CurrentKaiser PermanentePolicy N/A

Whole‑body computed tomography (CT) screening — Coverage Criteria

Governs use and medical necessity determination for whole-body CT scanning primarily as a screening service for asymptomatic individuals within Kaiser Permanente Washington; affects ordering providers and preauthorization reviewers.

Policy Summary

PayerKaiser Permanente

PolicyWhole‑body computed tomography (CT) screening — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review Date05/07/2024

Key ActionVerify authorization requirements by plan type and review whole-body CT requests against the Medically Necessary Service policy; submit the last 3 months of clinical notes to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

No published efficacy studiesevidence for whole-body CT screening in asymptomatic individuals

Not Medically Necessarycoverage stance for non‑Medicare members

Medicare: medically necessary when criteria metcoverage stance for Medicare members

05/07/2024last review date

Coverage Criteria for Whole-Body CT Screening

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Coverage by member type

Coverage determination for whole-body CT screening:

Medicare members: whole-body CT is considered medically necessary only when criteria in the applicable Medicare policy statements are met.

Refer to applicable Medicare coverage manuals, NCDs and LCDs for specific Medicare coverage criteria.

Non-Medicare members: Whole-body CT screening for asymptomatic individuals is considered Not Medically Necessary for Non‑Medicare members.

Kaiser MTAC concluded no published studies demonstrate efficacy of whole-body CT screening in asymptomatic individuals; the use of whole-body CT for general screening does not meet Kaiser Permanente Medical Technology Assessment criteria.

Use of whole-body CT scanning in the general screening of healthy, asymptomatic individuals is excluded because it does not meet Kaiser Permanente Medical Technology Assessment criteria. The Medical Technology Assessment Committee found no published studies demonstrating efficacy of whole-body CT screening in asymptomatic populations and concluded the procedure does not meet MTAC criteria for general screening. (See MTAC evidence conclusion.)

For Non‑Medicare members, whole-body CT screening of asymptomatic individuals is considered Not Medically Necessary due to lack of evidence demonstrating efficacy. Providers should expect that requests for whole-body CT as general screening for asymptomatic patients may be denied for Non‑Medicare plans.

Whole-body CT for asymptomatic screening — Covered Indications

Screening indication: Non-tailored whole-body CT offered to asymptomatic individuals for general screening is not supported by evidence and is not recommended.

FDA and Kaiser assessments found no demonstrated benefit and potential harms; no published studies evaluate efficacy of whole-body CT screening in asymptomatic individuals.

Provider Action Items and Authorization

Prior Authorization

Preauthorization and code verification

Whole‑body CT (whole body computed tomography) screening for asymptomatic individuals is not considered medically necessary for Non‑Medicare members. Review requests against the applicable Medically Necessary Service policy and verify coverage for the member's plan type before submitting.

For Non‑Medicare members: Whole Body CT screening — screening considered Not Medically Necessary and may be denied
Verify authorization requirements for specific codes and plan types using the Pre‑authorization Code Check

Documentation Required

Required documentation

If requesting whole‑body CT for asymptomatic screening, submit required documentation to support medical necessity. Incomplete submissions may result in denial or delayed review.

Required documentation: Last 3 months of clinical notes from the requesting provider and/or consulting specialist
Include any relevant diagnostic findings, symptoms, or clinical rationale that justify imaging beyond screening

Note

Additional provider action callout

Action required: include the clinical documentation listed above with the authorization request. Failure to provide requested notes or clinical justification is a frequent cause for denial.

Denial Risk

Denial risk for Non‑Medicare members

Denial risk: For Non‑Medicare members, whole‑body CT screening for asymptomatic individuals is considered Not Medically Necessary and may be denied. Providers should confirm medical necessity and submit supporting documentation if an exception is being requested.

Non‑Medicare members: screening considered Not Medically Necessary
Medicare members: considered medically necessary only when criteria in the applicable policy statements are met

Background

Whole-body CT screening refers to a non-tailored, non‑specific CT scan of multiple body regions offered to healthy, asymptomatic individuals for general disease screening. This use has been promoted as a preventive measure, but the FDA and Kaiser assessment report no data demonstrating that whole-body CT screening effectively detects disease early enough to improve outcomes, and MTAC found no published studies supporting efficacy; potential harms may outweigh uncertain benefits.

Definitions

Definition — Whole-body CT screening

DefinitionA non-tailored, non-specific CT scan of multiple body regions offered to asymptomatic individuals for general disease screening.

Purpose as marketedPromoted as a preventive or proactive health measure to healthy individuals with no symptoms or suspicion of disease.

Regulatory/assessment findingFDA: no data demonstrating whole-body CT screening is effective in detecting disease early enough to improve outcomes.

Policy Summary

PayerKaiser Permanente

PolicyWhole‑body computed tomography (CT) screening — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review Date05/07/2024

SourceLink

On This Page

OpenPayer

Whole‑body computed tomography (CT) screening — Coverage Criteria

Coverage Criteria for Whole-Body CT Screening

Coding and Billing

Provider Action Items and Authorization

Prior Authorization Notes

Background

Definitions

Frequency Limits

Contrast Rules

Not Covered