Download Back Pain Invasive Procedures

JOHNS HOPKINS HEALTHCARE
Medical Policy: Back Pain – Invasive Procedures
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
ACTION:
☐ New Policy
☒ Revising Policy Number: CMS18.05
☐ Superseding Policy Number
☐ Archiving Policy Number
☐ Retiring Policy Number
Policy Number
CMS18.05
Page 1 of 9
Effective Date: 03/06/2015
Review Dates: 03/06/15, 03/04/16
Johns Hopkins HealthCare (JHHC) provides a full spectrum of health care products and services for
Employer Health Programs, Priority Partners, and US Family Health Plan. Each line of business
possesses its own unique contract and guidelines which, for benefit and payment purposes, should be
consulted to know what benefits are available for reimbursement. Specific contract benefits, guidelines
or policies supersede the information outlined in this policy.
POLICY:
For US Family Health Plan see TRICARE Policy Manual 6010.57-M, February 1, 2008, Nervous
System: Chapter 4, Section 20.1.
This policy will focus on the following procedures for the treatment of back pain:
Facet blocks
Radiofrequency Ablation
Percutaneous Vertebroplasty
Percutaneous Kyphoplasty
Percutaneous Sacroplasty
I.
Facet Blocks [back to top]
A. When benefits are provided under the member’s contract, JHHC considers facet blocks
medically necessary for the diagnosis of facet pain in persons with moderate to severe
chronic* back or neck pain lasting more than 3 consecutive months when ALL of the
following criteria are met:
1.
Low back (lumbar/sacral), neck (cervical), or sacroiliac pain, suggestive of facet joint
origin as evidenced by absence of nerve root compression as documented in the
medical record on history, physical and radiographic evaluations; AND
2.
Pain has failed to respond to three months of conservative management which may
consist of therapies such as physical therapy, manipulation, nonsteroidal antiinflammatory medications, acetaminophen, or a home exercise program.
3.
A maximum of 1 set of diagnostic facet joint injections per spinal region (cervical or
lumbar/sacral) per side are considered medically necessary as a diagnostic test of
facetogenic back pain and a prognostic test for radiofrequency ablation therapy.
4.
Up to 3 facet joint injections (intra-articular or medial branch blocks) per sitting
constitute a “set” of facet joint injections.
5.
If 50% pain reduction is documented with the first set of injections using the visual
analog scale (See Appendix Figure 1) before and after the procedure, injections may
be repeated once to confirm the diagnosis of facetogenic back pain at least one week
JOHNS HOPKINS HEALTHCARE
Medical Policy: Back Pain – Invasive Procedures
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
Policy Number
CMS18.05
Page 2 of 9
(ideally two weeks) after the first block.
Once a structure is proven to be negative as a pain generator, no repeat injections
should be directed at that structure unless there is a new clinical presentation with
symptoms, signs, and diagnostic studies of known reliability and validity which
implicate that structure.
7.
Fluoroscopic and CT guidance are included in the procedure consistent with CPT
Coding rules and may not be billed separately with or without a modifier 59.
Unless specific benefits apply, facet joint injections (intra-articular and medial branch
blocks) are considered investigational as a therapeutic intervention (non-diagnostic) for back
and neck pain and for all other indications as the effectiveness of this modality, other than as
a diagnostic tool, has not been established.
6.
B.
II.
Radiofrequency Ablation (RFA): [back to top] For the purpose of this policy, discussion of
RFA refers to techniques that address pain attributed to facet or sacroiliac joints or radicular pain
without a definitive cause.
A. When benefits are provided under the member’s contract, JHHC considers radiofrequency
ablation medically necessary for patients who meet ALL of the following criteria:
1. Pain is categorized as refractory† or severe*; AND
2. Low back (lumbar/sacral) or neck (cervical) pain is suggestive of facet joint origin as
evidenced by absence of nerve root compression as documented in the medical record
on history, physical and radiographic evaluations; AND
3. Pain has failed to respond, as documented in the medical record, to three months of
conservative management which may consist of therapies such as nonsteroidal antiinflammatory medications, acetaminophen, manipulation, physical therapy, or a home
exercise program.
4. No prior spinal fusion surgery in the area being treated; AND
5. Pain is not radicular, (arising in the back and radiating into the limbs); AND
6. A diagnostic, temporary block with local anesthetic of the facet nerve (medial branch
block) or injection under fluoroscopic guidance into the facet joint has resulted in at
least a 50% reduction in pain.
7. Pain management and pain measurement must be documented using a Pain Intensity
Instrument such as the NIH Warren Grant Magnuson Clinical Center Scale, (Figure 1).
B. Only 1 treatment procedure per level per side is medically necessary and covered in a 6month period, per American Society of Interventional Pain Physicians (ASIPP).
Therapeutic frequency for medial branch neurotomy should remain at intervals of at least 6
months or longer per each region (maximum of 2 times per year) between each procedure,
provided that 50% or greater relief is obtained for 10 to 12 weeks. It is further suggested that
all regions be treated at the same time, provided all procedures are performed safely.
(Manchikanti et al. 2009).
C. Unless specific benefits apply, JHHC considers Radiofrequency denervation investigational
for the treatment of chronic spinal/back pain without definitive cause, as it does not meet
TEC criteria #2-5.
D. Unless specific benefits apply, JHHC considers Radiofrequency denervation investigational
for the treatment of headaches, as it does not meet TEC criteria #2-5.
JOHNS HOPKINS HEALTHCARE
Policy Number
CMS18.05
Medical Policy: Back Pain – Invasive Procedures
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
Page 3 of 9
E.
Unless specific benefits apply, JHHC considers pulsed radiofrequency investigational, as it
does not meet TEC criteria #2-5.
F.
Unless specific benefits apply, JHHC considers thoracic RFA investigational, as it does not
meet TEC criteria #2-5.
III.
Percutaneous Vertebroplasty [back to top]
A. When benefits are provided under the member’s contract, JHHC considers percutaneous
vertebroplasty medically necessary for the management of patients with osteolytic
metastatic cancer or advanced osteoporosis.
B. Unless specific benefits are provided, JHHC considers percutaneous vertebroplasty
investigational for all other indications, as it does not meet TEC criteria #2-5.
IV.
Percutaneous Kyphoplasty [back to top]
A. When benefits are provided under the member’s contract, JHHC considers percutaneous
kyphoplasty medically necessary for the management of patients with osteolytic metastatic
cancer or advanced osteoporosis.
B. Unless specific benefits are provided, JHHC considers percutaneous kyphoplasty
investigational for all other indications, as it does not meet TEC criteria #2-5.
V.
Percutaneous Sacroplasty [back to top]
A. Unless specific benefits are provided, JHHC considers percutaneous sacroplasty
investigational for all indications, as it does not meet TEC criteria #2-5.
Consistent with the Statement on Anesthetic Care during Interventional Pain Procedures for Adults
(2010) from the Anesthesia Society of America, general anesthesia and monitored anesthesia for the
majority of minor pain procedures should not be used and are not considered medically necessary in the
absence of medical documentation of unusual medical circumstances.
APPENDIX
I. Visual Analog Scale for Pain (Figure1):
NIH Warren Grant Magnuson Clinical Center scale
Indications: Adults and children (>9 years old) in all patient care settings who are able
to use numbers to rate the intensity of their pain.
(Figure and pain categories from National Institutes of Health Warren Grant Magnuson Clinical Center)
JOHNS HOPKINS HEALTHCARE
Medical Policy: Back Pain – Invasive Procedures
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
Policy Number
CMS18.05
Page 4 of 9
II. Definitions
*Moderate to severe pain is defined by consistent documentation using a Pain Intensity Instrument
such as the NIH Warren Grant Magnuson Clinical Center scale, (Figure 1).
*Chronic or persistent pain is defined as pain which lasts beyond the ordinary duration of time
that an insult or injury to the body needs to heal.
†Refractory pain is defined as pain that has failed to respond to three (3) months of conservative
medical management as documented in the medical record including, BOTH:
Therapeutic doses of pain medications including non-steroidal anti-inflammatory medications,
acetaminophen, and/or opiates; AND
Physical therapy as part of a comprehensive back program.
III. Documentation
1.
2.
3.
4.
5.
6.
Comprehensive Pain Evaluation (includes H&P and documents that other medical causes of
chronic back pain have been identified and adequately treated)
Imaging (report of MRI done within one year)
Physical Therapy within 24 months documenting patient was compliant with at least 3
months of program for treating back pain; OR documentation of chiropractic intervention
For RFA, documentation that patient has found pain relief after facet blocks
Pain log or diary kept by patient using a communication tool such as The American Chronic
Pain Association Pain Log at a frequency commensurate with the treatment offered. If
diagnostic by use of short acting agents such as lidocaine, pain will be documented on an
hourly basis for the first twenty-four hours after injection. For longer acting treatments, pain
will be documented on an ongoing daily basis to determine treatment efficacy.
Documentation is to follow standards outlined in the JHHC Medical Record Documentation
Standards Policy, COR.026.
http://www.hopkinsmedicine.org/johns_hopkins_healthcare/downloads/cor_026_medical_re
cord_documentation_standards_2014.pdf
BACKGROUND:
Facet joint injections (intra-articular and medial branch blocks) are percutaneous procedures in which
sensory afferent nerve fibers are blocked by short-acting local anesthetics or steroids in order to reduce
pain. This procedure can be used to diagnose facet joint syndrome as the cause of chronic back pain when
there is temporary or prolonged abolition of back pain following facet joint injection. Facet injections have
been accepted as a diagnostic modality for patients with a variety of chronic spinal pain syndromes. Facet
joint injections must be performed under imaging guidance to assure accurate placement of the needle in
the facet joint or on the medial nerve branch of the facet joint. After a satisfactory block has been obtained,
the patient is asked to indulge in activities that usually aggravated his/her pain and to record his/her
impressions of the effect of the procedure 4-8 hours after the injection.2
Radiofrequency Ablation (RFA) is a percutaneous procedure in which an electrical current is used to heat
up an area of nerve tissue, thereby decreasing pain from that specific area. RFA has been investigated and
JOHNS HOPKINS HEALTHCARE
Medical Policy: Back Pain – Invasive Procedures
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
Policy Number
CMS18.05
Page 5 of 9
proven to be safe and effective as a treatment modality for patients with a variety of chronic
spinal/back/neck pain syndromes resulting from arthritis and joint degeneration.1 Treatment objectives are
to eliminate pain, reduce the likelihood of recurrence, and prolong the time to recurrence by selectively
destroying pain fibers without inducing excessive sensory loss, motor dysfunction, or other complications.3
Percutaneous vertebroplasty (VP) is a therapeutic, interventional radiologic procedure for patients with
painful vertebral compression fractures (VCFs) due to primary or secondary osteoporosis. It involves
injection of bone cement into an osteolytic or osteoporotic fracture and is intended to relieve pain, improve
mobility, and prevent further collapse of the bone.5,1
Percutaneous kyphoplasty (KP) is a therapeutic, interventional radiological procedure for patients with
painful vertebral compression fractures (VCFs) due to primary or secondary osteoporosis or myeloma. It
involves expansion of the partially collapsed vertebral body with an inflatable bone tamp, followed by
injection of an acrylic polymer, which then hardens to maintain reduction of the fracture. Kyphoplasty is
intended to relieve pain, restore vertebral body height, and provide stability.13
Percutaneous sacroplasty is a variation of the vertebroplasty technique for treating sacral insufficiency
fracture (SIF) to restore the mechanical integrity and stability of the sacrum and, thereby, relieve pain and
restore mobility. Percutaneous sacroplasty, including sacral kyphoplasty, involves the injection of acrylic
(polymethylmethacrylate [PMMA]) or bioceramic bone cement into the SIF under the guidance of
computed tomography (CT).14
CODING INFORMATION:
CPT Copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark
of the American Medical Association.
Note: The following CPT/HCPCS codes are included below for informational purposes. Inclusion or
exclusion of a CPT/HCPCS code(s) below does not signify or imply member coverage or provider
reimbursement. The member's specific benefit plan determines coverage and referral requirements.
All inpatient admissions require pre-authorization.
PRE-AUTHORIZATION REQUIRED
Compliance with the provision in this policy may be monitored and addressed through
post-payment data analysis and/or medical review audits
Employer Health
Programs (EHP) **See
Specific Summary Plan
Description (SPD)
CPT ®
CODES
22510
Priority Partners (PPMCO)
refer to COMAR guidelines
and PPMCO SPD then apply
policy criteria
US Family Health Plan (USFHP),
TRICARE Medical Policy supersedes
JHHC Medical Policy. If there is no
Policy in TRICARE, apply the Medical
Policy Criteria
DESCRIPTION
Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body,
JOHNS HOPKINS HEALTHCARE
Medical Policy: Back Pain – Invasive Procedures
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
Policy Number
CMS18.05
Page 6 of 9
unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic
22511
22512
22513
22514
22515
64490
64491
64492
64493
64494
64495
64633
64634
Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body,
unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral
Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body,
unilateral or bilateral injection, inclusive of all imaging guidance; each additional
cervicothoracic or lumbosacral vertebral body (List separately in addition to code for
primary procedure)
Percutaneous vertebral augmentation, including cavity creation (fracture reduction and
bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1
vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance;
thoracic
Percutaneous vertebral augmentation, including cavity creation (fracture reduction and
bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1
vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar
Percutaneous vertebral augmentation, including cavity creation (fracture reduction and
bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1
vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each
additional thoracic or lumbar vertebral body (List separately in addition to code for primary
procedure)
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or
nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or
thoracic; single level
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or
nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or
thoracic; second level (List separately in addition to code for primary procedure)
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or
nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or
thoracic; third and any additional level(s) (List separately in addition to code for primary
procedure)
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral;
single level
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral;
second level (List separately in addition to code for primary procedure)
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral;
third and any additional level(s) (List separately in addition to code for primary procedure)
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance
(fluoroscopy or CT); cervical or thoracic, single facet joint
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance
(fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in
addition to code for primary procedure)
JOHNS HOPKINS HEALTHCARE
Medical Policy: Back Pain – Invasive Procedures
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
64635
64636
Policy Number
CMS18.05
Page 7 of 9
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance
(fluoroscopy or CT); lumbar or sacral, single facet joint
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance
(fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in
addition to code for primary procedure)
REVENUE
DESCRIPTION
CODES
Operating Room Services-General-Hospital; outpatient
0360
Ambulatory Surgical Care-General-Hospital; outpatient
0490
NOT COVERED
CPT ®
CODES
0200T
0201T
DESCRIPTION
Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a
balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and
bone biopsy, when performed
Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a
balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and
bone biopsy, when performed
ICD10 CODES ARE FOR INFORMATIONAL PURPOSES ONLY
Employer Health
Programs (EHP) **See
Specific Summary Plan
Description (SPD)
ICD10
CODES
C41.2
C41.4
C79.51C79.52
M50.2M50.93
M51.0M51.37
M53.81M53.83
M54.2
M54.3
Priority Partners (PPMCO)
refer to COMAR guidelines
and PPMCO SPD then apply
policy criteria
US Family Health Plan (USFHP),
TRICARE Medical Policy supersedes
JHHC Medical Policy. If there is no
Policy in TRICARE, apply the Medical
Policy Criteria
DESCRIPTION
Malignant neoplasm of vertebral column
Malignant neoplasm of pelvic bones, sacrum and coccyx
Secondary malignant neoplasm of bone and bone marrow
Cervical disc disorder
Thoracic, thoracolumbar, and lumbosacral intervertebral disc disorders
Other specified dorsopathies [cervical region] [covered for the diagnosis of facet pain with
chronic back or neck pain lasting more than 3 consecutive months]
Cervicalgia [covered for the diagnosis of facet pain with chronic back or neck pain lasting
more than 3 consecutive months]
Sciatica
JOHNS HOPKINS HEALTHCARE
Medical Policy: Back Pain – Invasive Procedures
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
M54.5
M54.6
M54.9
M81.0M81.8
Policy Number
CMS18.05
Page 8 of 9
Low back pain [lumbago]
Pain in thoracic spine [covered for the diagnosis of facet pain with chronic back or neck pain
lasting more than 3 consecutive months]
Dorsalgia, unspecified
Osteoporosis
REFERENCES STATEMENT:
Analyses of the scientific and clinical references cited below were conducted and utilized by the Johns
Hopkins HealthCare Medical Policy Team during the development and implementation of this medical
policy. Per NCQA standards, the Medical Policy Team will continue to monitor and review any newly
published clinical evidence and adjust the references below accordingly if deemed necessary.
CLINICAL
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Derrer D. (2013, October 1). Radiofrequency Ablation for Chronic Pain. Reviewed January 2,
2015. Retrieved from: http://www.webmd.com/pain-management/radiofrequencyablation?page=3
Schutz U, Cakir B, et al. (2011) Diagnostic Value of Lumbar Facet Joint Injection: A
Prospective Triple Cross-Over Study. PLoS ONE 6(11): e27991.
Bicket M, Horowitz J, et al. Epidural Injections in Prevention of Surgery for Spinal Pain:
Systematic Review and Meta-analysis of Randomized Controlled Trials. The Spine Journal
(2014); pii:S1529-9430(14)-1569-1.
Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back
pain: A Review of the Evidence for an American Pain Society Clinical Practice Guideline.
Spine. 2009;34(10):1078-1093.
Yang SC, Chen HS, et al. Clinical Evaluation of Percutaneous Vertebroplasty for Symptomatic
Adjacent Vertebral Compression Fracture. Journal of Spinal Disorder and Technology. 2013;
24(4); p. 130-136.
Niemisto L., Kalso E., Malmivaara A., et al. Radiofrequency Denervation for Neck and Back
Pain: A Systematic Review within the Framework. Cochrane Collaboration Back Review
Group. Reviewed: January 2, 2015. Retrieved from:
http://www.bestbets.org/bets/bet.php?id=992
Cohen SP, Strassels SA, et al. Outcome Predictors for Sacroiliac Joint (lateral branch)
Radiofrequency Denervation. Reg. Anesthesia and Pain Medicine (2009): Retrieved from:
http://www.ncbi.nlm.nih.gov/pubmed/19587617
Cohen SP, Huang JHY, Brummett C. Facet joint pain—advances in patient selection and
treatment. Nature Reviews (2013); 9:101-116.
Cohen SP, Raja SN. Pathogenesis, Diagnosis, and Treatment of Lumbar Zygapophysial Joint
Pain. Anesthesiology (2007); 106(3):591-614.
American Chronic Pain Association. Communication Tools.
http://www.theacpa.org/Communication-Tools
Molina HealthCare. Radiofrequency Ablation for Chronic Low Back Pain. Reviewed January 2,
JOHNS HOPKINS HEALTHCARE
Medical Policy: Back Pain – Invasive Procedures
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
12.
13.
14.
15.
16.
17.
18.
19.
Policy Number
CMS18.05
Page 9 of 9
2015. Retrieved from:
http://www.molinahealthcare.com/providers/sc/medicaid/PDF/Radiofrequency-Ablation-forchronic-back-pain-MCG-085.pdf
Hayes. Epidural Steroid Injections for Low Back Pain and Sciatica.
https://www.hayesinc.com/subscribers/subscriberHome.do
Hayes. Percutaneous Vertebroplasty. https://www.hayesinc.com/subscribers/subscriberHome.do
Hayes. Percutaneous Kyphoplasty: https://www.hayesinc.com/subscribers/subscriberHome.do
Hayes. Percutaneous Sacroplasty. https://www.hayesinc.com/subscribers/subscriberHome.do
Aetna Clinical Policy Bulletin. Clinical Policy Bulletin No. 0735. Pulsed Radiofrequency.
Reviewed on January 2, 2015. Retrieved from:
http://www.aetna.com/cpb/medical/data/700_799/0735.html
Aetna Clinical Policy Bulletin. Clinical Policy Bulletin No. 0016. Back Pain – Invasive
Procedures. Last Review January 2, 2015. Retrieved from:
http://www.aetna.com/cpb/medical/data/1_99/0016.html
United HealthCare Policy. Radiofrequency Ablation for Orthopedic Pain. Retrieved from:
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/enUS/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20
and%20Protocols/Medical%20Policies/Medical%20Policies/Ablative_Treatment_for_Spinal_Pa
in.pdf
United HealthCare Policy. Epidural Steroid and Facet Injections for Spinal Pain. Retrieved
from: https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/enUS/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20
and%20Protocols/Medical%20Policies/Medical%20Policies/Epidural_Steroid_and_Facet_Inject
ions_for_Spinal_Pain.pdf
REGULATORY
20.
21.
22.
23.
TRICARE Policy Manual 6010.57-M, February 1, 2008, Surgery: Chapter 4, Section 20.1,
Nervous System. Retrieved from: http://manuals.tricare.osd.mil
TRICARE Policy Manual 6010.57-M, February 1, 2008, Surgery: Chapter 4, Section 6.1,
Musculoskeletal System. Retrieved from: http://manuals.tricare.osd.mil
TRICARE Policy Manual 6010.57-M, February 1, 2008, Radiology: Chapter 5, Section 1.1,
Diagnostic Radiology (Diagnostic Imaging). Retrieved from: http://manuals.tricare.osd.mil
TRICARE Policy Manual 6010.57-M, February 1, 2008, Radiology: Chapter 5, Section 2.1,
Diagnostic Radiology (Diagnostic Ultrasound). Retrieved from: http://manuals.tricare.osd.mil