LCD L33459

Coverage Guidance

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)

Indications and Limitations of Coverage

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

N/A

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.

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 6/2/26.

ACR Committee. ACR-SPR Practice Parameter for Performing and Interpreting Diagnostic Computed Tomography (CT) ACR. Revised 2022. Accessed 6/2/26.