Thermography Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 09|03|2010 POLICY LAST REVIEWED: 02|04|2026 OVERVIEW Thermography is a noninvasive imaging technique that measures temperature distribution in organs and tissues. The visual display of this temperature information is known as a thermogram. Thermography has been proposed as a diagnostic tool for treatment planning and for evaluation of treatment effects for a variety of conditions. MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Medicare Advantage Plans The use of all forms of thermography is not covered as the evidence is insufficient to determine that the technology results in an improvement in the net health outcome. Commercial Products The use of all forms of thermography is considered not medically necessary as the evidence is insufficient to determine that the technology results in an improvement in the net health outcome. COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable not medically necessary/not covered benefits/coverage.
BACKGROUND Infrared radiation from the skin or organ tissue reveals temperature variations by producing brightly colored patterns on a liquid crystal display. Thermography involves the use of an infrared scanning device and can include various types of telethermographic infrared detector images and heat-sensitive cholesteric liquid crystal systems. Interpretation of the color patterns is thought to assist in the diagnosis of many disorders such as complex regional pain syndrome (previously known as reflex sympathetic dystrophy), breast cancer, Raynaud phenomenon, digital artery vasospasm in hand-arm vibration syndrome, peripheral nerve damage following trauma, impaired spermatogenesis in infertile men, degree of burns, deep vein thrombosis, gastric cancer, tear-film layer stability in dry-eye syndrome, Frey syndrome, headaches, low back pain, and vertebral subluxation. Thermography may also assist in treatment planning and procedure guidance by accomplishing the following tasks: identifying restricted areas of perfusion in coronary artery bypass grafting, identifying unstable atherosclerotic plaque, assessing response to methylprednisone in rheumatoid arthritis, and locating high undescended testicles. For individuals who have an indication for breast cancer screening or diagnosis who receive thermography, the evidence includes diagnostic accuracy studies and systematic reviews. Relevant outcomes are overall Medical Coverage Policy | Thermography

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

survival, disease-specific survival, and test validity. Using histopathologic findings compared to the reference standard, a series of systematic reviews of studies have evaluated the accuracy of thermography to screen and/or diagnose breast cancer and reported wide ranges of sensitivities and specificities. To date, no study has demonstrated that thermography is sufficiently accurate to replace or supplement mammography for breast cancer diagnosis. Moreover, there are no studies on the impact of thermography on patient management or health outcomes for patients with breast cancer. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have musculoskeletal injuries who receive thermography, the evidence includes diagnostic accuracy studies, a longitudinal prospective study, and a systematic review. Relevant outcomes are test validity, symptoms, and functional outcomes. A systematic review of studies on thermography for diagnosing musculoskeletal injuries found moderate levels of accuracy compared with other diagnostic imaging tests. There is no consistent reference standard. This evidence does not permit conclusions as to whether thermography is sufficiently accurate to replace or supplement standard testing. Moreover, there are no high-quality or randomized studies on the impact of thermography on patient management or health outcomes for patients with musculoskeletal injuries. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have temporomandibular joint (TMJ) disorder who receive thermography, the evidence includes a systematic review. Relevant outcomes are test validity, symptoms, and functional outcomes. A systematic review of studies on thermography for diagnosing TMJ disorder found a wide variation in accuracy compared to other diagnostics. There is no consistent reference standard. The evidence does not permit conclusions as to whether thermography is sufficiently accurate to replace or supplement standard testing. Moreover, there are no studies on the impact of thermography on patient management or health outcomes for patients with the TMJ disorder. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have miscellaneous conditions (eg, herpes zoster, pressure ulcers, diabetic foot) who receive thermography, the evidence primarily includes diagnostic accuracy studies. Outcomes in these studies are test validity, symptoms, and functional outcomes. Most studies assessed temperature gradients or the association between temperature differences and the clinical condition. Due to the small number of studies for each indication, diagnostic accuracy could not adequately be evaluated. The clinical utility of thermography has only been considered in a single study of diabetic foot ulcers. For other miscellaneous conditions, the clinical utility of thermography has not been investigated. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

CODING Medicare Advantage Plans and Commercial Products
There is no specific code for thermography therefore, thermography services should be reported using the following unlisted code.
93799 Unlisted cardiovascular service or procedure

RELATED POLICIES Unlisted Procedures

PUBLISHED Provider Update, April 2026 Provider Update, April 2025 Provider Update, November 2024 Provider Update, December 2023 Provider Update, December 2022

REFERENCES

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

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22. Dong F, Tao C, Wu J, et al. Detection of cervical lymph node metastasis from oral cavity cancer using a non-radiating, noninvasive digital infrared thermal imaging system. Sci Rep. May 08 2018; 8(1): 7219. PMID 29739969

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

22. Agazzi A, Fadanelli G, Vittadello F, et al. Reliability of LoSCAT score for activity and tissue damage assessment in a large cohort of patients with Juvenile Localized Scleroderma. Pediatr Rheumatol Online J. Jun 18 2018; 16(1): 37. PMID 29914516
23. Ranosz-Janicka I, Lis-Święty A, Skrzypek-Salamon A, et al. Detecting and quantifying activity/inflammation in localized scleroderma with thermal imaging. Skin Res Technol. Mar 2019; 25(2): 118-123. PMID 30030915
24. Cruz-Segura A, Cruz-Domínguez MP, Jara LJ, et al. Early Detection of Vascular Obstruction in Microvascular Flaps Using a Thermographic Camera. J Reconstr Microsurg. Sep 2019; 35(7): 541-548. PMID 31067581
25. Unger M, Markfort M, Halama D, et al. Automatic detection of perforator vessels using infrared thermography in reconstructive surgery. Int J Comput Assist Radiol Surg. Mar 2019; 14(3): 501-507. PMID 30519870
26. Chen R, Huang ZQ, Chen WL, et al. Value of a smartphone-compatible thermal imaging camera in the detection of peroneal artery perforators: Comparative study with computed tomography angiography. Head Neck. May 2019; 41(5): 1450-1456. PMID 30636085
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32. Anzengruber F, Alotaibi F, Kaufmann LS, et al. Thermography: High sensitivity and specificity diagnosing contact dermatitis in patch testing. Allergol Int. Apr 2019; 68(2): 254-258. PMID 30598404
33. Aydemir U, Sarıgoz T, Ertan T, et al. Role of digital infrared thermal imaging in diagnosis of acute appendicitis. Ulus Travma Acil Cerrahi Derg. Nov 2021; 27(6): 647-653. PMID 34710229
34. Umapathy S, Thulasi R, Gupta N, et al. Thermography and colour Doppler ultrasound: a potential complementary diagnostic tool in evaluation of rheumatoid arthritis in the knee region. Biomed Tech (Berl). May 26 2020; 65(3): 289-299. PMID 31821162
35. Jones B, Hassan I, Tsuyuki RT, et al. Hot joints: myth or reality? A thermographic joint assessment of inflammatory arthritis patients. Clin Rheumatol. Sep 2018; 37(9): 2567-2571. PMID 29679167
36. Schiavon G, Capone G, Frize M, et al. Infrared Thermography for the Evaluation of Inflammatory and Degenerative Joint Diseases: A Systematic Review. Cartilage. Dec 2021; 13(2_suppl): 1790S-1801S. PMID 34933442
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500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 5 (401) 274-4848 WWW.BCBSRI.COM

41. Hazenberg CE, van Netten JJ, van Baal SG, et al. Assessment of signs of foot infection in diabetes patients using photographic foot imaging and infrared thermography. Diabetes Technol Ther. Jun 2014; 16(6): 370-7. PMID 24690146
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50. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination for Thermography (220.11). 1992; https://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?NCDId=164&ncdver=1&DocID=220.11. Accessed July 26, 2024.

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    This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS