|
Medical Policy: 06.01.16
Original Effective Date: November 1996
Reviewed: April 2012
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Thermography studies are non-invasive imaging techniques that are intended to measure the skin surface temperature distribution of various organs and tissues. The infrared radiation from the tissues reveals temperature variations by producing brightly colored patterns on a liquid crystal display. Interpretation of the color pattern is thought to contribute to the diagnosis of many disorders including breast cancer, Raynaud's phenomenon, digital artery vasospasm, impaired spermatogenesis in infertile men, deep vein thrombosis, reflex sympathetic dystrophy, vertebral subluxation, and others.
In contrast to the skin surface thermography techniques used by some chiropractors and other providers, a newer invasive test called a temperature gradient study involves an intravenous catheter. The catheter is threaded into the coronary arteries to directly measure temperature differences on the inner artery walls. Researchers believe this information may be related to the presence of unstable coronary artery plaques and could be useful in diagnosing vulnerable patients.
The American Medical Association, the American College of Radiology, and the American College of Neurology have issued policy statements that specifically do not endorse or recommend thermography and temperature gradient studies as diagnostic techniques.
 Top
Prior Approval:
Not applicable
Top
Policy:
Thermography and temperature gradient studies are considered investigational for all applications because their efficacy in the clinical setting has not been established.
Rationale:
The American Medical Association, the American College of Radiology, American College of Neurology, the American College of Obstetricians and Gynecologists, and the National Headache Foundation have issued policy statements and other documents that neither recommend nor endorse thermography as a diagnostic tool.
In 1998, the Council on Chiropractic Practice issued a document that stated that thermography was an established method to detect temperature changes in spinal and paraspinal tissues related to vertebral subluxation. However, this recommendation is based on expert opinion and literature support of observational, pre-post, and/or case studies but not controlled studies. In addition, the American Chiropractic Association policy on infrared imaging for the above-listed evaluations is based on consensus guidelines and has no supporting references or documentation.
The Reflex Sympathetic Dystrophy Syndrome Association (RSD) and the International Research Foundation for RSD and Complex Regional Pain Syndrome (CRPS) issued guidelines for the treatment of RSD and CRPS. Each of these guidelines indicates thermography may be used to assist in the diagnosis of RSD/CRPS. However, neither guideline has supporting evidence for its conclusion.
Top
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 93740 Temperature gradient studies
Top
Selected References:
- Leclaire RM, Esdaile JM, Jequier JC, Rossignol M, Bourdouxhe M. Diagnostic accuracy of technologies used in low back pain assessment. Spine 1996 June; 1;21(11):1325-1330; discussion 1331.
- Lai HS, Duh YC, Tsai WA, Sun WZ. Role of thermography in the diagnosis of undescended testes. European Urology 1998;33(2):209-213.
- Parisky YR, Sardi A, Hamm R, Hughes K, Esserman L, Rust S, Callahan K. Efficacy of computerized infrared imaging analysis to evaluate mammographically suspicious lesions. AJR Am J Roentgenol. 2003 Jan;180(1):263-9.
- Ogan K, Roberts WW, Wilhelm DM, Bonnell L, Leiner D, Lindberg G, Kavoussi LR, Cadeddu JA. Infrared thermography and thermocouple mapping of radiofrequency renal ablation to assess treatment adequacy and ablation margins. Urology. 2003 Jul;62(1):146-51.
- ECRI. Thermography for Detection of Breast Masses. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2007 December 26. 8p/ (ECRI Hotline Response). Also available: http://www.ecri.org.
- Fitzgerald A, Berentson-Shaw J. Thermography as a screening and diagnostic tool: a systematic review. N Z Med J. 2012 Mar 9; 125(1351):80-91.
- Lovett KM, Liang BA Risks of online advertisement of direct-to-consumer thermography for breast cancer screening. Nat Rev Cancer. 2011 Dec; 11(12):827-8.
- Kontos M, Wilson R, Fentiman I. Digital infrared thermal imaging (DITI) of breast lesions: sensitivity and specificity of detection of primary breast cancers. Clin Radiol. 2011 Jun;66(6):536-9. Epub 2011 Mar 5.
- Wishart GC, Campisi M, Boswell M et al. The accuracy of digital infrared imaging for breast cancer detection in women undergoing breast biopsy. Eur J Surg Oncol. 2010 Jun; 36(6):535-40. Epub 2010 May 10.
- ECRI Institute. Thermography for detection of breast masses. Plymouth Meeting (PA): ECRI Institute; 2011 May 16. Available: http://www.ecri.org
Top
Policy History:
Date Reason Action
June 2011 Annual review Policy renewed
April 2012 Annual review Policy renewed
Top
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.
|
 |
