Thermography, also known as temperature gradient studies, is a non-invasive imaging techniques intended to measure temperature distribution within various organs and tissues. This policy addresses thermography/temperature gradient studies.

Investigational/Not Medically Necessary:

Thermography, also known as temperature gradient studies, is considered investigational/not medically necessary in all cases, including, but not limited to, use in the evaluation of breast lesions and musculoskeletal disorders.

Rationale

The American Medical Association (1998), the American College of Radiology (2005, 2006), the American Academy of Neurology (1990), the American College of Obstetricians and Gynecologists (2003), and the National Headache Foundation (2004) have issued policy statements or other documentation which specifically do not recommend or endorse thermography as a diagnostic technology. Specifically, citing a lack of supportive studies, the American Cancer Society (2006) states that thermography should not be used to replace mammography. The Work Loss Data Institute (2005), in its pain management guideline lists thermography under the category of interventions either not currently recommended or not specifically included as a major recommendation.

The Council on Chiropractic Practice (1998) issued a document stating thermography is an established method to detect temperature changes in spinal and paraspinal tissues related to vertebral subluxation. However, this recommendation is based on expert opinion and literature support of observational, pre-post and/or case studies, but not controlled studies. In 2003, an update and revision to the policy did not include any additional recommendation or supporting documentation.

The Reflex Sympathetic Dystrophy Syndrome Association (2002) and the International Research Foundation for Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome (RSD/CRPS) (2003) issued guidelines for the treatment of reflex sympathetic dystrophy and complex regional pain syndrome. Each of these guidelines indicates thermogram may be used to assist in the diagnosis of RSD/CRPS. However, neither guideline lists supporting evidence for its conclusion.

No published studies demonstrate how the results of thermography can be used to enhance patient management and improve patient health outcomes. The scientific literature is inadequate to validate the clinical role of thermography. Therefore, thermography is considered investigational/not medically necessary.

Background/Overview

Thermography, also known as temperature gradient studies, is a non-invasive imaging techniques intended to measure temperature distribution within various organs and tissues. The infrared radiation from the tissue reveals temperature variations by producing brightly colored patterns on a liquid crystal display. Interpretation of the color patterns has been proposed to assist in the diagnosis of many disorders including breast cancer, Raynaud’s phenomenon, digital artery vasospasm in hand-arm vibration syndrome, impaired spermatogenesis in infertile men, degree of burns, deep vein thrombosis, gastric cancer, tear-film layer stability in dry-eye syndrome, Frey’s syndrome, headache, low-back pain, reflex sympathetic dystrophy, 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, assessing response to methylprednisone in rheumatoid arthritis, and locating high undescended testicles.

The American Chiropractic Association (1999) 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 not responding to clinical treatment.
• To evaluate the physiological significance of equivocal or minor anatomical findings seen on myelogram, computed tomography (CT), and/or magnetic resonance imaging (MRI).
• To evaluate for feigned disorders.

The American Chiropractic Association policy on infrared imaging for the above-listed evaluations is based on consensus guidelines and has no supporting references or documentation.

Thermography, also known as temperature gradient studies, can include various types of telethermographic infrared detector images and heat-sensitive cholesteric liquid crystal systems.

Coding

The following codes for treatments and procedures applicable to this policy are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational/Not Medically Necessary:

CPT

ICD-9 Procedure

ICD-9 Diagnosis

References

Peer Reviewed Publications:

1. Allen J, Oates CP, Chishti AD, et al. Thermography and colour duplex ultrasound assessments of arterio-venous fistula function in renal patients. Physiol Meas. 2006; 27(1):51-60.
2. Bharara M, Cobb JE, Claremont DJ. Thermography and thermometry in the assessment of diabetic neuropathic foot: a case for furthering the role of thermal techniques. Int J Low Extrem Wounds. 2006; 5(4):250-260.
3. Devgan L, Bhat S, Aylward S, Spence RJ. Modalities for the assessment of burn wound depth. J Burns Wounds. 2006; 15(e2):7-15.
4. Gulevich SJ, Conwell TD, Lane, J, et al. Stress infrared telethermography is useful in the diagnosis of complex regional pain syndrome type I (formerly reflex sympathetic dystrophy). Clin J Pain. 1997; 13(1):50-59.
5. Keyserlingk JR, Ahlgren PD, Yu E, et al. Functional infrared imaging of the breast. IEEE Eng Med Biol Mag. 2000; 19(3):30-41.
6. Ng EY, Ung LN, Ng FC, Sim LS. Statistical analysis of healthy and malignant breast thermography. J Med Eng Technol. 2001; 25(6):253-263.
7. Parisky YR, Sardi A, Hamm R, et al. Efficacy for computerized infrared imaging analysis to evaluate mammographically suspicious lesions. AJR Am J Roentgenol. 2003; 180(1):263-269.
8. Toutouzas K, Drakopoulou M, Stefanadi E, et al. Intracoronary thermography: does it help us in clinical decision making? J Interv Cardiol. 2005; 18(6):285-289.
9. Venta I, Hyrkas T, Paakkari I, Ylipaavalniemi P. Thermographic imaging of postoperative inflammation modified by anti-inflammatory pretreatment. J Oral Maxillofac Surg. 2001; 59(2):145-148.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Neurology. Assessment: Thermography in Neurologic Practice. Report of the American Academy of Neurology Therapeutics and Technology Assessment Subcommittee. Neurology. 1990; 40(3 pt 1):523-525. Available at:  http://www.aan.com/professionals/practice/pdfs/gl0053.pdf.  Accessed on February 2, 2007.
2. American Cancer Society. Mammograms and Other Breast Imaging Procedures. Revised 09/2006. Available at: http://www.cancer.org/docroot/CRI/content/CRI_2_6X_Mammography_and_other_ Breast_Imaging_Procedures_5.asp. Accessed on February 2, 2007. 
3. American Chiropractic Association. American Chiropractic Association Policy: Infrared Imaging. Available at: http://www.amerchiro.org/level2_css.cfm?T1ID=10&T2ID=117. Accessed on February 2, 2007.
4. American College of Obstetricians and Gynecologists (ACOG). Practice Bulletin No. 42; Breast cancer screening. 2003.
5. American College of Radiology. Appropriateness Criteria for Acute Low Back Pain. Last reviewed 2005.  Available at: http://www.acr.org/s_acr/bin.asp?TrackID=&SID=1&DID=11801&CID=1205&VID=2&DOC=File.PDF.  Accessed on February 2, 2007.
6. American College of Radiology. ACR Appropriateness Criteria for Myelopathy. Last reviewed 2006. Available at: http://www.acr.org/s_acr/bin.asp?CID=1205&DID=11803&DOC=FILE.PDF. Accessed on February 2, 2007.
7. American Medical Association. H-175.988 Thermography Update. Available at: http://www.ama-assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/H-175.988.HTM. Accessed on February 2, 2007.
8. Centers for Medicare and Medicaid Services. National Coverage Determination for Thermography. NCD #220.11. Effective December 21, 1992. Available at: http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd. Accessed on February 5, 2007.
9. Council on Chiropractic Practice. Clinical Practice Guideline Number 1: Vertebral Subluxation in Chiropractic Practice. 1998. Available at: http://www.ccp-guidelines.org/guideline-1998.pdf. Accessed on February 5, 2007.
10. Council on Chiropractic Practice. Clinical Practice Guideline Number 1: Vertebral Subluxation in Chiropractic Practice 2003 Update and Revision. 2003. Available at: http://www.ccp-guidelines.org/guideline-2003.pdf. Accessed on February 5, 2007.
11. International Research Foundation for RSD/CRPS. Clinical Practice Guidelines: Reflex sympathetic dystrophy/complex regional pain syndrome (RSD/CRPS), 3rd ed. Available at: http://www.rsdfoundation.org/en/en_clinical_practice_guidelines.html. Accessed on February 6, 2007.
12. Reflex Sympathetic Dystrophy Syndrome Association (RSDSA). Clinical practice guidelines (second edition) for the diagnosis, treatment, and management of reflex sympathetic dystrophy/complex regional pain syndrome (RSD/CRPS). Milford (CT): Reflex Sympathetic Dystrophy Syndrome Association (RSDSA); 2002 Feb. 46 p.
13. Reflex Sympathetic Dystrophy Syndrome Association. The use of thermography in the diagnosis of CRPS: a physician’s opinion. Available at: http://www.rsds.org/3/education/thermography.htm. Accessed on February 6, 2007. 
14. Work Loss Data Institute. Pain. Corpus Christi (TX): Work Loss Data Institute; 2005. 182 p.
    

Index

The use of specific product names is illustrative only.  It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Policy History

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.

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