3D Rendering on CT/MRI/US Form

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3D Rendering on CT/MRI/US Medical Guideline

Service: 3D Rendering on CT/MRI/US

PUM 250-0045-1812

Medical Guideline Committee Approval Q2-06/2025 Effective Date 09/01/2025

Coverage for 3D rendering of CT/MRI/US may vary across plans. Refer to the member’s benefit plan document for coverage details.

Description:

The process of 3-D rendering creates 2-D images that convey the 3-D relationship of objects. 3-D rendering may take place on the same scanner the original studies were conducted on with built in 3-D software or by post-processing on an independent workstation. 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. Complex 3-D image rendering may require extensive independent workstation processing by a supervising physician and specially trained technologist.
This type of reconstruction has been applied to computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), computed tomography angiography (CTA), digital subtraction angiography (DSA), ultrasound (US) and other tomographic modalities.

Indications of Coverage:

3D rendering is considered medically necessary on CT/MRI/US when at least one of the following criteria are met:

A. Musculoskeletal conditions:

1. Evaluation of congenital skull abnormalities in newborns, infants, and toddlers (usually for preoperative planning); or

2. Complex joint fractures or pelvic fractures; or

3. Spine fractures (usually for preoperative planning); or

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4. Complex facial fractures B. Preoperative planning for other complex surgical cases

   C. Cerebral angiography (except for MRA and/or CTA- see Limitations of Coverage E.)

   D. Echocardiography (transthoracic or trans-esophageal) when used for one of the following:

5. Evaluation of at least a moderate degree of valvular stenosis or regurgitation

6. Guidance of transcatheter valve replacement, such as TAVR (transcatheter aortic valve replacement), mitral valve clipping or replacement, or fistula coiling

7. To assess LV (left ventricular) volume and EF (ejection fraction) prior to ICD (implantable cardioverter defibrillator) implantation, or prior to or within 12 months of having received chemotherapy which is potentially cardiotoxic.

   E. Ultrasound of Pelvic conditions:

8. Uterine intra-cavity lesion when initial US is equivocal or when the 3D ultrasound/sonohysterogram is being performed instead of hysteroscopy.

9. Hydrosalpinxes or peritoneal cysts when initial US is indeterminate or when the 3D ultrasound/sonohysterogram is being performed instead of hysteroscopy.

10. Lost IUD (inability to feel or see IUD string) and initial US is indeterminate; or

11. Uterine anomalies with initial US being indeterminate or equivocal; or

12. Infertility evaluation and initial US is indeterminate or equivocal or when the 3D ultrasound/sonohysterogram is being performed instead of hysteroscopy.

13. MRI Fusion Biopsy of the Prostate/Transrectal Ultrasound (TRUS, MRI/TRUS) F. Abdominal conditions:

14. MRCP for assessment of biliary tree

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Limitations of Coverage:

Benefit Limitations: Please note that in listing services or examples, when we say, “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to”.

A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.

B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

C. If used for a condition/diagnosis that is listed in the Indications of Coverage, but the criteria are not met, it will be considered not medically necessary. If used for other diagnosis not listed in the Indications of Coverage, it is deemed integral to the procedure.

D. 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.

E. For the use of 3D rendering services, generally accepted coding guidelines will be applied. Therefore, coding/billing for 3D rendering should not be submitted in conjunction with (including but not limited to the following): computer aided (CAD), MRA, CTA, nuclear medicine SPECT studies, PET, PET/CT, Mammogram, MRI breast, US Breast, Breast Tomosynthesis, CT Colonography (virtual colonoscopy), Cardiac MRI, Cardiac CT, Coronary CTA studies, bronchoscopy, nuclear medicine thyroid uptake, physician planned patient specific aortic endograft, and unlisted diagnostic radiographic procedures. As per standard coding guidelines, 3D rendering is inherent to these procedures.

F. Breast CT, including 3D rendering for all indications, are considered experimental, investigation.

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G. 3D, 4D, or 5D Obstetrical (OB) US is considered experimental, investigational, unproven.

Documentation Required:

• Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.
• Medical record information (including continued need/use if applicable) and medical necessity. Documentation should support the need for 3D rendering/reconstruction and how it is critical to the clinical management of the individual. It should include clinical evaluation or preoperative planning and why a traditional two-dimensional (2-D) imaging would not be useful.
• Correct coding for the item/service that meets all the coding guidelines.

Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered.

3D Rendering of MRI/CT/US is considered medically necessary only when indicated by the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

State mandates, laws or benchmark supersede this medical guideline.

Guideline Review History:

Implemented 12/01/21, 12/01/22, 07/01/23, 07/01/24, 09/01/25 Medical Guideline Committee Approval 06/24/21, 06/23/22, 06/29/23, 06/27/24, 06/26/25 Reviewed

06/24/21, 06/23/22, 06/29/23, 06/27/24, 06/26/25 Developed 06/24/21

Approved by the Medical Director

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Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes. Code Code Description
76376 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, OR OTHER TOMOGRAPHIC MODALITY WITH IMAGE POST-PROCESSING UNDER CURRENT SUPERVISION; NOT REQUIRING IMAGE POST-PROCESSING ON AN INDEPENDENT WORKSTATION
76377 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, OR OTHER TOMOGRAPHIC MODALITY WITH IMAGE POST-PROCESSSING UNDER CONCURRENT SUPERVISION; REQUIRING IMAGING POST-PROCESSING ON AN INDEPENDENT WORKSTATION C8001 3D ANATOMICAL SEGMENTATION IMAGING FOR PREOPERATIVE PLANNING, DATA PREPARATION AND TRANSMISSION, OBTAINED FROM PREVIOUS DIAGNOSTIC OMPUTED TOMOGRAPHIC OR MAGNETIC RESONANCE EXAMINATION OF THE SAME ANATOMY C9793 3D PREDICTIVE MODEL GENERATION FOR PRE-PLANNING OF A CARDIAC PROCEDURE, USING DATA FROM CARDIAC COMPUTED TOMOGRAPHY ANGIOGRAPHY WITH REPORT
G0566 3D RADIOSENSITIVITY-VALUE BONE IMAGING, ALGORITHM DERIVED, FROM PREVIOUS MAGNETIC RESONANCE EXAMINATION OF THE SAME ANATOMY

ASSOCIATED CODES 93319 3D ECHOCARDIOGRAPHIC IMAGING AND POSTPROCESSING DURING TRANSESOPHAGEAL ECHOCARDIOGRAPHY, OR DURING TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES, FOR THE ASSESSMENT OF CARDIAC STRUCTURE(S) (E.G., CARDIAC CHAMBERS AND VALVES, LEFT ATRIAL APPENDAGE, INTERATRIAL SEPTUM, INTERVENTRICULAR SEPTUM) AND FUNCTION, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR ECHOCARDIOGRAPHIC IMAGING)

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