin cancer. No further imaging is necessary if a nodule has been stable for 2 years. o Exceptions: Lesions that have a ground glass opacity component may require longer follow-up time than 2 years to exclude indolent adenocarcinoma 1 and ground glass lesions greater than 2 cm should be resected. 2 These cases should be sent for Medical Director review. o Although most cancerous nodules are solid, partly solid nodules are most likely to be malignant (usually bronchioalveolar cancer). 3 Likelihood of malignancy is 63% for partly solid nodule, 18% for nonsolid nodule, and 7% for solid nodule. 4 1 Radiology 2005:237: Siegelman SS. Hot Topics in Chest CT. Presented at: 24 th Annual Computed Body Tomography: The Cutting Edge, February 14-17, 2008, Orlando, FL. 3 Radiology 2006;239: AJR 2002 May;178(5): Patients with a personal history of malignancy that would reasonably metastasize 2011 MedSolutions, Inc. RETURN Page 19 of 62

20 to the lungs or mediastinum who are found to have pulmonary nodules of any size can have repeat chest imaging at 3, 6, 12, and 24 months. A nodule that grows at a rate consistent with cancer (doubling time 30 to 360 days) should be sampled for biopsy or resected.* *Chest 2004;125: PET scan (CPT or CPT 78815) is appropriate for the characterization of an SPN if the lesion is a distinct parenchymal lung nodule (not an infiltrate, ground glass opacity, or hilar enlargement) measuring greater than or equal to 7 mm (0.7 cm) on chest CT scan. o NOTE: Certain payers consider PET scan investigational for evaluating pulmonary nodules 1 cm or lung masses >4 cm. Their coverage policies will take precedence over MedSolutions guidelines. o Reference: J Nucl Med 2008;49: If PET scan is negative, chest CT should be performed at 3, 9, and 24 months.* *Radiology 2005; 237: Serial PET scans to evaluate lung nodules are not appropriate: if the original PET is positive, biopsy should be performed. If the original PET is negative but subsequent chest CT shows increase in size of the nodule, biopsy should be performed. * *Radiology 2006; 239:34-49 MRI of the chest is the least preferred modality for evaluation of lung nodules* *ACR Appropriateness Criteria, Solitary pulmonary nodule, MedSolutions, Inc. RETURN Page 20 of 62

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