Local Coverage Determination (LCD)

Computerized Axial Tomography (CT), Thorax

L33459

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Palmetto GBA	A and B MAC	10111 - MAC A	J - J	Alabama
Palmetto GBA	A and B MAC	10112 - MAC B	J - J	Alabama
Palmetto GBA	A and B MAC	10211 - MAC A	J - J	Georgia
Palmetto GBA	A and B MAC	10212 - MAC B	J - J	Georgia
Palmetto GBA	A and B MAC	10311 - MAC A	J - J	Tennessee
Palmetto GBA	A and B MAC	10312 - MAC B	J - J	Tennessee
Palmetto GBA	A and B and HHH MAC	11201 - MAC A	J - M	South Carolina
Palmetto GBA	A and B and HHH MAC	11202 - MAC B	J - M	South Carolina
Palmetto GBA	A and B and HHH MAC	11301 - MAC A	J - M	Virginia
Palmetto GBA	A and B and HHH MAC	11302 - MAC B	J - M	Virginia
Palmetto GBA	A and B and HHH MAC	11401 - MAC A	J - M	West Virginia
Palmetto GBA	A and B and HHH MAC	11402 - MAC B	J - M	West Virginia
Palmetto GBA	A and B and HHH MAC	11501 - MAC A	J - M	North Carolina
Palmetto GBA	A and B and HHH MAC	11502 - MAC B	J - M	North Carolina

LCD Information

Document Information

LCD ID
L33459

LCD Title
Computerized Axial Tomography (CT), Thorax

Proposed LCD in Comment Period
N/A

Source Proposed LCD
N/A

Original Effective Date
For services performed on or after 10/01/2015

Revision Effective Date
For services performed on or after 06/13/2024

Revision Ending Date
N/A

Retirement Date
N/A

Notice Period Start Date
N/A

Notice Period End Date
N/A

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(1)(D) items and services related to research and experimentation.

Title XVIII of the Social Security Act, §1862(a)(7) states Medicare will not cover any services or procedures associated with routine physical checkups.

42 CFR §410.32(b)(3)(i), (b)(3)(ii), (b)(3)(iii) Levels of supervision

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, §20.4.1 Diagnostic Services Defined, §20.4.3 Coverage of Outpatient Diagnostic Services Furnished on or Before December 31, 2009, §20.4.4 Coverage of Outpatient Diagnostic Services Furnished on or After January 1, 2010, and §20.4.5 Outpatient Diagnostic Services Under Arrangements

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §220.1 Computed Tomography (CT)

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

The following clinical indications apply to the computerized axial tomography (CT or CAT) of the thorax:

Evaluation of pulmonary, mediastinal, pleural and chest wall infections and their complications
Detection and characterization of mediastinal neoplasms and other processes
Assessment of cardiopulmonary failure or insufficiency
Diagnosis and/or staging of neoplastic and hematologic processes arising in the thorax or with potential involvement of the thorax
Detection and determination of nature and extent of cardiovascular abnormalities such as, but not limited to, aneurysm, dissection, embolism, thrombosis, congenital anomalies, postoperative complications and sequelae of atherosclerotic disease
For assessing and/or guiding drainage of pulmonary or pleural fluid collections such as abscess, empyema, effusion or pneumothorax
For characterizing and follow-up evaluation of interstitial and alveolar lung disease due to idiopathic, allergic, collagen-vascular, environmental or other causes
For evaluating thoracic sequelae of remote processes including, but not limited to, pancreatitis, gastrointestinal perforation and other processes
For assessing injury, potential injury or thoracic sequelae after trauma, burn, surgery, transplantation, radiation therapy, chemotherapy or invasive procedure such as pacemaker placement, chest tube placement or mechanical ventilation
Evaluation of the patient with symptoms that may be arising from the chest, or be referred to the chest including, but not limited to, cough, hemoptysis, chest pain, abdominal pain and others
To further characterize a suspected abnormality detected by another imaging test
Evaluation of a patient with myasthenia gravis to rule out thymic tumors
Performance of CT-guided biopsies and drainage procedures when fluoroscopy is inadequate
The most common symptom of an aortic dissection (occurring in approximately 90% of the cases) is sudden, excruciating pain most commonly located in the anterior chest. Patients may describe the pain as "cutting," "ripping," or "tearing". A sudden neurologic episode usually accompanies the onset of most instances of "painless" aortic dissection.

NOTE: Radiologic examinations of the chest represent the basic diagnostic tests used to identify abnormalities of the thorax. The chest x-ray and/or physical examination should be used to evaluate patients who present with signs and/or symptoms suggestive of chest pathology prior to proceeding to a CT scan.

In addition to the medical necessity requirements, the CT scan must be performed on a model of CT equipment that is recognized by the United States Food and Drug Administration (FDA) and has achieved the full market phase of development.

In keeping with American College of Radiology (ACR) Practice Guidelines and Technical Standards, CT thorax should be provided by qualified radiology personnel (radiology technicians, diagnostic radiologists). The patient’s condition should be monitored throughout the procedure. As this involves the patient being in a closed environment, claustrophobia or medical problems exacerbated by the enclosure may be exhibited.

Qualified physicians (such as board-certified radiologists) should perform the interpretation of the films.

The CT service should be furnished only when clinically appropriate for the patient’s symptoms or complaint. When performed as a screening function, it will not be covered.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes

Changes	Fields Changed
	N/A

Associated Information

Sources of Information

Bibliography

Open Meetings

Contractor Advisory Committee (CAC) Meetings

MAC Meeting Information URLs

Proposed LCD Posting Date

Comment Period Start Date

Comment Period End Date

Reason for Proposed LCD

Requestor Name	Requestor Letter
	View Letter

Requestor Information

Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code	Description
Please accept the License to see the codes.

Revenue Codes

Code	Description
Please accept the License to see the codes.

ICD-10-CM Codes that Support Medical Necessity

ICD-10-CM Codes that DO NOT Support Medical Necessity

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

Documentation must be legible, relevant and sufficient to justify the services billed. This documentation must be made available to the A/B MAC upon request.

Utilization Guidelines

Reasonable and necessary imaging which is felt to be required more frequently than 6 times a calendar year, must have substantial documentation to describe medical necessity.

Sources of Information

N/A

Bibliography

American College of Radiology (ACR) Committee. ACR-SABI-SPR-STR Practice Parameter for the Performance of Thoracic Computed Tomography (CT) ACR. Revised 2023. Accessed 5/8/24.

ACR Committee. ACR-SPR Practice Parameter for Performing and Interpreting Diagnostic Computed Tomography (CT) ACR. Revised 2022. Accessed 5/8/24.

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
06/13/2024	R13	Under *CMS National Coverage Policy* added and updated regulation section headings. Under *Bibliography* changes were made to citations to reflect AMA citation guidelines. Punctuation and typographical errors were corrected throughout the LCD.	Provider Education/Guidance
10/10/2019	R12	This LCD is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Title XVIII of the Social Security Act, §1833(e) was removed from the *CMS National Coverage Policy* section of this LCD and placed in the related Billing and Coding: Computerized Axial Tomography (CT), Thorax A56580 article. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
05/16/2019	R11	All coding located in the *Coding Information* section and all verbiage regarding billing and coding under the *Associated Information* section has been removed and is included in the related Billing and Coding: Computerized Axial Tomography (CT), Thorax A56580 article. Under *Coverage Indications, Limitations and/or Medical Necessity - Note* removed quoted Internet Only Manual (IOM) text and changed verbiage to read “In addition to the medical necessity requirements, the CT scan must be performed on a model of CT equipment that is recognized by the Food and Drug Administration (FDA) and has achieved the full market phase of development.” Under *Bibliography* access dates for references were updated. Acronyms were inserted where appropriate throughout the LCD. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
10/01/2018	R10	Under *ICD-10 Codes That Support Medical Necessity Group 1: Codes* deleted ICD-10 codes C43.11, C43.12, C44.102, C44.109, C44.112, C44.119, C44.122, C44.129, C44.192, C44.199, C4A.11, C4A.12, D03.11, D03.12, D04.11, D04.12, D22.11, D22.12, D23.11, D23.12, and R93.8. Under *ICD-10 Codes That Support Medical Necessity Group 1: Codes* added C43.111, C43.112, C43.121, C43.122, C4A.111, C4A.112, C4A.121, C4A.122, C44.1021, C44.1022, C44.1091, C44.1092, C44.1121, C44.1122, C44.1191, C44.1192, C44.1221, C44.1222, C44.1291, C44.1292, C44.1321, C44.1322, C44.1391, C44.1392, C44.1921, C44.1922, C44.1991, C44.1992, D03.111, D03.112, D03.121, D03.122, D04.111, D04.112, D04.121, D04.122, R93.811, R93.812, R93.813, R93.819, and R93.89. This revision is due to the Annual ICD-10 Code Update and becomes effective October 1, 2018. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes
08/20/2018	R9	Under *Associated Contract Numbers* added 11201, 11301, 11401, 11501, 10111, 10211, and 10311 as this LCD is being made an A/B MAC LCD. The Part A *Computerized Axial Tomography of the Chest/Thorax L34416* LCD is being retired on 8/19/18 due to being incorporated into the *Computerized Axial Tomography (CT), Thorax* *L33459* LCD. Under *ICD-10 Codes That Support Medical Necessity* added multiple ICD-10 codes due to consolidation of the LCD between lines of business. Under Coverage Indications, Limitations, and/or Medical Necessity the following verbiage was added: Evaluation of a patient with myasthenia gravis to rule out thymic tumors Performance of CT-guided biopsies and drainage procedures when fluoroscopy is inadequate The most common symptom of an aortic dissection (occurring in approximately 90% of the cases) is sudden, excruciating pain most commonly located in the anterior chest. Patients may describe the pain as "cutting," "ripping," or "tearing". A sudden neurologic episode usually accompanies the onset of most instances of "painless" aortic dissection. NOTE: Radiologic examinations of the chest represent the basic diagnostic tests used to identify abnormalities of the thorax. The chest x-ray and/or physical examination should be used to evaluate patients who present with signs and/or symptoms suggestive of chest pathology prior to proceeding to a CT scan. In addition to the medical necessity requirements, the CT scan must be performed on a model of CT equipment that meets the following criteria: The model must be known to the Food and Drug Administration; and Must be in the full market release phase of development	Provider Education/Guidance Creation of Uniform LCDs Within a MAC Jurisdiction
03/15/2018	R8	Under *CMS National Coverage Policy* added “Medicare” to the cited NCD manual reference and clarified the sections cited for CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 6, §§20.4.1 and 20.4.3-20.4.5. Under *CPT/HCPCS Codes- Group 1: Paragraph* deleted the verbiage. Under *Bibliography* corrected the title, url , amended date and accessed date for the first cited practice parameter and corrected the url, amended date and accessed date for the second cited practice parameter. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance Other
02/26/2018	R7	The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.	Change in Affiliated Contract Numbers
10/01/2017	R6	Under *ICD-10 Codes That Support Medical Necessity* deleted ICD-10 codes C96.2, D47.0 and N63 and added C96.20, C96.21, C96.22, C96.29, D47.02, D47.09, E85.81, E85.82, E85.89, I27.20, I27.21, I27.22, I27.23, I27.24, I27.29, I27.83, I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84, I50.89, N63.11, N63.12, N63.13, N63.14, N63.21, N63.22, N63.23, N63.24, N63.31, N63.32, N63.41, N63.42 and R06.03. The code description was revised for I50.1, J15.6, M33.01 and M33.11. This revision is due to the 2017 Annual ICD-10 Updates. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes
03/16/2017	R5	Under *CMS National Coverage Policy* revised the verbiage in Title XVIII of the Social Security Act, §1862(a)(1)(A) to read “ allows coverage and payment for only those services that are considered reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member”, revised the verbiage in Title XVIII of the Social Security Act, §1862(a)(1)(D) to read “items and services related to research and experimentation”, revised the verbiage in Title XVIII of the Social Security Act, §1862(a)(7) to read “states Medicare will not cover any services or procedures associated with routine physical checkups”, revised the verbiage for Title XVIII of the Social Security Act, §1833(e) to read “prohibits Medicare payment for any claim that lacks the necessary information to process that claim” and revised the verbiage in 42 CFR §410.32 (b)(3)(i), (b)(3)(ii), (b)(3)(iii) to read “Levels of Physician Supervision”.	Provider Education/Guidance
10/01/2016	R4	Under *ICD-10 Codes That Support Medical Necessity: Group 1* added D49.511, D49.512, D49.519, D49.59, I72.5, I72.6, J95.860, J95.861, J95.862, J95.863, J98.51, J98.59, K85.00, K85.01, K85.02, K85.10, K85.11, K85.12, K85.20, K85.21, K85.22, K85.30, K85.31, K85.32, K85.80, K85.81, K85.82, K85.90, K85.91, K85.92, K86.81, K86.89, N61.0, N61.1, Q25.21, Q25.29, Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, Q25.49, R93.41, R93.421, R93.422, R93.429, and R93.49 . Under *ICD-10 Codes That Support Medical Necessity: Group 1* deleted J98.5, K85.0, K85.1, K85.2, K85.3, K85.8, K85.9, K86.8, N61, and Q25.4. Under *ICD-10 Codes That Support Medical Necessity: Group 1* updated code description for C7A.094, C7A.095, C7A.096, C81.10, C81.11, C81.12, C81.13, C81.14, C81.15, C81.16, C81.17, C81.18, C81.19, C81.20, C81.21, C81.22, C81.23, C81.24, C81.25, C81.26, C81.27, C81.28, C81.29, C81.30, C81.31, C81.32, C81.33, C81.34, C81.35, C81.36, C81.37, C81.38, C81.39, C81.40, C81.41, C81.42, C81.43, C81.44, C81.45, C81.46, C81.47, C81.48, C81.49, C81.70, C81.71, C81.72, C81.73, C81.74, C81.75, C81.76, C81.77, C81.78, and C81.79. This revision is due to the Annual ICD-10 Code Update.	Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes
02/04/2016	R3	Under ICD-10 Codes that Support Medical Necessity Group 1: Paragraph removed “The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary and Note: Providers should continue to submit ICD-10-CM diagnosis codes without decimals on their claim forms and electronic claims” as this is not reasonable and necessary information. Under Associated Information in the Utilization Guidelines section, reworded the second paragraph to read “reasonable and necessary imaging which is felt to be required more frequently than six times a calendar year must have substantial documentation to describe medical necessity.”	Provider Education/Guidance Public Education/Guidance Typographical Error Other (Annual Validation)
10/01/2015	R2	Removed S25109A and added S25191A to ICD-10 Codes that Support Medical Necessity section.	Revisions Due To ICD-10-CM Code Changes
10/01/2015	R1	Under *CMS National Coverage Policy* capitalized (d) in reference to Title XVIII of the Social Security Act, §1862 (a)(1)(d). Corrected spelling of “excludes” in reference to Title XVIII of the Social Security Act, §1862 (a)(7). Under *Sources of Information and Basis for Decision* corrected titles of ACR references. Removed revised dates and added correct amended dates. Removed accessed date and added hyperlink for both references.	Provider Education/Guidance Other (Maintenance Annual Review)

Associated Documents

Attachments
N/A

Related Local Coverage Documents
Articles
A56580 - Billing and Coding: Computerized Axial Tomography (CT), Thorax

Updated On	Effective Dates	Status
06/07/2024	06/13/2024 - N/A	Currently in Effect	You are here
10/04/2019	10/10/2019 - 06/12/2024	Superseded	View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

CT of Thorax
Computerized Axial Tomography, Thorax

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Computerized Axial Tomography (CT), Thorax

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