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Medical Policy Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 547

BCBSA Reference Number: 2.02.16 (For Plan internal use only) Related Policies
Novel Lipid Risk Factors in Risk Assessment and Management of Cardiovascular Disease, #283 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Ultrasonographic measurement of carotid artery intima-medial thickness (CIMT) as a technique of identifying subclinical atherosclerosis is INVESTIGATIONAL for use in the screening, diagnosis, or management of atherosclerotic disease. Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

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The following codes are included below for informational purposes only; this is not an all-inclusive list. The following CPT codes are considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity: CPT Codes CPT codes: Code Description 93895 Quantitative carotid intima media thickness and carotid atheroma evaluation, bilateral

Description Coronary Heart Disease Heart disease is the leading cause of mortality in the United States, accounting for more than half of all deaths. Coronary heart disease (CHD), also known as coronary artery disease, is the most common cause of heart disease.1, In a 2023 update on heart disease and stroke statistics from the American Heart Association, it was estimated that 720,000 Americans have a new coronary attack (first hospitalized myocardial infarction or CHD death) and 335,000 have a recurrent attack annually. An estimated 20.5 million Americans ≥20 years of age have CHD. The prevalence of CHD was higher for males than females in all age groups. Total CHD prevalence is 7.1% in US adults ≥20 years of age; CHD prevalence is 8.7% for males and 5.8% for females. On the basis of data from the 2018 National Health Interview Survey, CHD prevalence estimates are 5.7% among White people, 5.4% among Black people, 8.6% among American Indian/Alaska Native people, and 4.4% among Asian people ≥18 years of age. Established major risk factors for CHD have been identified by the National Cholesterol Education Program Expert Panel. These risk factors include elevated serum levels of low-density lipoprotein cholesterol and 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. Diagnosis The third report of the National Cholesterol Education Program Adult Treatment Panel established various treatment strategies to modify the risk of CHD, with emphasis on target goals of low-density lipoprotein cholesterol. Pathology studies have demonstrated that levels of traditional risk factors are associated with the extent and severity of atherosclerosis. The third report of the National Cholesterol Education Program Adult Treatment Panel recommended use of the Framingham criteria to further stratify those patients with 2 or more risk factors for more intensive lipid management.2, However, at every level of risk factor exposure, there is substantial variation in the amount of atherosclerosis, presumably related to genetic susceptibility and the influence of other risk factors. Thus, there has been aninterest in identifying a technique that can improve the ability to diagnose those at risk of developing CHD, as well as to measure disease progression, particularly for those at intermediate risk. 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 atherosclerosis. B-mode ultrasound is most commonly used to measure CIMT. Carotid intima- media thickness is measured and averaged over several sites in each carotid artery. Imaging the far wall of each common carotid artery yields more accurate and reproducible CIMT measurements than imaging thenear wall. Two echogenic lines are produced, representing the lumen-intima interface and the media- adventitia interface. The distance between these 2 lines constitutes the CIMT. Summary Ultrasonographic measurement of 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-media thickening, which is a surrogate marker for atherosclerosis, may provide an opportunity to intervene earlier in atherogenic disease and/or monitor disease progression.

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For individuals who are undergoing cardiac risk assessment who receive ultrasonic measurement of carotid intima-media (or intimal-medial) thickness (CIMT), the evidence includes large cohort studies, case-control studies, and systematic reviews. Relevant outcomes are test accuracy and morbid events. Some studies have correlated increased CIMT with other commonly used markers for risk of coronary heart disease (CHD) and with risk for future cardiovascular (CV) events. Lorenz et al (2012) found in their meta-analysis that CIMT was associated with increased CV events, although CIMT progression over time was not associated with increased CV event risk. Peters et al (2012) found that 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 predictive value of CIMT is uncertain and that the predictive ability for any level of population risk cannot be determined with precision. Also, available studies do not define how the 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 objective of one study, however, was to define “normal” CIMT progression in low to moderate CV risk patients. Study results showed definite patterns related to various factors that could be used as a tool to earlier identify patients at increased CV risk, but patient outcomes were not assessed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. Policy History Date Action 7/2023 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 6/2022 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 6/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2021 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
Clarified coding information. 7/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 6/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 6/2018 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 2/2017 Annual policy review. New references added. 8/2015 Annual policy review. New references added. 1/2015 Clarified coding information. 9/2014 Annual policy review. New references added. 10/2013 Annual policy review. New references added. 11/2011-4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements.
1/1/2012 New policy, effective 01/01/2012, describing ongoing non-coverage. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

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