Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Full-Body Computerized Tomography (CT) Scan Screening
Policy #:MA09.012a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.


Full-body computerized tomography (CT) scanning of asymptomatic individuals for screening purposes is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.
Policy Guidelines

There is no Medicare coverage criteria addressing this service; therefore, the Company policy is applicable.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, full-body CT scanning is not eligible for payment under the medical benefits of the Company’s Medicare Advantage products because the service is considered experimental/investigational and, therefore, not covered.

Services that are experimental/investigational are excluded for the Company’s Medicare Advantage products. Therefore, they are not eligible for reimbursement consideration.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA has approved numerous devices for computerized tomography (CT) scan screening but not for full-body CT scan screening.

BILLING GUIDELINES

There is no specific Current Procedural Terminology (CPT) or Healthcare Common Procedural Coding System (HCPCS) code for full-body CT scanning. It is inappropriate to use a series of existing codes for various areas of the body. When reporting this noncovered service, use a code for an unlisted CT procedure.

Description

Computerized tomography (CT), which is sometimes called computerized axial tomography (CAT), has been used as an effective radiographic diagnostic tool for cross-sectional imaging since the 1970s. The US Food and Drug Administration (FDA) has approved the use of CT scans to confirm or exclude detectable anatomic abnormalities from benign and malignant etiologies in symptomatic individuals. The risks of radiation exposure from a typical diagnostic CT scan that is directed at a symptomatic target organ or disease state are accepted by the medical community as reasonable. The use of CT scanning as a screening tool for individuals who are asymptomatic but known to be at high risk for a particular disease (eg, colon cancer or lung cancer) is under investigation. Study participants are exposed to a limited amount of radiation because only a specific organ or area of the body is scanned.

Full-body (also called whole-body, ultrafast, or electronbeam computerized tomography [EBCT]) CT scan screening involves scanning the body from the neck to the pelvis. It is marketed as a preventive healthcare measure for asymptomatic individuals. Supporters believe that full-body CT scan screening can potentially save lives and avoid serious illness by finding the illness before it manifests or progresses.

The FDA prohibits manufacturers from promoting CT scan systems for full-body screening of asymptomatic individuals. The American College of Radiology has stated that there is insufficient evidence to justify the use of full-body CT scan screening for individuals with no symptoms or family history suggesting disease. In addition, public health agencies and national medical and professional societies (eg, the American Association of Physicists in Medicine), as well as the Health Physics Society, do not recommend full-body CT scan screening. No published studies have demonstrated that full-body CT scan screening reduces morbidity or mortality when used to screen healthy, asymptomatic individuals. The American Society of Radiation Technologists passed a resolution in June 2002 advising that CT scan screening should have a clinical basis and that it requires further scientific study. Full-body CT scan screening has not proved to be cost-efficient or effective in prolonging life.
References

American Association of Physicists in Medicine (AAPM). Policy on CT Whole Body Screening (PP 12-C). [AAPM Web site]. 12/03/2014. Available at:
http://www.aapm.org/org/policies/details.asp?id=357&type=PP. Accessed August 24, 2017.

American College of Radiology (ACR). ACR statement on whole body CT screening. [ACR Web site]. Original: 09/27/00. (Revised: 09/28/02). Available at:http://www.acr.org/About-Us/Media-Center/Position-Statements/Position-Statements-Folder/ACR-Statement-on-Whole-Body-CT-Screening. Accessed August 24, 2017.

Brenner DJ, Elliston CD. Estimated radiation risks potentially associated with full-body CT screening. Radiology. 2004; 232(3):735-738.

Buls N, de Mey J, Covens P, Stadnik T. Health screening with CT: prospective assessment of radiation dose and associated detriment. JBR-BTR. 2005; 88(1):12-16.

Canadian Health Services Research Foundation. Myth: whole-body screening is an effective way to detect hidden cancers. J Health Serv Res Policy. 2010; 15(2):118-9.

Dixon GD. Computed tomography for screening purposes: a review of the literature--2003. Mo Med. 2003; 100(2):140-144.

Martino, S. Computed Tomography in the 21st Century: Changing practice for Medical Imaging and Radiation Therapy Professionals. 2008. Available at: https://www.asrt.org/docs/default-source/publications/asrt_ct_consensus.pdf. Accessed September 27, 2017.

National Cancer Institute. Computed Tomography (CT) Scans and Cancer. 07/16/2013. Available at: http://www.cancer.gov/cancertopics/factsheet/detection/CT. Accessed August 24, 2017.

Obuchowski N, Modic MT. Total body screening: predicting actionable findings. Acad Radiol. 2006; 13(4):480-485.

Position Statement of the Health Physics Society. Whole-Body Computerized Tomographyscreening Should Not Be Performed. Original February 2003. (Reaffirmed July 2007) Available at: http://hps.org/documents/CTPosStm.pdf. Accessed August 24, 2017.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Whole body scanning using computed tomography (CT). Full-body CT scans: What you need to know [online brochure]. [FDA Web site]. Updated 03/23/2015. Available at: http://www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/ucm115340.htm. Accessed August 24, 2017.

US Preventive Services Task Force (USPSTF). Screening for coronary heart disease. Recommendation statement. Screening for Coronary Heart Disease. October 2009. Available at: http://www.uspreventiveservicestaskforce.org/3rduspstf/chd/chdrs.htm. Accessed August 24, 2017.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

THE FOLLOWING CODE REPRESENTS FULL-BODY COMPUTERIZED TOMOGRAPHY (CT) SCAN FOR SCREENING IN ASYMPTOMATIC INDIVIDUALS:

76497



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

This service is experimental/investigational for all diagnoses.


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

MA09.012a
05/08/2019This policy has been reissued in accordance with the Company's annual review process.
10/10/2018This policy has been reissued in accordance with the Company's annual review process.
10/24/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on Full-Body Computerized Tomography (CT) Scan Screening.
04/27/2016This policy will become effective 03/25/2015.

The policy has been reviewed and reissued to communicate the Company’s continuing position on Full-Body Computerized Tomography (CT) Scan Screening.
03/25/2015Revised policy number MA09.012a was issued. The policy has been reviewed and reissued to communicate the Company’s continuing position on Full-Body Computerized Tomography (CT) Scan Screening.


MA09.012
01/01/2015This is a new policy.






Version Effective Date: 03/25/2015
Version Issued Date: 03/25/2015
Version Reissued Date: 05/09/2019