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 Ischemia^1,2

• • 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 emboli^6,7

Clinical Suspicion of Vascular Disease
With abnormal or indeterminate ultrasound^6,7 for suspicion of:

• Tumor invasion^8,9
• Trauma¹⁰
• Vasculitis^1,11
• 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)

• 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

• Vascular EDS (vEDS) surveillance imaging: with inconclusive ultrasound or ultrasound suggestive of vascular pathology^17,18
• 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

16. 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.
17. Byers P. Vascular Ehlers-Danlos Syndrome. GeneReviews [Internet]. 2019;
18. 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.
19. Morris C. Williams Syndrome. GeneReviews [Internet]. 2023;

Coding Section 

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" 

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