Anthem Blue Cross Connecticut Commercial Clinical Policy

Anthem Blue Cross Connecticut CG-MED-51 Three-Dimensional (3-D) Rendering of Imaging Studies Form



3-D Rendering of Imaging Studies for Aneurysms (CTA)

Indications

(96212) Is the use of 3-D image rendering being used for clinical evaluation or preoperative planning where 2-D imaging cannot provide necessary information for the management of suspected or known aneurysms? 

Contraindications

(96213) Can the information provided by the 3-D image rendering be obtained adequately through traditional 2-D imaging for the assessment of aneurysms? 

3-D Rendering of Imaging Studies for Complex Fractures (CT)

Indications

(96214) Is the use of 3-D image rendering medically necessary for the evaluation or surgical planning of complex fractures that cannot be assessed adequately by 2-D imaging? 

Contraindications

(96215) Can the information required for the assessment of complex fractures be obtained sufficiently via traditional 2-D imaging studies? 

3-D Rendering of Imaging Studies for Congenital Abnormalities (CTA)

Indications

(96216) Is the 3-D image rendering meant to localize and characterize blood supply to congenital abnormalities critical for diagnosis and treatment planning? 

Contraindications

(96217) Can the necessary details for diagnosing and planning the treatment of congenital abnormalities be acquired through conventional 2-D imaging methods? 

3-D Rendering of Imaging Studies for Eagle Syndrome (CT)

Indications

(96218) Is the 3-D image rendering intended for clinical management of Eagle syndrome when critical information is not obtainable by 2-D imaging? 

Contraindications

(96219) Can the needed diagnostic information for Eagle Syndrome be sufficiently collected using standard 2-D CT scans? 

3-D Rendering of Imaging Studies for Gynecologic Ultrasound Indications

Indications

(96220) Is the 3-D ultrasound being ordered for abscess drainage mapping in pelvis and abdomen? 
(96221) Is the procedure aimed at investigating congenital anomalies of the uterus? 
(96222) Is it being used for the evaluation of the endometrium and uterine cavity due to symptoms such as abnormal bleeding? 
(96223) Will the 3D ultrasound assist with infertility investigation? 
(96224) Is it for the mapping of uterine fibroids prior to myomectomy? 
(96225) Is it for the evaluation of cornual ectopic pregnancies? 
(96226) Is the test used for cases with a history of DES exposure? 
(96227) Is it needed for locating an intrauterine device if symptomatic, e.g., abnormal bleeding or pain? 
(96228) Is it for the imaging of adnexal lesions detected on previous imaging studies? 

Contraindications

(96229) Are these gynecological assessments achievable with sufficient clarity and detail through regular 2-D pelvic sonograms? 

3-D Rendering of Imaging Studies for Mass, Tumor, Or Other Abnormal Structure Identification (CT, MRI)

Indications

(96230) Is the 3-D image rendering employed to further investigate a mass, tumor, or other abnormal structures previously identified on imaging studies and essential for clinical management? 

Contraindications

(96231) Could the necessary information about the mass, tumor, or other abnormal structures be detained adequately using 2-D imaging modalities? 

3-D Rendering of Imaging Studies in Preprocedural Planning for Endoscopic Sinus Surgery or Stereotactic Intracranial Surgery (CT)

Indications

(96232) Is the 3-D image rendering necessary for preoperative planning before computer-assisted endoscopic sinus surgery or stereotactic intracranial surgery? 

Contraindications

(96233) Is the volumetric data required for preoperative planning attainable through traditional 2-D imaging techniques? 

Other Covered Indications for 3-D Rendering of Imaging Studies

Notes: Specific conditions and interventions must be detailed in patient's medical records to determine coverage.

Indications

(96234) Does the patient require this procedure for any of the following indications: Pectus deformity, adolescent idiopathic scoliosis, thromboembolic disease, anatomic mapping prior to organ transplantation, kidney or renal pre-surgery planning, evaluation of injury and hemorrhage from trauma, complex facial trauma assessment, MRCP adjunct, echocardiography enhancement for specific cardiovascular conditions or procedures, or anticipated cardiotoxic chemotherapy? 

Contraindications

(96235) For the listed conditions and purposes, can the essential information be satisfactorily obtained by non-3-D imaging studies? 

Non-Covered Indications for 3-D Rendering of Imaging Studies

Indications

(96236) Is the 3-D image rendering requested when the information needed can be obtained through traditional 2-D imaging studies? 

Contraindications

(96237) Does the request meet the criteria set forth above for medical necessity in any way? 
Effective Date

09/27/2023

Last Reviewed

08/10/2023

Original Document

  Reference



This document addresses three-dimensional (3-D) rendering of imaging studies. 3-D rendering uses multiple thin sections of images and reconstructs them into 3-D images which can display anomalies or structures and enhance visualization of pathology. This technology may also be referred to as 3-D reconstruction or 3-D reformation.

Note: This document does not address CT Colonography (Virtual Colonoscopy), 3-D fetal ultrasound or 3-D mammography (digital breast tomosynthesis). Please see the following related document for additional information:

  • RAD.00038 Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care

Clinical Indications

Medically Necessary:

The use of 3-D image rendering is considered medically necessary for clinical evaluation or preoperative planning when the information provided cannot be obtained by traditional two-dimensional (2-D) imaging and is critical to the clinical management of the individual. Common indications for 3-D image rendering include, but are not limited to:

  1. Aneurysms, suspected or known (computed tomography angiography [CTA]); or
  2. Complex fractures (computed tomography [CT]); or
  3. To localize and characterize blood supply to congenital abnormalities for the purpose of diagnosis and treatment planning (CTA); or
  4. Eagle syndrome (CT); or
  5. Gynecologic ultrasound (US) indications (3D should not be performed routinely with all pelvic sonograms):
    1. Abscess drainage in the pelvis and abdomen; or
    2. Congenital anomalies of the uterus; or
    3. Evaluation of the endometrium and uterine cavity, if symptomatic (for example, abnormal bleeding); or
    4. Infertility; or
    5. Planned myomectomy-mapping of uterine fibroids; or
    6. Cornual ectopic pregnancies; or
    7. Diethylstilbestrol (DES) exposure; or
    8. Intrauterine device location, if symptomatic (for example, abnormal bleeding or pain); or
    9. Imaging of adnexal lesions; or
  6. Mass, tumor, or other abnormal structure previously identified on imaging (CT, MRI); or
  7. Prior to computer-assisted endoscopic sinus surgery or stereotactic computer assisted volumetric intracranial surgery (CT); or
  8. Pectus deformity (CT); or
  9. Scoliosis, adolescent idiopathic (US); or
  10. Thromboembolic disease (CTA); or
  11. Prior to organ transplantation for anatomic mapping (CTA); or
  12. Prior to kidney or renal surgery (CT); or
  13. Trauma, to assess for presence and location of vascular, solid organ, and visceral organ injury and hemorrhage, and determine the appropriate management option (CTA); or
  14. Trauma, complex facial (CT); or
  15. When used with magnetic resonance cholangiopancreatography (MRCP); or
  16. When used with echocardiography if the information produced from the 3D echocardiogram cannot be provided by a traditional 2D echocardiogram, or other testing for any of the following:
    1. Evaluation of congenital heart disease; or
    2. Preoperative planning of a cardiac procedure; or
    3. Planned use of cardiotoxic chemotherapy.

Not Medically Necessary:

The use of 3-D image rendering is considered not medically necessary when the criteria above are not met, and for the following:

  • When information provided can be obtained by traditional 2-D imaging (such as US, CT, MRI);
  • For use with an imaging study that is considered not medically necessary or investigational and not medically necessary;
  • For routine use without specifically being ordered by the requesting physician (such as the routine use with ultrasound).