BlueCross and BlueShield of Montana Medical Policy/Codes
Thermography
Chapter: Radiology
Current Effective Date: September 24, 2013
Original Effective Date: October 01, 1990
Publish Date: September 24, 2013
Revised Dates: September 30, 2009; June 12, 2012; August 29, 2013
Description

Thermography is a non-invasive imaging technique that is intended to measure temperature distribution of various organs and tissues.  The visual display of this temperature information is known as a thermogram.  Thermography has been proposed as a diagnostic tool for a variety of conditions, for treatment planning and to evaluate the effects of treatment.

Thermography involves use of an infrared scanning device. Infrared radiation from the skin or organ tissue reveals temperature variations by producing brightly colored patterns on a liquid crystal display.  Interpretation of the color patterns is thought to assist in the diagnosis of many disorders such as:

  • Complex regional pain syndrome ([CRPS] previously known as reflex sympathetic dystrophy);
  • Breast cancer;
  • Raynaud’s 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’s syndrome;
  • Headaches;
  • Low-back pain, and
  • Vertebral subluxation

Thermography is also thought to assist in treatment planning and procedure guidance such as:

  • 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.

The American Chiropractic Association suggests that high-resolution infrared imaging is of value in the diagnostic evaluation of patients when the clinical history suggests the presence of one of the following situations:

  • To obtain early diagnosis and monitor reflex sympathetic dystrophy syndromes.
  • To evaluate spinal nerve root fiber irritation and distal peripheral nerve fiber pathology for detection of sensory/autonomic dysfunction.
  • To evaluate and monitor soft tissue injuries, including segmental dysfunction/subluxation, sprain, and myofascial conditions (strains and myofascial pain syndromes) not responding to clinical treatment.
  • To evaluate the physiological significance of equivocal or minor anatomical findings seen on myelogram, computed tomography (CT) scan, and/or magnetic resonance imaging (MRI).
  • To evaluate for feigned disorders.

Thermography can include various types of telethermographic infrared detector images and heat-sensitive cholesteric liquid crystal systems.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions.  Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there is any exclusion or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Investigational

Blue Cross and Blue Shield of Montana (BCBSMT) considers the use of all forms of thermography experimental, investigational and unproven.

Rationale

This policy was originally created in 1990 and was updated regularly with searches of the MEDLINE database.  The most recent literature search was performed for the period March 2010 through March 2011.  Following is a summary of the key literature to date:

No published studies have demonstrated how the results of thermography can be used to enhance patient management and/or improve patient health outcomes.  The studies identified in literature searches tended to be small feasibility-type studies.  Several studies included patients with complex regional pain syndrome (CRPS).  For example, a study by Krumova et al. reported on skin temperature measurements in 22 patients with CRPS, 18 with non-CRPS pain, and 23 healthy controls.  Using long-term thermography, there was asymmetry in limb temperature in the CRPS group and, to some extent, in non-CRPS pain patients that was not seen in healthy controls.  However, the significance of these results is uncertain.  Some of the differences could be due to effects of medication, e.g., antiseizure or antidepressant medications.  In addition, the similarity of some findings between those with CRPS and non-CRPS pain limits applicability for use in diagnosis.  A study, by Schurmann and colleagues, reported on imaging in 18 patients with CRPS type I (CRPS I) and 13 patients with an incomplete clinical picture. Based on the study, the authors concluded that imaging methods (e.g., 3-phase bone scan, MRI, thermography) are not able to reliably differentiate between normal post-traumatic changes and changes due to CRPS I and that clinical findings remain the gold standard for diagnosis.

A study from Sweden, published in 2009, addressed the use of thermography for diagnosing foot problems in 65 diabetic patients.  They were examined with a liquid crystal thermography instrument, the SpectraSole (Linkoping, Sweden), immediately after a routine diabetic foot examination.  No device with this name has been cleared by the FDA for use in the U.S.  The 65 patients underwent a total of 69 SpectraSole examinations; the authors did not report why some patients had more than one examination.  The SpectraSole identified temperature differences between the right and left foot in 31 of the 69 examinations (45%).  Forty-two physical examinations classified patients as having no or only minor problems.  Of these, 11 (26%) were found to have temperature differences on the SpectraSole examination.  The remaining 27 examinations classified patients as having several and/or large problem areas.  Twenty (74%) of these were found to have temperature differences.  The study did not include a gold standard comparison, and the accuracy of the thermographic device was not evaluated.

Thermography has also been considered in the diagnosis of breast cancer.  In 2008, Arora and colleagues reported on the use of thermography on 92 patients who presented for a breast biopsy. When used in a screening mode (any positive reading was considered abnormal) for breast cancer, the sensitivity of thermography was 97% and specificity was 12%; when evaluated in a clinical mode (the lesion in question was used to determine an abnormal score), sensitivity was 90% and specificity was 44%.  These results must be viewed as preliminary.  The American College of Obstetrics and Gynecology (ACOG) does not recommend thermography for breast cancer screening.

Examples of other studies on thermography include evaluating the association between thermographic findings and post-herpetic neuralgia in patients with herpes zoster, surgical site healing in patients who underwent knee replacements, ulcer healing in patients with pressure ulcers, and post-treatment pain in patients with coccygodynia.  All of these studies were conducted outside of the United States, and none examined the impact of thermography on patient management decisions or health outcomes.

Summary

There is insufficient evidence to support the use of thermography for diagnosis.  Studies are lacking that thermography can accurately diagnose any condition or improve the accuracy of another diagnostic tool.  Moreover, there are no published studies evaluating whether use of thermography in patient management, such as to select a treatment or determine treatment effectiveness, improves health outcomes.  Thus, thermography is considered investigational.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes
Investigational for all codes.  88.81-88.89
ICD-10 Codes
G56.40, G56.41,G56.42, G57.70, G57.71, G57.72, G89.0, G89.2, G89.3, G89.4, G90.50, G90.51, G90.511, G90.512, G90.513, G90.519, G90.52, G90.521, G90.522, G90.523, G50.529, G90.59, M25.50, M25.51, M25.512, M25.519, M25.52, M25.521, M25.522, M25.529, M25.53, M25.531, M25.532, M25.539, M25.551, M25.552, M25.559, M25.56, M25.561, M25.562, M25,569, M25.57, M25.571, M25.572, M25.579, M54.00, M54.01, M54.02, M54.03, M54.04, M54.05, M54.06, M54.07, M54.08, M54.09, M51.1, M54.10, M54.11, M54.12, M54.13, M54.14, M54.15, M54.16, M54.17, M54.18, M54.2, M54.3, M54.30, M54.31, M54.32, M54.4, M54.40, M54.41, M54.42, M54.5, M54.6, M54.8, M54.81, M54.89, M54.9, M79.60, M79.601, M79.601, M79.602, M79.603, M79.604, M79.605, M79.606, M79.609, M79.62, M79.621, M79.622, M79.629, M79.631, M79.632, M79.639, M79.64, M79.641, M79.642, 79.643, M79.644, M79.645, M79.646, M79.65, M79.651, M79.652, M79.659, M79.66, M79.661, M79.662, M79.669, M79.67, M79.671, M79.672, M79.673, M79.674, M79.675,M79.676, R52
Procedural Codes: 93740, 93799
References
  1. International Research Foundation for RSD/CRPS.  Reflex sympathetic dystrophy/complex regional pain syndrome. Third ed. Tampa (FL): International Research Foundation for RSD/CRPS; (2003).
  2. American College of Obstetricians and Gynecologists (ACOG). Breast cancer screening. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2003. 12 p. (ACOG practice bulletin; no. 42). The currency of the guideline was reaffirmed in (2006).
  3. Schurmann, M., Zaspel, J., et al.  Imaging in early posttraumatic complex regional pain syndrome: a comparison of diagnostic methods.  Clin J Pain (2007) 23(5):449-57.
  4. Krumova, E.K., Frettlöh, J., et al.  Long-term skin temperature measurements - a practical diagnostic tool in complex regional pain syndrome. Pain (2008) 140(1):8-22.
  5. American College of Radiology.  ACR Appropriateness Criteria for Myelopathy. (2008). Available online at: www.guideline.gov . accessed (2011 June).
  6. American College of Radiology.  ACR Appropriateness Criteria low back pain. (2008). Available www.guideline.gov . (2011 June).
  7. Council on Chiropractic Practice.  Clinical Practice Guideline.  Vertebral Subluxation in Chiropractic Practice.  Third Edition, (2008).  Available online at: <http://www.ccp-guidelines.org>.  Last accessed (2011 May).
  8. Work Loss Data Institute.  Neck and upper back (acute & chronic). (2008). Available online at: www.guideline.gov .  Last accessed (2011 June).
  9. Work Loss Data Institute.  Pain (chronic) (2008).  Available online at: www.guideline.gov . Last accessed (2011 June).
  10. Arora, N., Martins, D., et al.  Effectiveness of a noninvasive digital infrared thermal imaging system in the detection of breast cancer.  Am J Surg (2008) 196(4):523-6.
  11. Roback, K., and M. Johansson.   Feasibility of a thermographic method for early detection of foot disorders in diabetes.  Diabet Technol Ther (2009) 11(10):663-7.
  12. Wu, C.L., Yu, K.L., et al.  The application of infrared thermography in the assessment of patients with coccygodynia before and after manual therapy combined with diathermy.  J Manipulative Physiol Ther (2009) 32(4):287-93.
  13. Han, S.S., Jung, C.H., et al.  Does skin temperature difference as measured by infrared thermography within 6 months of acute herpes zoster infection correlate with pain level?  Skin Res Tech (2010) 16(2):198-201.
  14. Nakagami, G., Sanada, H., et al.  Predicting delayed pressure ulcer healing using thermography: a prospective cohort study.   J Wound Care (2010) 19(11):465-72.
  15. Romano, C.L., Logoluso, N., et al.  Telethermographic findings after uncomplicated and septic total knee replacement.  Knee (2011) [Epub before print].
History
June 2012  Policy updated with literature search through March 2012. References 1 and 7 added; other references renumbered/removed. No change in policy statement.
September 2013 Policy formatting and language revised.  Policy statement unchanged.  Added CPT code 93740.
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Thermography