| Effective Date:09/01/2013 |
Title:Thermography & Temperature Gradient Studies
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| Revision Date:
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Document:BI413:00
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| CPT Code(s):93740
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Public Statement
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Effective Date:
a)
This policy
will apply to all services performed on or after the above revision date which
will become the new effective date.
b)
For all
services referred to in this policy that were performed before the revision
date, contact customer service for the rules that would apply.
Thermography
and temperature gradient studies have not been demonstrated to improve health
care outcomes. These studies are not covered.
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Medical Statement
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Thermography
and temperature gradient studies are considered experimental / investigational
for any use.
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Limits
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Intentially left empty
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Reference
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Agency for
Healthcare Research and Quality (AHRQ). Vulnerable Plaques: A Brief Review of
the Concept and Proposed Approaches to Diagnosis and Treatment. Jan 22,
2004.Available at:http://archive.ahrq.gov/clinic/ta/placque/placque.pdf.
American Cancer
Society (ACS). Mammograms and other breast imaging procedures. 2010. Available
at:
Click here
American College of
Obstetricians and Gynecologists (ACOG). Breast cancer screening. Washington
(DC): American College of Obstetricians and Gynecologists (ACOG); 2011 Aug. 11p.
(ACOG practice bulletin; no. 122).
American College of
Radiology (ACR). ACR appropriateness criteria. Breast Cancer Screening. 2012.
Available at:
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/BreastCancerScreening.pdf
American College of
Radiology (ACRb). ACR appropriateness criteria. Myelopathy. 2011.Available at:
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/Myelopathy.pdf
ECRI Institute. Thermography for
Detection of Breast Masses. May 2011.
Harper CM Jr, Low PA, Fealey RD,
et al. Utility of thermography in the diagnosis of lumbosacral radiculopathy.
Neurology. 1991; 41(7):1010-1014.
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Application to Products
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This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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