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

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).