37195
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Pre-specified diagnostic thresholds for perfusion parameters (many studies lacked pre-specified thresholds; documentation of the threshold used is necessary for interpretation)
- Reference standard details and whether reference standard interpretation was blinded to perfusion results (several studies had unclear blinding; documentation recommended)
- For evaluation of post-operative pediatric ppCMS: pre-operative perfusion imaging for comparison is important (most studies lacked pre-operative imaging)
- Adequate follow-up documentation when pathology is not available (several studies relied on clinic-radiological follow-up; authors noted that unclear or short follow-up was a limitation)
Key Coverage Criteria
- Cerebral computed tomography (CT) perfusion studies for the emergent evaluation of acute cerebral ischemia (acute stroke) when either of the following criteria is met: CT perfusion studies will be used as a supplement to non-contrast head CT; or Magnetic resonance imaging is unavailable or contraindicated;
- Cerebral magnetic resonance imaging (MRI) perfusion studies (diffusion-weighted or perfusion-weighted) for the evaluation of acute cerebral ischemia.
- Covered CPT (for CT perfusion) when selection criteria are met: 0042T — "Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time"
- Covered ICD-10 codes (if criteria are met): I63.00 - I63.9 (Cerebral infarction); I65.01 - I65.9 (Occlusion and stenosis of precerebral arteries, not resulting in cerebral infarction); I66.01 - I66.9 (Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction)
- Use of MR perfusion-weighted imaging (PWI) to differentiate high-grade glioma (HGG) from primary central nervous system lymphoma (PCNSL) (meta-analyses report high accuracy; DSC technique may be optimal).
- CT perfusion may be useful in differentiation/characterization of intracranial tumors (glioma grading, differentiation of high-grade gliomas from low-grade gliomas, lymphomas, metastases and abscess) — perfusion parameters (CBV, CBF, MTT, TTP) provide useful information that can impact management (Ding et al. 2006; Karegowda et al. 2017).
1 Active Policy
AETNA-CPB-0663 — Cerebral Perfusion Studies
Related Codes
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