Download Clinical Appropriateness Guidelines

Clinical Appropriateness Guidelines
Imaging Program Guidelines
Scheduled Effective Date: November 4, 2013
AIM Guidelines are regularly reviewed and updated. The following document has a
scheduled effective date of November 4, 2013. It is made available with the following
notice:
•
These guidelines apply only to utilization management cases adjudicated on or after
November 4, 2013. Guidelines in effect until November 3, 2013 can be found on the
AIM website at www.aimspecialtyhealth.com.
•
This document includes only those indications that have been revised, with language
that differs from the current Guidelines. A complete Guidelines document listing all
indications will be available on the AIM website on the future effective date of November 4, 2013.
Date of Origin: 3/30/2005
Last Reviewed:7/09/2013
Last Revised: 7/09/20139/2013
Copyright © 2013. AIM Specialty Health. All Rights Reserved
Clinical & Regulatory Guidelines
8600 W Bryn Mawr Avenue
South Tower - Suite 800
Chicago, IL 60631
P. 773.864.4600
F. 773.864.4662
www.aimspecialtyhealth.com
Table of Contents
Head & Neck Imaging ...............................................................................................................3
CT of the Head .......................................................................................................................................................3
MRI of the Head .....................................................................................................................................................9
MRI of the Orbit, Face & Neck (Soft Tissues) ......................................................................................................15
CT of the Neck (Soft Tissue) ................................................................................................................................18
CTA of the Neck ...................................................................................................................................................21
Head & Neck Bibliography ...................................................................................................................................25
Chest Imaging .........................................................................................................................29
CT of the Chest ....................................................................................................................................................29
Chest Biblography ................................................................................................................................................34
Abdominal & Pelvic Imaging ..................................................................................................38
CT of the Abdomen ..............................................................................................................................................38
CTA/MRA of the Abdomen ...................................................................................................................................46
CT of the Pelvis ....................................................................................................................................................49
CTA/MRA of the Pelvis .........................................................................................................................................55
CT of the Abdomen & Pelvis Combination ...........................................................................................................57
Abdomen & Pelvis Bibliography ...........................................................................................................................63
Extremity Imaging ...................................................................................................................66
CT of the Upper Extremity ....................................................................................................................................66
MRI of the Upper Extremity (Any Joint) ................................................................................................................69
MRI of the Upper Extremity (Non-Joint) ...............................................................................................................74
CT of the Lower Extremity ....................................................................................................................................77
MRI of the Lower Extremity (Joint & Non-Joint) ...................................................................................................80
Extremity Bibliography .........................................................................................................................................85
Table of Contents | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
2
Computed Tomography (CT)
Head
CPT Codes
70450.................. CT of head, without contrast
70460.................. CT of head, with contrast
70470.................. CT of head, without contrast, followed by re-imaging with contrast
Standard Anatomic Coverage
Ɣ From the skull base to vertex, covering the entire calvarium and intra-cranial contents.
Ɣ 6FDQFRYHUDJHPD\YDU\GHSHQGLQJRQWKHVSHFL¿FFOLQLFDOLQGLFDWLRQ
Imaging Considerations
Ɣ MRI of the head is preferable to CT in most clinical scenarios, due to its superior contrast resolution and lack of beamhardening artifact adjacent to the petrous bone (which may limit visualization in portions of the posterior fossa and
brainstem on CT). Notable exceptions to the use of head MRI as the neuroimaging procedure of choice are: acute intracranial hemorrhage (parenchymal, subarachnoid; subdural; epidural); initial evaluation of recent craniocerebral trauma;
osseous assessment of the calvarium, skull base and maxillofacial bones, including detection of calvarial and facial bone
IUDFWXUHVDQGHYDOXDWLRQRIFDOFL¿HGLQWUDFUDQLDOOHVLRQV
Ɣ MRI is more sensitive for detection of shearing trauma to the brain and diffuse axonal injury. It is also the preferred
technique for assessment of subacute and chronic intra-cranial hemorrhage.
Ɣ CT of the head is an alternative exam in patients who cannot undergo MRI.
Ɣ For CT imaging of the orbits, internal auditory canals (IACs) or temporal bones, see CPT codes 70480-70482.
Ɣ According to Medicare’s correct coding edits, a CT of the head is not usually performed with a CT of the orbits. These
studies are generally considered mutually exclusive procedures.
Ɣ Imaging studies of the head and neck are inherently bilateral. Duplicate requests for bilateral studies to image the right
and left side of the head are inappropriate.
Ɣ Screening for metastatic disease in a patient with stage I non-small cell lung cancer (NSCLC) in the absence of
neurologic symptoms is not indicated 1-6
Ɣ CT or MRI imaging is not typically indicated for simple pediatric febrile seizure in the absence of other neurological
¿QGLQJV7,8
Ɣ &7LVQRWW\SLFDOO\LQGLFDWHGIRUVXGGHQKHDULQJORVVLQWKHDEVHQFHRIRWKHUQHXURORJLFDO¿QGLQJV9,10
Ɣ For a pediatric patient, in the immediate evaluation of minor head injuries, CT of the head may not be indicated. Please use
the pediatric emergency care applied research network (PECARN) criteria to determine whether imaging is indicated 7,11
Common Diagnostic Indications
The following diagnostic indications for head CT are accompanied by pre-test considerations as well as clinical supporting data
and prerequisite information.
$EQRUPDOLWLHVGHWHFWHGRQRWKHULPDJLQJVWXGLHVZKLFKUHTXLUHDGGLWLRQDOFODUL¿FDWLRQWRGLUHFW
treatment
Cerebrovascular accident (CVA or stroke) and transient ischemic attack (TIA)
Ɣ May present with a variety of signs and symptoms, including sudden onset of weakness, focal sensory loss or speech
disorder
Ɣ Among patients being evaluated for CVA and possible thrombolytic therapy, unenhanced CT is often performed as the
initial modality (within the initial 24 hours after symptom onset), to detect a possible hemorrhagic stroke or mass lesion.
CT Head | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
3
Common Diagnostic Indications
&16¿QGLQJVGH¿FLWV±QHZRQVHWRUSURJUHVVLYHO\ZRUVHQLQJQHXURORJLFDODEQRUPDOLW\
Ɣ ,QFOXGLQJEXWQRWOLPLWHGWRWKHIROORZLQJFOLQLFDOV\PSWRPVDQG¿QGLQJV
ż
Anosmia (loss or impairment in sense of smell)
ż
Ataxia (inability to coordinate voluntary muscular movements)
ż
Bell’s palsy
ż
Dysgeusia (dysfunction in sense of taste)
ż
Facial numbness
ż
Gait disorder
ż
Hoarseness
ż
Other movement disorders
ż
Nystagmus (rapid, involuntary, oscillating ocular movements)
ż
Paresis or paralysis
ż
Tinnitus (ringing or roaring auditory sensation; may be either unilateral or bilateral; pulsatile or non-pulsatile;
transient or persistent)
ż
Other cranial nerve impairment
Note: Contrast-enhanced MRI, unless contraindicated, is generally recommended for evaluation of cranial nerve impairment.
Congenital anomaly
Ɣ Including but not limited to the following conditions:
ż
Chiari malformations
ż
Dandy-Walker spectrum
ż
Encephalocele
ż
Holoprosencephaly
ż
Macrocephaly
ż
Microcephaly
ż
Schizencephaly
ż
Septo-optic dysplasia
Craniosynostosis
Dementia
Ɣ Initial evaluation, if MRI is contraindicated; OR
Ɣ Rapid progression, if MRI is contraindicated
'HYHORSPHQWDOGHOD\
Ɣ In developmental delay, MRI is the preferred imaging modality over CT
Ɣ 7KHOLNHOLKRRGRIPDNLQJDVSHFL¿FQHXURLPDJLQJGLDJQRVLVLQFUHDVHVLQWKHSUHVHQFHRISK\VLFDOH[DPDEQRUPDOLWLHV
VXFKDVIRFDOPRWRU¿QGLQJVRUPLFURFHSKDO\
CT Head | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
4
Common Diagnostic Indications
+HDGDFKHLQDGXOW±ZKHQDQ\RQHRIWKHIROORZLQJFULWHULDLVPHW
Ɣ Sudden onset and severe, including thunderclap or worst headache of life; OR
Ɣ Progressively worsening with increased frequency and severity over short timeframe and/or despite physician supervised
appropriate therapy; OR
Ɣ :LWKQHZIRFDOQHXURORJLFVLJQVSDUWLFXODUO\SDSLOOHGHPDYLVXDO¿HOGGHIHFWVDQGQXFKDOULJLGLW\OR
Ɣ 1HZRQVHWKHDGDFKHVLQDFDQFHURULPPXQRGH¿FLHQWSDWLHQW
+HDGDFKHLQSHGLDWULFSDWLHQW±ZKHQDQ\RQHRIWKHIROORZLQJFULWHULDLVPHW
Ɣ Sudden onset and severe, including thunderclap or worst headache of life; OR
Ɣ Associated with neurological abnormalities such as nystagmus, papilledema, gait or motor disturbances; OR
Ɣ With fever, nuchal rigidity and other meningeal signs; OR
Ɣ Awakened repeatedly from sleep or develop upon awakening; OR
Ɣ Persistent headache with confusion, disorientation or vomiting; OR
Ɣ Persistent headaches of less than 6 months duration and not responsive to medical treatment; OR
Ɣ Persistent headaches, without a family history of migraines; OR
Ɣ )DPLOLDORUSHUVRQDOKLVWRU\RIGLVRUGHUVZLWKSUHGLVSRVLWLRQWR&16OHVLRQVDQGFOLQLFDOODERUDWRU\¿QGLQJVWKDWVXJJHVW
CNS involvement
+HPRUUKDJHKHPDWRPD
Ɣ Refers to non-traumatic, non-CVA and non-tumor-related intra-cranial bleed. Examples include hypertensive hemorrhage
and hemorrhage secondary to anti-coagulation or blood dyscrasia
Ɣ CT is the preferred technique for evaluation of acute intra-cranial hemorrhage
Ɣ MRI is usually preferred for evaluation of subacute and chronic hemorrhage
+\GURFHSKDOXVYHQWULFXORPHJDO\
Ɣ MRI is often the preferred for initial evaluation of patients with hydrocephalus. For patients with an indwelling shunt, CT is
usually adequate in the diagnostic follow-up of hydrocephalus.
,QFUHDVHGLQWUDFUDQLDOSUHVVXUHRUKHUQLDWLRQ
,QIHFWLRXVRULQÀDPPDWRU\SURFHVV
Ɣ Including but not limited to the following:
ż
Cerebral or cerebellar abscess
ż
Encephalitis
ż
Meningitis
ż
Neurocysticercosis
ż
2SSRUWXQLVWLFLQIHFWLRQSDUWLFXODUO\ZLWKLPPXQRVXSSUHVVHGRURWKHULPPXQRGH¿FLHQWFRQGLWLRQV
ż
Subdural empyema
0HQWDOVWDWXVFKDQJHVZLWKGRFXPHQWHGREMHFWLYHHYLGHQFHIURPQHXURORJLFH[DP
CT Head | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
5
Common Diagnostic Indications
Movement disorders
Ɣ Including Parkinson’s disease (particularly atypical cases with poor response to levodopa, in which there may be an
underlying structural disorder producing parkinsonian features); Huntington’s disease; idiopathic sporadic cerebellar
ataxia (olivopontocerebellar atrophy); and other conditions.
0XOWLSOHVFOHURVLVDQGRWKHUZKLWHPDWWHUGLVHDVHVZKHQ05,LVFRQWUDLQGLFDWHGRUQRWWROHUDWHG
Ɣ Initial diagnosis; OR
Ɣ Periodic scans to assess asymptomatic progression in multiple sclerosis during the course of disease; OR
Ɣ Tracking the progress of multiple sclerosis to establish a prognosis or evaluation of response to treatment; OR
Ɣ To evaluate changes in neurologic signs and symptoms
Neurocutaneous disorders
Ɣ Including but not limited to the following:
ż
1HXUR¿EURPDWRVLV
ż
Sturge-Weber syndrome
ż
Tuberous sclerosis
ż
Von Hippel-Lindau disease (VHL)
1HXURHQGRFULQHDEQRUPDOLW\VXJJHVWLYHRIDSLWXLWDU\OHVLRQ
Ɣ MRI is usually preferred over CT for evaluation of pituitary lesions
Ɣ Relevant laboratory and clinical abnormalities are required
3DSLOOHGHPD
3RVWRSHUDWLYHRUSRVWSURFHGXUHHYDOXDWLRQ
3UHRSHUDWLYHRUSUHSURFHGXUHHYDOXDWLRQ
1RWH7KLVLQGLFDWLRQLVWREHXVHGIRUSUHRSHUDWLYHHYDOXDWLRQRIFRQGLWLRQVQRWVSHFL¿FDOO\UHIHUHQFHGHOVHZKHUHLQWKLV
guideline.
3ULRUWROXPEDUSXQFWXUH
Seizure disorder
Ɣ New onset; OR
Ɣ Increasing frequency; OR
Ɣ Increasing severity
Sensorineural hearing loss, documented by audiology
Ɣ As work-up for acoustic neuroma (vestibular schwannoma) – also see primary intra-cranial tumors
Note: Contrast-enhanced MRI, unless contraindicated, is generally recommended for evaluation of sensorineural hearing loss.
CT Head | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
6
Common Diagnostic Indications
6\QFRSH
Ɣ Syncope (complete loss of consciousness) and near syncope (partial loss of consciousness)
When any of the following (a-c) applies:
a. Seizure activity was witnessed or is highly suspected at the time of the syncope
b. There is an abnormality on neurological examination
c.
The patient has at least one persistent neurological symptom
Trauma to head
Ɣ CT is usually preferred for the initial evaluation of acute head trauma, due to the high sensitivity for hemorrhage and
ability to display fractures
Ɣ Particularly when associated with:
ż
&DOYDULDOIUDFWXUHDVGHPRQVWUDWHGRQSODLQ¿OPUDGLRJUDSK\
ż
Change in mental status or amnesia
ż
)RFDOQHXURORJLFDOGH¿FLWV
ż
Loss of consciousness
ż
Seizures
ż
Signs of increased intracranial pressure
ż
Nausea / vomiting
ż
Worsening headaches
Ɣ Suspected hemorrhage, or subdural or epidural hematoma
7XPRUHYDOXDWLRQ±EHQLJQDQGPDOLJQDQW
Ɣ Including but not limited to the following lesions:
ż
Primary intra-cranial tumors
ż
Metastatic disease
8QH[SODLQHGPDVVOHVLRQLGHQWL¿HGRQSULRULPDJLQJ±VXUYHLOODQFHZLWKRXWSDWKRORJLFWLVVXH
FRQ¿UPDWLRQ
Ɣ Examples include suspected arachnoid cyst or epidermoid cyst
Vascular abnormalities
Ɣ Including but not limited to:
ż
Aneurysm
ż
Arteriovenous malformation (AVM)
ż
Cavernous malformation
ż
Cerebral vein thrombosis
ż
'XUDODUWHULRYHQRXV¿VWXOD'$9)
ż
Dural venous sinus thrombosis
ż
Venous angioma
Ɣ Either CTA or MRA are usually the imaging modalities of choice for some of these vascular abnormalities, such as
aneurysm evaluation.
CT Head | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
7
Common Diagnostic Indications
Ventricular shunt assessment
Vertigo and dizziness
Ɣ With recurrent or persistent symptoms and when evaluation for other etiologies has not been revealing
Ɣ Abnormal audiogram or auditory brainstem response
9LVXDOGLVWXUEDQFH±VXFKDVYLVXDO¿HOGORVVGLSORSLDDQGRWKHUDOWHUDWLRQVLQYLVLRQWKDWDUH
XQH[SODLQHGE\RSKWKDOPRORJLFH[DPDQGSDWLHQWKLVWRU\
:KHQWKHSDWLHQW¶VFRQGLWLRQPHHWVWKHKHDG05,JXLGHOLQHVEXW05,LVHLWKHUFRQWUDLQGLFDWHG
RUWKHSDWLHQWLVFODXVWURSKRELFDQGFDQQRWWROHUDWH05,H[DPLQDWLRQ
References
1.
The Society of Thoracic Surgeons. Choosing Wisely: Five Things Physicians and Patients Should Question. ABIM
Foundation; February 21, 2013. Available at www.choosingwisely.org
2.
American Thoracic Society and European Respiratory Society Consensus Report. Pretreatment evaluation of non-small
cell lung cancer. Am J Respir Crit Care Med 1997;156:320-332.
3.
Colice GL, Birkmeyer JD, Black WC, Littenberg B, Silvestri G. Cost-effectiveness of head CT in patients with lung
cancer without clinical evidence of metastases. Chest.1995;108(5):1264-1271.
4.
National Comprehensive Cancer Network. 1DWLRQDO&RPSUHKHQVLYH&DQFHU1HWZRUNFOLQLFDOSUDFWLFHJXLGHOLQHVLQ
oncology (NCCN Guidelines®): Non-small cell lung cancer. Fort Washington, PA: NCCN; 2012.
5.
Silvestri GA, Gould MK, Margolis ML, et al. Noninvasive staging of non-small cell lung cancer. ACCP Evidenced-Based
Clinical Practice Guidelines (2nd Edition). Chest. 2007;132(3suppl):178S-201S.
6.
Tanaka K, Kubota K, Kodama T, Nagai K, Nishiwaki Y. Extrathoracic staging is not necessary for non-small-cell lung
cancer with clinical stage T1–2 N0. Ann Thorac Surg. 1999;68(3):1039-1042.
7.
American Academy of Pediatrics. Choosing Wisely: Five Things Physicians and Patients Should Question. ABIM
Foundation; February 21, 2013. Available at www.choosingwisely.org.
8.
American Academy of Pediatrics. Subcommittee on Febrile Seizures. Febrile seizures: Guideline for the neurodiagnostic
evaluation of the child with a simple febrile seizure. Pediatrics. 2011 Feb;127(2):389-394.
9.
American Academy of Otolaryngology — Head and Neck Surgery Foundation. Choosing Wisely: Five Things
Physicians and Patients Should Question. ABIM Foundation; February 21, 2013. Available at www.choosingwisely.org.
10. Stachler RJ, Chandrasekhar SS, Archer SM, et al. Clinical practice guideline: Sudden hearing loss. Otolaryngol Head
1HFN6XUJ. 2012;146(3 Suppl):S1-35.
11. Kuppermann N, Holmes, JF, Dayan PS, et al; Pediatric Emergency Care Applied Research Network (PECARN).
,GHQWL¿FDWLRQRIFKLOGUHQDWYHU\ORZULVNRIFOLQLFDOO\LPSRUWDQWEUDLQLQMXULHVDIWHUKHDGWUDXPD$SURVSHFWLYHFRKRUW
study. Lancet. 2009;374(9696):1160-1170.
CT Head | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
8
Magnetic Resonance Imaging (MRI)
Head/Brain
CPT Codes
70551.................. MRI Head, without contrast
70552.................. MRI Head, with contrast
70553.................. MRI Head, without contrast, followed by re-imaging with contrast
Standard Anatomic Coverage
Ɣ From skull base to vertex, covering the entire calvarium and intra-cranial contents, including the internal auditory canals.
Ɣ 6FDQFRYHUDJHPD\YDU\GHSHQGLQJRQWKHVSHFL¿FFOLQLFDOLQGLFDWLRQ
Imaging Condiderations
Ɣ MRI of the head is preferable to CT in most clinical scenarios, due to its superior contrast resolution and lack of beamhardening artifact adjacent to the petrous bone (which may limit visualization in portions of the posterior fossa and
brainstem on CT). Exceptions to the use of brain MRI as the neuroimaging procedure of choice and situations with
preferred head imaging using CT include: osseous assessment of the calvarium, skull base and maxillofacial bones,
LQFOXGLQJGHWHFWLRQRIFDOYDULDODQGIDFLDOERQHIUDFWXUHVFDOFL¿HGOHVLRQVLQLWLDOHYDOXDWLRQRIUHFHQWFUDQLRFHUHEUDO
trauma; and acute intra-cranial hemorrhage (parenchymal; subarachnoid; subdural; epidural).
Ɣ MRI is more sensitive for detection of shearing trauma to the brain and diffuse axonal injury. It is also the preferred
technique for assessment of subacute and chronic intra-cranial hemorrhage.
Ɣ CT of the head is an alternative exam in patients who cannot undergo MRI.
Ɣ Images of the pituitary gland, maxillary sinuses or internal auditory canals (IACs) are included within the single assigned
CPT code for MRI imaging of the head and are not separately billable as multiple concurrent head MRI exams.
Ɣ MRI studies of the head and neck are inherently bilateral. Duplicate imaging requests for these studies are inappropriate.
Ɣ Screening for metastatic disease in a patient with stage I non-small cell lung cancer (NSCLC) in the absence of
neurologic symptoms is not indicated 1-6
Ɣ CT or MRI imaging is not typically indicated for simple pediatric febrile seizure in the absence of other neurological
¿QGLQJV7,8
Common Diagnostic Indications
The following diagnostic indications for head MRI are accompanied by pre-test considerations as well as supporting clinical
data and prerequisite information:
$EQRUPDOLWLHVGHWHFWHGRQRWKHULPDJLQJVWXGLHVZKLFKUHTXLUHDGGLWLRQDOFODUL¿FDWLRQWRGLUHFW
treatment
$UQROG&KLDUL,DQG,,PDOIRUPDWLRQV
&HUHEUDOSDOV\
Cerebrovascular accident (CVA or stroke) and transient ischemic attack (TIA)
Ɣ May present with a variety of signs and symptoms, including sudden onset of weakness, focal sensory loss or speech
disorder
MRI of the Head/Brain | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
9
Common Diagnostic Indications
&16¿QGLQJGH¿FLW±QHZRQVHWRUSURJUHVVLYHQHXURORJLFDODEQRUPDOLWLHV
Ɣ ,QFOXGLQJEXWQRWOLPLWHGWRWKHIROORZLQJFOLQLFDOV\PSWRPVDQG¿QGLQJV
ż
Anosmia (loss or impairment in sense of smell)
ż
Ataxia (inability to coordinate voluntary muscular movements)
ż
Bell’s palsy
ż
Dysgeusia (dysfunction in sense of taste)
ż
Facial numbness
ż
Gait disorder
ż
Hoarseness
ż
Other movement disorders
ż
Nystagmus (rapid, involuntary, oscillating ocular movements)
ż
Paresis or paralysis
ż
Tinnitus (ringing or roaring auditory sensation; may be unilateral or bilateral; either pulsatile or non-pulsatile)
ż
Any other cranial nerve impairment
Congenital anomaly
Ɣ Including but not limited to the following conditions:
ż
Chiari malformations
ż
Dandy-Walker spectrum
ż
Encephalocele
ż
Holoprosencephaly
ż
Macrocephaly
ż
Microcephaly
ż
Schizencephaly
ż
Septo-optic dysplasia
Dementia
Ɣ Initial evaluation, OR
Ɣ Rapid progression
'HYHORSPHQWDOGHOD\
Ɣ MRI is the preferred imaging modality over CT, in developmental delay
Ɣ 7KHOLNHOLKRRGRIPDNLQJDVSHFL¿FQHXURLPDJLQJGLDJQRVLVLQFUHDVHVLQWKHSUHVHQFHRISK\VLFDOH[DPDEQRUPDOLWLHV
VXFKDVIRFDOPRWRU¿QGLQJVRUPLFURFHSKDO\
(QFHSKDORSDWK\
+HDGDFKHLQDGXOW±ZKHQDQ\RQHRIWKHIROORZLQJFULWHULDLVPHW
Ɣ Sudden onset and severe, including thunderclap or worst headache of life; OR
Ɣ Progressively worsening with increased frequency and severity over short timeframe and/or despite physician supervised
appropriate therapy; OR
Ɣ :LWKQHZIRFDOQHXURORJLFVLJQVSDUWLFXODUO\SDSLOOHGHPDYLVXDO¿HOGGHIHFWVDQGQXFKDOULJLGLW\OR
Ɣ 1HZRQVHWKHDGDFKHVLQDFDQFHURULPPXQRGH¿FLHQWSDWLHQW
MRI of the Head/Brain | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
10
Common Diagnostic Indications
+HDGDFKHLQSHGLDWULFSDWLHQW±ZKHQDQ\RQHRIWKHIROORZLQJFULWHULDLVPHW
Ɣ Sudden onset and severe, including thunderclap or worst headache of life; OR
Ɣ Associated with neurological abnormalities such as nystagmus, papilledema, gait or motor disturbances; OR
Ɣ With fever, nuchal rigidity and other meningeal signs; OR
Ɣ Awakened repeatedly from sleep or develop upon awakening; OR
Ɣ Persistent headache with confusion, disorientation or vomiting; OR
Ɣ Persistent headaches of less than 6 months duration and not responsive to medical treatment; OR
Ɣ Persistent headaches, without a family history of migraines; OR
Ɣ )DPLOLDORUSHUVRQDOKLVWRU\RIGLVRUGHUVZLWKSUHGLVSRVLWLRQWR&16OHVLRQVDQGFOLQLFDOODERUDWRU\¿QGLQJVWKDWVXJJHVW
CNS involvement
+HDULQJORVVSURJUHVVLYHDV\PPHWULFDOKHDULQJGH¿FLWDVVRFLDWHGZLWK
Ɣ Abnormal neurological evaluation; $1'25
Ɣ Abnormal ear, nose and throat (ENT) evaluation such as, audiometry or auditory brainstem response (ABR)
+HPRUUKDJHKHPDWRPD
Ɣ Refers to non-traumatic, non-CVA and non-tumor-related intra-cranial bleed. Examples include hypertensive hemorrhage
and hemorrhage secondary to anti-coagulation or blood dyscrasia
Ɣ MRI is usually preferred for evaluation of subacute and chronic hemorrhage
Ɣ CT is the preferred technique for evaluation of acute intra-cranial hemorrhage
+\GURFHSKDOXVYHQWULFXORPHJDO\
Ɣ MRI is often the preferred for initial evaluation of patients with hydrocephalus. For patients with an indwelling shunt, CT is
usually adequate in the diagnostic follow-up of hydrocephalus
+\SR[LFLVFKHPLFHQFHSKDORSDWK\
,QIHFWLRXVRULQÀDPPDWRU\SURFHVV
Ɣ Including but not limited to the following:
ż
Cerebral or Cerebellar Abscess
ż
Encephalitis
ż
Meningitis
ż
Neurocysticercosis
ż
2SSRUWXQLVWLF,QIHFWLRQSDUWLFXODUO\ZLWKLPPXQRVXSSUHVVHGRURWKHULPPXQRGH¿FLHQWFRQGLWLRQV
ż
Subdural Empyema
0HQWDOVWDWXVFKDQJHVZLWKGRFXPHQWHGREMHFWLYHHYLGHQFHIURPQHXURORJLFH[DP
Movement disorders
Ɣ Including Parkinson’s disease (particularly atypical cases with poor response to levodopa, in which there may be an
underlying structural disorder producing parkinsonian features); Huntington’s disease; idiopathic sporadic cerebellar
ataxia (olivopontocerebellar atrophy); hemifacial spasm; and other conditions
MRI of the Head/Brain | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
11
Common Diagnostic Indications
0XOWLSOHVFOHURVLVDQGRWKHUZKLWHPDWWHUGLVHDVHV
Ɣ Initial diagnosis; OR
Ɣ Periodic scans to assess asymptomatic progression in multiple sclerosis during the course of disease; OR
Ɣ Tracking the progress of multiple sclerosis to establish a prognosis or evaluation of response to treatment; OR
Ɣ To evaluate changes in neurologic signs and symptoms
Neurocutaneous disorders
Ɣ Including but not limited to the following:
ż
1HXUR¿EURPDWRVLV
ż
Sturge-Weber Syndrome
ż
Tuberous Sclerosis
ż
Von Hippel-Lindau Disease (VHL)
1HXURHQGRFULQHDEQRUPDOLW\VXJJHVWLYHRIDSLWXLWDU\OHVLRQ
Ɣ Relevant laboratory and clinical abnormalities are required
3DSLOOHGHPD
3RVWRSHUDWLYHRUSRVWSURFHGXUHHYDOXDWLRQ
3UHRSHUDWLYHRUSUHSURFHGXUHHYDOXDWLRQ
1RWH7KLVLQGLFDWLRQLVWREHXVHGIRUSUHRSHUDWLYHHYDOXDWLRQRIFRQGLWLRQVQRWVSHFL¿FDOO\UHIHUHQFHGHOVHZKHUHLQWKLV
guideline.
Seizure disorder
Ɣ New onset; OR
Ɣ Increasing frequency; OR
Ɣ Increasing severity
Sensorineural hearing loss, documented by audiology
Ɣ As work-up for acoustic neuroma (vestibular schwannoma) – also see primary intra-cranial tumors
6\QFRSH
Ɣ Syncope (complete loss of consciousness) and near syncope (partial loss of consciousness)
When any of the following (a-c) applies:
a. Seizure activity was witnessed or is highly suspected at the time of the syncope
b. There is an abnormality on neurologic examination
c.
The patient has at least one persistent neurologic symptom
MRI of the Head/Brain | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
12
Common Diagnostic Indications
Trauma to head
Ɣ MRI is generally used to evaluate suspected shearing lesions and diffuse axonal injury in closed head trauma as well as
assessment of the subacute or chronic sequelae of head injury
Ɣ CT is often performed as the initial imaging exam in acute head trauma, particularly when associated with:
ż
Calvarial fracture
ż
Change in mental status or amnesia
ż
)RFDOQHXURORJLFDOGH¿FLWV
ż
Loss of consciousness
ż
Seizures
ż
Signs of increased intracranial pressure
ż
Nausea / vomiting
ż
Worsening headaches
Ɣ Suspected hemorrhage, or subdural or epidural hematoma
7ULJHPLQDOQHXUDOJLDSDUWLFXODUO\ZKHQDW\SLFDORUDW\SLFDOIDFLDOSDLQZLWKRXWIRFDOREMHFWLYH
signs
Ɣ Atypical manifestations of trigeminal neuralgia include facial burning, boring crushing or pulsating sensations, which may
be relatively constant.
Ɣ Typical features of trigeminal neuralgia include the sudden, extremely sharp, stabbing, shock-like or throbbing pain in the
facial region.
7XPRUHYDOXDWLRQ±EHQLJQDQGPDOLJQDQW
Ɣ Including but not limited to the following lesions:
ż
Primary intra-cranial tumors
ż
Metastatic disease
8QH[SODLQHGPDVVOHVLRQLGHQWL¿HGRQSULRULPDJLQJ±VXUYHLOODQFHZLWKRXWSDWKRORJLFWLVVXH
FRQ¿UPDWLRQ
Ɣ Examples include suspected Arachnoid Cyst or Epidermoid Cyst
Vascular abnormalities
Ɣ Including but not limited to:
ż
Aneurysm
ż
Arterio-venous malformation (AVM)
ż
Cavernous malformation
ż
Cerebral vein thrombosis
ż
'XUDODUWHULRYHQRXV¿VWXOD'$9)
ż
Dural venous sinus thrombosis
ż
Venous angioma
Ɣ Either CTA or MRA are usually the imaging modalities of choice for some of the vascular abnormalities, such as
aneurysm evaluation
Vasculitis
MRI of the Head/Brain | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
13
Common Diagnostic Indications
Ventricular shunt assessment
Vertigo and dizziness
Ɣ With recurrent or persistent symptoms and when evaluation for other etiologies has not been revealing
Ɣ Abnormal audiogram or auditory brainstem response
9LVXDOGLVWXUEDQFHVXFKDVYLVXDO¿HOGORVVGLSORSLDDQGRWKHUDOWHUDWLRQVLQYLVLRQWKDWDUH
XQH[SODLQHGE\RSKWKDOPRORJLFH[DPDQGSDWLHQWKLVWRU\
References
1.
The Society of Thoracic Surgeons. Choosing Wisely: Five Things Physicians and Patients Should Question. ABIM
Foundation; February 21, 2013. Available at www.choosingwisely.org
2.
American Thoracic Society and European Respiratory Society Consensus Report. Pretreatment evaluation of non-small
cell lung cancer. Am J Respir Crit Care Med 1997;156:320-332.
3.
Colice GL, Birkmeyer JD, Black WC, Littenberg B, Silvestri G. Cost-effectiveness of head CT in patients with lung
cancer without clinical evidence of metastases. Chest.1995;108(5):1264-1271.
4.
National Comprehensive Cancer Network. 1DWLRQDO&RPSUHKHQVLYH&DQFHU1HWZRUNFOLQLFDOSUDFWLFHJXLGHOLQHVLQ
oncology (NCCN Guidelines®): Non-small cell lung cancer. Fort Washington, PA: NCCN; 2012.
5.
Silvestri GA, Gould MK, Margolis ML, et al. Noninvasive staging of non-small cell lung cancer. ACCP Evidenced-Based
Clinical Practice Guidelines (2nd Edition). Chest. 2007;132(3suppl):178S-201S.
6.
Tanaka K, Kubota K, Kodama T, Nagai K, Nishiwaki Y. Extrathoracic staging is not necessary for non-small-cell lung
cancer with clinical stage T1–2 N0. Ann Thorac Surg. 1999;68(3):1039-1042.
7.
American Academy of Pediatrics. Five Things Physicians and Patients Should Question. ABIM Foundation; February 21,
2013. Available at www.choosingwisely.org.
8.
American Academy of Pediatrics. Subcommittee on Febrile Seizures. Febrile seizures: Guideline for the neurodiagnostic
evaluation of the child with a simple febrile seizure. Pediatrics. 2011 Feb;127(2):389-394.
MRI of the Head/Brain | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
14
Magnetic Resonance Imaging (MRI)
Orbit, Face & Neck (Soft Tissues)
CPT Codes
70540.................. MRI orbit, face and neck, without contrast
70542.................. MRI orbit, face and neck, with contrast
70543.................. MRI orbit, face and neck, without contrast, followed by re-imaging with contrast
Standard Anatomic Coverage
Ɣ 6FDQFRYHUDJHLVGHSHQGHQWRQWKHVSHFL¿FDQDWRPLFDUHDRIFOLQLFDOLQWHUHVW([DPVXVXDOO\LQFOXGHPXOWLSODQDU
imaging, using different pulse sequences.
Imaging Considerations
Ɣ MRI is usually preferred over CT for evaluation of the sella turcica and visual pathways, unless contraindicated.
Ɣ &7LVJHQHUDOO\WKHPRGDOLW\RIFKRLFHIRUWUDXPDWLFLQMXU\FDOFL¿HGOHVLRQVORFDOL]HGLQIHFWLRQIRUH[DPSOHRUELWDO
extension of an adjacent complicated sinusitis), and foreign body evaluation, after initial radiographic evaluation for a
radiopaque foreign body.
Ɣ CT of the neck is an alternative exam in patients who cannot undergo MRI.
Ɣ Duplicate exam requests for two or more MRI studies of the head (for example, bilateral head MRIs for right and left
orbital evaluation) or neck are inappropriate. These exams are inherently bilateral.
Ɣ An MRI of the orbit, face and neck is not allowed for imaging the IACs. See MRI of the brain (CPT codes 70551 –
70553).
Common Diagnostic Indications
The following diagnostic indications for MRI of the orbit, face and neck (soft tissues) are accompanied by pre-test
considerations as well as supporting clinical data and prerequisite information.
$EQRUPDOLWLHVGHWHFWHGRQRWKHULPDJLQJVWXGLHVZKLFKUHTXLUHDGGLWLRQDOFODUL¿FDWLRQWRGLUHFW
treatment
Congenital anomalies
Glottic lesion
Ɣ Further assessment following endoscopic detection
Hoarseness
Ɣ Unexplained, following direct visualization and/or prior non-diagnostic imaging of neck/upper chest (extending along the
course of the recurrent laryngeal nerves) 1,2
,QIHFWLRXVRULQÀDPPDWRU\SURFHVV
Ɣ Including but not limited to the following conditions:
ż
Abscess
ż
Cellulitis (for example, orbital cellulitis)
ż
Osteomyelitis
MRI of Orbit, Face, Neck | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
15
Common Diagnostic Indications
Laryngeal edema
/\PSKDGHQRSDWK\±VXVSHFWHGRUNQRZQ
Ɣ When persistent and unexplained
Mass lesion
Ɣ Palpable neck mass: OR
Ɣ 1RQSDOSDEOHDQGXQH[SODLQHGRQSULRULPDJLQJH[DP±IRUVXUYHLOODQFHZLWKRXWSDWKRORJLFWLVVXHFRQ¿UPDWLRQOR
Ɣ Evaluation of lesions including:
ż
Branchial cleft cyst
ż
Thyroglossal duct cyst
ż
Lymphangioma
ż
Cystic hygroma
1DVDOLQGLFDWLRQV±QRWOLVWHGHOVHZKHUH
ż
Anosmia
ż
Recurrent epistaxis
ż
Nasal airway obstruction or polyposis refractory to medical therapy
Obstructive thyroid nodule or thyromegaly (goiter)
Ɣ Following thyroid US or thyroid scintigraphy
Ɣ When associated with mass effect on the upper airway or esophagus
Ɣ For pre-operative evaluation
2UELWDOLQGLFDWLRQV±QRWOLVWHGHOVHZKHUH
Ɣ
Including but not limited to:
ż
Extraocular myopathy
ż
Extraocular weakness or non-conjugate eye movements
ż
Nystagmus
ż
Optic neuritis
ż
Orbital pseudotumor
ż
Papilledema (refers to swelling and elevation of optic disc – a sign of increased intracranial pressure)
ż
Proptosis
ż
Strabismus
ż
Thyroid ophthalmopathy
ż
Visual loss unexplained by ophthalmic evaluation
Stridor
Ɣ For subacute and chronic stridor, advanced imaging may follow neck (soft tissue) radiographs and ENT evaluation
7UDXPDWRWKHRUELWDQGIDFH
Ɣ CT preferable for bony assessment
MRI of Orbit, Face, Neck | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
16
Common Diagnostic Indications
7UDXPDWRWKHVRIWWLVVXHVRIWKHQHFN
7XPRUHYDOXDWLRQ±SULPDU\QHRSODVPDQGPHWDVWDWLFGLVHDVH
Ɣ Including but not limited to the following anatomic structures:
ż
Facial structures
ż
Larynx and subglottic regions
ż
Nasopharynx, oropharynx and hypopharynx
ż
Neck soft tissues, surrounding the airway and glands
ż
Optic nerve
ż
Orbit
ż
Salivary glands
ż
Sella turcica (pituitary tumors including macroadenoma and microadenoma)
ż
Sinuses
ż
Thyroid and parathyroid glands
8SSHUDLUZD\REVWUXFWLRQ
Ɣ Including but not limited to tracheal stenosis
9RFDOFRUGSDUDO\VLV
Ɣ Unexplained, following endoscopic diagnosis
Ɣ May be unilateral or bilateral
:HJHQHU¶VJUDQXORPDWRVLV±VXVSHFWHGRUNQRZQ
References
1.
American Academy of Otolaryngology — Head and Neck Surgery Foundation. Choosing Wisely: Five Things
Physicians and Patients Should Question. ABIM Foundation; February 21, 2013. Available at www.choosingwisely.org.
2.
Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline: hoarseness (dysphonia). 2WRODU\QJRO+HDG1HFN
Surg. 2009;141(3 Suppl 2):S1-S31.
MRI of Orbit, Face, Neck | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
17
Computed Tomography (CT)
Neck for Soft Tissue Evaluation
CPT Codes
70490.................. CT Soft Tissues of Neck, without contrast
70491.................. CT Soft Tissues of Neck, with contrast
70492.................. CT Soft Tissues of Neck without contrast, followed by re-imaging with contrast
Standard Anatomic Coverage
Ɣ Axial images from the skull base to the clavicles.
Imaging Considerations
Ɣ CT is generally the modality of choice for the following indications: detection of sialolithiasis (salivary gland calculi);
following trauma to the soft tissues of the neck; and during foreign body evaluation, after initial radiographic assessment
for a radiopaque foreign body.
Common Diagnostic Indications
The following diagnostic indications for neck CT are accompanied by pre-test considerations as well as supporting clinical data
and prerequisite information.
$EQRUPDOLWLHVGHWHFWHGRQRWKHULPDJLQJVWXGLHVZKLFKUHTXLUHDGGLWLRQDOFODUL¿FDWLRQWRGLUHFW
treatment
)RUHLJQERG\LQWKHXSSHUDHURGLJHVWLYHWUDFWRUVXUURXQGLQJQHFNWLVVXHV
Ɣ Following neck radiographs (for soft tissue evaluation)
Glottic lesion
Ɣ Further assessment following endoscopic detection
Hoarseness
Ɣ Unexplained, following direct visualization and/or prior non-diagnostic imaging of neck/upper chest (extending along the
course of the recurrent laryngeal nerves) 1,2
,QIHFWLRXVRULQÀDPPDWRU\SURFHVV
Ɣ Including but not limited to the following:
ż
Abscess
ż
Cellulitis
ż
Osteomyelitis
Laryngeal edema
/\PSKDGHQRSDWK\
Ɣ When persistent and/or unexplained
CT Neck (Soft Tissue) | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
18
Common Diagnostic Indications
Mass lesion
Ɣ Palpable neck mass: OR
Ɣ 1RQSDOSDEOHDQGXQH[SODLQHGRQSULRULPDJLQJH[DP±IRUVXUYHLOODQFHZLWKRXWSDWKRORJLFWLVVXHFRQ¿UPDWLRQOR
Ɣ Evaluation of lesions including:
ż
Branchial cleft cyst
ż
Thyroglossal duct cyst
ż
Lymphangioma
ż
Cystic hygroma
Obstructive thyroid nodule or thyromegaly (goiter)
Ɣ Following thyroid ultrasound or thyroid scintigraphy
Ɣ When associated with mass effect on the upper airway or esophagus
Ɣ For pre-operative evaluation
Parathyroid adenoma 3
Ɣ Following parathyroid ultrasound or parathyroid scintigraphy; OR
Ɣ CT is indicated for patients with a failed parathyroidectomy, or to assist in preoperative planning in those patients with
aberrant anatomy
1RWH05,PD\EHXVHGIRUSDWLHQWVZLWKUHFXUUHQWK\SHUSDUDWK\URLGLVPZKHQWKHUHLVDQHHGWRORFDWHUHVLGXDODEQRUPDO
parathyroid tissue
5HWURSKDU\QJHDOQHFNPDVV
6DOLYDU\SDURWLGJODQGGXFWDOFDOFXOLVLDOROLWKLDVLV
Stridor
Ɣ For subacute and chronic stridor, advanced imaging may follow neck (soft tissue) radiographs and ENT evaluation
7UDXPDWLFLQMXU\WRWKHVRIWWLVVXHVRIWKHQHFN
7XPRUHYDOXDWLRQ±EHQLJQDQGPDOLJQDQWSULPDU\QHRSODVPDQGPHWDVWDWLFGLVHDVH
Ɣ For diagnosis, staging, evaluation of response to treatment and pre-operative assessment
8SSHUDLUZD\REVWUXFWLRQ
Ɣ Including but not limited to tracheal stenosis
9RFDOFRUGSDUDO\VLV
Ɣ Unexplained, following endoscopic diagnosis
Ɣ May be unilateral or bilateral; CT may aid in localizing the side and level of vocal cord paralysis
CT Neck (Soft Tissue) | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
19
References
1.
American Academy of Otolaryngology — Head and Neck Surgery Foundation. Choosing Wisely: Five Things
Physicians and Patients Should Question. ABIM Foundation; February 21, 2013. Available at www.choosingwisely.org.
2.
Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline: hoarseness (dysphonia). 2WRODU\QJRO+HDG1HFN
Surg. 2009;141(3 Suppl 2):S1-S31.
3.
Johnson NA, Tublin ME, Ogilvie JB. Parathyroid imaging: technique and role in the preoperative evaluation of primary
hyperparathyroidism. AJR Am J Roentgenol. 2007 Jun;188(6):1706-1715.
CT Neck (Soft Tissue) | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
20
CT Angiography (CTA)
Neck
CPT Codes
70498.................. CTA of neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing
Standard Anatomic Coverage
Ɣ CTA of the neck involves image acquisition from the aortic arch to the skull base, to visualize major vessels which include
the extracranial carotid arteries and vertebral arteries. The major venous structures may also be interrogated with CT
angiographic technique.
Imaging Considerations
Ɣ Duplex Doppler examination of the extracranial carotid arteries is often performed prior to CTA.
Ɣ CTA of the neck is an alternative exam in patients who cannot undergo MRA.
Ɣ Screening for carotid artery stenosis is not indicated in asymptomatic adult patients 1-3
Common Diagnostic Indications
The following diagnostic indications for neck CTA are accompanied by pre-test considerations as well as supporting clinical
data and prerequisite information.
$EQRUPDOLWLHVGHWHFWHGRQFDURWLG'RSSOHUXOWUDVRXQGRURWKHULPDJLQJVWXGLHVZKLFKUHTXLUH
DGGLWLRQDOFODUL¿FDWLRQWRGLUHFWWUHDWPHQW
Aneurysm
$UWHULRYHQRXVPDOIRUPDWLRQ
&RQJHQLWDODQRPDOLHVRIWKHFDURWLGDQGYHUWHEUREDVLODUFLUFXODWLRQV
Dissection
Intramural hematoma
0XOWLSOHVFOHURVLV
Ɣ Evaluation of venous structures to assess for venous stenosis as a cause of multiple sclerosis, and referred to as chronic
FHUHEURVSLQDOYHQRXVLQVXI¿FLHQF\RU&&69,LVFRQVLGHUHGQRWPHGLFDOO\DSSURSULDWH059LQSUHSDUDWLRQIRUHLWKHUD
neurosurgical or percutaneous procedure to treat multiple sclerosis is therefore considered not medically appropriate
3RVWRSHUDWLYHRUSRVWSURFHGXUDOHYDOXDWLRQ
CTA Neck | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
21
Common Diagnostic Indications
3UHRSHUDWLYHHYDOXDWLRQSULRUWRFDUGLDFVXUJHU\
Ɣ Evaluation of carotid artery disease prior to cardiac surgery is indicated when symptoms or high-risk criteria are
present,4-15 including but not limited to the following:
ż
Age greater than or equal to 65 years
ż
Prior history of CVA
ż
Prior history of TIA
ż
Diabetes
ż
Hypertension
ż
Left main coronary stenosis
ż
Peripheral arterial disease
ż
Smoking history
ż
History of known cervical carotid disease
ż
Carotid bruit on exam
ż
50% or greater known carotid stenosis
ż
$WULDO¿EULOODWLRQ
ż
.QRZQH[WHQVLYHDRUWLFFDOFL¿FDWLRQ
ż
History of prior cardiac surgery
ż
History of prior myocardial infarction
ż
History of congestive heart failure
ż
+LVWRU\RIFKURQLFUHQDOLQVXI¿FLHQF\
3UHRSHUDWLYHRUSUHSURFHGXUDOHYDOXDWLRQ
1RWH7KLVLQGLFDWLRQLVWREHXVHGIRUSUHRSHUDWLYHHYDOXDWLRQRIFRQGLWLRQVQRWVSHFL¿FDOO\UHIHUHQFHGHOVHZKHUHLQWKLV
guideline.
6WHQRVLVRURFFOXVLRQRIWKHH[WUDFUDQLDOFDURWLGDUWHULHV
Ɣ Following work-up with duplex Doppler examination of the carotid arteries, unless diagnosis is substantiated by clinical
H[DP¿QGLQJV
Ɣ Common clinical manifestations may include:
ż
Confusion
ż
'LI¿FXOW\VSHDNLQJRUXQGHUVWDQGLQJVSHHFK
ż
Dizziness
ż
Gait disturbance
ż
Loss of balance or coordination
ż
Loss of consciousness
ż
Numbness, weakness or paralysis of the face, arm or leg on one side of the body
ż
Sudden severe headache that is unexplained
ż
Visual disturbance, particularly in one eye
CTA Neck | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
22
Common Diagnostic Indications
6WHQRVLVRURFFOXVLRQRIYHUWHEUDODUWHULHV
Ɣ ,QSDWLHQWVZLWKVLJQVDQGV\PSWRPVRIYHUWHEUREDVLODULQVXI¿FLHQF\9%,RUYHUWHEUDOEDVLODULVFKHPLD
Ɣ 6\PSWRPVRI9%,DUHXVXDOO\WHPSRUDU\GXHWRGLPLQLVKHGEORRGÀRZLQWKHSRVWHULRUFLUFXODWLRQRIWKHEUDLQ
Ɣ Common clinical manifestations may include:
ż
Acute sensorineural hearing loss
ż
Ataxia
ż
Diplopia
ż
Dysarthria
ż
Dysphagia
ż
Facial numbness and paresthesias
ż
/LPEDQGWUXQNVHQVRU\GH¿FLWV
ż
Loss of taste sensation
ż
Motor paresis
ż
Nystagmus
ż
Vertigo
ż
9LVXDO¿HOGGHIHFWV
7KURPERHPEROLFGLVHDVHRIPDMRULQWUDFUDQLDODUWHULDODQGRUYHQRXVV\VWHPVLQFOXGLQJGXUDO
venous sinus thrombosis
Traumatic vascular injury to the extracranial carotid and vertebral arteries
9DVFXORSDWK\LQFOXGLQJ¿EURPXVFXODUG\VSODVLD)0'
9HQRXVWKURPERVLVRUFRPSUHVVLRQ
References
1.
American Academy of Family Physicians. Ten Things Physicians and Patients Should Question. ABIM Foundation;
Updated February 21, 2013.
2.
Wolff T, Guirguis-Blake J, Miller T, et al. Screening For Asymptomatic Carotid Artery Stenosis. Rockville, MD: Agency
for Healthcare Research and Quality; December 2007. Evidence Syntheses No. 50. Available at www.ncbi.nlm.nih.gov/
books/NBK33504/
3.
Wolff T, Guirguis-Blake J, Miller T, Gillespie M, Harris R. Screening for carotid artery stenosis: an update of the evidence
for the U.S. Preventive Services Task Force. Ann Intern Med. 2007 Dec 18;147(12):860-870.
4.
The Society of Thoracic Surgeons. Choosing Wisely: Five Things Physicians and Patients Should Question. ABIM
Foundation; February 21, 2013. Available at www.choosingwisely.org
5.
%HQH¿FLDOHIIHFWRIFDURWLGHQGDUWHUHFWRP\LQV\PSWRPDWLFSDWLHQWVZLWKKLJKJUDGHFDURWLGVWHQRVLV1RUWK$PHULFDQ
Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1991 Aug 15;325(7):445-53.
6.
Cournot M, Boccalon H, Cambou JP, et al. Accuracy of the screening physical examination to identify subclinical
atherosclerosis and peripheral arterial disease in asymptomatic subjects. J Vasc Surg. 2007 Dec;46(6):1215-21.
7.
Durand DJ, Perler BA, Roseborough GS, Grega MA, Borowicz LM Jr, Baumgartner WA, Yuh DD. Mandatory versus
selective preoperative carotid screening: a retrospective analysis. Ann Thorac Surg. 2004 Jul;78(1):159-66.
CTA Neck | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
23
8.
)LOVRX¿)5DKPDQLDQ3%&DVWLOOR-*%URQVWHU'$GDPV'+,QFLGHQFHWRSRJUDSK\SUHGLFWRUVDQGORQJWHUPVXUYLYDO
after stroke in patients undergoing coronary artery bypass grafting. Ann Thorac Surg. 2008 Mar;85(3):862-70.
9.
Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report
of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
Circulation. 2011 Dec 6;124(23):e652-735.
10. Hogue CW Jr, Murphy SF, Schechtman KB, Dávila-Román VG. Risk factors for early or delayed stroke after cardiac
surgery. Circulation. 1999 Aug 10;100(6):642-7.
11. Naylor AR, Bown MJ. Stroke after cardiac surgery and its association with asymptomatic carotid disease: an updated
systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2011 May;41(5):607-24.
12. 5DWFKIRUG(9-LQ='L7XOOLR05HWDO&DURWLGEUXLWIRUGHWHFWLRQRIKHPRG\QDPLFDOO\VLJQL¿FDQWFDURWLGVWHQRVLVWKH
Northern Manhattan Study. Neurol Res. 2009 Sep;31(7):748-52.
13. Stamou SC, Hill PC, Dangas G, et al. Stroke after coronary artery bypass: incidence, predictors, and clinical outcome.
6WURNH. 2001 Jul;32(7):1508-13.
14. Stansby G, Macdonald S, Allison R, et al. Asymptomatic carotid disease and cardiac surgery consensus. Angiology.
2011 Aug;62(6):457-460.
15. Tarakji KG, Sabik JF 3rd, Bhudia SK, Batizy LH, Blackstone EH. Temporal onset, risk factors, and outcomes associated
with stroke after coronary artery bypass grafting. JAMA. 2011 Jan 26;305(4):381-90.
CTA Neck | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
24
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28
Computed Tomography (CT)
Chest
CPT Codes
71250.................. Chest CT without contrast
71260.................. Chest CT with contrast
71270.................. Chest CT without contrast, followed by re-imaging with contrast
Standard Anatomic Coverage
Ɣ Lung apices through costophrenic sulci
Ɣ 6FDQFRYHUDJHPD\YDU\GHSHQGLQJRQWKHVSHFL¿FFOLQLFDOLQGLFDWLRQ
Imaging Considerations
Ɣ In the majority of clinical situations, chest radiographs should be performed prior to advanced imaging with CT, preferably
within 30 days of the chest CT exam request.
Ɣ CT chest is not appropriate for cardiac and coronary artery imaging. Please review guidelines for cardiac CT and CCTA.
Ɣ When the purpose of the study is imaging of the heart, including the coronary arteries, do not request both a chest CT
and a dedicated cardiac/coronary artery CT.
Common Diagnostic Indications
The following diagnostic indications for chest CT are accompanied by pre-test considerations as well as supporting clinical
data and prerequisite information.This section contains: General Chest, Pulmonary, Mediastinal and Hilar, Pleural, Chest Wall
and Diaphragm
General Chest
Congenital thoracic anomalies
&RXJKSHUVLVWLQJRUPRUHZHHNVZLWKQRUPDOFKHVW;UD\
Ɣ Unresponsive to medical treatment and/or after evaluation for other causes (e.g., post-nasal drainage, asthma,
JDVWURHVRSKDJHDOUHÀX[GLVHDVHDQGPHGLFDWLRQHIIHFWVOR
Ɣ &RXJKLQLPPXQRVXSSUHVVHGHJ+,9DIWHURUJDQRUERQHPDUURZWUDQVSODQWRQLQÀL[LPDERURWKHUWXPRUQHFURVLV
factor antagonists individual (In these individuals, a higher level of suspicion is warranted); OR
Ɣ Other etiologies for chronic cough which include, but are not limited to:
ż
Smoking
ż
Chronic bronchitis
ż
Cough-inducing medications (e.g., ACE inhibitors)
ż
Exposure to an environmental irritant
ż
Respiratory infection
ż
Neoplasm
)HYHURIXQNQRZQRULJLQ
ż
Lasting more than three weeks with exceptions for immunocompromised patients
ż
Following standard work-up to localize the source
+HPRSW\VLV
Ɣ Initial evaluation should be performed with chest x-ray
CT Chest | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
29
Common Diagnostic Indications
,QIHFWLRXVDQGLQÀDPPDWRU\SURFHVVHV±H[FOXGLQJSQHXPRQLD
Ɣ For initial evaluation and surveillance
Ɣ Including but not limited to the following thoracic abnormalities:
ż
Lung abscess
ż
Mediastinitis
ż
Sternal infection (particularly following cardiac surgery)
ż
Empyema
ż
Mediastinal abscess
ż
Other infectious processes
0DOLJQDQF\±SULPDU\QHRSODVPDQGPHWDVWDWLFGLVHDVH
Ɣ For staging and periodic follow-up of documented malignancy
ż
For renal cell carcinoma (where biopsy is contraindicated) when surgical resection is planned, ultrasound or CT
¿QGLQJVKLJKO\VXVSLFLRXVIRUFDQFHUPD\FRQVWLWXWHGRFXPHQWDWLRQRIPDOLJQDQF\
Ɣ For annual screening of lung cancer in high-risk patients when all of the following are met:
ż
Patient has no signs or symptoms suggestive of underlying cancer
ż
Patient’s age is equal to or greater than 55 and less than or equal to 74
ż
There is at least a 30 pack-year history of cigarette smoking (and if former smoker, quit date is within previous 15
years)
1RWH)RUVFUHHQLQJRIOXQJFDQFHUWKHSDWLHQWLVH[SHFWHGWRKDYHORZGRVH&7VFDQVSHUIRUPHGRQFHD\HDUIRU
consecutive years
3HUVLVWHQWSQHXPRQLD
Ɣ Refractory to medical treatment of adequate duration (at least four weeks); OR
Ɣ Suspected to be secondary to obstruction or recurrent pneumonia in the same location within six months
3RVLWLYHVSXWXPF\WRORJ\IRUPDOLJQDQF\
3RVWRSHUDWLYHRUSRVWSURFHGXUHHYDOXDWLRQ
3UHRSHUDWLYHRUSUHSURFHGXUHHYDOXDWLRQ
1RWH7KLVLQGLFDWLRQLVWREHXVHGIRUSUHRSHUDWLYHHYDOXDWLRQRIFRQGLWLRQVQRWVSHFL¿FDOO\UHIHUHQFHGHOVHZKHUHLQWKLV
guideline.
Sarcoidosis
Ɣ Initial evaluation and periodic follow-up
6WUXFWXUDODEQRUPDOLWLHVRQFKHVW;±UD\ZKLFKUHTXLUHIXUWKHUFODUL¿FDWLRQZLWK&7
Trauma
Ɣ Injury involving the chest wall, cardiomediastinal structures and/or lungs
8QH[SODLQHGZHLJKWORVV±VLJQL¿FDQWZHLJKWORVVH[FHHGLQJRIGHVLUDEOHERG\ZHLJKWRYHU
DVKRUWWLPHLQWHUYDOPRQWKVRUOHVVDIWHULQLWLDOHYDOXDWLRQIRURWKHUFDXVHV
CT Chest | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
30
Common Diagnostic Indications
Pulmonary
$VEHVWRVUHODWHGEHQLJQDQGPDOLJQDQWOHVLRQVLQYROYLQJWKHOXQJVDQGSOHXUD
ż
Pleural plaques
ż
Interstitial lung disease
ż
Malignant mesothelioma
ż
Pleural effusion
ż
Lung cancer
Bronchiectasis
Ɣ Consider high resolution chest CT (HRCT) technique
%XOORXVHPSK\VHPD
Ɣ Following initial evaluation with chest radiographs
Ɣ Consider high resolution chest CT (HRCT) technique
+\SHUOXFHQWOXQJOHVLRQVLQSHGLDWULFSDWLHQWV
Ɣ Including but not limited to the following thoracic abnormalities:
ż
Congenital lobar emphysema
ż
Congenital cystic adenomatoid malformation
,QWHUVWLWLDOOXQJGLVHDVHSXOPRQDU\¿EURVLV
Ɣ Consider high resolution chest CT (HRCT) technique
2WKHUSQHXPRFRQLRVHV
3XOPRQDU\PDVVRUVXVSLFLRXVSDUHQFK\PDODEQRUPDOLW\RQUHFHQWFKHVW;UD\RURWKHULPDJLQJ
exam
3XOPRQDU\QRGXOHV±ZLWKVXVSLFLRQRIXQGHUO\LQJPDOLJQDQF\
Ɣ Initial evaluation and periodic surveillance of stable lesions for up to 2 years at approximately 6 month intervals
Ɣ 1RGXOHVDUHJHQHUDOO\GH¿QHGDVFPLQVL]H
Pulmonary sequestration
CT Chest | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
31
Common Diagnostic Indications
Mediastinal and Hilar
(YDOXDWLRQRIWKHWKRUDFLFDRUWD±DQHXU\VPDQGGLVVHFWLRQ
Ɣ In patients with suspected thoracic aortic aneurysm; OR
Ɣ ,QSDWLHQWVZLWKFRQ¿UPHGWKRUDFLFDRUWLFDQHXU\VPZLWKQHZRUZRUVHQLQJVLJQVV\PSWRPVOR
Ɣ )RURQJRLQJVXUYHLOODQFHRIVWDEOHSDWLHQWVZLWKFRQ¿UPHGWKRUDFLFDRUWLFDQHXU\VPZKRKDYHQRWXQGHUJRQHLPDJLQJRI
the thoracic aorta within the preceding six months; OR
Ɣ In patients with suspected aortic dissection; OR
Ɣ ,QSDWLHQWVZLWKFRQ¿UPHGDRUWLFGLVVHFWLRQZKRKDYHQHZRUZRUVHQLQJV\PSWRPVOR
Ɣ ,QSDWLHQWVZLWKFRQ¿UPHGDRUWLFGLVVHFWLRQLQZKRPVXUJLFDOUHSDLULVDQWLFLSDWHGWRDVVLVWLQSUHRSHUDWLYHSODQQLQJOR
Ɣ )RURQJRLQJVXUYHLOODQFHRIVWDEOHSDWLHQWVZLWKFRQ¿UPHGDRUWLFGLVVHFWLRQZKRKDYHQRWXQGHUJRQHLPDJLQJRIWKH
thoracic aorta within the preceding year; OR
Ɣ ,QSDWLHQWVZLWKFRQ¿UPHGDRUWLFGLVVHFWLRQRUWKRUDFLFDRUWLFDQHXU\VPZKRKDYHXQGHUJRQHVXUJLFDOUHSDLUZLWKLQWKH
preceding year and have not undergone imaging of the thoracic aorta within the preceding six months
+LODUHQODUJHPHQWRQUHFHQWFKHVW;UD\
+RDUVHQHVVRUYRFDOFRUGZHDNQHVVVXVSHFWHGWRUHVXOWIURPUHFXUUHQWODU\QJHDOQHUYHLQMXU\
.QRZQKLODUDQGRUPHGLDVWLQDOO\PSKDGHQRSDWK\PDVV
Ɣ Periodic follow-up
0HGLDVWLQDOZLGHQLQJRQUHFHQWFKHVW;UD\
Penetrating atherosclerotic aortic ulcer
6XSHULRUYHQDFDYD69&V\QGURPH
Thymoma
Ɣ Note that approximately 15% of patients with myasthenia gravis will have a thymoma
Tracheobronchial lesion evaluation
Traumatic aortic injury
9DVFXOLWLVRIWKHWKRUDFLFDRUWDRUEUDQFKYHVVHO
3OHXUDO&KHVW:DOODQG'LDSKUDJP
$EQRUPDOSOHXUDOÀXLGFROOHFWLRQLQFOXGLQJHIIXVLRQKHPRWKRUD[HPS\HPDDQGFK\ORWKRUD[
Note: Ultrasound should be considered as the initial imaging modality and prior to a diagnostic or therapeutic pleural tap 1-4
Chest wall mass
'LDSKUDJPDWLFKHUQLD
CT Chest | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
32
Common Diagnostic Indications
Pleural mass
3QHXPRWKRUD[±XQH[SODLQHGRUUHFXUUHQW
Thoracic outlet syndrome
8QH[SODLQHGGLDSKUDJPDWLFHOHYDWLRQRULPPRELOLW\
References
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Benamore RE, Warakaulle DR, Traill ZC. Imaging of pleural disease. Imaging. 2008;20:236–225.
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sonography versus radiography. Radiology 1994;191(3):681–684.
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McLoud TC, Flower CD. Imaging the pleura: sonography, CT, and MR imaging. AJR Am J Roentgenol. 1991
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Yu H. Management of pleural effusion, empyema, and lung abscess. Semin Intervent Radiol. 2011 Mar;28(1):75-86.
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33
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J Roentgenol. 2003;181(1):163-169.
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American College of Radiology. ACR Appropriateness Criteria®: Blunt Chest Trauma—Suspected Aortic Injury. Updated
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Bronchogenic Carcinoma. Updated 2010. http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/
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org/~/media/ACR/Documents/AppCriteria/Diagnostic/ScreeningForPulmonaryMetastases.pdf. Updated 2010. Accessed
March 1, 2012.
13. American College of Radiology. ACR Appropriateness Criteria®: Solitary Pulmonary Nodule. http://www.
acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonThoracicImaging/
SolitaryPulmonaryNoduleDoc10.aspx. Accessed February 21, 2012.
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Resonance Imaging (MRI) of the Breast. Updated 2008. http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/
MRI_Breast.pdf. Accessed February 21, 2012.
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(HRCT) of the Lungs in Adults. Updated 2010. http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/HRCT_
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34. Irwin RS, Madison JM. Diagnosis and treatment of cough. N Engl J Med. 2000;343(23):1715-1721.
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42. Kuhl CK. Current status of breast MR imaging. Part 2. clinical applications. Radiology. 2007;244(3):672-691.
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Chest Bibliography | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
37
Computed Tomography (CT)
Abdomen
CPT Codes
74150.................. CT abdomen; without contrast
74160.................. CT abdomen; with contrast
74170.................. CT abdomen; without contrast, followed by re-imaging with contrast
Standard Anatomic Coverage
Ɣ Diaphragmatic dome to iliac crests
Ɣ 6FDQFRYHUDJHPD\YDU\GHSHQGLQJRQWKHVSHFL¿FFOLQLFDOLQGLFDWLRQ
Imaging Considerations
Ɣ For most gallbladder and hepatobiliary conditions, ascites evaluation and certain renal abnormalities (such as detection
of gallstones, hydronephrosis and differentiation of cystic, complex and solid lesions), initial imaging should be
considered using ultrasound.
Ɣ 9HUL¿FDWLRQRIF\VWLFOHVLRQVLQDEGRPLQDOYLVFHUDFDQXVXDOO\EHZHOOGRFXPHQWHGZLWKXOWUDVRXQG
Ɣ For abdominal symptoms in the pediatric population abdominal ultrasound frequently provides diagnostic information
without incurring radiation exposure from CT 1,2
Ɣ Ultrasound studies may be limited in obese patients.
Common Diagnostic Indications
The following diagnostic indications for abdominal CT are accompanied by pre-test considerations as well as supporting
clinical data and prerequisite information. This section contains: General abdominal, hepatobiliary, pancreatic, gastrointestinal,
genitourinary, splenic, and vascular indications.
General Abdominal
$EGRPLQDOSDLQ
Ɣ Unexplained by any of the following:
ż
&OLQLFDO¿QGLQJVOR
ż
Physical examination; OR
ż
Other imaging studies
$EQRUPDOLWLHVGHWHFWHGRQRWKHULPDJLQJVWXGLHVZKLFKUHTXLUHDGGLWLRQDOFODUL¿FDWLRQWRGLUHFW
treatment
Ascites
Ɣ For diagnosis and surveillance, following non-diagnostic ultrasound 3
Congenital anomaly
'LIIXVHXQH[SODLQHGORZHUH[WUHPLW\HGHPD
Note: For female patients, to exclude an occult lesion causing mass effect, vascular compression, or intraluminal thrombi,
ultrasound should be considered as the initial imaging modality 4
CT Abdomen | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
38
Common Diagnostic Indications
)HYHURIXQNQRZQRULJLQ
Ɣ Lasting more than three weeks with exceptions for immunocompromised patients
Ɣ Following standard work-up to localize the source
+HPDWRPDKHPRUUKDJH
Hernia
Ɣ For diagnosis of a hernia with suspected complications or presurgical planning including, but not limited to the following
types of hernia:
ż
Femoral
ż
Internal
ż
Inguinal
ż
Spigelian (through semilunar line, lateral to rectus abdominis muscle)
ż
Ventral
Incisional hernia
Ɣ For diagnosis of a hernia with suspected complications or presurgical planning
Note: Ultrasound should be considered as the initial imaging modality 5
,QIHFWLRXVRULQÀDPPDWRU\SURFHVV
Ɣ Including but not limited to the following:
ż
Abscess
ż
'LIIXVHLQÀDPPDWLRQSKOHJPRQ
ż
Fistula
/\PSKDGHQRSDWK\
Ɣ For initial detection and follow-up
3DOSDEOHDEGRPLQDOPDVV
Note: For pediatric patients, ultrasound should be considered as the initial imaging modality 6-9
3RVWRSHUDWLYHRUSRVWSURFHGXUHHYDOXDWLRQ
3UHRSHUDWLYHRUSUHSURFHGXUHHYDOXDWLRQ
1RWH7KLVLQGLFDWLRQLVWREHXVHGIRUSUHRSHUDWLYHHYDOXDWLRQRIFRQGLWLRQVQRWVSHFL¿FDOO\UHIHUHQFHGHOVHZKHUHLQWKLV
guideline.
5HWURSHULWRQHDODEQRUPDOLW\±¿EURVLVLQÀDPPDWLRQDQGQHRSODVP
Trauma
Ɣ )ROORZLQJVLJQL¿FDQWEOXQWRUSHQHWUDWLQJLQMXU\WRWKHDEGRPHQ
CT Abdomen | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
39
Common Diagnostic Indications
7XPRUHYDOXDWLRQSULPDU\QHRSODVPRUPHWDVWDWLFGLVHDVH
Ɣ For diagnosis
Ɣ Initial staging
Ɣ Periodic follow-up
Note: For pediatric patients, ultrasound should be considered as the initial imaging modality 8
8QH[SODLQHGZHLJKWORVV±VLJQL¿FDQWZHLJKWORVVH[FHHGLQJRIGHVLUDEOHERG\ZHLJKWRYHU
VKRUWWLPHLQWHUYDOVL[PRQWKVRUOHVVDIWHULQLWLDOHYDOXDWLRQIRURWKHUFDXVHV
+HSDWRELOLDU\
Acute cholecystitis
Ɣ Following clinical examination and non-diagnostic ultrasound for the evaluation of right upper quadrant pain 10-13
&LUUKRVLVIRUHYDOXDWLRQRIKHSDWRFHOOXODUFDUFLQRPD
Elevated liver transaminases
Ɣ Including alanine transaminase (ALT) and aspartate transaminase (AST)
Ɣ Following an abnormal or inconclusive abdominal ultrasound
Ɣ In patients on medications known to cause liver transaminase elevation, such as statins for hyperlipidemia,
DFHWDPLQRSKHQQRQVWHURLGDODQWLLQÀDPPDWRU\GUXJV'LODQWLQŠSURWHDVHLQKLELWRUVDQGVXOIRQDPLGHV7KHVH
medications should be stopped whenever possible and liver chemistries repeated before performing advanced imaging
Ɣ Other causes for elevated liver transaminases include excessive alcohol intake, cirrhosis, hepatitis, hepatic steatosis as
well as other hepatic and non-hepatic disorders. Consider additional diagnostic labs such as hepatitis panel and serum
alpha fetoprotein, as appropriate
Focal liver lesion characterization
Ɣ Complex or solid, including but not limited to:
ż
Focal nodular hyperplasia
ż
For diagnosis of liver hemangioma, following non-diagnostic ultrasound 14
ż
Hepatic adenoma
ż
Other focal pathologic abnormalities in the liver
ż
Hepatic cyst with complex features or cystic metastasis
1RWH$VLPSOHOLYHUF\VWZKLFKKDVEHQLJQFKDUDFWHULVWLFVRQXOWUDVRXQGPD\QRWUHTXLUHDGYDQFHGLPDJLQJRUVXUYHLOODQFH15
Jaundice
Ɣ With abnormal liver function tests (transaminases) and unexplained icterus, following an abdominal ultrasound
Ɣ CT imaging used to evaluate for diffuse or multifocal parenchymal liver disease as well as biliary obstruction
+HSDWRPHJDO\
Ɣ For clinically suspected or worsening hepatic enlargement
Note: Ultrasound should be considered as the initial imaging modality 16
CT Abdomen | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
40
Common Diagnostic Indications
Pancreatic
$FXWHSDQFUHDWLWLV
Ɣ With suspected complications including:
ż
Pancreatic necrosis
ż
Abscess
ż
Pseudocyst
ż
3HULSDQFUHDWLFÀXLG
1RWH3DWLHQWVZLWKPLOGDFXWHXQFRPSOLFDWHGSDQFUHDWLWLVXVXDOO\GRQRWUHTXLUHFURVVVHFWLRQDOLPDJLQJDVLGHIURP
XOWUDVRXQGLGHQWL¿FDWLRQRIJDOOVWRQHVDQGRUELOLDU\GXFWDOFDOFXOLDVDSRWHQWLDOFDXVH
.QRZQSDQFUHDWLFPDVV
Ɣ CT pancreas with pancreatic protocol is indicated 17
Note: MRI pancreas may be performed as an alternative study
3DQFUHDWLFSVHXGRF\VW
Ɣ With prior history of pancreatitis or pancreatic trauma
1RWH)RUDSDWLHQWZLWKDNQRZQSDQFUHDWLFSVHXGRF\VWUHTXLULQJIROORZXSVXUYHLOODQFHXOWUDVRXQGVKRXOGEHFRQVLGHUHGDV
the initial imaging modality 18
Gastrointestinal
$SSHQGLFHDORUSHULDSSHQGLFHDOPDVV±XQH[SODLQHGRQSK\VLFDOH[DPDQGRWKHULPDJLQJ
studies
$SSHQGLFLWLV
Ɣ Following a non-diagnostic ultrasound in the following patient populations:
ż
Pediatric patients 9,19-22
ż
Pregnant woman if MRI is contraindicated or unavailable
Ɣ For patient populations not listed above:
ż
Suspected appendicitis following clinical evaluation
Bowel obstruction
Diverticulitis
(QWHULWLVDQGRUFROLWLV
,QÀDPPDWRU\ERZHOGLVHDVH,%'
Ɣ For follow-up of known IBD, with new signs/symptoms suggesting exacerbation
ż
Crohn’s disease
ż
Ulcerative colitis
Ischemic bowel
CT Abdomen | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
41
Common Diagnostic Indications
Genitourinary
$FXWHS\HORQHSKULWLV
Ɣ In a patient with any of the following:
ż
Diabetes; OR
ż
History of renal calculi; OR
ż
History of renal surgery; OR
ż
Absence of response after 72 hours of therapy 23
Adrenal lesion
Ɣ Following a non-diagnostic ultrasound in neonate patients 24
Ɣ )RUFKDUDFWHUL]DWLRQRIDQLQGHWHUPLQDWHDGUHQDOPDVVLGHQWL¿HGRQSULRULPDJLQJ±VXFKDVDEHQLJQDGHQRPDYHUVXVD
metastatic deposit; OR
Ɣ When there is biochemical evidence of an adrenal endocrine abnormality
Hematuria
+\GURQHSKURVLV
Ɣ Evaluation for possible obstructing ureteral or urinary bladder lesion
Ɣ When ultrasound is non-diagnostic or abnormal and unexplained, requiring further evaluation
5HFXUUHQWORZHUXULQDU\WUDFWLQIHFWLRQ
Ɣ In female patients with any of the following:
ż
Non-responsive to conventional therapy; OR
ż
Frequent reinfection
Renal cyst
Ɣ Following a non-diagnostic ultrasound 25
1RWH$VLPSOHUHQDOF\VWZKLFKKDVEHQLJQFKDUDFWHULVWLFVRQXOWUDVRXQGPD\QRWUHTXLUHDGYDQFHGLPDJLQJRUVXUYHLOODQFH
Renal lesion
Ɣ Characterization of indeterminate lesion, particularly a mass, demonstrated on prior imaging
Note: For pediatric patients, ultrasound should be considered as the initial imaging modality 26
5HQDOQHRSODVP
Ɣ For diagnosis, initial staging and pre-operative evaluation, re-staging and treatment monitoring
Note: For pediatric patients, ultrasound should be considered as the initial imaging modality 26
8QGHVFHQGHGWHVWLFOHFU\SWRUFKLGLVP
CT Abdomen | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
42
Common Diagnostic Indications
Urinary tract calculi
Ɣ Where renal or ureteral calculi are suspected in a patient following clinical evaluation:
ż
In adult patients who have not yet undergone initial CT for evaluation of urinary tract calculi; 27 OR
Ɣ Following a non-diagnostic ultrasound or KUB in any one of the following scenarios:
ż
Pediatric patients 28-31
ż
Pregnant female patients 9,29,30,32
ż
Suspected recurrent urinary tract calculi 9,30,31
ż
Patients with known renal calculi or staghorn calculi before or after lithotripsy 33
ż
Patients with ureteral calculi known to be located at the pelvic brim
:RUVHQLQJUHQDOIXQFWLRQ
Ɣ Following a non-diagnostic ultrasound
1RWH1RQFRQWUDVWHYDOXDWLRQLVLQGLFDWHGLQLQGLYLGXDOVZLWKZRUVHQLQJUHQDOIXQFWLRQDVFRQWUDVWDGPLQLVWUDWLRQPD\
SRWHQWLDOO\ZRUVHQUHQDOIXQFWLRQLQWKHVHSDWLHQWV34
6SOHQLF
,QGHWHUPLQDWHVSOHQLFOHVLRQRQSULRULPDJLQJVXFKDVXOWUDVRXQG
1RWH6SOHQLFKHPDQJLRPDLVWKHPRVWFRPPRQEHQLJQVSOHQLFWXPRUDQGPD\EHIROORZHGZLWKVSOHQLFXOWUDVRXQG35
6SOHQLFKHPDWRPD
Ɣ Parenchymal
Ɣ Subcapsular
Ɣ Peri-splenic
6SOHQRPHJDO\
Ɣ For clinically suspected or worsening splenic enlargement
Note: Ultrasound should be considered as the initial imaging modality 35
Vascular
$QHXU\VPGLODWLRQRIDEGRPLQDODRUWDDQGRUEUDQFKYHVVHO
Ɣ Following inconclusive ultrasound in patients with suspected aneurysm / dilation
Ɣ Follow-up imaging of patients with an established aneurysm / dilation when ultrasound imaging is or has been
inconclusive
Ɣ Pre-operative assessment or prior to percutaneous endovascular stent graft placement
Ɣ Annual post-operative surveillance of stable patients who have undergone open surgical repair in whom ultrasound is or
has been inconclusive
Ɣ Post-operative surveillance of stable patients who have been treated with endovascular stent graft
Ɣ Suspected complication of an aneurysm / dilation, such as aneurysmal rupture or infection – requiring urgent imaging
CT Abdomen | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
43
Common Diagnostic Indications
Aortic dissection
Ɣ May evaluate with either CT or CTA
ż
Usually results from subdiaphragmatic extension of a thoracic aortic dissection
7KURPERVLVLQWKHV\VWHPLFDQGSRUWDOYHQRXVFLUFXODWLRQV
Ɣ Following initial evaluation with inconclusive Doppler ultrasound
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Jun;39(2):265-287, ix.
11. Harvey RT, Miller WT Jr. Acute biliary disease: initial CT and follow-up US versus initial US and follow-up CT. Radiology.
1999 Dec;213(3):831-836.
12. Ralls PW, Colletti PM, Lapin SA, Chandrasoma P, Boswell WD Jr, Ngo C, Radin DR, Halls JM. Real-time sonography in
suspected acute cholecystitis. Prospective evaluation of primary and secondary signs. Radiology. 1985 Jun;155(3):767771.
13. Spence SC, Teichgraeber D, Chandrasekhar C. Emergent right upper quadrant sonography. J Ultrasound Med. 2009
Apr;28(4):479-496.
14. Caturelli E, Pompili M, Bartolucci F, Siena DA, Sperandeo M, Andriulli A, Bisceglia M. Hemangioma-like lesions in
chronic liver disease: diagnostic evaluation in patients. Radiology. 2001 Aug;220(2):337-342.
15. Gore RM, Newmark GM, Thakrar KH, Mehta UK, Berlin JW. Hepatic incidentalomas. Radiol Clin North Am. 2011
Mar;49(2):291-322.
16. Tchelepi H, Ralls PW, Radin R, Grant E. Sonography of diffuse liver disease. J Ultrasound Med. 2002 Sep;21(9):10231032.
17. Low G, Panu A, Millo N, Leen E. Multimodality imaging of neoplastic and nonneoplastic solid lesions of the pancreas.
Radiographics. 2011 Jul-Aug;31(4):993-1015.
18. Lawson TL. Acute pancreatitis and its complications. Computed tomography and sonography. Radiol Clin North Am.
1983 Sep;21(3):495-513.
19. Doria AS, Moineddin R, Kellenberger CJ, Epelman M, Beyene J, Schuh S, Babyn PS, Dick PT. US or CT for Diagnosis
of Appendicitis in Children and Adults? A Meta-Analysis. Radiology. 2006 Oct;241(1):83-94.
CT Abdomen | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
44
20. Krishnamoorthi R, Ramarajan N, Wang NE, Newman B, Rubesova E, Mueller CM, Barth RA. Effectiveness of a staged
US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA.
Radiology. 2011 Apr;259(1):231-239
21. Newman B. Ultrasound body applications in children. Pediatr Radiol. 2011 Sep;41 Suppl 2:555-561.
22. Wan MJ, Krahn M, Ungar WJ, Caku E, Sung L, Medina LS, Doria AS. Acute appendicitis in young children: costeffectiveness of US versus CT in diagnosis--a Markov decision analytic model. Radiology. 2009 Feb;250(2):378-386.
23. Soulen MC, Fishman EK, Goldman SM, Gatewood OM. Bacterial renal infection: role of CT. Radiology 1989;
171(3):703-707.
24. Westra SJ, Zaninovic AC, Hall TR, Kangarloo H, Boechat MI. Imaging of the adrenal gland in children. Radiographics.
1994 Nov;14(6):1323-1340.
25. Einstein DM, Herts BR, Weaver R, Obuchowski N, Zepp R, Singer A. Evaluation of renal masses detected by excretory
urography: cost-effectiveness of sonography versus CT. AJR Am J Roentgenol. 1995 Feb;164(2):371-375.
26. Son J, Lee EY, Restrepo R, Eisenberg RL. Focal renal lesions in pediatric patients. AJR Am J Roentgenol. 2012
Dec;199(6):W668-W682.
27. +RSSH+6WXGHU5.HVVOHU709RFN36WXGHU8(7KRHQ\+&$OWHUQDWHRUDGGLWLRQDO¿QGLQJVWRVWRQHGLVHDVHRQ
XQHQKDQFHGFRPSXWHUL]HGWRPRJUDSK\IRUDFXWHÀDQNSDLQFDQLPSDFWPDQDJHPHQWJ Urol. 2006 May;175(5):17251730; discussion 1730.
28. Johnson EK, Faerber GJ, Roberts WW, Wolf JS Jr, Park JM, Bloom DA, Wan J. Are stone protocol computed
tomography scans mandatory for children with suspected urinary calculi? Urology. 2011 Sep;78(3):662-666.
29. Mandeville JA, Gnessin E, Lingeman JE. Imaging evaluation in the patient with renal stone disease.Semin Nephrol.
2011 May;31(3):254-258.
30. Moesbergen TC, de Ryke RJ, Dunbar S, Wells JE, Anderson NG. Distal ureteral calculi: US follow-up. Radiology. 2011
Aug;260(2):575-580.
31. Resorlu B, Kara C, Resorlu EB, Unsal A. Effectiveness of ultrasonography in the postoperative follow-up of pediatric
patients undergoing ureteroscopic stone manipulation. Pediatr Surg Int. 2011 Dec;27(12):1337-1341.
32. Dhar M, Denstedt JD. Imaging in diagnosis, treatment, and follow-up of stone patients. Adv Chronic Kidney Dis. 2009
Jan;16(1):39-47.
33. Coughlin BF, Risius B, Streem SB, Lorig RJ, Siegel SW. Abdominal radiograph and renal ultrasound versus excretory
urography in the evaluation of asymptomatic patients after extracorporeal shock wave lithotripsy. J Urol. 1989
Dec;142(6):1419-1423.
34. Committee on Drugs and Contrast Media, American College of Radiology. ACR Manual on Contrast Media. Version 8.
Reston, VA: ACR; 2012.
35. Benter T, Klühs L, Teichgräber U. Sonography of the spleen. J Ultrasound Med. 2011 Sep;30(9):1281-93.
CT Abdomen | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
45
CT Angiography (CTA) and
MR Angiography (MRA)
Abdomen
CPT Codes
74175.................. Computed tomographic angiography, abdomen, with contrast material(s), including non-contrast images, if
performed, and image post-processing
74185.................. Magnetic resonance angiography, abdomen; without or with contrast
Standard Anatomic Coverage
Ɣ Anatomic coverage for CPT codes 74175 (CTA) and 74185 (MRA) includes the major arterial and/or venous structures in
the abdomen, from the diaphragmatic dome through the iliac crests.
Imaging Considerations
Ɣ For CTA of the abdominal aorta and iliofemoral vasculature with lower extremity runoff, use CPT code 75635.
Ɣ For MRA of the abdominal aorta and iliofemoral vasculature, with lower extremity runoff, use the following CPT codes:
CPT 74185 MRA Abdomen x 1 and CPT 73725 MRA Lower Extremities x 2
Ɣ Doppler ultrasound examination is an excellent means to identify a wide range of vascular abnormalities, both arterial
and venous in origin. This well-established modality should be considered in the initial evaluation of many vascular
disorders listed below.
Ɣ CTA of the abdomen is an alternative exam in patients who cannot undergo MRA. (See biosafety issues in the
administrative guideline document)
Common Diagnostic Indications
The following diagnostic indications for abdominal CTA and MRA are accompanied by pre-test considerations as well as
supporting clinical data and prerequisite information.
$QHXU\VPGLODWLRQRIDEGRPLQDODRUWDDQGRUEUDQFKYHVVHO
Ɣ Following inconclusive ultrasound in patients with suspected aneurysm / dilation
Ɣ Follow-up imaging of patients with an established aneurysm / dilation when ultrasound imaging is or has been
inconclusive
Ɣ Pre-operative assessment or prior to percutaneous endovascular stent graft placement
Ɣ Annual post-operative surveillance of stable patients who have undergone open surgical repair in whom ultrasound is or
has been inconclusive
Ɣ Post-operative surveillance of stable patients who have been treated with endovascular stent graft
Ɣ Suspected complication of an aneurysm / dilation, such as aneurysmal rupture or infection – requiring urgent imaging
$UWHULRYHQRXVPDOIRUPDWLRQ$90RUDUWHULRYHQRXV¿VWXOD$9)
1RWH)RUUHQDORUVXSHU¿FLDO$90XOWUDVRXQGVKRXOGEHFRQVLGHUHGDVWKH¿UVWLPDJLQJPRGDOLW\
Dissection
Of the abdominal aorta and/or branch vessel
+HPDWRPDKHPRUUKDJH
CTA & MRA Abdomen | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
46
Common Diagnostic Indications
Mesenteric ischemia
Ɣ May have an acute or chronic and progressive (intestinal or abdominal angina) presentation
3RUWDOK\SHUWHQVLRQ
3UHRSHUDWLYHRUSUHSURFHGXUHHYDOXDWLRQ
1RWH7KLVLQGLFDWLRQLVWREHXVHGIRUSUHRSHUDWLYHHYDOXDWLRQRIFRQGLWLRQVQRWVSHFL¿FDOO\UHIHUHQFHGHOVHZKHUHLQWKLV
guideline.
3ULRUWRUHVHFWLRQRISHOYLFQHRSODVP
Pseudoaneurysm
Of the abdominal aorta and/or branch vessel
Renal artery stenosis
For suspected renovascular hypertension from renal artery stenosis, required clinical information includes at least
2-3 serial blood pressure measurements and a list of current anti-hypertensive medications. Renal artery CTA or
MRA may be performed in the following clinical scenarios:
Ɣ Refractory hypertension, in patients on therapeutic doses of 3 or more anti-hypertensive medications. Note that for
hypertension easily managed on 1-2 anti-hypertensive medications, imaging may not be required
Ɣ +\SHUWHQVLRQZLWKUHQDOIDLOXUHRUSURJUHVVLYHUHQDOLQVXI¿FLHQF\
Ɣ Accelerated or malignant hypertension
Ɣ Abrupt onset of hypertension
Ɣ Hypertension developing in patients younger than 30 years of age
Ɣ Deteriorating renal function on angiotensin converting enzyme inhibition
Ɣ Abdominal bruit, suspected to originate in the renal artery
Ɣ Generalized arteriosclerotic occlusive disease with hypertension
Ɣ Unilateral small renal size (> 1.5 cm difference in renal size on ultrasound)
Ɣ Following an abnormal renal Doppler ultrasound suggestive of renal artery stenosis
Ɣ 5HFXUUHQWXQH[SODLQHGHSLVRGHVRI³ÀDVK´SXOPRQDU\HGHPD
1RWH'RSSOHUXOWUDVRXQGH[DPLQDWLRQRIWKHUHQDODUWHULHVKDVEHHQVKRZQLQWKHSHHUUHYLHZHGOLWHUDWXUHWREHHI¿FDFLRXV
DQGFRVWHI¿FLHQWLQGHWHFWLQJUHQDODUWHU\VWHQRVLV+RZHYHULWLVOHVVVHQVLWLYHWKDQ&7$05$IRUGHWHFWLRQRIUHQRYDVFXODU
hypertension.
6WHQRVLVRURFFOXVLRQRIWKHDEGRPLQDODRUWDRUEUDQFKYHVVHOV
Ɣ Due to:
ż
Atherosclerosis
ż
Thromboembolism
ż
Other causes
6XUJLFDOSODQQLQJIRUDNLGQH\GRQRU
CTA & MRA Abdomen | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
47
Common Diagnostic Indications
6XUJLFDOSODQQLQJIRUUHQDOWXPRUUHVHFWLRQ
6XVSHFWHGOHDNIROORZLQJDEGRPLQDODRUWLFVXUJHU\
Traumatic vascular injury
8QH[SODLQHGEORRGORVVLQWKHDEGRPHQ
9DVFXODUDQDWRPLFGHOLQHDWLRQIRURWKHUVXUJLFDODQGLQWHUYHQWLRQDOSURFHGXUHV
Ɣ Including but not limited to the following clinical scenarios:
ż
For surgical porto-systemic shunt placement or TIPS (transjugular intrahepatic porto-systemic shunt)
ż
For hepatic chemo-embolization procedure
ż
For vascular delineation prior to operative resection of an abdominal neoplasm
ż
For pre- and post-procedure evaluation of bypass grafts, stents and vascular anastomoses
9DVFXODUHYDOXDWLRQRIORZHUH[WUHPLW\FODXGLFDWLRQ
Ɣ CPT Coding for abdominal aortic and run-off evaluation, which involves image post-processing for three-dimensional
reconstructions, should follow:
ż
For CTA: 75635 - CTA of abdominal aorta and bilateral iliofemoral lower extremity run-off without contrast, followed
by re-imaging with contrast
ż
For MRA: 74185 - abdominal MRA and 73725 - bilateral lower extremity MRAs
Ɣ Either CTA or MRA is indicated in a patient with classic presenting symptoms of claudication from peripheral arterial
disease, such as diminished/absent peripheral pulses and cramping pain in the legs (particularly in the thighs and calves)
ZKHQZDONLQJZKLFKGLVDSSHDUVDWUHVW2WKHUFOLQLFDO¿QGLQJVZKLFKVXSSRUWQRQLQYDVLYHDVVHVVPHQWZLWK&7$RU05$
include lower extremity cutaneous ulcers and gangrene
Ɣ In the absence of classic peripheral symptoms of claudication, then obtain a vascular surgical consultation and
perform lower extremity non-invasive arterial evaluation, which may include the following: segmental systolic pressure
measurements, segmental limb plethysmography, continuous wave Doppler and duplex ultrasonography. Ankle brachial
LQGLFHV$%,RIPD\XQGHUJRDGYDQFHGLPDJLQJ5HVWSDLQRUVHYHUHRFFOXVLYHGLVHDVHW\SLFDOO\RFFXUVZLWK$%,
0.5
9DVFXODULQYDVLRQRUFRPSUHVVLRQE\DQDEGRPLQDOWXPRU
Vasculitis
Venous thrombosis or occlusion
Ɣ Consider initial evaluation with Doppler ultrasound
ż
Portal and mesenteric venous systems
ż
Systemic venous system:
Ŷ IVC thrombosis or extrinsic compression / occlusion, for example by tumor
Ŷ Hepatic vein thrombosis (Budd-Chiari syndrome)
Ŷ Renal vein thrombosis
Ŷ Other major abdominal vessels
CTA & MRA Abdomen | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
48
Computed Tomography (CT)
Pelvis
CPT Codes
72192.................. CT of pelvis, without contrast
72193.................. CT of pelvis, with contrast
72194.................. CT of pelvis without contrast, followed by re-imaging with contrast
Standard Anatomic Coverage
Ɣ Iliac crests to ischial tuberosities
Ɣ &RYHUDJHPD\YDU\GHSHQGLQJRQWKHVSHFL¿FFOLQLFDOLQGLFDWLRQIRUWKHH[DP
Imaging Considerations
Ɣ Consider using ultrasound for indications such as differentiation of cystic, complex and solid lesions and initial ascites
evaluation
Ɣ 9HUL¿FDWLRQRIF\VWLFOHVLRQVLQWKHSHOYLVLVXVXDOO\ZHOOHVWDEOLVKHGZLWKXOWUDVRXQG
Ɣ Ultrasound studies may be limited in obese patients
Common Diagnostic Indications
The following diagnostic indications for pelvic CT are accompanied by pre-test considerations as well as supporting clinical
data and prerequisite information. This section contains: General pelvic, intestinal, genitourinary, vascular, and osseous
indications
General Pelvic
$EQRUPDOLWLHVGHWHFWHGRQRWKHULPDJLQJVWXGLHVZKLFKUHTXLUHDGGLWLRQDOFODUL¿FDWLRQWRGLUHFW
treatment
Ascites
Ɣ For diagnosis and surveillance, following non-diagnostic ultrasound 1
Congenital anomaly
'LIIXVHXQH[SODLQHGORZHUH[WUHPLW\HGHPD
Note: For female patients, to exclude an occult lesion causing mass effect, vascular compression, or intraluminal thrombi,
ultrasound should be considered as the initial imaging modality 2
)HYHURIXQNQRZQRULJLQ
Ɣ Lasting more than three weeks with exceptions for immunocompromised patients
Ɣ Following standard work-up to localize the source
+HPDWRPDKHPRUUKDJH
CT Pelvis | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
49
Common Diagnostic Indications
Hernia
Ɣ For diagnosis of a hernia with suspected complications or presurgical planning including, but not limited to the following
types of hernia:
ż
Femoral
ż
Internal
ż
Inguinal
ż
Spigelian (through semilunar line, lateral to rectus abdominis muscle)
ż
Ventral
Incisional hernia
Ɣ For diagnosis of a hernia with suspected complications or presurgical planning
Note: Ultrasound should be considered as the initial imaging modality 3
,QIHFWLRXVRULQÀDPPDWRU\SURFHVV
Ɣ Including but not limited to the following:
ż
Abscess
ż
'LIIXVHLQÀDPPDWLRQSKOHJPRQ
ż
Fistula
ż
Recurrent cystitis (male with at least two episodes or female with failed antibiotic therapy)
/\PSKDGHQRSDWK\
Ɣ For initial detection and follow-up
3DOSDEOHSHOYLFPDVV
Ɣ When palpable pelvic mass requires further evaluation following pelvic ultrasound in female patients
Note: For pediatric patients, ultrasound should be considered as the initial imaging modality 4-6
3HOYLFSDLQ
Ɣ For female patients, following non-diagnostic transabdominal and transvaginal pelvic ultrasound 5,7-8
Ɣ Unexplained by any of the following:
ż
&OLQLFDO¿QGLQJVOR
ż
Physical examination; OR
ż
Other imaging studies
3RVWRSHUDWLYHRUSRVWSURFHGXUHHYDOXDWLRQ
3UHRSHUDWLYHRUSUHSURFHGXUHHYDOXDWLRQ
1RWH7KLVLQGLFDWLRQLVWREHXVHGIRUSUHRSHUDWLYHHYDOXDWLRQRIFRQGLWLRQVQRWVSHFL¿FDOO\UHIHUHQFHGHOVHZKHUHLQWKLV
guideline.
5HWURSHULWRQHDODEQRUPDOLW\±¿EURVLVLQÀDPPDWLRQDQGQHRSODVP
CT Pelvis | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
50
Common Diagnostic Indications
Trauma
Ɣ )ROORZLQJVLJQL¿FDQWEOXQWRUSHQHWUDWLQJLQMXU\WRWKHSHOYLV
7XPRUHYDOXDWLRQSULPDU\QHRSODVPRUPHWDVWDWLFGLVHDVH
Ɣ For diagnosis
Ɣ Initial staging
Ɣ Periodic follow-up
Note: For pediatric patients, ultrasound should be considered as the initial imaging modality 4, 6
8QH[SODLQHGZHLJKWORVV±VLJQL¿FDQWZHLJKWORVVH[FHHGLQJRIGHVLUDEOHERG\ZHLJKWRYHU
VKRUWWLPHLQWHUYDOVL[PRQWKVRUOHVVDIWHULQLWLDOHYDOXDWLRQIRURWKHUFDXVHV
Intestinal
$SSHQGLFHDORUSHULDSSHQGLFHDOPDVV±XQH[SODLQHGRQSK\VLFDOH[DPDQGRWKHULPDJLQJ
studies
$SSHQGLFLWLV
Ɣ Following a non-diagnostic ultrasound in the following patient populations:
ż
Pediatric patients 5,9-12
ż
Pregnant women if MRI is contraindicated or unavailable
Ɣ For patient populations not listed above:
ż
Suspected appendicitis following clinical evaluation
Bowel obstruction
Diverticulitis
(QWHULWLVDQGRUFROLWLV
,QÀDPPDWRU\ERZHOGLVHDVH,%'
Ɣ For follow-up of known IBD, with new signs/symptoms suggesting exacerbation
ż
Crohn’s disease
ż
Ulcerative colitis
Ischemic bowel
Genitourinary
Hematuria
+\GURQHSKURVLV
Ɣ Evaluation for possible obstructing ureteral or urinary bladder lesion
Ɣ When ultrasound is non-diagnostic or abnormal and unexplained, requiring further evaluation
CT Pelvis | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
51
Common Diagnostic Indications
5HFXUUHQWORZHUXULQDU\WUDFWLQIHFWLRQ
Ɣ In female patients with any of the following:
ż
Non-responsive to conventional therapy; OR
ż
Frequent reinfection
8QGHVFHQGHGWHVWLFOHFU\SWRUFKLGLVP
Urinary tract calculi
Ɣ Where renal or ureteral calculi are suspected in a patient following clinical evaluation:
ż
In adult patients who have not yet undergone initial CT for evaluation of urinary tract calculi;13 OR
Ɣ Following a non-diagnostic ultrasound or KUB in any one of the following scenarios:
ż
Pediatric patients 14-17
ż
Pregnant female patients 5, 15,16,18
ż
Suspected recurrent urinary tract calculi 5,16,17
ż
Patients with known renal calculi or staghorn calculi before or after lithotripsy 19
ż
Patients with ureteral calculi known to be located at the pelvic brim
Vascular
$QHXU\VPGLODWLRQRIDEGRPLQDODRUWDDQGRUEUDQFKYHVVHO
Ɣ Following inconclusive ultrasound in patients with suspected aneurysm / dilation
Ɣ Follow-up imaging of patients with an established aneurysm / dilation when ultrasound imaging is or has been
inconclusive
Ɣ Pre-operative assessment or prior to percutaneous endovascular stent graft placement
Ɣ Annual post-operative surveillance of stable patients who have undergone open surgical repair in whom ultrasound is or
has been inconclusive
Ɣ Post-operative surveillance of stable patients who have been treated with endovascular stent graft
Ɣ Suspected complication of an aneurysm / dilation, such as aneurysmal rupture or infection – requiring urgent imaging
$RUWRLOLDFGLVVHFWLRQ
ż
May evaluate with either CT or CTA
7KURPERVLVLQWKHV\VWHPLFDQGSRUWDOYHQRXVFLUFXODWLRQV
Ɣ Following initial evaluation with inconclusive Doppler ultrasound
Osseous
$FXWHSHOYLFWUDXPDIRUIUDFWXUHHYDOXDWLRQ
Ɣ Radiographs should be performed prior to CT
+LSRVWHRQHFURVLV
Ɣ When the patient is unable to undergo hip MRI or radionuclide bone scintigraphy, which are more sensitive modalities
WKDQKLS&7LQLQGLYLGXDOVZLWKQRUPDOKLS¿OPVRULQFRQFOXVLYHUDGLRJUDSKLFHYLGHQFHRIKLSRVWHRQHFURVLV
Ɣ In known hip osteonecrosis and femoral head collapse by radiography, CT may help in the pre-operative planning, to
GH¿QHWKHORFDWLRQDQGH[WHQWRIGLVHDVHLQSDWLHQWVZLWKSDLQIXOKLSV
CT Pelvis | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
52
Common Diagnostic Indications
2VVHRXVWXPRUHYDOXDWLRQLQWKHSHOYLV
Ɣ MRI or radionuclide bone scintigraphy may be more appropriate for detection of skeletal metastases and primary bone
tumors unless otherwise contraindicated
Osteoid osteoma
Ɣ Requires negative or inconclusive hip radiographs prior to CT imaging
Sacroiliitis
Ɣ Following sacroiliac joint radiographs
6WUHVVLQVXI¿FLHQF\IUDFWXUHLQWKHSHOYLV
Ɣ 5DGLRJUDSKVDUHDUHTXLUHG¿UVWVWHSEHIRUHRWKHULPDJLQJLVSHUIRUPHG
ż
Subsequent advanced imaging often includes MRI or radionuclide bone scan as the next step
6XVSLFLRQRISHOYLFRVWHRP\HOLWLVRUVHSWLFDUWKULWLV
Ɣ When the patient is unable to undergo hip MRI or radionuclide bone scintigraphy
References
1.
Thoeni RF. The role of imaging in patients with ascites. AJR Am J Roentgenol. 1995 Jul;165(1):16-18.
2.
Sonin AH, Mazer MJ, Powers TA. Obstruction of the inferior vena cava: a multiple-modality demonstration of causes,
manifestations, and collateral pathways. Radiographics. 1992 Mar;12(2):309-322.
3.
Beck WC, Holzman MD, Sharp KW, Nealon WH, Dupont WD, Poulose BK. Comparative effectiveness of dynamic
abdominal sonography for hernia vs computed tomography in the diagnosis of incisional hernia. J Am Coll Surg. 2013
Mar;216(3):447-453.
4.
Garel L, Dubois J, Grignon A, Filiatrault D, Van Vliet G. US of the pediatric female pelvis: a clinical perspective.
Radiographics. 2001;21(6):1393-1407.
5.
Minton KK, Abuhamad A. 2012 Ultrasound First forum proceedings. J Ultrasound Med. 2013;32. In press.
6.
Wu A, Siegel MJ. Sonography of pelvic masses in children: diagnostic predictability. AJR Am J Roentgenol.
1987;148(6):1199-1202.
7.
6DED/*XHUULHUR66XOFLV53LOORQL0$MRVVD60HOLV*0DOODULQL*05,DQG³WHQGHUQHVVJXLGHG´WUDQVYDJLQDO
ultrasonography in the diagnosis of recto-sigmoid endometriosis. J Magn Reson Imaging. 2012 Feb;35(2):352-60.
8.
Timmerman D, Van Calster B, Testa AC, Guerriero S, Fischerova D, Lissoni AA, Van Holsbeke C, Fruscio R,
Czekierdowski A, Jurkovic D, Savelli L, Vergote I, Bourne T, Van Huffel S, Valentin L. Ovarian cancer prediction in
adnexal masses using ultrasound-based logistic regression models: a temporal and external validation study by the
IOTA group. Ultrasound Obstet Gynecol. 2010 Aug;36(2):226-34.
9.
Doria AS, Moineddin R, Kellenberger CJ, Epelman M, Beyene J, Schuh S, Babyn PS, Dick PT. US or CT for diagnosis
of appendicitis in children and adults? a meta-analysis. Radiology. 2006 Oct;241(1):83-94.
10. Krishnamoorthi R, Ramarajan N, Wang NE, Newman B, Rubesova E, Mueller CM, Barth RA. Effectiveness of a staged
US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA.
Radiology. 2011 Apr;259(1):231-239.
11. Newman B. Ultrasound body applications in children. Pediatr Radiol. 2011;41 Suppl 2:555-561.
12. Wan MJ, Krahn M, Ungar WJ, Caku E, Sung L, Medina LS, Doria AS. Acute appendicitis in young children: costeffectiveness of US versus CT in diagnosis--a Markov decision analytic model. Radiology. 2009 Feb;250(2):378-86.
CT Pelvis | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
53
13. +RSSH+6WXGHU5.HVVOHU709RFN36WXGHU8(7KRHQ\+&$OWHUQDWHRUDGGLWLRQDO¿QGLQJVWRVWRQHGLVHDVHRQ
XQHQKDQFHGFRPSXWHUL]HGWRPRJUDSK\IRUDFXWHÀDQNSDLQFDQLPSDFWPDQDJHPHQWJ Urol. 2006 May;175(5):1725-30;
discussion 1730.
14. Johnson EK, Faerber GJ, Roberts WW, Wolf JS Jr, Park JM, Bloom DA, Wan J. Are stone protocol computed
tomography scans mandatory for children with suspected urinary calculi? Urology. 2011 Sep;78(3):662-666.
15. Mandeville JA, Gnessin E, Lingeman JE.Imaging evaluation in the patient with renal stone disease.Semin Nephrol. 2011
May;31(3):254-258.
16. Moesbergen TC, de Ryke RJ, Dunbar S, Wells JE, Anderson NG. Distal ureteral calculi: US follow-up. Radiology. 2011
Aug;260(2):575-580.
17. Resorlu B, Kara C, Resorlu EB, Unsal A. Effectiveness of ultrasonography in the postoperative follow-up of pediatric
patients undergoing ureteroscopic stone manipulation. Pediatr Surg Int. 2011 Dec;27(12):1337-1341.
18. Dhar M, Denstedt JD. Imaging in diagnosis, treatment, and follow-up of stone patients. Adv Chronic Kidney Dis. 2009
Jan;16(1):39-47.
19. Coughlin BF, Risius B, Streem SB, Lorig RJ, Siegel SW. Abdominal radiograph and renal ultrasound versus excretory
urography in the evaluation of asymptomatic patients after extracorporeal shock wave lithotripsy. J Urol. 1989
Dec;142(6):1419-1423.
CT Pelvis | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
54
CT Angiography (CTA) and
MR Angiography (MRA)
Pelvis
CPT Codes
72191.................. Computed tomographic angiography, pelvis, with contrast material(s), including non-contrast images, if
performed, and image post-processing
72198.................. Magnetic resonance angiography, pelvis; without contrast, followed by re-imaging with contrast
Standard Anatomic Coverage
Ɣ Iliac crests to ischial tuberosities.
Ɣ 6FDQFRYHUDJHPD\YDU\GHSHQGLQJRQWKHVSHFL¿FFOLQLFDOLQGLFDWLRQIRUWKHH[DP
Imaging Considerations
Ɣ Doppler ultrasound examination is an excellent means to identify a wide range of vascular abnormalities, both arterial
and venous in origin. This well-established modality should be considered in the initial evaluation of many vascular
disorders listed below.
Ɣ MRA should also be considered in patients with a history of either previous contrast reaction to intravascular
administration of iodinated radiographic contrast material or atopy.
Ɣ CTA of the pelvis is an alternative exam in patients who cannot undergo MRA. (See biosafety issues in the administrative
guideline document).
Ɣ Requests for pelvic CTA or MRA in addition to a request for a MRA or CTA abdominal aorta and bilateral iliofemoral lower
extremity runoff study are not allowed.
Common Diagnostic Indications
The following diagnostic indications for pelvic CTA and MRA are accompanied by pre-test considerations as well as supporting
clinical data and prerequisite information:
$QHXU\VPGLODWLRQRIDEGRPLQDODRUWDDQGRUEUDQFKYHVVHO
Ɣ Following inconclusive ultrasound in patients with suspected aneurysm / dilation
Ɣ Follow-up imaging of patients with an established aneurysm / dilation when ultrasound imaging is or has been
inconclusive
Ɣ Pre-operative assessment or prior to percutaneous endovascular stent graft placement
Ɣ Annual post-operative surveillance of stable patients who have undergone open surgical repair in whom ultrasound is or
has been inconclusive
Ɣ Post-operative surveillance of stable patients who have been treated with endovascular stent graft
Ɣ Suspected complication of an aneurysm / dilation, such as aneurysmal rupture or infection – requiring urgent imaging
$UWHULRYHQRXVPDOIRUPDWLRQ$90RUDUWHULRYHQRXV¿VWXOD$9)
1RWH)RUUHQDORUVXSHU¿FLDO$90XOWUDVRXQGVKRXOGEHFRQVLGHUHGDVWKH¿UVWLPDJLQJPRGDOLW\
Dissection
Of the abdominal aorta and/or branch vessel
CTA & MRA Pelvis | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
55
Common Diagnostic Indications
+HPDWRPDKHPRUUKDJH
Of the abdominal aorta and/or branch vessel
Mesenteric ischemia
Ɣ May have an acute or chronic and progressive (intestinal or abdominal angina) presentation
Pseudoaneurysm
Of the abdominal aorta and/or branch vessel
6WHQRVLVRURFFOXVLRQRIWKHORZHUDEGRPLQDODRUWDLOLDFDUWHULHVRURWKHUEUDQFKYHVVHOVLQWKH
SHOYLV
6XUJLFDOSODQQLQJIRUDNLGQH\GRQRU
6XVSHFWHGOHDNIROORZLQJDEGRPLQDODRUWLFVXUJHU\
Traumatic vascular injury
8QH[SODLQHGEORRGORVVLQWKHSHOYLV
9DVFXODUDQDWRPLFGHOLQHDWLRQIRURWKHUVXUJLFDODQGLQWHUYHQWLRQDOSURFHGXUHV
Ɣ For vascular delineation prior to operative resection of a pelvic neoplasm
Ɣ For pre- and post-procedure evaluation of bypass grafts, stents and vascular anastomoses
9DVFXODULQYDVLRQRUFRPSUHVVLRQE\DSHOYLFWXPRU
Vasculitis
Venous thrombosis or occlusion
Ɣ Following initial evaluation with inconclusive Doppler ultrasound
CTA & MRA Pelvis | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
56
Computed Tomography (CT)
Abdomen & Pelvis Combination
CPT Codes
74176.................. CT of abdomen and pelvis, without contrast
74177.................. CT of abdomen and pelvis, with contrast
74178.................. CT of abdomen and pelvis, without contrast, followed by re-imaging with contrast
Standard Anatomic Coverage
Ɣ Diaphragmatic dome through pubic symphysis
Ɣ 6FDQFRYHUDJHPD\YDU\GHSHQGLQJRQWKHVSHFL¿FFOLQLFDOLQGLFDWLRQ
Imaging Considerations
Ɣ 9HUL¿FDWLRQRIF\VWLFOHVLRQVLQWKHDEGRPLQDODQGSHOYLVLVXVXDOO\ZHOOHVWDEOLVKHGZLWKXOWUDVRXQG
Ɣ For abdominal symptoms in the pediatric population abdominal ultrasound frequently provides diagnostic information
without incurring radiation exposure from CT 1,2
1. American Academy of Pediatrics. Choosing Wisely: Five Things
Physicians and Patients Should Question. ABIM Foundation; 2013.
http://www.choosingwisely.org. Accessed February 21, 2013.
Common Diagnostic Indications
2. Saito
JM. Beyond
appendicitis:
Evaluation
and surgical
treatment
The following diagnostic indications for combined abdominal
and pelvic
CT Exams
are accompanied
by pre-test
considerations
Curr
Opin
Pediatr.
2012
of
pediatric
acute
abdominal
pain.
as well as supporting clinical data and prerequisite information. This section contains: General abdominal and pelvic,
Jun;24(3):357-364.
gastrointestinal, genitourinary, vascular indications
General Abdominal and Pelvic
$EGRPLQDOSHOYLFSDLQ
Ɣ For female patients, following non-diagnostic transabdominal and transvaginal pelvic ultrasound 3-5
Ɣ Unexplained by any of the following:
ż
&OLQLFDO¿QGLQJVOR
ż
Physical examination; OR
ż
Other imaging studies
$EQRUPDOLWLHVGHWHFWHGRQRWKHULPDJLQJVWXGLHVZKLFKUHTXLUHDGGLWLRQDOFODUL¿FDWLRQWRGLUHFW
treatment
Ascites
Ɣ For diagnosis and surveillance, following non-diagnostic ultrasound 6
Congenital anomaly
'LIIXVHXQH[SODLQHGORZHUH[WUHPLW\HGHPD
Note: For female patients, to exclude an occult lesion causing mass effect, vascular compression, or intraluminal thrombi,
ultrasound should be considered as the initial imaging modality 7
)HYHURIXQNQRZQRULJLQ
Ɣ Lasting more than three weeks with exceptions for immunocompromised patients
Ɣ Following standard work-up to localize the source
CT Abdomen & Pelvis Combination | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
57
Common Diagnostic Indications
+HPDWRPDKHPRUUKDJH
Hernia
Ɣ For diagnosis of a hernia with suspected complications or presurgical planning including, but not limited to the following
types of hernia:
ż
Femoral
ż
Internal
ż
Inguinal
ż
Spigelian (through semilunar line, lateral to rectus abdominis muscle)
ż
Ventral
Incisional hernia
Ɣ For diagnosis of a hernia with suspected complications or presurgical planning
Note: Ultrasound should be considered as the initial imaging modality 8
,QIHFWLRXVRULQÀDPPDWRU\SURFHVV
Ɣ Including but not limited to the following:
ż
Abscess
ż
'LIIXVHLQÀDPPDWLRQSKOHJPRQ
ż
Fistula
ż
Recurrent cystitis (male with at least two episodes or female with failed antibiotic therapy)
/\PSKDGHQRSDWK\
Ɣ For initial detection and follow-up
3DOSDEOHDEGRPLQDOSHOYLFPDVV
Ɣ When palpable pelvic mass requires further evaluation following pelvic ultrasound in female patients
Note: For pediatric patients, ultrasound should be considered as the initial imaging modality 3,9-13
3RVWRSHUDWLYHRUSRVWSURFHGXUHHYDOXDWLRQ
3UHRSHUDWLYHRUSUHSURFHGXUHHYDOXDWLRQ
1RWH7KLVLQGLFDWLRQLVWREHXVHGIRUSUHRSHUDWLYHHYDOXDWLRQRIFRQGLWLRQVQRWVSHFL¿FDOO\UHIHUHQFHGHOVHZKHUHLQWKLV
guideline.
5HWURSHULWRQHDODEQRUPDOLW\±¿EURVLVLQÀDPPDWLRQDQGQHRSODVP
Trauma
Ɣ )ROORZLQJVLJQL¿FDQWEOXQWRUSHQHWUDWLQJLQMXU\WRWKHDEGRPHQ
7XPRUHYDOXDWLRQSULPDU\QHRSODVPRUPHWDVWDWLFGLVHDVH
Ɣ For diagnosis
Ɣ Initial staging
Ɣ Periodic follow-up
Note: For pediatric patients, ultrasound should be considered as the initial imaging modality 10,12,13
CT Abdomen & Pelvis Combination | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
58
Common Diagnostic Indications
8QH[SODLQHGZHLJKWORVV±VLJQL¿FDQWZHLJKWORVVH[FHHGLQJRIGHVLUDEOHERG\ZHLJKWRYHU
VKRUWWLPHLQWHUYDOVL[PRQWKVRUOHVVDIWHULQLWLDOHYDOXDWLRQIRURWKHUFDXVHV
Gastrointestinal
$SSHQGLFHDORUSHULDSSHQGLFHDOPDVV±XQH[SODLQHGRQSK\VLFDOH[DPDQGRWKHULPDJLQJ
studies
$SSHQGLFLWLV
Ɣ Following a non-diagnostic ultrasound in the following patient populations:
ż
Pediatric patients 3,14-17
ż
Pregnant woman if MRI is contraindicated or unavailable
Ɣ For patient populations not listed above:
ż
Suspected appendicitis following clinical evaluation
Bowel obstruction
Diverticulitis
(QWHULWLVDQGRUFROLWLV
,QÀDPPDWRU\ERZHOGLVHDVH,%'
Ɣ For follow-up of known IBD, with new signs/symptoms suggesting exacerbation
ż
Crohn’s disease
ż
Ulcerative colitis
Ischemic bowel
Genitourinary
$FXWHS\HORQHSKULWLV
Ɣ In a patient with any of the following:
ż
Diabetes; OR
ż
History of renal calculi; OR
ż
History of renal surgery; OR
ż
Absence of response after 72 hours of therapy 18
Hematuria
+\GURQHSKURVLV
Ɣ Evaluation for possible obstructing ureteral or urinary bladder lesion
Ɣ When ultrasound is non-diagnostic or abnormal and unexplained, requiring further evaluation
CT Abdomen & Pelvis Combination | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
59
Common Diagnostic Indications
5HFXUUHQWORZHUXULQDU\WUDFWLQIHFWLRQ
Ɣ In female patients with any of the following:
ż
Non-responsive to conventional therapy; OR
ż
Frequent reinfection
5HQDOQHRSODVP
Ɣ For diagnosis, initial staging and pre-operative evaluation, re-staging and treatment monitoring
Note: For pediatric patients, ultrasound should be considered as the initial imaging modality 19
8QGHVFHQGHGWHVWLFOHFU\SWRUFKLGLVP
Urinary tract calculi
Ɣ Where renal or ureteral calculi are suspected in a patient following clinical evaluation:
ż
In adult patients who have not yet undergone initial CT for evaluation of urinary tract calculi;20 OR
Ɣ Following a non-diagnostic ultrasound or KUB in any one of the following scenarios:
ż
Pediatric patients21-24
ż
Pregnant female patients 3,22,23,25
ż
Suspected recurrent urinary tract calculi 3,23,24
ż
Patients with known renal calculi or staghorn calculi before or after lithotripsy 26
ż
Patients with ureteral calculi known to be located at the pelvic brim
:RUVHQLQJUHQDOIXQFWLRQ
Ɣ Following a non-diagnostic ultrasound
1RWH1RQFRQWUDVWHYDOXDWLRQLVLQGLFDWHGLQLQGLYLGXDOVZLWKZRUVHQLQJUHQDOIXQFWLRQDVFRQWUDVWDGPLQLVWUDWLRQPD\
SRWHQWLDOO\ZRUVHQUHQDOIXQFWLRQLQWKHVHSDWLHQWV27
Vascular
$QHXU\VPGLODWLRQRIDEGRPLQDODRUWDDQGRUEUDQFKYHVVHO
Ɣ Following inconclusive ultrasound in patients with suspected aneurysm / dilation
Ɣ Follow-up imaging of patients with an established aneurysm / dilation when ultrasound imaging is or has been
inconclusive
Ɣ Pre-operative assessment or prior to percutaneous endovascular stent graft placement
Ɣ Annual post-operative surveillance of stable patients who have undergone open surgical repair in whom ultrasound is or
has been inconclusive
Ɣ Post-operative surveillance of stable patients who have been treated with endovascular stent graft
Ɣ Suspected complication of an aneurysm / dilation, such as aneurysmal rupture or infection – requiring urgent imaging
$RUWRLOLDFGLVVHFWLRQ
Ɣ May evaluate with either CT or CTA
ż
Usually results from subdiaphragmatic extension of a thoracic aortic dissection\
7KURPERVLVLQWKHV\VWHPLFDQGSRUWDOYHQRXVFLUFXODWLRQV
Ɣ Following initial evaluation with inconclusive Doppler ultrasound
CT Abdomen & Pelvis Combination | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
60
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52. 3LQWR,&KLPHQR35RPR$HWDO8WHULQH¿EURLGVXWHULQHDUWHU\HPEROL]DWLRQYHUVXVDEGRPLQDOK\VWHUHFWRP\IRU
treatment–a prospective, randomized, and controlled clinical trial. Radiology. 2003;226(2):425-431.
53. Qaseem A, Denberg TD, Hopkins RH Jr, et al. Screening for colorectal cancer: a guidance statement from the American
College of Physicians. Ann Intern Med. 2012;156(5):378-386.
54. Rozenbilt AM, Patlas M, Rosenbaum AT, et al. Detection of endoleaks after endovascular repair of abdominal aortic
aneurysm: value of unenhanced and delayed helical CT acquisitions. Radiology. 2003;227(2):426-433.
55. Ruehm SG, Hany TF, Pfammatter T, et al. Pelvic and lower extremity arterial imaging: diagnostic performance of threedimensional contrast-enhanced MR angiography. AJR AmJ Roentgenol. 2000;174(4):1127-1135
56. 6D¿DQ5'7H[WRU6&5HQDODUWHU\VWHQRVLVN Engl J Med. 2001;344(6):431-442.
57. Saini S, Imaging of the hepatobiliary tract. N Eng J Med. 1997;336(26):1889-1894.
58. Sahani D, Saini S, Pena C, et al. Using multidetector CT for preoperative vascular evaluation of liver neoplasms:
technique and results. AJR Am J Roentgenol. 2002;179(1):53-59.
59. Scheidler J, Heuck AF. Imaging of cancer of the cervix. Radiol Clin North Am 2002;40(3):577-590.
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doppler US, and MR angiography. Radiographics. 2000;20(5):1355-1368.
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64. 7DPDL.7RJDVKL.,WR7HWDO05LPDJLQJ¿QGLQJVRIDGHQRP\RVLVFRUUHODWLRQZLWKKLVWRSDWKRORJLFIHDWXUHVDQG
diagnostic pitfalls. Radiographics. 2005:25(1):21-40.
65. Teichman JM, Acute renal colic from ureteral calculus. N Engl J Med. 2004;350(7):684-693.
66. Tolia AJ, Landis R, Lamparello P, Rosen R, Macari M. Type II endoleaks after endovascular repair of abdominal aortic
aneurysms: natural history. Radiology. 2005;235(2):683-686.
67. Van den Berg JC. Inguinal hernias:MRI and ultrasound. Magn Reson Imaging Clin N Am. 2004;12:689-705.
68. Van Gelder RE, Birnie E. Florie J, et al. CT colonography and colonoscopy: assessment of patient preference in a
5-week follow-up study. Radiology. 2004;233(2):328-337.
69. Visser K, Kock MCJM, Kuntz KM, et al. Cost-effectiveness targets for multi-detector row CT angiography in the work-up
of patients with intermittent claudication. Radiology. 2003;227(3):647-656.
70. Vitellas KM, Keogan MT, Spritzer CE, Nelson RC. MR cholangiopancreatography of bile and pancreatic duct
abnormalities with emphasis on the single-shot fast spin-echo technique. Radiographics. 2000;20(4):939-957.
71. Wiesner W, Khurana B, Ji H, Ros PR. CT of acute bowel ischemia. Radiology. 2003;226(3):635-650.
Abdomen & Pelvis Bibliography | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
65
Computed Tomography (CT)
Upper Extremity
CPT Codes
73200.................. CT upper extremity, without contrast
73201.................. CT upper extremity, with contrast
73202.................. CT upper extremity, without contrast, followed by re-imaging with contrast
Standard Anatomic Coverage
Ɣ 6FDQFRYHUDJHGHSHQGVRQWKHVSHFL¿FFOLQLFDOLQGLFDWLRQIRUWKHH[DPDQGYDULHVFRQVLGHUDEO\EDVHGRQDQDWRPLF
FRQVLGHUDWLRQVIURPVKRXOGHUWKURXJK¿QJHUVDQGFOLQLFDOPDQLIHVWDWLRQV
Ɣ Depending on the protocol used, the CT data acquisition(s) may allow for diagnostic multi-planar reconstructions through
the region of interest.
Imaging Considerations
Ɣ Conventional radiographs should be obtained before advanced imaging.
Ɣ CT is often the preferred modality for evaluation of displaced fractures and subluxations, whereas stress fractures and
some incomplete and non-displaced fractures may be better imaged with MRI or radionuclide bone scintigraphy.
Ɣ ,IUDGLRJUDSKLF¿QGLQJVDUHW\SLFDORIRVWHRP\HOLWLVDGYDQFHGLPDJLQJPD\QRWEHQHFHVVDU\
Ɣ ,QRVWHRP\HOLWLV&7PD\EHKHOSIXOLQGH¿QLQJERQHVHTXHVWUD
Ɣ For evaluation of musculoskeletal tumors, MRI is generally preferred over CT, unless there is a contraindication to
performance of an MRI exam.
Ɣ Use of contrast (intravenous or intra-articular for CT arthrogram) is at the discretion of both the ordering and imaging
physicians.
Ɣ Brachial plexus imaging: MRI, when not contraindicated, is the preferred imaging modality for brachial plexus. The
brachial plexus is a network of nerves in the neck, passing under the clavicle and into the axilla. Assign either a CT or
MRI of the upper extremity for imaging the brachial plexus.
Common Diagnostic Indications
The following diagnostic indications for upper extremity CT are accompanied by pre-test considerations as well as supporting
clinical data and prerequisite information.
$EQRUPDOLWLHVGHWHFWHGRQRWKHULPDJLQJVWXGLHVZKLFKUHTXLUHDGGLWLRQDOFODUL¿FDWLRQWRGLUHFW
treatment
&KURQLFVKRXOGHUSDLQ
Ɣ ,QDSDWLHQWZKHUHIRFXVHGKLVWRU\DQGSK\VLFDOH[DPVXJJHVWQRQVSHFL¿FXSSHUH[WUHPLW\SDLQURWDWRUFXII
tendinopathy, adhesive capsulitis or subacromial impingement syndrome; AND
Ɣ Following non-diagnostic conventional radiographs; AND
Ɣ Patient has completed a minimum of six (6) consecutive weeks of physician supervised conservative therapy for the
current episode of pain, including but not limited to:
ż
Physical therapy (home exercise only if physical therapy is not available); AND
Ɣ After trial of conservative therapy as listed above, patient fails to show substantial improvement on clinical re-evaluation
&7DFFRPSDQ\LQJDQDUWKURJUDP&7DUWKURJUDSK\
CT Upper Extremity | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
66
Common Diagnostic Indications
Fracture evaluation
Ɣ 7RFRQ¿UPDVXVSHFWHGRFFXOWIUDFWXUHIROORZLQJLQLWLDOUDGLRJUDSKVOR
Ɣ 7RGH¿QHWKHH[WHQWRIDQDFXWHIUDFWXUHDQGSRVLWLRQRIIUDFWXUHIUDJPHQWVOR
Ɣ To assess fracture healing for delayed union or non-union
+HPDUWKURVLVEORRG\MRLQWHIIXVLRQGRFXPHQWHGE\DUWKURFHQWHVLV
,QIHFWLRXVSURFHVV
Ɣ In a patient where focused history and physical exam suggest an underlying soft tissue infection when:
ż
Patient is unresponsive to treatment including but not limited to antibiotics or incision/drainage
Ɣ Abscess - to determine the location and extent for surgical treatment
Ɣ Osteomyelitis – following non-diagnostic radiographs and when MRI is contraindicated
,QWUDDUWLFXODUORRVHERG\LQFOXGLQJV\QRYLDORVWHRFKRQGURPDWRVLV
1HXURSDWKLFRVWHRG\VWURSK\&KDUFRWMRLQW
Ɣ Following conventional radiographs, when there is need for additional diagnostic information from a CT exam to direct
treatment decisions (such as concern for an underlying infectious process)
2VWHRQHFURVLV>DYDVFXODUQHFURVLV$91DVHSWLFQHFURVLV@
Ɣ 5HTXLUHVLQLWLDOSODLQ¿OPVSULRUWRDGYDQFHGLPDJLQJ
Ɣ MRI is often the preferred imaging modality, particularly for evaluation in the early stages of osteonecrosis
Ɣ Common anatomic locations for osteonecrosis in the upper extremity are:
ż
Humeral head
ż
Radial head
ż
Carpal navicular bone
ż
Lunate bone (lunate osteonecrosis also referred to as Kienbock’s disease)
3RVWRSHUDWLYHRUSRVWSURFHGXUHHYDOXDWLRQ
3UHRSHUDWLYHRUSRVWSURFHGXUHHYDOXDWLRQ
1RWH7KLVLQGLFDWLRQLVWREHXVHGIRUSUHRSHUDWLYHHYDOXDWLRQRIFRQGLWLRQVQRWVSHFL¿FDOO\UHIHUHQFHGHOVHZKHUHLQWKLV
guideline.
6HSWLFDUWKULWLVZKHQ05,LVFRQWUDLQGLFDWHG
Ɣ When any of the following risk factors are present:
ż
Underlying joint disease
ż
IV drug abuse
ż
Diabetes
ż
Presence of cutaneous ulcers; OR
Ɣ Pre-operative planning
CT Upper Extremity | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
67
Common Diagnostic Indications
6LJQL¿FDQWWUDXPD
Ɣ 8VXDOO\SUHFHGHGE\LQLWLDOSODLQ¿OPUDGLRJUDSKV
7XPRUHYDOXDWLRQSULPDU\QHRSODVPRUPHWDVWDWLFGLVHDVH
Ɣ 6RIWWLVVXHHYDOXDWLRQZKHQSURPLQHQWFDOFL¿FDWLRQVDUHVHHQRQUDGLRJUDSKOR
Ɣ When MRI is contraindicated, following a non-diagnostic radiograph and one of the following:
ż
Suspected lipoma or ganglion cyst, following non-diagnostic ultrasound 1
ż
Biopsy-proven malignancy;
ż
Palpable mass on physical exam
ż
Increasing in size since discovery
ż
Greater than 5cm in size
ż
Below the deep fascia
ż
3DLQIXOZLWKRXWVLJQRILQIHFWLRQRULQÀDPPDWRU\FKDQJH
:KHQWKHSDWLHQW¶VFRQGLWLRQPHHWVWKHXSSHUH[WUHPLW\05,JXLGHOLQHVEXWWKHUHLVHLWKHUD
FRQWUDLQGLFDWLRQWR05,RUWKHSDWLHQWFDQQRWWROHUDWH05,H[DPLQDWLRQIRUH[DPSOHGXHWR
FODXVWURSKRELD
References
1.
Lakkaraju A, Sinha R, Garikipati R, Edward S, Robinson P. Ultrasound for initial evaluation and triage of clinically
suspicious soft-tissue masses. Clin Radiol. 2009 Jun;64(6):615-621.
CT Upper Extremity | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
68
Magnetic Resonance Imaging (MRI)
Upper Extremity (Any Joint)
CPT Codes
73221.................. MRI upper extremity, any joint, without contrast
73222.................. MRI upper extremity, any joint, with contrast
73223.................. MRI upper extremity, any joint, without contrast, followed by re-imaging with contrast
Standard Anatomic Coverage
Ɣ 6FDQFRYHUDJHGHSHQGVRQWKHVSHFL¿FFOLQLFDOLQGLFDWLRQIRUWKHH[DPDQGYDULHVFRQVLGHUDEO\EDVHGRQDQDWRPLFIURP
shoulder joint through hand/digits) and clinical considerations.
Ɣ MRI routinely provides multi-planar imaging through the region of interest.
Imaging Considerations
Ɣ Conventional radiographs should be obtained before advanced imaging.
Ɣ Use of contrast (intravenous or intra-articular) is at the discretion of both the ordering and imaging physicians.
Ɣ CT is often the preferred modality for evaluation of displaced fractures and subluxations, whereas stress fractures and
some incomplete and non-displaced fractures may be better imaged with MRI or radionuclide bone scintigraphy.
Ɣ MRI is used more often to evaluate internal derangements of the joints and related tendinous, ligamentous and
cartilaginous structures.
Ɣ 05,LVDOVRXVHIXOIRUHYDOXDWLRQRISRVVLEOHRVWHRP\HOLWLVGHVSLWHQHJDWLYHRUQRQGLDJQRVWLFSODLQ¿OPVDQGRUWULSOH
phase bone scintigraphy. One exception for osteomyelitis is detection of bone sequestra, which may be better depicted
with CT.
Ɣ ,IUDGLRJUDSKLF¿QGLQJVDUHW\SLFDORIRVWHRP\HOLWLVDGYDQFHGLPDJLQJPD\QRWEHQHFHVVDU\
Ɣ For evaluation of musculoskeletal tumors, MRI is generally preferred over CT, unless there is a contraindication to
performance of an MRI exam.
Ɣ For suspected osteonecrosis, MRI is often more sensitive than CT and bone scintigraphy.
Ɣ ,PSODQWHGVXUJLFDOKDUGZDUHLQFOXGLQJMRLQWSURVWKHVHVPD\SURGXFHVXI¿FLHQWORFDODUWLIDFWWRSUHFOXGHDGHTXDWH
imaging through the region containing hardware.
Common Diagnostic Indications
The following diagnostic indications for upper extremity MRI are accompanied by pre-test considerations as well as supporting
clinical data and prerequisite information. This section contains general upper extremity, shoulder, elbow, wrist and hand joint
indications
*HQHUDO8SSHU([WUHPLW\
$EQRUPDOLWLHVGHWHFWHGRQRWKHULPDJLQJVWXGLHVZKLFKUHTXLUHDGGLWLRQDOFODUL¿FDWLRQWRGLUHFW
treatment
(0*SURYHQHQWUDSPHQWQHXURSDWK\DIWHUFRQVHUYDWLYHWKHUDS\WRGLUHFWWUHDWPHQW
ż
Suspected entrapment neuropathy, cubital tunnel detail, and/or carpal tunnel are not considered medically
necessary
MRI Upper Extremity Any Joint | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
69
Common Diagnostic Indications
Fracture evaluation
Ɣ 7RFRQ¿UPDVXVSHFWHGRFFXOWIUDFWXUHIROORZLQJLQLWLDOUDGLRJUDSKVOR
Ɣ 7RGH¿QHWKHH[WHQWRIDQDFXWHIUDFWXUHOR
Ɣ To assess fracture healing for delayed union or non-union
+HPDUWKURVLVEORRG\MRLQWHIIXVLRQGRFXPHQWHGE\DUWKURFHQWHVLV
,QIHFWLRXVSURFHVV
Ɣ In a patient where focused history and physical exam suggest a underlying soft tissue infection when:
ż
Patient is unresponsive to treatment including but not limited to antibiotics or incision/drainage
Ɣ Abscess – to determine the location and extent for surgical treatment
Ɣ Osteomyelitis – following non-diagnostic radiographs
,QWUDDUWLFXODUORRVHERG\LQFOXGLQJV\QRYLDORVWHRFKRQGURPDWRVLV
Ligament and tendon injuries
Ɣ In a patient following a focused history and physical exam; AND
Ɣ Patient has completed a minimum of six (6) consecutive weeks of physician supervised conservative therapy for the
current episode of pain, including but not limited to:
ż
Physical therapy (home exercise only if physical therapy is not available); AND
Ɣ After trial of conservative therapy as listed above, patient fails to show substantial improvement on clinical re-evaluation
05,DFFRPSDQ\LQJDQDUWKURJUDP05DUWKURJUDSK\
1HXURSDWKLFRVWHRG\VWURSK\&KDUFRWMRLQW
Ɣ Following conventional radiographs, when there is need for additional diagnostic information from an MRI exam to direct
treatment decisions (such as concern for an underlying infectious process)
Osteochondral lesion
2VWHRQHFURVLV>DYDVFXODUQHFURVLV$91DVHSWLFQHFURVLV@
Ɣ 5HTXLUHVLQLWLDOSODLQ¿OPVSULRUWRDGYDQFHGLPDJLQJ
Ɣ Common anatomic locations for osteonecrosis in the upper extremity are:
ż
Humeral head
ż
Radial head
ż
Carpal navicular bone
ż
Lunate bone (lunate osteonecrosis also referred to as Kienbock’s disease)
3RVWRSHUDWLYHRUSRVWSURFHGXUHHYDOXDWLRQ
3UHRSHUDWLYHRUSUHSURFHGXUHHYDOXDWLRQ
1RWH7KLVLQGLFDWLRQLVWREHXVHGIRUSUHRSHUDWLYHHYDOXDWLRQRIFRQGLWLRQVQRWVSHFL¿FDOO\UHIHUHQFHGHOVHZKHUHLQWKLV
guideline.
MRI Upper Extremity Any Joint | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
70
Common Diagnostic Indications
6HSWLFDUWKULWLV
Ɣ When any of the following risk factors are present:
ż
Underlying joint disease
ż
Joint prosthesis
ż
IV drug abuse
ż
Diabetes
ż
Presence of cutaneous ulcers; OR
Ɣ Pre-operative planning
6LJQL¿FDQWWUDXPD
Ɣ 8VXDOO\SUHFHGHGE\LQLWLDOSODLQ¿OPUDGLRJUDSKV
7XPRUHYDOXDWLRQSULPDU\QHRSODVPRUPHWDVWDWLFGLVHDVH
Ɣ 6RIWWLVVXHHYDOXDWLRQZKHQSURPLQHQWFDOFL¿FDWLRQVDUHVHHQRQUDGLRJUDSKOR
Ɣ Following a non-diagnostic radiograph and one of the following:
ż
Suspected lipoma or ganglion cyst, following non-diagnostic ultrasound 1
ż
Biopsy-proven malignancy
ż
Palpable mass on physical exam
ż
Increasing in size since discovery
ż
Greater than 5cm in size
ż
Below the deep fascia
ż
3DLQIXOZLWKRXWVLJQRILQIHFWLRQRULQÀDPPDWRU\FKDQJH
Shoulder Joint Imaging
$FXWHURWDWRUFXIIWHDU
Ɣ Patient is a candidate for surgery; AND
Ɣ ([DPVXJJHVWVDQDFXWHIXOOWKLFNQHVVWUDXPDWLFWHDULQDQRWKHUZLVHQRUPDOURWDWRUFXII¿QGLQJVLQFOXGHEXWDUHQRW
limited to:
ż
Painful arc sign
ż
Drop arm sign
ż
Weakness in external rotation
ż
Non-diagnostic ultrasound
ż
Atrophy of the shoulder girdle
$FXWHVKRXOGHUSDLQ
Ɣ Following non-diagnostic conventional radiographs; AND
Ɣ In a patient who is a candidate for corticosteroid or anesthetic injection and one of the following:
ż
Suspected bursitis; OR
ż
Suspected long head of biceps tenosynovitis
MRI Upper Extremity Any Joint | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
71
Common Diagnostic Indications
&KURQLFVKRXOGHUSDLQ
Ɣ ,QDSDWLHQWZKHUHIRFXVHGKLVWRU\DQGSK\VLFDOH[DPVXJJHVWQRQVSHFL¿FXSSHUH[WUHPLW\SDLQURWDWRUFXII
tendinopathy, adhesive capsulitis or subacromial impingement syndrome; AND
Ɣ Following non-diagnostic conventional radiographs; AND
Ɣ Patient has completed a minimum of six (6) consecutive weeks of physician supervised conservative therapy for the
current episode of pain, including but not limited to:
ż
Physical therapy (home exercise only if physical therapy is not available); AND
Ɣ After trial of conservative therapy as listed above, patient fails to show substantial improvement on clinical re-evaluation
Glenoid labral tear
Other glenoid labral and associated ligamentous lesions
Ɣ Including but not limited to the following:
ż
Bankart lesion
ż
Bankart variation lesions
ż
ALPSA (Anterior Labroligamentous Periosteal Sleeve Avulsion) lesion
ż
HAGL (Humeral Avulsion of the Inferior Glenohumeral Ligament) lesion
ż
SLAP (Superior Labral tear from Anterior to Posterior) tear/lesion
6XVSHFWHGRFFXOWVKRXOGHUIUDFWXUH
Ɣ With high clinical suspicion and negative or inconclusive shoulder radiographs
Elbow Imaging
%LFHSVWHQGRQUXSWXUH
Ɣ At insertion onto radial tuberosity
&DSLWHOODURVWHRFKRQGULWLV
(SLFRQG\OLWLV
Ɣ In a patient following a focused history and physical exam; AND
Ɣ Following non-diagnostic conventional radiographs; AND
Ɣ Patient has completed a minimum of twelve (12) consecutive weeks of physician supervised conservative therapy for the
current episode of pain, including but not limited to any of the following:
ż
Physical therapy (home exercise only if physical therapy is not available); AND
Ɣ After trial of conservative therapy as listed above, patient fails to show substantial improvement on clinical re-evaluation
Note: Epicondylitis is generally considered a clinical diagnosis and imaging usually does not change management. Specialist
evaluation should be strongly considered prior to advanced imaging
Medial collateral ligament tear
6XVSHFWHGRFFXOWHOERZIUDFWXUH
Ɣ With high clinical suspicion and negative or inconclusive elbow radiographs
MRI Upper Extremity Any Joint | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
72
Common Diagnostic Indications
3UHRSHUDWLYHDVVHVVPHQWKHWHURWRSLFRVVL¿FDWLRQ
7ULFHSVWHQGRQUXSWXUH
Ɣ From olecranon insertion site
$GGLWLRQDO,QGLFDWLRQVIRU:ULVWDQG+DQG,PDJLQJ
6FDSKRLGIUDFWXUH
7ULDQJXODU¿EURFDUWLODJHFRPSOH[7)&&WHDU
8OQDUFROODWHUDOOLJDPHQWWHDUJDPHNHHSHU¶VWKXPE
References
1.
Lakkaraju A, Sinha R, Garikipati R, Edward S, Robinson P. Ultrasound for initial evaluation and triage of clinically
suspicious soft-tissue masses. Clin Radiol. 2009 Jun;64(6):615-621.
MRI Upper Extremity Any Joint | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
73
Magnetic Resonance Imaging (MRI)
Upper Extremity (Non-Joint)
CPT Codes
73218.................. MRI upper extremity, non-joint, without contrast
73219.................. MRI upper extremity, non-joint, with contrast
73220.................. MRI upper extremity, non-joint, without contrast, followed by re-imaging with contrast
Standard Anatomic Coverage
Ɣ 6FDQFRYHUDJHGHSHQGVRQWKHVSHFL¿FFOLQLFDOLQGLFDWLRQIRUWKHH[DPDQGYDULHVFRQVLGHUDEO\EDVHGRQDQDWRPLFIURP
shoulder joint through hand/digits) and clinical considerations.
Ɣ MRI routinely provides multi-planar imaging through the region of interest.
Imaging Considerations
Ɣ Conventional radiographs should be obtained before advanced imaging.
Ɣ CT is often the preferred modality for evaluation of displaced fractures and subluxations, whereas stress fractures and
some incomplete or non-displaced fractures may be better imaged with MRI or radionuclide bone scintigraphy.
Ɣ MRI is often the preferred modality for evaluation of soft tissue abnormalities and for interrogation of possible
RVWHRP\HOLWLVGHVSLWHQHJDWLYHRUQRQGLDJQRVWLFSODLQ¿OPVDQGRUWULSOHSKDVHERQHVFLQWLJUDSK\2QHH[FHSWLRQIRU
osteomyelitis is detection of bone sequestra, which may be better depicted with CT.
Ɣ ,IUDGLRJUDSKLF¿QGLQJVDUHW\SLFDORIRVWHRP\HOLWLVDGYDQFHGGLDJQRVWLFLPDJLQJPD\QRWEHQHFHVVDU\
Ɣ Use of contrast is at the discretion of both the ordering and imaging physicians.
Ɣ Brachial Plexus Imaging: MRI, when not contraindicated is the preferred imaging modality for brachial plexus. The
brachial plexus is a network of nerves in the neck, passing under the clavicle and into the axilla. Assign either a CT or
MRI of the upper extremity (non-joint) for imaging the brachial plexus.
Common Diagnostic Indications
The following diagnostic indications for upper extremity MRI (non-joint) are accompanied by pre-test considerations as well as
supporting clinical data and prerequisite information.
$EQRUPDOLWLHVGHWHFWHGRQRWKHULPDJLQJVWXGLHVZKLFKUHTXLUHDGGLWLRQDOFODUL¿FDWLRQWRGLUHFW
treatment
%UDFKLDOSOH[RSDWK\
%UDFKLDOSOH[XVPDVV
(0*SURYHQHQWUDSPHQWQHXURSDWK\DIWHUFRQVHUYDWLYHWKHUDS\WRGLUHFWWUHDWPHQW
ż
Suspected entrapment neuropathy, cubital tunnel detail, and/or carpal tunnel are not considered medically
necessary
Fracture evaluation
Ɣ 7RFRQ¿UPDVXVSHFWHGRFFXOWIUDFWXUHIROORZLQJLQLWLDOUDGLRJUDSKVOR
Ɣ 7RGH¿QHWKHH[WHQWRIDQDFXWHIUDFWXUHOR
Ɣ To assess fracture healing for delayed union or non-union
MRI Upper Extremity Non-Joint | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
74
Common Diagnostic Indications
,QIHFWLRXVSURFHVV
Ɣ In a patient where focused history and physical exam suggest an underlying soft tissue infection when:
ż
Patient is unresponsive to treatment including but not limited to antibiotics or incision/drainage
Ɣ Abscess - to determine the location and extent for surgical treatment
Ɣ Osteomyelitis – following non-diagnostic radiographs
Myositis
Ɣ To determine optimal location for biopsy; OR
Ɣ To monitor treatment response
3HUVLVWHQWXSSHUH[WUHPLW\SDLQ±XQUHVSRQVLYHWRVL[ZHHNVRIFRQVHUYDWLYHWUHDWPHQW
Ɣ ,QDSDWLHQWZKHUHIRFXVHGKLVWRU\DQGSK\VLFDOH[DPVXJJHVWQRQVSHFL¿FXSSHUH[WUHPLW\SDLQAND
Ɣ Following non-diagnostic conventional radiographs; AND
Ɣ Patient has completed a minimum of six (6) consecutive weeks of physician supervised conservative therapy for the
current episode of pain, including but not limited to:
ż
NSAIDs or steroids (oral or injection) – unless contraindicated; OR
ż
Physical therapy (home exercise only if physical therapy is not available); AND
Ɣ After trial of conservative therapy as listed above, patient fails to show substantial improvement on clinical re-evaluation
1RWH)RUVXVSLFLRQRIVSHFL¿FHWLRORJ\SOHDVHUHIHUWRFRUUHVSRQGLQJLQGLFDWLRQ
3RVWRSHUDWLYHRUSRVWSURFHGXUHHYDOXDWLRQ
3UHRSHUDWLYHRUSUHSURFHGXUHHYDOXDWLRQ
1RWH7KLVLQGLFDWLRQLVWREHXVHGIRUSUHRSHUDWLYHHYDOXDWLRQRIFRQGLWLRQVQRWVSHFL¿FDOO\UHIHUHQFHGHOVHZKHUHLQWKLV
guideline.
6HSWLFDUWKULWLV
Ɣ When there is a clinical consideration of contiguous spread of infection into the adjacent soft-tissues of the joint, which
would not normally be included on an MRI joint exam; AND
Ɣ For cases of known septic arthritis, MRI may be used when any of the following risk factors are present:
ż
Underlying joint disease
ż
Joint prosthesis
ż
IV drug abuse
ż
Diabetes
ż
Presence of cutaneous ulcers; OR
Ɣ Pre-operative planning
6LJQL¿FDQWWUDXPD
Ɣ 8VXDOO\SUHFHGHGE\LQLWLDOSODLQ¿OPUDGLRJUDSKV
MRI Upper Extremity Non-Joint | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
75
Common Diagnostic Indications
7XPRUHYDOXDWLRQSULPDU\QHRSODVPRUPHWDVWDWLFGLVHDVH
Ɣ 6RIWWLVVXHHYDOXDWLRQZKHQSURPLQHQWFDOFL¿FDWLRQVDUHVHHQRQUDGLRJUDSKOR
Ɣ Following a non-diagnostic radiograph and one of the following:
ż
Suspected lipoma or ganglion cyst, following non-diagnostic ultrasound 1
ż
Biopsy-proven malignancy
ż
Palpable mass on physical exam
ż
Increasing in size since discovery
ż
Greater than 5cm in size
ż
Below the deep fascia
ż
3DLQIXOZLWKRXWVLJQRILQIHFWLRQRULQÀDPPDWRU\FKDQJH
8OQDUFROODWHUDOOLJDPHQWWHDUJDPHNHHSHU¶VWKXPE
References
1.
Lakkaraju A, Sinha R, Garikipati R, Edward S, Robinson P. Ultrasound for initial evaluation and triage of clinically
suspicious soft-tissue masses. Clin Radiol. 2009 Jun;64(6):615-621.
MRI Upper Extremity Non-Joint | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
76
Computed Tomography (CT)
Lower Extremity
CPT Codes
73700.................. CT lower extremity without contrast
73701.................. CT lower extremity with contrast
73702.................. CT lower extremity without contrast, followed by re-imaging with contrast
Standard Anatomic Coverage
Ɣ Scan coverage depends on the anatomic area of concern and varies considerably, based on anatomic (from hip through
toes) and clinical considerations.
Ɣ Depending on the protocol used, the CT data acquisition(s) may allow for diagnostic multi-planar reconstructions through
the region of interest.
Imaging Considerations
Ɣ Conventional radiographs should be obtained before advanced imaging.
Ɣ CT is often the preferred modality for evaluation of displaced fractures and subluxations, whereas stress fractures and
some incomplete and non-displaced fractures may be better imaged with MRI or radionuclide bone scintigraphy.
Ɣ ,IUDGLRJUDSKLF¿QGLQJVDUHW\SLFDORIRVWHRP\HOLWLVDGYDQFHGLPDJLQJPD\QRWEHQHFHVVDU\
Ɣ ,QRVWHRP\HOLWLV&7PD\EHKHOSIXOLQGH¿QLQJERQ\VHTXHVWUD
Ɣ Use of contrast (intravenous and intra-articular) is at the discretion of both the ordering and imaging physicians.
Common Diagnostic Indications
The following diagnostic indications for lower extremity CT are accompanied by pre-test considerations as well as supporting
clinical data and prerequisite information.
$EQRUPDOLWLHVGHWHFWHGRQRWKHULPDJLQJVWXGLHVZKLFKUHTXLUHDGGLWLRQDOFODUL¿FDWLRQWRGLUHFW
treatment
&7DFFRPSDQ\LQJDQDUWKURJUDP&7DUWKURJUDSK\
Fracture evaluation
Ɣ 7RFRQ¿UPDVXVSHFWHGRFFXOWIUDFWXUHIROORZLQJLQLWLDOUDGLRJUDSKVOR
Ɣ 7RGH¿QHWKHH[WHQWRIDQDFXWHIUDFWXUHDQGSRVLWLRQRIIUDFWXUHIUDJPHQWVOR
Ɣ To assess fracture healing for delayed union or non-union
,QIHFWLRXVSURFHVV
Ɣ In a patient where focused history and physical exam suggest an underlying soft tissue infection when:
ż
Patient is unresponsive to treatment including but not limited to antibiotics or incision/drainage
Ɣ Abscess - to determine the location and extent for surgical treatment
Ɣ Osteomyelitis – following non-diagnostic radiographs
CT Lower Extremity | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
77
Common Diagnostic Indications
1HXURSDWKLFRVWHRG\VWURSK\&KDUFRWMRLQW
Ɣ Following conventional radiographs, when there is need for additional diagnostic information from a CT exam to direct
treatment decisions (such as concern for an underlying infectious process)
2VWHRQHFURVLV>DYDVFXODUQHFURVLV$91DVHSWLFQHFURVLV@
Ɣ 5HTXLUHVLQLWLDOSODLQ¿OPVSULRUWRDGYDQFHGLPDJLQJ
Ɣ MRI is often the preferred imaging modality, particularly for evaluation during the early stages of osteonecrosis
3HUVLVWHQWORZHUH[WUHPLW\SDLQH[FOXGLQJNQHHMRLQW±XQUHVSRQVLYHWRVL[ZHHNVRI
conservative treatment
Ɣ ,QDSDWLHQWZKHUHIRFXVHGKLVWRU\DQGSK\VLFDOH[DPVXJJHVWQRQVSHFL¿FORZHUH[WUHPLW\SDLQAND
Ɣ Following non-diagnostic conventional radiographs; AND
Ɣ Patient has completed a minimum of six (6) consecutive weeks of physician supervised conservative therapy for the
current episode of pain, including but not limited to:
ż
NSAIDs or steroids (oral or injection) – unless contraindicated; AND
ż
Physical therapy (home exercise only if physical therapy is not available); AND
Ɣ After trial of conservative therapy as listed above, patient fails to show substantial improvement on clinical re-evaluation
1RWH)RUVXVSLFLRQRIVSHFL¿FHWLRORJ\SOHDVHUHIHUWRFRUUHVSRQGLQJLQGLFDWLRQ
3RVWRSHUDWLYHRUSRVWSURFHGXUHHYDOXDWLRQ
3UHRSHUDWLYHRUSUHSURFHGXUHHYDOXDWLRQ
1RWH7KLVLQGLFDWLRQLVWREHXVHGIRUSUHRSHUDWLYHHYDOXDWLRQRIFRQGLWLRQVQRWVSHFL¿FDOO\UHIHUHQFHGHOVHZKHUHLQWKLV
guideline.
6HSWLFDUWKULWLVZKHQ05,LVFRQWUDLQGLFDWHG
Ɣ When any of the following risk factors are present:
ż
Underlying joint disease
ż
Joint prosthesis
ż
IV drug abuse
ż
Diabetes
ż
Presence of cutaneous ulcers; OR
Ɣ Pre-operative planning
6LJQL¿FDQWWUDXPD
Ɣ 8VXDOO\SUHFHGHGE\LQLWLDOSODLQ¿OPUDGLRJUDSKV
Tarsal coalition
Ɣ Following foot radiographs
CT Lower Extremity | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
78
Common Diagnostic Indications
7XPRUHYDOXDWLRQSULPDU\QHRSODVPRUPHWDVWDWLFGLVHDVH
Ɣ 6RIWWLVVXHHYDOXDWLRQZKHQSURPLQHQWFDOFL¿FDWLRQVDUHVHHQRQUDGLRJUDSKOR
Ɣ When MRI is contraindicated, following a non-diagnostic radiograph and one of the following
ż
Suspected lipoma or Baker’s (popliteal) cyst, following non-diagnostic ultrasound 1,2
ż
Biopsy-proven malignancy
ż
Palpable mass on physical exam
ż
Increasing in size since discovery
ż
Greater than 5cm in size
ż
Below the deep fascia
ż
3DLQIXOZLWKRXWVLJQRILQIHFWLRQRULQÀDPPDWRU\FKDQJH
:KHQWKHSDWLHQW¶VFRQGLWLRQPHHWVWKHORZHUH[WUHPLW\05,JXLGHOLQHVEXWWKHUHLVHLWKHUD
FRQWUDLQGLFDWLRQWR05,RUWKHSDWLHQWFDQQRWWROHUDWH05,H[DPLQDWLRQIRUH[DPSOHGXHWR
FODXVWURSKRELD
References
1.
Lakkaraju A, Sinha R, Garikipati R, Edward S, Robinson P. Ultrasound for initial evaluation and triage of clinically
suspicious soft-tissue masses. Clin Radiol. 2009 Jun;64(6):615-621.
2.
Ward EE, Jacobson JA, Fessell DP, et al. Sonographic detection of Baker’s cysts: comparison with MRI. AJR Am J
Roentgenol. 2001;176:373-380.
CT Lower Extremity | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
79
Magnetic Resonance Imaging (MRI)
Lower Extremity (Joint & Non-Joint)
CPT Codes
73718.................. MRI lower extremity, other than joint, without contrast
73719.................. MRI lower extremity, other than joint, with contrast
73720.................. MRI lower extremity, other than joint, without contrast followed by re-imaging with contrast
73721.................. MRI lower extremity, any joint, without contrast
73722.................. MRI lower extremity, any joint, with contrast
73723.................. MRI lower extremity, any joint, without contrast followed by re-imaging with contrast
Standard Anatomic Coverage
Ɣ 6FDQFRYHUDJHGHSHQGVRQWKHVSHFL¿FFOLQLFDOLQGLFDWLRQDQGYDULHVFRQVLGHUDEO\EDVHGRQDQDWRPLFDQGFOLQLFDO
considerations.
Ɣ If medically appropriate, an MRI exam may be requested for each major area of the right and left lower extremities: hip,
thigh, knee, lower leg (calf), ankle, or foot (includes toes)
Ɣ Routine MRI examinations provide multi-planar imaging of the joint or non-joint region(s) of interest.
Imaging Considerations
Ɣ Conventional radiographs should be obtained before advanced imaging.
Ɣ Use of contrast (intravenous and intra-articular) is at the discretion of both the ordering and imaging physicians.
Ɣ CT is often the preferred modality for evaluation of displaced fractures and subluxations, whereas stress fractures and
some incomplete and non-displaced fractures may be better imaged with MRI or radionuclide bone scintigraphy.
Ɣ MRI is often used to evaluate soft tissue abnormalities and to interrogate for possible osteomyelitis, despite negative
RUQRQGLDJQRVWLFSODLQ¿OPVDQGRUWULSOHSKDVHERQHVFLQWLJUDSK\2QHH[FHSWLRQIRURVWHRP\HOLWLVLVGHWHFWLRQRIERQH
sequestra, which may be better depicted with CT.
Ɣ ,IUDGLRJUDSKLF¿QGLQJVDUHW\SLFDORIRVWHRP\HOLWLVDGYDQFHGLPDJLQJPD\QRWEHQHFHVVDU\
Ɣ For suspected osteonecrosis, MRI is often more sensitive than CT or bone scintigraphy.
Ɣ ,PSODQWHGVXUJLFDOKDUGZDUHLQFOXGLQJMRLQWSURVWKHVHVPD\SURGXFHVXI¿FLHQWORFDODUWLIDFWWRSUHFOXGHDGHTXDWH
imaging through the region containing hardware.
Ɣ For suspected Baker’s cysts, ultrasound should be performed before advanced imaging exams.
Common Diagnostic Indications
The following diagnostic indications for lower extremity MRI are accompanied by pre-test considerations as well as supporting
clinical data and prerequisite information. This section contains general lower extremity, hip, knee, ankle and foot indications
General Lower Extremity
$EQRUPDOLWLHVGHWHFWHGRQRWKHULPDJLQJVWXGLHVZKLFKUHTXLUHDGGLWLRQDOFODUL¿FDWLRQWRGLUHFW
treatment
Fracture evaluation
Ɣ 7RFRQ¿UPDVXVSHFWHGRFFXOWIUDFWXUHIROORZLQJLQLWLDOUDGLRJUDSKVOR
Ɣ 7RGH¿QHWKHH[WHQWRIDQDFXWHIUDFWXUHOR
Ɣ To assess fracture healing for delayed union or non-union
MRI Lower Extremity | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
80
Common Diagnostic Indications
+HPDUWKURVLVEORRG\MRLQWHIIXVLRQGRFXPHQWHGE\DUWKURFHQWHVLV
,QIHFWLRXVSURFHVV
Ɣ In a patient where focused history and physical exam suggest an underlying soft tissue infection when:
ż
Patient is unresponsive to treatment including but not limited to antibiotics or incision/drainage
Ɣ Abscess - to determine the location and extent for surgical treatment
Ɣ Osteomyelitis – following non-diagnostic radiographs
,QWUDDUWLFXODUORRVHERG\LQFOXGLQJV\QRYLDORVWHRFKRQGURPDWRVLV
05,DFFRPSDQ\LQJDQDUWKURJUDP05DUWKURJUDSK\
Myositis
Ɣ To determine optimal location for biopsy; OR
Ɣ To monitor treatment response
Osteochondral lesion
2VWHRQHFURVLV>DYDVFXODUQHFURVLV$91DVHSWLFQHFURVLV@
Ɣ 5HTXLUHVLQLWLDOSODLQ¿OPVSULRUWRDGYDQFHGLPDJLQJ
Ɣ MRI is often the preferred imaging modality, particularly for evaluation during the early stages of osteonecrosis
3HUVLVWHQWORZHUH[WUHPLW\SDLQH[FOXGLQJNQHHMRLQW±XQUHVSRQVLYHWRVL[ZHHNVRI
conservative treatment
Ɣ ,QDSDWLHQWZKHUHIRFXVHGKLVWRU\DQGSK\VLFDOH[DPVXJJHVWQRQVSHFL¿FORZHUH[WUHPLW\SDLQAND
Ɣ Following non-diagnostic conventional radiographs; AND
Ɣ Patient has completed a minimum of 6-8 consecutive weeks of physician supervised conservative therapy for the current
episode of pain, including but not limited to:
ż
NSAIDs or steroids (oral or injection) – unless contraindicated; AND
ż
Physical therapy (home exercise only if physical therapy is not available); AND
Ɣ After trial of conservative therapy as listed above, patient fails to show substantial improvement on clinical re-evaluation
Ɣ Not medically necessary for plantar fasciitis unless surgery is being considered after a failure of six (6) months of
physician supervised conservative treatment
1RWH)RUVXVSLFLRQRIVSHFL¿FHWLRORJ\SOHDVHUHIHUWRFRUUHVSRQGLQJLQGLFDWLRQ
3RVWRSHUDWLYHRUSRVWSURFHGXUHHYDOXDWLRQ
3UHRSHUDWLYHRUSUHSURFHGXUHHYDOXDWLRQ
1RWH7KLVLQGLFDWLRQLVWREHXVHGIRUSUHRSHUDWLYHHYDOXDWLRQRIFRQGLWLRQVQRWVSHFL¿FDOO\UHIHUHQFHGHOVHZKHUHLQWKLV
guideline.
MRI Lower Extremity | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
81
Common Diagnostic Indications
6HSWLFDUWKULWLV
Ɣ When any of the following risk factors are present:
ż
Underlying joint disease
ż
Joint prosthesis
ż
IV drug abuse
ż
Diabetes
ż
Presence of cutaneous ulcers; OR
Ɣ Pre-operative planning
6LJQL¿FDQWWUDXPD
Ɣ 8VXDOO\SUHFHGHGE\LQLWLDOSODLQ¿OPUDGLRJUDSKV
7XPRUHYDOXDWLRQSULPDU\QHRSODVPRUPHWDVWDWLFGLVHDVH
Ɣ 6RIWWLVVXHHYDOXDWLRQZKHQSURPLQHQWFDOFL¿FDWLRQVDUHVHHQRQUDGLRJUDSKOR
Ɣ Following a non-diagnostic radiograph and one of the following
ż
Suspected lipoma or Baker’s (popliteal) cyst, following non-diagnostic ultrasound 1,2
ż
Biopsy-proven malignancy
ż
Palpable mass on physical exam
ż
Increasing in size since discovery
ż
Greater than 5cm in size
ż
Below the deep fascia
ż
3DLQIXOZLWKRXWVLJQRILQIHFWLRQRULQÀDPPDWRU\FKDQJH
+LS-RLQW
Labral tear
/HJJ&DOYp3HUWKHVGLVHDVH
Ɣ Eponym for osteonecrosis (infarction) of bony epiphysis in femoral heads, usually in 4-8 year old age range
Ɣ Requires initial radiographic evaluation
2FFXOWKLSIUDFWXUH
Ɣ With high clinical suspicion and negative or inconclusive hip radiographs
6OLSSHGFDSLWDOIHPRUDOHSLSK\VLV
Ɣ Atraumatic fracture through the physeal plate; affected population is often overweight teenagers
Ɣ Requires initial radiographic evaluation
MRI Lower Extremity | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
82
Common Diagnostic Indications
Knee Joint
&KRQGURPDODFLDSDWHOOD
Ɣ In a patient following a focused history and physical exam; AND
Ɣ Following non-diagnostic conventional radiographs; AND
Ɣ Patient has completed a minimum of twelve (12) consecutive weeks of physician supervised conservative therapy for the
current episode of pain, including but not limited to:
ż
Physical therapy (home exercise only if physical therapy is not available); AND
Ɣ After trial of conservative therapy as listed above, patient fails to show substantial improvement on clinical re-evaluation
Ligament tear
Ɣ In a patient where focused history and physical exam suggests a ligament tear; AND
Ɣ Patient has completed a minimum of four (4) consecutive weeks of physician supervised conservative therapy for the
current episode of pain, including but not limited to:
ż
Physical therapy (home exercise only if physical therapy is not available); AND
Ɣ After trial of conservative therapy as listed above, patient fails to show substantial improvement on clinical re-evaluation;
OR
Ɣ )RUSUHRSHUDWLYHHYDOXDWLRQEDVHGRQSK\VLFDOH[DP¿QGLQJVZKLFKPD\LQFOXGHRQHRIWKHIROORZLQJ
ż
Positive Lachman test; OR
ż
Positive pivot shift test; OR
ż
Positive anterior or posterior drawer test; OR
ż
Positive medial or lateral stress tests
0HQLVFDOWHDULQMXU\
Ɣ In a patient where focused history and physical exam suggests a meniscal tear; AND
Ɣ Patient has completed a minimum of four (4) consecutive weeks of physician supervised conservative therapy for the
current episode of pain, including but not limited to:
ż
NSAIDs or steroids (oral or injection) – unless contraindicated; AND
ż
Physical therapy (home exercise only if physical therapy is not available); AND
Ɣ After trial of conservative therapy as listed above, patient fails to show substantial improvement on clinical re-evaluation;
OR
Ɣ )RUSUHRSHUDWLYHHYDOXDWLRQEDVHGRQSK\VLFDOH[DP¿QGLQJVZKLFKPD\LQFOXGHRQHRIWKHIROORZLQJ
ż
3RVLWLYH0F0XUUD\WHVWZLWKPLQLPDONQHHÀH[LRQOR
ż
A severe twisting injury after which activity could not be resumed; OR
ż
An anterior cruciate ligament tear is present; OR
ż
Locking; OR
ż
Swelling and symptoms develop immediately after an acute injury; OR
ż
Inability to bear weight; OR
ż
Inability to fully extend knee
Osteochondritis dissecans3
3RVWRSHUDWLYHHYDOXDWLRQIROORZLQJUHSDLURIDOLJDPHQWRXVRUWHQGLQRXVWHDUZLWKQHZ
V\PSWRPV
MRI Lower Extremity | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
83
Common Diagnostic Indications
Ankle and Foot
Acute and chronic tendon injuries
Ɣ In a patient following a focused history and physical exam; AND
Ɣ Following non-diagnostic conventional radiographs; AND
Ɣ Patient has completed a minimum of six (6) consecutive weeks of physician supervised conservative therapy for the
current episode of pain, including but not limited to:
ż
Physical therapy (home exercise only if physical therapy is not available); AND
Ɣ After trial of conservative therapy as listed above, patient fails to show substantial improvement on clinical re-evaluation
$FXWHWHQGRQUXSWXUH
Ɣ For pre-operative evaluation based on
ż
Severe muscle weakness from the involved tendon; OR
ż
Non-diagnostic X-ray for bone avulsion; OR
ż
Non-diagnostic ultrasound evaluation
'LDEHWLFIRRWGLVHDVH
Ɣ Osteomyelitis – following non-diagnostic radiographs
0RUWRQ¶VQHXURPD
Ɣ When the diagnosis is not clear on physical examination or ultrasound
1HXURSDWKLFRVWHRG\VWURSK\&KDUFRWMRLQW
Ɣ Following foot radiographs, when there is need for additional diagnostic information from an MRI exam to direct
treatment decisions (such as concern for an underlying infectious process)
Tarsal coalition
Ɣ Following foot radiographs
Note: CT may be preferred for bony coalition
Tarsal tunnel
Ɣ Following EMG nerve conduction study if not responsive to four weeks of conservative therapy
Ɣ 1HXURSDWK\VHFRQGDU\WRHQWUDSPHQWRUFRPSUHVVLRQRIWKHSRVWHULRUWLELDOQHUYHRULWVEUDQFKHVLQWKH¿EURRVVHRXV
WXQQHOGHHSWRWKHÀH[RUUHWLQDFXOXP
References
1.
Lakkaraju A, Sinha R, Garikipati R, Edward S, Robinson P. Ultrasound for initial evaluation and triage of clinically
suspicious soft-tissue masses. Clin Radiol. 2009 Jun;64(6):615-621
2.
Ward EE, Jacobson JA, Fessell DP, et al. Sonographic detection of Baker’s cysts: comparison with MRI. AJR Am J
Roentgenol. 2001;176:373-380.
3.
American Academy of Orthopaedic Surgeons. Diagnosis and Treatment of Osteochondritis Dissecans: Guideline and
Evidence Report. Rosemont, IL: AAOS; December 4, 2010. http://www.aaos.org/Research/guidelines/OCDGuideline.
asp. Accessed April 11, 2013.
MRI Lower Extremity | Copyright © 2013. AIM Specialty Health. All Rights Reserved.
84
Extremity Bibliography
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