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.

Purpose
Sinus/Maxillofacial Computed tomography (CT) primarily provides information about bony structures but may also be useful in evaluating soft tissue masses. It can help document the extent of facial bone fractures, facial infections, masses and abscesses. The primary role of CT scans is to aid in the diagnosis and management of recurrent and chronic sinusitis, or to define the anatomy of the sinuses prior to surgery.

Policy 
A single authorization for CPT codes 70486, 70487, 70488, or 76380 includes imaging of the entire maxillofacial area, including face and sinuses. Multiple authorizations are not required.

INDICATIONS 
Sinusitis
Rhinosinusitis

• Clinical suspicion of fungal infection (1,2,3)
• Clinical suspicion of complications, such as (3,4):
  • Preseptal, orbital, or intracranial infection (5)
  • Osteomyelitis
  • Cavernous sinus thrombosis
• Acute (< 4 weeks) or subacute (4-12 weeks) sinusitis (presumed infectious)
  • Not responding to medical management including 2 or more courses of antibiotics in the past 3 months
• Recurrent acute rhinosinusitis with 4 or more annual episodes without persistent symptoms in-between
• Chronic recurrent sinusitis (6) (> 12 weeks)
  • Not responding to medical management* and with at least two of the following:
    • Mucopurulent discharge
    • Nasal obstruction and congestion
    • Facial pain, pressure, and fullness
    • Decreased or absent sense of smell
• With nasal polyps especially unilateral polyps, concern for polyps extending outside of the nasal cavity, or other atypical presentations (6)

*NOTE: Medical management for chronic sinusitis includes nasal saline irrigation and/or topical intranasal steroids. In chronic sinusitis, repeat imaging is not necessary unless
clinical signs or symptoms have changed. Biologics such as dupilumab can be used to treat chronic sinusitis with nasal polyposis.

• Allergic Rhinitis – sinus imaging usually not indicated unless there are signs of complicated infection, signs of neoplasm, or persistence of symptoms/chronic rhinosinusitis despite treatment (including antihistamines) and is a possible surgicalcandidate (7)
• If suspected as a cause of poorly controlled asthma (endoscopic sinus surgery improves outcomes) (8)
• To evaluate in the setting of unilateral nasal polyps or obstruction (6)

NOTE: Imaging may be indicated in those predisposed to complications, including diabetes, immune-compromised state, immotile cilia disorders, or a history of facial trauma or surgery.

Pediatric Rhinosinusitis (9)

• Persistent or recurrent sinusitis not responding to treatment (primarily antibiotics, treatment may require a change of antibiotics)
• Suspicion of orbital or central nervous system involvement (e.g., swollen eye, proptosis, altered consciousness, seizures, nerve deficit)
• Clinical suspicion of a fungal infection (more common in immunocompromised children)

Infection
Suspected

• Osteomyelitis (after x-rays and MRI cannot be performed) (10)
• Abscess based on clinical signs and symptoms of infection

Known or Suspected Structural Abnormalities
Deviated Nasal Septum, Polyp, or Other Structural Abnormality Seen on Direct Imaging/Visualization

• Causing significant airway obstruction AND
• Imaging is needed to plan surgery or determine if surgery is appropriate (11,12)

Suspected Sinonasal Mass

• Based on exam, nasal endoscopy, or prior imaging (6,11)

Facial Mass (13,14)

• Present on physical exam and remains non-diagnostic after x-ray or ultrasound is completed, OR
• Known or highly suspected head and neck cancer on examination

Facial Trauma (15,16,17,18)

• Serious facial injury with concern for fracture on exam (e.g., bony step off, ecchymosis, nasal deformity, depression, malocclusion)
• Note: x-rays should be performed for isolated dental/mandibular injury
• Suspected facial bone fracture with indeterminate x-ray
• For further evaluation of a known fracture for treatment or surgical planning

Cranial Nerve Abnormalities
Trigeminal Neuralgia/Neuropathy (1)
*If MRI is contraindicated or cannot be performed (for evaluation of the extracranial nerve course)

• If atypical features (i.e., bilateral, hearing loss, dizziness/vertigo, visual changes, sensory loss, numbness, pain > 2 min, pain outside trigeminal nerve distribution, progression)

Anosmia or Dysosmia (11,19)

• When persistent, of unknown origin and nasal endoscopy has been performed for evaluation of peripheral sinonasal disease and/or bone-related pathology

Other Indications
Refractory Asthma

• These patients benefit from medical treatment and surgery together (8,20) 

CSF Rhinorrhea

• When looking to characterize a bony defect (11)

Note: For intermittent leaks and complex cases, consider CT/MRI/Nuclear Cisternography. There should be a high suspicion or confirmatory CSF fluid laboratory testing (Beta-2 transferrin assay)

Salivary Glands

• Sialadenitis (infection and inflammation of the salivary glands) with indeterminate ultrasound, bilateral symptoms or concern for abscess (21)
• Suspected or known salivary gland stones (22)

Osteonecrosis of Jaw (23)

• Possible etiologies: bisphosphonate treatment, dental procedures, Denosumab, radiation treatment

NOTE: MRI should be reserved for those patients who have soft tissue extension of the disease.

Prior to Bone Marrow Transplant (BMT)

• For initial workup

Procedural Evaluations
Post-operative/Procedural Evaluation

• When imaging, physical, or laboratory findings indicate surgical or procedural complications

Pre-operative/Procedural Evaluation

• Pre-operative evaluation for a planned surgery or procedure

Further Evaluation of Indeterminate Findings
Unless follow up is otherwise specified within the guideline:

• For initial evaluation of an inconclusive finding on a prior imaging report 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)

Cone Beam CT (11,24,25)

• Can be used in the evaluation of rhinosinusitis for the above-mentioned indications and for surgical planning/pre-operative evaluation in non-neoplastic indications.

*Cone beam CT is not approvable in the evaluation of dentomaxillofacial imaging

Genetics and Rare Syndromes
Granulomatosis

• Granulomatosis with polyangiitis (Wegener’s granulomatosis) disease (26)

Combination Studies
Neck/Face CT or MRI and PET

• Neck/Face CT or MRI is indicated in addition to PET for Head and Neck Cancer
  • For surgical or radiation planning
  • 3-4 months after end of treatment in patients with locoregionally advanced disease or with altered anatomy

Sinus CT/Chest CT

• Granulomatosis with polyangiitis (Wegener’s granulomatosis) disease (GPA)

Sinus CT/Chest CT/Abdomen and Pelvis CT/Brain MRI

• Prior to Bone Marrow Transplant

Rationale/Background
Rhinosinusitis
Society consensus recommendation is not to order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis.  Viral infections cause the majority of acute rhinosinusitis and only 0.5 percent to 2 percent progress to bacterial infections. Most acute rhinosinusitis resolves without treatment in two weeks.li.”⁵² 

Uncomplicated acute rhinosinusitis is generally diagnosed clinically and does not require a sinus CT scan or other imaging. Antibiotics are not recommended for patients with uncomplicated acute rhinosinusitis who have mild illness and assurance of follow-up. If a decision is made to treat, amoxicillin with clavulanate should be first-line antibiotic treatment for most acute rhinosinusitis. If improvement is not demonstrated, it is recommended to change antibiotics to either high-dose amoxicillin plus clavulanate, doxycycline, a fluoroquinolone such as moxifloxacin or levofloxacin, or a dual treatment of clindamycin plus a third-generation oral cephalosporin. (3)

COVID-19
Anosmia and dysgeusia have been reported as common early symptoms in patients with COVID-19, occurring in greater than 80 percent of patients. For isolated anosmia, imaging is typically not needed once the diagnosis of COVID has been made, given the high association. As such, COVID testing should be done prior to imaging. (28,29,30)

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  noncompatible defibrillator or pacemaker), metallic fragments in a high-risk location, patient exceeds wight limit/dimensions of MRI machine

References

1. American College of Radiology. ACR Appropriateness Criteria® Cranial Neuropathy. 2022; 2023:
2. Silveira M, Anselmo-Lima W, Faria F, Queiroz D, Nogueira R et al. Impact of early detection of acute invasive fungal rhinosinusitis in immunocompromised patients. BMC Infect Dis. Apr 5, 2019; 19: 310. 10.1186/s12879-019-3938-y.
3. Frerichs N, Brateanu A. Rhinosinusitis and the role of imaging. Cleve Clin J Med. Jul 31, 2020; 87: 485-492. 10.3949/ccjm.87a.19092.
4. Dankbaar J, van Bemmel A, Pameijer F. Imaging findings of the orbital and intracranial complications of acute bacterial rhinosinusitis. Insights Imaging. Oct 2015; 6: 509-18. 10.1007/s13244-015-0424-y.
5. El Mograbi A, Ritter A, Najjar E, Soudry E. Orbital Complications of Rhinosinusitis in the Adult Population: Analysis of Cases Presenting to a Tertiary Medical Center Over a 13-Year Period. Annals of Otology, Rhinology &amp; Laryngology. 2019; 128: 563 - 568. 10.1177/0003489419832624.
6. Rosenfeld R, Piccirillo J, Chandrasekhar S, Brook I, Ashok Kumar K et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. Apr 2015; 152: S1-s39. 10.1177/0194599815572097.
7. Seidman M, Gurgel R, Lin S, Schwartz S, Baroody F et al. Clinical Practice Guideline: Allergic Rhinitis. Otolaryngol Head Neck Surg. 2015/02/01; 152: S1-S43.  10.1177/0194599814561600.
8. Vashishta R, Soler Z, Nguyen S, Schlosser R. A systematic review and meta-analysis of asthma outcomes following endoscopic sinus surgery for chronic rhinosinusitis. Int Forum Allergy Rhinol. Oct 2013; 3: 788-94. 10.1002/alr.21182.
9. American College of Radiology. ACR Appropriateness Criteria® Sinusitis-Child. 2018.
10. Pincus D, Armstrong M, Thaller S. Osteomyelitis of the craniofacial skeleton. Seminars in plastic surgery. 2009; 23: 73-79. 10.1055/s-0029-1214159.
11. American College of Radiology. ACR Appropriateness Criteria® Sinonasal Disease. 2021.
12. Poorey V, Gupta N. Endoscopic and computed tomographic evaluation of influence of nasal septal deviation on lateral wall of nose and its relation to sinus diseases. Indian J Otolaryngol Head Neck Surg. Sep 2014; 66: 330-5. 10.1007/s12070-014-0726-2.
13. Bansal A, Oudsema R, Masseaux J, Rosenberg H. US of Pediatric Superficial Masses of the Head and Neck. RadioGraphics. 2018; 38: 1239 - 1263. 10.1148/rg.2018170165.
14. Razek A, Huang B. Soft Tissue Tumors of the Head and Neck: Imaging-based Review of the WHO Classification. RadioGraphics. 2011; 31: 1923 - 1954. 10.1148/rg.317115095.
15. American College of Radiology. ACR Appropriateness Criteria® Head Trauma. 2020.
16. American College of Radiology. ACR Appropriateness Criteria® Major Blunt Trauma. 2019
17. Oh J, Kim S, Whang K. Traumatic Cerebrospinal Fluid Leak: Diagnosis and Management. Korean J Neurotrauma. Oct 2017; 13: 63-67. 10.13004/kjnt.2017.13.2.63.
18. Reddy B, Naik D, Kenkere D. Role of Multidetector Computed Tomography in the Evaluation of Maxillofacial. Cureus. 2023; 15: e35008.
19. Lie G, Wilson A, Campion T, Adams A. What’s that smell? A pictorial review of the olfactory pathways and imaging assessment of the myriad pathologies that can affect them. Insights Imaging. 2021; 12: 7. 10.1186/s13244-020-00951-x.
20. Sahay S, Gera K, Bhargava S, Shah A. Occurrence and impact of sinusitis in patients with asthma and/or allergic rhinitis. J Asthma. Aug 2016; 53: 635-43. 10.3109/02770903.2015.1091005.
21. Abdel Razek A, Mukherji S. Imaging of sialadenitis. Neuroradiol J. Jun 2017; 30: 205-215. 10.1177/1971400916682752.
22. Kalia V, Kalra G, Kaur S, Kapoor R. CT Scan as an Essential Tool in Diagnosis of Nonradiopaque Sialoliths. J Maxillofac Oral Surg. Mar 2015; 14: 240-4. 10.1007/s12663-012-0461-8.
23. Wongratwanich P, Shimabukuro K, Konishi M, Nagasaki T, Ohtsuka M et al. Do various imaging modalities provide potential early detection and diagnosis of medication-related osteonecrosis of the jaw? A review. Dentomaxillofac Radiol. 2021; 50: true. 10.1259/dmfr.20200417.
24. Bozdemir E, Gormez O, Yıldırım D, Aydogmus Erik A. Paranasal sinus pathoses on cone beam computed tomography. J Istanb Univ Fac Dent. 2016; 50: 27-34. 10.17096/jiufd.47796.
25. Han M, Kim H, Choi J, Park D, Han J. Diagnostic usefulness of cone-beam computed tomography versus multi-detector computed tomography for sinonasal structure evaluation. Laryngoscope Investig Otolaryngol. Jun 2022; 7: 662-670. 10.1002/lio2.792.
26. Pakalniskis M G, Berg A D, Policeni B A, Gentry L R, Sato Y et al. The Many Faces of Granulomatosis With Polyangiitis: A Review of the Head and Neck Imaging Manifestations. AJR Am J Roentgenol. 2015; 205: W619-29. 10.2214/ajr.14.13864.
27. Washington State Health Care Authority. WSHCA Health Technology Clinical Committee: 20150515A – Imaging for Rhinosinusitis. [Final Adoption: July 10, 2015]. https://www.hca.wa.gov/assets/program/rhino_final_findings_decision_071015[1].pdf.
28. Geyer M, Nilssen E. Evidence-based management of a patient with anosmia. Clin Otolaryngol. Oct 2008; 33: 466-9. 10.1111/j.1749-4486.2008.01819.x.
29. Lechien J, Chiesa-Estomba C, De Siati D, Horoi M, Le Bon S et al. Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study. Eur Arch Otorhinolaryngol. Aug 2020; 277: 2251-2261. 10.1007/s00405-020-05965-1.
30. Saniasiaya J, Islam M, Abdullah B. Prevalence of Olfactory Dysfunction in Coronavirus Disease 2019 (COVID-19): A Meta-analysis of 27,492 Patients. Laryngoscope. Apr 2021; 131: 865-878. 10.1002/lary.29286.

Coding Section 

Code	Number	Description
CPT	70486	Computed tomography, maxillofacial area; without contrast material
	70487	Computed tomography, maxillofacial area; with contrast material(s)
	70488	Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections
	76380	Computed tomography, limited or localized follow-up study
	0722T	Quantitative computed tomography (CT) tissue characterization.

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, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated 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 2024 Forward     

12/02/2024	Annual review, updating policy for clarity and consistency, adding contraindications and preferred studies adding verbiage regarding bone marrow transplant, clarifying anosmia indication. Also updating description, rationale and references.
01/01/2024	New Policy