Summary Of Evidence

In ACR–SPR–STR PRACTICE PARAMETER FOR THE PERFORMANCE OF CHEST RADIOGRAPHY (a practice guideline from the American College of Radiology, the Pediatric Society for Radiology and the Society of Thoracic Radiology) 2017 revision, in the Section of Indications and Contraindications (page 2 or 9); indication number 5 states:

“Preoperative radiographic evaluation when cardiac or respiratory symptoms are present when there is a significant potential for thoracic pathology that may influence anesthesia or the surgical result or lead to increased perioperative morbidity or mortality. Routine preoperative chest x-rays are not appropriate [2]."

Also, under Section V - Specifications of the Examination, the language includes:

"The written or electronic request for chest radiography should provide sufficient information to demonstrate the medical necessity of the examination and allow for its proper performance and interpretation. Documentation that satisfies medical necessity includes 1) signs and symptoms and/or 2) relevant history (including known diagnoses). Additional information regarding the specific reason for the examination or a provisional diagnosis would be helpful and may at times be needed to allow for the proper performance and interpretation of the examination."

In American College of Radiology ACR Appropriateness Criteria; Routine Chest Radiography (2000-updated 2015); in the section Summary of Recommendations:

Summary of Recommendations

• Available evidence does not support the broad performance of routine chest radiography. Despite the frequent demonstration of abnormalities, routine chest radiographs uncommonly add clinically significant information that would not have been predicted by a reliable history and physical examination.
• In the case of the preoperative chest radiograph, evidence suggests that increased management value may accompany advanced patient age (especially >70 years) and certain other patient- and procedure-related risk factors (eg, history of cardiopulmonary disease, unreliable history and physical examination, high-risk surgery); however, the ability of a preoperative chest radiograph to forecast postoperative pulmonary complications is low.
• The decision to perform a chest radiograph in the preoperative, preintervention, hospital admission, and asymptomatic outpatient settings should principally derive from a need to investigate a clinical suspicion for acute or unstable chronic cardiopulmonary disease that could influence patient care. Selective ordering is recommended, including in patients of advanced age or otherwise at increased risk.
• Routine chest radiography is not definitively indicated in uncomplicated hypertension. There may be value in patients with moderate to severe hypertension and potential aortic coarctation or cardiogenic edema, in addition to patients with overt cardiopulmonary signs or symptoms.
• The anticipated value from ordering a chest radiograph should be weighed against adverse effects, including radiation exposure, procedural delay, anxiety, and potential morbidity from the investigation of incidental findings."

In an FDA publication; White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging, (updated 2-23-2017) there is discussion regarding types of imaging, concerns about radiation exposure and types of unnecessary exposure the white paper states:

“3. Unnecessary Radiation Exposure”

“Because CT, fluoroscopy, and nuclear medicine require the use of radiation, some level of radiation exposure is inherent in these types of procedures. Nevertheless, when these procedures are conducted appropriately, the medical benefits they can provide generally outweigh the risks.”

“However, if proper precautions are not taken, patients may be exposed to radiation without clinical need or benefit. Unnecessary radiation exposure may result from the use of a radiation dose above what is optimal to meet the clinical need in a given procedure. To a point, using a higher radiation dose can produce a higher-resolution image. If the dose is too low, the quality of the resulting image may be poor, and, as a result, a physician may not be able to make an accurate clinical determination. An optimal radiation dose is one that is as low as reasonably achievable while maintaining sufficient image quality to meet the clinical need.”

“Unnecessary radiation exposure may also result from the performance of a particular medical imaging procedure when it is not medically justified given a patient’s signs and symptoms, or when an alternative might be preferable given a patient’s lifetime history of radiation exposure.”

“There is broad agreement that steps should be taken to reduce unnecessary exposure to radiation”

Further on, under Issues Related to Decision Making: “In some cases, ordering physicians may lack or be unaware of recommended criteria to guide their decisions about whether or not a particular imaging procedure is medically efficacious. As a result, they may order imaging procedures without sufficient justification and unnecessarily expose patients to radiation. Various professional organizations, including American College of Radiology (ACR) and the American College of Cardiology (ACC), have developed and are working to disseminate imaging referral criteria, called “appropriateness criteria” or “appropriate use criteria,” associated with a number of medical conditions.18 However, criteria for appropriate ordering of medical imaging exams have not yet been broadly adopted by the practicing medical community.”

In a document entitled Choosing Wisely (a collaboration of the American Board of Internal Medicine, the American College of Radiology and Consumer Reports), a 2012 publication for patients and physicians-with Subtitle Chest X-Rays Before Surgery-When You Need One and When You Don’t; the language states: 

“A chest X-ray usually doesn’t help."

“Many people are given a chest X-ray to “clear” them before surgery. Some hospitals require a chest X-ray for almost every patient. But, if you do not have symptoms of heart or lung disease, and your risk is low, an X-ray probably will not help. It is not likely to show a serious problem that would change your treatment plan.”

“A chest X-ray does not help the surgeon or the anesthesiologist manage your care. Most of the time, a careful medical history and physical exam are all you need.”

• In the Annals of the Royal College of Medicine, v.92(8); 2010 Nov. in an article entitled: Erect Chest Radiography in the Setting of the Acute Abdomen: Essential tool or an unnecessary waste of resources?, the authors state as their conclusion: 
• “The majority of CXRs performed on emergency surgical admissions with abdominal pain are unnecessary. By obtaining a clear history, performing a thorough clinical examination and following the RCR guidelines most of the CXRs could be avoided. This would lead to less radiation exposure, reduce delays to diagnosis, and provide significant financial savings.”

Searching the National Library of Medicine, there was no supporting literature regarding or suggesting chest radiographs in the setting of common headaches, pain, unspecified urinary tract infections, lower back pain, trauma unrelated to the thorax or upper abdomen or unspecified conditions such a “general signs and symptoms”. 

Although frequency of radiographs is not part of this local coverage determination, recent articles in the past 2 years are questioning the high frequency of repeat radiographs in the ICU, post certain procedures, and on ventilator patients.

Analysis of Evidence

Level of Evidence:  Evidence excellent with articles and white papers within recent years. 

Of the 47 references cited in the ACR Appropriateness Criteria^® Routine Chest Radiography document, 45 are categorized as diagnostic references including 1 well designed study, 2 good quality studies, and 4 quality studies that may have design limitations. Additionally, 1 reference is categorized as a therapeutic reference. There are 39 references that may not be useful as primary evidence. There is 1 reference that is a meta-analysis study. The 47 references cited in the ACR Appropriateness Criteria^® Routine Chest Radiography document were published from 1965-2014. While there are references that report on studies with design limitations, 3 well designed or good quality studies provide good evidence.

Quality –  High quality evidence as shown by supportive papers by major national clinical societies and the Federal Drug Administration

Strength –  Major strength as evidence that papers relate to current recommended national standards of care for patients.  Policy simplifications also reduce provider errors.

Weight –   No literature differs or is opposite to national society recommendations, or to FDA concerns.   

The most recent peer reviewed guidelines recommend not ordering or requiring routine preoperative or preprocedural chest X-rays in patients with no cardiac, pulmonary or thoracic issues to avoid unnecessary radiation, unnecessary outpatient visits for patients, and to save money for patient co-pays and the Medicare system. The Medicare Manuals do not support coverage for services that are not reasonable and necessary for the diagnosis or treatment of an illness or to repair a damaged organ. Chest radiographs taken for distant fractures or situations unrelated to any signs, symptoms or tests of pulmonary, cardiac, thoracic or related conditions are considered not reasonable and necessary. The criteria stated by the American College of Radiology is a recently accepted standard.

Radiographs of the chest are common tests performed in many outpatient offices (radiology and many others), clinics, outpatient hospital departments, inpatient hospital episodes, skilled nursing facilities, homes, and other settings. They can be used for many pulmonary diseases, cardiac diseases, infections and inflammatory diseases, chest and upper abdominal trauma situations, malignant and metastatic diseases, allergic and drug related diseases. There are thousands of diagnoses which would constitute reasonable and necessary conditions for chest X-rays. Despite that, Noridian data shows that there are a large number of chest radiographs that do NOT appear reasonable and necessary. To simplify this policy, make it easier for patients to receive, and for physicians to be reimbursed for chest X-rays and avoiding coding errors, we are converting this to a negative policy.

Noridian is listing those diagnoses that are not reasonable and necessary based on literature from medical societies and clear community standards and for which data analysis shows are the more common reasons for denial. A chest X-ray that is not reasonable and necessary contributes to unneeded patient radiation exposure, patient anxiety, unnecessary visits to a medical or radiology facility, and increased costs to both patients and the Medicare Trust Fund. 

In general, preprocedural chest X-rays in the absence of symptomatic pulmonary or cardiac diseases, chest X-rays in the absence of signs or symptoms, and chest X-rays for minor trauma of the head, lower back or extremities are not reasonable and necessary. If a patient with known, but stable, asymptomatic cardiac or pulmonary disease requires a chest x-ray, the reason(s) for the chest radiograph(s) must be clearly documented in the clinical chart with an explanation of how the results of the X-ray will be used for the patient's care. 

If a patient with known but stable, asymptomatic cardiac or pulmonary disease requires a pre-procedural chest X-ray, the reason(s) must be documented in the clinical chart with an explanation of how the results of the X-ray would be used for the patient’s care. Patients with symptomatic cardiac or pulmonary conditions (e.g., adverse change in cough, orthopnea, dyspnea on exertion, recent decrement in SaO2), planning surgery performed in ASC or outpatient facilities, the chart must document how the x-ray results will be used to make treatment decisions.

Radiographs of the chest are commonly performed in outpatient offices (radiology and many others), clinics, outpatient hospital departments, inpatient hospital episodes, skilled nursing facilities, homes, and other settings. They are used to diagnose and aid in treatment decisions for pulmonary diseases, cardiac diseases, infections and inflammatory diseases, chest and upper abdominal trauma situations, malignant and metastatic diseases, allergic and drug related diseases.

In general, preprocedural chest X-rays in the absence of pulmonary or cardiac diseases, chest X-rays in the absence of signs or symptoms, and chest X-rays for minor trauma of the head, lower back or extremities are not the current accepted medical practice.