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.

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.



  









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.