Medical Policy: 02.02.14 

Original Effective Date: June 2012 

Reviewed: January 2018 

Revised: January 2015 


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.



Coronary heart disease (CHD) accounts for 30.8% of all deaths in the United States. Major risk factors for CHD have been identified by the National Cholesterol Education Program (NCEP) Expert Panel. These risk factors include elevated serum levels of low-density lipoprotein  cholesterol (LDL-C), total cholesterol, and reduced levels of high-density lipoprotein cholesterol. Other risk factors include a history of cigarette smoking, hypertension, family history of premature CHD, and age.


Ultrasonographic measurement of the carotid intima-media (or intimal-medial) thickness (CIMT) refers to the use of B-mode ultrasound to determine the thickness of the 2 innermost layers of the carotid artery wall, the intima and the media. Detection and monitoring of intima-medial thickening, which is a surrogate marker for artherosclerosis, may provide an opportunity to intervene earlier in atherogenic disease and/or monitor disease progression.


The carotid arteries can be well-visualized by ultrasonography, and ultrasonographic measurement of the carotid intima-media thickness (CIMT) has been investigated as a technique to identify and monitor subclinical artherosclerosis. B-mode ultrasound is most commonly used to measure CIMT. The intima-media thickness (IMT) is measured and averaged over several sites in each carotid artery. Imaging of the far wall of each common carotid artery yields more accurate and reproducible IMT measurements than imaging of the near wall. Two echogenic lines are produced, representing the lumen- intima interface and the media-adventitia interface. The distance between these two lines constitutes the IMT.


Measurement of carotid intima-media (or intimal-medial) thickness (CIMT) is primarily meant to assess risk for future disease, and therefore can be evaluated as a prognostic measure. Assessment of a prognostic measure typically focuses on 3 categories of evidence: 1) technical performance; 2) prognostic value (i.e. significant association between the test result and health outcomes); and 3) effect on health outcomes (i.e. demonstration that use of the prognostic information clinically can alter clinical management and/or improve net health outcomes compared with patient management without use of the prognostic tool). In some cases, it is important to evaluate whether the test provides incremental information above the standard workup to determine whether the test has utility in clinical practice.


The literature on the use of CIMT for cardiac risk stratification consists of numerous cohort studies and systematic reviews of these cohort studies. The evidence from large, prospective cohort studies has established that CIMT is an independent risk factor for CAD. However, systemic reviews have concluded that the ability of CIMT to reclassify patients into clinically relevant categories is modest and may not be clinically important. The uncertainty concerning the ability to reclassify patients into clinically relevant categories limits the potential for CIMT to improve health outcomes. Also, there is no direct evidence on the clinical utility of measuring CIMT for cardiac risk stratification. The available evidence on reclassification into clinically relevant categories does not indicate that use of CIMT will improve health outcomes.



For individuals who are undergoing cardiac risk assessment who receive ultrasonic measurement of carotid intima-media (or intimal-medial) thickness, the evidence includes large cohort studies and systematic reviews. Some studies correlate increased CIMT with many other commonly used markers for risk of coronary heart disease (CHD) and with risk for future cardiovascular events. A 2012 meta-analysis of individual participant data by Lorenz et. al. found that CIMT was associated with increased cardiovascular events although CIMT progression over time was not associated with increased cardiovascular event risk. In a systematic review by Peters et. al. (2012), the added predictive value of CIMT was modest, and the ability to reclassify patients into clinically relevant categories was not demonstrated. The results from these reviews and other studies have demonstrated the predictived value of CIMT is uncertain, and the predictive ability for any level of population risk cannot be determined with precision. In addition, available studies do not define how use of CIMT in clinical practice improves outcomes. There is no scientific literature that directly tests the hypothesis that measurement of CIMT results in improved patient outcomes and no specific guidance on how measurements of CIMT should be incorporated into risk assessment and risk management. The evidence is insufficient to determine the effects of the technology on net health outcomes.


Practice Guidelines and Position Statements


U.S. Preventative Services Task Force (USPSTF)

In October 2009, the U.S. Preventative Services Task Force (USPSTF) published a systemic review of CIMT within the scope of a larger recommendation statement entitled “Coronary Heart Disease: Screening Using Non-Traditional Risk Factors”. Coronary heart disease is the most common cause of mortality in adults in the United States. Treatment to prevent CHD events by modifying risk factors is currently based on the Framingham risk model, which sorts individuals into low, intermediate or high risk groups. If the risk model could be improved, treatment might be better targeted, thereby maximizing screening benefits and minimizing harms. The most likely opportunity to improve the model is use of additional risk factors to reclassify those in the intermediate risk group to either high or low risk.


Summary of Recommendation

The U.S. Preventative Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of using the nontraditional risk factors discussed in this statement to screen asymptomatic men and women with no history of CAD to prevent CHD events.


The nontraditional risk factors include in this recommendation are high sensitivity C reactive protein (hs-CRP), ankle brachial index (ABI), leukocyte count, fasting blood glucose level, periodontal disease, carotid intima-media thickness (carotid IMT), coronary artery calcification (CAC) score on electron beam computed tomography (EBCT), homocystein level and lipoprotein(a) level.


American College of Cardiology Foundation (ACCF)/American Heart Association (AHA)

In 2010, the American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) issued a practice guideline for the assessment of cardiovascular risk in asymptomatic adults which indicates, the measurement of carotid artery intima-media thickness is reasonable for assessment of cardiovascular risk assessment in asymptomatic adults at intermediate risk. The guidelines note an increased CIMT reading may be used as a guide in determining clinical utility, but evidence has not demonstrated improvements in outcomes when incorporating CIMT measurement into treatment decision making. Additionally, the guidelines state “clinical tools integrating carotid IMT within global risk scoring system are not available. The incremental value of carotid IMT and cost effectiveness beyond that available from standard risk assessments to improve overall patient outcomes is not established.”


American College of Cardiology (ACC) /American Heart Association (AHA)

In 2013, the American College of Cardiology (ACC)/American Heart Association (AHA) issued a guideline on the assessment of cardiovascular risk which indicates, CIMT is not recommended for routine measurement in clinical practice for risk assessment for first atherosclerotic cardiovascular disease (ASCVD) event. (Grade N (No Recommendation For or Against); Level of Evidence B (Limited populations evaluated; data derived from a single randomized trial or nonrandomized studies); ACC/AHA Class III (No benefit – procedure/test not helpful).


Regulatory Status

In February 2003, SonoCalc® (SonoSite) was cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. The FDA determined that this software was substantially equivalent to existing image display products for use in the automatic measurement of the IMT of the carotid artery from images obtained from ultrasound systems. Subsequently, several other devices have been approved through the 510(k) process.


Prior Approval:

Not applicable



Ultrasonographic measurement of carotid intima-media thickness (CIMT) as a technique of identifying subclinical atherosclerosis is considered investigational for use in the screening, diagnosis, or management of atherosclerotic disease.


Based on peer reviewed medical literature the available studies do not define how the use of CIMT in clinical practice improves outcomes.  Also, there is no scientific literature that directly tests the hypothesis that measurement of CIMT results in improved patient outcomes and no specific guidance on how measurements of CIMT should be incorporated into risk assessment and risk management. The existing evidence is insufficient to determine the impact of this technology on net health outcomes. Therefore, carotid intima-media thickness (CIMT) is considered investigational for the use in the screening, diagnosis or management of atherosclerotic disease.


Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.

  • 0126T Common carotid intima-media thickness (IMT) study for evaluation of atherosclerotic burden or coronary heart disease risk factor assessment.
  • 93895 Quantitative carotid intima media thickness and carotid atheroma evaluation, bilateral


Selected References:

  • Lorenz MW, Polak JF, Kavousi M et al. Carotid intima-media thickness progression to predict cardiovascular events in the general population (the PROG-IMT collaborative project): a meta-analysis of individual participant data. Lancet. 2012 Jun 2; 379(9831):2053-62. Epub 2012 Apr27.
  • Peters SA, den Ruijter HM, Bots ML et al. Improvements in risk stratification for the occurrence of cardiovascular disease by imaging subclinical atherosclerosis: a systematic review. Heart 2012; 98(3):177-84.
  • Roger VL, Go AS, Lloyd-Jones DM et al. on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2012 update: a report from the American Heart Association. Circulation. 2012; 125:e2-e220.
  • Johnson HM, Turke TL, Grossklaus M et al. Effects of an office-based carotid ultrasound screening intervention. J AM Soc Echocardiogr 2011; 24(7):738-47.
  • Ikeda K, Takahashi T, Yamada H et al. Effect of intenstive statin therapy on regression of carotid intima-media thickness in patients with subclinical atherosclerosis (a prospective, randomized trial: PEACE (Pitavastatin Evaluation of Atherosclerosis Regression by Intensive Cholesterol-lowering Therapy) study. Eur J Prev Cardiol. 2012 Jun 11. [Epub ahead of print].
  • Polak JF, Pencina MJ, O’Leary DH et al. Common carotid artery intima-media thickness progression as a predictor of stroke in multi-ethnic study of atherosclerosis. Stroke. 2011 Nov; 42(11):2017-21. Epub 2011 Sep 1.
  • Bis JC, Kavousi M, Franceschini N et al. Meta-analysis of genome-wide association studies for the CHARGE consortium identifies common variants associated with carotid intima media thickness and plaque. Nat genet. 2011 Sep 11; 43(10): 940-7. doi: 10.1038/ng.920.
  • Polak JF, Pencina MJ, Pencina KM et al. Carotid-wall intima-media thickness and cardiovascular events. N Engl J Med. 2011 Jul 21; 365(3):213-21.
  • Polak JF, Funk LC, O’Leary DH. Inter-reader differences in common carotid artery intima-media thickness: implications for cardiovascular risk assessment and vascular age determination. J Ultrasound Med. 2011 Jul; 30(7):915-20.
  • Plichart M, Celermajer DS, Zureik M et al. Carotid intima-media thickness in plaque-free site, carotid plaques and coronary heart disease risk prediction in older adults. The Three-City Study. Atherosclerosis 2011; 219(2):917-24.
  • Keo HH, Baumgartner I, Hirsch AT et al. Carotid plaque and intima-media thickness and the incidence of ischemic events in patients with atherosclerotic vascular disease. Vasc Med 2011; 16(5):323-30.
  • Nambi V, Chambless L, He M et al. Common carotid artery intima-media thickness is as good as carotid intima-media thickness of all carotid artery segments in improving prediction of coronary heart disease risk in the Atherosclerosis Risk Communities (ARIC) study. Eur Heart J 2012; 33(2):183-90.
  • Xie W, Liang L, Zhao L et al. Combination of carotid intima-media thickness and plaque for better predicting risk of ischaemic cardiovascular events. Heart 2011; 97(16):1326-31.
  • Costanzo P, Perrone-Filardi P, Vassallo E et al. Does carotid intima-media thickness regression predict reduction of cardiovascular events? A meta-analysis of 41 randomized trials. J Am Coll Cardiol. 2010 Dec 7; 56(24):2006-20.
  • Mookadam F, Moustafa SE, Lester SJ et al. Subclinical atherosclerosis: evolving role of carotid intima-media thickness. Prev Cardiol. 2010 Fall; 13(4):186-97. doi: 10.1111/j/1751-7141.2010.00072.x.
  • ECRI, Carotid Intima-Media Thickness for Assessing Coronary Artery Disease Risk, June 2012
  • U.S. Preventative Service Task Force Using Nontraditional Risk Factors in Coronary Heart Disease Risk Assessment, Recommendation Statement, October 2009.
  • 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults: Executive Summary, Philip Greenland, M.D., FACC, FAHA et al. Journal of the American College of Cardiology Vol. 56, No. 25, 2010
  • Goff D, Lloyd-Jones DM, Bennet G, et. al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, published online November 12, 2013. PMID 24222018
  • Lim LS, et. al. Atherosclerotic Cardiovascular Disease Screening in Adults: American College of Preventative Medicine Position Statement on Preventative Practice, AM J Prev Med. 2011 Mar; 40(3):381.el-10.
  • Hester M. Den Ruijter, PhD, Sanne A.E. Peters, MSc, et. al, Common Carotid Intima_Media Thickness Measurements in Cardiovascular Risk Prediction: A Meta-Analysis, JAMA 2012;308(8):796-803.doi:10.1001
  • Micheil L. Bots M.D., Hester M. den Ruijter, PhD, Should We Indeed Measure Carotid Intima-Media Thickness for Improving Prediction of Cardiovascular Events After IMPROVE Journal of American College of Cardiology 2012.
  • UpToDate. Carotid Intima-Media Thickness, Eric de Groot, M.D., PhD, John JP Kastelein, M.D., PhD, FESC, Raphael Duivenvoorden, M.D., PhD. Topic last updated January 14, 2016.
  • Baber U, Mehran R, Satori S, et. al. Prevalence, Impact, and Predictive Value of Detecting Subclinical Coronary and Carotid Atherosclerosis in Asymptomatic Adults: The BioImage Study. J Am Coll Cardiol. Mar 24 2015;65(11):1065-1074
  • Steinl D and Kaufman B, Ultrasound Imaging for Risk Assessment in Atherosclerosis. Int J Mol Sci 2015 May, 16(5):9749-9769
  • Writing Group Members, Mozaffarian D, Benjamin EJ, et al. Heart disease and stroke statistics-2016 update: a report from the American Heart Association. Circulation. Jan 26 2016;133(4):e38-360. PMID 26673558
  • Den Ruijter HM, Peters SA, Anderson TJ, et al. Common carotid intima-media thickness measurements in cardiovascular risk prediction: a meta-analysis. JAMA. Aug 22 2012;308(8):796-803. PMID 22910757
  • van den Oord SC, Sijbrands EJ, ten Kate GL, et al. Carotid intima-media thickness for cardiovascular risk assessment: systematic review and meta-analysis. Atherosclerosis. May 2013;228(1):1-11. PMID 23395523
  • Lorenz MW, Schaefer C, Steinmetz H, et al. Is carotid intima media thickness useful for individual prediction of cardiovascular risk? Ten-year results from the Carotid Atherosclerosis Progression Study (CAPS). Eur Heart J. Aug 2010;31(16):2041-2048. PMID 20530503
  • Patel J, Al Rifai M, Blaha MJ, et. al. Coronary artery calcium improves risk assessment in adults with family history of premature coronary heart disease: results from multiethnic study of atherosclerosis. Circ Cardiovasc Imaging. Jun 2015;8(6);e003186. PMID 26047825
  • Baber U, Mehran R, Sartori S, et al. Prevalence, impact, and predictive value of detecting subclinical coronary and carotid atherosclerosis in asymptomatic adults: the BioImage study. J Am Coll Cardiol. Mar 24 2015;65(11):1065-1074. PMID 25790876
  • Johnson HM, Turke TL, Grossklaus M, et al. Effects of an office-based carotid ultrasound screening intervention. J Am Soc Echocardiogr. Jul 2011;24(7):738-747. PMID 21477989


Policy History:

  • January 2018 - Annual Review, Policy Renewed
  • January 2017 - Annual Review, Policy Renewed
  • January 2016 - Annual Review, Policy Renewed
  • January 2015 - Annual Review, Policy Revised
  • February 2014 - Annual Review, Policy Revised
  • May 2013 - Annual Review, Policy Renewed
  • June 2012 - New Policy

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.


*CPT® is a registered trademark of the American Medical Association.