Clinical UM Guideline


Subject: Three-Dimensional (3-D) Rendering of Imaging Studies
Guideline #:  CG-MED-51 Publish Date:    10/17/2018
Status: Reviewed Last Review Date:    09/13/2018


This document addresses three-dimensional (3-D) rendering of imaging studies. 3-D rendering uses multiple thin sections of images and reconstructs them into 3-D images which can display anomalies or structures and enhance visualization of pathology. This technology may also be referred to as 3-D reconstruction or 3-D reformation.

Note: This document does not address CT Colonography (Virtual Colonoscopy), 3-D fetal ultrasound or 3-D mammography (digital breast tomosynthesis). Please see the following related document for additional information:

Clinical Indications

Medically Necessary:

The use of 3-D image rendering is considered medically necessary for clinical evaluation or preoperative planning when the information provided cannot be obtained by traditional two-dimensional (2-D) imaging, and is critical to the clinical management of the individual. Common indications for 3-D image rendering include, but are not limited to:

Not Medically Necessary:

The use of 3-D image rendering is considered not medically necessary for the following:


The following codes for treatments and procedures applicable to this guideline 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.




3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation


3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation



ICD-10 Diagnosis



All diagnoses

Discussion/General Information

The process of 3-D rendering creates 2-D images that convey the 3-D relationship of objects. 3-D rendering may take place on the same scanner the original studies were conducted on with built in 3-D software or by post-processing on an independent workstation. Complex 3-D image rendering may require extensive independent workstation processing by a supervising physician and specially trained technologist. This type of reconstruction has been applied to computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), computed tomography angiography (CTA), digital subtraction angiography (DSA), ultrasound (US) and other tomographic modalities. Studies vary widely for the scope of use of 3-D image rendering. However, the consensus of published literature supports the use of 3-D image rendering for a variety of indications.


Multiple studies have compared 2-D to 3-D DSA for the detection and evaluation of intracranial aneurysms (Kucukay, 2012; Wong; 2012) and concluded that 3-D DSA improved detection of aneurysms compared to 2-D DSA. Chen and colleagues (2012) evaluated the clinical value of 3-D time of flight (TOF) MRA for the diagnosis and planning of 165 individuals with subarachnoid hemorrhage. Treatment planning with volume rendering (VR) 3-D-TOF-MRA was compared to actual treatment decisions that had been carried out on each aneurysm using DSA. The authors concluded that VR 3-D-TOF-MRA is a reliable diagnostic and screening tool in the detection or ruling out of aneurysms. HaiFeng and colleagues (2017) performed a meta-analysis of 18 studies (n=3463) and found that 3D-TOF-MRA had an “excellent diagnostic performance” for the assessment of intracranial aneurysms.

Complex Facial Trauma and Tumors

Significant benefits have been demonstrated with the use of 3-D rendering for head, neck and facial reconstruction secondary to soft tissue tumors or traumatic facial injuries. A 2007 literature and case review by Fernandes evaluated 3-D rendering of CT imaging for the treatment planning of complex reconstruction secondary to soft tissue and bony tumors of the head and neck, post-traumatic deformities such as gunshot wounds, and for correction of craniofacial deformities. The authors reported that the use of computer-aided rendering of 3-D images of the disease process or defects allowed the surgeon to manipulate the information in the preoperative setting to aid in the planning of the surgery.

Kaur and colleagues (2010) assessed 3-D CT reconstruction for the evaluation and surgical planning of mid-face fractures. A total of 100 cases of maxillofacial trauma with mid-face fractures were subjected to clinical examination, conventional plain film radiography and 3-D CT. Traffic accidents were the most common etiology of the trauma, followed by assault, fall, and sports related injuries. In 28 cases, 3-D CT had significant impact on the final diagnosis and treatment planning of the fractures. The authors concluded that 3-D CT was valuable in cases of severe facial injury, but much less useful in minor trauma.

Gynecologic Conditions

The role of 3-D sonography in gynecologic imaging is evolving and has proven beneficial in certain cases. In a consecutive series of 66 women, Benacerraf and colleagues (2008) evaluated whether a 3-D reconstructed coronal view of the uterus provided added benefit to standard gynecologic sonography. For all evaluations, a 2-D pelvic sonography was performed followed by 3-D sonography. The authors reported that 3-D coronal views of the uterus added value to the 2-D scan in 16 (24%) of the 66 women. In 5 of these 16 cases, the coronal view added information about findings not observed with 2-D imaging. In the other 11 cases, the diagnostic findings were more confidently seen using the coronal view. The coronal view was helpful in 4 (12.5%) of 32 women with an endometrium less than 5 mm, 1 of 6 women whose endometrium was incompletely seen with 2-D sonography, and 11 (39%) of 28 women whose endometrium measured at least 5 mm. For those with normal findings on 2-D scans, the coronal view did not provide benefit. There were 5 uterine anomalies in the series consisting of 4 cases of arcuate uterus and 1 case of subseptate uterus. Uterine shape anomalies were diagnosed using the coronal view in 3 women referred due to infertility.

A retrospective study (Ghates, 2008) evaluated 80 women that underwent sonohysterography with both conventional 2-D sonohysterography and 3-D multiplanar imaging (volume of data acquired and reconstructed in the transverse, sagittal, and coronal planes). Three readers interpreted the 2-D scans alone and then the 2-D and 3-D images together. Average blinded reader scores for identification of endometrial abnormality were not significantly different, and there was no significant difference when polyps, fibroids, and septations were evaluated separately. However, the average scores for definition of fundal contour were significantly different for 2-D alone versus 2-D and 3-D combined. The authors reported that 3-D reformations are a helpful adjunct to 2-D images alone for the evaluation and exclusion of uterine contour abnormalities. However, 3-D combined with 2-D transvaginal sonohysterography is not a significant improvement over 2-D imaging alone for detection of endometrial abnormalities.

More recently, Sakhel and colleagues (2013) evaluated the role of 3-D sonography as a first-line imaging technique for gynecologic pelvic disease. The authors reported that 3-D sonography should be the initial imaging of choice for “patients suspected of müllerian anomalies; and IUD localization in symptomatic patients.” Further noted was that “3-D sonography should also be considered as an adjunct to 2-D sonography in select adnexal masses, such as evaluation of a suspected hydrosalpinx.”

In a 2017 Cochrane review, Nieuwenhuis and colleagues evaluated 13 studies (1053 subjects) for the comparison of 3D saline infusion sonography (SIS) versus 2D SIS in diagnosing focally growing lesions in abnormal uterine bleeding (AUB) or subfertility. A meta-analysis that favored 3D SIS to hysteroscopy had a sensitivity of 94.5% (95% confidence interval [CI]; 90.6% to 96.9%) and a specificity of 99.4% (95% CI; 96.2% to 99.9%). A meta-analysis comparing 2D SIS to 3D SIS showed no statistically significant difference. The authors concluded that both 2D SIS and 3D SIS are very accurate and should be considered alternatives to hysteroscopy. However, the authors considered the quality of evidence low since some studies lacked sufficient study method reporting.

The American Institute of Ultrasound in Medicine (Benacerraf, 2005) convened a panel of physicians and scientists with expertise in 3-D ultrasound in obstetrics and gynecology to discuss the current state of the art for 3-D ultrasound (US). The panel reported the following gynecology applications as examples of clinical utility for 3-D US:

Cardiac Conditions

3-D echocardiography is more accurate than 2-D echocardiography for the detection of chemotherapy induced cardiotoxicity (Tann, 2014; Tann, 2012). Chemotherapy-induced cardiac dysfunction can include arrhythmias, heart failure, myocardial ischemia or infarction, hypertension, and thromboembolism. Limitations of 2-D echocardiography as compared to 3-D include poor endocardial definition, ventricular foreshortening, and the use of mathematical models and geometrical assumptions to calculate the LV volumes (Tann, 2012). Additionally, multiple studies (Jacobs, 2006; Takuma, 2001) demonstrate superiority of 3-D versus 2-D echocardiography.

Hu and colleagues (2008) demonstrated the reliability of multidetector CT (MDCT) angiography and 3-D reconstruction for diagnosing coarctation of the aorta. In this small study, 16 children underwent both color Doppler echocardiography (CDE) and MDCT. In addition to the CT axial slices, 3-D reconstructions such as volume rendering and multiple planar reformation were used to diagnose coarctation and other cardiac abnormalities. The authors concluded that MDCT angiography combined with 3-D reconstruction provides reliable diagnostic information about thoracic aortic anatomy for pediatric preoperative planning.

Other Indications

Various 3-D rendering imaging studies have effectively evaluated additional indications including:

Other Considerations

According to a 2016 “Practice Parameter for the Performance and Interpretation of Body computed CT Angiography (CTA)” developed jointly by the American College of Radiology (ACR), the North American Society of Cardiovascular Imagers (NASCI), the Society for Pediatric Radiology (SPR), and the Society of Interventional Radiology (SIR), indications for body CTA including interpretation using 3-D renderings include the following:

A 2015 “Practice Parameter for the Performance of Cervicocerebral Magnetic Resonance Angiography (MRA)” developed jointly by the ACR, the American Society of Neuroradiology (ASNR), the Society of NeuroInterventional Surgery (SNIS), and the Society for Pediatric Radiology (SPR) reports that MRA is a general term that refers to a diverse group of MR pulse sequences and each sequence may be performed with 2-D or 3-D techniques.

According to the 2015 practice parameter for cervicocerebral MRA:

Pediatric Indications for Cervicocerebral MRA:

MRI/MRA is typically the imaging modality of choice for the initial evaluation of the cervicocerebral vasculature in children. It is a noninvasive and low-risk examination free of ionizing radiation, as compared to conventional endovascular or CT angiographic procedures. Studies of pediatric stroke that compared MRA to conventional angiography found MRA to be accurate in delineating stenosis and/or occlusion and able to demonstrate vascular anatomy in a variety of pathological conditions. In some clinical instances, follow-up computed tomographic angiography (CTA) or catheter angiography may be necessary to fully characterize the abnormality.

Indications for cervicocerebral MRA in the pediatric population include, but are not limited to, the definition and evaluation of the following:

Indications for cervicocerebral MRA in the adult population include, but are not limited to, the definition and evaluation of the following:

Evaluation of the aortic arch and subclavian arteries in adults and children may require separate techniques and sequences. Indications include, but are not limited to, the following:

A 2015 “Practice Parameter for the Performance of Body Magnetic Resonance Angiography (MRA)” developed jointly by the ACR, NASCI and the SPR reports that contrast enhanced (CE)-MRA methods rely on enhancement of the blood signal by intravascular paramagnetic contrast agents, typically gadolinium-based, and use a rapid, three-dimensional (3D) T1-weighted gradient echo acquisition. The parameter also states that a “body MRA is a proven and useful tool for the evaluation, assessment of severity, and follow-up of diseases of the vascular system.”

A 2014 “Practice Parameter for the Performance of Pediatric Computed Tomography (CT)” developed jointly by the ACR, American Society of Emergency Radiology (ASER), the Society of Computed Body Tomography and Magnetic Resonance (SCBT-MR) and the SPR includes the following information:

Chest- Postprocessing 2-D reformations, maximum intensity projection (MIP) reconstructions, and 3-D volume rendering may be useful adjuncts in displaying the anatomy. 2-D reformation and sliding thin-slab MIP techniques have been found to increase sensitivity in the detection of lung nodules and arteriovenous malformations.

Abdomen- Postprocessing 2-D reformations, maximum intensity projection (MIP) reconstructions, and 3-D volume rendering may be useful adjuncts in displaying the anatomy, especially in evaluation of vascular anatomy.



Cornual pregnancy: A pregnancy in the interstitial segment of a unicornuate or bicornuate uterus.


Müllerian anomalies: Malformations of the fallopian tubes and uterus.


Subarachnoid hemorrhage: Bleeding in the space between the two membranes that surround the brain.



Peer Reviewed Publications:

  1. Albes JM, Seemann MD, Heinemann MK, Ziemer G. Correction of anterior thoracic wall deformities: improved planning by means of 3D-spiral-computed tomography. Thorac Cardiovasc Surg. 2001; 49(1):41-44.
  2. Bamba Y, Nonaka M, Nakajima S, Yamasaki M. Three-dimensional reconstructed computed tomography-magnetic resonance fusion image-based preoperative planning for surgical procedures for spinal lipoma or tethered spinal cord after myelomeningocele repair. Neurol Med Chir (Tokyo). 2011; 51(5):397-402.
  3. Benaceraff BR, Benson CB, Abuhamad AZ, et al. Three and 4-Dimensional ultrasound in obstetrics and Gynecology, proceedings of the American Institute of Ultrasound in Medicine Consensus Conference, J Ultrasound Med, 2005; 24(12):1587-1597.
  4. Benacerraf BR, Shipp TD, Bromley B. Which patients benefit from a 3D reconstructed coronal view of the uterus added to standard routine 2D pelvic sonography, AJR Am J Roentgenol. 2008; 190(3):626-629.
  5. Chen YC, Sun ZK, Li MH, et al. The clinical value of MRA at 3.0 T for the diagnosis and therapeutic planning of patients with subarachnoid haemorrhage. Eur Radiol. 2012; 22(7):1404-1412.
  6. Dong Y, Dong Y, Hu G, Xu Q. Three-dimensional reconstruction of extremity tumor regions by CT and MRI image data fusion for subject-specific preoperative assessment and planning. Comput Aided Surg. 2011; 16(5):220-233.
  7. Fernandes R, DiPasquale J. Computer-aided surgery using 3D rendering of maxillofacial pathology and trauma. Int J Med Robot. 2007; 3(3):203-206.
  8. Fishman EK, Horton KM, Johnson PT. Multidetector CT and three-dimensional CT angiography for suspected vascular trauma of the extremities. Radiographics. 2008; 28(3):653-665; discussion 665-666.
  9. Froehler MT. Endovascular treatment of ruptured intracranial aneurysms. Curr Neurol Neurosci Rep. 2013; 13(2):326.
  10. Ghate SV, Crockett MM, Boyd BK, et al. Sonohysterography: do 3D reconstructed images provide additional value, AJR, 2008; 190:W227-W233.
  11. HaiFeng L, YongSheng X, YangQin X, et al. Diagnostic value of 3D time-of-flight magnetic resonance angiography for detecting intracranial aneurysm: a meta-analysis. Neuroradiology. 2017; 59(11):1083-1092.
  12. Hu XH, Huang GY, Pa M, et al. Multidetector CTmangiography and 3D reconstruction in young children with coarctation of the aorta. Pediatr Cardiol. 2008; 29(4):726-731.
  13. Inoue A, Ohnishi T, Kohno S, et al. Utility of three-dimensional computed tomography for anatomical assistance in endoscopic endonasal transsphenoidal surgery. Neurosurg Rev. 2015; 38(3):559-565.
  14. Jacobs LD, Salgo IS, Goonewardena S, et al. Rapid online quantification of left ventricular volume from real-time three-dimensional echocardiographic data. Eur Heart J. 2006; 27(4):460-468.
  15. Kaur J, Chopra R. Three dimensional CT reconstruction for the evaluation and surgical planning of mid face fractures: a 100 case study. J Maxillofac Oral Surg. 2010; 9(4):323-328.
  16. Kosar MI, Atalar MH, Sabancioğullari V, et al. Evaluation of the length and angulation of the styloid process in the patient with pre-diagnosis of Eagle syndrome. Folia Morphol (Warsz). 2011; 70(4):295-299.
  17. Kucukay F, Okten RS, Tekiner A, et al. Three-dimensional volume rendering digital subtraction angiography in comparison with two-dimensional digital subtraction angiography and rotational angiography for detecting aneurysms and their morphological properties in patients with subarachnoid hemorrhage. Eur J Radiol. 2012; 81(10):2794-2800.
  18. Lou EH, Chan AC, Donauer A, et al. Ultrasound-assisted brace casting for adolescent idiopathic scoliosis, IRSSD Best research paper 2014. Scoliosis. 2015; 10:13.
  19. Mari FS, Nigri G, Pancaldi A, et al. Role of CT angiography with three-dimensional reconstruction of mesenteric vessels in laparoscopic colorectal resections: a randomized controlled trial. Surg Endosc. 2013; 27(6):2058-2067.
  20. Nieuwenhuis LL, Hermans FJ, Bij de Vaate AJM, et al. Three-dimensional saline infusion sonography compared to two-dimensional saline infusion sonography for the diagnosis of focal intracavitary lesions. Cochrane Database Syst Rev. 2017;(5):CD011126.
  21. Ringe KI, Hartung D, von Falck C, et al. 3D-MRCP for evaluation of intra- and extrahepatic bile ducts: comparison of different acquisition and reconstruction planes. BMC Med Imaging. 2014; 14:16.
  22. Sakhel K, Benson CB, Platt LD, et al. Begin with the basics: role of 3-dimensional sonography as a first-line imaging technique in the cost-effective evaluation of gynecologic pelvic disease, J Ultrasound Ned, 2013; 32(3):381-388.
  23. Takuma S, Ota T, Muro T, et al. Assessment of left ventricular function by real-time 3-dimensional echocardiography compared with conventional noninvasive methods. J Am Soc Echocardiogr. 2001; 14(4):275-284.
  24. Tan T, Scherrer-Crosbie M. Assessing the cardiac toxicity of chemotherapeutic agents: role of echocardiography, Curr Cardiovasc Imaging Rep. 2012; 5(6):403-409.
  25. Tan T. Scherrer-Crosbie M. cardiac complications of chemotherapy; role of imaging. Curr Treat Options Cardiovasc Med. 2014; 16(4):296.
  26. Wong KE, Gorton GE 3rd, Tashjian DB, et al. Evaluation of the treatment of pectus carinatum with compressive orthotic bracing using three dimensional body scans. J Pediatr Surg. 2014; 49(6):924-927.
  27. Wong SC, Nawawi O, Ramli N, et al. Benefits of 3D rotational DSA compared with 2D DSA in the evaluation of intracranial aneurysm. Acad Radiol. 2012; 19(6):701-717.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. ACR–ASER–SCBT-MR–SPR. Practice Parameter for the Performance of Pediatric Computed Tomography (CT). Revised 2014. Available at: Accessed on August 7, 2018.
  2. ACR-ASNR–SNIS–SPR. Practice Parameter for the Performance of Cervicocerebral Magnetic Resonance Angiography (MRA). Revised 2015. Available at: Available at: Accessed on August 7, 2018.
  3. ACR-NASCI-SIR-SPR. Practice Parameter for the Performance and Interpretation of Body computed CT Angiography (CTA). Revised 2016. Available at: Available at: Accessed on August 7, 2018
  4. ACR–NASCI–SPR. Practice Parameter for the Performance of Body Magnetic Resonance Angiography (MRA). Revised 2015. Available at: Available at: Accessed on August 7, 2018.

Three Dimensional Reformation
Three Dimensional Rendering
Three Dimensional Reconstruction

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.







Medical Policy & Technology Assessment Committee (MPTAC) review. Rationale and References sections updated.



MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Discussion/General Information and References sections.



MPTAC review. Formatting updated in clinical indication section. Discussion/General Information and Reference sections updated.



MPTAC review. Note in description section updated. Removed ICD-9 codes from Coding section.



MPTAC review. Initial document development.