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«PacifiCare’s medical management guidelines represent the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. They are ...»

-- [ Page 65 ] --

- proven parenchymal hemorrhage or hematoma (rating of 8 for CTA, head; MR preferred) (ACR, Cerebrovascular Disease, 2006) American Heart Association (AHA): In the AHA guideline for the management of spontaneous intracerebral hemorrhage there is no specific recommendation rating for CTA, but the text indicates that "CT angiography may provide additional detail in patients with suspected aneurysm or arteriovenous malformation." (Broderick et al., 2007) In the AHA guideline for the early management of adults with ischemic stroke, there is no specific recommendation rating for CTA, but the text indicates that helical CT angiography provides a means to rapidly and noninvasively evaluate the vasculature, both intracranially and extracranially, to provide potentially important information about the presence of vessel occlusions or stenoses. Preliminary data suggest a high diagnostic accuracy of CT angiography for evaluation of large-vessel intracranial occlusions as compared with ultrasound and digital subtraction angiography. The role of CT angiography in making acute treatment decisions has not yet been established. (Adams et al., 2007) In 2000, the Stroke Council of the American Heart Association published guidelines for the management of patients with unruptured ICAs. The guidelines consider 2 patient groups, those without prior history of SAH and those with previous SAH. Investigation using CT, CTA, MRA, and DSA is discussed. The guidelines state that CT alone is inadequate since small ICAs could be missed, depending on slice thickness. CTA is suggested for several patient groups, including patients with unruptured ICAs who are receiving conservative follow-up; patients with partially clipped ICAs; patients who have undergone endovascular treatment; and as a screening tool in high-risk patients. This guideline also indicates that only grade C recommendations can be made regarding screening for ICAs and that the cost-effectiveness of this type of screening has not been evaluated in randomized controlled trials. This recommendation concluded that screening for asymptomatic ICAs in the general population is not indicated. The Stroke Council experts discussed specific issues to be addressed in screening patients with familial ICA syndrome (2 relatives, third-degree or closer, with radiologically proven ICAs) where studies have shown increased incidence of ICAs. They point out that cost-effectiveness has not been evaluated in clinical studies, recommendations regarding screening in this group are controversial, and screening should be considered on an individual basis. (Bederson et al., 2000) European Commission: The European Commission published referral guidelines for diagnostic imaging in 2000. These guidelines were the product of collaboration between experts representing European radiology and nuclear medicine, and the UK Royal College of Radiologists. For investigation of stroke, CT is the recommended investigation; CTA is not specifically mentioned. For investigation of TIAs, CTA is listed as an imaging technique, though the comment is made Computed Tomography (CT) Angiography of the Head - Commercial Medical Management Guideline that this technology (as well as angiography and MRA) is a more expensive alternative to ultrasound as a method of evaluating the carotid arteries. (European Commission, 2000) References and Resources Resources Adams HP Jr, del Zoppo G, Alberts MJ, et al.; American Heart Association; American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists.

Stroke. 2007 May;38(5):1655-711. Epub 2007 Apr 12. Erratum in: Stroke. 2007 Jun;38(6):e38.

American College of Radiology (ACR). ACR Appropriateness Criteria. Cerebrovascular Disease. Last Review date:

2006. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ Bash S, Villablanca JP, Jahan R, et al., Intracranial vascular stenosis and occlusive disease: evaluation with CT angiography, MR angiography, and digital subtraction angiography. AJNR Am J Neuroradiol. 2005 May;26(5):1012-21.

Bederson JB, Awad IA, Wiebers DO. et al. Recommendations for the management of patients with unruptured intracranial aneurysms: A Statement for healthcare professionals from the Stroke Council of the American Heart Association. Stroke. 2000 Nov;31(11):2742-50.

Brandt T, Knauth M, Wildermuth S, et al. CT angiography and Doppler sonography for emergency assessment in acute basilar artery ischemia. Stroke. 1999;30(3):606-612.

Broderick J, Connolly S, Feldmann E, et al., American Heart Association; American Stroke Association Stroke Council;

High Blood Pressure Research Council; Quality of Care and Outcomes in Research Interdisciplinary Working Group.

Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke. 2007 Jun;38(6):2001-23.





CareCore National. Criteria for Medical Imaging. 2007.

Chappell ET, Moure FC, Good MC. Comparison of computed tomographic angiography with digital subtraction angiography in the diagnosis of cerebral aneurysms: a meta-analysis. Neurosurgery. 2003;52(3):624-631.

Chen CJ, Lee TH, Hsu HL, Tseng YC, Lin SK, Wang LJ, Wong YC. Multi-Slice CT angiography in diagnosing total versus near occlusions of the internal carotid artery: comparison with catheter angiography. Stroke. 2004 Jan;35(1):83-5.

Dehdashti AR, Binaghi S, Uske A, Regli L. Comparison of multislice computerized tomography angiography and digital subtraction angiography in the postoperative evaluation of patients with clipped aneurysms. J Neurosurg. 2006 Mar;104(3):395-403.

European Commission Referral Guidelines for Imaging. Radiation Protection 118. Luxembourg: Office for Official

Publications of the European Communities. 2000. Available at:

http://ec.europa.eu/energy/nuclear/radioprotection/publication/doc/118_en.pdf. Accessed August 2007.

Computed Tomography (CT) Angiography of the Head - Commercial Medical Management Guideline Hayes, Inc. Hayes Directory. Computed Tomography Angiography for Acute Ischemic Stroke. February 2005. Updated January 2007.

Hayes, Inc. Hayes Directory. Computed Tomography Angiography for Intracerebral Aneurysm and Subarachnoid Hemorrhage. February 2005. Updated January 2007.

Hoh BL, Cheung AC, Rabinov JD, et al. Results of a prospective protocol of computed tomographic angiography in place of catheter angiography as the only diagnostic and pretreatment planning study for cerebral aneurysms by a combined neurovascular team. Neurosurgery. 2004;54(6):1329-1342.

Kadri S, Brunel H, Bourbotte G, Delort P, Lust S, Bonafe A. [Can multislice helical computed tomography replace conventional angiography in the diagnosis of non traumatic subarachnoid hemorrhage?] J Neuroradiol. 2006 Feb;33(1):45-50.

Knauth M, von Kummer R, Jansen O, et al. Potential of CT angiography in acute ischemic stroke. AJNR Am J Neuroradiol. 1997;18(6):1001-1010.

Krishnan A, Mattox DE, Fountain AJ, Hudgins PA. CT arteriography and venography in pulsatile tinnitus: preliminary results. AJNR Am J Neuroradiol. 2006 Sep;27(8):1635-8.

Schramm P, Schellinger PD, Fiebach JB, et al. Comparison of CT and CT angiography source images with diffusionweighted imaging in patients with acute stroke within 6 hours after onset. Stroke. 2002;33(10):2426-2432.

Schramm P, Schellinger PD, Klotz E, et al. Comparison of perfusion computed tomography and computed tomography angiography source images with perfusion-weighted imaging and diffusion-weighted imaging in patients with acute stroke of less than 6 hours' duration. Stroke. 2004;35(7):1652-1658.

Shrier DA, Tanaka H, Numaguchi Y, et al. CT angiography in the evaluation of acute stroke. AJNR Am J Neuroradiol.

1997;18(6):1011-1020.

Solenski NJ. Transient ischemic attacks: Part I. Diagnosis and evaluation. Am Fam Physician. 2004;69(7):1666-1674.

Suwanwela NC, Phanthumchinda K, Suwanwela N. Transcranial doppler sonography and CT angiography in patients with atherothrombotic middle cerebral artery stroke. Am J Neuroradiol. 2002;23(8):1352-1355.

Tanaka H, Numaguchi Y, Konno S, Shrier DA, Shibata DK, Patel U. Initial experience with helical CT and 3D reconstruction in therapeutic planning of cerebral AVMs: comparison with 3D time-of-flight MRA and digital subtraction angiography. J Comput Assist Tomogr. 1997 Sep-Oct;21(5):811-7.

Teksam M, McKinney A, Casey S, et al. Multi-section CT angiography for detection of cerebral aneurysms. AJNR Am J Neuroradiol. 2004;25(9):1485-1492.

Tipper G, U-King-Im JM, Price SJ, Trivedi RA, Cross JJ, Higgins NJ, Farmer R, Wat J, Kirollos R, Kirkpatrick PJ, Antoun NM, Gillard JH. Detection and evaluation of intracranial aneurysms with 16-row multislice CT angiography.

Clin Radiol. 2005 May;60(5):565-72.

van der Schaaf IC, Velthuis BK, Wermer MJ, Frenkel NJ, Majoie CB, Witkamp TD, de Kort G, Freling NJ, Rinkel GJ;

ASTRA Study Group. Multislice computed tomography angiography screening for new aneurysms in patients with Computed Tomography (CT) Angiography of the Head - Commercial Medical Management Guideline previously clip-treated intracranial aneurysms: Feasibility, positive predictive value, and interobserver agreement. J Neurosurg. 2006 Nov;105(5):682-8.

Velthuis BK, van Leeuwen MS, Witkamp TD, et al. Surgical anatomy of the cerebral arteries in patients with subarachnoid hemorrhage: comparison of computerized tomography angiography and digital subtraction angiography. J Neurosurg. 2001;95(2):206-212.

Verro P, Tanenbaum LN, Borden NM, et al. CT angiography in acute ischemic stroke: preliminary results. Stroke.

2002;33(1):276-278.

Villablanca JP, Hooshi P, Martin N, et al. Three-dimensional helical computerized tomography angiography in the diagnosis, characterization, and management of middle cerebral artery aneurysms: comparison with conventional angiography and intraoperative findings. J Neurosurg. 2002;97(6):1322-1332.

Wermer MJ, Buskens E, van der Schaaf IC, et al. Yield of screening for new aneurysms after treatment for subarachnoid hemorrhage. Neurology. 2004;62(3):369-375.

White PM, Wardlaw JM, Easton V. Can non-invasive imaging accurately depict intracranial aneurysms? A systematic review. Radiology. 2000;217(2):361-70.

White PM, Wardlaw JM. Unruptured intracranial aneurysms. J Neuroradiol. 2003;30(5):336-50.

Wildermuth S, Knauth M, Brandt T, et al. Role of CT angiography in patient selection for thrombolytic therapy in acute hemispheric stroke. Stroke. 1998;29(5):935-938.

Wintermark M, Uske A, Chalaron M, et al. Multislice computerized tomography angiography in the evaluation of intracranial aneurysms: a comparison with intraarterial digital subtraction angiography. J Neurosurg. 2003;98(4):828Wu J, Chen X, Shi Y, Chen S. Noninvasive three-dimensional computed tomographic angiography in preoperative detection of intracranial arteriovenous malformations. Chin Med J (Engl). 2000 Oct;113(10):915-20.

History/Updates Typographical error corrected in References & Resources section. Contact Information updated.

8/13/2009 Policy revised and renamed and approved by MTAC on October 18, 2007. Policy held for posting due to 3/12/2008 American College of Radiology socialization. Additional unproven indications were added to the Coverage Rationale. CMS information updated. Policy CT Angiography For the Diagnosis and Management of Neurological Disorders (2004T0478A) archived.

Deleted CPT codes 61055 and 62284. Added CPT codes 0042T, 70450, 70460, and 70470.

8/15/2007 Contact Information For questions regarding this policy, send an email to the Medical Technology Interpretation Service at medical_drug_interpretation@uhc.com with the word "Medical" in the subject line.

Computed Tomography (CT) Angiography of the Head - Commercial Medical Management Guideline Coding The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this policy are for reference purposes only.

Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.

CPT Codes:

0042T Cerebral perfusion analysis using computed tomography with contrast administration, including postprocessing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time 70450 Computed tomography, head or brain; without contrast material 70460 Computed tomography, head or brain; with contrast material(s) 70470 Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections 70496 Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation.

Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supercede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.

Confidential and Proprietary, © UnitedHealthcare, Inc. 2009 Computed Tomography (CT) Angiography of the Head - Commercial Medical Management Guideline TITLE: Computerized Dynamic Posturography Authorized By: Medical Management Guideline Committee



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