CT Angiography, Upper Extremity - CAM 726

GENERAL INFORMATION

It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted. 

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Policy 
When a separate CTA and CT exam is requested, documentation requires a medical reason that clearly indicates why additional CT imaging of the upper extremity is needed.

INDICATIONS
Hand Ischemia1,2

  • Acute symptoms (including):
    • Ischemic ulceration without segmental temperature change
    • Ischemic ulceration with painful ischemia
    • Acute sustained loss of perfusion with or without acral ulceration
    • Imminent loss of digit

NOTE: Does not require prior arterial Doppler

  • For clinical symptoms, following abnormal arterial Doppler, when CTA results will change management
    • Includes Raynaud’s (can be associated with scleroderma), Buerger disease, and

other vasculopathies3

  • Clinical concern for vascular cause of ulcers with abnormal or indeterminate ultrasound4
  • After stenting or surgery with signs of recurrence or indeterminate ultrasound5

Deep Venous Thrombosis or Embolism

  • After abnormal ultrasound of arm veins if it will change management
  • After negative or indeterminate ultrasound to rule out other causes
  • For evaluation of central veins
  • Clinical suspicion of upper arterial emboli6,7

Clinical Suspicion of Vascular Disease
With abnormal or indeterminate ultrasound6,7 for suspicion of:

  • Tumor invasion8,9
  • Trauma10
  • Vasculitis1,11
  • Aneurysm11
  • Stenosis/occlusions12

Hemodialysis Graft Dysfunction
If Doppler ultrasound was not adequate for treatment decisions13

Vascular Malformation
NOTE: (MRA preferred however CTA useful in delineating some high flow lesions such as an arteriovenous malformation)

  • After initial evaluation with ultrasound
  • Preoperative planning

A concurrent CT is also approvable for initial evaluation and/or preoperative planning if MRI is contraindicated or cannot be performed, or per surgeon preference.

Traumatic Injuries
Clinical findings suggestive of arterial injury10

Evaluation of Tumor
When needed for clarification of vascular invasion from tumor after prior imaging (may be approved in combination with CT or MRI of tumor)

Pre-Operative/Procedural Evaluations
Pre-operative evaluation for a planned surgery or procedure14

Post-Operative/Procedural Evaluations
A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery.15,16 Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Further Evaluation of Indeterminate Findings on Prior Imaging
Unless follow-up is otherwise specified within the guideline

  • For initial evaluation of an inconclusive finding on a prior imaging report (i.e., X-ray, ultrasound or CT) that requires further clarification.
  • One follow-up exam of a prior indeterminate MR/CT finding to ensure no suspicious interval change has occurred. (No further surveillance unless specified as highly suspicious or change was found on last follow-up exam.)

Genetic Syndromes and Rare Diseases

  • Known vascular EDS (vEDS) with acute extremity pain and concern for dissection/rupture17,18
  • Vascular EDS (vEDS) surveillance imaging: with inconclusive ultrasound or ultrasound suggestive of vascular pathology17,18
  • Known Williams Syndrome: when there is concern for vascular disease based on abnormal exam or imaging findings (such as diminished pulses, bruits or signs of diffuse thoracic aortic stenosis)19
  • For other syndromes and rare diseases not otherwise addressed in the guideline, coverage is based on a case-by-case basis using societal guidance

Rationale
BACKGROUND
Contraindications and Preferred Studies

  • Contraindications and reasons why a CT/CTA cannot be performed may include: impaired renal function, significant allergy to IV contrast, pregnancy (depending on trimester).
  • Contraindications and reasons why an MRI/MRA cannot be performed may include: impaired renal function, claustrophobia, non-MRI compatible devices (such as non- compatible defibrillator or pacemaker), metallic fragments in a high-risk location, patient exceeds weight limit/dimensions of MRI machine.

References

  1. Hotchkiss R, Marks T. Management of acute and chronic vascular conditions of the hand. Curr Rev Musculoskelet Med. Mar 2014; 7: 47-52. 10.1007/s12178-014-9202-6.
  2. Wong V, Major M, Higgins J. Nonoperative Management of Acute Upper Limb Ischemia. Hand (N Y). Jun 2016; 11: 131-43. 10.1177/1558944716628499.
  3. McMahan Z H, Wigley F M. Raynauds phenomenon and digital ischemia: a practical approach to risk stratification, diagnosis and management. Int J Clin Rheumtol. 2010; 5: 355-370. 10.2217/ijr.10.17.
  4. Rosyid F. Etiology, pathophysiology, diagnosis and management of diabetics’ foot ulcer. Int J Res  Med Sci. 2017; 5: 4206-13. http://dx.doi.org/10.18203/2320-6012.ijrms20174548.
  5. Pollak A, Norton P, Kramer C. Multimodality imaging of lower extremity peripheral arterial disease: current role and future directions. Circ Cardiovasc Imaging. Nov 2012; 5: 797-807. 10.1161/circimaging.111.970814.
  6. Bozlar U, Ogur T, Khaja M, All J, Norton P. CT angiography of the upper extremity arterial system: Part 2- Clinical applications beyond trauma patients. AJR Am J Roentgenol. Oct 2013; 201: 753-63. 10.2214/ajr.13.11208.
  7. Bozlar U, Ogur T, Norton P, Khaja M, All J. CT angiography of the upper extremity arterial system: Part 1-Anatomy, technique, and use in trauma patients. AJR Am J Roentgenol. Oct 2013; 201: 745-52. 10.2214/ajr.13.11207.
  8. Garner H W, Wessell D E, Lenchik L, Ahlawat S, Baker J C et al. ACR Appropriateness Criteria: Soft Tissue Masses: 2022 Update. Journal of the American College of Radiology. 2023; 20: S234 - S245. 10.1016/j.jacr.2023.02.009.
  9. Jin T, Wu G, Li X, Feng X. Evaluation of vascular invasion in patients with musculoskeletal tumors of lower extremities: use of time-resolved 3D MR angiography at 3-T. Acta Radiol. May 2018; 59: 586-592. 10.1177/0284185117729185.
  10. Wani M, Ahangar A, Ganie F, Wani S, Wani N. Vascular injuries: trends in management. Trauma Mon. Summer 2012; 17: 266-9. 10.5812/traumamon.6238.
  11. Seitz L, Seitz P, Pop R, Lötscher F. Spectrum of Large and Medium Vessel Vasculitis in Adults: Primary Vasculitides, Arthritides, Connective Tissue, and Fibroinflammatory Diseases. Current Rheumatology Reports. 2022; 24: 352 - 370. 10.1007/s11926-022-01086-2.
  12. Conte M S, Pomposelli F B, Clair D G, Geraghty P J, McKinsey J F et al. Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication. Journal of Vascular Surgery. 2015; 61: 2S - 41S.e1. 10.1016/j.jvs.2014.12.009.
  13. Murphy E, Ross R, Jones R, Gandy S, Aristokleous N et al. Imaging in Vascular Access. Cardiovasc Eng Technol. Sep 2017; 8: 255-272. 10.1007/s13239-017-0317-y.
  14. Azene E M, Steigner M L, Aghayev A, Ahmad S, Clough R E et al. ACR Appropriateness Criteria: Lower Extremity Arterial Claudication-Imaging Assessment for Revascularization: 2022 Update. Journal of the American College of Radiology. 2022; 19: S364 - S373. 10.1016/j.jacr.2022.09.002.
  15. Conte M S, Bradbury A W, Kolh P, White J V, Dick F et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg. 2019; 69: 3S-125S.e40. 10.1016/j.jvs.2019.02.016.
  1. Cooper K, Majdalany B S, Kalva S P, Chandra A, Collins J D et al. ACR Appropriateness Criteria® Lower Extremity Arterial Revascularization-Post-Therapy Imaging. J Am Coll Radiol. 2018; 15: S104-s115. 10.1016/j.jacr.2018.03.011.
  2. Byers P. Vascular Ehlers-Danlos Syndrome. GeneReviews [Internet]. 2019;
  3. Bowen J, Hernandez M, Johnson D, Green C, Kammin T et al. Diagnosis and management of vascular Ehlers-Danlos syndrome: Experience of the UK national diagnostic service, Sheffield. European Journal of Human Genetics. 2023; 31: 749 - 760. 10.1038/s41431-023-01343-7.
  4. Morris C. Williams Syndrome. GeneReviews [Internet]. 2023;

Coding Section 

Code Number

Description

CPT 73206 Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing

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,  and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2019 Forward     

11/11/2024 Annual review, policy updated for clarity and consistency, adding evaluation of tumor, genetic syndromes, rare diseases and contraindications and preferred studies. Also updating rationale and references.
11/15/2023 Annual review, updating entire policy for clarity. Adding verbiage regarding vascular Malformations and indeterminate prior imaging findings.
11/16/2022 Annual review, changing the GFR range for individual with renal impairment from 30-89 to 30-45. No other changes.

11/01/2021 

Annual review, no change to policy intent. 

11/03/2020

Annual review, no change to policy intent. Updating policy for clarity and updating references 

11/18/2019

New Policy

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