BlueCross BlueShield of Tennessee Medical Policy Manual

Plethysmography

DESCRIPTION

Plethysmography is a non-invasive technique for measuring the amount of blood flow present or passing through, an organ or other part of the body. Plethysmography is used to diagnose deep vein thrombosis and arterial occlusive disease.

Plethysmography is used as the sole diagnostic modality for these conditions, or as an initial evaluation to determine the need for venography or arteriography. A variety of plethysmographic techniques are available.

POLICY

See also policies for specific applications of Plethysmography:

ADDITIONAL INFORMATION

The specific applications of air displacement plethysmography, electrical impedance plethysmography for scanning of the breast and thoracic electrical bioimpedance and inert gas re-breathing devices in the outpatient setting are individually addressed in separate policies.

It may be medically necessary to perform spirometry, or pulmonary function test in conjunction with total body plethysmography. Functional residual capacity or residual volume, expired gas collection quantitative, and thoracic gas volume is considered elements of (included in) the total body plethysmography procedure.

The performance of more than one plethysmography procedure on a single day or more than three performed within a 60-day period should be reviewed for medical necessity. Situations such as radical change in the individual's condition, indicating an acute exacerbation of circulatory blockage, may indicate the need for more than one measurement on a single day. Situations that might indicate the need for more than three plethysmography procedures within a 60-day period are deterioration of the individual's status, exacerbation of symptoms, and complications of therapy.

No controlled studies were found in the published literature that validates the application of plethysmograph for those modalities listed in the investigational statement. No evidence was found to show that evaluation of the status of the modalities listed in the investigational statement can predict clinical events and, thus, be used to alter the treatment of individuals.

SOURCES

American Academy Respiratory Care. (2001). Clinical Practice Guideline. Body Plethysmography 2001 Revision & Update. Retrieved July 22, 2009 from http://www.rcjournal.com/cpgs/pdf/05.01.506.pdf.

Annals of Emergency Medicine. (2003, July). Clinical policy: Critical issues in the evaluation and management of adult patients presenting with suspected lower-extremity deep venous thrombosis. Retrieved July 22, 2009 from http://www.acep.org/WorkArea/DownloadAsset.aspx?id=8812.

Bar Yishay, E. (2009). Whole-body plethysmography the human factor. Chest, 135 (6), 1412 - 1414. (Level 5 Evidence)

Complete Guide to Medicare Coverage Issues [Computer software]. (2009, April). Plethysmography (NDC 20.14, p. 2-20). The Ingenix Complete Guide to Medicare Coverage Issues.

Complete Guide to Medicare Coverage Issues [Computer software]. (2009, April). Cardiac output monitoring by thoracic electrical bioimpedance (TEB) (NDC 20.16, p. 2-23). The Ingenix Complete Guide to Medicare Coverage Issues.

Goldman, L., & Ausiello, D., (Eds.). (2007). Cecil Medicine (23rd ed., pp.720 - 722,). Philadelphia: Saunders Elsevier.

Hayes. Medical Technology Directory. (2003, January). Electrical bioimpedance for the measurement of cardiac output. Retrieved July 22, 2009 from www.Hayesinc.com/subscribers.

Hayes. Medical Technology Directory. (2006, January). Air displacement plethysmography for the measurement of body composition. Retrieved July 22, 2009 from www.Hayesinc.com/subscribers.

Hayes. Medical Technology Directory. (2006, January). Plethysmography for diagnosis of deep vein thrombosis of the legs. Retrieved July 22, 2009 from www.Hayesinc.com/subscribers.

Hayes. Medical Technology Directory. (2007, January). Plethysmography for chronic venous insufficiency. Retrieved July 22, 2009 from www.Hayesinc.com/subscribers.

Herman-Gerhard, M., Gardin, J. M., Jaff, M., Mohler, E., Roman, M., & Nasqvi, T. Z. (2006). Guidelines for noninvasive vascular laboratory testing: A report from the American Society of Echocardiography and the Society for Vascular Medicine and Biology. Vascular Medicine, 11 (3), 183-200.

Mason, R., Murray, J., Broaddus, V., & Nadel, J., (Eds.). (2005). Murray & Nadel’s Textbook of Respiratory Medicine (4th ed. pp.681 – 685). Philadelphia: Saunders Elsevier.

National Guideline Clearinghouse. (2005). ACR appropriateness criteria suspected lower extremity deep vein thrombosis. Retrieved July 22, 2009 from http://www.guidelines.gov.

Poorisrisak, P., Vrang, C., Henriksen, J., Klug, B., Hanel, B., & Bisgaard, H. (2009). Accuracy of whole-body plethysmography requires biological calibration. Chest, 135 (6), 1476 - 1480. (Level 4 Evidence)

U. S. Department of Health & Human Services. Centers for Medicare & Medicaid Services. National Coverage Analyses. (September, 2008). LDC for Noninvasive Vascular Studies (L1352). Retrieved July 22, 2009 from http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=1352&lcd_version=42&basket=lcd%3A1352%3A42%3ANoninvasive+Vascular+Studies%3AFI%3ABlueCross+BlueShield+of+Tennessee+%28Riverbend+Government+Benefits+Administrator%29+%2800390%29%3A.

U. S. Department of Health & Human Services. Centers for Medicare & Medicaid Services. National Coverage Analyses. (October, 2005). LCD for cardiac output monitoring by thoracic electrical bioimpedance (TEB) (L6095). Retrieved July 22, 2009 from http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=6095&lcd_version=21&show=all.

U. S. Department of Health & Human Services. Centers for Medicare & Medicaid Services. National Coverage Analyses. (June, 2007). Article for thoracic electrical bioimpedance coverage (A19027). Retrieved July 22, 2009 from http://www.cms.hhs.gov/mcd/viewarticle.asp?article_id=19027&article_version=4&show=all.

U. S. Food and Drug Administration. (2003, February). Center for Devices and Radiological Health. 510(K) Premarket Notification Database. K023707. Retrieved July 22, 2009 from http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm?ID=9981.

Wabel, P., Chamney, P., Moissl, U., & Jirka, T. (2009). Importance of whole-body bioimpedance spectroscopy for the management of fluid balance. Blood Purification, 27 (1), 75 - 80. (Level 5 Evidence)

Wabel, P., Ulrich, M., Chamney, P., Jirka, T., Machek, P., Pounce, P., et al. (2008). Towards improved cardiovascular management: the necessity of combining blood pressure and fluid overload. Nephrology Dialysis Transplant, 23 (9), 2965 - 2971. (Level 5 Evidence)

Wang, S. M., Hu, Z. J., Li, S. Q., Huang, X. L. & Ye, C. S. (2006). Effect of external valvuloplasty of the deep vein in the treatment of chronic venous insufficiency of the lower extremity. Journal of Vascular Surgery, 44 (6), 1296-1230. (Level 4 Evidence)

West, J. B., & Wagner, P. D. (2000). Ventilation, Blood Flow, and Gas Exchange. In J. F. Murray & J. A. Nadel: Textbook of Respiratory Medicine (3rd ed., pp. 56-60, 104-108, 783-805). Philadelphia: W.B. Saunders Company.

ORIGINAL EFFECTIVE DATE:  4/81

MOST RECENT REVIEW DATE:  10/8/2009

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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