AIM Guidelines

Clinical Appropriateness Guidelines:
Advanced Imaging
Imaging Program Guidelines
Effective Date: January 1, 2018
Proprietary
Guideline Last Revised Last Reviewed

Administrative 07-26-2016 07-26-2016
Head and Neck 11-01-2016 11-01-2016
Chest 09-07-2017 09-07-2017

Cardiac 11-14-2017 11-14-2017
Abdomen and Pelvis 11-01-2016 11-01-2016
Spine 07-26-2016 07-26-2016
Extremity 07-26-2016 07-26-2016

PET or PET/CT 11-01-2016 11-01-2016
MRI Bone Marrow Blood Supply 08-27-2015 07-26-2016
Magnetic Resonance Spectroscopy (MRS) 06-19-2012 07-26-2016
Quantitative CT (QCT) Bone Mineral Densitometry 11-01-2016 11-01-2016
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Copyright © 2018. AIM Specialty Health. All Rights Reserved www.aimspecialtyhealth.com
Table of Contents
Description and Application of the Guidelines.........................................................................4
Administrative Guidelines.........................................................................................................5
Ordering of Multiple Studies....................................................................................................................................5
Pre-test Requirements............................................................................................................................................6
Head & Neck Imaging................................................................................................................7

CT of the Head........................................................................................................................................................7
MRI of the Head....................................................................................................................................................17
CTA/MRA of the Head: Cerebrovascular...............................................................................................................26
Functional MRI (fMRI) Brain..................................................................................................................................30
PET Brain Imaging................................................................................................................................................31
CT of the Orbit, Sella Turcica, Posterior Fossa, Temporal Bone, including Mastoids...........................................32
MRI of the Orbit, Face & Neck (Soft Tissues).......................................................................................................35
CT of the Paranasal Sinus & Maxillofacial Area....................................................................................................38
MRI Temporomandibular Joint (TMJ)....................................................................................................................41
CT of the Neck (Soft Tissue).................................................................................................................................42
CTA/MRA of the Neck...........................................................................................................................................45
Chest Imaging..........................................................................................................................47
CT of the Chest.....................................................................................................................................................47
CTA of the Chest (Non-Coronary).........................................................................................................................56
MRI of the Chest...................................................................................................................................................59
MRA of the Chest..................................................................................................................................................62
MRI of the Breast..................................................................................................................................................65
Cardiac Imaging.......................................................................................................................68
Myocardial Perfusion Imaging...............................................................................................................................68
Cardiac Blood Pool Imaging..................................................................................................................................74
Infarct Imaging......................................................................................................................................................77
Stress Echocardiography (SE)..............................................................................................................................78
Transesophageal Echocardiography (TEE)..........................................................................................................85
Resting Transthoracic Echocardiography (TTE)...................................................................................................87
CT Cardiac (Structure)..........................................................................................................................................95
Coronary CT Angiography (CCTA) and CT Derived Fractional Flow Reserve (FFR-CT).....................................98
Cardiac CT - Quantitative Evaluation of Coronary Calcification..........................................................................103
MRI - Cardiac......................................................................................................................................................104
PET Myocardial Imaging.....................................................................................................................................107
Cardiac Bibliography...........................................................................................................................................114
Table of Contents | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 2
Abdominal & Pelvic Imaging................................................................................................. 119
CT of the Abdomen.............................................................................................................................................119
MRI of the Abdomen...........................................................................................................................................128
MRCP of the Abdomen........................................................................................................................................133
CTA/MRA of the Abdomen..................................................................................................................................135
CTA Abdominal Aorta and Bilateral Illiofemoral Lower Extremity Run-off...........................................................139
CT of the Pelvis...................................................................................................................................................141
MRI of the Pelvis.................................................................................................................................................148
Fetal MRI.............................................................................................................................................................154
CTA/MRA of the Pelvis........................................................................................................................................156
CT of the Abdomen & Pelvis Combination..........................................................................................................158
CTA of the Abdomen & Pelvis Combination........................................................................................................164
CT Colonography (Virtual Colonscopy)...............................................................................................................167
Spine Imaging........................................................................................................................169
CT of the Cervical Spine.....................................................................................................................................169
MRI of the Cervical Spine...................................................................................................................................173
CT of the Thoracic Spine.....................................................................................................................................177
MRI of the Thoracic Spine...................................................................................................................................180
CT of the Lumbar Spine......................................................................................................................................183
MRI of the Lumbar Spine....................................................................................................................................186
MRA of the Spinal Canal.....................................................................................................................................189
Spine Biblography...............................................................................................................................................190
Extremity Imaging..................................................................................................................192
CT of the Upper Extremity...................................................................................................................................192
MRI of the Upper Extremity (Any Joint)...............................................................................................................195
MRI of the Upper Extremity (Non-Joint)..............................................................................................................201
CTA/MRA of the Upper Extremity........................................................................................................................204
CT of the Lower Extremity...................................................................................................................................205
MRI of the Lower Extremity (Joint & Non-Joint)..................................................................................................208
CTA/MRA of the Lower Extremity........................................................................................................................213
Extremity Bibliography........................................................................................................................................215
PET Imaging.. .........................................................................................................................218

PET Applications including Oncologic Tumor Imaging........................................................................................218
Quantitative CT (QCT)............................................................................................................230
QCT - Bone Mineral Densitometry......................................................................................................................230
MRI Bone Marrow Blood Supply............................................................................................233

MRI - Bone Marrow Blood Supply.......................................................................................................................233
Bibliography........................................................................................................................................................234
Magnetic Resonance Spectroscopy (MRS) ..........................................................................235

MRS....................................................................................................................................................................235
Table of Contents | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 3
Description and Application
of the Guidelines
AIM’s Clinical Appropriateness Guidelines (hereinafter “AIM’s Clinical Appropriateness Guidelines” or the
“Guidelines”) are designed to assist providers in making the most appropriate treatment decision for a specific
clinical condition for an individual. As used by AIM, the Guidelines establish objective and evidence-based, where
possible, criteria for medical necessity determinations. In the process, multiple functions are accomplished:
●● To establish criteria for when services are medically necessary
●● To assist the practitioner as an educational tool
●● To encourage standardization of medical practice patterns
●● To curtail the performance of inappropriate and/or duplicate services
●● To advocate for patient safety concerns
●● To enhance the quality of healthcare
●● To promote the most efficient and cost-effective use of services
AIM’s guideline development process complies with applicable accreditation standards, including the requirement
that the Guidelines be developed with involvement from appropriate providers with current clinical expertise
relevant to the Guidelines under review and be based on the most up to date clinical principles and best practices.
Relevant citations are included in the “References” section attached to each Guideline. AIM reviews all of its
Guidelines at least annually.
AIM makes its Guidelines publicly available on its website twenty-four hours a day, seven days a week. Copies of
AIM’s Clinical Appropriateness Guidelines are also available upon oral or written request. Although the Guidelines
are publicly-available, AIM considers the Guidelines to be important, proprietary information of AIM, which cannot
be sold, assigned, leased, licensed, reproduced or distributed without the written consent of AIM.
AIM applies objective and evidence-based criteria and takes individual circumstances and the local delivery
system into account when determining the medical appropriateness of health care services. The AIM Guidelines
are just guidelines for the provision of specialty health services. These criteria are designed to guide both
providers and reviewers to the most appropriate services based on a patient’s unique circumstances. In all
cases, clinical judgment consistent with the standards of good medical practice should be used when applying
the Guidelines. Guideline determinations are made based on the information provided at the time of the request.
It is expected that medical necessity decisions may change as new information is provided or based on unique
aspects of the patient’s condition. The treating clinician has final authority and responsibility for treatment
decisions regarding the care of the patient and for justifying and demonstrating the existence of medical necessity
for the requested service. The Guidelines are not a substitute for the experience and judgment of a physician
or other health care professionals. Any clinician seeking to apply or consult the Guidelines is expected to use
independent medical judgment in the context of individual clinical circumstances to determine any patient’s care
or treatment.
The Guidelines do not address coverage, benefit or other plan specific issues. If requested by a health plan, AIM
will review requests based on health plan medical policy/guidelines in lieu of AIM’s Guidelines.
The Guidelines may also be used by the health plan or by AIM for purposes of provider education, or to review
the medical necessity of services by any provider who has been notified of the need for medical necessity review,
due to billing practices or claims that are not consistent with other providers in terms of frequency or some other
manner.
CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and
other data are copyright by the American Medical Association. All Rights Reserved. AMA does not directly or indirectly practice medicine or dispense
medical services. AMA assumes no liability for the data contained herein or not contained herein.
Guideline Description and Administrative Guidelines | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 4
Administrative Guideline:
Ordering of Multiple Studies
Requests for multiple imaging studies to evaluate a suspected or identified condition and requests for repeated
imaging of the same anatomic area are subject to additional review to avoid unnecessary or inappropriate
imaging.
Simultaneous Ordering of Multiple Studies
In many situations, ordering multiple imaging studies at the same time is not clinically appropriate because:
●● Current literature and/or standards of medical practice support that one of the requested imaging studies
is more appropriate in the clinical situation presented; or
●● One of the imaging studies requested is more likely to improve patient outcomes based on current
literature and/or standards of medical practice; or
●● Appropriateness of additional imaging is dependent on the results of the lead study.
When multiple imaging studies are ordered, the request will often require a peer-to-peer conversation to
understand the individual circumstances that support the medically necessity of performing all imaging studies
simultaneously.
Examples of multiple imaging studies that may require a peer-to-peer conversation include:
¾¾ CT brain and CT sinus for headache
¾¾ MRI brain and MRA brain for headache
¾¾ MRI cervical spine and MRI shoulder for pain indications
¾¾ MRI lumbar spine and MRI hip for pain indications
¾¾ MRI or CT of multiple spine levels for pain or radicular indications
¾¾ MRI foot and MRI ankle for pain indications
¾¾ Bilateral exams, particularly comparison studies
There are certain clinical scenarios where simultaneous ordering of multiple imaging studies is consistent with
current literature and/or standards of medical practice. These include:
¾¾ Oncologic imaging – Considerations include the type of malignancy and the point along the care
continuum at which imaging is requested
¾¾ Conditions which span multiple anatomic regions – Examples include certain gastrointestinal indications
or congenital spinal anomalies
Repeated Imaging
In general, repeated imaging of the same anatomic area should be limited to evaluation following an intervention,
or when there is a change in clinical status such that imaging is required to determine next steps in management.
At times, repeated imaging done with different techniques or contrast regimens may be necessary to clarify a
finding seen on the original study.
Repeated imaging of the same anatomic area (with same or similar technology) may be subject to additional
review in the following scenarios:
●● Repeated imaging at the same facility due to motion artifact or other technical issues
●● Repeated imaging requested at a different facility due to provider preference or quality concerns
●● Repeated imaging of the same anatomic area (MRI or CT) based on persistent symptoms with no clinical
change, treatment, or intervention since the previous study
●● Repeated imaging of the same anatomical area by different providers for the same member over a short
period of time
Administrative Guideline:
Pre-Test Requirements
Critical to any finding of clinical appropriateness under the guidelines for specific imaging exams is a
determination that the following are true with respect to the imaging request:
●● A clinical evaluation has been performed prior to the imaging request (which should include a complete
history and physical exam and review of results from relevant laboratory studies, prior imaging and
supplementary testing) to identify suspected or established diseases or conditions.
●● For suspected diseases or conditions:
○○ Based on the clinical evaluation, there is a reasonable likelihood of disease prior to imaging; and
○○ Current literature and standards of medical practice support that the requested imaging study is
the most appropriate method of narrowing the differential diagnosis generated through the clinical
evaluation and can be reasonably expected to lead to a change in management of the patient; and
○○ The imaging requested is reasonably expected to improve patient outcomes based on current
literature and standards of medical practice.
●● For established diseases or conditions:
○○ Advanced imaging is needed to determine whether the extent or nature of the disease or condition
has changed; and
○○ Current literature and standards of medical practice support that the requested imaging study is the
most appropriate method of determining this and can be reasonably expected to lead to a change in
management of the patient; and
○○ The imaging requested is reasonably expected to improve patient outcomes based on current
literature and standards of medical practice.
●● If these elements are not established with respect to a given request, the determination of
appropriateness will most likely require a peer-to-peer conversation to understand the individual and
unique facts that would supersede the pre-test requirements set forth above. During the peer-to-peer
conversation, factors such as patient acuity and setting of service may also be taken into account.
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

●● From the skull base to vertex, covering the entire calvarium and intracranial contents
●● Scan coverage may vary, depending on the specific clinical indication
Technology Considerations
●● MRI of the head is preferable to CT in most clinical scenarios, due to its superior contrast resolution and lack of
beam-hardening 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 where CT is preferred:
○○ initial evaluation of recent craniocerebral trauma
○○ evaluation of acute intracranial hemorrhage (parenchymal, subarachnoid, subdural, epidural)
○○ evaluation of calcified intracranial lesions
○○ osseous assessment of the calvarium, skull base and maxillofacial bones, including detection of calvarial and
facial bone fractures
Common Diagnostic Indications

This section begins with general indications for CT Head, followed by Neurologic Signs and Symptoms and Vascular
indications.
General Head/Brain
Abnormal imaging findings

Follow up of abnormal or indeterminate findings on a prior imaging study when required to direct treatment
Acoustic neuroma
Management of known acoustic neuroma when at least one of the following applies:
●● Symptoms suggestive of recurrence or progression
●● Following conservative treatment or incomplete resection at 6, 18, 30, and 42 months
●● Post resection, baseline imaging and follow up at 12 months after surgery
Congenital or developmental anomaly

Diagnosis or management (including perioperative evaluation) of a suspected or known congenital anomaly or
developmental condition
Examples include Chiari malformation, craniosynostosis, macrocephaly, and microcephaly.
Dementia**
●● Initial evaluation to exclude a secondary cause of symptoms
●● Evaluation of rapidly progressive symptoms
** requires contraindication to MRI
CT Head | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 7

Hearing loss, sensorineural**
Diagnosis—detection of acoustic neuroma or other retrocochlear lesion in persons diagnosed with sensorineural
hearing loss characterized by either of the following features:
●● Gradual onset of unilateral or asymmetric hearing loss demonstrated by audiometric testing (15 dB or greater at 2
consecutive frequencies between 0.5 and 3 kHz)
●● Hearing loss associated with at least one neurologic sign or symptom known to increase the pretest probability of a
retrocochlear lesion
Horner’s syndrome**
Hydrocephalus/ventricular assessment
Diagnosis of suspected increased intracranial pressure or hydrocephalus
Management of ventricular shunt
Infectious disease
Diagnosis or management (including perioperative evaluation) of infection involving the brain or related structures
Inflammatory disease
Diagnosis or management of inflammatory disease with CNS involvement
Lumbar puncture risk assessment

●● Evaluation prior to lumbar puncture when at least one of the following is present:
○○ Papilledema
○○ Abnormal neurological exam
○○ Absent venous pulsations on funduscopic exam
○○ Altered mental status
○○ Evidence for meningeal irritation
Movement disorders
Initial evaluation of the following movement disorders, to exclude an underlying structural lesion
●● Hemifacial spasm
●● Huntington’s disease
●● Multiple system atrophy (MSA)
●● Parkinson’s disease with atypical features
●● Progressive supranuclear palsy
●● Secondary dystonia
●● Other focal or lateralizing movement disorder, such as hemiballismus, athetosis or chorea
Note: Imaging is generally not indicated for evaluation of typical Parkinson’s disease, essential tremor or primary dystonia.
Multiple sclerosis and other white-matter diseases**

Diagnosis of suspected demyelinating disease
Management or surveillance of established disease

Neurocutaneous disorders
Diagnosis or management (including perioperative evaluation) of CNS lesions associated with a known
neurocutaneous disorder
Examples include neurofibromatosis, Sturge-Weber syndrome, tuberous sclerosis, von Hippel-Lindau disease
Papilledema
Pituitary adenoma
Diagnosis of suspected pituitary adenoma when supported by symptoms and laboratory findings
Management (including perioperative evaluation) of known adenoma
Seizure disorder
●● Initial evaluation, to rule out a structural brain lesion as a cause of seizure
●● Evaluation of seizures increasing in frequency or severity
●● Prior to discontinuation of anticonvulsant therapy in patients who have not been previously imaged
Trauma
Initial evaluation when a mechanism of injury has been identified and at least one of the following features is
present:
●● Age 65 or greater
●● Retrograde amnesia
●● At least two (2) episodes of emesis
●● Evidence of open, depressed or basilar skull fracture
●● Focal neurologic findings
●● Glasgow coma score less than 15 or altered mental status
●● High risk mechanism of injury
●● Seizure
Tumor (benign or malignant)

Diagnosis of suspected tumor when supported by the clinical presentation
Management (including perioperative evaluation) of established tumor when imaging is required to direct treatment
Surveillance of established tumor

Neurologic Signs & Symptoms
This section contains indications for Bell’s palsy, headache, mental status change, syncope, vertigo/dizziness, and visual
disturbance.
Advanced imaging based on nonspecific signs or symptoms is subject to a high level of clinical review.
Appropriateness of imaging depends upon the context in which it is requested. At a minimum, this includes a differential
diagnosis and temporal component, along with documented findings on physical exam.
Additional considerations which may be relevant include comorbidities, risk factors, and likelihood of disease based on age
and gender.
In general, the utility of structural brain imaging is limited to the following categories, each with a unique set of clinical
presentations:
●● Identification of a space occupying lesion or other focal abnormality (tumor, CVA)
●● Detection of parenchymal abnormalities (atrophy, demyelinating disease, infection, ischemic change)
●● Identification of ventricular abnormalities (hydrocephalus)
There are a number of common symptoms or conditions for which the likelihood of an underlying central nervous
system process is extremely low. The following indications include specific considerations and requirements which
help to determine appropriateness of advanced imaging for these symptoms.
Bell’s palsy (peripheral facial weakness)

Evaluation of hemifacial weakness when either of the following is present:
●● Additional neurologic findings suggestive of intracranial pathology
●● Symptoms persisting beyond six (6) weeks
Headache
New headache
●● When associated with one or more red flag features (see Table below); OR,
●● Headache has not improved or has worsened during a course of physician-directed treatment, and the patient has
been reevaluated by a clinician following completion of therapy.
Recurrent headache
●● When associated with at least one red flag feature (see Table) and advanced imaging (CT or MRI) has not been
performed to evaluate the headache; OR,
●● When CT or MRI has been performed to evaluate the headache, and a red flag feature has developed since the
prior imaging study; OR,
●● Headaches are increasing in frequency and/or severity despite at least four (4) weeks of physician-directed
treatment and reevaluation by a clinician following completion of therapy.

Table: Red flag features for headache
Headache Characteristics Associated clinical features and conditions

●● Brought on by exertion or valsalva ●● Abnormal neurological exam during the headache episode or in
●● Cluster headache not previously evaluated with MRI between episodes (Note: photophobia and nausea are not considered
●● Postural/positional abnormalities on neurologic exam)
●● Thunderclap or sentinel headache—sudden onset ●● Neck or facial pain (concern for dissection)—see Dissection indication
and severe (worst headache of life) reaching in CTA/MRA Head guideline
maximal intensity within minutes ●● Neck stiffness and fever—see Infectious disease and Inflammatory
disease indications
●● Risk factors for venous thrombosis—see Venous thrombosis indication
Patient Populations High-risk vascular patient

●● Age over 50 years with new onset of headache ●● Personal or family history (at least one first-degree relative) of
●● Known malignancy aneurysm, subarachnoid hemorrhage (SAH), or arteriovenous
●● Increased genetic risk for intracranial neoplasms malformation (AVM)
(including basal cell nevus syndrome, ●● Heritable condition associated with intracranial aneurysm formation,
Gorlin syndrome, Li-Fraumeni syndrome, including autosomal dominant polycystic kidney disease, Ehlers-Danlos
neurofibromatosis type 1 and type 2, Turcot syndrome, Marfan syndrome, neurofibromatosis type 1 and type 2, and
syndrome, and von Hippel-Lindau syndrome) other rare conditions (including hereditary hemorrhagic telangiectasia,
●● Immunodeficiency (including HIV) multiple endocrine neoplasia, pseudoxanthoma elasticum)
Mental status changes, with documented objective evidence from neurologic exam
Syncope
Evaluation for a structural brain lesion when associated with at least one of following:
●● Documented abnormality on neurological examination
●● Presence of at least one persistent neurological symptom
●● Witnessed or highly suspected seizure activity at the time of the episode
Vertigo and dizziness

Evaluation for a structural brain lesion when either of the following is present:
●● Abnormal audiogram or auditory brainstem response
●● Signs or symptoms suggestive of a CNS lesion
Note: Vertigo or dizziness which is clearly related to positional change does not require advanced imaging.
Visual disturbance
Evaluation for central nervous system pathology when suggested by the ophthalmologic exam

Vascular indications
This section contains indications for aneurysm, cerebrovascular accident/transient ischemic attack, congenital/developmental
vascular anomalies, hemorrhage/hematoma, and venous thrombosis.
Aneurysm
●● Screening in asymptomatic high-risk individuals
○○ At least two (2) first degree relatives with intracranial aneurysm or subarachnoid hemorrhage
○○ Presence of a heritable condition which predisposes to intracranial aneurysm (examples include autosomal
dominant polycystic kidney disease and Ehlers-Danlos syndrome type IV)
●● Diagnosis of suspected aneurysm based on neurologic signs or symptoms (for isolated headache, see Headache
indication)
●● Management (including perioperative evaluation) of known (treated or untreated) intracranial aneurysm when
associated with new or worsening neurologic symptoms
●● Surveillance of known aneurysm in the absence of new or worsening symptoms
○○ Initial evaluation at 6–12 months following diagnosis, then every 1–2 years
○○ Follow-up after treatment with clips, endovascular coil or stenting
Cerebrovascular accident (CVA or stroke) and transient ischemic attack (TIA)

Diagnosis of signs or symptoms suggestive of acute infarction
Note: CT is preferred for evaluation of acute intracranial hemorrhage. MRI is preferred for evaluation of subacute and
chronic hemorrhage.
Management of CVA when imaging is required to direct treatment
Congenital or developmental vascular anomaly

Diagnosis or management of known or suspected vascular anomaly
Examples include arteriovenous malformation (AVM), cavernous malformation, dural arteriovenous fistula (DAVF).
Hemorrhage / hematoma
Diagnosis of suspected hemorrhage (intracranial or subarachnoid) or hematoma
Management (including perioperative evaluation) of known hemorrhage (intracranial or subarachnoid) or hematoma,
when imaging is required to direct treatment

Venous thrombosis (including dural venous sinus thrombosis, venous sinus thrombosis,
cerebral vein thrombosis)
Diagnosis (requires at least one clinical finding AND one risk factor, OR at least two clinical findings as specified
below)
●● Clinical findings
○○ Headache
●● Risk factors
○○ Bechet’s disease
○○ Coagulopathy (examples: protein S, protein C, antithrombin 3, antiphospholipid antibody)
○○ Drugs (including all trans retinoic acid [ATRA])
○○ Iron deficiency anemia
○○ Known malignancy
○○ Meningitis /intracranial infection
○○ Oral contraceptive
○○ Pregnancy
○○ Prior episodes of venous sinus thrombosis
○○ Trauma
Management (including perioperative evaluation) of established venous thrombosis
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have a migraine or need neuroimaging? JAMA. 2006;296(10):1274-1283.
31. Devenney E, Neale H, Forbes RB. A systematic review of causes of sudden and severe headache (Thunderclap
Headache): should lists be evidence based? J Headache Pain. 2014;15(1):49.
32. Donington J, Ferguson M,Thoracic Oncology Network of American College of Chest Physicians; Workforce on
Evidence-Based Surgery of Society of Thoracic Surgeons, et al. American College of Chest Physicians and Society of
Thoracic Surgeons consensus statement for evaluation and management for high-risk patients with stage I non-small
cell lung cancer. Chest. 2012 Dec;142(6):1620-35.
33. Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW. Clinical policy: Critical issues in the evaluation
and management of adult patients presenting to the emergency department with acute headache. J Emerg Nurs.
2009;35(3):e43-e71.
34. Fischera M, Marziniak M, Gralow I, Evers S. The incidence and prevalence of cluster headache: A meta-analysis of
population-based studies. Cephalalgia. 2008;28(6):614-618.
35. Fogang Y, Naeije G, Ligot N. Transient Neurologic Deficits: Can Transient Ischemic Attacks Be Discrimated from
Migraine Aura without Headache? J Stroke Cerebrovasc Dis. 2015;24(5):1047-1051.
36. Frishberg BM, Rosenberg JH, Matchar DB, et al. Evidence-based guidelines in the primary care setting: neuroimaging in
patients with nonacute headache. Available from Am Acad Neurol [online]. 2000:1-25.
37. Gross BA, Frerichs KU, Du R. Sensitivity of CT angiography, T2-weighted MRI,and magnetic resonance angiography in
detecting cerebral arteriovenous malformations and associated aneurysms. J Clin Neurosci. 2012 Aug;19(8):1093-5.
38. Harnan SE, Pickering A, Pandor A. et al. Clinical decision rules for adults with minor head injury: a systematic review. J

Trauma. 2011 Jul;71(1):245-51
39. Hawasli AH, Chicoine MR, Dacey RG. Choosing Wisely. Neurosurgery. 2015;76(1):1-6.
40. Honningsvåg L-M, Hagen K, Håberg A, Stovner LJ, Linde M. Intracranial abnormalities and headache: A population
based imaging study (HUNT MRI). Cephalalgia. 2015.
41. Hughes PD, Becker GJ. Screening for intracranial aneurysms in autosomal dominant polycystic kidney disease.
Nephrology (Carlton). 2003 Aug;8(4):163-70.
42. Iurlaro S, Beghi E, Massetto N, et al. Does headache represent a clinical marker in early diagnosis of cerebral venous
thrombosis? A prospective multicentric study. Neurol Sci. 2004;25 Suppl 3:S298-S299.
43. Josephson CB, White PM, Krishan A, Al-Shahi Salman R. Computed tomography angiography or magnetic resonance
angiography for detection of intracranial vascular malformations in patients with intracerebral haemorrhage. Cochrane
Database Syst Rev. 2014;9:CD009372.
44. Kernick DP, Ahmed F, Bahra A, et al. Imaging patients with suspected brain tumour: Guidance for primary care. Br J Gen
Pract. 2008;58(557):880-885.
45. Kesser BW. Clinical thresholds for when to test for retrocochlear lesions: con. Arch Otolaryngol Head Neck Surg. 2010
Jul;136(7):727-9.
46. Kirby S, Purdy RA. Headaches and Brain Tumors. Neurol Clin. 2014;32(2):423-432.
47. Kurth T, Buring JE, Rist PM. Headache, migraine and risk of brain tumors in women: prospective cohort study. J
Headache Pain. 2015;16(1).
48. Kuruvilla DE, Lipton RB. Appropriate Use of Neuroimaging in Headache. Curr Pain Headache Rep. 2015 Jun;19(6):490.
49. Lehman VT, Barrick BJ, Pittelkow MR, Peller PJ, Camilleri MJ, Lehman JS. Diagnostic imaging in paraneoplastic
autoimmune multiorgan syndrome: retrospective single site study and literature review of 225 patients [published online
2014 Jul 29]. Int J Dermatol. doi: 10.1111/ijd.12603.
50. Loder E, Weizenbaum E, Frishberg B, Silberstein S. Choosing wisely in headache medicine: The american headache
society’s list of five things physicians and patients should question. Headache. 2013;53(10):1651-1659.
51. Lynch KM, Brett F. Headaches that kill: A retrospective study of incidence, etiology and clinical features in cases of
sudden death. Cephalalgia. 2012;32(13):972-978.
52. Maeda M, Yagishita A, Yamamoto T, Sakuma H, Takeda K. Abnormal hyperintensity within the subarachnoid space
evaluated by fluid-attenuated inversion-recovery MR imaging: a spectrum of central nervous system diseases. Eur
Radiol. 2003;13 Suppl 4:L192-L201.
53. Mitchell P, Wilkinson ID, Hoggard N, et al. Detection of subarachnoid haemorrhage with magnetic resonance imaging. J
Neurol Neurosurg Psychiatry. 2001;70(2):205-211.
54. Morris Z, Whiteley WN, Longstreth WT, et al. Incidental findings on brain magnetic resonance imaging: systematic
review and meta-analysis. BMJ. 2009;339:b3016.
55. Nesbitt a. D, Goadsby PJ. Cluster headache. BMJ. 2012;344(apr11 1):e2407-e2407.
56. Ozsvath RR, Casey S, Lustrin ES, Alberico R a. Cerebral Venography: of CT and MR Projection. Am J Roentgenol.
1997;169(December):1699-1707.
57. Pandor A, Harnan S, Goodacre S, Diagnostic accuracy of clinical characteristics for identifying CT abnormality after
minor brain injury: a systematic review and meta-analysis. J Neurotrauma. 2012 Mar 20;29(5):707-18.
58. Pierot L, Portefaix C, Rodriguez-Régent C, et al. Role of MRA in the detection of intracranial aneurysm in the acute
phase of subarachnoid hemorrhage. J Neuroradiol. 2013 Jul;40(3):204-10.
59. Polmear a. Sentinel headaches in aneurysmal subarachnoid haemorrhage: What is the true incidence? A systematic
review. Cephalalgia. 2003;23(10):935-941.
60. Rozenfeld MN, Ansari SA, Shaibani A, Russell EJ, Mohan P, Hurley MC. Should patients with autosomal dominant
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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

●● From skull base to vertex, covering the entire calvarium and intracranial contents, including the internal auditory
canals
●● Scan coverage may vary, depending on the specific clinical indication.
●● MRI of the head is preferable to CT in most clinical scenarios, due to its superior contrast resolution and lack of
beam-hardening 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 where CT is preferred:
○○ initial evaluation of recent craniocerebral trauma
○○ evaluation of acute intracranial hemorrhage (parenchymal, subarachnoid, subdural, epidural)
○○ evaluation of calcified intracranial lesions
○○ osseous assessment of the calvarium, skull base and maxillofacial bones, including detection of calvarial and
facial bone fractures

This section begins with general indications for MRI Head/Brain, followed by Neurologic Signs and Symptoms and Vascular
indications.
General Head/Brain

Acoustic neuroma
Management of known acoustic neuroma when at least one of the following applies:
●● Symptoms suggestive of recurrence or progression
●● Following conservative treatment or incomplete resection at 6, 18, 30, and 42 months
●● Post resection, baseline imaging and follow up at 12 months after surgery

Diagnosis or management (including perioperative evaluation) of a suspected or known congenital anomaly or
developmental condition
Examples include Chiari malformation, craniosynostosis, macrocephaly, and microcephaly.
Dementia
●● Initial evaluation to exclude a secondary cause of symptoms
●● Evaluation of rapidly progressive symptoms
MRI of the Head/Brain | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 17
Hearing loss, sensorineural
Diagnosis—detection of acoustic neuroma or other retrocochlear lesion in persons diagnosed with sensorineural
hearing loss characterized by any of the following features:
●● Idiopathic sudden onset sensorineural loss
Horner’s syndrome
Hydrocephalus/ventricular assessment
Diagnosis of suspected increased intracranial pressure or hydrocephalus
Management of ventricular shunt
Infectious disease
Diagnosis or management (including perioperative evaluation) of infection involving the brain or related structures
Diagnosis or management of inflammatory disease with CNS involvement
Movement disorders
Initial evaluation of the following movement disorders, to exclude an underlying structural lesion
●● Hemifacial spasm
●● Huntington’s disease
●● Multiple system atrophy (MSA)
●● Parkinson’s disease with atypical features
●● Progressive supranuclear palsy
●● Secondary dystonia
●● Other focal or lateralizing movement disorder, such as hemiballismus, athetosis or chorea
Note: Imaging is generally not indicated for evaluation of typical Parkinson’s disease, essential tremor or primary dystonia.
Multiple sclerosis and other white-matter diseases

Diagnosis of suspected demyelinating disease
Management or surveillance of established disease
Neurocutaneous disorders
Diagnosis or management (including perioperative evaluation) of CNS lesions associated with a known
neurocutaneous disorder
Examples include neurofibromatosis, Sturge-Weber syndrome, tuberous sclerosis, von Hippel-Lindau disease
Papilledema
Pituitary adenoma
Diagnosis of suspected pituitary adenoma when supported by symptoms and laboratory findings
Management (including perioperative evaluation) of known adenoma
Seizure disorder
●● Initial evaluation, to rule out a structural brain lesion as a cause of seizure
●● Evaluation of seizures increasing in frequency or severity
●● Prior to discontinuation of anticonvulsant therapy in patients who have not been previously imaged
Trauma
Following initial evaluation with CT, when MRI is needed to direct management or inform prognosis
Trigeminal neuralgia and persistent idiopathic facial pain

Evaluation for a structural lesion or demyelinating disease as a cause of symptoms

Diagnosis of suspected tumor when supported by the clinical presentation
Management (including perioperative evaluation) of established tumor when imaging is required to direct treatment
Surveillance of established tumor
Neurologic Signs & Symptoms

This section contains indications for Bell’s palsy, headache, syncope, tinnitus, vertigo/dizziness, and visual disturbance.
Advanced imaging based on nonspecific signs or symptoms is subject to a high level of clinical review.
Appropriateness of imaging depends upon the context in which it is requested. At a minimum, this includes a differential
diagnosis and temporal component, along with documented findings on physical exam.
Additional considerations which may be relevant include comorbidities, risk factors, and likelihood of disease based on age
and gender.
In general, the utility of structural brain imaging is limited to the following categories, each with a unique set of clinical
presentations:
●● Identification of a space occupying lesion or other focal abnormality (tumor, CVA)
●● Detection of parenchymal abnormalities (atrophy, demyelinating disease, infection, ischemic change)
●● Identification of ventricular abnormalities (hydrocephalus)
There are a number of common symptoms or conditions for which the likelihood of an underlying central nervous
system process is extremely low. The following indications include specific considerations and requirements which
help to determine appropriateness of advanced imaging for these symptoms.
Bell’s palsy (peripheral facial weakness)

Evaluation of hemifacial weakness when either of the following is present:
●● Additional neurologic findings suggestive of intracranial pathology
●● Symptoms persisting beyond six (6) weeks
Headache
New headache
●● When associated with one or more red flag features (see Table below); OR,
●● Headache has not improved or has worsened during a course of physician-directed treatment, and the patient has
been reevaluated by a clinician following completion of therapy.
Recurrent headache
●● When associated with at least one red flag feature (see Table below) and advanced imaging (CT or MRI) has not
been performed to evaluate the headache; OR,
●● When CT or MRI has been performed to evaluate the headache, and a red flag feature has developed since the
prior imaging study; OR,
●● Headaches are increasing in frequency and/or severity despite at least four (4) weeks of physician-directed
treatment and reevaluation by a clinician following completion of therapy.
Table: Red flag features for headache
Headache Characteristics Associated clinical features and conditions

●● Brought on by exertion or valsalva ●● Abnormal neurological exam during the headache episode or in
●● Cluster headache not previously evaluated with MRI between episodes (Note: photophobia and nausea are not considered
●● Postural/positional abnormalities on neurologic exam)
●● Thunderclap or sentinel headache—sudden onset ●● Neck or facial pain (concern for dissection)—see Dissection indication
and severe (worst headache of life) reaching in CTA/MRA Head guideline
maximal intensity within minutes ●● Neck stiffness and fever—see Infectious disease and Inflammatory
disease indications
●● Risk factors for venous thrombosis—see Venous thrombosis indication
Patient Populations High-risk vascular patient

●● Age over 50 years with new onset of headache ●● Personal or family history (at least one first-degree relative) of
●● Known malignancy aneurysm, subarachnoid hemorrhage (SAH), or arteriovenous
●● Increased genetic risk for intracranial neoplasms malformation (AVM)
(including basal cell nevus syndrome, ●● Heritable condition associated with intracranial aneurysm formation,
Gorlin syndrome, Li-Fraumeni syndrome, including autosomal dominant polycystic kidney disease, Ehlers-Danlos
neurofibromatosis type 1 and type 2, Turcot syndrome, Marfan syndrome, neurofibromatosis type 1 and type 2, and
syndrome, and von Hippel-Lindau syndrome) other rare conditions (hereditary hemorrhagic telangiectasia, multiple
●● Immunodeficiency (including HIV) endocrine neoplasia, pseudoxanthoma elasticum)
Mental status changes, with documented objective evidence from neurologic exam
Syncope
Evaluation for a structural brain lesion when associated with at least one of following:
●● Documented abnormality on neurological examination
●● Presence of at least one persistent neurological symptom
●● Witnessed or highly suspected seizure activity at the time of the episode
Tinnitus
Evaluation for vascular pathology, when tinnitus is pulsatile in quality
Evaluation for retrocochlear pathology, when at least one of the following features is present:
●● Abrupt or sudden onset
●● Associated neurologic findings
●● Unilateral or asymmetric symptoms
○○ Abnormality on audiogram or auditory brainstem response is required if present longer than six (6) months
Evaluation for a structural lesion when either of the following is present:
●● Abnormal audiogram or auditory brainstem response
●● Signs or symptoms suggestive of a CNS lesion
Visual disturbance
Evaluation for central nervous system pathology when suggested by the ophthalmologic exam
Vascular indications
This section contains indications for aneurysm, cerebrovascular accident, congenital/developmental vascular anomalies,
hemorrhage/hematoma, vasculitis, and venous thrombosis.
Aneurysm
indication)
Cerebrovascular accident (CVA or stroke) and transient ischemic attack (TIA)

Diagnosis of signs or symptoms suggestive of acute infarction
Note: CT is preferred for evaluation of acute intracranial hemorrhage. MRI is preferred for evaluation of subacute and
chronic hemorrhage.
Management of CVA when imaging is required to direct treatment

Diagnosis or management (including perioperative evaluation) of a suspected or known congenital vascular
anomaly or developmental condition
Vasculitis
Evaluation of vasculitis with known or suspected CNS involvement
below)
○○ Headache
●● Risk factors
○○ Pregnancy
○○ Trauma
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33. Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW. Clinical policy: Critical issues in the evaluation
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34. Fischera M, Marziniak M, Gralow I, Evers S. The incidence and prevalence of cluster headache: A meta-analysis of
population-based studies. Cephalalgia. 2008;28(6):614-618.
35. Fogang Y, Naeije G, Ligot N. Transient Neurologic Deficits: Can Transient Ischemic Attacks Be Discrimated from
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36. Frishberg BM, Rosenberg JH, Matchar DB, et al. Evidence-based guidelines in the primary care setting: neuroimaging in
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40. Honningsvåg L-M, Hagen K, Håberg A, Stovner LJ, Linde M. Intracranial abnormalities and headache: A population
based imaging study (HUNT MRI). Cephalalgia. 2015.
43. Josephson CB, White PM, Krishan A, Al-Shahi Salman R. Computed tomography angiography or magnetic resonance
angiography for detection of intracranial vascular malformations in patients with intracerebral haemorrhage. Cochrane
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44. Kernick DP, Ahmed F, Bahra A, et al. Imaging patients with suspected brain tumour: Guidance for primary care. Br J Gen
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46. Kirby S, Purdy RA. Headaches and Brain Tumors. Neurol Clin. 2014;32(2):423-432.
47. Kurth T, Buring JE, Rist PM. Headache, migraine and risk of brain tumors in women: prospective cohort study. J
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50. Loder E, Weizenbaum E, Frishberg B, Silberstein S. Choosing wisely in headache medicine: The american headache
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51. Lynch KM, Brett F. Headaches that kill: A retrospective study of incidence, etiology and clinical features in cases of
sudden death. Cephalalgia. 2012;32(13):972-978.
52. Maeda M, Yagishita A, Yamamoto T, Sakuma H, Takeda K. Abnormal hyperintensity within the subarachnoid space
evaluated by fluid-attenuated inversion-recovery MR imaging: a spectrum of central nervous system diseases. Eur
Radiol. 2003;13 Suppl 4:L192-L201.
53. Mitchell P, Wilkinson ID, Hoggard N, et al. Detection of subarachnoid haemorrhage with magnetic resonance imaging. J
Neurol Neurosurg Psychiatry. 2001;70(2):205-211.
54. Morris Z, Whiteley WN, Longstreth WT, et al. Incidental findings on brain magnetic resonance imaging: systematic
review and meta-analysis. BMJ. 2009;339:b3016.
55. Nesbitt a. D, Goadsby PJ. Cluster headache. BMJ. 2012;344(apr11 1):e2407-e2407.
56. Ozsvath RR, Casey S, Lustrin ES, Alberico R a. Cerebral Venography: of CT and MR Projection. Am J Roentgenol.
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57. Pandor A, Harnan S, Goodacre S, Diagnostic accuracy of clinical characteristics for identifying CT abnormality after
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64. Schaafsma JD, Koffijberg H, Buskens E, Velthuis BK, van der Graaf Y, Rinkel GJE. Cost-effectiveness of magnetic
resonance angiography versus intra-arterial digital subtraction angiography to follow-up patients with coiled intracranial
aneurysms. Stroke. 2010;41(8):1736-1742.
65. Schankin CJ, Ferrari U, Reinisch VM, Birnbaum T, Goldbrunner R, Straube a. Characteristics of brain tumour-associated
headache. Cephalalgia. 2007;27(8):904-911.
66. Secretariat. MA. Neuroimaging for the Evaluation of Chronic Headaches: An Evidence-Based Analysis. Ont Health
Technol Assess Ser. 2010; 10(26): 1–57.
67. Sharifi S, Nederveen AJ, Booij J et al. Neuroimaging essentials in essential tremor: a systematic review. Neuroimage
Clin. 2014 May 9;5:217-31.
68. 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.
69. St Martin MB, Hirsch BE. Imaging of hearing loss. Otolaryngol Clin North Am. 2008 Feb;41(1):157-178.
71. Suchowersky O, Reich S, Quality Standards Subcommittee of the American Academy of Neurology, et al. Practice
Parameter: diagnosis and prognosis of new onset Parkinson disease (an evidence-based review): report of the Quality
Standards Subcommittee of the American Academy of Neurology. Neurology. 2006 Apr 11;66(7):968-75.
72. The Society of Thoracic Surgeons. Choosing Wisely: Five Things Physicians and Patients Should Question. ABIM
Foundation; February 21, 2013. Available at www.choosingwisely.org
74. Tunkel DE, Bauer C a., Sun GH, et al. Clinical Practice Guideline: Tinnitus Executive Summary. Otolaryngol – Head
Neck Surg. 2014;151(4):533-541.
2007;13(5):261-271.
76. Vattoth S, Shah R, Curé JK. A compartment-based approach for the imaging evaluation of tinnitus. AJNR Am J
Neuroradiol. 2010 Feb;31(2):211-218.
Aug 15;66(4):601-8.
78. Vos PE, Alekseenko Y, European Federation of Neurological Societies. Mild traumatic brain injury. Eur J Neurol. 2012
Feb;19(2):191-84: Harnan SE, Pickering A, Pandor A, Goodacre SW. Clinical decision rules for adults with minor head
injury: a systematic review. J Trauma. 2011 Jul;71(1):245-51.
79. Wang HZ, Simonson TM, Greco WR, Yuh WT. Brain MR imaging in the evaluation of chronic headache in patients
without other neurologic symptoms. Acad Radiol. 2001;8(5):405-408.
80. Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology. 2000;216:342-349.
81. Wiebers DO. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and
endovascular treatment. Lancet. 2003;362:103-110.
CT Angiography (CTA) and MR Angiography
(MRA) Head: Cerebrovascular
CPT Codes
70496 �� Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if
performed, and image postprocessing
70544 �� Magnetic resonance angiography, head, without contrast
70545 �� Magnetic resonance angiography, head, with contrast
70546 �� Magnetic resonance angiography, head, without contrast, followed by re-imaging with contrast

●● CTA or MRA may be performed to assess the major intracranial arteries of the anterior and posterior circulations
(including the Circle of Willis) as well as the venous structures (major cerebral veins and dural venous sinuses).
●● For specific clinical indications, exams may be tailored to the region of interest.
●● M
RA of the head includes imaging of the entire arteriovenous system of the brain. Separate requests for concurrent
imaging of the arteries and the veins in the head are inappropriate.
Choice of Imaging Study

Advantages of CTA
●● Higher sensitivity for detection of mural calcification
●● Absence of in-plane flow phenomenon which can exaggerate the degree of stenosis
●● Improved detection of surgical clips and stents
●● Shorter scan time, resulting in less motion artifact and better quality images
Advantages of MRA
●● Provides information about the age of blood
●● No need for iodinated contrast material
●● No exposure to ionizing radiation
Combination with MRI

●● In the majority of clinical situations, appropriateness of a second imaging study is dependent on the results of
the lead study. This is particularly true with regard to MRI and MRA of the same anatomic region, as there is
considerable overlap in visualizing vascular structures. Therefore, it is prudent to begin with the optimal study for the
indication requested.
●● When ordered in combination, peer to peer conversation will be required to understand the individual and unique
facts that would support the medical necessity of all imaging studies requested.

CTA and MRA of the Head | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 26
Aneurysm
indication)
Cerebrovascular accident (CVA)

●● E
valuation for stenosis or occlusion of the intracranial arteries following confirmation of recent non-hemorrhagic CVA
on MRI or CT scan
●● Evaluation for a vascular etiology following confirmation of a recent hemorrhagic CVA on MRI or CT scan

Diagnosis or management (including perioperative or periprocedural management) of a suspected or known
cerebrovascular anomaly
Dissection
Diagnosis of suspected intracranial artery dissection when suggested by the clinical presentation
Management (including perioperative evaluation) of established dissection
Headache
Evaluation for a vascular etiology when all of the following requirements have been met:
●● MRI or CT criteria for imaging of headache are met
●● MRI/CT has not determined the etiology of the headache
●● Headache is persistent and undifferentiated
Note: Undifferentiated headache refers to those not meeting criteria for a primary headache disorder (tension-type,
migraine or cluster).
Pulsatile tinnitus
●● Evaluation for vascular etiology
Stenosis or occlusion of intracranial arteries

●● Diagnosis or management of known or suspected steno-occlusive disease
Thromboembolic disease of major intracranial arterial systems
Trauma
●● When vascular involvement is known or suspected
Trigeminal neuralgia
●● Evaluation for vascular etiology

●● Evaluation of vascular supply to established tumor
Vascular abnormalities associated with sickle cell disease
Vasculitis
Diagnosis or management of vasculitis with known or suspected CNS involvement
below)
○○ Headache
●● Risk factors
○○ Pregnancy
○○ Trauma
References
5. Caranci F, Briganti F, Cirillo L, Leonardi M, Muto M. Epidemiology and genetics of intracranial aneurysms. Eur J Radiol.
2013;82(10):1598-1605.
2009;40(2):476-481.
Neurosurg. 2012Aug;117(2):309-15.
Radiology. 2010;255(2):570-577.
15. LeFevre ML, U.S. Preventive Services Task Force. Screening for asymptomatic carotid artery stenosis: U.S. Preventive
Services Task Force recommendation. Ann Intern Med. 2014;161(5):356-362.
19. Vattoth S, Shah R, Curé JK. A compartment-based approach for the imaging evaluation of tinnitus. AJNR Am J
Neuroradiol. 2010 Feb;31(2):211-218.
Aug 15;66(4):601-8.
Functional Magnetic Resonance Imaging
(fMRI) Brain
CPT Codes
70554 �� Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive
body part movement and/or visual stimulation, not requiring physician or psychologist administration
70555 �� Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive
body part movement and/or visual stimulation, requiring physician or psychologist administration of entire
neurofunctional testing

●● From the skull base to vertex, covering the intra-cranial contents
●● Functional MRI of the brain may be used to localize eloquent areas in the brain, prior to resection of neoplasm or
medically intractable epileptogenic foci.
●● Studies have shown excellent agreement in language localization, when comparing functional brain MRI with the
Wada test and direct electrical stimulation.
●● Advantages of functional brain MRI over a Wada test include the non-invasive technique (not requiring catheter
placement and contrast injection), lack of ionizing radiation, shorter time-requirement, lower cost and quicker post-
procedural recovery. Additionally, the Wada test is considered limited in right hemisphere dominance.
●● Advantages of functional brain MRI over intraoperative electrocortical stimulation include its non-invasive technique
and more extensive anatomic brain mapping. Direct electrical stimulation is an invasive procedure, which usually
evaluates only one hemisphere (limiting assessment for partial or bilateral language dominance) and usually
identifies only eloquent brain regions on the surface of the brain.
●● Functional MRI may successfully map primary brain activities related to motor, sensory and language functions.
Examples of tasks which may be used include sentence completion (to map language) and bilateral hand squeeze
task (for sensory motor mapping).

Brain tumors
●● Preoperative neurosurgical planning, as a replacement for a Wada test or direct electrical stimulation mapping
Seizures refractory to medical treatment

●● Preoperative neurosurgical planning, as a replacement for a Wada test or direct electrical stimulation mapping
Functional MRI of the Brain | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 30
Positron Emission Tomography (PET)
Brain Imaging
CPT Codes
78608 �� PET brain, metabolic evaluation
78609 �� PET brain, perfusion evaluation
Commonly Used Radiopharmaceuticals

●● 2-(fluorine-18) fluoro-2-deoxy-d-glucose (FDG) Scan coverage may vary, depending on the specific clinical
indication

Brain tumor
●● Diagnosis or staging
●● Differentiation of post treatment scarring from residual or recurrent disease
Frontotemporal lobe dementia and Alzheimer’s disease

A one-time FDG-PET scan for differentiating between frontotemporal dementia and Alzheimer’s disease is medically
necessary and appropriate, provided that all of the following conditions are met:
●● A recent diagnosis of frontotemporal dementia or Alzheimer’s disease has been made by a physician experienced in
the evaluation of dementia.
●● There is documentation of cognitive decline of at least six (6) months duration.
●● A comprehensive clinical evaluation has been performed, including all of the following:
○○ History and physical examination, including an assessment of activities of daily living from a well-acquainted
informant other than the patient.
○○ Cognitive scales or neuropsychological testing
○○ Laboratory testing to evaluate for metabolic causes of cognitive impairment
○○ Structural imaging of the brain (CT or MRI) to identify a structural cause for cognitive impairment
○○ The evaluation has not clearly identified a specific neurodegenerative disease or other cause for the clinical
symptoms.
○○ Results of the PET scan will help clarify the diagnosis in order to guide future treatment.
○○ A brain SPECT has not been obtained for the same indication.
Note: Documentation of this evaluation, including results of all testing, and a current list of medications are required.
Refractory seizures / epilepsy

●● Pre-surgical evaluation to identify a focus of seizure activity in patients who have failed conventional medical therapy
PET Brain Imaging | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 31
Computed Tomography (CT) Orbit, Sella
Turcica, Posterior Fossa, Temporal Bone,
including Mastoids
CPT Codes
70480 �� CT of orbit, sella or posterior fossa and outer, middle or inner ear, without contrast
70481 �� CT of orbit, sella or posterior fossa and outer, middle or inner ear, with contrast
70482 �� CT of orbit, sella or posterior fossa and outer, middle or inner ear, without contrast, followed by re-imaging
with contrast

●● Anatomic coverage and protocol specifications will vary, depending on the clinical indication. Anatomic evaluation
includes the internal auditory canals (IACs), posterior fossa, sella turcica, orbits and temporal bone, with the mastoid
air cells.
●● Targeted evaluation, such as CT of the temporal bones, involves collimated views through the region of
interest, often in two imaging planes: axial images (petrous bones through mastoid tips) and coronal views
(temporomandibular joints through temporal bones).
●● CT is often the preferred study for suspected fracture or follow-up of a known fracture, foreign body detection,
assessment of calcified lesions and temporal bone evaluation.
●● With capability for high-resolution osseous imaging, CT can provide detailed anatomic depiction of the temporal
bone anatomy, including the middle and inner ear structures.
●● MRI (unless contraindicated) is usually preferred over CT for evaluation of the sella turcica, internal auditory canal
regions and visual pathways, as well as for most soft tissue tumor evaluation.
●● Bony changes from a sellar, para-sellar or orbital mass or infectious process are usually well demonstrated by CT.

This section begins with general indications, followed by orbital and otic indications.
General indications


Diagnosis or management (including perioperative evaluation) of a suspected or known congenital anomaly
or developmental condition of the orbit, temporal bone, sella turcica or posterior fossa (see Standard Anatomic
Coverage for detail)
Infectious disease
Diagnosis or management (including perioperative evaluation) of infection involving the orbit, temporal bone, sella
turcica or posterior fossa
Diagnosis or management of inflammatory disease known to involve the orbit, temporal bone, sella turcica or
posterior fossa
Localized facial pain – when persistent and unexplained
CT of Orbit, Sella Turcica, Posterior Fossa, Temporal Bone, Mastoids | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 32
Osseous lesions
Examples include fibrous dysplasia, Paget’s disease and otosclerosis
Trauma to the orbit, temporal bone, or skull base

Diagnosis or management (including perioperative evaluation) of benign or malignant tumor of the orbit, temporal
bone, sella turcica or posterior fossa
Orbital indications
Diagnosis or management of any of the following:

●● Dysconjugate gaze
●● Exophthalmos (or proptosis)
●● Extraocular muscle weakness
●● Nystagmus
●● Optic neuritis
●● Orbital pseudotumor
●● Papilledema
●● Strabismus
●● Thyroid ophthalmopathy
●● Visual field defect
Foreign body in the orbit

●● Following non-diagnostic X-ray
Visual disturbance
Evaluation for orbital or optic nerve pathology when suggested by the ophthalmologic exam
Otic indications
Cholesteatoma
Cochlear implant
Preoperative and post-operative evaluation
Conductive hearing loss
Sensorineural hearing loss**

Diagnosis—detection of acoustic neuroma or other retrocochlear pathology in persons diagnosed with
sensorineural hearing loss characterized by either of the following features:
**requires contraindication to MRI
Tinnitus**
Evaluation for vascular pathology when tinnitus is pulsatile in quality
Evaluation for retrocochlear pathology when at least one of following features is present:
●● Abrupt or sudden onset
●● Associated neurologic findings
●● Unilateral or asymmetric symptoms
○○ Abnormality on audiogram or auditory brainstem response is required if present longer than six (6) months.
**requires contraindication to MRI

●● Evaluation of signs or symptoms suggestive of a CNS lesion
●● Symptoms associated with abnormal audiogram or auditory brainstem response
References
1. Baguley D, McFerran D, Hall D. Tinnitus. Lancet. 2013 Nov 9;382(9904):1600-1607.
Jul;136(7):725-7.
Review.
Jul;136(7):727-9.
5. Sajisevi M, Weissman JL, Kaylie DM. What is the role of imaging in tinnitus? Laryngoscope. 2014 Mar;124(3):583-584.
7. Tunkel DE, Bauer CA, Sun GH, et al. Clinical Practice Guideline: Tinnitus Executive Summary. Otolaryngol Head Neck
Surg. 2014;151(4):533-541.
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

●● Scan coverage is dependent on the specific anatomic area of clinical interest, and may include the following:
○○ Facial structures
○○ Larynx and subglottic regions
○○ Nasopharynx, oropharynx and hypopharynx
○○ Neck soft tissues, surrounding the airway and glands
○○ Optic nerve
○○ Orbit
○○ Salivary glands
○○ Sinuses
○○ Thyroid and parathyroid gland
●● MRI is usually preferred over CT for evaluation of the sella turcica and visual pathways.
●● CT is generally the modality of choice for traumatic injury, calcified lesions, localized infection (for example, orbital
extension of an adjacent complicated sinusitis), and foreign body evaluation following initial radiographic evaluation
for a radiopaque foreign body.
●● CT is preferred for visualization of soft tissue structures in the neck.
●● MRI of the orbit, face and neck is not indicated for imaging the internal auditory canals (see MRI brain, CPT codes
70551–70553).

This section begins with general indications, followed by nasal, neck, and orbital indications.
General indications

Congenital anomalies
Diagnosis or management (including perioperative evaluation) of a suspected or known congenital anomaly of the
orbit, maxillofacial area, or soft tissue structures of the neck (see Standard Anatomic Coverage for detail)
Horner’s syndrome
Infectious disease (excluding sinusitis)

Diagnosis or management (including perioperative evaluation) of infection involving the orbit, maxillofacial area, or
soft tissue of the neck
Note: For sinus infection, see CT Paranasal Sinus and Maxillofacial Area
MRI of Orbit, Face, Neck | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 35
Diagnosis or management of inflammatory disease known to involve the orbit, maxillofacial area, or soft tissue
structures of the neck
Example includes Wegener’s granulomatosis (granulomatosis with polyangiitis)
Osteonecrosis of the jaw

Evaluation following non-diagnostic Panorex/radiographs
Thyroid nodule or thyromegaly (goiter)

●● Following thyroid ultrasound or thyroid scintigraphy
●● When associated with mass effect on the upper airway or esophagus
●● For preoperative evaluation
Trauma to facial structures or soft tissues of the neck
Tumor (primary neoplasm or metastatic disease)

Diagnosis of suspected malignancy based on exam findings or testing abnormalities
Management (including perioperative evaluation) of known malignancy when imaging is required to direct treatment
Exclusion: Advanced imaging is not indicated for surveillance imaging of non-Hodgkin’s lymphoma for a patient in
remission and there has been at least two (2) years since the most recent course of chemotherapy.
Note: Surveillance applies to patients with no signs or symptoms of recurrent or persistent disease.
Nasal indications
Evaluation of any of the following:

●● Anosmia
●● Recurrent epistaxis
●● Nasal airway obstruction or polyposis refractory to medical therapy
Neck indications
Hoarseness, dysphonia or vocal cord weakness/paralysis

Initial evaluation when at least one of the following applies:
●● Following laryngoscopy, when findings suggest recurrent laryngeal nerve dysfunction or identify a suspicious lesion
●● Symptoms persisting longer than one month which are unexplained by laryngoscopy
●● Presence of at least one of the following high risk features:
○○ Tobacco use
○○ Alcohol abuse
○○ Hemoptysis
○○ History of radiation therapy
○○ Known head and neck malignancy
Laryngeal edema
Lymphadenopathy
●● When persistent and unexplained
Neck mass
●● Evaluation of a palpable neck mass
●● Follow up of a non-palpable neck mass identified on a prior imaging study
●● Management (including perioperative evaluation) of known cystic neck mass or other benign tumor
Parathyroid adenoma
●● Diagnosis following abnormal parathyroid ultrasound or scintigraphy
●● Management following failed parathyroidectomy for localization of residual parathyroid tissue
Stridor / Tracheal stenosis / Upper airway obstruction

●● For subacute and chronic stridor, soft tissue radiographs and ENT evaluation are required.
Orbital indications
Diagnosis or management of any of the following:

●● Dysconjugate gaze
●● Exophthalmos (or proptosis)
●● Extraocular muscle weakness
●● Nystagmus
●● Optic neuritis
●● Orbital pseudotumor
●● Papilledema
●● Strabismus
●● Thyroid ophthalmopathy
●● Visual field defect
Visual disturbance
Evaluation for orbital or optic nerve pathology when suggested by the ophthalmologic exam
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. Arce K, Assael LA, Weissman JL, Markiewicz MR. Imaging findings in bisphosphonate-related osteonecrosis of jaws. J
Oral Maxillofac Surg. 2009;67(5 Suppl):75-84.
3. Leite AF, Ogata Fdos S, de Melo NS, Figueiredo PT. Imaging findings of bisphosphonate-related osteonecrosis of the
jaws: a critical review of the quantitative studies [published online 2014 Jun 11]. Int J Dent. doi: 10.1155/2014/784348.
4. Paul BC, Branski RC, Amin MR. Diagnosis and management of new-onset hoarseness: a survey of the American
Broncho-Esophagological Association. Ann Otol Rhinol Laryngol. 2012;121(10):629-634.
5. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck
Surg. 2009;141(3 Suppl 2):S1-S31.
Paranasal Sinus & Maxillofacial Area
CPT Codes
70486 �� CT of maxillofacial area, without contrast
70487 �� CT of maxillofacial area, with contrast
70488 �� CT of maxillofacial area, without contrast, followed by re-imaging with contrast

●● Includes the sinuses, facial structures and maxillary regions. Individual scan coverage depends on the specific
clinical request, but generally includes images through the entire frontal, ethmoid, maxillary and sphenoid sinuses.
Coverage may be extended to include the mandible and temporomandibular joint (TMJ) in select cases and
depending on the clinical indication. CT sections may be obtained in one or two (usually coronal and axial) planes.

Congenital anomaly
Diagnosis or management (including perioperative evaluation) of a suspected or known congenital maxillofacial
anomaly when imaging is required to direct treatment
Infectious disease
Diagnosis or management (including perioperative evaluation) of the following:
●● Fungal or other complex sinus infections
●● Osteomyelitis of the facial bones
Diagnosis or management of inflammatory disease known to involve the maxillofacial region
Examples include Wegener’s granulomatosis (granulomatosis with polyangiitis)

Evaluation following non-diagnostic Panorex/radiographs
Sinus and nasal indications

Diagnosis or management (including perioperative evaluation) of the following:
●● Anosmia
●● Foreign body in the maxillofacial region
●● Mucocoele of paranasal sinuses
●● Nasal airway obstruction refractory to medical therapy
●● Polyposis
●● Recurrent epistaxis
CT Paranasal Sinus & Maxillofacial Area | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 38
Sinusitis / rhinosinusitis
Acute, Uncomplicated Sinusitis / Rhinosinusitis
●● Defined as symptoms that last for less than 4 weeks. Common symptoms include purulent rhinorrhea, postnasal
drainage, anosmia, nasal congestion, facial pain, headache, fever, cough, purulent discharge and/or findings of an
upper respiratory tract infection.
●● No radiographic imaging is usually necessary for immunocompetent patients with acute rhinosinusitis, unless a
complication or alternative diagnosis is suspected that requires imaging.
●● CT may be performed if symptoms persist beyond 3 – 4 weeks of adequate treatment, which may include antibiotics,
nasal steroids and/or decongestants. Under these circumstances, a complication of acute sinusitis/rhinosinusitis or
an alternative diagnosis may warrant CT imaging of the paranasal sinuses.
Acute Recurrent Sinusitis / Rhinosinusitis

●● Defined as 3 or more separate episodes of sinusitis during the past year
●● Imaging used to corroborate the diagnosis and/or investigate for underlying causes of acute recurrent sinusitis.
●● Clinicians should assess patients with recurrent acute sinusitis / rhinosinusitis for factors that modify management,
such as allergic rhinitis, cystic fibrosis, immunocompromised states, ciliary dyskinesia and anatomic variations.
Chronic Sinusitis / Rhinosinusitis

●● Defined as signs and symptoms of sinusitis that last for 12 weeks or longer
●● Imaging used to corroborate the diagnosis and/or investigate for underlying causes of chronic sinusitis.
●● Clinicians should assess patients with chronic sinusitis / rhinosinusitis for factors that modify management, such as
allergic rhinitis, cystic fibrosis, immunocompromised states, ciliary dyskinesia and anatomic variations.
Peri-Orbital Swelling Associated with Sinus Infection

Barosinusitis / Headache Refractory to Antibiotics and Responding only to Decongestants / Oral Steroids
Temporomandibular disease (TMD)

Diagnosis of a temporomandibular joint (TMJ) source of TMD when at least one of the following applies:
●● Panorex is inconclusive or not available
●● Panorex findings require further characterization
●● Panorex is normal but high clinical suspicion for TMJ pathology remains, and the results will change management
(including perioperative evaluation)
Note: Temporomandibular disease is a collective term, which includes disorders of both the masticatory muscles and the
TMJ. CT is generally not indicated when a muscular etiology for TMD is suspected. Most TMJ pathology can be
evaluated with a Panorex radiograph.
Trauma to the facial bones
Tumor or mass lesion in the sinus or nasal region

Diagnosis or management (including perioperative evaluation) of benign or malignant tumors
References
1. American Academy of Orofacial Pain. Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management. De
Leeuw R, Klasser GD, eds. Chicago: Quintessence Publishing Co., Inc.; 2013.
2. American Association of Oral and Maxillofacial Surgeons (AAOMS). Clinical Paper: Temporomandibular Disorders.
Rosemont, IL: AAOMS; 2013.
5. Scrivani SJ, Keith DA, Kaban LB. Temporomandibular disorders. N Engl J Med. 2008;359(25):2693-2705.
6. Setzen G, Ferguson BJ, Han JK, et al. Clinical consensus statement: appropriate use of computed tomography for
paranasal sinus disease. Otolaryngol Head Neck Surg. 2012;147(5):808-816.
Temporomandibular Joint (TMJ)
CPT Codes
70336 �� MRI of the Temporomandibular Joint(s)

●● Bilateral study, including open and closed mouth views, often performed with surface coils
●● Images may be obtained in axial, (oblique) sagittal and (oblique) coronal planes.

Arthropathy of the temporomandibular joints
Frozen jaw
Temporomandibular joint dysfunction

Evaluation of persistent symptoms when all of the following requirements are met:
●● X-ray or Panorex has not provided sufficient information to guide treatment.
●● Intervention is being considered.
●● S
ymptoms have not improved with conservative treatment, including NSAIDs or acetaminophen, a short-term trial of
soft diet and proper chewing techniques, and an oral appliance (such as a bite block).
Trauma to the temporomandibular joints

●● Evaluation of meniscal position and integrity
Note: Conventional radiographs, Panorex views or CT of the TMJ are preferred for initial evaluation of trauma.
MRI Temporomandibular Joint | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 41
Neck for Soft Tissue Evaluation
CPT Codes
70490 �� CT, soft tissue neck, without contrast
70491 �� CT, soft tissue neck, with contrast
70492 �� CT, soft tissue neck, without contrast, followed by re-imaging with contrast

●● Axial images from the skull base to the clavicles
●● 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.

Congenital anomaly
Diagnosis or management (including perioperative evaluation) of a suspected or known congenital or
developmental anomaly of the soft tissue structures of the neck
Foreign body in the upper aero-digestive tract or surrounding neck tissue

●● Following non-diagnostic neck radiograph
Hoarseness, dysphonia, or vocal cord weakness/paralysis

●● Presence of at least one of the following high risk features:
○○ Tobacco use
○○ Hemoptysis
Horner’s syndrome
Infectious disease
Diagnosis or management (including perioperative evaluation) of infection involving soft tissue structures in the
neck
Diagnosis or management of inflammatory disease involving soft tissue structures in the neck
CT Neck (Soft Tissue) | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 42
Laryngeal edema
Lymphadenopathy
●● When persistent and unexplained
Neck mass
●● Evaluation of a palpable neck mass
●● Follow up of a non-palpable neck mass identified on a prior imaging study
●● Management (including perioperative evaluation) of known cystic neck mass or other benign tumor

Evaluation following non-diagnostic X-ray or Panorex
Parathyroid adenoma
●● Evaluation of suspected adenoma following abnormal parathyroid ultrasound or scintigraphy
●● Localization of residual parathyroid tissue following failed parathyroidectomy
●● Preoperative planning in patients with aberrant anatomy
Salivary / parotid gland ductal calculi
Stridor
●● For subacute and chronic stridor, soft tissue radiographs and ENT evaluation are required.
Thyroid nodule or thyromegaly (goiter)

●● Following thyroid ultrasound or thyroid scintigraphy
●● When associated with mass effect on the upper airway or esophagus
●● For preoperative evaluation
Tracheal stenosis or upper airway obstruction
Traumatic injury to soft tissues of the neck

Diagnosis of suspected malignancy based on exam findings or testing abnormalities
Management (including perioperative evaluation) of known malignancy when imaging is required to direct treatment
Exclusion: Advanced imaging is not indicated for surveillance imaging of non-Hodgkin’s lymphoma for a patient in
remission and there has been at least two (2) years since the most recent course of chemotherapy.
References
1. American Academy of Otolaryngology – Head & Neck Surgery Foundation. Choosing Wisely: CT scans or MRIs for
hoarseness. Philadelphia, PA: ABIM Foundation; February 21, 2013. Available at www.choosingwisely.org. Accessed
August 15, 2016
2. American Society of Hematology. Choosing Wisely: Limit surveillance CT scans following treatment for lymphoma.
Philadelphia, PA: ABIM Foundation; December 4, 2013 and December 3, 2014. Available at www.choosingwisely.org.
Accessed August 15, 2016
4. 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.
Surg. 2009;141(3 Suppl 2):S1-S31.
(MRA) Neck
CPT Codes
70498 �� CTA, neck, with contrast material(s), including noncontrast images, if performed, and image post-processing
70547 �� MRA, neck, without contrast
70548 �� MRA, neck, with contrast
70549 �� MRA, neck, without contrast, followed by re-imaging with contrast

●● CTA and MRA of the neck involve image acquisitions from the aortic arch to the skull base, to visualize major
vessels including the extracranial carotid arteries and vertebral arteries. The major venous structures may also be
interrogated with CT and MR angiographic techniques.
Choice of Imaging Study

●● Duplex Doppler ultrasound is a first line imaging study for most carotid indications.
Advantages of CTA
●● Higher sensitivity for detection of mural calcification
●● Absence of in-plane flow phenomenon which can exaggerate the degree of stenosis
●● Improved detection of surgical clips and stents
●● Shorter scan time, resulting in less motion artifact and better quality images
Advantages of MRA
●● Provides information about the age of blood
●● No need for iodinated contrast material

Aneurysm or dissection of carotid or vertebral arteries
Carotid stenosis or occlusion

Diagnosis or management of known or suspected steno-occlusive disease
●● Following abnormal or equivocal duplex Doppler study, unless the diagnosis is supported by clinical exam findings
Note: Screening for carotid disease utilizing advanced imaging is not appropriate.

Diagnosis or management (including perioperative evaluation) of a vascular anomaly of the carotid or vertebral
arteries including arteriovenous malformation (AVM)
Horner’s syndrome
Intramural hematoma
Post-operative or post-procedure evaluation
CTA and MRA Neck | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 45
Preoperative or pre-procedure evaluation
Note: This indication is for preoperative evaluation of conditions not specifically referenced elsewhere in this guideline.
Exclusions:
●● S
creening for carotid disease using advanced imaging in preparation for coronary artery bypass graft (CABG)
surgery is not considered appropriate.
●● M
RV (or CTV) in preparation for either a neurosurgical or percutaneous procedure to treat multiple sclerosis is not
considered appropriate
Thromboembolic disease of major extracranial arterial and/or venous systems
Traumatic vascular injury to the extracranial carotid and vertebral arteries
Vasculopathy (including fibromuscular dysplasia and vasculitis)
Venous thrombosis or compression
Vertebrobasilar stenosis or occlusion
References
1. American Academy of Family Physicians. Choosing Wisely: Ten Things Physicians and Patients Should Question. ABIM
Foundation; Updated February 21, 2013. Available at www.choosingwisely.org.
2. LeFevre ML, U.S. Preventive Services Task Force. Screening for asymptomatic carotid artery stenosis: U.S. Preventive
Services Task Force recommendation. Ann Intern Med. 2014;161(5):356-362.
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.
CTA and MRA Neck | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 46
Chest
CPT Codes
71250 �� Chest CT without contrast
71260 �� Chest CT with contrast
71270 �� Chest CT without contrast, followed by re-imaging with contrast
G0297 �� Low dose CT scan (LDCT) for lung cancer screening

●● Lung apices through costophrenic sulci
●● Scan coverage may vary, depending on the specific clinical indication.
●● 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.
●● CT chest is not appropriate for cardiac and coronary artery imaging. Please see guidelines for cardiac CT and CCTA.
●● 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.

Indications for chest CT are contained in general chest, pulmonary, mediastinal and hilar, pleural, chest wall and diaphragm.
General Chest
Broncho-pleural fistula
Congenital thoracic anomalies
Cough persisting three (3) or more weeks with normal chest X-ray
●● Unresponsive to medical treatment and/or after evaluation for other causes (e.g., post-nasal drainage, asthma,
gastroesophageal reflux disease and medication effects); OR
●● Cough in immunosuppressed (e.g. HIV, after organ or bone marrow transplant, on infliximab or other tumor necrosis
factor antagonists individual (In these individuals, a higher level of suspicion is warranted); OR
●● Other etiologies for chronic cough which include, but are not limited to:
○○ Smoking
○○ Chronic bronchitis
○○ Cough-inducing medications (e.g., ACE inhibitors)
○○ Exposure to an environmental irritant
○○ Respiratory infection
○○ Neoplasm
Fever of unknown origin

●● Lasting more than three weeks with exceptions for immunocompromised patients
●● Following standard work-up to localize the source
Hemoptysis
●● Following non-diagnostic chest radiographs
Horner’s syndrome
CT Chest | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 47

Infectious and inflammatory processes when not otherwise specified
●● For initial evaluation and surveillance
Note: This indication is for evaluation of infectious and inflammatory processes not specifically referenced elsewhere in this
guideline (e.g., pneumonia complications, mediastinitis, sternal infection, lung abscess and empyema).
Lung abscess
Lung cancer screening

●● For annual screening of lung cancer (all of the following)
○○ Patient has no signs or symptoms suggestive of underlying cancer
○○ Patient’s age is equal to or greater than 55 and less than or equal to 80
○○ There is at least a 30 pack-year history of cigarette smoking (and if former smoker, quit date is within previous 15
years)
○○ Patient does not have a health problem that substantially limits life expectancy or the ability/willingness to
undergo an intervention with curative intent
Note: One (1) pack-year of smoking equals smoking one pack (20 cigarettes) per day for one year or 7300 cigarettes
annually. CT should be performed using a low-dose technique (LDCT).
Mediastinitis
●● Includes:
○○ Mediastinal infection/abscess
○○ Fibrosing mediastinitis
Paraneoplastic syndrome with unknown primary

Note: This includes Lambert Eaton syndrome, myasthenia gravis, paraneoplastic cerebellar degeneration, opsoclonus-
myoclonus ataxia, positive paraneoplastic panel, anti-GAD antibody syndrome (stiff-person’s syndrome), voltage-
gated K+ channelopathy (epilepsy syndrome), limbic encephalitis (rapidly progressive dementia syndromes with
abnormal lumbar puncture), dermatomyositis/polymyositis, and anti-NMDA
Persistent pneumonia
●● Repeat radiographs show no improvement following at least four (4) weeks of medical treatment
●● Recurrent pneumonia in the same location within six months
●● Patient is immunosuppressed
Pneumonia, complications
(any one of the following)
●● Following non-diagnostic chest radiograph
●● Immunosuppressed patient
Note: Complications of the mediastinum, lung parenchyma, or pleura include abscess, bronchopleural fistula, complicated
or loculated parapneumonic effusion, empyema, necrotic pneumonia, and purulent pericarditis
Positive sputum cytology for malignancy

Pulmonary embolism
●● For moderate or high clinical suspicion of pulmonary embolism or follow-up when recurrent thromboembolism is a
concern in patients on adequate medical therapy

Sarcoidosis
●● Initial evaluation and periodic follow-up
Sternal infection and dehiscence

Note: Rare complication of cardiothoracic surgery
Structural abnormalities on chest X–ray, which require further clarification with CT
Trauma
●● Injury involving the chest wall, cardiomediastinal structures and/or lungs

Management of biopsy-proven malignancy
●● For renal cell carcinoma (where biopsy is contraindicated) when surgical resection is planned, ultrasound or CT
findings highly suspicious for cancer may constitute documentation of malignancy
Exclusions—advanced imaging is not indicated in the following scenarios:
●● Breast cancer
○○ Staging of low risk breast cancer (stage 2B or less) in the absence of signs or symptoms suggestive of
metastatic disease
○○ Surveillance of breast cancer in the absence of signs or symptoms of recurrent disease
●● Colon cancer
○○ Surveillance imaging of colon cancer in remission, unless one of the following high risk features is present:
■■ Lymphatic or venous invasion
■■ Lymph node involvement
■■ Perineural invasion
■■ Poorly differentiated tumor
■■ T4 tumor
■■ Associated with bowel obstruction
■■ Close, indeterminate or positive margins
■■ Fewer than 12 nodes examined at surgery
■■ Localized perforation
●● Gynecologic malignancies
○○ Surveillance imaging in patients with previously treated gynecologic malignancies including ovarian,
endometrial, cervical, vaginal or vulvar cancer (Note: This exclusion does not apply to sarcoma or other rare
histologies not typically associated with these structures).
●● Non-Hodgkin’s lymphoma
○○ Surveillance imaging of non-Hodgkin’s lymphoma for a patient in remission and there has been at least two (2)
years since the most recent course of chemotherapy
●● Prostate cancer
○○ Staging of low risk prostate cancer: Gleason score equal to six (6), PSA less than 10 ng/mL, and stage T1 or
T2
○○ Follow up or surveillance of prostate cancer following completion of therapy in the absence of a rising PSA
Unexplained weight loss – significant weight loss exceeding 10% of desirable body weight, over
a short time interval (6 months or less), after initial evaluation for other causes

Pulmonary
Asbestos-related benign and malignant lesions, involving the lungs and pleura
○○ Pleural plaques
○○ Interstitial lung disease
○○ Malignant mesothelioma
○○ Pleural effusion
○○ Lung cancer
Bronchiectasis
●● Consider high resolution chest CT (HRCT) technique
Interstitial lung disease / pulmonary fibrosis

●● Consider high resolution chest CT (HRCT) technique
Occupational lung disease (pneumoconioses)

●● Diagnosis and management of any one of the following:
○○ Silicosis
○○ Coal workers pneumoconiosis
○○ Progressive massive fibrosis
○○ Hard metal pneumoconiosis
○○ Talcosis
○○ Caplan’s syndrome (in patients with Rheumatoid Arthritis)
Pulmonary mass or suspicious parenchymal abnormality on recent chest X-ray or other imaging
exam
Pulmonary nodule(s) – without a known primary malignancy
A nodule is defined as a rounded or regular opacity measuring up to 3 cm in diameter. Nodules are classified as solid
or subsolid. Solid nodules are further classified as calcified or non-calcified. Follow-up recommendations are based on
classification, as well as patient risk stratification. For calcified nodules, risk may be correlated with patterns of calcification.
Those nodules with benign-appearing calcifications do not generally require follow up.
In patients under the age of 35 years, primary lung cancer is rare, and the risks associated with radiation exposure are
increased. Therefore, patients in this age range fall outside of the recommendations established by the Fleischner Society
with regard to follow up.
Patients who are immunosuppressed, or who have known or prior malignancy, or who have growing nodules are excluded
from Fleischner Society recommendations. In these patients, follow-up imaging is at the discretion of the treating physician.
Follow-up imaging of multiple nodules should be based on the recommendations pertinent to the most suspicious nodule.
An incomplete thoracic CT refers to a CT that includes only a portion of the lung parenchyma such as a CT or CTA of the
abdomen, neck or extremity.

Non-calcified nodules
●● Age < 35 years:
○○ Nodules ≥ 1 cm
○○ Nodules with suspicious morphology
●● Age 35 years or older:
○○ Solid nodules – see Table 1
○○ Subsolid nodules – see Table 2
Nodules identified on incomplete thoracic CT
●● Less than 6 mm – no follow-up imaging required
●● 6 mm to 8 mm – 3- to 12-month follow up with complete chest CT with subsequent follow up per Table 1 or Table 2
●● More than 8 mm or suspicious morphology – complete chest CT with subsequent follow up per Table 1 or Table 2
Calcified nodules
●● Nodules with benign calcification patterns do not require routine follow up. This includes granulomas and nodules
with popcorn calcifications.
●● Follow up of nodules with other types of calcification patterns is at the discretion of the ordering provider.
Table 1: Follow-up recommendations for solid non-calcified pulmonary nodules

Solid nodule size Risk factors Solitary Multiple
Less than 6 mm Low No follow up
High* Optional follow-up exam at 12 months
6 mm to 8 mm 1) 6 to 12 months
N/A
or Lung-RADS 3 2) 18 to 24 months 1) 3 to 6 months
More than 8 mm N/A 1) 3 months 2) 18 to 24 months
2) 6 months
3) 18 to 24 months unless
diagnostic PET-CT or
tissue sampling performed
Any size when prior imaging N/A No follow up
has documented 24 months
of stability
*High risk is defined by any of the following:

●● Smoking history (any)
●● First-degree relative with lung cancer
●● Significant exposure to asbestos, uranium and/or radon, typically through high risk profession
Table 2: Follow-up recommendations for subsolid non-calcified pulmonary nodules

Subsolid nodule size Solitary ground glass Solitary part solid Multiple subsolid
Less than 6 mm No routine follow up No routine follow up 1) 3 to 6 months
2) 24 months
3) 48 months
Greater than or equal to 1) 6 to 12 months 1) 3 to 6 months 1) 3 to 6 months
6 mm or Lung-RADS 3 2) Every 2 years thereafter 2) Every year for 5 years
2) Follow up based on most
for a total of 5 years suspicious nodule (part
solid or ground glass)
Tables 1 and 2, Abbreviation: Lung-RADS™, American College of Radiology Lung CT Screening Reporting and Data
System. Adapted from MacMahon H, Naidich DP, Goo JM, et al. Radiology. 2017;284(1):228-243.
Pulmonary sequestration

Mediastinal and Hilar
Hilar enlargement on recent chest X-ray
Hoarseness, dysphonia or vocal cord weakness/paralysis

●● Presence of at least one of the following high-risk features:
○○ Tobacco use
○○ Hemoptysis
Known hilar and/or mediastinal lymphadenopathy / mass

●● Periodic follow-up
Mediastinal widening on recent chest X-ray
Penetrating atherosclerotic aortic ulcer
Superior vena cava (SVC) syndrome
Thoracic aorta evaluation

Acute aortic syndrome (any one of the following)
●● Diagnosis and management
●● Periodic surveillance in patients with established acute aortic syndrome undergoing medical management
Note: Initial diagnosis of acute aortic syndrome is considered a medical emergency. This indication includes aortic rupture,
dissection, pseudoaneurysm, mural hematoma, and penetrating ulcer mediastinal hematoma.
Non-acute thoracic aorta (any one of the following)

●● In patients with suspected thoracic aortic aneurysm
●● In patients with confirmed thoracic aortic aneurysm with new or worsening signs/symptoms
●● For ongoing surveillance of stable patients with confirmed thoracic aortic aneurysm who have not undergone
imaging of the thoracic aorta within the preceding six months
●● In patients with confirmed aortic dissection in whom surgical repair is anticipated (to assist in preoperative planning)
●● For ongoing surveillance of stable patients with confirmed aortic dissection who have not undergone imaging of the
thoracic aorta within the preceding year
●● In patients with confirmed aortic dissection or thoracic aortic aneurysm who have undergone surgical repair within
the preceding year and have not undergone imaging of the thoracic aorta within the preceding six months
●● In patients being evaluated for potential transcatheter aortic valve implantation/replacement (TAVI or TAVR) provided
that the patient has not undergone CTA or MRA of the chest within the preceding 60 days
Note: See acute aortic syndrome (section above) for complications of aneurysm including aortic dissection.
Thymoma
●● Note that approximately 15% of patients with myasthenia gravis will have a thymoma
Tracheobronchial lesion evaluation

Traumatic aortic injury
Vasculitis of the thoracic aorta or branch vessel
Pleural, Chest Wall and Diaphragm

Abnormal pleural fluid collection, including effusion, hemothorax, empyema and chylothorax
Note: Ultrasound should be considered as the initial imaging modality and prior to a diagnostic or therapeutic pleural tap.
Chest wall mass
Diaphragmatic hernia
Pleural mass
Pneumothorax – unexplained or recurrent
Thoracic outlet syndrome
Unexplained diaphragmatic elevation or immobility
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CT Angiography (CTA)
Chest (Non-Coronary)
CPT Codes
71275 �� CTA of chest (non-coronary), with contrast material(s), including non-contrast images, if performed, and
image post-processing

●● Scan coverage varies depending on the clinical indication. This exam does not include cardiac and coronary artery
indications.
●● Chest CTA may be used for anatomic depiction from the pulmonary apices through the costophrenic sulci.
Advantages of CTA:
●● Rapidly acquired exam, with excellent anatomic detail afforded by most multidetector CT scanners
Disadvantages of CTA:
●● Potential complications from use of intravascular iodinated contrast administration
Biosafety Issues:
●● Ordering and imaging providers are responsible for considering safety issues prior to the CTA exam. One of the
most significant considerations is the requirement for intravascular iodinated contrast material, which may have an
adverse effect on patients with a history of documented allergic contrast reactions or atopy, as well as on individuals
with renal impairment, who are at greater risk for contrast-induced nephropathy.
Ordering Issues:
●● CTA chest is not appropriate for cardiac and coronary artery imaging. Please review guidelines for cardiac CT and
CCTA.
●● Pulmonary embolus is rare in the absence of elevated blood D-dimer levels and certain specific risk factors.

Indications for chest CTA are contained in general chest, thoracic aorta and great vessel, and pulmonary artery and vein.
General Chest
Developmental anomalies of the thoracic vasculature
●● Examples of congenital thoracic vascular anomalies include but are not limited to the following:
○○ Aortic coarctation
○○ Double aortic arch
○○ Hypoplastic or atretic pulmonary arteries
○○ Inferior vena caval interruption
○○ Partial anomalous pulmonary venous return
○○ Persistent left-sided superior vena cava
○○ Right-sided aortic arch
○○ Total anomalous pulmonary venous return
○○ Truncus arteriosus
Post-traumatic vascular injury
CTA Chest (Non-Coronary) | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 56
Systemic venous thrombosis or occlusion, including superior vena cava (SVC) syndrome
Subclavian steal syndrome
Vascular involvement from neoplasm in the chest
Thoracic Aorta and Great Vessel

Atheromatous disease
●● Evaluation of the thoracic aorta as a source of distal emboli when transthoracic and/or transesophageal
echocardiography are non-diagnostic
Hematoma
Stent graft evaluation, including detection of an endoleak

●● Pre-procedure assessment and post-procedure follow-up

Acute aortic syndrome
●● Periodic surveillance in patients with established acute aortic syndrome undergoing medical management
Note: Initial diagnosis of acute aortic syndrome is considered a medical emergency. This guideline includes aortic rupture,
dissection, pseudoaneurysm, mural hematoma, and penetrating ulcer mediastinal hematoma
Non-acute thoracic aorta
Note: See acute aortic syndrome section for complications of aneurysm including aortic dissection
Vasculitis
Pulmonary Artery and Vein
Pulmonary arterial hypertension
Pulmonary arteriovenous malformation (AVM)
Pulmonary embolism
●● For moderate or high clinical suspicion of pulmonary embolism or follow-up when recurrent thromboembolism is a
concern in patients on adequate medical therapy
References
1. American College of Radiology. ACR–NASCI–SIR–SPR Practice Parameter for the Performance and Interpretation
of Body Computed Tomography Angiography (CTA). Revised 2016. Available at http://www.acr.org/~/media/ACR/
Documents/PGTS/guidelines/ Body_CTA.pdf. Accessed August 25, 2016.
3. Ketai LH, Mohammed TL, Kirsch J, et al.; American College of Radiology Expert Panel on Thoracic Imaging. ACR
Appropriateness Criteria® Hemoptysis. J Thorac Imaging. 2014;29(3):W19-W22.
4. Schoepf UJ, Costello P. CT angiography for diagnosis of pulmonary embolism: state of the art. Radiology. 2004;
230(2):329-337.
Chest
CPT Codes
71550 �� MRI chest, without contrast
71551 �� MRI chest, with contrast
71552 �� MRI chest, without contrast, followed by re-imaging with contrast

●● Chest MRI studies are often performed as problem-solving exams, following chest CT. In these circumstances,
anatomic coverage will depend on the specific indication for the study.
●● MRI of the chest should not be performed for imaging of the heart. For cardiac indications, see Cardiac MRI
guideline section and corresponding CPT codes 75557–75563, 75565.
Advantages of chest MRI:
●● Chest MRI may be helpful after a CT in the following scenarios:
○○ Defining mediastinal and hilar lymphadenopathy (particularly after an unenhanced chest CT exam)
○○ Determining direct lung tumor invasion into the mediastinum and hilar structures, without the need for iodinated
contrast material in CT
○○ Assessing spinal canal extension from a postero-medially located thoracic mass
○○ Evaluating a suspected Pancoast tumor (also referred to as apical pleuro-pulmonary groove or superior
pulmonary sulcus tumors) for direct chest wall extension, given the multiplanar capability of MRI
Disadvantages of chest MRI:

●● Lung lesions are usually better imaged with CT when compared with MRI, given the superior spatial resolution of CT.
●● MRI should not be performed in patients with certain implanted devices that are not MRI compatible, such as
pacemakers.
Ordering issues:
●● For initial evaluation of most thoracic lesions, such as pulmonary nodules and masses, chest CT is considered the
study of choice.
●● Contrast utilization for chest MRI is at the discretion of the ordering and imaging providers.
●● For cardiac and coronary artery imaging, see Cardiac MRI guidelines.

MRI Chest | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 59
Documented malignancy – primary neoplasm and metastatic disease
●● For staging and periodic surveillance
●● To evaluate the mediastinum, hila, pericardium, heart, chest wall and paraspinal region
Horner’s syndrome
Mediastinal and hilar mass lesions – when abnormal findings cannot be thoroughly evaluated
with CT
●● Particularly in patients who have an allergic history to intravascular iodinated CT contrast material or who have renal
insufficiency and thus are at greater risk for contrast-induced nephropathy
●● Chest MRI may be helpful in the following circumstances:
○○ To differentiate mediastinal and hilar lesions from vascular structures; OR
○○ To assess vascular invasion by tumor; OR
○○ To detect spinal extension from a postero-medially located chest mass
Pancoast tumor
●● To evaluate for chest wall extension at the superior pulmonary sulcus
Superior vena cava syndrome

Acute aortic syndrome (any one of the following)
●● periodic surveillance in patients with established acute aortic syndrome undergoing medical management
dissection, pseudoaneurysm, mural hematoma, and penetrating ulcer mediastinal hematoma.
Non-acute thoracic aorta (any one of the following)

Thymoma evaluation or history of myasthenia gravis

Note: Approximately 15% of patients with myasthenia gravis will have a thymoma.
References
1. American Academy of Otolaryngology — Head and Neck Surgery Foundation. Choosing Wisely: CT scans or MRIs for
Hoarseness. ABIM Foundation; February 21, 2013. Available at http://www.choosingwisely.org/clinician-lists/american-
academy-otolaryngology-head-and-neck-surgery-ct-scans-or-mris-for-hoarseness/ Accessed August 25, 2016.
2. Ghaye B, Szapiro D, Dacher JN, et al. Percutaneous ablation for atrial fibrillation: the role of cross-sectional imaging.
4. Konen E, Merchant N, Provost Y, et al. Coarctation of the aorta before and after correction: the role of cardiovascular
MRI. AJR Am J Roentgenol. 2004;182:1333-1339.
5. Kreitner KF, Ley S, Kauczor HU, et al. Chronic thromboembolic pulmonary hypertension: pre- and postoperative
assessment with breath-hold MRI imaging techniques. Radiology. 2004;232(2):535-543.
6. Kunz RP, Oberholzer K, Kuroczynski W, et al. Assessment of chronic aortic dissection: contribution of different
ECGgated breath- hold MRI techniques. AJR Am J Roentgenol. 2004;182(5):1319-1326.
7. Munden RF, Bruzzi J. Imaging of non-small cell lung cancer. Radiol Clin N Am. 2005;43(3):467-480.
8. Orel SG, Schnall MD. MR imaging of the breast for the detection, diagnosis, and staging of breast cancer. Radiology.
2001;220(1):13-30.
9. Ravenel JG, Rosenzweig KE, Kirsch J, et al. ACR Appropriateness Criteria non-invasive clinical staging of bronchogenic
carcinoma. J Am Coll Radiol. 2014;11(9), 849-856.
10. Talti S, Yucel EK, Lipton MJ. CT and MR imaging of the thoracic aorta: current techniques and clinical applications.
Radiol Clin N Am. 2004;42(3):565-585.
11. Tan BB, Flaherty KR, Kazerooni EA, et al. The solitary pulmonary nodule. Chest. 2003;123(1):89S-96S.
12. Tarver RD, Teague SD, Heitkamp DE, Conces DJ Jr. Radiology of community-acquired pneumonia. Radiol Clin N Am.
2005;43(3):497-512.
13. Tatli S, Yucel EK, Lipton MJ. CT and MR imaging of the thoracic aorta: current techniques and clinical applications.
Radiol Clin N Am. 2004;42(3):565-585.
14. Tunick PA, Krinsky GA, Lee VS, Kronzon I. Diagnostic imaging of thoracic aortic atherosclerosis. AJR Am J Roentgenol.
2000;174(4):1119-1125.
MR Angiography (MRA)
Chest
CPT Codes
71555 �� MRA of chest (excluding the myocardium) without contrast, followed by re-imaging with contrast

●● Scan coverage varies depending on the clinical indication
●● Chest MRA may be used for vascular anatomic depiction, from the pulmonary apices through the costophrenic sulci.
Advantages of Chest MRA:
●● Use of MR imaging is advantageous over CT in avoiding ionizing radiation and allowing for direct multiplanar
imaging.
Disadvantages of Chest MRA:

●● With MRA, artifact due to patient motion may have a particularly significant impact on exam quality.
●● MRA cannot be performed in patients with certain implanted devices that are not MRI compatible, such as
pacemakers.

Chest MRA indications are contained in common chest MRA, thoracic aorta and great vessel, and pulmonary artery and vein.
Common Chest MRA

○○ Patent ductus arteriosus
○○ Transposition of the great vessels
Post-traumatic vascular injury
Subclavian steal
Systemic venous thrombosis or occlusion, including superior vena cava (SVC) syndrome
Vascular involvement from neoplasm in the chest
MRA Chest | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 62
Thoracic Aorta and Great Vessel
Atheromatous disease
(All of the following)
●● When CT is contraindicated
●● Evaluation of the thoracic aorta as a source of distal emboli when transthoracic and/or transesophageal
echocardiography are non-diagnostic
Stent graft evaluation, including detection of an endoleak

●● Pre-procedure assessment and post-procedure follow-up

Acute aortic syndrome
●● periodic surveillance in patients with established acute aortic syndrome undergoing medical management
dissection, pseudoaneurysm, mural hematoma, and penetrating ulcer mediastinal hematoma
Non-acute thoracic aorta
Vasculitis
Pulmonary Artery and Vein

Pulmonary arterial hypertension
Pulmonary arteriovenous malformation (AVM)
Pulmonary embolism
●● Rarely requested and used only in selected cases, for example when intravenous iodinated contrast material for a
CTA is contraindicated due to significant iodinated contrast allergy, and a diagnostic ventilation/perfusion (V/Q) study
cannot be obtained
●● For clinically suspected pulmonary embolism or follow-up when recurrent thromboembolism is a concern in patients
on adequate medical therapy
References
1. Ho VB, Corse WR, Hood MN, Rowedder AM. Magnetic resonance angiography of the thoracic vessels. Semin
Ultrasound CT MR. 2003 Aug;24(4):192-216.
3. Maki DD, Siegelman ES, Roberts DA, Baum RA, Gefter WB. Pulmonary arteriovenous malformations: three-dimensional
gadolinium-enhanced MR angiography-initial experience. Radiology. 2001;219(1):243-246.
4. Pereles FS, McCarthy RM, Baskaran V, et al. Thoracic aortic dissection and aneurysm: evaluation with nonenhanced
true FISP MR angiography in less than 4 minutes. Radiology. 2002;223(1):270-274.
5. Sonnet S, Buitrago-Téllez CH, Scheffler K, et al. Dynamic time-resolved contrast-enhanced two-dimensional MR
projection angiography of the pulmonary circulation: standard technique and clinical applications. AJR Am J Roengenol.
2002;179(1):159-165.
6. Wu C, Zhang J, Ladner CJ, et al. Subclavian steal syndrome: diagnosis with perfusion metrics from contrast-enhanced
MR angiographic bolus-timing examination – initial experience. Radiology. 2005;235(3):927-933.
Magnetic Resonance Imaging (MRI) Breast
Also referred to as MR Mammography
(MRM)
CPT Codes
77058 �� MRI of breast, without and/or with contrast material(s); unilateral
77059 �� MRI of breast, without and/or with contrast material(s); bilateral
Technique:
●● It is strongly recommended that breast MRI examinations be performed with a dedicated breast coil.
Limitations:
●● Breast MRI is not recommended as a screening technique in patients with average-risk for breast cancer.
●● Breast MRI is not recommended to assess suspicious breast lesions in order to avoid a biopsy.
●● Breast MRI should not be used to differentiate cysts from solid lesions, which is well evaluated with ultrasound.
Additional Comments:
●● A bilateral MRI study of the breast is correctly coded to CPT 77059. Requesting two unilateral studies (77058) to
perform a bilateral exam is inappropriate. Billing 77058 two times for the same date of service or separately over
subsequent days in order to describe a bilateral procedure fragments the service into its component parts and is not
allowed.

Breast MRI indications are contained in diagnostic evaluation and annual screening with breast carcinoma diagnosis and
breast implant rupture not requiring a breast carcinoma diagnosis.
For Breast Carcinoma: Diagnostic Evaluation
BI-RADS category 3 findings

●● A single follow-up MRI may be performed at 6 months following a breast MRI with BI-RADS category 3 findings
Differentiation of palpable mass(es) from surgical scar tissue

●● Following breast surgery, breast reconstruction or radiation therapy
Invasion of breast cancer deep to fascia

●● MRI evaluation of breast prior to surgical treatment may be useful in both mastectomy and breast conservation
candidates to define the relationship of the tumor to the fascia and its extension into the pectoralis major, serratus
anterior, and/or intercostal muscles
Invasive carcinoma and ductal carcinoma in situ (DCIS)

●● To determine the extent of disease and the presence of multifocality and multicentricity
Lesion characterization
●● When other imaging examinations, such as ultrasound and mammography, and physical examination are
inconclusive for the presence of breast cancer, and biopsy could not be performed (e.g., possible distortion on only
one mammographic view without a sonographic correlate)
MRI Breast | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 65
Metastatic cancer
●● Primary is unknown and suspected to be of breast origin.
●● In patients presenting with metastatic disease and/or axillary adenopathy and no mammographic or physical findings
of primary breast carcinoma.
Neoadjuvant chemotherapy
●● MR mammography may be performed before, during and after chemotherapy to assess response to treatment and
extent of residual disease, prior to surgery.
Post-lumpectomy with positive margins

●● To evaluate for residual disease in patients whose pathology specimens demonstrate close or positive margins for
residual disease
Post-operative tissue reconstruction

●● To evaluate suspected cancer recurrence in patients with tissue transfer flaps (rectus, latissimus, dorsi, and gluteal)
Recurrence of breast cancer

●● In women with a prior history of breast cancer and suspicion of recurrence when clinical, mammographic, and/or
sonographic findings are inconclusive
For Breast Carcinoma: Annual Screening
Individuals who received radiation to the chest between ages 10 and 30 years
Individuals with a genetic predisposition to breast cancer, in either themselves or a first degree
relative, which may include any of the following:
●● Bannayan-Riley-Ruvalcaba syndrome
●● BRCA1 and BRCA2
●● Cowden syndrome
●● Li-Fraumeni syndrome
Individuals known to have any of the following genetic mutations:

●● ATM
●● CDH1
●● CHEK2
●● PALB2
History of lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH) or atypical lobular
hyperplasia (ALH) on biopsy
Lifetime risk ~ 20% or greater

●● As defined by BRCAPRO or other models that are largely dependent on family history
For Breast Implant Rupture: Not Requiring Breast Carcinoma Diagnosis
Breast MRI is indicated to screen for asymptomatic rupture of a silicone breast implant
beginning 3 years after implantation and every other year thereafter
Evaluation of symptomatic patients with breast implants, for detection of implant rupture
References
1. Afonso N, Bouwman D. Lobular carcinoma in situ. Eur J Cancer Prev. 2008;17(4):312-316.
2. Alberta Provincial Breast Tumour Team, Magnetic resonance imaging for breast cancer screening, pre-operative
assessment, and follow-up. Edmonton (Alberta): Alberta Health Services, Cancer Care; 2012 Jan. 19 p. (Clinical
practice guideline; no. BR-007).
3. American College of Radiology. ACR Practice Guideline for the Performance of Contrast-Enhanced Magnetic
Resonance Imaging (MRI) of the Breast. Updated 2013. Available at http://www.acr.org/~/media/ACR/Documents/PGTS/
guidelines/ MRI_Breast.pdf. Accessed August 25, 2016
4. Bahrs SD, Baur A, Hattermann V, et al. BI-RADS 3 lesions at contrast-enhanced breast MRI: is an initial short-interval
follow-up necessary? Acta Radiol. 2014;55(3):260-265.
5. Berg WA, Gutierrez L, NessAiver MS, et al. Diagnostic accuracy of mammography, clinical examination, US, and MR
imaging in preoperative assessment of breast cancer. Radiology. 2004;233(3), 830-849.
6. Boisserie-Lacroix M, Ziade C, Hurtevent-Labrot G, et al. Is a one-year follow-up an efficient method for better
management of MRI BI-RADS® 3 lesions? Breast. 2016;27:1-7.
7. Cardoso F, Loibl S, Pagani O, et al. The European Society of Breast Cancer Specialists recommendations for the
management of young women with breast cancer. Eur J Cancer. 2012;48(18):3355-3377.
8. Chikarmane SA, Birdwell RL, Poole PS, et al. Characteristics, Malignancy Rate, and Follow-up of BI-RADS Category
3 Lesions Identified at Breast MR Imaging: Implications for MR Image Interpretation and Management. Radiology.
2016;280(3):707-15.
9. Degnim AC, Visscher DW, Berman HK, et al. Stratification of breast cancer risk in women with atypia: a Mayo cohort
study. J Clin Oncol. 2007;25(19):2671-2677.
10. Fancellu A, Turner RM, Dixon JM, et al. Meta-analysis of the effect of preoperative breast MRI on the surgical
management of ductal carcinoma in situ. Br J Surg. 2015;102(8):883-893.
11. Hlawatsch A, Teifke A, Schmidt M, Thelan M. Preoperative assessment of breast cancer: sonography versus MR
imaging. AJR Am J Roengenol. 2002;179(6):1493-1501.
12. Huang W, Fisher PR, Dulaimy K, et al. Detection of breast malignancy: diagnostic MR protocol for improved specificity.
Radiology. 2004;232(2):585-591.
13. IKNL (Comprehensive Cancer Centre the Netherlands) and the Knowledge Institute of Medical Specialists (KiMS).
(2012). Breast Cancer - Imaging BI-RADS: Reporting in relation to the Breast Imaging Reporting and Data System
(breast cancer): Richtlijnen. Available at http://richtlijnendatabase.nl/en/richtlijn/breast_cancer/diagnostics/imaging/bi-
rads.html Accessed August 30, 2016
14. Kriege M, Brekelmans CT, Boetes C, et al. Efficacy of MRI and mammography for breast-cancer screening in women
with a familial or genetic predisposition. N Engl Med. 2004;351(5):427-437.
15. Kuhl CK. Current status of breast MR imaging. Part 2. clinical applications. Radiology. 2007;244(3):672-691.
16. Lee CH, Dershlaw DD, Kopans D, et al. Breast cancer screening with imaging: recommendations from the Society of
Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the
detection of clinically occult breast cancer. J Am Coll Radiol. 2010;7(1):18-27.
17. Lee CH. Problem solving MR imaging of the breast. Radiol Clin N Am. 2004;42(5):919-934.
18. Lee JM, Orel SG, Czerniecki BJ, Solin LJ, Schnall MD. MRI before reexcision surgery in patients with breast cancer.
AJR Am J Roengenol. 2004;182(2):473-480.
19. Lee SG, Orel SG, Woo IJ, et al. MR imaging screening of the contralateral breast in patients with newly diagnosed
breast cancer: preliminary results. Radiology. 2003;226(3):773-778.
20. Schnall M, Orel S. Breast MR imaging in the diagnostic setting. Magn Reson Imaging Clin N Am. 2006;14(3):329-337.
21. Song JW, Kim HM, Bellfi LT, Chung KC. The effect of study design biases on the diagnostic accuracy of
magnetic resonance imaging for detecting silicone breast implant ruptures: a meta-analysis. Plast Reconstr Surg.
2011;127(3):1029-1044.
22. U.S. Food and Drug Administration (FDA). Update on the safety of silicone gel-filled breast implants. Executive
Summary. June 2011. Available at http://www.fda.gov/downloads/MedicalDevices/ProductsandMedicalProcedures/
ImplantsandProsthetics/BreastImplants/UCM260090.pdf Accessed August 26, 2016
23. Willey SC, Cocilovo C. Screening and follow-up of the patient at high risk for breast cancer. Obstet Gynecol.
2007;110(6):1404-1416.
24. Zhou WB, Xue DQ, Liu XA, et al. The influence of family history and histological stratification on breast cancer risk in
women with benign breast disease: a meta-analysis. J Cancer Res Clin Oncol. 2011 Jul;137(7):1053-60.
Nuclear Cardiology
Myocardial Perfusion Imaging
CPT Codes
78451 �� Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or
quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when
performed); single study, at rest or stress (exercise or pharmacologic)
78452 �� Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative
wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple
studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
78453 �� Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction
by first pass or gated technique, additional quantification, when performed); single study, at rest or stress
(exercise or pharmacologic)
78454 �� Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by
first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or
stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection

●● Thallium-201 Chloride
●● Technetium-99m Sestamibi
●● Technetium-99m Tetrofosmin
Uses of Myocardial Perfusion Imaging (MPI)

●● The primary use of MPI is in the diagnosis, exclusion or evaluation of obstructive coronary artery disease (CAD).
●● MPI is also used for management of established coronary artery disease.
●● MPI may be used for assessment of myocardial viability in patients who have had myocardial infarction.
Imaging Considerations
●● A recent EKG is strongly recommended, preferably within 30 days of request for a Myocardial Perfusion Imaging
exam. The findings on the resting EKG may be important in determining the need for imaging, the selection of the
appropriate imaging protocol and may also show evidence of ischemia at rest or interval myocardial infarction.
●● Age, gender and the character of the chest pain provide useful predictors of CAD, as stratified in Table 1 below.
Table 1*: Pre-Test Probability of Coronary Artery Disease by Age, Gender and Symptoms
Very Low < 5% Intermediate probability 10-90%

Low Probability < 10% High Probability > 90%
*Reference for Table 1: Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA Guidelines for Exercise Testing: Executive
Summary. Circulation. 1997;96:345-354.
Age (yr) Gender Typical/Definite Atypical/Probable Non-Anginal Asymptomatic

Angina Pectoris Angina Pectoris Chest Pain
30-39 Men Intermediate Intermediate Low Very Low
Women Intermediate Very Low Very Low Very Low
40-49 Men High Intermediate Intermediate Low
Women Intermediate Low Very Low Very Low
Women Intermediate Intermediate Low Very Low
Women High Intermediate Intermediate Low
Myocardial Perfusion Imaging (MPI) | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 6
Myocardial Perfusion Imaging and Stress Echocardiography may provide useful information on Coronary Heart Disease.
Comparison data on Sensitivity and Specificity are provided in Table 2 below. Due to regional variation in technical expertise
and interpretive proficiency, the clinician should use the diagnostic imaging modality that has been proven most accurate in
his/her practices.
Table 2**: Comparison of Non-Invasive Diagnostic Imaging

** Reference for Table 2: Zaret BL, Bellar GA. Clinical Nuclear Cardiology. 3rd Edition. Philadelphia: Elsevier Mosby
Publishers; 2005, page 539
Nuclear Imaging Stress Echo Sensitivity Nuclear Imaging Stress Echo Specificity
Sensitivity (%) (%) Specificity (%) (%)
Exercise (7 studies) 83% 78% 83% 91%
Dobutamine (8 studies) 86% 80% 73% 86%
Adenosine (3 studies) 89% 63% 73% 86%
Dipyridamole (4 83% 68% 88% 89%
studies)
Several clinical indications listed for Myocardial Perfusion Imaging include standard methods of risk assessment, such as the
SCORE (Systematic Coronary Risk Evaluation) or the Framingham risk score calculation. These risk calculation systems
include consideration of the following factors:
Age Sex
Abnormal Lipid Profile Hypertension
Diabetes Mellitus (always = high risk) Cigarette Smoking
Other coronary risk factors such as family history of premature CAD, coronary artery calcification, C reactive protein levels,
obesity, etc., are not included in the standard methods of risk assessment but are thought to contribute to CAD risk.
●● Selection of the optimal diagnostic work-up for evaluation or exclusion of coronary artery disease should be made
within the context of available studies (which include treadmill stress test, stress myocardial perfusion imaging,
stress echocardiography, cardiac PET imaging and invasive cardiac/coronary angiography), so that the resulting
information facilitates patient management decisions and does not merely add a new layer of testing.
●● Occasionally, it may be appropriate to do a second non-invasive test for diagnosis or exclusion of CAD when the
initially selected test is technically suboptimal and the diagnosis of CAD cannot be established or excluded.
●● In order to optimize image quality, imaging protocols may need to be modified in specific patient populations.
Thus, patients who are obese may benefit from 2 day imaging protocols and/or prolonged image acquisition times.
Similarly, imaging in the prone position may improve accuracy in patients who are obese and women with high
likelihood of breast attenuation artifact. Patients whose baseline EKG demonstrates left bundle branch block, may
be better suited to pharmacologic stress imaging than to exercise stress protocols.
●● Rarely, absolute or relative contraindications to MPI will be encountered. MPI should not be used in pregnant
or lactating women. Patients who are unable to remain motionless for several minutes or comprehend simple
instructions are not suitable candidates for MPI. Image quality in morbidly obese patients (BMI >40) is usually
suboptimal such that consideration should be given to other imaging modalities. If imaging studies using other
radioactive tracers have been recently performed, adequate time must elapse to allow for clearance of activity from
the heart and surrounding regions.
●● For patients who are unable to walk on a treadmill for non-cardiac reasons (orthopedic limitations, claudication,
neurological conditions, advanced lung disease, etc.), exercise stress testing is not an option. These patients will
require pharmacological testing with echo or nuclear imaging.
●● It is anticipated that the evaluation of patients with acute chest pain will occur in the emergency room or in an
inpatient setting and MPI performed in these locations is not included in the AIM preauthorization program.
Suspected coronary artery disease in asymptomatic patients
●● Patients with high-risk of CAD (SCORE) who have not had evaluation of coronary artery disease (MPI, stress echo,
cardiac PET, coronary CTA or cardiac catheterization) within the preceding three (3) years; OR
●● Patients with moderate or high risk of CAD (SCORE) who have a high risk occupation that would endanger others
in the event of a myocardial infarction, for example: airline pilot, law-enforcement officer, firefighter, mass transit
operator, bus driver) who have not had evaluation of coronary artery disease (MPI, stress echo, cardiac PET,
coronary CTA or cardiac catheterization) within the preceding three (3) years; OR
●● Patients with diseases/conditions with which coronary artery disease commonly coexist and who have not had
evaluation of coronary artery disease (MPI, stress echo, cardiac PET, coronary CTA or cardiac catheterization)
within the preceding three (3) years:
○○ Diabetes mellitus; OR
○○ Abdominal aortic aneurysm; OR
○○ Established and symptomatic peripheral vascular disease; OR
○○ Prior history of cerebrovascular accident (CVA), transient ischemic attack (TIA) or carotid endarterectomy (CEA)
or high grade carotid stenosis (>70%); OR
○○ Chronic renal insufficiency or renal failure; OR
●● Patients who have undergone cardiac transplantation and have had no evaluation for coronary artery disease within
the preceding one (1) year; OR
●● Patients in whom a decision has been made to treat with interleukin 2
●● Patients awaiting solid organ transplantation who have not undergone evaluation for coronary artery disease within
the preceding one (1) year
Suspected coronary artery disease in symptomatic patients who have not had evaluation of
coronary artery disease (MPI, stress echo, cardiac PET, coronary CTA or cardiac catheterization)
within the preceding sixty (60) days
●● Chest pain
○○ With intermediate or high pretest probability of CAD (Table 1); OR
○○ With low or very low pretest probability of CAD (Table 1) and high risk of CAD (SCORE)
●● Atypical symptoms: syncope, shortness of breath (dyspnea), neck, jaw, arm, epigastric or back pain, or sweating
(diaphoresis)
○○ With moderate or high risk of CAD (SCORE)
●● Other symptoms; palpitation, dizziness, lightheadedness, near syncope, nausea, vomiting, anxiety, weakness, fatigue,
etc.
○○ With high risk of CAD (SCORE)
●● Patients with any cardiac symptom who have diseases/conditions with which coronary artery disease commonly
coexists such as:
●● Patients who have undergone cardiac transplantation; OR
●● Patients in whom a decision has been made to treat with Interleukin 2; OR
●● Patients awaiting solid organ transplantation
Established coronary artery disease in asymptomatic patients

Established coronary artery disease (diagnosed by previous cardiac catheterization, MPI,
cardiac PET, or stress echo) in patients who have new or worsening symptoms
Note: If symptoms are typical of myocardial ischemia cardiac catheterization may be more appropriate than MPI

cardiac PET, or stress echo) in patients who have not undergone revascularization and have no
symptoms or stable symptoms
●● No evaluation of CAD (MPI, stress echo, cardiac PET, coronary CTA or cardiac catheterization) within the preceding
three (3) years
●● No evaluation of CAD (MPI, cardiac PET, stress echo, coronary CTA or cardiac catheterization) within the preceding
one (1) year in a patient who has undergone cardiac transplantation and has been found to have CAD since
transplantation
Established coronary artery disease in patients who have undergone revascularization

●● For evaluation of new or worsening cardiac symptoms
○○ If symptoms are typical of myocardial ischemia cardiac catheterization may be more appropriate than MPI; OR
●● For evaluation of stable patients who have undergone coronary artery bypass grafting more than five (5) years
previously and who have not had an evaluation for coronary artery disease (MPI, stress echo, cardiac PET, coronary
CTA or cardiac catheterization) within the past two (2) years
○○ Stable patients whose revascularization has been incomplete may undergo MPI three (3) years following the
procedure and every three (3) years thereafter; OR
●● For evaluation of stable patients who have undergone percutaneous coronary intervention(PCI) more than three (3)
years previously and who have not had an evaluation for coronary artery disease (MPI, stress echo, cardiac PET,
coronary CTA or cardiac catheterization) within the past three (3) years when any of the following applies
○○ The patient has undergone PCI of the left main (LM) coronary artery or the proximal left anterior descending
(LAD) coronary artery
○○ The patient has undergone PCI of more than one coronary artery
○○ The patient has chronic total occlusion of a coronary artery and the vessel on which PCI was performed is
supplying collateral flow to the occluded vessel
○○ The patient is known to have only one patent coronary artery.
○○ Left ventricular ejection fraction LVEF is <35%
Established coronary artery disease in patients who have had myocardial infarction (ST
elevation or non-ST elevation) or unstable angina within the preceding ninety (90) days provided
that:
●● The patient did not undergo coronary angiography at the time of the acute event; AND
●● The patient is currently clinically stable
Established Kawasaki Disease with Coronary Artery Involvement

●● Every two year evaluation for confirmed small to medium coronary artery aneurysm
●● Annual evaluation for confirmed large (giant) coronary artery aneurysm, multiple or complex aneurysms or coronary
artery obstruction confirmed by angiography
Patients with new onset arrhythmias (patient can be symptomatic or asymptomatic)
This guideline applies to patients with suspected or established CAD
●● Patients with sustained (lasting more than 30 seconds) or non-sustained (more than 3 beats but terminating within
30 seconds) ventricular tachycardia; OR
●● Patients with atrial fibrillation or flutter and high or moderate risk of CAD (SCORE); OR
●● Patients with atrial fibrillation or flutter and established CAD; OR
●● Patients who have frequent premature ventricular contractions (PVC) defined as more than thirty (30) PVCs per
hour on ambulatory EKG (Holter) monitoring
○○ It is not clinically indicated to perform MPI for evaluation of infrequent premature atrial or ventricular
depolarizations
Patients with new onset congestive heart failure or recently recognized left ventricular systolic
dysfunction (patient can be symptomatic or asymptomatic)
For patients in this category whose CAD risk (SCORE) is high, cardiac catheterization may be more appropriate than non-
invasive evaluation
●● Provided that new or worsening CAD has not been excluded as the cause of LV dysfunction/ CHF by any of the
following tests: MPI, stress echo, cardiac PET, coronary CTA or cardiac catheterization
Patients with abnormal exercise treadmill test (performed without imaging)

●● Abnormal findings on an exercise treadmill test include (chest pain, ST segment change, abnormal BP response or
complex ventricular arrhythmias)
Patients who have undergone recent (within the past 60 days) stress echocardiography
●● When the stress echocardiogram is technically suboptimal, technically limited, inconclusive, indeterminate, or
equivocal, such that myocardial ischemia cannot be adequately excluded
○○ It is not appropriate to perform MPI on patients who have had a recent normal or abnormal stress
echocardiogram
○○ A stress echocardiogram is deemed to be abnormal when there are echocardiographic abnormalities.
Electrocardiographic abnormalities without echocardiographic evidence of ischemia are considered to be
normal studies
Patients with abnormal findings on cardiac CT / coronary CTA

Symptomatic Patients:
●● With coronary artery calcium score > 400 Agatston units; OR
●● Intermediate severity coronary stenosis on coronary CTA
Note: If symptoms are typical of myocardial ischemia cardiac catheterization may be more appropriate than MPI
Asymptomatic patients who have not had MPI, stress echo, cardiac PET or cardiac catheterization within the
preceding three (3) years:
●● Intermediate severity coronary stenosis coronary CTA
Patients with abnormal findings on cardiac catheterization

●● To determine flow limiting significance of intermediate coronary stenosis
Myocardial viability evaluation
MPI may be used to evaluate myocardial viability in patients who
●● Have established coronary artery disease; AND
●● Have left ventricular systolic dysfunction (Left Ventricular Ejection Fraction <55%); AND
●● Are candidates for revascularization
Note: Pharmacologic stress echocardiography with a drug such as dobutamine that increases myocardial contractility is
the preferred protocol
Pre-operative cardiac evaluation of patients undergoing non-cardiac surgery

This guideline applies to patients undergoing non-emergency surgery
It is assumed that those who require emergency surgery will undergo inpatient pre-operative evaluation
●● Patients with active cardiac conditions such as unstable coronary syndromes (unstable angina), decompensated
heart failure (NYHA function of class IV, worsening or new onset heart failure), significant arrhythmias (third degree
AV block Mobitz II AV block, uncontrolled supraventricular arrhythmia, symptomatic ventricular arrhythmias,
ventricular tachycardia), symptomatic bradycardia or severe stenotic valvular lesions. It is recommended that these
conditions be evaluated and managed per ACC/AHA guidelines prior to considering elective surgery. That evaluation
may include MPI
Low-risk surgery (endoscopic procedures, superficial procedures, cataract surgery, breast surgery, ambulatory surgery)
●● Provided that there are no active cardiac conditions (as outlined above), MPI prior to low-risk surgery is considered
not medically necessary
Intermediate risk surgery (including but not limited to intraperitoneal and intrathoracic surgery, carotid endarterectomy,
head and neck surgery, orthopedic surgery, prostate surgery, gastric bypass surgery) or High-risk surgery (including but not
limited to aortic and other major vascular surgery, peripheral vascular surgery) when
●● The patient has not had a normal coronary angiogram, SE, MPI, CCTA, Cardiac PET perfusion study or
revascularization procedure within the previous one (1) year; AND
●● At least one of the following applies:
○○ Patient has established CAD (prior MI, prior PTCA, stent, or CABG) or presumed CAD (Q waves on EKG,
abnormal MPI, SE or cardiac PET); OR
○○ Patient has compensated heart failure or prior history of heart failure (CHF); OR
○○ Patient has diabetes mellitus; OR
○○ Patient has chronic renal insufficiency or renal failure; OR
○○ Patient has a history of cerebrovascular disease (TIA, CVA or documented carotid stenosis requiring carotid
endarterectomy); OR
○○ Patient is unable to walk on a treadmill for reasons other than obesity
Abnormal EKG findings

Some patients have resting EKG findings which would render the interpretation of an exercise EKG test difficult or impossible.
In these situations patients who, in the absence of the EKG abnormality, would not meet approval criteria for MPI, may be
approved for MPI because exercise EKG testing without imaging would provide little clinically useful data. Patients with the
following resting EKG abnormalities are included this category:
●● Left bundle branch block; OR
●● Ventricular paced rhythm; OR
●● Left ventricular hypertrophy with repolarization abnormality; OR
●● Digoxin effect; OR
●● 1 mm ST depression or more on a recent EKG (within the past 30 days); OR
●● Pre-excitation syndromes (E.G. WPW syndrome)
Unable to walk on a treadmill for reasons other than obesity
Nuclear Cardiology: Cardiac Blood Pool Imaging
Blood Pool Imaging includes MUGA (Multi-Gated
Acquisition) & First Pass Radionuclide Ventriculography
CPT Codes
78472 �� Gated equilibrium; planar, single study, wall motion plus ejection fraction
78473 �� Gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction
78481 �� First pass technique; single study, wall motion study plus ejection fraction
78483 �� First pass technique; multiple studies, wall motion study plus ejection fraction
78494 �� Gated equilibrium: SPECT, at rest, wall motion study plus ejection fraction
78496 �� This code is an add-on code to be used in conjunction with 78472. As such, this code does not require
separate review.

●● Technetium-99m
●● Primarily used to evaluate global and regional ventricular function and to determine ejection fraction(s)
●● May be used in the evaluation of intracardiac shunting or diastolic function
●● First-pass studies display initial transit of the radiotracer bolus passing through the cardiopulmonary and central
systemic circulations. Right and/or left ventricular function may be evaluated.
●● Equilibrium studies display gated data (MUGA) which is acquired over many cardiac cycles, using a blood pool
radiotracer. Both right and left ventricles may be evaluated.
●● First pass studies should be acquired on a high count-rate camera in order that images have sufficient temporal
resolution. High count-rate cameras are not required for MUGA.
●● Studies may be performed at rest and/or during exercise.
●● MUGA studies are technically more difficult in patients with irregular heart rhythms. Imaging times may have to be
prolonged to acquire adequate data.
●● Selection of the optimal diagnostic imaging for cardiac evaluation should be made within the context of other
available studies (which include transthoracic echocardiography, transesophageal echocardiography, stress
myocardial perfusion imaging, stress echocardiography, cardiac MRI, cardiac CT, cardiac PET imaging and invasive
cardiac/coronary angiography), so that the resulting information facilitates patient management decisions and does
not merely add a new layer of testing.
●● Some disease states and medications interfere with red blood cell labeling. These should be taken into account
when selecting the optimal imaging modality.
●● In interpretation of this document, the term “clinically stable” is taken to mean that the patient has no new or
worsening cardiac symptoms and there are no changes on cardiovascular examination.
Cardiac Blood Pool Imaging | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 12
Evaluation of left ventricular function
Note: It is assumed that left ventricular function will be evaluated using a single imaging modality. Thus, if left ventricular
function has been evaluated recently by echocardiography reevaluation using blood pool imaging is not necessary
●● Initial evaluation of known or suspected heart failure; OR
●● Reevaluation of patients with known LV dysfunction (systolic or diastolic) in a patient with a deterioration in clinical status;
OR
●● Evaluation of patients with resting EKG abnormalities (LBBB, RBBB with left anterior or posterior hemiblock, LVH,
RVH, Q waves suggestive of prior infarction); OR
●● Reevaluation of patients with known heart failure (systolic or diastolic) in a patient with a change in clinical status; OR
●● Baseline and serial reevaluation in patients undergoing, planning to undergo or who have undergone therapy with
cardiotoxic agents (examples including but not limited to some chemotherapeutic agents for cancer, Novantrone
[mitoxantrone] for multiple sclerosis); OR
●● Screening study for left ventricular dysfunction every two (2) years in clinically stable and first-degree relatives of
patients with inherited cardiomyopathy; OR
●● Evaluation of suspected restrictive, infiltrative or genetic cardiomyopathy; OR
●● Evaluation of patients with diagnosed or suspected myocarditis; OR
●● Evaluation of LV function in a patient with known cardiomyopathy being considered for cardiac resynchronization
therapy (CRT), implantable defibrillator (AICD) or ventricular assist device (VAD); OR
●● Initial evaluation for cardiac resynchronization therapy (CRT) device optimization following implantation; OR
●● Evaluation of a patient being treated with cardiac resynchronization therapy (CRT) with new or persistent signs or
symptoms of heart failure for device optimization; OR
●● Blood pool imaging is indicated for optimization of device settings in patients with ventricular assist device (VAD); OR
●● When left ventricular dysfunction is suggested by other testing (chest x-ray, elevated BNP) and LV function has not
been evaluated by another modality since that testing was performed; OR
●● Where a clinically significant discrepancy that might influence patient management exists in the evaluation of left
ventricular dysfunction by two other imaging modalities, MUGA/First Pass can be used as an arbiter; OR
●● Pre and post cardiac transplantation
Evaluation of right ventricular function

●● In patients suspected of having right ventricular dysfunction based on history and/or physical examination; OR
●● Reevaluation of patients with established right ventricular dysfunction in patients with a change in clinical status; OR
●● Evaluation of right ventricular function in patients with pulmonary hypertension; OR
●● Evaluation of right ventricular function in patients with diagnoses known to cause right ventricular dysfunction
including but not limited to coronary artery disease, valvular heart disease, left ventricular dysfunction, congenital
heart disease, morbid obesity, sleep apnea syndrome, advanced lung disease, pulmonary thromboembolic disease,
and right ventricular dysplasia; OR
●● Evaluation of right ventricular function in patients with myocardial infarction where right ventricular involvement is
suspected; OR
●● Evaluation of right ventricular function in patients who are being evaluated for or have undergone cardiac or lung
transplantation
Coronary artery disease (CAD) (applies to patients with established coronary artery disease)
●● Recent (less than 3 weeks) acute coronary syndrome (myocardial infarction or unstable angina) for initial
assessment of LV function
○○ This study is usually done prior to discharge
○○ Not required if left ventricular function has been assessed using another imaging modality; OR
●● Prior acute coronary syndrome (myocardial infarction or unstable angina) for reevaluation of ventricular function
during recovery phase (up to six [6] months following acute coronary syndrome); OR
after the recovery phase (more than six [6] months) in patients who develop new signs or symptoms suggestive of
heart failure; OR
●● Prior myocardial infarction for reevaluation of LV function in patients being considered for AICD or cardiac
resynchronization therapy (CRT)
Congenital heart disease

●● For detection and localization of shunts (ventricular septal defect [VSD], atrial septal defect [ASD], patent ductus
arteriosus [PDA], anomalous pulmonary venous drainage)
○○ Echocardiography is generally considered to be a preferable imaging modality in this clinical situation
●● For evaluation of RV and/or LV function in a patient with established complex congenital heart disease
Valvular heart disease

●● Established valvular heart disease in patients with new or worsening signs or symptoms
○○ In patients with suspected valvular heart disease echocardiography is the appropriate initial imaging modality; OR
●● Patients with severe asymptomatic aortic regurgitation to assist in optimal timing of aortic valve replacement
○○ Rest and stress studies are appropriate in this clinical situation
Nuclear Cardiology
Infarct Imaging
CPT Codes
78466 �� Planar, infarct avid; qualitative or quantitative
78468 �� Planar, infarct avid; with ejection fraction by first pass technique
78469 �� SPECT, infarct avid; with or without quantification
Radiopharmaceuticals
●● Technetium-99m Pyrophosphate
●● Infarct imaging is typically optimal at 48-72 hours post-event
●● False positive findings have been attributed to the following conditions:
○○ Amyloidosis
○○ Cardiac valvular and pericardial calcification
○○ Cardiomyopathy
○○ Doxorubicin (Adriamycin) Treatment
○○ Myocarditis and Pericarditis
○○ Prior myocardial infarction, that remains persistently positive
○○ Radiation Therapy
○○ Ventricular aneurysm
●● Selection of the optimal diagnostic imaging for cardiac evaluation should be made within the context of other
available studies (which include treadmill stress test, stress myocardial perfusion imaging, stress echocardiography,
cardiac MRI, cardiac PET imaging and invasive cardiac/coronary angiography), so that the resulting information
facilitates patient management decisions and does not merely add a new layer of testing.

Suspected acute myocardial infarction, which likely occurred within the last 7 days
●● Including interrogation of the following:
○○ Negative (past expected peak) cardiac enzymes
○○ Abnormal baseline ECG, due to prior myocardial infarction
○○ Left bundle branch block
Differentiation of subendocardial (non-Q-wave) infarction versus ischemia
Post-cardioversion
Following significant chest trauma or major surgical procedure, with chest pain
Infarct Imaging | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 15
Cardiac Echocardiography
Stress Echocardiography (SE)
CPT Codes
93350 �� Echocardiography, transthoracic during rest and cardiovascular stress test using treadmill, bicycle exercise
and/or pharmacologically induced stress, with interpretation and report
93351 �� Echocardiography, transthoracic during rest and cardiovascular stress test using treadmill, bicycle exercise
and/or pharmacologically induced stress, with interpretation and report; including performance of continuous
electrocardiographic monitoring with physician supervision
93320 �� This code is an add-on code to be used in conjunction with 93350, 93351. As such, this code does not
require separate review
Uses of Stress Echocardiography (SE)

●● The primary use of SE is in the diagnosis or exclusion of obstructive coronary artery disease (CAD).
●● SE is also used for management of established coronary artery disease.
●● SE may be used for assessment of myocardial viability in patients who have had myocardial infarction.
●● SE is occasionally used in the evaluation of valvular heart disease, and for the detection and management of occult
pulmonary hypertension.
●● A recent EKG is strongly recommended, preferably within 7 days of request for stress echocardiogram. The findings
on the resting EKG may help to determine the need for imaging and may also show evidence of ischemia at rest or
interval myocardial infarction.
●● Unlike MPI, stress echocardiography does not expose the patient to ionizing radiation.
●● Age, gender and the character of the chest pain provide useful predictors of CAD, as stratified in Table 1 below.
Table 1*: Pre-Test Probability of Coronary Artery Disease by Age, Gender and Symptoms
Very Low < 5% Intermediate probability 10-90%
Low Probability < 10% High Probability > 90%
*Reference for Table 1: Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA Guidelines for Exercise Testing: Executive
Summary. Circulation. 1997;96:345-354.
Age (yr) Gender Typical/Definite Atypical/Probable Non-Anginal Chest Asymptomatic
Angina Pectoris Angina Pectoris Pain
30-39 Men Intermediate Intermediate Low Very Low
Women Intermediate Very Low Very Low Very Low
Women Intermediate Low Very Low Very Low
Women Intermediate Intermediate Low Very Low
Women High Intermediate Intermediate Low
Stress Echocardiography (SE) | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 16
Myocardial Perfusion Imaging and Stress Echocardiography may provide useful information on Coronary Heart Disease.
Comparison data on Sensitivity and Specificity are provided in Table 2 below. Due to regional variation in technical expertise
and interpretive proficiency, the clinician should use the diagnostic imaging modality that has been proven most accurate in
his/her practices.
Table 2**: Comparison of Non-Invasive Diagnostic Imaging

** Reference for Table 2: Zaret BL, Bellar GA. Clinical Nuclear Cardiology. 3rd Edition. Philadelphia: Elsevier Mosby
Publishers; 2005, page 539
Nuclear Imaging Stress Echo Sensitivity Nuclear Imaging Stress Echo Specificity
Sensitivity (%) (%) Specificity (%) (%)
Exercise (7 studies) 83% 78% 83% 91%
Dobutamine (8 studies) 86% 80% 73% 86%
Adenosine (3 studies) 89% 63% 73% 86%
Dipyridamole (4 83% 68% 88% 89%
studies)
Several clinical indications listed for Stress Echo include standard methods of risk assessment, such as the SCORE
(Systematic Coronary Risk Evaluation) or the Framingham risk score calculation. These risk calculation systems include
consideration of the following factors:
Age Sex
Abnormal Lipid Profile Hypertension
Diabetes Mellitus (always = high risk) Cigarette Smoking
Other coronary risk factors such as family history of premature CAD, coronary artery calcification, C reactive protein levels,
obesity etc. are not included in the standard methods of risk assessment but are thought to contribute to coronary artery
disease risk.
●● Selection of the optimal diagnostic work-up for evaluation or exclusion of coronary artery disease should be made
within the context of available studies (which include treadmill stress test, stress myocardial perfusion imaging,
stress echocardiography, cardiac PET imaging and invasive cardiac/coronary angiography), so that the resulting
●● Occasionally it may be appropriate to do a second non-invasive test for diagnosis or exclusion of CAD when the
initially selected test is technically suboptimal and the diagnosis of CAD cannot be established or excluded.
●● SE may be performed using either physical or pharmacologic stress. If physical stress is used, the choice rests
between treadmill exercise test and bicycle exercise test. While it is possible to acquire images during exercise in
patients undergoing bicycle exercise testing, image quality during treadmill exercise is suboptimal. In this situation,
the “stress” images are actually acquired immediately following peak exercise. Thus, the laboratory must be set up
in a manner that allows imaging to be completed within 45 to 60 seconds after peak exercise.
●● Some patients may not be suitable candidates for SE. Image quality is frequently suboptimal in morbidly obese
patients and in those with advanced lung disease. If image quality at rest is inadequate, the test should be canceled
and consideration given to an alternative imaging modality.
●● For patients who are unable to walk on a treadmill for non-cardiac reasons (orthopedic limitations, claudication,
neurological conditions, advanced lung disease, etc. exercise stress testing is not an option. These patients will
require pharmacological testing with echo or nuclear imaging.
●● It is anticipated that the evaluation of patients with acute chest pain will occur in the emergency room or in an
inpatient setting and stress echo performed in these locations is not included in the AIM preauthorization program.
●● Patients with high-risk of CAD (SCORE) who have not had evaluation of coronary artery disease (MPI, stress echo,
●● Patients with moderate or high risk of CAD (SCORE) who have a high risk occupation that would endanger others
in the event of a myocardial infarction (for example: airline pilot, law-enforcement officer, firefighter, mass transit
●● Patients with diseases/conditions with which coronary artery disease commonly coexists and who have not had
○○ Chronic renal insufficiency; OR
●● Patients who have undergone cardiac transplantation and have had no evaluation for coronary artery disease within
●● Chest pain
●● Atypical symptoms: syncope, shortness of breath (dyspnea), neck, jaw, arm, epigastric or back pain, sweating
(diaphoresis)
●● Other symptoms: palpitation, dizziness, lightheadedness, near syncope, nausea, vomiting, anxiety, weakness,
fatigue, etc.
coexists such as:

Note: If symptoms are typical of myocardial ischemia cardiac catheterization may be more appropriate than SE

three (3) years
transplantation

○○ If symptoms are typical of myocardial ischemia cardiac catheterization may be more appropriate than SE; OR
○○ Stable patients whose revascularization has been incomplete may undergo SE three (3) years following the
●● For evaluation of stable patients who have undergone percutaneous coronary intervention(PCI) more than three (3)
that
Established Kawasaki Disease with Coronary Artery Involvement

●● Every two year evaluation for confirmed small to medium coronary artery aneurysm
○○ It is not appropriate to perform stress echocardiography for evaluation of infrequent premature atrial or
ventricular depolarizations
invasive evaluation

●● Abnormal findings on an exercise treadmill test include (chest pain, ST segment change, abnormal BP response or
Patients who have undergone recent (within the past 60 days) myocardial perfusion imaging
(MPI)
●● When the MPI is technically suboptimal, technically limited, inconclusive, indeterminate, or equivocal, such that
myocardial ischemia cannot be adequately excluded
○○ It is not appropriate to perform SE on patients who have had a recent normal or abnormal MPI
○○ An MPI is deemed to be abnormal when there are abnormalities on the nuclear imaging portion of the test.
Electrocardiographic abnormalities without evidence of ischemia on the nuclear imaging portion of the test are
considered to be normal studies

Note: If symptoms are typical of myocardial ischemia, cardiac catheterization may be more appropriate than stress echo

Myocardial viability evaluation
Stress Echo may be used to evaluate myocardial viability in patients who
●● Have established coronary artery disease; AND
●● Have left ventricular systolic dysfunction (Left Ventricular Ejection Fraction <55%); AND
●● Are candidates for revascularization
Note: Pharmacologic stress echocardiography with a drug such as dobutamine that increases myocardial contractility is
the preferred protocol

This guideline applies to patients undergoing non-emergency surgery
It is assumed that those who require emergency surgery will undergo in-patient pre-operative evaluation
may include Stress Echo
●● Provided that there are no active cardiac conditions (as outlined above) Stress Echo prior to low-risk surgery is
considered not medically necessary
Intermediate risk surgery (including but not limited to intraperitoneal and intrathoracic surgery, carotid endarterectomy, head
and neck surgery, orthopedic surgery, prostate surgery, gastric bypass surgery) or High-risk surgery (including but not limited
to aortic and other major vascular surgery, peripheral vascular surgery) when
endarterectomy); OR
○○ Patient is unable to walk on a treadmill for reasons other than obesity
●● Stress echocardiography may be used in evaluation of asymptomatic patients with any of the following valvular
lesions
○○ Severe aortic stenosis
○○ Severe aortic regurgitation with normal left ventricular size and function
○○ Severe mitral stenosis
○○ Severe mitral regurgitation with normal left ventricular size and function; OR
●● Stress echocardiography may be used in evaluation of symptomatic patients with any of the following valvular
lesions
○○ Aortic stenosis of uncertain degree (due to the presence of co-existent severe left ventricular systolic
dysfunction). Pharmacologic stress echocardiography with a drug such as dobutamine that increases
myocardial contractility is the preferred protocol
○○ Moderate mitral stenosis
○○ Moderate mitral regurgitation
Pulmonary hypertension
●● For evaluation of patients with suspected pulmonary hypertension whose resting echocardiogram fails to confirm
that diagnosis, such that exercise induced pulmonary hypertension needs to be excluded; OR
●● For evaluation of right and/or left ventricular function during exercise in patients with established exercised induced
pulmonary hypertension
Hypertrophic obstructive cardiomyopathy

●● For the evaluation of dynamic changes during exercise in patients with an established diagnosis of hypertrophic
obstructive cardiomyopathy who do not have a resting outflow tract gradient of 50 mm Hg or more
Abnormal EKG findings

Some patients have resting EKG findings which would render the interpretation of an exercise EKG test difficult or impossible.
In these situations patients who, in the absence of the EKG abnormality, would not meet approval criteria for SE, may be
approved for SE because exercise EKG testing without imaging would provide little clinically useful data. Patients with the
following resting EKG abnormalities are included in this category:
●● Left bundle branch block; OR
●● Ventricular paced rhythm; OR
●● Left ventricular hypertrophy with repolarization abnormality; OR
●● Digoxin effect; OR
●● 1 mm ST depression or more on a recent EKG (within the past 30 days); OR
●● Pre-excitation syndromes (e.g. WPW syndrome)
Unable to walk on a treadmill for reasons other than obesity
Transesophageal Echocardiography
(TEE)
CPT Codes
93312 �� TEE real-time with image documentation (2-D) (with or without M-mode recording)
93313 �� Placement of transesophageal probe only
93314 �� Image acquisition, interpretation and report only
93315 �� TEE for congenital cardiac anomalies
93316 �� Placement of transesophageal probe only (congenital cardiac anomalies)
93317 �� Image acquisition, interpretation and report only (congenital cardiac anomalies)
93320 �� This code is an add-on code to be used in conjunction with 93312, 93314, 93315, 93317. As such, this code
does not require separate review

●● Heart, proximal great vessels, pericardium
●● In general, it is assumed that TEE is appropriately used as an adjunct or subsequent test to transthoracic
echocardiography (TTE) when suboptimal TTE images preclude obtaining a diagnostic study.
●● There are some clinical situations for which TEE is a more appropriate initial imaging test than TTE. These
situations are outlined below under Common Diagnostic Indications for TEE.
●● Since TEE requires conscious sedation, it should only be performed at locations where cardiac monitoring and
appropriate equipment for cardiopulmonary resuscitation are readily available.
●● Patients with oropharyngeal or esophageal pathology which contraindicates intubation of the esophagus are not
suitable candidates for TEE.
●● Intraoperative TEE (93318) is beyond the scope of AIMs diagnostic imaging management program and will not be
addressed in this document.

In patients who have had, or are likely to have suboptimal transthoracic imaging
●● When image quality is suboptimal such that the clinical question(s) prompting the TEE has/have not been
adequately answered; OR
●● When it is likely that transthoracic imaging will be suboptimal in the following situations:
○○ Previous transthoracic echocardiograms were of suboptimal quality
○○ In patients with severe abnormalities of thoracic contour (pectus deformities, severe kyphoscoliosis)
○○ In patients who have recently had thoracic surgery where post-operative tenderness or the location of dressings
or incisions would preclude imaging from the usual transthoracic locations
○○ Following severe chest trauma
○○ Following extensive burns to the thorax
○○ In patients with a cardiac diagnosis made by TEE who require reevaluation, the results of which would lead to a
change in therapy (e.g. resolution of an intracardiac thrombus following anticoagulation)
Transesophageal Echocardiography (TEE) | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 23
In patients whose clinical situation suggests that TEE may be preferable to transthoracic
echocardiography
●● In evaluation of suspected acute aortic pathology; OR
●● In evaluation of valvular structure and function to assess suitability for and assist in planning of surgical or catheter
based valvular intervention; OR
●● To diagnose/manage endocarditis with a moderate or high pretest probability (e.g. bacteremia, especially staph
bacteremia or fungemia); OR
●● To diagnose/manage endocarditis involving prosthetic heart valves; OR
●● In evaluation of persistent fever in a patient with an intracardiac device to exclude endocarditis; OR
●● In evaluation of a patient with atrial fibrillation/flutter to facilitate clinical decision-making with regards to
anticoagulation and/or cardioversion and/or ablation
○○ TEE is not required when the decision has been made to anticoagulate the patient and not perform
cardioversion; OR
●● In evaluation of a patient who has undergone surgical correction of complex congenital heart disease for the
exclusion of intracardiac thrombus; OR
●● In evaluation for cardiovascular source of embolic event when no non-cardiac source has been identified
Transesophageal Echocardiography (TEE) | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 24
Resting Transthoracic
Echocardiography (TTE)
CPT Codes
93303 �� Transthoracic echocardiography or congenital cardiac anomalies; complete
93304 �� Transthoracic echocardiography or congenital cardiac anomalies; follow-up or limited study
93306 �� Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording,
when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler
echocardiography
93307 �� Transthoracic echocardiography; complete, without spectral Doppler echocardiography, or color flow Doppler
echocardiography
93308 �� Transthoracic echocardiography; complete, without spectral Doppler echocardiography, or color flow Doppler
echocardiography follow-up or limited study
93321 �� This code is an add-on code to be used in conjunction with 93303, 93304, 93308. As such, this code does
not require separate review
93325 �� This code is an add-on code to be used in conjunction with 93303, 93304, 93308. As such, this code does

●● Heart, proximal great vessels, pericardium
Advantages of transthoracic echocardiography:
●● No risk to the patient
●● Minimal patient discomfort
●● Widely available
●● Extremely portable
Disadvantages of transthoracic echocardiography:

●● Image quality suboptimal in some patients
●● Less sensitive than transesophageal echocardiography in some clinical situations
Ordering Issues:
●● Transthoracic echocardiography should only be acquired on equipment which has the capability to perform Doppler
echocardiography (pulsed-wave and continuous wave with spectral display) and color flow velocity mapping.
●● In interpretation of this document, the term “clinically stable” is taken to mean that the patient has no new or
worsening cardiac symptoms and there are no changes on cardiovascular examination.
Resting Transthoracic Echocardiography (TTE) | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 25
Suspected valvular heart disease
●● Evaluation of cardiac murmurs when the diagnosis of valvular heart disease has not been established
○○ After the diagnosis of valvular heart disease has been established, follow the guidelines for the specific valvular
lesion (eg, established aortic stenosis)
●● Initial evaluation for mitral valve prolapse when signs or symptoms of mitral valve prolapse are present
●● Initial evaluation for bicuspid aortic valve when there is a family history (established diagnosis in a first-degree
relative)
Established native valvular stenosis (does not apply to congenital valvular stenosis)
●● Changing signs or symptoms; OR
●● Reevaluation of clinically stable patients with moderate or severe stenosis annually; OR
●● Reevaluation of clinically stable patients with mild stenosis every three (3) years; OR
●● Assessment of changes in hemodynamic severity and left ventricular function in patients with known aortic stenosis
during pregnancy
Established native valvular regurgitation

●● Changing signs or symptoms; OR
●● Reevaluation of clinically stable patients with moderate or severe regurgitation annually; OR
●● Reevaluation of clinically stable patients with mild regurgitation every three (3) years
Established bicuspid aortic valve

●● Changing signs or symptoms suggesting the development of aortic valve dysfunction; OR
●● Bicuspid aortic valve and dilated aortic root on prior echo (annual echocardiography is indicated); OR
●● Bicuspid aortic valve and normal aortic root on prior echo [echo at three (3) yearly intervals is indicated]
Established mitral valve prolapse

●● Changing signs or symptoms
Prosthetic cardiac valves (mechanical or bioprosthetic) and patients who have undergone valve
repair
This guideline does not apply to valve replacement or repair for correction of congenital heart disease in childhood – see
indication Evaluation of patients with congenital heart disease.
●● Initial post-operative evaluation of valve function (baseline study); OR
●● Signs and/or symptoms suggesting dysfunction of a repaired or replaced valve; OR
●● Annual reevaluation of a patient with a prosthetic or repaired heart valve noted on prior imaging study to have
moderate or severe dysfunction (stenosis or regurgitation); OR
●● Evaluation at three (3) yearly intervals of a patient with a prosthetic or repaired heart valve noted on prior imaging
study to have mild dysfunction (stenosis or regurgitation); OR
●● Annual reevaluation of clinically stable adults (age 19 years or older) who have undergone valve repair or
implantation of a bioprosthetic valve more than seven (7) years previously
○○ This guideline does not apply to patients with a mechanical valve prosthesis; OR
●● Following transcatheter aortic valve implantation/replacement (TAVI or TAVR), TTE is appropriate in clinically stable
patients on one (1) occasion within the first three (3) months, at one (1) year, and annually thereafter.
Evaluation of patients with congenital heart disease
●● Evaluation of patients in whom congenital heart disease is suspected based on signs and symptoms (including murmur,
cyanosis, unexplained arterial desaturation, abnormal arterial pulses) abnormal EKG, abnormal chest x-ray; OR
●● Patients with chromosomal abnormalities or major extra cardiac abnormality associated with a high incidence of
coexisting cardiac abnormality; OR
●● Patients with established congenital heart disease (repaired or unrepaired) in whom there is a change in clinical status; OR
●● Adult patients with a childhood history of congenital heart disease (with or without prior surgical repair) in whom the
original diagnosis is uncertain or when the precise nature of the structural abnormalities or hemodynamics is unclear; OR
●● Annual echocardiography is appropriate in clinically stable patients age six (6) years or older with established
complex congenital heart disease (with or without prior surgical repair) in whom surveillance for ventricular function,
valvular function or pulmonary artery pressure is important in clinical decision-making
○○ This does not include patients with successfully repaired patent ductus arteriosus, small atrial or ventricular
septal defects, bicuspid aortic valve or mitral valve prolapse; OR
●● Echocardiography is appropriate in clinically stable patients age five (5) years or younger with established congenital
heart disease (with or without prior surgical repair) in whom surveillance for ventricular function, AV valvular
regurgitation or pulmonary artery pressure is important in clinical decision-making; OR
●● Initial outpatient post-operative evaluation of patients who have undergone surgical or catheter-based procedures to
correct congenital heart disease (within 60 days of the procedure); OR
●● TTE is appropriate every three (3) years in the follow up of patients who have undergone catheter-based closure of
atrial or ventricular septal defects; OR
●● Non adult patients (less than or equal to 18 years old) who are undergoing staged surgical correction of congenital
heart disease; OR
●● Patients in whom a decision to perform surgical or catheter based repair of congenital heart disease has been made
and in whom echocardiography will be used to assist with procedural planning
Evaluation of ventricular function
Note: It is assumed that left ventricular function will be evaluated using a single imaging modality. Thus, if left ventricular
function has been evaluated recently by blood pool imaging reevaluation using echocardiography is not necessary.
Hypertension
●● Initial evaluation of patients with an established diagnosis of hypertension; OR
●● Annual evaluation of non-adult patients (less than or equal to 18 years old) with an established diagnosis of
hypertension
Heart Failure / Cardiomyopathy / Left Ventricular Dysfunction
●● Initial evaluation of known or suspected heart failure; OR
●● Reevaluation of patients with known heart failure (systolic or diastolic) in a patient with a deterioration in clinical status;
OR
●● Reevaluation of patients with known LV dysfunction (systolic or diastolic) in a patient with a deterioration in clinical status;
OR
●● Reevaluation of clinically stable non-adult (age 18 years or younger) patients with left ventricular systolic dysfunction
(Left Ventricular ejection fraction <60%) at six (6) monthly intervals; OR
●● Screening study every two (2) years in clinically stable first-degree relatives of patients with inherited
cardiomyopathy {see specific indications for hypertrophic obstructive cardiomyopathy (HOCM) below}; OR
●● Evaluation of suspected restrictive, infiltrative or genetic cardiomyopathy; OR
●● Initial evaluation of suspected hypertrophic obstructive cardiomyopathy (HOCM) ; OR
●● Reevaluation of known hypertrophic obstructive cardiomyopathy (HOCM) in a patient with a change in clinical status
to guide or evaluate therapy; OR
●● Annual reevaluation non-adult (age 18 years or younger) first-degree relatives of patients with established
hypertrophic obstructive cardiomyopathy (HOCM); OR
●● Evaluation every five (5) years of adult (age 19 years or older) first-degree relatives of patients with established
hypertrophic obstructive cardiomyopathy (HOCM); OR
●● Annual reevaluation of asymptomatic adult (age 19 years or older) patients with known hypertrophic obstructive
cardiomyopathy (HOCM); OR
●● Reevaluation of asymptomatic non-adult (age 18 years or younger) patients with known hypertrophic obstructive
cardiomyopathy (HOCM) at six (6) monthly intervals
Implantable devices
●● Evaluation of LV function in a patient with known cardiomyopathy being considered for cardiac resynchronization
therapy (CRT), implantable defibrillator (AICD) or ventricular assist device (VAD); OR
●● Initial evaluation for cardiac resynchronization therapy (CRT) device optimization following implantation; OR
●● Evaluation of a patient being treated with cardiac resynchronization therapy (CRT) with new or persistent signs or
symptoms of heart failure for device optimization; OR
●● Echocardiography is indicated for optimization of device settings in patients with ventricular assist device (VAD); OR
●● Echocardiography is indicated for evaluation of signs and/or symptoms suggestive of device related complications in
patients with ventricular assist device (VAD)
Abnormalities on other testing

●● Evaluation of patients with resting EKG abnormalities (LBBB, RBBB with left anterior or posterior hemiblock, LVH,
RVH, Q waves suggestive of prior infarction); OR
●● When left ventricular dysfunction is suggested by other testing (chest imaging, elevated BNP) and LV function has
not been evaluated by another modality since that testing was performed; OR
●● Where a significant discrepancy (more than would be expected for the range of error of the methods) exists in the
evaluation of left ventricular dysfunction by two other imaging modalities, echocardiography can be used as an
arbiter
Other
●● Pre and post cardiac transplant evaluation; OR
●● Evaluation of known or suspected myocarditis; OR
●● Echocardiography to evaluate right ventricular function in patients with disease likely to affect right ventricular
function including but not limited to chronic lung diseases and sleep apnea syndrome; OR
●● Baseline and serial reevaluation in patients undergoing, planning to undergo or who have undergone therapy with
cardiotoxic agents (examples including but not limited to some chemotherapeutic agents for cancer, Novantrone®
(mitoxantrone) for multiple sclerosis
Evaluation of patients with cardiac arrhythmias

●● In patients who have sustained (lasting more than 30 seconds) or nonsustained (more than 3 beats but terminating
within 30 seconds) ventricular tachycardia
●● In patients who have sustained (lasting more than 30 seconds) or non-sustained (more than 3 beats but terminating
within 30 seconds) supraventricular tachycardia (including but not limited to atrial fibrillation, atrial flutter, atrial
tachycardia, AV node reentrant tachycardia, etc.
●● In patients who have frequent premature ventricular contractions (PVC) defined as more than thirty (30) PVCs per
○○ It is not clinically indicated to perform echocardiography for evaluation of infrequent premature atrial or
Evaluation of infective endocarditis (native or prosthetic valves)

●● Patients with suspected endocarditis (positive blood cultures and/or a new murmur on physical examination)
●● Reevaluation of patients with established endocarditis who have any of the following
○○ Virulent organism; OR
○○ Severe hemodynamic lesion; OR
○○ Aortic involvement; OR
○○ Persistent bacteremia; OR
○○ Clinical deterioration
Evaluation of patients with suspected coronary artery disease

●● Chest pain
○○ Resting echocardiography may suggest a cause for the chest pain other than myocardial ischemia (mitral valve
prolapse) and is therefore a reasonable imaging procedure in patients with chest pain
○○ If coronary artery disease is a likely diagnosis and if a resting echocardiogram cannot be performed while the
patient is experiencing the pain, a provocative test (exercise or pharmacological stress test with or without
imaging as appropriate) is preferable
○○ Resting echocardiography has no role in screening for coronary artery disease in asymptomatic patients; OR
●● Echocardiography is appropriate in the evaluation of patients with suspected aberrant or anomalous coronary origins
or coronary artery fistula
Evaluation of patients with known coronary artery disease
●● Recent (< 3 weeks) acute coronary syndrome (myocardial infarction or unstable angina) and hemodynamic
instability or signs or symptoms suggesting a complication of myocardial infarction including but not limited to
acute mitral regurgitation, hypoxemia, abnormal chest x-ray, acute ventricular septal rupture, free wall rupture /
tamponade, shock, right ventricular involvement, heart failure, or thrombus
○○ This study is usually requested on an inpatient; OR
●● Recent (< 3 weeks) acute coronary syndrome (myocardial infarction or unstable angina) for initial assessment of LV
function
○○ This study is usually done prior to discharge
○○ Not required if left ventricular function has been assessed using a different imaging modality; OR
during recovery phase {up to six (6) months following acute coronary syndrome}; OR
after the recovery phase {more than six (6) months} in patients who develop new symptoms or signs suggestive of
heart failure; OR
●● Prior myocardial infarction for reevaluation of LV function in patients being considered for AICD or cardiac
resynchronization therapy (CRT); OR
●● Annual echocardiography is appropriate in non-adult patients (less than or equal to 18 years old) with an established
diagnosis of aberrant or anomalous coronary origins or coronary artery fistula if the findings on echocardiography
will impact clinical decision making; OR
Evaluation of Kawasaki disease

●● Echocardiography is appropriate in the evaluation of patients with suspected Kawasaki disease; OR
●● Echocardiography is appropriate in patients with an established diagnosis of Kawasaki disease at 2–4 weeks and
again at 6-8 weeks following diagnosis whether or not there was coronary artery involvement; OR
●● Echocardiography is appropriate for periodic surveillance up to one year following diagnosis of Kawasaki disease in
patients with persistent fever; OR
●● Echocardiography is appropriate for periodic surveillance up to one year following diagnosis of Kawasaki disease
when previous echocardiograms reveal any of the following:
○○ Coronary abnormalities
○○ Left ventricular dysfunction
○○ Pericardial effusion
○○ Valvular regurgitation (other than trace or trivial regurgitation)
○○ Aortic dilation; OR
●● Annual echocardiography is appropriate in patients with an established diagnosis of Kawasaki disease who have
small or medium sized coronary artery aneurysms; OR
●● Semiannual (every six months) echocardiography is appropriate in patients with an established diagnosis of
Kawasaki disease who have large or giant coronary artery aneurysms or coronary artery obstruction
Evaluation of signs, symptoms or abnormal testing
●● Echocardiography is appropriate in the evaluation of the following newly recognized symptoms {dyspnea,
lightheadedness, syncope, palpitations, reduced functional capacity, orthopnea, paroxysmal nocturnal dyspnea,
transient ischemic attack (TIA) or cerebrovascular attack (CVA)}; OR
●● Echocardiography is appropriate in the evaluation of chest pain not thought to be due to myocardial ischemia or
infarction. If myocardial ischemia or infarction is thought to be the cause, resting outpatient echocardiography is not
appropriate; OR
●● Echocardiography is appropriate in the evaluation of the following newly recognized signs suggesting structural
heart disease (murmur, cyanosis, ankle edema, ascites, elevation of jugular venous pressure, unexplained weight
gain, tachycardia, tachypnea, audible third heart sound, lung crackles suggestive of pulmonary edema); OR
●● Echocardiography is appropriate in the evaluation of patients who are hemodynamically unstable or hypotensive for
unknown reasons; OR
●● Echocardiography is appropriate in further evaluation of abnormal results from other testing which suggests
underlying cardiac disease {abnormal chest imaging suggesting cardiac chamber enlargement, valvular or
congenital heart disease or congestive heart failure, abnormal EKG suggesting chamber hypertrophy, valvular or
congenital heart disease (LBBB, RBBB with anterior or posterior hemiblock, left or right ventricular hypertrophy or
Q waves suggestive of prior infarction) or abnormal laboratory results suggesting congestive heart failure such as
elevated B-type natriuretic peptide (BNP)}
○○ When other cardiac testing raises concerns of underlying coronary artery disease, provocative testing is
recommended over resting echocardiography; OR
●● Echocardiography is appropriate in the evaluation of respiratory failure of unknown cause; OR
●● Echocardiography is appropriate annually in the evaluation of patients with syndromes which place them at
increased risk for the development of acquired myocardial or aortic diseases (for example, Marfan Syndrome,
Ehlers-Danlos Syndrome, Turner Syndrome, etc.); OR
●● Echocardiography is appropriate in the evaluation of suspected acute rheumatic fever
Evaluation of patients with pulmonary embolus

●● In patients with known acute pulmonary embolus, echocardiography may be performed as it is useful in guiding
initial decision making (thrombectomy, thrombolysis)
○○ Echocardiography is not indicated in the initial evaluation of a patient with suspected pulmonary embolism in
order to establish the diagnosis; OR
●● In patients who have had a pulmonary embolus, echocardiography may be performed to evaluate right ventricular
function and pulmonary artery pressure. If right ventricular function and pulmonary artery pressure are normal,
repeated studies are not necessary
Evaluation of patients with pulmonary hypertension

●● Echocardiography is indicated for evaluation of suspected pulmonary hypertension; OR
●● Echocardiography is indicated in follow-up of pulmonary arterial pressures in patients with pulmonary hypertension
to evaluate response to treatment; OR
●● Echocardiography may be performed annually in clinically stable patients with an established diagnosis of
pulmonary hypertension; OR
●● Echocardiography may be performed to evaluate signs or symptoms which may be attributable to worsened
pulmonary hypertension
Evaluation of aortic disease
●● Echocardiography is appropriate on one occasion when ascending aortic aneurysm / dilation or dissection is
suspected based on symptoms of chest pain or shortness of breath or abnormal physical findings suggesting these
diagnoses
○○ Although some providers will use transthoracic echocardiography in evaluation of diseases of the thoracic aorta,
transesophageal echocardiography (TEE) is often preferable in this situation
●● Echocardiography is indicated annually when pathology of the ascending aorta (aneurysm / dilation or dissection)
is suspected because the patient has an established diagnosis of a connective tissue disease or genetic condition
which predisposes to ascending aortic pathology including but not limited to Marfan syndrome, Ehlers-Danlos
syndrome and familial aortic dilation (this guideline does not apply to surveillance of patients with bicuspid aortic
valve – see separate guideline for this condition above)
●● Echocardiography is appropriate for evaluation of the ascending aorta in patients with a suspected connective tissue
disease or genetic condition which predisposes to ascending aortic pathology including but not limited to Marfan
syndrome, Ehlers-Danlos syndrome and familial aortic dilation
●● Annual echocardiography is appropriate in patients with an established diagnosis of ascending aortic aneurysm or
dissection
○○ Annual echocardiographic evaluation is usually sufficient in clinically stable patients but more frequent testing
may be appropriate in some situations (e.g. in longitudinal follow-up of large or enlarging thoracic aneurysms, in
follow-up of recently diagnosed thoracic aneurysms until stability is established)
●● Echocardiography is appropriate in patients with an established diagnosis of ascending aortic aneurysm or
dissection who develop new symptoms or signs of aortic aneurysm or dissection.
Evaluation of pericardial diseases

●● Echocardiography is indicated in the evaluation of suspected pericardial conditions including but not limited to
pericardial effusion, pericardial mass, constrictive pericarditis, effusive-constrictive conditions, patients post cardiac
surgery or suspected pericardial tamponade
●● Echocardiography is indicated in the evaluation of established pericardial conditions including but not limited to
moderate and large pericardial effusion, pericardial mass, constrictive pericarditis, effusive-constrictive conditions,
patients post cardiac surgery or suspected pericardial tamponade
○○ Routine surveillance of known small pericardial effusions with no change in clinical status is not appropriate
Evaluation of cardiac masses or cardiac source of embolus

●● Echocardiography is indicated in the diagnosis or exclusion of a cardiac source of embolus in a patient who has
had or appears to have had a systemic embolic event (although transesophageal echocardiography (TEE) is often
preferable in this situation)
●● Echocardiography is indicated in the pre- and post-treatment evaluation of cardiac masses (tumor or thrombus)
○○ Annual echocardiographic evaluation is usually sufficient in clinically stable patients with cardiac masses
(tumors or thrombus) but more frequent testing may be appropriate in some situations (e.g. in longitudinal
follow-up of enlarging masses or in follow-up of recently diagnosed masses until stability is established)
Cardiac (Structure)
CPT Codes
75572 �� Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including
3-D image post-processing, assessment of cardiac function, and evaluation of venous structures if performed)
75573 �� Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in
the setting of congenital heart disease (including 3-D post-processing, assessment of left ventricular cardiac
function, right ventricular structure and function and evaluation of venous structures, if performed)

●● Heart and great vessels within the thorax
Advantages of Cardiac CT:
○○ Rapidly acquired exams, with excellent anatomic detail afforded by most multi-detector CT scanners with 64 or
more active detector rows
Disadvantages of Cardiac CT include:

●● Potential complications from use of intravascular iodinated contrast administration (see biosafety issues, below)
●● Exposure to ionizing radiation
●● Potential factors that may limit the image quality during acquisition of Cardiac CT such as:
○○ Uncontrolled atrial or ventricular arrhythmias
○○ Inability to image at a desired heart rate, which may occur despite beta blocker administration
○○ Inability of the patient to comply with the requirements of scanning (patient motion during image acquisition,
inability to comply with breath hold requirements, inability to lie supine, claustrophobia)
○○ Because of the radiation exposure issues careful consideration should be given to other imaging modalities in
pregnant women and children
Biosafety Issues:
●● Ordering and imaging providers are responsible for considering safety issues prior to the cardiac CT exam. One
of the most significant considerations is the requirement for intravascular iodinated contrast material, which may
have an adverse effect on patients with a history of documented allergic contrast reactions or atopy, as well as on
individuals with renal impairment, who are at greater risk for contrast-induced nephropathy. In addition, radiation
safety issues including cumulative exposure to ionizing radiation should be considered.
Ordering Issues:
●● This guideline does not apply to coronary CT angiography (CPT 75574).
●● This guideline does not apply to Cardiac CT for quantitation of coronary artery calcification (CPT 75571).
●● Selection of the optimal diagnostic work-up for cardiac evaluation should be made within the context of other
available studies (which include transthoracic and transesophageal echocardiography and cardiac MRI), so that the
resulting information facilitates patient management decisions and does not merely add a new layer of testing.
●● There are uncommon circumstances when both Cardiac CT and Cardiac MRI should be ordered for the same
clinical presentation. The specific rationale must be delineated at the time of request.
●● In general, follow-up Cardiac CT exams should be performed only when there is a clinical change, with new signs or
symptoms, or specific finding(s) requiring imaging surveillance.
CT Cardiac (Structure) | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 33
●● For evaluation of suspected or established congenital heart disease in patients whose echocardiogram is technically
limited or non-diagnostic; OR
●● For further evaluation of patients whose echocardiogram suggests a new diagnosis of complex congenital heart
disease; OR
●● For evaluation of complex congenital heart disease in patients who are less than one year post surgical correction; OR
●● For evaluation of complex congenital heart disease in patients who have new or worsening symptoms and/or a
change in physical examination; OR
●● To assist in surgical planning for patients with complex congenital heart disease; OR
●● For surveillance in asymptomatic patients with complex congenital heart disease who have not had cardiac MRI or
cardiac CT within the preceding year
○○ Cardiac MRI or transesophageal echocardiography may be preferable to cardiac CT in order to avoid radiation
exposure
Cardiomyopathy
●● Evaluation of patients with suspected arrhythmogenic right ventricular dysplasia; OR
●● To assess LV function in patients with suspected or established cardiomyopathy when all other non-invasive imaging
is not feasible or technically suboptimal
○○ Other modalities providing non-invasive evaluation of LV function include transthoracic and transesophageal
echocardiography, blood pool imaging (MUGA or First pass) and cardiac MRI; OR
●● To assess RV function in patients with suspected RV dysfunction when all other non-invasive imaging is not feasible
or technically suboptimal
○○ Other modalities providing non-invasive evaluation of RV function include transthoracic and transesophageal
echocardiography, blood pool imaging (MUGA or First pass) and cardiac MRI

●● Evaluation of suspected dysfunction of native or prosthetic cardiac valves when all other cardiac imaging options are
not feasible or technically suboptimal
○○ Other modalities providing non-invasive evaluation of native or prosthetic valves include transthoracic and
transesophageal echocardiography, and cardiac MRI
●● Evaluation of established dysfunction of native or prosthetic cardiac valves when all other cardiac imaging options
are not feasible or technically suboptimal
○○ Other modalities providing non-invasive evaluation of native or prosthetic valves include transthoracic and
transesophageal echocardiography, and cardiac MRI
Evaluation of patients with established coronary artery disease

●● Non-invasive localization of coronary bypass grafts or potential grafts (including internal mammary artery) and/or
evaluation of retrosternal anatomy in patients undergoing repeat surgical revascularization
Intra-cardiac and para-cardiac masses and tumors

●● In patients with a suspected cardiac or para-cardiac mass (thrombus, tumor, etc.) suggested by transthoracic
echocardiography, transesophageal echocardiography, blood pool imaging or contrast ventriculography who have
not undergone cardiac CT or cardiac MRI within the preceding 60 days; OR
●● In patients with established cardiac or para-cardiac mass (thrombus, tumor, etc.) who are clinically unstable; OR
●● In patients with established cardiac or para-cardiac mass (thrombus, tumor, etc.) who are clinically stable and have
not undergone cardiac CT or cardiac MRI within the preceding year; OR
●● In patients with established cardiac or para-cardiac mass (thrombus, tumor, etc.) who have undergone treatment
(chemotherapy, radiation therapy, thrombolysis, anticoagulation or surgery) within the preceding year and have not
had cardiac CT or cardiac MRI within the preceding 60 days
Cardiac aneurysm and pseudoaneurysm
Evaluation of pericardial conditions (pericardial effusion, constrictive pericarditis, or congenital

pericardial diseases)
●● In patients with suspected pericardial constriction; OR
●● In patients with suspected congenital pericardial disease; OR
●● In patients with suspected pericardial effusion who have undergone echocardiography deemed to be technically
suboptimal in evaluation of the effusion; OR
●● In patients whose echocardiogram shows a complex pericardial effusion (loculated, containing solid material)
Evaluation of cardiac venous anatomy

●● For localization of the pulmonary veins in patients with chronic or paroxysmal atrial fibrillation/flutter who are being
considered for ablation; OR
●● Coronary venous localization prior to implantation of a biventricular pacemaker
Evaluation of the thoracic aorta

●● In patients with suspected thoracic aortic aneurysm / dilation who have not undergone CT or MRI of the thoracic
aorta within the preceding 60 days; OR
●● In patients with confirmed thoracic aortic aneurysm / dilation with new or worsening signs/symptoms; OR
●● For ongoing surveillance of stable patients with confirmed thoracic aortic aneurysm / dilation who have not
undergone surgical repair and have not had imaging of the thoracic aorta within the preceding six months; OR
●● In patients with suspected aortic dissection; OR
●● In patients with confirmed aortic dissection who have new or worsening symptoms; OR
●● In patients with confirmed aortic dissection in whom surgical repair is anticipated (to assist in preoperative planning);
OR
thoracic aorta within the preceding year; OR
●● In patients with confirmed aortic dissection or thoracic aortic aneurysm / dilation who have undergone surgical repair
within the preceding year and have not undergone imaging of the thoracic aorta within the preceding six months; OR
●● In patients who have sustained blunt chest trauma, penetrating aortic trauma or iatrogenic trauma as a result of
aortic instrumentation; OR
that the patient has not undergone cardiac CT or cardiac MRI within the preceding 60 days
Coronary CT Angiography (CCTA) and CT
Derived Fractional Flow Reserve (FFR-CT)
CPT Codes
75574 �� Computed tomographic angiography, heart, coronary arteries and bypass grafts (where present), with
contrast material, including 3-D image post-processing (including evaluation of cardiac structure and
morphology, assessment of cardiac function, and evaluation of venous structures, if performed)
0501T �� Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography
angiography data using computation fluid dynamics physiologic simulation software analysis of functional
data to assess the severity of coronary artery disease; data preparation and transmission, analysis of fluid
dynamics and simulated maximal coronary hyperemia, generation of estimated FFR model, with anatomical
data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report
0502T �� Data preparation and transmission
0503T �� Analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model
0504T �� Anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation
and report
Note: Codes 0501T–0504T are effective January 1, 2018. These codes should be reported if FFR is estimated from CCTA data.
Scope of this Guideline

The guideline addresses the appropriate application of CCTA and FFR-CT in the evaluation and management of outpatients.
It does not address the use of CCTA and FFR-CT in the emergency room or inpatient settings.
Guideline Interpretation
This guideline does not supersede the enrollee’s health plan medical policy specific to CCTA and FFR-CT.
Preamble
CCTA provides direct images of the coronary arteries (anatomical imaging); as such, it differs from more established
noninvasive approaches to evaluation of the coronary arteries. Both myocardial perfusion imaging (MPI) and stress
echocardiography (SE), for example, do not directly image the coronary arteries, but instead evaluate a parameter which is
thought to reflect coronary blood flow to the myocardium and thereby infer the presence (or absence) of coronary stenosis
(physiological imaging). In the case of MPI, myocardial uptake of an isotope is evaluated; whereas, with SE, decreased
myocardial contractile reserve is assumed to be ischemic and therefore indicative of coronary stenosis.
CCTA has been compared to SE and MPI and has been found to be non-inferior, or superior, depending on the study and the
endpoints evaluated. CCTA offers advantages over older approaches including shorter patient throughput times and lower
radiation exposure (in the case of MPI). Furthermore, the negative predictive value of CCTA is very high (93%–100%). CCTA
also has limitations including the need to use iodinated contrast agents (which may limit use in patients with renal impairment)
and the reduction of image quality in morbidly obese patients, those with heavy coronary calcium burdens and those with
coronary stents. Beta blockers are frequently required to slow heart rate, and claustrophobic patients may have difficulty with
scanning protocols.
The ability to measure fractional flow reserve by CT (FFR-CT) has the potential to expand the clinical application of CCTA.
FFR-CT adds a physiological dimension to the CCTA such that coronary stenosis can be visualized anatomically and then
evaluated for flow limiting significance. Thus, the availability of FFR-CT would be expected to assist with decisions regarding
subsequent care including the need for coronary angiography, the likelihood of benefit from revascularization, etc. FFR-CT
cannot be performed as a stand-alone service, but rather is available (if indicated) to patients who have undergone CCTA.
Currently, FFR-CT calculations are performed at a location physically removed from the imaging site following electronic
transmission of the imaging data. Results are usually available within 24 hours, but shorter turnaround times are feasible on
request.
Recent literature comparing CCTA combined with FFR-CT to traditional noninvasive coronary artery disease (CAD) evaluation
has signaled that the former approach is non-inferior in terms of clinical endpoints and may offer advantages in terms of cost
of care and radiation exposure.
Coronary CT Angiography (CCTA) and FFR-CT | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 98
The use of CT Coronary Angiography (CCTA), with or without Fractional Flow Reserve assessed by CT
(FFR-CT), may be covered when accompanied by pre-test considerations as well as supporting clinical
data and prerequisite information based on the following diagnostic indications.
For purposes of this guideline, a patient is considered to be “symptomatic” when one of the following (1–4) applies:
1. Chest pain
●● With intermediate or high pretest probability of CAD; OR
●● With low or very low pretest probability of CAD and high risk of CAD (SCORE)
2. Atypical symptoms: syncope, shortness of breath (dyspnea), neck, jaw, arm, epigastric or back pain, or sweating
(diaphoresis)
●● With moderate or high risk of CAD (SCORE)
3. Other symptoms: palpitation, dizziness, lightheadedness, near syncope, nausea, vomiting, anxiety, weakness,
fatigue, etc.
●● With high risk of CAD (SCORE)
4. Patients with any cardiac symptom who have diseases/conditions with which CAD commonly coexists, such as:
●● Abdominal aortic aneurysm; OR
●● Chronic renal insufficiency or renal failure; OR
●● Diabetes mellitus; OR
●● Established and symptomatic peripheral vascular disease; OR
●● Prior history of cerebrovascular accident (CVA), transient ischemic attack (TIA) or carotid endarterectomy (CEA)
or high grade carotid stenosis (>70%)
Indications where FFR-CT will not be required in conjunction with CCTA
Congenital coronary artery anomalies

●● For evaluation of suspected congenital anomalies of the coronary arteries
Indications where FFR-CT may be appropriate but is not a required capability of the performing
imaging facility
Congestive heart failure/cardiomyopathy/left ventricular dysfunction

●● For exclusion of CAD in patients with left ventricular ejection fraction <55% and low to moderate coronary heart
disease risk (using standard methods of risk assessment, such as the SCORE risk calculation) in whom CAD has
not been excluded as the etiology of the cardiomyopathy
○○ Patients with high coronary heart disease risk should undergo cardiac catheterization
Preoperative evaluation for patients undergoing non-coronary cardiac surgery

●● Evaluation of symptomatic or asymptomatic patients at moderate coronary heart disease risk (using standard
methods of risk assessment, such as the SCORE risk calculation) to avoid an invasive angiogram, where all the
necessary preoperative information can be obtained using cardiac CT
○○ Procedures include open and percutaneous valvular procedures or ascending aortic surgery
Suspected coronary artery disease in patients who have had abnormal exercise EKG test
(performed without imaging) within the past 60 days
●● When both of the following apply
○○ Patient is symptomatic
○○ During testing the patient had exercise-induced chest pain, ST segment change, abnormal BP response or
complex ventricular arrhythmias
Suspected coronary artery disease in patients who have had equivocal MPI or SE within the
past 60 days
○○ The imaging portion of the study is neither clearly normal nor clearly abnormal
Suspected coronary artery disease in patients who have had abnormal MPI or SE within the past
60 days
○○ The imaging portion of the study is abnormal
Indications where FFR-CT may be appropriate and is a required capability of the imaging facility
Suspected coronary artery disease in symptomatic patients who have abnormal resting EKG
●● When resting EKG abnormalities (left bundle branch block, electronically paced ventricular rhythm, left ventricular
hypertrophy with repolarization abnormalities, resting ST segment depression 1 mm or more, digoxin effect or pre-
excitation syndrome) would render an exercise treadmill test (without imaging) uninterpretable
Suspected coronary artery disease in symptomatic patients who have not had recent CAD
evaluation
●● When no CAD imaging evaluation (MPI, cardiac PET, stress echo, CCTA or coronary angiography) has been
performed within the preceding sixty (60) days
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tomography for the evaluation of patients with stable chest pain. Int J Cardiol. 2015;183:173-7.
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evaluation of acute undifferentiated chest discomfort in the emergency department (CAPTURE). Am J Cardiol.
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38. Roifman I, Wijeysundera HC, Austin PC, et al. Comparison of Anatomic and Clinical Outcomes in Patients Undergoing
Alternative Initial Noninvasive Testing Strategies for the Diagnosis of Stable Coronary Artery Disease. J Am Heart Assoc.
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their anatomic course by contrast-enhanced electron beam tomography and three-dimensional reconstruction. Am J
Cardiol. 2001;87(2):193-7.
40. SCOT-HEART Investigators. CT coronary angiography in patients with suspected angina due to coronary heart disease
(SCOT-HEART): an open-label, parallel-group, multicentre trial. Lancet. 2015;385(9985):2383-91.
41. Shreibati JB, Baker LC, Hlatky MA. Association of coronary CT angiography or stress testing with subsequent utilization
and spending among Medicare beneficiaries. JAMA. 2011;306(19):2128-36.
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guiding percutaneous coronary intervention. N Engl J Med. 2009;360(3):213-24.
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Angiography to Guide Management of Patients With Coronary Disease. J Am Coll Cardiol. 2016;67(15):1759-68.
Cardiac Computed Tomography (CT)
for Quantitative Evaluation of Coronary
Calcification
CPT Codes
75571 �� Computed tomography, heart, without contrast material, with quantitative evaluation of coronary artery
calcium

●● Coronary Artery Imaging
Advantages of cardiac CT for quantitative evaluation of coronary artery calcification:
○○ Rapidly acquired exams
○○ Coronary artery calcification has been shown to correlate with the presence of atheromatous coronary artery
disease
Disadvantages of cardiac CT for quantitative evaluation of coronary artery calcification:

○○ Exposure to ionizing radiation
○○ No role in the evaluation of patients with symptoms potentially due to coronary artery disease
○○ Not clear that risk stratification data provided by quantitative evaluation of coronary artery calcification impacts
patient outcomes
Biosafety issues:
●● Ordering and imaging providers are responsible for considering safety issues prior to performing quantitative
evaluation of coronary artery calcification
Ordering issues:
●● Cardiac CT for quantitative evaluation of coronary artery calcification is not covered by most healthcare insurers as
a screening study.
●● This guideline pertains to cardiac CT for quantitative evaluation of coronary artery calcification using either Electron
Beam CT (EBCT) or Multi-Detector CT (MDCT).
●● This guideline does not apply to coronary CT angiography (CPT 75574).
●● This guideline does not apply to cardiac CT for evaluation of cardiac structure and function (CPT 75572-75573).
Quantitative Evaluation of Coronary Artery Calcification

The use of cardiac CT for quantitative evaluation of coronary artery calcification has not been
conclusively shown to impact patient outcomes and is therefore considered to be not medically
necessary in all clinical situations
Cardiac CT for Quantitative Evaluation of Coronary Artery Calcification | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 41
Cardiac
CPT Codes
75557 �� Cardiac MRI for morphology and function, without contrast material
75559 �� Cardiac MRI for morphology and function, without contrast material, with stress imaging
75561 �� Cardiac MRI for morphology and function, without contrast material, followed by contrast material
75563 �� Cardiac MRI for morphology and function, without contrast material, followed by contrast material with stress imaging
75565 �� Add-on code to be used in conjunction with 75557, 75559, 75561, and 75563. As such, this code does not
require separate review.
Coding Considerations
Only one procedure in the series 75557–75563 is appropriately reported per session.
Patient Compatibility Issues:
●● Gating Issues: As with other cardiac imaging modalities, the acquisition of images is frequently gated to the
electrocardiogram. Thus, in patients with irregular heart rhythms, image quality may be suboptimal.
Biosafety Issues:
●● Ordering and imaging providers are responsible for considering biosafety issues prior to MRI examination, to
ensure patient safety. Among the generally recognized contraindications to MRI exam performance are permanent
pacemakers (some newer models are MRI compatible) or implantable cardioverter-defibrillators (ICD), intracranial
aneurysm surgical clips that are not compatible with MR imaging, as well as other devices considered unsafe in
MRI scanners (including certain implanted materials in the patient as well as external equipment, such as portable
oxygen tanks).
●● Contrast utilization is at the discretion of the ordering and imaging providers.
Ordering Issues:

Coronary artery disease
Patients who have had a myocardial infarction
●● To assess viability of the infarcted myocardium utilizing delayed hyperenhancement (contrast studies) when other
studies (myocardial perfusion imaging or stress echocardiography) have yielded equivocal or indeterminate results; OR
●● To assess LV function post myocardial infarction when there is discordant information from other studies or when
other studies are technically suboptimal; OR
●● To assess mitral valve regurgitation post-myocardial infarction when echocardiography is technically suboptimal; OR
●● To assess ventricular septal defects post-myocardial infarction when echocardiography is technically suboptimal; OR
●● To delineate pericardial effusions associated with acute myocardial infarction when echocardiography is technically
suboptimal
Patients with suspected coronary artery disease
●● For evaluation of patients with suspected congenital coronary anomalies
Cardiac MRI | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 42
Myocarditis
●● For the evaluation of patients with suspected myocarditis; OR
●● For follow-up evaluation LV function of patients with an established diagnosis of myocarditis whose transthoracic
echocardiogram is technically suboptimal
Cardiomyopathy
●● To assess LV function in symptomatic patients with suspected or established cardiomyopathy when there is
discordant information from other studies or when other studies are technically suboptimal; OR
●● Annual evaluation for suspected cardiomyopathy in clinically stable patients with an established diagnosis of a
chronic and progressive disease (excluding CAD) which may result in cardiomyopathy when echocardiography fails
to exclude cardiomyopathy. This guideline applies to infiltrative cardiomyopathies (e.g. sarcoidosis; amyloidosis;
hemochromatosis), hypertrophic obstructive cardiomyopathy (HOCM) and non-compaction cardiomyopathy; OR
●● Reevaluation of clinically stable patients with cardiomyopathy at yearly intervals when echocardiography is
technically suboptimal; OR
●● Evaluation of patients with suspected arrhythmogenic right ventricular dysplasia; OR
●● For coronary vein mapping in patients with cardiomyopathy for whom cardiac resynchronization therapy (CRT) is
planned
Cardiac aneurysm or pseudoaneurysm

●● For evaluation of suspected congenital anomalies of the coronary arteries; OR
●● For evaluation of suspected or established congenital heart disease in patients whose echocardiogram is technically
limited or nondiagnostic; OR
●● For further evaluation of patients whose echocardiogram suggests a new diagnosis of complex congenital heart
disease; OR
●● For evaluation of complex congenital heart disease in patients who are less than one year post surgical correction; OR
●● For evaluation of complex congenital heart disease in patients who have new or worsening symptoms and/or a
change in physical examination; OR
●● To assist in surgical planning for patients with complex congenital heart disease; OR
●● For surveillance in asymptomatic patients with complex congenital heart disease who have not had cardiac MRI or
cardiac CT within the preceding year

●● Following inconclusive echocardiography or when echocardiography is not feasible; OR
●● When moderate or severe valvular disease diagnosed using other imaging modalities requires further definition and
that information is likely to affect subsequent management of the patient
○○ To assess valvular lesions and measure regurgitant volume, regurgitant fraction, ejection fraction and ventricular
volumes
○○ To help determine the timing for valvular surgery
Intra-cardiac and para-cardiac masses and tumors

●● In patients with a suspected cardiac or para-cardiac mass (thrombus, tumor, etc.) suggested by transthoracic
echocardiography, transesophageal echocardiography, blood pool imaging or contrast ventriculography who have
not undergone cardiac MRI or cardiac CT within the preceding 60 days; OR
●● In patients with established cardiac or para-cardiac mass (thrombus, tumor, etc.) who are clinically unstable; OR
●● In patients with established cardiac or para-cardiac mass (thrombus, tumor, etc.) who are clinically stable and have
not undergone cardiac MRI or cardiac CT within the preceding year; OR
●● In patients with established cardiac or para-cardiac mass (thrombus, tumor, etc.) who have undergone treatment
(chemotherapy, radiation therapy, thrombolysis, anticoagulation or surgery) within the preceding year and have not
had cardiac MRI or cardiac CT within the preceding 60 days
Evaluation of cardiac venous anatomy
●● For localization of the pulmonary veins in patients with chronic or paroxysmal atrial fibrillation/flutter who are being
considered for ablation; OR
●● Coronary venous localization prior to implantation of a biventricular pacemaker
Evaluation of pericardial conditions (pericardial effusion, constrictive pericarditis, or congenital

pericardial diseases)
●● In patients with suspected pericardial constriction; OR
●● In patients with suspected congenital pericardial disease; OR
●● In patients with suspected pericardial effusion (including hemopericardium) who have undergone echocardiography
deemed to be technically suboptimal in evaluation of the effusion; OR
●● In patients whose echocardiogram shows a complex pericardial effusion (loculated, containing solid material)
Evaluation of the thoracic aorta

●● In patients with suspected thoracic aortic aneurysm / dilation who have not undergone CT or MRI of the thoracic
aorta within the preceding 60 days; OR
●● In patients with confirmed thoracic aortic aneurysm / dilation with new or worsening signs/symptoms; OR
●● For ongoing surveillance of stable patients with confirmed thoracic aortic aneurysm / dilation who have not
undergone imaging of the thoracic aorta within the preceding six months; OR
●● In patients with suspected aortic dissection; OR
●● In patients with confirmed aortic dissection who have new or worsening symptoms; OR
●● In patients with confirmed aortic dissection in whom surgical repair is anticipated (to assist in pre-operative
planning); OR
thoracic aorta within the preceding year; OR
●● In patients with confirmed aortic dissection or thoracic aortic aneurysm / dilation who have undergone surgical repair
within the preceding year and have not undergone imaging of the thoracic aorta within the preceding six months; OR
●● In patients who have sustained blunt chest trauma, penetrating aortic trauma or iatrogenic trauma as a result of
aortic instrumentation; OR
that the patient has not undergone cardiac CT or cardiac MRI within the preceding 60 days
Myocardial Imaging
CPT Codes
78491 �� PET myocardial perfusion, single study
78492 �� PET myocardial perfusion, multiple studies
78459 �� PET myocardial, metabolic evaluation

●● Ammonia (13NH3)
●● Rubidium Chloride (82 RbCl)
●● 2-(18F) FLURO-2DEOXY-D-GLUCOSE (FDG)
●● P
erfusion PET imaging, using ammonia or rubidium isotopes, is used to differentiate areas of myocardium with
normal coronary blood flow from those with abnormal coronary blood flow.
●● Rest and/or pharmacological stress perfusion PET imaging can be performed.
●● W
hen non-invasive imaging is required in morbidly obese patients (BMI > or = 40 kg/m2), with suspected or
established CAD, perfusion PET imaging may be considered as the initial test (because of a higher likelihood of
technically suboptimal image quality on nuclear stress testing and stress echocardiography in this patient subgroup).
●● P
ET perfusion imaging may also be a preferable initial noninvasive test for other patients in whom conventional
nuclear perfusion imaging is likely to be suboptimal including those with breast implants, previous mastectomy,
pleural or pericardial effusion, chest wall deformity and those with suboptimal prior nuclear imaging due to
attenuation artifact.
●● P
erfusion PET myocardial imaging is not appropriate for screening for coronary artery disease in asymptomatic
low-risk patients regardless of age or body habitus. Whenever possible and clinically appropriate, exercise stress
testing should be used in preference to pharmacological testing. However, for patients who are unable to exercise
or who have baseline EKG abnormalities which make pharmacological testing preferable, PET imaging is preferable
to conventional nuclear perfusion imaging or stress echocardiography.
●● M
etabolic evaluation (to determine myocardial viability) is performed using PET flurodeoxyglucose (FDG) imaging.
Metabolic PET imaging has been shown to be useful in identification of patients who are likely to benefit from
revascularization.
●● P
ET metabolic imaging of the myocardium provides clinically useful information only when the myocardium
is deemed to be nonviable using other imaging modalities (conventional nuclear perfusion imaging or
echocardiography) or when such imaging modalities are inconclusive regarding the viability status of the
myocardium.
●● P
erfusion PET imaging and metabolic PET imaging may occasionally be appropriate in the evaluation of myocardial
pathologic processes other than coronary artery disease (e.g. sarcoidosis).
●● Isotopes used in PET imaging require special handling arrangements because of their short half-lives.
●● W
hile rubidium may be produced in a commercially available on-site generator, ammonia requires cyclotron
production.
●● C
ardiac PET perfusion imaging has higher temporal and special resolution than conventional nuclear perfusion
imaging.
●● C
ardiac PET has the ability to quantify regional myocardial blood flow and myocardial flow reserve, and this
information may be useful in determining optimal treatment.
●● P
rognostic information derived from cardiac PET perfusion imaging is enhanced by gated imaging used to provide
LV function evaluation.
Myocardial PET Imaging | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 45
●● Radiation exposure should be considered in selection of the optimal study for evaluation for cardiac disease.
●● S
election of the optimal diagnostic imaging for cardiac evaluation should be made within the context of other
available modalities (which include treadmill stress test, conventional nuclear perfusion imaging, stress
echocardiography, cardiac CT, cardiac MRI and invasive cardiac/coronary angiography), so that the resulting
Note: For the purposes of interpretation of this guideline, the term “conventional nuclear perfusion imaging” refers to imaging
using Thallium or Technetium isotopes.
Common Diagnostic Indications for PET Perfusion Imaging

PET perfusion imaging is appropriate as the initial noninvasive stress imaging test for suspected or established CAD for
patients who have a relative contraindication(s) to conventional nuclear perfusion imaging (Table 1) and/or a contraindication
to exercise stress testing (Table 2) who meet any of the indications for stress testing outlined below.
Table 1. Relative contraindications to conventional nuclear perfusion imaging

Morbid obesity (BMI > or = 40 kg/m2)
Breast implant(s) in situ
Previous suboptimal conventional nuclear perfusion imaging which was suboptimal due to attenuation artifact
Previous conventional nuclear imaging discordant with coronary angiographic findings
Known pericardial or pleural effusion
Prior mastectomy
Chest wall deformity
Table 2. Contraindications to exercise stress testing
1. Resting EKG abnormalities
a. Complete left bundle branch block LBBB
b. Electronically paced ventricular rhythm
c. Resting ST depression > 1mm
d. Left ventricular hypertrophy (LVH) with secondary repolarization abnormalities
e. Digoxin effect
f. Pre-excitation (e.g. Wolfe Parkinson White syndrome)
g. Previous false positive EKG stress test
2. Conditions limiting exercise capacity such that target heart rate (HR) is unlikely to be achieved
a. Orthopedic or neurological impairment
b. Severe COPD
c. Severe heart failure
d. Severe claudication
e. Prior failure to achieve target HR
f. Use of negatively chronotropic medications which cannot be temporarily withheld for testing
3. Severe valvular stenosis
4. Presence of an implanted cardioverter-defibrillator (ICD)
●● P
atients with high-risk of CAD (SCORE) who have not had evaluation of coronary artery disease (MPI, stress echo,
●● P
atients with moderate or high risk of CAD (SCORE) who have a high risk occupation that would endanger others
in the event of a myocardial infarction, for example: airline pilot, law-enforcement officer, firefighter, mass transit
●● P
atients with diseases/conditions with which coronary artery disease commonly coexist and who have not had
●● P
atients who have undergone cardiac transplantation and have had no evaluation for coronary artery disease within
●● Patients in whom a decision has been made to treat with interleukin 2
●● P
atients awaiting solid organ transplantation who have not undergone evaluation for coronary artery disease within
●● Chest pain
●● Atypical symptoms: syncope, shortness of breath (dyspnea), neck, jaw, arm, epigastric or back pain, or sweating
(diaphoresis)
●● Other symptoms; palpitation, dizziness, lightheadedness, near syncope, nausea, vomiting, anxiety, weakness,
fatigue, etc.
coexists such as:

Note: If symptoms are typical of myocardial ischemia, cardiac catheterization may be more appropriate than perfusion PET
imaging.

three (3) years
transplantation

○○ If symptoms are typical of myocardial ischemia, cardiac catheterization may be more appropriate than MPI; OR
○○ Stable patients whose revascularization has been incomplete may undergo MPI three (3) years following the
●● For evaluation of stable patients who have undergone percutaneous coronary intervention (PCI) more than three (3)
that:
Established Kawasaki disease with coronary artery involvement

●● Every two-year evaluation for confirmed small to medium coronary artery aneurysm
This guideline applies to patients with suspected or established CAD.
○○ It is not clinically indicated to perform perfusion PET imaging for evaluation of infrequent premature atrial or
invasive evaluation.

●● A
bnormal findings on an exercise treadmill test include (chest pain, ST segment change, abnormal BP response or

Note: If symptoms are typical of myocardial ischemia, cardiac catheterization may be more appropriate than MPI.

This guideline applies to patients undergoing non-emergency surgery.
It is assumed that those who require emergency surgery will undergo inpatient preoperative evaluation.
may include MPI.
●● Provided that there are no active cardiac conditions (as outlined above), MPI prior to low-risk surgery is considered
not medically necessary.
Intermediate-risk surgery (including but not limited to intraperitoneal and intrathoracic surgery, carotid endarterectomy,
head and neck surgery, orthopedic surgery, prostate surgery, gastric bypass surgery) or High-risk surgery (including but
not limited to aortic and other major vascular surgery, peripheral vascular surgery) when
endarterectomy)
PET perfusion imaging is appropriate in follow up to other noninvasive stress imaging tests in
the following situations:
Patients who have undergone recent (within the past 60 days) stress echocardiography or conventional nuclear
perfusion imaging
●● When the initial test is technically suboptimal, technically limited, inconclusive, indeterminate, or equivocal, such that
myocardial ischemia cannot be adequately excluded
○○ It is not appropriate to perform PET perfusion imaging on patients who have had a recent normal or abnormal
stress echocardiogram or conventional nuclear perfusion imaging test.
○○ An initial stress imaging test is deemed to be abnormal when there are echocardiographic or perfusion
abnormalities. Studies with electrocardiographic abnormalities without echocardiographic or perfusion evidence
of ischemia are considered to be normal studies.
PET perfusion imaging – sarcoidosis:

PET perfusion imaging is appropriate in the evaluation of patients with suspected or established cardiac
sarcoidosis when performed in conjunction with metabolic PET imaging
Common Diagnostic Indications for Metabolic PET Imaging
Metabolic PET imaging for evaluation of myocardial viability – when all four of the following
conditions are met:
●● The patient has established coronary artery disease; AND
●● Left ventricular systolic dysfunction; AND
●● Viability status is not defined by other testing; AND
●● Revascularization is being considered
Metabolic PET imaging for evaluation of non-coronary cardiac diseases

●● Metabolic PET imaging (with or without perfusion imaging) may be used in the diagnosis or management of cardiac
sarcoidosis
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Abdomen
CPT Codes
74150 �� CT abdomen; without contrast
74160 �� CT abdomen; with contrast
74170 �� CT abdomen; without contrast, followed by re-imaging with contrast

●● Diaphragmatic dome to iliac crests
●● 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.
●● Verification of cystic lesions in abdominal viscera can usually be well-documented with ultrasound.
●● Ultrasound studies may be limited in obese patients.

This section contains general abdominal, hepatobiliary, pancreatic, gastrointestinal, genitourinary, splenic, and vascular
indications.
General Abdominal
Abdominal pain
●● Unexplained by any of the following:
○○ Clinical findings; OR
○○ Physical examination; OR
○○ Other imaging studies
Abnormalities detected on other imaging studies which require additional clarification to direct
treatment
Ascites
●● For diagnosis and surveillance, following non-diagnostic ultrasound
Congenital anomaly
Diffuse, unexplained lower extremity edema

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

Hematoma / hemorrhage
CT Abdomen | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 119
Hernia
●● For diagnosis of a hernia with suspected complications or presurgical planning including, but not limited to the
following types of hernia:
○○ Femoral
○○ Internal
○○ Inguinal
○○ Spigelian (through semilunar line, lateral to rectus abdominis muscle)
○○ Ventral
Incisional hernia
●● For diagnosis of a hernia with suspected complications or presurgical planning
Note: Ultrasound should be considered as the initial imaging modality
Infectious or inflammatory process

●● Including but not limited to the following:
○○ Abscess
○○ Diffuse inflammation / phlegmon
○○ Fistula
Iron deposition/overload in hemochromatosis

●● When MRI is contraindicated; AND
●● To exclude iron overload in patients with hemochromatosis who are candidates for chelation therapy or phlebotomy
Lymphadenopathy
●● For initial detection and follow-up
Palpable abdominal mass

Note: For pediatric patients, ultrasound should be considered as the initial imaging modality

Retroperitoneal abnormality – fibrosis, inflammation and neoplasm
Trauma
●● Following significant blunt or penetrating injury to the abdomen
Diagnosis, management or surveillance of known or suspected malignancy
metastatic disease
●● Colon cancer
■■ T4 tumor
T2
short time interval (six months or less), after initial evaluation for other causes
Hepatobiliary
Acute cholecystitis
●● Evaluation of suspected complications of acute cholecystitis when abdominal ultrasound is non-diagnostic
Examples include perforation, abscess, gangrenous or hemorrhagic cholecystitis, gallstone ileus and Mirizzi’s syndrome
Cirrhosis for evaluation of hepatocellular carcinoma
Elevated liver transaminases
●● Including alanine transaminase (ALT) and aspartate transaminase (AST)
●● Following an abnormal or inconclusive abdominal ultrasound
●● In patients on medications known to cause liver transaminase elevation, such as statins for hyperlipidemia,
acetaminophen, non-steroidal anti-inflammatory drugs, Dilantin®, protease inhibitors and sulfonamides. These
medications should be stopped whenever possible and liver chemistries repeated before performing advanced imaging
●● 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 lesions

Indeterminate lesions (not biopsied and not fully characterized by prior imaging)
●● Initial evaluation of an indeterminate lesion identified on prior imaging when any of the following are present:
○○ Size > 1 cm in diameter
○○ Multiple lesions
○○ Known cirrhosis
○○ Chronic hepatitis
○○ Sclerosing cholangitis
○○ Primary biliary cirrhosis
○○ Hemochromatosis
○○ Hemosiderosis
○○ Oral contraceptive use
○○ Anabolic steroid use
●● Follow up or surveillance at 3 to 6 months when any of the above risk factors are present, or when the lesion is
enhancing, poorly defined or increasing in size
Benign lesions (biopsy-proven or fully characterized by imaging)
●● Follow up when symptoms suggest a change in size or character
●● Periodic evaluation of known adenoma
Hepatomegaly
●● For clinically suspected or worsening hepatic enlargement
Jaundice
●● With abnormal liver function tests (transaminases) and unexplained icterus, following an abdominal ultrasound
●● CT imaging used to evaluate for diffuse or multifocal parenchymal liver disease as well as biliary obstruction
Pancreatic
Acute pancreatitis
●● With suspected complications including:
○○ Pancreatic necrosis
○○ Abscess
○○ Pseudocyst
○○ Peri-pancreatic fluid
Note: Patients with mild acute, uncomplicated pancreatitis usually do not require cross-sectional imaging, aside from
ultrasound identification of gallstones and/or biliary ductal calculi, as a potential cause
Known pancreatic mass
●● CT pancreas with pancreatic protocol is indicated
Note: MRI pancreas may be performed as an alternative study
Pancreatic pseudocyst
●● With prior history of pancreatitis or pancreatic trauma
Note: For a patient with a known pancreatic pseudocyst requiring follow-up surveillance, ultrasound should be considered
as the initial imaging modality
Gastrointestinal
Appendiceal or peri-appendiceal mass – unexplained on physical exam and other imaging
studies
Appendicitis
Diagnosis
●● Male patients or non-pregnant female patients
●● Following a non-diagnostic ultrasound in pregnant patients when MRI is contraindicated or unavailable
Management
●● Failure of non-operative therapy
●● Complications of appendicitis
Bowel obstruction
Diverticulitis
Enteritis and/or colitis
Inflammatory bowel disease (IBD)

Diagnosis
●● Evaluation of suspected Crohn’s disease following non-diagnostic upper and lower endoscopy
Management
●● Evaluation of new or worsening symptoms to confirm exacerbation or evaluate for complications, including stricture,
abscess or fistula
Ischemic bowel
Genitourinary
Acute pyelonephritis
●● In a patient with any of the following:
○○ Diabetes; OR
○○ History of renal calculi; OR
○○ History of renal surgery; OR
○○ Absence of response after 72 hours of therapy
Adrenal lesion
●● Following a non-diagnostic ultrasound in neonate patients
●● For characterization of an indeterminate adrenal mass identified on prior imaging – such as a benign adenoma
versus a metastatic deposit; OR
●● When there is biochemical evidence of an adrenal endocrine abnormality
Hematuria
Hydronephrosis
●● Evaluation for possible obstructing ureteral or urinary bladder lesion
●● When ultrasound is non-diagnostic or abnormal and unexplained, requiring further evaluation
Renal cyst
●● Following a non-diagnostic ultrasound
Note: A simple renal cyst which has benign characteristics on ultrasound may not require advanced imaging or surveillance
Renal lesion
●● Characterization of indeterminate lesion, particularly a mass, demonstrated on prior imaging
Renal neoplasm
●● For diagnosis, initial staging and pre-operative evaluation, re-staging and treatment monitoring
Undescended testicle (cryptorchidism)
Urinary tract calculi

Initial evaluation of suspected renal or ureteral calculi in patients with no history of nephrolithiasis
Suspected recurrence
●● History of radiolucent calculus
●● History of radiopaque calculus and atypical presentation
●● History of radiopaque calculus and typical presentation, following non-diagnostic ultrasound
Management and follow up
●● In patients planning to undergo treatment with percutaneous nephrolithotomy, ureteroscopy or shock wave
lithotripsy, when CT has not been performed within the preceding 30 days
●● Symptomatic patients with known radiolucent calculi
●● Symptomatic patients with radiopaque calculi, following non-diagnostic KUB or ultrasound
●● Asymptomatic patients with known radiolucent calculi, persistent hydronephrosis on ultrasound, and treatment
involving either shock wave lithotripsy or ureteroscopic stone extraction
Pregnancy
●● Diagnosis or management, following non-diagnostic ultrasound or KUB
Worsening renal function

Note: Non-contrast evaluation is indicated in individuals with worsening renal function, as contrast administration may
potentially worsen renal function in these patients.
Splenic
Indeterminate splenic lesion on prior imaging, such as ultrasound
Note: Splenic hemangioma is the most common benign splenic tumor and may be followed with splenic ultrasound.
Splenic hematoma
●● Parenchymal
●● Subcapsular
●● Peri-splenic
Splenomegaly
●● For clinically suspected or worsening splenic enlargement
Vascular
Aneurysm of the abdominal aorta

●● Following inconclusive ultrasound in patients with suspected aneurysm/dilation of the abdominal aorta
●● Follow-up imaging of patients with an established aneurysm/dilation when most recent ultrasound imaging is
inconclusive
●● Pre-operative assessment or prior to percutaneous endovascular stent graft placement
●● Annual post-operative surveillance of stable patients who have undergone open surgical repair when most recent
ultrasound imaging is inconclusive
●● Post-operative surveillance of stable patients who have been treated with endovascular stent graft
●● Suspected complication of an aneurysm/dilation, such as aneurysmal rupture or infection—requiring urgent imaging
●● Prior to transcatheter aortic valve implantation/replacement (TAVI or TAVR), unless advanced imaging has been
performed for this indication within the preceding 60 days
Aortic dissection
●● May evaluate with either CT or CTA
○○ Usually results from subdiaphragmatic extension of a thoracic aortic dissection
Thrombosis in the systemic and portal venous circulations

●● Following initial evaluation with inconclusive Doppler ultrasound
References
1. American Association for the Study of Liver Diseases. Choosing Wisely: CT or MRI to monitor benign focal lesions.
ABIM Foundation. June 15, 2014. Available at http://www.choosingwisely.org/clinician-lists/american-association-study-
liver-disease-ct-or-mri-to-monitor-benign-focal-lesions/ Accessed on June 28, 2017.
2. American College of Emergency Physicians. Choosing Wisely: CT of abdomen and pelvis for ED patients under 50.
ABIM Foundation. October 27, 2014. Available at http://www.choosingwisely.org/clinician-lists/acep-ct-of-abdomen-and-
pelvis-for-ed-patients-under-50/ Accessed on Accessed on April 27, 2017.
Philadelphia, PA: ABIM Foundation; December 4, 2013. Available at http://www.choosingwisely.org/clinician-lists/
american-society-hematology-limit-surveillance-ct-scans-following-treatment-for-lymphoma/ Accessed on April 27, 2017.
4. American Urological Association. Choosing Wisely: Pelvis CT scans for low-risk, localized prostate cancer. Philadelphia,
PA: ABIM Foundation; June 11, 2015. Available at http://www.choosingwisely.org/clinician-lists/american-urological-
association-pelvis-ct-scans-for-low-risk-localized-prostate-cancer/. Accessed on April 27, 2017.
5. Angelucci E, Barosi G, Camaschella C, et al. Italian Society of Hematology practice guidelines for the management of
iron overload in thalassemia major and related disorders. Haematologica. 2008;93(5):741-752.
6. Arguedas MR, Chen VK, Eloubeidi MA, et al. Screening for hepatocellular carcinoma in patients with hepatitis C
cirrhosis: a cost-utility analysis. Am J Gastroenterol. 2003;98(3):679-690.
7. Assy N, Nasser G, Djibre A, et al. Characteristics of common solid liver lesions and recommendations for diagnostic
workup. World J Gastroenterol. 2009;15(26):3217-3227.
8. 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.
9. Benter T, Klühs L, Teichgräber U. Sonography of the spleen. J Ultrasound Med. 2011 Sep;30(9):1281-93.
10. Berland LL, Silverman SG, Gore RM, et al. Managing Incidental Findings on Abdominal CT: White Paper of the ACR
Incidental Findings Committee. J Am Coll Radiol. 2010;7(10):754-773.
11. Brancatelli G, Federle MP, Grazioli L, et al. Focal nodular hyperplasia: CT findings with emphasis on multiphasic helical
CT in 78 patients. Radiology. 2001;219(1):61-68.
12. 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.
13. Chou R, Cuevas C, Fu R, et al. Imaging Techniques for the Diagnosis and Staging of Hepatocellular Carcinoma. Agency
for Healthcare Research and Quality (US). Comparative Effectiveness Review Number 143. October 2014. Available at
http://www.effectivehealthcare.ahrq.gov/ehc/products/479/1990/liver-cancer-final-141022.pdf Accessed on September
28, 2016.
14. Chung DJ, Huh KC, Choi WJ, Kim JK. CT colonography using 16-MDCT in the evaluation of colorectal cancer. AJR Am
J Roentgenol. 2005;184(1):98-103.
15. Cristiano A, Dietrich A, Spina JC, et al. Focal nodular hyperplasia and hepatic adenoma: current diagnosis and
management. Updates Surg. 2014;66(1): 9-21.
16. Dhar M, Denstedt JD. Imaging in diagnosis, treatment, and follow-up of stone patients. Adv Chronic Kidney Dis. 2009
Jan;16(1):39-47.
17. Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for diagnosis of appendicitis in children and adults? A meta-
analysis. Radiology. 2006 Oct;241(1):83-94.
18. Frauenfelder T, Wildermuth S, Marincel B, Boehm T. Nontraumatic emergent abdominal vascular conditions: advantages
of multi-detector row CT and three-dimensional imaging. Radiographics. 2004;24(2):481-496.
19. Gore RM, Newmark GM, Thakrar KH, Mehta UK, Berlin JW. Hepatic incidentalomas. Radiol Clin North Am. 2011
Mar;49(2):291-322
20. Gore RM, Thakrar KH, Newmark GM, Mehta UK, Berlin JW. Gallbladder imaging. Gastroenterol Clin North Am. 2010
Jun;39(2):265-287, ix.
21. Gore RM, Thakrar KH, Wenzke DR, et al. That liver lesion on MDCT in the oncology patient: is it important? Cancer
Imaging. 2012;12:373-384.
22. Grazioli L, Federle MP, Brancatelli G, et al. Hepatic adenomas: imaging and pathologic findings. Radiographics.
2001;21(4):877-892.
23. Halligan S, Altman DG, Taylor SA, et al. CT colonography in the detection of colorectal polyps and cancer: systematic
review, meta-analysis, and proposed minimum data set for study level reporting. Radiology. 2005;237(3):893-904.
24. Ho PJ, Tay L, Lindeman R, Catley L, Bowden DK. Australian guidelines for the assessment of iron overload and iron
chelation in transfusion-dependent thalassaemia major, sickle cell disease and other congenital anaemias. Intern Med J.
2011;41(7):516-524.
26. Jeong YY, Kang HK, Chung TW, et al. Uterine cervical carcinoma after therapy: CT and MR Imaging findings.
Radiographics. 2003;23(4):969-981.
27. Jung SE. Lee JM, Rha SE, et al. CT and MR Imaging of ovarian tumors with emphasis on differential diagnosis.
Radiographics. 2002;22(6):1305–1325.
28. Kim AY, Ha HK. Evaluation of suspected mesenteric ischemia: efficacy of radiologic studies. Radiol Clin North Am.
2003;41(2):327-342.
29. Kim T, Federie MP, Baron RL, et al. Discrimination of small hepatic hemangiomas from hypervascular malignant tumors
smaller than 3 cm with three-phase helical CT. Radiology. 2001;219(3):699-706.
30. Kirkpatrick ID, Greenberg HM. Evaluating the CT diagnosis of clostridium difficile colitis: should CT guide therapy? AJR
Am J Roentgenol. 2001;176(3):635-639
31. Lamba R, Fananapazir G, Corwin MT, et al. Diagnostic imaging of hepatic lesions in adults. Surg Oncol Clin N Am.
2014;23(4):789-820.
32. Lang G, Schmiegel W, Nicolas V, et al. Impact of Small Bowel MRI in Routine Clinical Practice on Staging of Crohn’s
Disease. J Crohns Colitis. 2015;9(9):784-794.
33. Loch T. Prostate cancer diagnostics: innovative imaging in case of multiple negative biopsies. World J Urol.
2011;29(5):607-614.
34. 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.
35. Lucey MR, Terrault N, Ojo L, et al. Long-term management of the successful adult liver transplant: 2012 practice guideline
by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Liver Transpl.
2013;19(1):3-26.
36. Mandeville JA, Gnessin E, Lingeman JE. Imaging evaluation in the patient with renal stone disease. Semin Nephrol. 2011
May;31(3):254-258.
37. Marrero JA, Ahn J, Rajender Reddy K. American College of Gastroenterology clinical guideline: the diagnosis and
management of focal liver lesions. Am J Gastroenterol. 2014;109(9):1328-1347.
38. Matsuki M, Kani H, Tatsugami F, et al. Preoperative assessment of vascular anatomy around the stomach by 3D imaging
using MDCT before laparoscopy-assisted gastrectomy. AJR Am J Roentgenol. 2004;183(1):145-151.
targets: a systematic review. Eur Urol. 2013; 63(1):125-140.
40. Mottet N, Bellmunt J, Bolla M, et al. EAU-ESTRO-SIOG Guidelines on Prostate Cancer. Part 1: Screening, Diagnosis, and
Local Treatment with Curative Intent. Eur Urol. 2016; pii: S0302-2838(16)30470-5.
43. NCCN Imaging Appropriate Use Criteria for Prostate Cancer (Version 2.2017). Available at http://www.nccn.org. ©National
44. Nelson AW, Harvey RC, Parker RA, et al. Repeat prostate biopsy strategies after initial negative biopsy: meta-regression
comparing cancer detection of transperineal, transrectal saturation and MRI guided biopsy. PLoS One. 2013;8(2): e57480.
45. Panes J, Bouzas R, Chaparro M, et al. Systematic review: the use of ultrasonography, computed tomography and magnetic
resonance imaging for the diagnosis, assessment of activity and abdominal complications of Crohn’s disease. Aliment
Pharmacol Ther. 2011;34(2):125-145.
46. Pang EH, Harris AC, Chang SD. Approach to the solitary liver lesion: imaging and when to biopsy. Can Assoc Radiol J.
2016;67(2):130-148.
47. Sandborn WJ. Crohn’s disease evaluation and treatment: clinical decision tool. Gastroenterology. 2014;147(3):702-705.
48. World Gastroenterology Organisation. Practice Guideline - Inflammatory Bowel Disease. August 2015. Available at http://
www.worldgastroenterology.org/UserFiles/file/guidelines/inflammatory-bowel-disease-english-2015.pdf Accessed on
September 28, 2016.
49. Wu LM, Xu JR, Gu HY, et al. Is magnetic resonance imaging a reliable diagnostic tool in the evaluation of active Crohn’s
disease in the small bowel? J Clin Gastroenterol. 2013;47(4):328-338.
Abdomen
CPT Codes
74181 �� MRI of abdomen, without contrast
74182 �� MRI of abdomen, with contrast
74183 �� MRI of abdomen, without contrast, followed by re-imaging with contrast

●● Scan coverage depends on the specific clinical indication for the abdominal MRI. General landmarks extend from
the diaphragmatic dome to the iliac crests
●● Abdominal MRI studies are usually targeted for further evaluation of indeterminate or questionable findings,
identified on more standard imaging exams such as ultrasound and CT.
●● For evaluation of vascular abnormalities such as renal artery stenosis and celiac/superior mesenteric artery stenosis
(in chronic mesenteric ischemia), Doppler ultrasound, MRA or CTA should be considered as the preferred imaging
modalities.
●● The CPT code assignment for an MRI procedure is based on the anatomic area imaged. Requests for multiple MRI
imaging of the same anatomic area to address patient positional changes, additional sequences or equipment are
not allowed. These variations or extra sequences are included within the original imaging request.

treatment
Appendicitis
Diagnosis and management
●● In pregnant patients, following a non-diagnostic ultrasound
Note: This guideline is intended only for pregnant patients
Congenital anomaly
Contraindication to CT (contrast allergy, renal disease, pregnancy)

●● Iodinated contrast risks (i.e., allergy, renal disease)
○○ Patient meets appropriateness criteria for CT, and MRI has been shown to have superior diagnostic accuracy to
non-contrast CT
●● Pregnancy
○○ MRI is a reasonable alternative for the requested indication
Diffuse liver disease

●● Following an inconclusive or abnormal abdominal ultrasound or CT
●● Including the following hepatic disorders:
○○ Cirrhosis
MRI Abdomen | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 128
Focal liver lesions
Indeterminate lesions (not biopsied and not fully characterized by prior imaging)
●● Initial evaluation of an indeterminate lesion identified on prior imaging when any of the following are present:
○○ Size > 1 cm in diameter
○○ Multiple lesions
○○ Known cirrhosis
○○ Sclerosing cholangitis
○○ Primary biliary cirrhosis
○○ Hemochromatosis
○○ Hemosiderosis
○○ Oral contraceptive use
○○ Anabolic steroid use
●● Follow up or surveillance at 3 to 6 months when any of the above risk factors are present, or when the lesion is
enhancing, poorly defined or increasing in size
Benign lesions (biopsy-proven or fully characterized by imaging)
●● Follow up when symptoms suggest a change in size or character
●● Periodic evaluation of known adenoma
Indeterminate abdominal mass

●● For further evaluation and characterization of indeterminate lesions arising in the solid abdominal viscera and
surrounding anatomic structures, including but not limited to the following anatomic sites:
○○ Adrenal – characterization of an adrenal mass, including differentiation of adrenal adenoma from metastasis
○○ Assess vascular invasion or compression by pelvic or renal tumor
○○ Kidney – evaluation of an indeterminate renal mass
○○ Other abdominal and retroperitoneal anatomic structures
○○ Pancreas
○○ Spleen

●● CT is usually the initial imaging modality of choice for infectious and inflammatory conditions
○○ Abscess

Diagnosis
Management
abscess or fistula
Iron deposition/overload in hemochromatosis

●● To exclude iron overload in patients with hemochromatosis who are candidates for chelation therapy or phlebotomy
Lymphadenopathy
●● When abdominal CT is non-diagnostic
●● May be useful for differentiating enlarged lymph nodes from vascular structures (with flow void on MRI), as follow-up
from an unenhanced abdominal CT exam

Management of biopsy-proven malignancy, when MRI is needed to guide treatment in either of the following
scenarios:
●● CT is contraindicated or expected to be suboptimal (due to contrast allergy or anticipated contrast nephrotoxicity)
●● Evidence-based literature has shown MRI to have superior diagnostic accuracy to CT.
metastatic disease
●● Colon cancer
■■ T4 tumor
T2
References
1. American Association for the Study of Liver Diseases. Choosing Wisely: CT or MRI to monitor benign focal lesions.
ABIM Foundation. June 15, 2014. Available at http://www.choosingwisely.org/clinician-lists/american-association-study-
liver-disease-ct-or-mri-to-monitor-benign-focal-lesions/ Accessed on June 28, 2017.
5. Angelucci E, Barosi G, Camaschella C, et al. Italian Society of Hematology practice guidelines for the management of
iron overload in thalassemia major and related disorders. Haematologica. 2008;93(5):741-752.
6. Arguedas MR, Chen VK, Eloubeidi MA, et al. Screening for hepatocellular carcinoma in patients with hepatitis C
cirrhosis: a cost-utility analysis. Am J Gastroenterol. 2003;98(3):679-690.
7. Assy N, Nasser G, Djibre A, et al. Characteristics of common solid liver lesions and recommendations for diagnostic
workup. World J Gastroenterol. 2009;15(26):3217-3227.
8. Berland LL, Silverman SG, Gore RM, et al. Managing Incidental Findings on Abdominal CT: White Paper of the ACR
Incidental Findings Committee. J Am Coll Radiol. 2010;7(10):754-773.
9. Chou R, Cuevas C, Fu R, et al. Imaging Techniques for the Diagnosis and Staging of Hepatocellular Carcinoma. Agency
for Healthcare Research and Quality (US). Comparative Effectiveness Review Number 143. October 2014. Available at
http://www.effectivehealthcare.ahrq.gov/ehc/products/479/1990/liver-cancer-final-141022.pdf Accessed on September
28, 2016.
10. Cristiano A, Dietrich A, Spina JC, et al. Focal nodular hyperplasia and hepatic adenoma: current diagnosis and
management. Updates Surg. 2014;66(1): 9-21.
11. Gore RM, Thakrar KH, Wenzke DR, et al. That liver lesion on MDCT in the oncology patient: is it important? Cancer
Imaging. 2012;12:373-384.
12. Ho PJ, Tay L, Lindeman R, Catley L, Bowden DK. Australian guidelines for the assessment of iron overload and iron
chelation in transfusion-dependent thalassaemia major, sickle cell disease and other congenital anaemias. Intern Med J.
2011;41(7):516-524.
13. Israel GM, Krinsky GA. MR imaging of the kidneys and adrenal glands. Radiol Clin North Am. 2003;41(1):145-159.
14. Jeong YY, Kang HK, Chung TW, et al. Uterine cervical carcinoma after therapy: CT and MR Imaging findings.
Radiographics. 2003;23(4):969-981.
15. Jung SE. Lee JM, Rha SE, et al. CT and MR Imaging of ovarian tumors with emphasis on differential diagnosis.
Radiographics. 2002;22(6):1305–1325.
16. Kamel IR, Bluemke DA. MR imaging of liver tumors. Radiol Clin North Am. 2003; 41(1): 51-65. 32.
17. Keogan MT, Edelman RR. Technologic advances in abdominal MR imaging. Radiology. 2001;220(2):310-320.
18. Kim AY, Ha HK. Evaluation of suspected mesenteric ischemia: efficacy of radiologic studies. Radiol Clin North Am.
2003;41(2):327-342.
19. Kinkel K, Lu Y, Mehdizade A, Pelte MF, Hricak H. Intermediate ovarian mass at US: incremental value of second imaging
test for characterization–meta-analysis and bayesian analysis. Radiology. 2005;236(1):85-94.
20. Lamba R, Fananapazir G, Corwin MT, et al. Diagnostic imaging of hepatic lesions in adults. Surg Oncol Clin N Am.
2014;23(4):789-820.
2011;29(5):607-614.
23. Lucey MR, Terrault N, Ojo L, et al. Long-term management of the successful adult liver transplant: 2012 practice
guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation.
Liver Transpl. 2013;19(1):3-26.
24. Marrero JA, Ahn J, Rajender Reddy K. American College of Gastroenterology clinical guideline: the diagnosis and
management of focal liver lesions. Am J Gastroenterol. 2014;109(9):1328-1347.
and Local Treatment with Curative Intent. Eur Urol. 2016; pii: S0302-2838(16)30470-5.
29. NCCN Imaging Appropriate Use Criteria for Prostate Cancer (Version 2.2017). Available at http://www.nccn.org. ©National
comparing cancer detection of transperineal, transrectal saturation and MRI guided biopsy. PLoS One. 2013;8(2):e57480.
31. Panes J, Bouzas R, Chaparro M, et al. Systematic review: the use of ultrasonography, computed tomography and magnetic
resonance imaging for the diagnosis, assessment of activity and abdominal complications of Crohn’s disease. Aliment
Pharmacol Ther. 2011;34(2):125-145.
32. Pang EH, Harris AC, Chang SD. Approach to the Solitary Liver Lesion: Imaging and When to Biopsy. Can Assoc Radiol J.
2016;67(2):130-148.
34. Sarigianni M, Liakos A, Vlachaki E, et al. Accuracy of magnetic resonance imaging in diagnosis of liver iron overload: a
systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2015 Jan;13(1):55-63.e5.
September 28, 2016.
Magnetic Resonance Cholangiopancreatography
(MRCP) Abdomen
CPT Codes
74181 �� MRI of abdomen, without contrast

●● Magnetic resonance cholangiopancreatography (MRCP) is used to evaluate the biliary and pancreatic ductal
systems non-invasively and is covered under CPT code 74181, abdominal MRI without contrast.
●● MRCP studies are usually targeted for further evaluation of indeterminate or questionable findings, identified on
more standard imaging exams such as ultrasound and CT.
●● When magnetic resonance cholangiopancreatography (MRCP) is requested in addition to a MRI of the abdomen,
only one MRI abdomen code should be allowed. Additional sequences obtained for MRCP are considered part of
the primary procedure.
●● MRCP is performed using heavily T2-weighted images to display hyperintense signal from static or slowly-moving
fluid-filled structures.
●● Advantages of MRCP when compared with ERCP include non-invasive imaging technique, no ionizing radiation,
no anesthesia required, often better anatomic visualization proximal to a ductal obstruction, may detect extra-ductal
abnormalities not evident by ERCP
●● Disadvantages of MRCP when compared with ERCP include limited spatial resolution and therefore less sensitive
exam for detection of more subtle abnormalities, only provides diagnostic information compared with ERCP which
has both diagnostic and therapeutic capabilities, as a consequence, MRCP may result in a delay for needed
therapeutic interventions performed with ERCP (such as sphincterotomy, stone extraction, stent placement),
susceptibility artifact on MRI may occur (for example, from metallic foreign bodies/surgical clips in the right upper
abdominal quadrant) and result in image degradation.
●● MRCP is appropriate in cases of incomplete or failed ERCP or when ERCP cannot be safely performed (e.g.,
following pancreatic ductal trauma or a significant allergy to iodinated contrast material) or when ERCP is precluded
by anatomic considerations such as a biliary-enteric surgical anastomosis.
●● Significant upper abdominal ascites and large cystic/fluid-filled structures may impede visualization of the pancreatic
and biliary ductal systems with MRCP.

Biliary tract dilatation, biochemical evidence of biliary obstruction and/or unexplained RUQ pain
●● Including but not limited to the detection of:
○○ Choledocholithiasis
○○ Benign stricture
○○ Mass lesion (benign or malignant)
○○ Fistula
High clinical suspicion for choledocholithiasis in a patient who is post-cholecystectomy
Primary sclerosing cholangitis
Recurrent acute pancreatitis of unknown etiology

●● To identify possible causes such as congenitally aberrant ductal anatomy (e.g., choledochal cyst, pancreas divisum
and annular pancreas)
MRCP Abdomen | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 133
Suspected biliary and/or pancreatic ductal abnormalities
References
1. Fayad LM, Kowalski T, Mitchell DG. MR cholangiopancreatography: evaluation of common pancreatic disease. Radiol
Clin North Am. 2003;41(1):97-114.
MRCP Abdomen | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 134
CT/MR Angiography (CTA/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

●● 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.
●● For CTA of the abdominal aorta and iliofemoral vasculature with lower extremity runoff, use CPT code 75635
●● 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.
●● 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.
●● CTA of the abdomen is an alternative exam in patients who cannot undergo MRA.

Aneurysm of the abdominal aorta
●● Following inconclusive ultrasound in patients with suspected aneurysm/dilation of the abdominal aorta
inconclusive
Arteriovenous malformation (AVM) or arteriovenous fistula (AVF)

Note: For renal or superficial AVM, ultrasound should be considered as the first imaging modality
Dissection
Of the abdominal aorta and/or branch vessel
Mesenteric ischemia
●● May have an acute or chronic and progressive (intestinal or abdominal angina) presentation
Portal hypertension
CTA and MRA Abdomen | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 135
Prior to resection of pelvic neoplasm
Pseudoaneurysm
Renal artery stenosis

●● Suspected renovascular hypertension from renal artery stenosis with at least one of the following
○○ Refractory hypertension, in patients receiving therapeutic doses of three (3) or more anti-hypertensive
medications with documentation of at least two (2) abnormal serial blood pressure measurements
○○ Hypertension with renal failure or progressive renal insufficiency
○○ Accelerated or malignant hypertension
○○ Abrupt onset of hypertension
○○ Hypertension developing in patients younger than 30 years of age
●● Deteriorating renal function on angiotensin converting enzyme inhibition
●● Abdominal bruit, suspected to originate in the renal artery
●● Generalized arteriosclerotic occlusive disease with hypertension
●● Unilateral small renal size (greater than 1.5 cm difference in renal size on ultrasound)
●● Following an abnormal renal Doppler ultrasound suggestive of renal artery stenosis
●● Recurrent, unexplained episodes of “flash” pulmonary edema
Note: Doppler ultrasound examination of the renal arteries has been shown in the peer-reviewed literature to be efficacious
and cost-efficient in detecting renal artery stenosis. However, it is less sensitive than CTA/MRA for detection of
renovascular hypertension
Stenosis or occlusion of the abdominal aorta or branch vessels

●● Due to:
○○ Atherosclerosis
○○ Thromboembolism
○○ Other causes
Surgical planning for a kidney donor
Surgical planning for renal tumor resection
Suspected leak following abdominal aortic surgery
Traumatic vascular injury
Unexplained blood loss in the abdomen
Vascular anatomic delineation for other surgical and interventional procedures

●● Including but not limited to the following clinical scenarios:
○○ For surgical porto-systemic shunt placement or TIPS (transjugular intrahepatic porto-systemic shunt)
○○ For hepatic chemo-embolization procedure
○○ For vascular delineation prior to operative resection of an abdominal neoplasm
○○ For pre- and post-procedure evaluation of bypass grafts, stents and vascular anastomoses
Vascular evaluation of lower extremity claudication
●● CPT Coding for abdominal aortic and run-off evaluation, which involves image post-processing for three-dimensional
reconstructions, should follow:
○○ For CTA: 75635 - CTA of abdominal aorta and bilateral iliofemoral lower extremity run-off without contrast,
followed by re-imaging with contrast
○○ For MRA: 74185 - abdominal MRA and 73725 - bilateral lower extremity MRAs
●● 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) when walking, which disappears at rest. Other clinical findings which support non-invasive assessment with
CTA or MRA include lower extremity cutaneous ulcers and gangrene.
●● 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 indices (ABI) of < 0.9 may undergo advanced imaging. Rest pain or severe occlusive disease
typically occurs with ABI < 0.5
Vascular invasion or compression by an abdominal tumor
Vasculitis
Venous thrombosis or occlusion

Evaluation of suspected thrombosis or occlusion of major abdominal vessels, including portal and systemic
venous systems
●● Ultrasound is required as the initial study to evaluate the following:
○○ Hepatic or portal vein thrombosis
○○ Renal vein thrombosis
○○ Splenic vein thrombosis
Note: Ultrasound is not required for suspected thrombosis of the IVC or other venous structures in the abdomen and pelvis.
Visceral artery aneurysms

●● Diagnosis, management, and surveillance of visceral artery aneurysms including:
○○ Renal
○○ Celiac
○○ Splenic
○○ Hepatic
○○ Superior/inferior mesenteric and their branches
References
1. Anderson JL, Halperin JL, Albert N, et al. Management of Patients With Peripheral Artery Disease (Compilation of
2005 and 2011 ACCF/AHA Guideline Recommendations): A Report of the American College of Cardiology Foundation/
American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(14):1555-1570.
2. Bolduc JP, Oliva VL, Therasse E. Diagnosis and Treatment of Renovascular Hypertension: A Cost Benefit Analysis. AJR
Am J Roentgenol. 2005;184:931-937.
3. Cademartiri F, Raaijmakers RHJM, Kuiper JW, et al. Multi-detector row CT angiography in patients with abdominal
angina. Radiographics. 2001;24(4):969-984.
4. Glockner JF. Three dimensional galdolinium-enhanced MR angiography: applications for abdominal imaging.
Radiographics. 2001;21(2):357-370
6. Korst MBJM, Joosten FBM, Postma CT, et al. Accuracy of normal-dose contrast-enhanced MR angiography in
assessing renal artery stenosis and accessory renal arteries. AJR Am J Roentgenol. 2000;174(3):629-634.
7. Leiner T, Kessels,AGH, Nelemans PJ, et al. Peripheral arterial disease: comparison of color duplex US and
contrastenhanced MR angiography for diagnosis. Radiology. 2005;235(2):699-708.
8. Masunaga H, Takehara Y, Isoda H, et al. Assessment of gadolinium-enhanced time-resolved three dimensional MR
angiography for evaluating renal artery stenosis. AJR Am J Roentgenol. 2001;176(5):1213-1219.
9. Zhang LJ, Yang GF, Qi J, Shen W. Renal artery aneurysm: diagnosis and surveillance with multidetector-row computed
tomography. Acta Radiol. 2007;48(3):274-279.
Abdominal Aorta and Bilateral Iliofemoral
Lower Extremity Run-Off
CPT Codes
75635 �� Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with
contrast material(s), including non-contrast images, if performed, and image post-processing

●● Anatomic coverage for CPT code 75635 (CTA) includes the abdominal aorta and bilateral iliofemoral vasculature, in
addition to lower extremity run-off to the level of the popliteal regions at the knees and often extending through the
calf vasculature to the ankle and foot regions.
●● CTA of the abdomen is an alternative exam for patients who cannot undergo MRA.
●● Additional, separate requests for a CTA of the pelvis and/or the lower extremities, along with CPT code 75635, are
inappropriate.

Aneurysm of abdominal aorta or branch vessel
●● Following inconclusive ultrasound in patients with suspected aneurysm/dilation of the abdominal aorta or branch
vessel
inconclusive
●● Prior to transcatheter aortic valve implantation/replacement (TAVI or TAVR), unless advanced imaging of the
abdomen or pelvis has been performed for this indication within the preceding 60 days
Critical ischemia of lower extremities

●● For example, in diabetic vascular disease with ischemic ulcers or gangrene
Dissection
Hemorrhage
CTA Abdominal Aorta with Bilateral Lower Extremity Runoff | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 139
Peripheral arterial disease
●● Evaluation of peripheral arterial disease of the lower extremities following non-invasive confirmation (ankle brachial
index, toe-brachial index, segmental pressure examination, or duplex ultrasound) in patients with claudication or
critical limb ischemia who have no contraindication to revascularization
●● Evaluation of peripheral arterial disease of the lower extremities following non-invasive confirmation (ankle brachial
index, toe-brachial index, segmental pressure examination, or duplex ultrasound) in patients with ischemic ulceration
who have no contraindication to revascularization
●● Periodic follow up of patients who have undergone lower extremity revascularization when non-invasive evaluation
(ankle brachial index, toe-brachial index, segmental pressure examination, or duplex ultrasound) suggests recurrent
stenosis or occlusion
●● Following vascular procedures (angiography or revascularization) or trauma involving the lower extremity when non-
invasive evaluation suggests a complication (dissection, pseudoaneurysm, external compression, etc.) and CTA will
be used to direct subsequent management

Pseudoaneurysm
Thromboembolism
References
1. Anderson JL, Halperin JL, Albert N, et al. Management of Patients With Peripheral Artery Disease (Compilation of
2005 and 2011 ACCF/AHA Guideline Recommendations): A Report of the American College of Cardiology Foundation/
American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2012;61(14):1555-1570.
3. Macedo TA, Stanson AW, Oderich GS, et al. Infected aortic aneurysms: imaging findings. Radiology. 2004;231(1):250-
257.
4. Martin ML, Tay KH, Flak B, et al. Multidetector CT Angiography of the aortoiliac system and lower extremities: a
prospective comparison with digital subtraction angiography. AJR Am J Roentgenol. 2003;180(4):1085-1091.
CTA Abdominal Aorta with Bilateral Lower Extremity Runoff | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 140
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

●● Iliac crests to ischial tuberosities
●● Coverage may vary, depending on the specific clinical indication for the exam
●● Consider using ultrasound for indications such as differentiation of cystic, complex and solid lesions and initial
ascites evaluation.
●● Verification of cystic lesions in the pelvis is usually well-established with ultrasound.

This section contains general pelvic, intestinal, genitourinary, vascular, and osseous indications.
General Pelvic
treatment
Ascites
Congenital anomaly


Hernia
○○ Femoral
○○ Internal
○○ Inguinal
○○ Ventral
CT Pelvis | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 141
Incisional hernia

○○ Abscess
○○ Fistula
○○ Recurrent cystitis (male with at least two episodes or female with failed antibiotic therapy)
Lymphadenopathy
Palpable pelvic mass

●● When palpable pelvic mass requires further evaluation following pelvic ultrasound in female patients
●● Male patients
Pelvic pain
●● For female patients, following non-diagnostic transabdominal and transvaginal pelvic ultrasound

Trauma
●● Following significant blunt or penetrating injury to the pelvis
metastatic disease
●● Colon cancer
■■ T4 tumor
T2
short time interval (six months or less) after initial evaluation for other causes
Intestinal
studies
Appendicitis
Diagnosis
Management
Bowel obstruction
Diverticulitis

Diagnosis
Management
abscess or fistula
Ischemic bowel
Genitourinary
Hematuria
Hydronephrosis

Pregnancy
Vascular
Aneurysm of iliac and femoral vessels
●● Following inconclusive ultrasound in patients with suspected aneurysm/dilation of the iliac or femoral vessels
inconclusive
●● Annual postoperative surveillance of stable patients who have undergone open surgical repair when most recent
Aorto-iliac dissection

Osseous
Acute pelvic trauma, for fracture evaluation
●● Radiographs should be performed prior to CT
Hip osteonecrosis
●● When the patient is unable to undergo hip MRI or radionuclide bone scintigraphy, which are more sensitive
modalities than hip CT, in individuals with normal hip films or inconclusive radiographic evidence of hip
osteonecrosis
●● In known hip osteonecrosis and femoral head collapse by radiography, CT may help in the preoperative planning, to
define the location and extent of disease in patients with painful hips
Osseous tumor evaluation in the pelvis

●● MRI or radionuclide bone scintigraphy may be more appropriate for detection of skeletal metastases and primary
bone tumors unless otherwise contraindicated
Osteoid osteoma
●● Requires negative or inconclusive hip radiographs prior to CT imaging
Sacroiliitis
●● Following sacroiliac joint radiographs
Stress / insufficiency fracture in the pelvis

●● Radiographs are a required first step before other imaging is performed
○○ Subsequent advanced imaging often includes MRI or radionuclide bone scan as the next step
Suspicion of pelvic osteomyelitis or septic arthritis

●● When the patient is unable to undergo hip MRI or radionuclide bone scintigraphy
References
ABIM foundation. October 27, 2014. Available at http://www.choosingwisely.org/clinician-lists/acep-ct-of-abdomen-and-
pelvis-for-ed-patients-under-50/ Accessed on September 28, 2016.
Mar;216(3):447-453.
5. Cannistra SA. Cancer of the ovary. N Engl J Med. 2004;351(24):2519-2529.
Jan;16(1):39-47.
8. Fulgham P, Assimos D, Pearle M, Preminger G. Clinical Effectiveness Protocols for Imaging in the Management of
Ureteral Calculous Disease: AUA Technology Assesssment. Linthicum, MD: American Urological Association; 2012.
http://www.auanet.org/common/pdf/education/clinical-guidance/Imaging-Assessment.pdf. Accessed September 20,
2013.
10. Hoppe H, Studer R, Kessler TM, Vock P, Studer UE, Thoeny HC. Alternate or additional findings to stone disease on
unenhanced computerized tomography for acute flank pain can impact management. J Urol. 2006 May;175(5):1725-30;
discussion 1730.
2011;29(5):607-614.
Liver Transpl. 2013;19(1):3-26.
14. Mandeville JA, Gnessin E, Lingeman JE. Imaging evaluation in the patient with renal stone disease. Semin Nephrol.
2011 May;31(3):254-258.
comparing cancer detection of transperineal, transrectal saturation and MRI guided biopsy. PLoS One. 2013;8(2):
e57480.
21. Panes J, Bouzas R, Chaparro M, et al. Systematic review: the use of ultrasonography, computed tomography and
magnetic resonance imaging for the diagnosis, assessment of activity and abdominal complications of Crohn’s disease.
Aliment Pharmacol Ther. 2011;34(2):125-145.
23. Smith-Bindman R, Aubin C, Bailitz J, Bengiamin RN, et al. Ultrasonography versus computed tomography or suspected
nephrolithiasis. N Engl J Med. 2014 Sep 18;371(12):1100-10.
September 28, 2016.
Pelvis
CPT Codes
72195 �� MRI of pelvis, without contrast
72196 �� MRI of pelvis, with contrast
72197 �� MRI of pelvis, without contrast, followed by re-imaging with contrast

●● Coverage may vary, depending on the specific clinical indication for the exam
●● Depending on the patient’s presenting signs and symptoms, pelvic imaging should be directed to the most
appropriate modality for clinical work-up.
●● Diagnostic evaluation of the pelvis may be performed with pelvic ultrasound (trans-abdominal and trans-vaginal),
which is the initial imaging modality for most gynecologic abnormalities. Transabdominal pelvic sonography
is also used for urinary bladder assessment, such as post-void residual urine volume. Endoscopy and barium
examinations are well established procedures for intestinal evaluation. Cystoscopy is often used for lower urinary
tract assessment, pelvic CT or MRI.
●● Verification of cystic lesions in the pelvis is usually well-established with ultrasound.
●● CPT code assignment for an MRI procedure is based on the anatomic area imaged. Authorization requests for
multiple MR imaging of the same anatomic area to address patient positional changes, additional sequences or
equipment are not allowed.

treatment
Adenomyosis of the uterus following pelvic ultrasound
Adnexal mass(es) following pelvic ultrasound

●● Usually performed to further evaluate problematic cases which are initially detected on pelvic ultrasound. Some
uses of pelvic MRI in adnexal lesion evaluation include: differentiation of an ovarian mass from an exophytic or
pedunculated fibroid; more confident identification of an ovarian dermoid/teratoma, following an ultrasound or other
imaging exam; and demonstration of findings to suggest malignancy in some adnexal masses.
●● Includes assessment of suspected hemorrhagic cystic lesions and tumors
Appendicitis
Diagnosis and management
●● In pregnant patients, following a non-diagnostic ultrasound
Note: This guideline is intended only for pregnant patients
Bilateral hip osteonecrosis (avascular necrosis; aseptic necrosis)

●● MRI is the modality of choice for evaluation of osteonecrosis, particularly when there is clinical suspicion with hip
pain and negative or inconclusive hip radiographs
Bladder or urethral diverticula
MRI Pelvis | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 148
Congenital anomaly
Contraindication to CT (contrast allergy, renal disease, pregnancy)

●● Iodinated contrast risks (i.e., allergy, renal disease)
○○ Patient meets appropriateness criteria for CT, and MRI has been shown to have superior diagnostic accuracy to
non-contrast CT
●● Pregnancy
○○ MRI is a reasonable alternative for the requested indication
Endometriosis
●● Following pelvic ultrasound
Infectious or inflammatory process of the soft tissues

●● CT is usually the imaging modality of choice for infectious and inflammatory conditions
○○ Abscess
○○ Diffuse inflammation

Diagnosis
Management
abscess or fistula
Lymphadenopathy
●● When pelvic CT is non-diagnostic
●● May be useful for differentiating enlarged lymph nodes from vascular structures (with flow void on MRI), as follow-up
from an unenhanced pelvic CT exam
Obstetrical abnormalities pelvimetry or obstetrical complications
Osteomyelitis or septic arthritis
Pelvic floor disorders associated with urinary or bowel incontinence
Pelvic venous thrombosis evaluation
Sacral insufficiency fracture
Sacroiliitis
●● Following sacroiliac joint radiographs
Axial Spondyloarthropathy (SpA)
Diagnosis of Spondyloarthropathy (SpA)
●● Negative or equivocal radiographs for sacroiliitis (Grade 0-2) AND
●● Back pain has persisted for at least three months AND
●● Clinical evidence for inflammatory back pain defined as at least four of the following five features:
○○ Age less than 40
○○ Insidious onset
○○ Improvement with exercise
○○ No improvement with rest
○○ Pain at night which improves on getting up
Management of Spondyloarthopathy
Therapy response in patients with ankylosing spondylitis
●● Baseline study prior to treatment when the diagnosis of AS is based on radiographic findings
●● Evaluate therapy response in patients with ankylosing spondylitis and all of the following:
○○ Established diagnosis of ankylosing spondylitis
○○ No response to therapy
○○ At least three months of tumor necrosis factor (TNF) inhibitor therapy
Significant pelvic injury

●● Following pelvic or sacral radiographs
Sports hernia (athletic pubalgia)

●● Pain persists at least 6 weeks
●● Non-diagnostic radiographs
●● Following a trial of conservative therapy that lasts at least 6 weeks
●● Patient is a surgical candidate
●● Pain is insidious, progressive, worsens with valsalva or movement
●● No detectable inguinal or ventral hernia on exam
Note: Groin pain can be sometime be referred from the hip. See separate guideline for femoral neck stress fracture if that
is of concern.
Diagnosis
●● Evaluation of suspected prostate cancer in patients with a rising PSA and negative transrectal ultrasound biopsy
(TRUS)
Management of biopsy-proven malignancy, when MRI is needed to guide treatment in either of the following
scenarios:
●● CT is contraindicated or expected to be suboptimal (due to contrast allergy or anticipated contrast nephrotoxicity)
●● Evidence-based literature has shown MRI to have superior diagnostic accuracy to CT.
metastatic disease
●● Colon cancer
■■ T4 tumor
T2
Uterine artery embolization procedures

●● Often performed for treatment of persistent bleeding from uterine fibroids
MRI is generally not indicated in the following clinical situations

The indications listed in this section generally do not require advanced imaging using MRI. If there are circumstances that
require MRI imaging, a peer-to-peer discussion may be required.
Piriformis syndrome
Note: Advanced imaging is generally not indicated.
References
Accessed August 15, 2016.
4. Ascher SM, Reinhold C. Imaging of cancer of the endometrium. Radiol Clin North Am. 2002;40(3):563-576.
5. Calin A, Dijkmans BA, Emery P, et al. Outcomes of a multicentre randomised clinical trial of etanercept to treat
ankylosing spondylitis. Ann Rheum Dis. 2004;63:1594-1600.
6. Farber AJ, Wilckens JH. Sports hernia: diagnosis and therapeutic approach. J Am Acad Orthop Surg. 2007;15(8):507-
514.
7. Fielding JR. MR imaging of the female pelvis. Radiol Clin North Am. 2003;41(1):179-192.
8. Garvey JFW, Hazard H. Sports hernia or groin disruption injury? Chronic athletic groin pain: a retrospective study of 100
patients with long-term follow-up. Hernia. 2013;815-823.
9. Gorman JD, Sack KE, Davis JC Jr. Treatment of ankylosing spondylitis by inhibition of tumor necrosis factor alpha. N
Engl J Med. 2002;346:1349–1356.
10. Hegedus EJ, Stern B, Reiman MP, Tarara D, Wright A a. A suggested model for physical examination and conservative
treatment of athletic pubalgia. Phys Ther Sport. 2013;14(1):3-16.
11. Khan W, Zoga AC, Meyers WC. Magnetic resonance imaging of athletic pubalgia and the sports hernia: Current
understanding and practice. Magn Reson Imaging Clin N Am. 2013;21(1):97-110.
12. Kingston JA, Jegatheeswaran S, Macutkiewicz C, et al. A European survey on the aetiology, investigation and
management of the “sportsman’s groin”. Hernia. 2014;18(6):803-10.
Disease. J Crohns Colitis; 2015; 9(9):784-794.
14. Lange JFM, Kaufmann R, Wijsmuller a. R, et al. An international consensus algorithm for management of chronic
postoperative inguinal pain. Hernia. 2014.
15. Litwin DEM, Sneider EB, McEnaney PM, Busconi BD. Athletic Pubalgia (Sports Hernia). Clin Sports Med.
2011;30(2):417-434.
2011;29(5):607-614.
Liver Transpl. 2013;19(1):3-26.
e57480.
24. Panes J, Bouzas R, Chaparro M, et al. Systematic review: the use of ultrasonography, computed tomography and
magnetic resonance imaging for the diagnosis, assessment of activity and abdominal complications of Crohn’s disease.
Aliment Pharmacol Ther. 2011;34(2):125-145.
September 28, 2016.
28. Zoga AC, Kavanagh EC, Omar IM, et al. Athletic Pubalgia and the “sports hernia”: MR imaging findings. Radiology.
2008;247(3):797-807.
Fetal MRI
CPT Codes
74712 �� Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when
performed; single or first gestation
74713 �� each additional gestation (List separately in addition to code for primary procedure)

●● Field of view should be tailored to fetal and maternal size.
●● Single shot fast spin echo and other rapid acquisition sequences are important to minimize the effects of fetal
motion.
●● Ultrasound is the gold standard and primary imaging modality for assessment of the fetus.
●● MRI is reserved as a problem solving tool in select circumstances for further assessment of abnormalities detected
or incompletely characterized on ultrasound.
●● MRI should generally be done without contrast as gadolinium is considered a category C drug.
●● The long-term effects of MRI on the fetus are unknown; however, no adverse effects have been found to date.

Assessment prior to fetal intervention
●● Following non-diagnostic ultrasound
Complication of monochorionic twins

●● Following non-diagnostic ultrasound (any one♦ of the following)
○○ Anatomy of conjoined twins
○○ Demise of a monochorionic cotwin
Congenital anomaly of the abdomen and pelvis

○○ Abdominal mass
○○ Bowel obstruction
○○ Genitourinary anomaly except rectourethral fistula
Congenital anomaly of the chest

○○ Congenital diaphragmatic hernia
○○ Congenital pulmonary airway malformation
○○ Pleural effusion
♦ List may not be exclusive | MRI Pelvis – Fetal | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 154
Congenital anomaly of the head and neck
○○ Agenesis of the corpus callosum
○○ Cleft palate
○○ Cortical malformation
○○ Dandy-Walker syndrome
○○ Encephalocele
○○ Holoprosencephaly
○○ Infarct, hemorrhagic or non-hemorrhagic
○○ Intracranial mass
○○ Meningocele/encephalocele
○○ Neck mass
○○ Posterior fossa anomaly
○○ Vascular malformation, including vein of Galen
○○ Ventriculomegaly
○○ Vermian hypoplasia
Congenital anomaly of the spine

○○ Caudal regression
○○ Congenital anomaly of the vertebrae
○○ Neural tube defect
○○ Sacrococcygeal teratoma
Placental complication
○○ Abruption
○○ Accreta
○○ Gestational trophoblastic disease
○○ Previa
References
1. American College of Radiology. ACR-SPR Practice Parameter for the Safe and Optimal Performace of Fetal Magnetic
Resonance Imaging (MRI). Reston, VA: ACR; 2015. Available at http://www.acr.org/~/media/ACR/Documents/PGTS/
guidelines/MRI_Fetal.pdf Accessed August 29, 2016.
2. Australia and New Zealand Horizon Scanning Network. Horizon Scanning Technology Horizon Scanning Report: MRI for
the detection of foetal abnormalities. Canberra: Commonwealth of Australia; October 2007. http://www.horizonscanning.
gov.au/ Accessed September 10, 2014.
3. Levine D. Obstetric MRI. J Magn Reson Imaging. 2006;24(1):1-15.
♦ List may not be exclusive | MRI Pelvis – Fetal | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 155
CT/MR Angiography (CTA/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

●● Scan coverage may vary, depending on the specific clinical indication for the exam
●● 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.
●● CTA of the pelvis is an alternative exam in patients who cannot undergo MRA.
●● 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.

Aneurysm of the iliac or femoral vessels
●● Following inconclusive ultrasound in patients with suspected aneurysm/dilation of the iliac or femoral vessels
inconclusive

Dissection
Of the iliac arteries or branches
Mesenteric ischemia
CTA and MRA Pelvis | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 156
Pseudoaneurysm
Stenosis or occlusion of the lower abdominal aorta, iliac arteries or other branch vessels in the
pelvis
Surgical planning for a kidney donor
Suspected leak following abdominal aortic surgery
Unexplained blood loss in the pelvis

●● For vascular delineation prior to operative resection of a pelvic neoplasm
●● For pre- and post-procedure evaluation of bypass grafts, stents and vascular anastomoses
Vascular invasion or compression by a pelvic tumor
Vasculitis


References
CTA and MRA Pelvis | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 157
Abdomen and 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

●● Diaphragmatic dome through pubic symphysis
●● Verification of cystic lesions in the abdominal and pelvis is usually well-established with ultrasound.
●● For abdominal symptoms in the pediatric population abdominal ultrasound frequently provides diagnostic information
without incurring radiation exposure from CT.

This section contains general abdominal and pelvic, gastrointestinal, genitourinary, and vascular indications.
General Abdominal and Pelvic

Abdominal / pelvic pain
treatment
Ascites
Congenital anomaly


CT Abdomen & Pelvis Combination | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 158
Hernia
○○ Femoral
○○ Internal
○○ Inguinal
○○ Ventral
Incisional hernia

○○ Abscess
○○ Fistula
○○ Recurrent cystitis (male with at least two episodes or female with failed antibiotic therapy)
Lymphadenopathy
Palpable abdominal / pelvic mass

●● 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.

Trauma
●● Following significant blunt or penetrating injury to the abdomen
metastatic disease
●● Colon cancer
■■ T4 tumor
T2
short time interval (six months or less), after initial evaluation for other causes
Gastrointestinal
studies
Appendicitis
Diagnosis
Management
Bowel obstruction
Diverticulitis

Diagnosis
Management
abscess or fistula
Ischemic bowel
Genitourinary
Acute pyelonephritis
●● In a patient with any of the following:
○○ Diabetes; OR
○○ History of renal calculi; OR
○○ History of renal surgery; OR
○○ Absence of response after 72 hours of therapy
Hematuria
Hydronephrosis
Renal neoplasm
●● 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.
Pregnancy
Worsening renal function

Note: Non-contrast evaluation is indicated in individuals with worsening renal function, as contrast administration may
potentially worsen renal function in these patients.
Vascular
Aneurysm of the abdominal aorta, iliac or femoral vessels

●● Following inconclusive ultrasound in patients with suspected aneurysm/dilation of the abdominal aorta, iliac or
femoral vessels
●● Follow-up imaging of patients with an established aneurysm/dilation when most recent ultrasound imaging is inconclusive
Aorto-iliac dissection
○○ Usually results from subdiaphragmatic extension of a thoracic aortic dissection

References
Mar;216(3):447-453.
Jan;16(1):39-47.
6. Fulgham P, Assimos D, Pearle M, Preminger G. Clinical Effectiveness Protocols for Imaging in the Management of
Ureteral Calculous Disease: AUA Technology Assesssment. Linthicum, MD: American Urological Association; 2012.
http://www.auanet.org/common/pdf/education/clinical-guidance/Imaging-Assessment.pdf. Accessed September 20,
2013.
8. Hoppe H, Studer R, Kessler TM, Vock P, Studer UE, Thoeny HC. Alternate or additional findings to stone disease on
unenhanced computerized tomography for acute flank pain can impact management. J Urol. 2006 May;175(5):1725-30;
discussion 1730.
2011;29(5):607-614.
Liver Transpl. 2013;19(1):3-26.
11. Mandeville JA, Gnessin E, Lingeman JE. Imaging evaluation in the patient with renal stone disease. Semin Nephrol.
2011 May;31(3):254-258.
e57480.
18. Smith-Bindman R, Aubin C, Bailitz J, Bengiamin RN, et al. Ultrasonography versus computed tomography or suspected
nephrolithiasis. N Engl J Med. 2014 Sep 18;371(12):1100-10.
Abdomen and Pelvis Combination
CPT Codes
74174 �� Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast
images, if performed, and image postprocessing

●● Anatomic coverage for CPT code 74174 (CTA abdomen and pelvis combination) includes the major arterial and/or
venous structures in the abdomen, from the diaphragmatic dome to the ischial tuberosities.
●● Coverage for an abdominal CTA generally includes the abdominal aorta and these visceral arteries (aortic
branches):
○○ Renal arteries
○○ Celiac artery
○○ Splenic artery
○○ Hepatic artery
○○ Superior mesenteric artery
●● Coverage for a pelvic CTA includes the aortic bifurcation and these arteries:
○○ Common iliac artery
○○ Internal iliac artery (aka hypogastric) and its branches
○○ External iliac artery
●● Full evaluation of the superior and inferior mesenteric artery generally requires both CTA abdomen and pelvis.
●● Complete evaluation of the femoral artery generally requires CT angiography with ileofemoral lower extremity runoff
(CPT 75635).
●● For CTA of the abdominal aorta and iliofemoral vasculature with lower extremity runoff, use CPT code 75635
●● CTA is an alternative exam in patients who cannot undergo MRA.
●● Requests for a combination CTA abdomen and pelvis study in addition to a request for a CTA abdominal aorta and
bilateral iliofemoral lower extremity runoff study are not allowed
●● The primary reason to combine CTA’s of the abdomen and pelvis is to evaluate for a vascular disease that affects
both the abdominal aorta (covered by the CTA abdomen) and the iliac arteries (covered by CTA pelvis). Some
examples include ischemia, occlusion, aneurysm, trauma, vasculitis.
●● Aortic stent grafts often cover the infrarenal abdominal aorta and proximal iliac arteries. CTA abdomen and pelvis
should be used to evaluate complications such as endoleak in these cases.
●● Aortic dissection will often be requested at a CTA chest (CPT 71275) and abdomen. Pelvis is not required.
CTA Abdomen & Pelvis Combination | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 164
Aneurysm of the abdominal aorta, iliac or femoral vessels
●● Following inconclusive ultrasound in patients with suspected aneurysm/dilation of the abdominal aorta, iliac or
femoral vessels
inconclusive
●● Preoperative assessment or prior to percutaneous endovascular stent graft placement

Dissection
Mesenteric ischemia

Prior to resection of pelvic neoplasm
Pseudoaneurysm
Stenosis or occlusion of the abdominal aorta or branch vessels

●● Due to:
○○ Atherosclerosis
○○ Thromboembolism
○○ Other causes
Suspected leak following abdominal aortic surgery or intervention (endoleak)
Unexplained blood loss in the abdomen

●● Including but not limited to the following clinical scenarios:
○○ For vascular delineation prior to operative resection of an abdominal neoplasm
○○ For pre- and post-procedure evaluation of bypass grafts, stents and vascular anastomoses
Vascular invasion or compression by an abdominal tumor

Vasculitis

Evaluation of suspected thrombosis or occlusion of major abdominal vessels, including portal and systemic
venous systems
●● Ultrasound is required as the initial study to evaluate the following:
○○ Hepatic or portal vein thrombosis
○○ Renal vein thrombosis
○○ Splenic vein thrombosis
Note: Ultrasound is not required for suspected thrombosis of the IVC or other venous structures in the abdomen and pelvis.

○○ Renal
○○ Celiac
○○ Splenic
○○ Hepatic
References
CT Colonography
(Virtual Colonoscopy)
CPT Codes
74261 �� Diagnostic CT colonography without contrast
74262 �� Diagnostic CT colonography with contrast including non-contrast images if performed
74263 �� Screening CT colonography including image post-processing

●● Use of helical CT and reconstruction algorithms to provide endoluminal visualization of the colon, as well as
anatomic depiction throughout much of the abdomen and pelvis. Both 2D and 3D reconstructions are routinely used
for colonic evaluation. Colonic preparation is required, similar to standard fiberoptic colonoscopy. Another similarity
to fiberoptic colonoscopy is the requirement for air insufflation to distend the colon
●● CPT codes for CT of the abdomen (74150–74170) and CT of the Pelvis (72192–72194) should not be used when a
CT colonography exam is requested.
●● Depending on the presenting signs and symptoms, other studies such as fiberoptic colonoscopy and barium
examination may be helpful for evaluation of the colon.
●● CT colonography requires cleansing bowel preparation and air insufflation for colonic distention, similar to fiberoptic
colonoscopy.

This section contains indications for diagnostic CT colonography (74261, 74262) and for screening CT colonography (74263).
Indications for Diagnostic CT Colonography (74261, 74262)
Coagulopathy
Complications from prior fiberoptic colonoscopy
Diverticulitis, with increased risk of perforation
Failed or incomplete fiberoptic colonoscopy of the entire colon, due to inability to pass the
colonoscope proximally. Failure to advance the colonoscope may be secondary to:
●● Obstructing neoplasm
●● Spasm
●● Redundant colon
●● Altered anatomy or scarring from previous surgery
●● Stricture
●● Extrinsic compression
Increased sedation risk

●● For example, COPD or previous adverse reaction to anesthesia
Known colonic obstruction, when standard fiberoptic colonoscopy is contraindicated
Lifetime or long-term anticoagulation, with increased patient risk if discontinued
CT Colonography (Virtual Colonoscopy) | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 167
Indication for Screening CT Colonography (74263)
As an alternative to either conventional (optical) colonoscopy or double contrast barium

enema for colorectal cancer screening, in individuals beginning at the age of 50 years and at a
frequency of every 5 years
References
1. Chung DJ, Huh KC, Choi WJ, Kim JK. CT colonography using 16-MDCT in the evaluation of colorectal cancer. AJR Am
J Roentgenol. 2005;184(1):98-103.
2. Cohnen M, Vogt C, Beck A, et al. Feasibility of MDCT colonography in ultra-low-dose technique in the detection of
colorectal lesions: comparison with high-resolution video colonoscopy. AJR Am J Roentgenol. 2004;183(5):1355-1359.
3. Halligan S, Altman DG, Taylor SA, et al. CT colonography in the detection of colorectal polyps and cancer: systematic
review, meta-analysis, and proposed minimum data set for study level reporting. Radiology. 2005;237(3):893-904.
4. Macari M, Bini EJ. CT Colonography: where have we been and where are we going? Radiology. 2005;237(3):819-833.
CT Colonography (Virtual Colonoscopy) | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 168
Cervical Spine
CPT Codes
72125 �� CT of cervical spine, without contrast
72126 �� CT of cervical spine, with contrast
72127 �� CT of cervical spine, without contrast, followed by re-imaging with contrast

●● Entire cervical spine (C1-C7), from the craniocervical junction through the T1 vertebra
●● Axial images are routinely obtained, with capability for coronal and sagittal reconstructions
●● MRI is the modality of choice for most cervical spine imaging indications, unless contraindicated or not tolerated by
the patient (for example, secondary to claustrophobia)
●● CT is the preferred technique for certain clinical scenarios such as suspected fracture, follow-up of known fracture,
osseous tumor evaluation and congenital vertebral defects, as well as procedures such as cervical spine CT
myelography
●● Do not use CT cervical spine for imaging of the soft tissues of the neck. See CPT codes 70490-70492 CT soft tissue
neck for this service

MRI is the preferred modality for most cervical spine imaging, except for a few indications which include
CT evaluation of bony abnormalities (such as suspected fracture or fracture follow-up; osseous tumor
assessment; developmental vertebral abnormalities) and CT myelography
treatment
Fracture evaluation
●● Following initial evaluation with radiographs
Post-myelogram CT or CT following other cervical spine interventional procedure
Post-trauma
●● Neurologic deficit with possible spinal cord injury
●● Progressively worsening pain
Significant acute trauma to the cervical spine region
When the patient’s condition meets the cervical spine MRI guidelines, but there is either a
contraindication to MRI or the patient cannot tolerate MRI examination (for example, due to
claustrophobia)
For most other indications, MRI is the preferred modality for advanced cervical spine imaging, unless contraindicated
Chiari malformation (Arnold-Chiari malformation)
CT Cervical Spine | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 169
Congenital spine anomalies
●● Cervical spine dysraphism and other congenital anomalies involving the cervical spine and/or spinal cord
●● Congenital vertebral defects for assessment of bony defects such as segmentation and fusion anomalies
Infectious process
○○ Abscess
○○ Osteomyelitis
○○ Discitis
Neck pain without neurologic or radicular features

Note: This guideline does not apply to patients with known or suspected malignancy, infection, or underlying conditions
which predispose to instability at the craniocervical junction.
Diagnosis of the etiology of neck pain in patients who are willing and able to undergo spine surgery or epidural
steroid injection (ESI) when both of the following criteria are met:
●● Lack of improvement or worsening during a six (6) week course of therapy with at least two (2) different forms of
treatment
●● Cervical spine X-ray is negative or does not clearly explain the cause of the patient’s symptoms.
Neck pain with radiculopathy

Note: This guideline does not apply to patients with known or suspected malignancy, infection, myelopathy, or underlying
conditions which predispose to instability at the craniocervical junction.
Diagnosis of the etiology of cervical nerve root compression in patients who are willing and able to undergo spine
surgery or cervical epidural steroid injection (ESI) when either of the following criteria are met:
●● Documented abnormality on neurological exam in a dermatome/radicular distribution that has not previously been
imaged or has progressed since a prior imaging study has been performed
treatment

Rheumatoid arthritis
●● For suspected cervical subluxation in a patient with confirmed rheumatoid arthritis
Severe scoliosis, for the following patient populations:

●● In patients with a high risk for neural axis abnormalities, such as infantile and juvenile idiopathic scoliosis and
congenital scoliosis; OR
●● With adolescent idiopathic scoliosis and atypical findings (pain, rapid progression, development of neurologic signs/
symptoms); OR
●● With scoliosis related to other pathologic processes such as neurofibromatosis; OR
●● For pre-operative evaluation of severe scoliosis
Spondyloarthropathies
Note: Including but not limited to: ankylosing spondylitis, reactive arthritis, psoriatic arthritis, spondyloarthritis associated
with inflammatory bowel disease, juvenile-onset spondyloarthritis
●● For diagnosis following non-diagnostic work-up including but not limited to:
○○ Radiographs
○○ Standard laboratory work-up for spondyloarthropathy
Syringohydromyelia (syrinx)
Tumor evaluation
○○ Primary or metastatic neoplasm involving the vertebrae
○○ Tumor spread within the spinal canal
○○ Spinal cord neoplasm
References
1. Abbed KM, Coumans JV. Cervical radiculopathy: pathophysiology, presentation, and clinical evaluation. Neurosurgery.
2007 Jan;60(1 Supp1 1):S28-34.
2. Ahn NU, Ahn UM, Ipsen B, Mechanical neck pain and cervicogenic headache. Neurosurgery. 2007 Jan;60(1 Supp1
1):S21-7.
3. Alentado VJ, Lubelski D, Steinmetz MP, Benzel EC, Mroz TE. Optimal duration of conservative management prior to
surgery for cervical and lumbar radiculopathy: a literature review. Global Spine J. 2014 Dec;4(4):279-86. doi: 10.1055/s-
0034-1387807. Epub 2014 Aug 28. Review.
4. Anekstein Y, Blecher R, Smorgick Y et al. What is the best way to apply the Spurling test for cervical radiculopathy? Clin
Orthop Relat Res. 2012 Sep;470(9):2566-72.
5. Corey DL, Comeau D. Cervical radiculopathy. Med Clin North Am. 2014 Jul;98(4):791-9
6. Duggal N, Pickett GE, Mitsis DK, et al. Early clinical and biomechanical results following cervical arthroplasty. Neurosurg
Focus. Sep 15 2004;17(3):E9.
7. Ellenberg MR, Honet JC, Treanor WJ. Cervical radiculopathy. Arch Phys Med Rehabil. 1994 Mar;75(3):342-52.
8. Eubanks JD. Cervical radiculopathy: nonoperative management of neck pain and radicular symptoms. Am Fam
Physician. 2010 Jan 1;81(1):33-40.
9. Forbush SW, Cox T, Wilson E. Treatment of patients with degenerative cervical radiculopathy using a multimodal
conservative approach in a geriatric population: a case series J Orthop Sports Phys Ther. 2011 Oct;41(10):723-33
10. Fortin J, Riethmiller DW, Vilensky JA. No clear winner in differing imaging modalities for cervical radiculopathy. Pain
Physician. 2002 Jul;5(3):285-7.
11. Gross A, Kay TM, Cervical Overview Group, et al. Exercises for mechanical neck disorders. Cochrane Database Syst
Rev. 2015 Jan 28;1:CD004250.
12. Gross A, Langevin P, Burnie SJ, et al. Manipulation and mobilisation for neck pain contrasted against an inactive control
or another active treatment. Cochrane Database Syst Rev. 2015 Sep 23;(9):CD004249.
13. Kuijper B, Tans JT, Beelen A, Nollet F, de Visser M. Cervical collar or physiotherapy versus wait and see policy for recent
onset cervical radiculopathy: randomised trial. BMJ. 2009 Oct 7;339:b3883
14. Mummaneni PV, Kaiser MG, Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association
of Neurological Surgeons and Congress of Neurological Surgeons, et al. Preoperative patient selection with magnetic
resonance imaging, computed tomography, and electroencephalography: does the test predict outcome after cervical
surgery? J Neurosurg Spine. 2009 Aug;11(2):119-29.
15. Narváez JA, Narváez J, Serrallonga M, et al. Cervical spine involvement in rheumatoid arthritis: correlation between
neurological manifestations and magnetic resonance imaging findings. Rheumatology (Oxford). 2008 Dec;47(12):1814-9
16. Nordin M, Carragee EJ, Hogg-Johnson S, Assessment of neck pain and its associated disorders: results of the Bone
and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976). 2008 Feb
15;33(4 Suppl):S101-22.
17. Rhee JM, Yoon T, Riew KD. Cervical radiculopathy. J Am Acad Orthop Surg. 2007 Aug;15(8):486-94.
18. van Eerd M, Patijn J, Lataster A. Cervical facet pain. Pain Pract. 2010 Mar-Apr;10(2):113-23.
19.
Cervical Spine
CPT Codes
72141 �� MRI of cervical spine, without contrast
72142 �� MRI of cervical spine, with contrast
72156 �� MRI of cervical spine, without contrast, followed by re-imaging with contrast

●● Entire cervical spine (C1-C7), from the craniocervical junction through the T1 vertebra
●● For most cervical spine abnormalities, MRI is the examination of choice
●● CT of the cervical spine is often reserved for suspected fracture, follow-up of a known fracture, osseous tumor
evaluation, congenital vertebral defects and procedures such as cervical spine CT myelography
●● In most other clinical situations, MRI is the preferred modality for cervical spine imaging, unless contraindicated [due
to pacemaker, implantable cardioverter-defibrillator (ICD), and other non-compatible devices unsafe for use in an
MRI scanner] or not tolerated by the patient (usually secondary to claustrophobia)
●● The CPT code assignment for an MRI procedure is based on the anatomic area imaged. Authorization requests for
multiple MRI imaging of the same anatomic area to address patient positional changes, additional sequences or
equipment are not allowed. These variations or extra sequences are included within the original imaging request

treatment
Chiari malformation (Arnold-Chiari malformation)

●● Cervical spine dysraphism and other congenital anomalies involving the cervical spine and/or spinal cord
Fracture evaluation
Infectious process
○○ Abscess
○○ Discitis

●● Initial diagnosis; OR
●● Periodic scans to assess asymptomatic progression in multiple sclerosis during the course of disease; OR
●● Tracking the progress of multiple sclerosis to establish a prognosis or evaluation of response to treatment; OR
●● To evaluate changes in neurologic signs and symptoms
MRI Cervical Spine | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 173
Myelopathy
Neck pain without neurologic or radicular features

Note: This guideline does not apply to patients with known or suspected malignancy, infection, or underlying conditions
which predispose to instability at the craniocervical junction.
Diagnosis of the etiology of neck pain in patients who are willing and able to undergo spine surgery or epidural
steroid injection (ESI) when both of the following criteria are met:
treatment
●● Cervical spine X-ray is negative or does not clearly explain the cause of the patient’s symptoms.
Neck pain with radiculopathy

Note: This guideline does not apply to patients with known or suspected malignancy, infection, myelopathy, or underlying
conditions which predispose to instability at the craniocervical junction.
Diagnosis of the etiology of cervical nerve root compression in patients who are willing and able to undergo spine
surgery or cervical epidural steroid injection (ESI) when either of the following criteria are met:
●● Documented abnormality on neurological exam in a dermatome/radicular distribution that has not previously been
imaged or has progressed since a prior imaging study has been performed
treatment
Post-trauma

Rheumatoid arthritis
●● For suspected cervical subluxation in a patient with confirmed rheumatoid arthritis

symptoms); OR
Significant acute trauma to the cervical spine region
Spinal cord infarct
○○ Radiographs
Note: Including but not limited to ankylosing spondylitis, reactive arthritis, psoriatic arthritis, spondyloarthritis associated
Tumor evaluation
References
1. Abbed KM, Coumans JV. Cervical radiculopathy: pathophysiology, presentation, and clinical evaluation. Neurosurgery.
2007 Jan;60(1 Supp1 1):S28-34.
2. Ahn NU, Ahn UM, Ipsen B, Mechanical neck pain and cervicogenic headache. Neurosurgery. 2007 Jan;60(1 Supp1
1):S21-7.
3. Alentado VJ, Lubelski D, Steinmetz MP, Benzel EC, Mroz TE. Optimal duration of conservative management prior to
surgery for cervical and lumbar radiculopathy: a literature review. Global Spine J. 2014 Dec;4(4):279-86. doi: 10.1055/s-
0034-1387807. Epub 2014 Aug 28. Review.
4. Anekstein Y, Blecher R, Smorgick Y et al. What is the best way to apply the Spurling test for cervical radiculopathy? Clin
Orthop Relat Res. 2012 Sep;470(9):2566-72.
5. Corey DL, Comeau D. Cervical radiculopathy. Med Clin North Am. 2014 Jul;98(4):791-9
6. Duggal N, Pickett GE, Mitsis DK, et al. Early clinical and biomechanical results following cervical arthroplasty. Neurosurg
Focus. Sep 15 2004;17(3):E9.
7. Ellenberg MR, Honet JC, Treanor WJ. Cervical radiculopathy. Arch Phys Med Rehabil. 1994 Mar;75(3):342-52.
8. Eubanks JD. Cervical radiculopathy: nonoperative management of neck pain and radicular symptoms. Am Fam
Physician. 2010 Jan 1;81(1):33-40.
9. Forbush SW, Cox T, Wilson E. Treatment of patients with degenerative cervical radiculopathy using a multimodal
conservative approach in a geriatric population: a case series J Orthop Sports Phys Ther. 2011 Oct;41(10):723-33
10. Fortin J, Riethmiller DW, Vilensky JA. No clear winner in differing imaging modalities for cervical radiculopathy. Pain
Physician. 2002 Jul;5(3):285-7.
11. Gross A, Kay TM, Cervical Overview Group, et al. Exercises for mechanical neck disorders. Cochrane Database Syst
Rev. 2015 Jan 28;1:CD004250.
12. Gross A, Langevin P, Burnie SJ, et al. Manipulation and mobilisation for neck pain contrasted against an inactive control
or another active treatment. Cochrane Database Syst Rev. 2015 Sep 23;(9):CD004249.
13. Kuijper B, Tans JT, Beelen A, Nollet F, de Visser M. Cervical collar or physiotherapy versus wait and see policy for recent
onset cervical radiculopathy: randomised trial. BMJ. 2009 Oct 7;339:b3883
14. Mummaneni PV, Kaiser MG, Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association
of Neurological Surgeons and Congress of Neurological Surgeons, et al. Preoperative patient selection with magnetic
resonance imaging, computed tomography, and electroencephalography: does the test predict outcome after cervical
surgery? J Neurosurg Spine. 2009 Aug;11(2):119-29.
15. Narváez JA, Narváez J, Serrallonga M, et al. Cervical spine involvement in rheumatoid arthritis: correlation between
neurological manifestations and magnetic resonance imaging findings. Rheumatology (Oxford). 2008 Dec;47(12):1814-9
16. Nordin M, Carragee EJ, Hogg-Johnson S, Assessment of neck pain and its associated disorders: results of the Bone
and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976). 2008 Feb
15;33(4 Suppl):S101-22.
17. Rhee JM, Yoon T, Riew KD. Cervical radiculopathy. J Am Acad Orthop Surg. 2007 Aug;15(8):486-94.
18. van Eerd M, Patijn J, Lataster A. Cervical facet pain. Pain Pract. 2010 Mar-Apr;10(2):113-23.
Thoracic Spine
CPT Codes
72128 �� CT of thoracic spine, without contrast
72129 �� CT of thoracic spine, with contrast
72130 �� CT of thoracic spine, without contrast, followed by re-imaging with contrast

●● Entire thoracic spine (T1-T12), from the cervicothoracic region through the thoracolumbar junction
●● Advanced diagnostic imaging of the thoracic spine is indicated in selected clinical scenarios and is performed
significantly less often than in the lumbar and cervical regions
●● MRI is the modality of choice for most thoracic spine imaging indications, unless contraindicated or not tolerated by
●● CT is the preferred technique for certain clinical scenarios such as suspected fracture, osseous tumor evaluation,
congenital vertebral defects and interventional procedures such as CT myelography
●● Authorization request for re-imaging, due to technically limited exams, is the responsibility of the imaging provider

MRI is the preferred modality for most thoracic spine imaging, except for a few indications which include
CT evaluation of bony abnormalities (such as suspected fracture or fracture follow-up; occasional
osseous tumor assessment; developmental vertebral abnormalities) and CT myelography
treatment
Fracture evaluation
Post-myelogram CT or CT following other thoracic spine interventional procedure
Post-trauma
When the patient’s condition meets the thoracic spine MRI guidelines, but there is either a
claustrophobia)
For most other indications, MRI is the preferred modality for advanced thoracic spine imaging, unless contraindicated

●● Thoracic spine dysraphism and other congenital anomalies involving the thoracic spine and/or spinal cord
CT Thoracic Spine | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 177
Infectious process
○○ Abscess
○○ Discitis
Mid-back pain with signs of compression

●● In a patient with mid-back or radicular pain and red flag signs including:
○○ Reflex abnormality
○○ Objective muscle weakness
○○ Objective sensory abnormality in the thoracic dermatome distribution
○○ Spasticity
Note: Imaging in patients with polyneuropathy without additional abnormalities on neurological exam is not indicated1-4
Non-specific mid-back pain

●● In a patient where focused history and physical exam suggest non-specific thoracic pain and/or referred posterior
chest pain and all of the following are met:
○○ Patient is a potential candidate for surgery or epidural steroid injection; AND
○○ Patient has, following clinical examination, completed a minimum of 4-6 consecutive weeks of physician
supervised conservative therapy for the current episode of pain, including but not limited to any of the following:
■■ NSAIDs
■■ Muscle relaxants
■■ Steroids
■■ Physical therapy; AND
○○ After trial of conservative therapy as listed above, patient fails to show substantial improvement on clinical re-
evaluation; OR
●● Mid-back pain not meeting the above criteria but associated with “red flag” symptoms such as unexplained weight
loss, history of malignant disease, fever, drug abuse, or tuberculosis, abnormal labs suggestive of malignancy such
as abnormal serum or urine electrophoresis, elevated prostate specific antigen (PSA)

Note: This indication is for pre-operative evaluation of conditions not specifically referenced elsewhere in this guideline.
Severe scoliosis, including the following patient populations:

symptoms); OR
Note: Including but not limited to: ankylosing spondylitis, reactive arthritis, psoriatic arthritis, spondyloarthritis associated with
inflammatory bowel disease, juvenile-onset spondyloarthritis
○○ Radiographs
Tumor evaluation
References
1. American Association of Neuromuscular and Electrodiagnostic Medicine. Choosing Wisely: Five Things Physicians and
Patients Should Question. ABIM Foundation; February 10, 2015. Available at www.choosingwisely.org.
2. England JD, Gronseth GS, Franklin G, et al. Practice Parameter: evaluation of distal symmetric polyneuropathy: role of
laboratory and genetic testing (an evidence-based review). Neurology. 2009;72(2):185-192.
3. Tracy JA, Dyck PJB. Investigations and treatment of chronic inflammatory demyelinating polyradiculoneuropathy and
other inflammatory demyelinating polyneuropathies. Curr Opin Neurol. 2010;23(3):242-248.
4. England JD, Gronseth GS, Franklin G, et al. Distal symmetric polyneuropathy: a definition for clinical research: report
of the American Academy of Neurology, the American Association of Electrodiagnostic Medicine, and the American
Academy of Physical Medicine and Rehabilitation. Neurology. 2005;64(2):199-207.
Thoracic Spine
CPT Codes
72146 �� MRI of thoracic spine, without contrast
72147 �� MRI of thoracic spine, with contrast
72157 �� MRI of thoracic spine, without contrast, followed by re-imaging with contrast

●● Entire thoracic spine (T1-T12), from the cervicothoracic region through the thoracolumbar junction
●● Imaging planes generally include sagittal and axial/oblique axial (parallel with the disc spaces) views
●● Advanced imaging of the thoracic spine is indicated in selected clinical scenarios and is performed significantly less
often than in the cervical and lumbar regions
●● CT is the preferred technique for certain indications, including fracture detection, follow-up of a known fracture,
osseous tumor assessment, congenital vertebral defects and for interventional procedures, such as CT myelography
●● In most other clinical situations, MRI is the modality of choice for thoracic spine imaging, unless contraindicated or
not tolerated by the patient (for example, secondary to claustrophobia)
not allowed. These variations or extra sequences are included within the original imaging request

treatment

●● Thoracic spine dysraphism and other congenital anomalies involving the thoracic spine and/or spinal cord
Fracture evaluation
Infectious process
○○ Abscess
○○ Discitis
Mid-back pain with signs of compression

●● In a patient with mid-back or radicular pain and red flag signs including:
○○ Objective sensory abnormality in the thoracic dermatome distribution
○○ Spasticity
MRI Thoracic Spine | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 180
●● Initial diagnosis; OR
●● Periodic scans to assess asymptomatic progression in multiple sclerosis during the course of disease; OR
●● Tracking the progress of multiple sclerosis to establish a prognosis or evaluation of response to treatment; OR
●● To evaluate changes in neurologic signs and symptoms
Myelopathy
Non-specific mid-back pain

●● In a patient where focused history and physical exam suggest non-specific thoracic pain and/or referred posterior
chest pain and all of the following are met:
○○ Patient has, following clinical examination, completed a minimum of 4-6 consecutive weeks of physician
■■ NSAIDs
■■ Steroids
evaluation; OR
●● Mid-back pain not meeting the above criteria but associated with “red flag” symptoms such as unexplained weight
Post-trauma
Pre-operative or pre-procedure evaluation

Note: This indication is to be used for pre-operative evaluation of conditions not specifically referenced elsewhere in this
guideline

symptoms); OR
Spinal cord infarct
○○ Radiographs
Tumor evaluation
References
Lumbar Spine
CPT Codes
72131 �� CT of lumbar spine, without contrast
72132 �� CT of lumbar spine, with contrast
72133 �� CT of lumbar spine, without contrast, followed by re-imaging with contrast

●● Entire lumbar spine (L1-L5), from the thoracolumbar region through the lumbosacral junction
●● CT of the lumbar spine is often reserved for suspected fracture, follow-up of a known fracture, skeletal abnormalities
such as spondylolysis and spondylolisthesis in operative candidates, congenital vertebral defects, osseous tumor
evaluation, and procedures such as lumbar CT myelography
●● For most other lumbar spine abnormalities, MRI is the modality of choice, unless contraindicated or not tolerated by

MRI is the preferred modality for most lumbar spine advanced imaging, except for a few indications
which include CT evaluation of bony abnormalities (such as suspected fracture or fracture follow-up;
skeletal abnormalities such as spondylolysis and spondylolisthesis in operative candidates; osseous
tumor assessment; developmental vertebral abnormalities) as well as lumbar CT myelography
treatment
Fracture evaluation
Post-trauma
Post-myelogram CT or CT following other lumbar spine interventional procedure
Spondylolysis and spondylolisthesis

●● Following non-diagnostic or abnormal lumbar spine radiographs (including oblique views) which require additional
clarification to direct treatment in an operative candidate
When the patient’s condition meets the lumbar spine MRI guidelines, but there is either a
claustrophobia)
CT Lumbar Spine | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 183
For most other indications, MRI is the preferred modality for advanced lumbar spine imaging, unless contraindicated
●● Lumbar spine dysraphism and other congenital anomalies involving the lumbar spine and/or lower spinal cord
(Conus Medullaris). filum terminale or nerve roots, when MRI is contraindicated
Infectious process
○○ Abscess
○○ Arachnoiditis
○○ Discitis
Low back pain with signs of cauda equina compression1

●● In a patient with low back or radicular pain and red flag signs including:
○○ Severe bilateral sciatica, especially L5-S1 distribution
○○ Saddle or genital sensory disturbance
○○ Bladder, bowel or sexual dysfunction
Note: The diagnosis of acute cord compression is often considered a medical emergency and typically not managed by
elective outpatient imaging
Low back pain with signs of radicular compression

●● In a patient with low back or radicular pain and neurologic findings related to the lumbar spine such as:
○○ Objective sensory abnormality in the lumbar dermatome distribution
○○ Spasticity
Non-specific low back pain

●● In a patient where focused history and physical exam suggest non-specific lumbar pain and/or referred buttock or
lower extremity pain and all of the following are met:
○○ Patient has, following clinical examination, completed a minimum of six (6) consecutive weeks of physician
■■ NSAIDs
■■ Steroids
evaluation; OR
●● Low back pain not meeting the above criteria but associated with “red flag” symptoms such as unexplained weight

Note: This indication is for pre-operative evaluation of conditions not specifically referenced elsewhere in this guideline.
Severe scoliosis, including the following patient populations:
●● With high risk for neural axis abnormalities, such as infantile and juvenile idiopathic scoliosis and congenital
scoliosis; OR
symptoms); OR
●● With scoliosis related to other pathologic processes, such as neurofibromatosis; OR
○○ Radiographs
Tethered cord
Tumor evaluation
References
1. Gardner A, Gardner E, Morley T. Cauda equina syndrome: a review of the current clinical and medico-legal position. Eur
Spine J. 2011;20(5):690-697.
Lumbar Spine
CPT Codes
72148 �� MRI of lumbar spine, without contrast
72149 �� MRI of lumbar spine, with contrast
72158 �� MRI of lumbar spine, without contrast, followed by re-imaging with contrast

●● Entire lumbar spine (L1-L5), from the thoracolumbar region through the lumbosacral junction
●● Imaging planes generally include sagittal and axial/oblique axial (parallel with disc spaces) views
●● For most other lumbar spine abnormalities, MRI is the modality of choice, unless contraindicated or not tolerated by
●● Lumbar spine CT is often reserved for suspected fracture, follow-up of a known fracture, skeletal abnormalities
such as spondylolysis and spondylolisthesis in operative candidates, congenital vertebral defects, osseous tumor
evaluation, and procedures such as lumbar CT myelography
●● For the majority of patients with acute low back pain, symptoms and/or physical exam findings will improve or
resolve during a trial of conservative treatment and diagnostic imaging is not necessary
●● The spinal cord normally ends at L1-L2, which is seen on thoracic MRI. If the conus medullaris is not seen on
thoracic spine imaging, the spinal cord is presumed to be tethered and lumbar MRI is appropriate
●● Definitive diagnosis is not achieved in as many as 85% of patients with low back pain
not allowed. These variations or extra sequences are included within the original imaging request
Common Diagnostic Imaging

treatment

●● Lumbar spine dysraphism and other congenital anomalies involving the lumbar spine and/or lower spinal cord
(conus medullaris), filum terminale or nerve roots
Fracture evaluation
Infectious process
○○ Abscess
○○ Arachnoiditis
○○ Discitis
MRI Lumbar Spine | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 186
Low back pain with signs of cauda equina compression1
●● In a patient with low back or radicular pain and red flag signs including:
○○ Severe bilateral sciatica, especially L5-S1 distribution
○○ Saddle or genital sensory disturbance
○○ Bladder, bowel or sexual dysfunction
Note: The diagnosis of acute cord compression is often considered a medical emergency and typically not managed by
elective outpatient imaging
Low back pain with signs of radicular compression

●● In a patient with low back or radicular pain and neurologic findings related to the lumbar spine such as:
○○ Objective sensory abnormality in the lumbar dermatome distribution
○○ Spasticity
Myelopathy involving the lower spinal cord
Non-specific low back pain2-4

●● In a patient where focused history and physical exam suggest non-specific lumbar pain and/or referred buttock or
lower extremity pain and all of the following are met:
○○ Patient has, following clinical examination, completed a minimum of six (6) consecutive weeks of physician
■■ NSAIDs
■■ Steroids
evaluation; OR
●● Low back pain not meeting the above criteria but associated with “red flag” symptoms such as unexplained weight
Post-trauma

guideline

symptoms); OR
Spinal cord infarct
○○ Radiographs
Spondylolysis and spondylolisthesis

●● Following non-diagnostic or abnormal lumbar spine radiographs (including oblique views) which require additional
clarification to direct treatment, in an operative candidate
Tethered cord
Tumor evaluation
References
1. Gardner A, Gardner E, Morley T. Cauda equina syndrome: a review of the current clinical and medico-legal position. Eur
Spine J. 2011;20(5):690-697.
2. American College of Physicians. Choosing Wisely: Five Things Physicians and Patients Should Question. Philadelphia,
PA: ABIM Foundation; April 4, 2012. Available at http://choosingwisely.org/wp-content/uploads/2012/04/5things_12_
factsheet_Amer_College_Phys.pdf. Accessed May 15, 2012
3. North American Spine Society. Choosing Wisely: Five Things Physicians and Patients Should Question. Philadelphia,
PA: ABIM Foundation; October 9, 2013. Available at http://www.choosingwisely.org/societies/north-american-spine-
society/ Accessed October 10, 2015.
4. American College of Emergency Physicians. Choosing Wisely: Ten Things Physicians and Patients Should Question.
Philadelphia, PA: ABIM Foundation; October 14, 2013 and October 27, 2014. Available at http://www.choosingwisely.org/
societies/american-college-of-emergency-physicians/ Accessed October 10, 2015.
MR Angiography (MRA)
Spinal Canal
CPT Codes
72159 �� Magnetic resonance angiography of spinal canal

●● Scan coverage depends on the specific clinical indication for the spinal canal MRA
●● General landmarks extend from the cranio-cervical junction through the lumbosacral region
●● MRA of the spinal canal is an infrequently requested exam. Potential applications which have been described
include evaluation of spinal arteriovenous fistula (AVF) and arteriovenous malformation (AVM). These vascular
lesions are usually detected by MRI or myelography. Intra-arterial digital subtraction angiography (DSA) of the spinal
vasculature may be necessary to define the precise location and type of vascular abnormality
●● MRI of the spinal canal CPT 72159 includes imaging of the entire spinal canal. Requests for multiple exams to
address each anatomic area of the spinal canal are inappropriate
Magnetic Resonance Angiography of the Spinal Canal

●● MR Angiography (MRA) of the spinal canal is an evolving technology under clinical development. This clinical
application of MRA and its impact on health outcomes will continue to undergo review, as new evidence-based
studies are published. At this point, medically necessary applications are limited (see below). Interval routine
coverage for MR angiography of the spinal canal is not generally available and is not considered medically
appropriate at this time
Diagnostic Indications
treatment

MRA Spinal Canal | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 189
Spine Bibliography
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6. Blackmore CC, Emerson SS, Mann FA, Koepsell TD. Cervical spine imaging in patients with trauma: determination of
fracture risk to optimize use. Radiology. 1999;211:759-765.
7. Bot JC, Blezer EL, Kamphorst W, et al. The spinal cord in multiple sclerosis: relationship of high spatial-resolution
quantitative MR imaging findings to histopathologic results. Radiology. 2004;233:531-540.
8. Brant-Zawadzki MN, Dennis SC, Gade GF, Weinstein MP. Low back pain. What the clinician wants to know. Radiology.
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9. Braun J, van den Berg R, Baraliakos X, et al. 2010 update of the ASAS/EULAR recommendations for the management
of ankylosing spondylitis. Ann Rheum Dis 2011;70(6):896-904.
10. Bub L, Balckmore CC, Mann FA, Lomoschitz FM. Cervical spine fractures in patients 65 years and older: a clinical
prediction rule for blunt trauma. Radiology. 2005;234:143-149.
11. Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet.
2009. 373(9662):463-472.
12. Chou R, Qaseem A, Owens DK, Shekelle P. Diagnostic imaging for low back pain: advice for high-value health care from
the American College of Physicians. Ann Int Med. 2011;154:181-189.
13. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the
American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491
14. Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344(5):363-370.
15. Gilbert FJ, Grant AM, Gillan MGC, et al. Low back pain: influence of early MR imaging or CT on treatment and outcome-
multicenter randomized trial. Radiology. 2004;231:343-351.
16. Gillan MG, Gilbert FJ, Andrew JE, et al. Influence of imaging on clinical decision making in the treatment of lower back
pain. Radiology. 2001;220:393-399.
17. Gray DT, Hollingworth W, Balckmore CC, et al. Conventional radiography, rapid MR imaging and conventional MR
imaging for low back pain: activity-based costs and reimbursement. Radiology. 2003;227:669-680.
18. Guyer RD, Ohnmeiss DD. Contemporary concepts in spine care lumbar discography. Spine. 1995;20(18):2048-2059.
19. Hanson JA, Blackmore CC, Mann FA, Wilson AJ. Cervical spine injury. a clinical decision rule to identify high-risk
patients for helical CT screening. AJR Am J Roentgenol. 2000;174:713-717.
20. Jaramillo D, Poussaint TY, Grottkau BE, et al. Scoliosis: evidence-based diagnostic evaluation. Neuroimaging Clin N
Am. 2003;13:335-341.
21. Jaramillo D, Poussaint TY, Grottkau BE. Scoliosis: evidence-based diagnostic evaluation. Neuroimaging Clin N Am.
2003;13:335-341.
22. Jarvik J. Imaging of adults with low back pain in the primary care setting. Neuroimaging Clin N Am. 2003;13:293-305.
23. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137:586-
597.
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24. Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back
pain: a randomized controlled trial. JAMA. 2003;289:2810-2818.
25. Keenan HT, Hollingshead MC, Chung CJ, Ziglar MK. Using CT of the cervical spine for early evaluation of pediatric
patients with head trauma. AJR Am J Roentgenol. 2001;177:1405-1409.
26. Koeller KK, Rosenblum RS, Morrision AL. Neoplasms of the spinal cord and filum terminale: radiologic-pathologic
correlation. Radiographics. 2000;20:1721-1749.
27. Mazanec DJ, Podichetty,VK, Hsia A. Lumbar canal stenosis: start with nonsurgical therapy. Cleve Clin J Med.
2002;69(11):909-917.
28. National Collaborating Centre for Chronic Conditions (UK). Rheumatoid Arthritis: National Clinical Guideline for
Management and Treatment in Adults. National Institute for Health and Clinical Excellence (NICE) Clinical Guidelines,
No. 79. London: Royal College of Physicians (UK); February 2009.
29. Quality Standards Subcommittee of the American Academy of Neurology. Practice parameters: magnetic resonance
imaging in the evaluation of low back syndrome. Neurology. 1994;44:767-770.
30. Resnick DK, Malone DG, Ryken TC. Guidelines for the use of discography for the diagnosis of painful degenerative
lumbar disc disease. Neurosurg Focus. 2002;13(2):1-9.
31. Shekelle P. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of
Physicians and the American Pain Society. What’s new? What’s different? National Guideline Clearinghouse, Expert
commentary. http://www.guidelines.gov/expert/expert-commentary.aspx?id=16452. February 11, 2008. Accessed
January 3, 2012.
32. Sliker C, Mirvis S, Shanmuganathan K. Assessing cervical spine stability in obtunded blunt trauma patients: review of
medical literature. Radiology. 2005;234:733-739.
33. Staiger TO, Paauw DS, Deyo RA, Jarvik JG. Imaging studies for acute low back pain. When and when not to order
them. Postgrad Med. 1999;105(4):161-162,165-166,171-172.
34. Wintermark M, Mouhsine E, Theumann N, et al. Thoracolumbar spine fractures in patients who have sustained severe
trauma: depiction with multi-detector row CT. Radiology. 2003;227:681-689
39. North American Spine Society. Choosing Wisely: Five Things Physicians and Patients Should Question. Philadelphia,
PA: ABIM Foundation; October 9, 2013. Available at http://www.choosingwisely.org/societies/north-american-spine-
society/ Accessed October 10, 2015.
40. American College of Emergency Physicians. Choosing Wisely: Ten Things Physicians and Patients Should Question.
Philadelphia, PA: ABIM Foundation; October 14, 2013 and October 27, 2014. Available at http://www.choosingwisely.org/
societies/american-college-of-emergency-physicians/ Accessed October 10, 2015.
Spine Bibliography | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 191
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

●● Scan coverage depends on the specific clinical indication for the exam and varies considerably, based on anatomic
considerations (from shoulder through fingers) and clinical manifestations
●● Depending on the protocol used, the CT data acquisition(s) may allow for diagnostic multi-planar reconstructions
through the region of interest
●● Conventional radiographs should be obtained before advanced imaging
●● 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
●● If radiographic findings are typical of osteomyelitis, advanced imaging may not be necessary
●● In osteomyelitis, CT may be helpful in defining bone sequestra
●● For evaluation of musculoskeletal tumors, MRI is generally preferred over CT, unless there is a contraindication to
performance of an MRI exam
●● Use of contrast (intravenous or intra-articular for CT arthrogram) is at the discretion of both the ordering and imaging physicians
●● 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

treatment
Chronic shoulder pain

●● In a patient where focused history and physical exam suggest non-specific upper extremity pain, rotator cuff
tendinopathy, adhesive capsulitis or subacromial impingement syndrome; AND
●● Following non-diagnostic conventional radiographs; AND
●● Patient has completed a minimum of six (6) consecutive weeks of physician supervised conservative treatment for
the current episode of pain, including but not limited to:
○○ Physical therapy (home exercise only if physical therapy is not available); AND
●● After trial of conservative treatment as listed above, patient fails to show substantial improvement on clinical reevaluation
CT accompanying an arthrogram (CT arthrography)
Fracture evaluation
●● To confirm a suspected (occult) fracture following initial radiographs; OR
●● To define the extent of an acute fracture and position of fracture fragments; OR
●● To assess fracture healing for delayed union or non-union
CT Upper Extremity | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 192
Hemarthrosis (bloody joint effusion)
●● Documented by arthrocentesis except in cases when arthrocentesis is contraindicated (e.g. non-traumatic causes of
hemarthrosis such as sickle cell, anticoagulant, or hemophilia)
Infectious process
●● In a patient where focused history and physical exam suggest an underlying soft tissue infection when:
○○ Patient is unresponsive to treatment including but not limited to antibiotics or incision/drainage
●● Abscess - to determine the location and extent for surgical treatment
●● Osteomyelitis – following non-diagnostic radiographs and when MRI is contraindicated
●● Fasciitis
Intra-articular loose body, including synovial osteochondromatosis
Neuropathic osteodystrophy (Charcot joint)

●● 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)
Osteonecrosis [avascular necrosis (AVN); aseptic necrosis]

●● Requires initial plain films, prior to advanced imaging
●● MRI is often the preferred imaging modality, particularly for evaluation in the early stages of osteonecrosis
●● Common anatomic locations for osteonecrosis in the upper extremity are:
○○ Humeral head
○○ Radial head
○○ Carpal navicular bone
○○ Lunate bone (lunate osteonecrosis also referred to as Kienbock’s disease)

guideline
Pre-operative evaluation of anterior glenohumeral instability

●● Radiography insufficient for presurgical planning; AND
●● Recurrent anterior shoulder dislocation; OR
●● First time dislocation
○○ Young and at high risk for recurrence1-2
Septic arthritis - when MRI is contraindicated

●● When any of the following risk factors are present:
○○ Underlying joint disease
○○ Joint prosthesis
○○ IV drug abuse
○○ Diabetes
○○ Presence of cutaneous ulcers; OR
●● Pre-operative planning
Significant trauma
●● Usually preceded by initial plain film radiographs
Soft tissue mass
●● Soft-tissue evaluation when prominent calcifications are seen on radiograph;
●● Spontaneous soft tissue hemorrhage with or without palpable mass
●● Surveillance, without pathologic tissue confirmation, of an unexplained mass identified on prior imaging
●● Following a non-diagnostic radiograph to evaluate a palpable mass found on physical exam
Note: MRI is typically preferred in the evaluation of soft tissue masses
Tumor evaluation: primary neoplasm or metastatic disease

●● Biopsy-proven malignancy
When the patient’s condition meets the upper extremity MRI guidelines, but there is either a
claustrophobia)
References
1. Bencardino JT, Gyftopoulos S, Palmer WE. Imaging in anterior glenohumeral instability. Radiology. 2013;269(2):323-
337.
2. Piasecki DP, Verma NN, Romeo AA, Levine WN, Bach BR Jr, Provencher MT. Glenoid bone deficiency in recurrent
anterior shoulder instability: diagnosis and management. J Am Acad Orthop Surg. 2009;17(8):482-493.
3. 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 ;64(6):615-621.
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

(from shoulder joint through hand/digits) and clinical considerations
●● MRI routinely provides multi-planar imaging through the region of interest
●● Use of contrast (intravenous or intra-articular) is at the discretion of both the ordering and imaging physicians
●● MRI is used more often to evaluate internal derangements of the joints and related tendinous, ligamentous and
cartilaginous structures
●● MRI is also useful for evaluation of possible osteomyelitis, despite negative or non-diagnostic plain films and/or triple-phase
bone scintigraphy. One exception for osteomyelitis is detection of bone sequestra, which may be better depicted with CT
●● For evaluation of musculoskeletal tumors, MRI is generally preferred over CT, unless there is a contraindication to
performance of an MRI exam
●● For suspected osteonecrosis, MRI is often more sensitive than CT and bone scintigraphy
●● Implanted surgical hardware, including joint prostheses, may produce sufficient local artifact to preclude adequate
imaging through the region containing hardware

This section contains general upper extremity, shoulder, elbow, and wrist and hand joint indications.
General Upper Extremity
treatment
EMG-proven entrapment neuropathy after conservative therapy to direct treatment

●● Suspected entrapment neuropathy, cubital tunnel detail, and/or carpal tunnel are not considered medically
necessary
Fracture evaluation12
(Any one of the following)
●● To confirm a suspected occult/stress fracture following non-diagnostic initial radiographs at high risk sites:
○○ Scaphoid
○○ Lunate
●● To define the extent of an acute fracture when surgery is being considered
●● To assess fracture healing for delayed union or non-union, when repeat radiographs are non-diagnostic
MRI Upper Extremity (Any Joint) | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 195
Infectious process
●● In a patient where focused history and physical exam suggest a underlying soft tissue infection when:
●● Abscess – to determine the location and extent for surgical treatment
●● Osteomyelitis – following non-diagnostic radiographs
●● Fasciitis
Intraarticular loose body

●● Following non-diagnostic radiographs
Note: Includes synovial osteochondromatosis
Ligament and tendon injuries

●● In a patient following a focused history and physical exam; AND
●● After a trial of conservative treatment (that may include physical therapy, for the current episode of pain); AND
●● Patient fails to show substantial improvement on clinical reevaluation
MRI accompanying an arthrogram (MR arthrography)

●● Following conventional radiographs, when there is need for additional diagnostic information from an MRI exam to
Non-specific upper extremity pain

●● In a patient where focused history and physical exam suggest non-specific upper extremity pain; AND
●● Following normal or non-diagnostic conventional radiographs; AND
●● Atraumatic; AND
●● At least one of the following:
○○ Significant weakness; OR
○○ No improvement following clinical re-evaluation after a minimum of six (6) consecutive weeks of physician
supervised conservative treatment for the current episode of pain, including but not limited to:
■■ NSAIDs or steroids (oral or injection) – unless contraindicated
■■ Physical therapy (home exercise only if physical therapy is not available)
Note: For suspicion of specific etiology, especially red flag conditions such as tumor, infection and acute trauma, please
refer to the corresponding indication
Osteochondral lesion

●● Common anatomic locations for osteonecrosis in the upper extremity are:
○○ Humeral head
○○ Radial head
○○ Carpal navicular bone
○○ Lunate bone (lunate osteonecrosis also referred to as Kienbock’s disease)
Pigmented Villonodular synovitis (PVNS)

guideline
Septic arthritis
○○ Diabetes
Significant trauma
Soft tissue mass

●● Soft-tissue evaluation when prominent calcifications are seen on radiograph

Shoulder Joint Imaging

Anterior glenohumeral instability/labral tear
Diagnosis of anterior glenohumeral instability/anterior labral tear
●● Recurrent anterior shoulder dislocation2 OR
●● First time dislocation
○○ Young and at high risk for recurrence3
Acute shoulder pain

●● In a patient who is a candidate for corticosteroid or anesthetic injection and one of the following:
○○ Suspected bursitis; OR
○○ Suspected long head of biceps tenosynovitis
Chronic shoulder pain

●● In a patient where focused history and physical exam suggest non-specific upper extremity pain, adhesive capsulitis
or subacromial impingement syndrome; AND
●● After trial of conservative treatment as listed above, patient fails to show substantial improvement on clinical re-evaluation
Rotator Cuff Tear
Diagnosis of acute rotator cuff tear
●● Following non-diagnostic radiographs and/or ultrasound
●● At least one (1) positive sign to support the diagnosis of rotator cuff tear (see Table 1)
●● No improvement after an initial trial of conservative therapy, including 4 weeks of physical therapy, unless the patient
is at high risk for an acute full thickness rotator cuff tear (see Table 2)
Diagnosis of chronic rotator cuff tear
●● At least one (1) positive sign to support the diagnosis of rotator cuff tear (see Table 1)
●● Following non-diagnostic radiograph and/or ultrasound
●● Symptoms have persisted for more than 3 months despite optimal medical management
Management of rotator cuff tear
●● Post-operative 5
○○ Suspicion of recurrent rotator cuff tear
○○ Post-surgical complication
Note: For patients who have not had surgery when there is a concern for recurrent rotator cuff tear, see the diagnosis of
rotator cuff tear guideline. Ultrasound, radiographs, or CT arthrography are generally preferred in the evaluation of
recurrent rotator cuff tear after total shoulder arthroplasty
Table 1: Findings suggestive of a rotator cuff tear include but are not limited to the following: 12
Positive (elicits weakness and/or pain) for at least one of the following:
●● Apley scratch test ●● External rotation lag sign ●● Lift off
●● Apprehension ●● Hawkins-Kennedy ●● Neer
●● Belly press/belly off ●● Hornblower ●● Painful arc
●● Cross body ●● Infraspinatus muscle strength test ●● Patte
●● Drop arm/sign ●● Jobe’s test ●● Resisted abduction
●● Empty can / Full can
Table 2: High risk patients have at least one of the following symptoms to suggest either an acute full
thickness rotator cuff tear or an alternative etiology for acute shoulder pain
●● Acute traumatic event ●● Decreased pulse
●● Positive drop arm ●● Plateau in therapy response
●● Profound loss of strength ●● Worsening of symptoms during therapy
●● Loss of sensation ●● At least two signs of a SLAP tear
Superior Labrum Anterior Posterior (SLAP) tears
Diagnosis of SLAP tears
●● Clinical findings of a SLAP tear (see Table 3) and one of the following:
○○ Symptoms do not improve or worsen after 4 weeks of conservative therapy
○○ High risk patient defined as (see Table 4)
Management of Labral tears
●● Pre-operative
○○ Labral tear established by a modality other than MRI; OR
○○ More than 1 year between MRI and surgical evaluation
●● Post-operative
○○ No clinical improvement; AND
○○ At least three months after surgery
Table 3: Clinical findings of a SLAP tear may include but are not limited to the following: 6-8
Pain exacerbated by overhead activity or heavy lifting
Popping or locking of the shoulder
Signs of shoulder instability:
●● Speed’s biceps tendon test
●● O’Brien’s test
●● Compression-Rotation test
●● Yergason’s test
Table 4: Patients at High Risk for SLAP tears:

●● Acute trauma; AND
●● Under 45 years of age; OR
●● Evidence of suprascapular nerve entrapment including but not limited to
○○ Posterolateral shoulder pain; OR
○○ Supraspinatus and/or infraspinatus weakness; OR
○○ Supraspinatus and/or infraspinatus atrophy
Suspected occult shoulder fracture

●● With high clinical suspicion and negative or inconclusive shoulder radiographs
Elbow Imaging
Biceps tendon rupture
●● At insertion onto radial tuberosity
Capitellar osteochondritis
Epicondylitis
●● After a trial of conservative treatment (that may include physical therapy for strengthening); AND
●● 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
Ulnar collateral ligament tear
Suspected occult elbow fracture
●● With high clinical suspicion and negative or inconclusive elbow radiographs
Triceps tendon rupture

●● From olecranon insertion site
Additional Indications for Wrist and Hand Imaging

Scaphoid fracture
Triangular fibrocartilage complex (TFCC) tear
Ulnar collateral ligament tear (gamekeeper’s thumb)

MRI is not indicated in the following clinical situations
The indications listed in this section do not require advanced imaging using MRI. If there are circumstances that require MRI
imaging, a peer-to-peer discussion may be required.
Subacromial impingement 9-11

Note: Imaging is not indicated unless there is concern for a rotator cuff tear
References
suspicious soft-tissue masses. Clin Radiol. 2009 Jun;64(6):615-621.
2. Bencardino JT, Gyftopoulos S, Palmer WE. Imaging in anterior glenohumeral instability. Radiology. 2013;269(2):323-
337.
3. Li X, Ma R, Nielsen NM, Gulotta LV, Dines JS, Owens BD. Management of shoulder instability in the skeletally immature
patient. J Am Acad Orthop Surg. 2013;21(9):529-537.
4. Jain NB, Wilcox RB 3rd, Katz JN, Higgins LD. Clinical examination of the rotator cuff. PM R. 2013;5(1):45-56.
5. Mohana-Borges AV, Chung CB, Resnick D. MR imaging and MR arthrography of the postoperative shoulder: spectrum
of normal and abnormal findings. Radiographics. 2004;24(1):69-85.
6. Hanchard NC, Lenza M, Handoll HH, Takwoingi Y. Physical tests for shoulder impingements and local lesions of bursa,
tendon or labrum that may accompany impingement. Cochrane Database Syst Rev. 2013;4:CD007427.
7. Keener JD, Brophy RH. Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment. J Am Acad
Orthop Surg. 2009;17(10):627-637.
8. Nam EK, Snyder SJ. The diagnosis and treatment of superior labrum, anterior and posterior (SLAP) lesions. Am J
Sports Med. 2003;31(5):798-810
9. Diercks R, Bron C, Dorrestijn O, et al. Guideline for diagnosis and treatment of subacromial pain syndrome. Acta
Orthop. 2014;85(3):314-322.
10. Ketola S, Lehtinen J, Rousi T, Nissinen M, Huhtala H, Arnala I. Which patients do not recover from shoulder
impingement syndrome, either with operative treatment or with nonoperative treatment? Acta Orthop. March 2015:1-6.
11. Ketola S, Lehtinen J, Arnala I, et al. Does arthroscopic acromioplasty provide any additional value in the treatment of
shoulder impingement syndrome?: a two-year randomised controlled trial. J Bone Joint Surg Br. 2009;91(10):1326-
1334.
12. Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Am J Sports Med. 29(1):100-111.
13. Hegedus EJ, Goode a. P, Cook CE, et al. Which physical examination tests provide clinicians with the most value
when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med.
2012;46(14):964-978
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

(from shoulder joint through hand/digits) and clinical considerations
●● MRI routinely provides multi-planar imaging through the region of interest
and some incomplete or non-displaced fractures may be better imaged with MRI or radionuclide bone scintigraphy
●● MRI is often the preferred modality for evaluation of soft tissue abnormalities and for interrogation of possible
osteomyelitis, despite negative or non-diagnostic plain films and/or triple-phase bone scintigraphy. One exception for
osteomyelitis is detection of bone sequestra, which may be better depicted with CT
●● If radiographic findings are typical of osteomyelitis, advanced diagnostic imaging may not be necessary
●● Use of contrast is at the discretion of both the ordering and imaging physicians
●● 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

treatment
Brachial plexopathy
Brachial plexus mass
EMG-proven entrapment neuropathy after conservative therapy to direct treatment

●● Suspected entrapment neuropathy, cubital tunnel detail, and/or carpal tunnel are not considered medically
necessary
Fracture evaluation
○○ Scaphoid
○○ Lunate
MRI Upper Extremity (Non-Joint) | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 201
Infectious process
●● Fasciitis
Myositis
●● To determine optimal location for biopsy; OR
●● To monitor treatment response
Persistent upper extremity pain – unresponsive to six (6) weeks of conservative treatment
●● In a patient where focused history and physical exam suggest non-specific upper extremity pain; AND
○○ NSAIDs or steroids (oral or injection) – unless contraindicated; OR
●● After trial of conservative treatment as listed above, patient fails to show substantial improvement on clinical re-
evaluation
Note: For suspicion of specific etiology, please refer to corresponding indication

guideline.
Septic arthritis
●● 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
●● For cases of known septic arthritis, MRI may be used when any of the following risk factors are present:
○○ Diabetes
Significant trauma
Soft tissue mass

Ulnar collateral ligament tear (gamekeeper’s thumb)
References
(MRA) Upper Extremity
CPT Codes
73206 �� Computed tomographic angiography, upper extremity, with contrast material(s), including non-contrast
images, if performed, and image post-processing
73225 �� Magnetic resonance angiography, upper extremity, without and with contrast

●● Depends on the specific anatomic area of interest, from the axillary region through the hand and digits
●● CT and MR angiographic techniques include arterial and/or venous assessment, depending on the clinical indication
●● Other generally available non-invasive arterial studies of the upper extremity circulation should be considered prior
to advanced diagnostic imaging with CTA or MRA. These include segmental systolic pressure measurements,
plethysmographic analysis, continuous wave Doppler and/or duplex ultrasonography
●● CT angiography utilizes the data obtained from standard CT imaging. A request for a CT exam in addition to a CT
Angiography of the same anatomic area during the same imaging session is inappropriate
●● For MR arthrography of the upper extremity, see CPT codes 73221-73223
●● For imaging the brachial plexus, see CT upper extremity or MRI upper extremity, non-joint

Aneurysm / dilation
Arterial entrapment syndrome
Arterio-venous malformation (AVM) or fistula (AVF)
Dialysis graft evaluation

●● Following duplex Doppler assessment
Dissection
Intramural hematoma

Raynaud’s syndrome
Steno-occlusive disease
●● Usually atherosclerotic in origin
Thromboembolic disease – arterial or venous
Vascular invasion or compression by a musculoskeletal neoplasm
Vasculitis
CTA and MRA Upper Extremity | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 204
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

●● Scan coverage depends on the anatomic area of concern and varies considerably, based on anatomic (from hip
through toes) and clinical considerations
●● Depending on the protocol used, the CT data acquisition(s) may allow for diagnostic multi-planar reconstructions
through the region of interest
●● In osteomyelitis, CT may be helpful in defining bony sequestra
●● Use of contrast (intravenous and intra-articular) is at the discretion of both the ordering and imaging physicians

treatment
CT accompanying an arthrogram (CT arthrography)
Fracture evaluation
●● To confirm a suspected (occult) fracture following initial radiographs; OR
●● To define the extent of an acute fracture and position of fracture fragments; OR
●● To assess fracture healing for delayed union or non-union

Infectious process
●● Abscess – to determine the location and extent for surgical treatment
●● Osteomyelitis – following non-diagnostic radiographs and when MRI is contraindicated
●● Fasciitis

●● Following conventional radiographs, when there is need for additional diagnostic information from a CT exam to
CT Lower Extremity | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 205
●● MRI is often the preferred imaging modality, particularly for evaluation during the early stages of osteonecrosis
Persistent lower extremity pain (excluding knee joint)

●● In a patient where focused history and physical exam suggest non-specific lower extremity pain; AND
●● After a trial of conservative treatment (that may include physical therapy, NSAIDs, steroids unless contraindicated,
for this current episode of pain); AND

Note: For post-operative evaluation of conditions not specifically referenced elsewhere in this guideline.

Exclusion: This indication does not apply to preoperative evaluation for primary total knee arthroplasty for osteoarthritis.
Septic arthritis - when MRI is contraindicated

○○ Diabetes
Significant trauma
Tarsal coalition
●● Following foot radiographs
Soft tissue mass

Note: MRI is typically preferred in the evaluation of soft tissue masses

When the patient’s condition meets the lower extremity MRI guidelines, but there is either a
claustrophobia)
References
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.
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

●● Scan coverage depends on the specific clinical indication and varies considerably, based on anatomic and clinical
considerations. 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)
●● Routine MRI examinations provide multi-planar imaging of the joint or non-joint region(s) of interest
●● Use of contrast (intravenous and intra-articular) is at the discretion of both the ordering and imaging physicians
●● MRI is often used to evaluate soft tissue abnormalities and to interrogate for possible osteomyelitis, despite negative
or non-diagnostic plain films and/or triple-phase bone scintigraphy. One exception for osteomyelitis is detection of
bone sequestra, which may be better depicted with CT
●● For suspected osteonecrosis, MRI is often more sensitive than CT or bone scintigraphy
●● Implanted surgical hardware, including joint prostheses, may produce sufficient local artifact to preclude adequate
imaging through the region containing hardware
●● For suspected Baker’s cysts, ultrasound should be performed before advanced imaging exams

This section contains general lower extremity, hip, knee, and ankle and foot indications.
General Lower Extremity
treatment
MRI Lower Extremity (Joint & Non-Joint) | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 208
Fracture evaluation5-12
○○ Femoral neck/proximal femur
○○ Tibia (anterior/lateral)
○○ Patella
○○ Medial malleolus
○○ Talus
○○ Navicular
○○ Metatarsal base (second and fifth digits)
○○ Great toe seasamoid

Infectious process
●● Fasciitis
Intraarticular loose body

●● Following non-diagnostic radiographs
Note: Includes synovial osteochondromatosis
MRI accompanying an arthrogram (MR arthrography)
Myositis
●● To determine optimal location for biopsy; OR
●● To monitor treatment response
Osteochondral lesion

●● MRI is often the preferred imaging modality, particularly for evaluation during the early stages of osteonecrosis
Persistent lower extremity pain (excluding knee joint)

●● In a patient where focused history and physical exam suggest non-specific lower extremity pain; AND
●● After a trial of conservative treatment (that may include physical therapy, NSAIDs, steroids unless contraindicated,
for this current episode of pain); AND
Pigmented Villonodular synovitis (PVNS)
Note: For post-operative evaluation of conditions not specifically referenced elsewhere in this guideline. This guideline
does not include post-operative knee replacement for osteoarthritis
Preoperative or pre-procedure evaluation, for conditions other than knee replacements for
osteoarthritis
Note: For preoperative evaluation of conditions not specifically referenced elsewhere in this guideline.
Exclusion: This indication does not apply to preoperative evaluation for primary total knee arthroplasty for osteoarthritis.
Radiographs are typically sufficient for the preoperative evaluation for osteoarthritis prior to total knee arthroplasty.
Septic arthritis
○○ Diabetes
Significant trauma
Soft tissue mass

●● Soft-tissue evaluation when prominent calcifications are seen on radiograph;
●● Evaluation of a palpable soft tissue mass (excluding posterior knee masses) on physical examination following a
non-diagnostic radiograph
●● Evaluation of a palpable posterior knee mass on physical examination following a non-diagnostic radiograph AND a
non-diagnostic ultrasound

Hip Joint
Labral tear
Occult hip fracture

●● With high clinical suspicion and negative or inconclusive hip radiographs
Knee Joint
Chondromalacia patella (patellofemoral pain syndrome)3

●● Patient has completed a minimum of four (4) consecutive weeks of physician supervised conservative treatment for
the current episode of pain; AND
Ligament tear
●● In a patient where focused history and physical exam suggests a ligament tear; AND
evaluation; OR
●● For pre-operative evaluation, based on physical exam findings which may include one of the following:
○○ Positive Lachman test; OR
○○ Positive pivot shift test; OR
○○ Positive anterior or posterior drawer test; OR
○○ Positive medial or lateral stress tests
Meniscal tear/injury
●● In a patient where focused history and physical exam suggests a meniscal tear; AND
○○ NSAIDs or steroids (oral or injection) – unless contraindicated; AND
evaluation; OR
●● For pre-operative evaluation, based on physical exam findings which may include one of the following:
○○ Positive McMurray test with minimal knee flexion; OR
○○ A severe twisting injury after which activity could not be resumed; OR
○○ An anterior cruciate ligament tear is present; OR
○○ Locking; OR
○○ Swelling and symptoms develop immediately after an acute injury; OR
○○ Inability to bear weight; OR
○○ Inability to fully extend knee
Osteochondritis dissecans4
Post-operative evaluation following repair of a ligamentous or tendinous tear, with new

symptoms
Ankle and Foot
Acute and chronic tendon injuries

●● After a trial of conservative treatment (that may include physical therapy, for the current episode of pain); AND
Acute tendon rupture

●● For pre-operative evaluation based on
○○ Severe muscle weakness from the involved tendon; OR
○○ Non-diagnostic X-ray for bone avulsion; OR
○○ Non-diagnostic ultrasound evaluation
Diabetic foot disease
Morton’s neuroma
●● When the diagnosis is not clear on physical examination or ultrasound

●● 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)
Plantar fasciitis
●● For pre-operative evaluation following a failure of six (6) months of physician supervised conservative treatment
Tarsal coalition
●● Following foot radiographs
Note: CT may be preferred for bony coalition
Tarsal tunnel
●● Following EMG nerve conduction study if not responsive to four weeks of conservative treatment
●● Neuropathy secondary to entrapment or compression of the posterior tibial nerve or its branches in the fibro-osseous
tunnel, deep to the flexor retinaculum
References
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 Medical Society for Sports Medicine. Choosing Wisely: Five Things Physicians and Patients Should Question.
ABIM Foundation; 2014. Available at www.choosingwisely.org.
4. 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.
5. Tins BJ, Garton M, Cassar-Pullicino VN, Tyrrell PNM, Lalam R, Singh J. Stress fracture of the pelvis and lower limbs
including atypical femoral fractures-a review. Insights Imaging. 2015;6(1):97-110.
7. Kiuru MJ, Pihlajamaki HK, Ahovuo JA. Fatigue stress injuries of the pelvic bones and proximal femur: evaluation with
MR imaging. Eur Radiol. 2003;13(3):605-611.
8. Kiuru MJ, Pihlajamaki HK, Hietanen HJ, Ahovuo JA. MR imaging, bone scintigraphy, and radiography in bone stress
injuries of the pelvis and the lower extremity. Acta Radiol. 2002;43(2):207-212.
9. Ohta-Fukushima M, Mutoh Y, Takasugi S, Iwata H, Ishii S. Characteristics of stress fractures in young athletes under 20
years. J Sports Med Phys Fitness. 2002;42(2):198-206.
10. Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg. 8(6):344-353.
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(MRA) Lower Extremity
CPT Codes
73706 �� Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast
images, if performed, and image postprocessing
73725 �� Magnetic resonance angiography, lower extremity, without and with contrast

●● Depends on the area of interest and may extend from the iliofemoral regions through the feet
●● Other generally available non-invasive arterial studies of the lower extremity circulation should be considered prior
to advanced diagnostic imaging with CTA or MRA. These may include segmental systolic pressure measurements,
plethysmographic analysis, continuous wave Doppler and/or duplex ultrasonography of the lower extremity arterial
or venous circulations
●● 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
●● CT angiography utilizes the data obtained from standard CT imaging. An authorization request for a CT exam in
addition to a CT angiography of the same anatomic area during the same imaging session is inappropriate
●● A request for a CT lower extremity venogram is a request for a CTA of the lower extremity. A quick look at the
vasculature of the lower extremity at the time of a CT or CTA of the chest for pulmonary embolism evaluation should
not be separately entered or reported

Aneurysm / dilation
Arterial entrapment syndrome
Arteriovenous malformation (AVM) or fistula (AVF)
Critical ischemia
●● For example, in diabetic vascular disease with ischemic ulcers or gangrene
Dissection
Intramural hematoma

Thromboembolic disease – arterial or venous
CTA and MRA Lower Extremity | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 213
Vascular assessment for lower extremity claudication
●● CPT coding for abdominal aortic and run-off evaluation, which involves image post-processing for three-dimensional
reconstructions, should follow:
○○ For CTA: 75635 - CTA of abdominal aorta and bilateral iliofemoral lower extremity run-off without contrast,
followed by re-imaging with contrast
○○ For MRA: 74185 - abdominal MRA and 73725 - bilateral lower extremity MRAs
●● 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) when walking, which disappears at rest
●● 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 indices (ABI) of < 0.9 may undergo advanced imaging. Rest pain or severe occlusive disease
typically occurs with ABI < 0.5
Vascular invasion or compression by a musculoskeletal neoplasm
Vasculitis
Venous compression, due to surrounding mass effect
Venous thrombosis
CTA and MRA Lower Extremity | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 214
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55. Diercks R, Bron C, Dorrestijn O, et al. Guideline for diagnosis and treatment of subacromial pain syndrome. Acta
Orthop. 2014;85(3):314-322.
56. Ketola S, Lehtinen J, Rousi T, Nissinen M, Huhtala H, Arnala I. Which patients do not recover from shoulder
impingement syndrome, either with operative treatment or with nonoperative treatment? Acta Orthop. March 2015:1-6.
57. Ketola S, Lehtinen J, Arnala I, et al. Does arthroscopic acromioplasty provide any additional value in the treatment of
shoulder impingement syndrome?: a two-year randomised controlled trial. J Bone Joint Surg Br. 2009;91(10):1326-
1334.
58. Tins BJ, Garton M, Cassar-Pullicino VN, Tyrrell PNM, Lalam R, Singh J. Stress fracture of the pelvis and lower limbs
including atypical femoral fractures-a review. Insights Imaging. 2015;6(1):97-110.
60. Kiuru MJ, Pihlajamaki HK, Ahovuo JA. Fatigue stress injuries of the pelvic bones and proximal femur: evaluation with
MR imaging. Eur Radiol. 2003;13(3):605-611.
61. Kiuru MJ, Pihlajamaki HK, Hietanen HJ, Ahovuo JA. MR imaging, bone scintigraphy, and radiography in bone stress
injuries of the pelvis and the lower extremity. Acta Radiol. 2002;43(2):207-212.
62. Ohta-Fukushima M, Mutoh Y, Takasugi S, Iwata H, Ishii S. Characteristics of stress fractures in young athletes under 20
years. J Sports Med Phys Fitness. 2002;42(2):198-206.
63. Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg. 8(6):344-353.
64. Murray SR, Reeder MT, Udermann BE, Pettitt RW. High-risk stress fractures: pathogenesis, evaluation, and treatment.
Compr Ther. 2006;32(1):20-25.
65. Arendt EA, Griffiths HJ. The use of MR imaging in the assessment and clinical management of stress reactions of bone
in high-performance athletes. Clin Sports Med. 1997;16(2):291-306
66. Hegedus EJ, Goode a. P, Cook CE, et al. Which physical examination tests provide clinicians with the most value
when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med.
2012;46(14):964-978
PET Applications including
Oncologic Tumor Imaging
CPT Codes
Dedicated PET Imaging:
78811 �� PET imaging, limited area
78812 �� PET imaging, skull to mid-thigh
78813 �� PET imaging, whole body
PET/CT Imaging:
78814 �� PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; limited area
78815 �� PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; skull base to mid-thigh
78816 �� PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; whole body
Commonly Used Radiopharmaceutical/Scanner

●● 2-(fluorine-18) fluoro-2-deoxy-d-glucose (FDG), performed on a dedicated PET or integrated (hybrid) PET/CT scanner
●● Radiopharmaceuticals other than 2-(fluorine-18) fluoro-2-deoxy-d-glucose (FDG) are still under active investigation.
The use of PET is generally limited to clinical situations in which tissue confirmation of malignancy has been established and
standard imaging has not provided sufficient information to guide treatment decisions.
Standard imaging usually consists of CT or MRI, but may include xray, bone scan or ultrasound. In the majority of situations
where residual or recurrent disease is of concern, biopsy remains the most reliable method of confirmation. In addition, timing
of PET with regard to radiation treatment and other forms of therapy is critical, as the inflammatory response may lead to false
positive findings.
Based on these considerations and the considerable nuance that exists across tumor types, peer-to-peer discussions will often
be necessary to determine appropriateness of PET imaging.
Routine surveillance with PET or other imaging studies in asymptomatic patients has not been shown to improve survival or
impact the ability to palliate recurrent disease, and is therefore not recommended.

Bladder, renal pelvis and ureter
●● Initial treatment strategy
○○ Evaluation of stage II or stage III bladder cancer prior to surgery
Note: PET is not indicated in bladder tumors which have not invaded the muscle (stage < cT2).
●● Subsequent treatment strategy
○○ Evaluation of objective signs or symptoms of disease when CT or MRI has not clearly demonstrated recurrence
or progression
Bone/cartilage and connective/other soft tissue

●● Surveillance
○○ After one post-treatment study (documenting no evidence of disease) in the setting of curative disease
(considered subsequent treatment strategy), PET can only be used to evaluate suspicion of recurrence based
on signs, symptoms or other imaging findings.
PET or PET/CT including Oncologic Tumor Imaging | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 218
Brain and spinal cord – (applies to full body PET) (If metabolic PET for Brain imaging is desired,
please direct to PET – Brain Imaging, CPT code 78608)
●● Surveillance
Note: Standard PET (body) imaging is sometimes used as staging, particularly for CNS lymphoma, or metastatic disease
detected in the central nervous system. Primary brain tumors traditionally are imaged utilizing metabolic Brain FDG-
PET scanning.
Breast cancer, invasive (male and female)

●● Initial treatment strategy when a diagnosis of invasive breast cancer has been established and any of the following
apply:
○○ Locally advanced disease (stage IIIA-IIIC) has been established and standard imaging does not clearly
demonstrate metastatic disease
○○ Symptom-directed staging has been performed and is equivocal or suspicious for metastatic disease
○○ Standard imaging studies are equivocal or non-diagnostic for the extent of known metastatic disease
○○ Detection of recurrent or progressive disease, when standard imaging is equivocal or non-diagnostic
○○ Suspected worsening of disease based on objective signs or symptoms (such as rising tumor markers), when
standard imaging has been performed and does not clearly identify site of recurrence or progression
Note: Standard imaging includes CT or MRI and bone scan, and may also include ultrasound when liver involvement is
suspected. In the setting of bone-only metastatic disease, evaluation for progression or regression may be best
imaged by PET.
Cervix
○○ After definitive diagnosis of cervical cancer has been made
●● Surveillance
Colorectal cancer
●● Initial treatment strategy—Detection of metastatic disease when all of the following are true:
○○ Standard imaging has been performed (CT or ultrasound) and suggests resectable metastatic disease.
○○ Lesion(s) is/are greater than 1 cm in diameter.
○○ Lesion(s) is/are in a location not amenable to biopsy, or biopsy is considered high risk.
○○ Confirmation of metastatic disease will impact the decision to proceed with curative surgery
Note: A negative standard workup is considered sufficient for staging. In patients who cannot undergo contrast-
enhanced CT due to contrast allergy or renal disease, PET may be utilized if the patient has potentially
curable disease.
●● Radiation planning—Rectal cancer only
○○ Prior to initiation of radiation therapy
○○ CT is equivocal for metastatic disease and lesion(s) is/are greater than 1 cm in diameter.
○○ CT demonstrates potentially surgically curable recurrence.
○○ CT does not demonstrate a focus of recurrence but CEA level is rising.
○○ Signs or symptoms are suggestive of recurrence and CT with contrast is contraindicated.
Note: PET is not appropriate to assess response to chemotherapy due to an unacceptably high rate of false
positive and false negative studies.
Digestive system, including small intestine, liver, biliary, peritoneum, GI stromal tumors (GIST),
and anal cancers—excludes colorectal, esophageal, gastric and gastroesophageal junction
cancers, and pancreatic adenocarcinoma
●● Surveillance
Note: Alternative imaging modalities should be considered in those tumor types for which falsely negative PET or PET/
CT results are commonly reported, including mucinous neoplasia, islet cell tumors, carcinoid tumors, other well-
differentiated neuroendocrine tumors, and well-differentiated hepatocellular tumors. PET should be used with
caution.
Endocrine non-thyroid (includes pituitary and adrenal)

●● Initial treatment
●● Subsequent treatment
●● Surveillance
Esophageal and gastroesophageal junction cancers
○○ Standard imaging has been performed and has not demonstrated metastatic disease
●● Radiation planning
○○ Assessment of response to chemoradiation, (as definitive treatment or prior to surgery) when performed at least
5 weeks after completion of therapy; OR,
○○ Evaluation of suspected recurrence based on signs or symptoms, when standard modalities are equivocal for
recurrent disease
Gastric cancer
●● Initial treatment strategy—Detection of metastatic disease in tumors initially staged 1B or higher when all of the
following are true:
○○ Standard imaging has been performed and has not clearly demonstrated metastatic disease.
○○ Patient is a candidate for curative surgery.
○○ To determine resectability of residual disease following completion of primary (neoadjuvant) treatment, when
follow-up evaluation with standard modalities does not demonstrate metastatic disease
○○ Evaluation of suspected recurrence based on signs or symptoms, when standard modalities are equivocal for
recurrent disease
Note: Standard evaluation includes endoscopic ultrasound and contrast-enhanced CT scan.
Head and neck, including lip, oral cavity, pharynx, larynx, nasal cavity, ear, sinuses, eye, or
occult head and neck primary
○○ Evaluation of Stage III and IV cancers (tumors greater than 4 cm in size, or any evidence of regional node
involvement) of the oral cavity, oropharynx, hypopharynx, nasopharynx, larynx and sinus
○○ Following biopsy suggestive of a head and neck primary tumor (squamous cell cancer, adenocarcinoma, or
anaplastic undifferentiated epithelial tumor) when CT or MRI evaluation of the neck has not detected a primary
site of tumor
○○ Evaluation of disease following clinical response to treatment, no sooner than 12 weeks after completion of
therapy
○○ Evaluation of suspected recurrence based on signs or symptoms, when CT or MRI is equivocal or non-
diagnostic for recurrent disease
○○ Follow up of an equivocal post-treatment PET scan, no sooner than 4 weeks after the study, to determine need
for further intervention such as neck dissection
Note: PET is not generally indicated for evaluation of lip and salivary gland cancers, regardless of stage.
Kidney cancer
○○ Evaluation of the extent of disease when curative resection of primary tumor or limited metastatic disease is
planned, and standard imaging is equivocal for additional sites of disease.
●● Subsequent treatment strategy—Evaluation of suspected recurrence when all of the following are true:
○○ Standard imaging is equivocal for recurrent disease.
○○ Biopsy cannot be performed.
○○ Tumor has been shown to be PET avid (if a prior PET scan has been performed).
Note: Bone scan and brain MRI should be performed for clinical suspicion of metastatic disease in renal cell carcinoma, as
false negative PET results are commonly reported for this tumor type.
Lung cancer
Pulmonary nodule
●● Evaluation of a solitary pulmonary nodule when all of the following features are present:
○○ Nodule is well-demarcated, solid or part solid, and lacks a benign calcification pattern.
○○ Size is greater than 8 mm but less than 3 cm in greatest diameter
○○ Nodule is surrounded by aerated lung parenchyma
○○ There is no associated adenopathy, atelectasis or pleural effusion
Non-small cell lung cancer

○○ Diagnosis in patients with a strong clinical or radiographic suspicion of non-small cell lung cancer
○○ Evaluation of the extent of disease following biopsy confirmation of non-small cell lung cancer
○○ Evaluation following induction or neoadjuvant therapy to determine eligibility for resection
○○ Restaging following completion of adjuvant therapy
○○ Evaluation of signs or symptoms of disease when CT or MRI has not clearly demonstrated recurrence or
progression
○○ Differentiation of tumor from benign conditions (atelectasis, consolidation, or radiation fibrosis) when CT clearly
delineates the abnormal findings
Note: Areas previously treated with radiation therapy can remain FDG avid for up to 2 years.
Small cell lung cancer

○○ Prior to definitive therapy when standard imaging suggests limited stage disease
○○ Evaluation of suspected worsening of disease when standard imaging is equivocal for recurrence or
progression
Lymphoma
Suspected lymphoma
●● Initial evaluation of suspected lymphoma when lymph nodes are not amenable to biopsy
Note: PET scan prior to histologic determination is not routinely recommended, as PET-avid lymphadenopathy can result
from both benign and other malignant processes.
Chronic lymphocytic leukemia (CLL) or Small lymphocytic lymphoma (SLL)

●● Suspicion of Richter’s transformation when PET is utilized to direct biopsy
Note: Suspicion of Richter’s transformation is most commonly based on a presentation of rapidly enlarging lymph nodes,
onset of B symptoms, hepatosplenomegaly, and elevated serum lactate dehydrogenase (LDH) levels.
Hodgkin’s lymphoma
●● Initial treatment strategy (often performed as an adjunct to CT chest/abdomen/pelvis)
○○ Evaluation of response following 2–4 cycles of treatment
○○ Post-treatment evaluation
○○ Evaluation of suspected recurrence or progression of disease based on standard imaging or objective signs/
symptoms
Note: For post-treatment evaluation, PET should not be performed sooner than 3 weeks following completion of all cycles of
chemotherapy, or sooner than 12 weeks following completion of radiation therapy.
Low grade/indolent non-Hodgkin’s lymphoma or lymphoproliferative disorders (other than CLL/SLL)

○○ Evaluation of suspected transformation to a more aggressive lymphoma based on clinical signs or symptoms
○○ Prior to initiation of therapy
○○ Post-treatment response evaluation, when initial PET scan has demonstrated FDG uptake
○○ Evaluation of suspected recurrence or progression of disease based on standard imaging, when there is an
indication to resume systemic treatment
○○ Evaluation of suspected transformation to a more aggressive lymphoma based on clinical signs or symptoms
Note: For post-treatment evaluation, PET should not be performed sooner than 3 weeks following completion of all cycles
of chemotherapy, or sooner than 12 weeks following completion of radiation therapy.
Intermediate or High grade (aggressive) non-Hodgkin’s lymphoma and other subtypes

●● Initial treatment strategy (often performed as an adjunct to CT chest/abdomen/pelvis)
○○ Evaluation of response following 2–4 cycles of treatment of stage III and IV disease, when standard imaging
has not clearly demonstrated progression or regression of disease
○○ Post-treatment evaluation
○○ Evaluation of suspected recurrence or progression of disease based on standard imaging or objective signs/
symptoms
Myeloma
○○ Differentiation of smoldering myeloma from active myeloma when skeletal survey and/or whole body MRI is
negative for bone involvement
○○ When routine evaluation with laboratory findings or bone survey suggests recurrence or progression of disease
Note: Routine follow-up evaluation includes quantitative immunoglobulins and M protein (serum and urine), routine CBC,
kidney function, and calcium levels, and bone surveys. Additional evaluation may also include bone marrow aspirate
and biopsy, serum free light chain assays, MRI, and flow cytometry.
Neuroendocrine tumor, particularly poorly differentiated disease

●● Surveillance
Note: Alternative imaging modalities, such as octreotide scans, should be considered in those tumor types for which falsely
negative PET or PET/CT results are commonly reported, including well-differentiated neuroendocrine tumors. PET
should be used with caution.
Other cancers not listed

●● Surveillance
Ovarian cancer (epithelial)

○○ Evaluation of indeterminate lesions detected by other imaging modalities, including ultrasound and CT or MRI,
when additional information is required to guide management
○○ Evaluation of objective evidence of recurrent disease (such as rising tumor markers or increasing ascites) when
CT or MRI does not clearly demonstrate recurrence or progression.
Pancreatic adenocarcinoma
●● Initial treatment strategy—Detection of extra-pancreatic disease in patients who are candidates for resection when
all of the following are true:
○○ Dedicated, high quality imaging of the pancreas has been performed (see Note below)
○○ Extra-pancreatic disease has not been clearly identified
○○ Any of the following high-risk features are present
■■ CA 19-9 level greater than 100 U/ml
■■ Primary tumor greater than 2 cm in size
■■ Enlarged regional nodes
■■ Tumor is considered borderline resectable
Note: Standard, high quality dedicated imaging evaluation of the pancreas includes a dedicated pancreatic protocol
CT scan (multi-detector computed tomography angiography using a dual-phase pancreatic protocol, with images
obtained in the pancreatic and portal venous phase of contrast enhancement) or MRI if CT is contraindicated. MRI
may also be used to clarify CT-indeterminate liver lesions or suspected pancreatic tumors not visible on CT.
Paraneoplastic syndrome including neurologic syndrome

●● PET or PET/CT is indicated for initial evaluation of individuals with paraneoplastic syndrome
Prostate adenocarcinoma
Not medically necessary for any indication
Note: FDG-PET/CT is not recommended for routine use for prostate cancer management because data remain insufficient.
Furthermore, further study is needed to determine the best use of choline PET/CT in men with prostate cancer.
Skin, including:
Melanoma
●● Initial treatment strategy—Evaluation for metastatic disease when any of the following are true:
○○ Regional lymph node involvement has been demonstrated and standard imaging studies do not clearly
demonstrate metastatic disease.
○○ Metastatic disease is suspected based on signs or symptoms, and standard imaging demonstrates an abnormal
finding that is suspicious for metastatic disease.
○○ Standard imaging studies are equivocal or non-diagnostic for the extent of known metastatic disease
○○ Evaluation of objective signs or symptoms of metastatic disease when CT or MRI has not clearly demonstrated
recurrence or progression
Note: An isolated finding of a new skin lesion is not sufficient evidence of systemic recurrence.
Mucosal Melanoma
○○ Detection of metastatic disease
○○ Evaluation of disease following clinical response to treatment, no sooner than 12 weeks after completion of
therapy
○○ Evaluation of signs or symptoms of metastatic disease when CT or MRI has not clearly demonstrated
recurrence or progression
Note: An isolated finding of a new mucosal lesion is not sufficient evidence of systemic recurrence.
Non-melanoma skin (includes basal cell, squamous cell, and Merkel cell)
●● Surveillance
■■ After one post-treatment study (documenting no evidence of disease) in the setting of curative disease
(considered subsequent treatment strategy), PET can only be used to evaluate suspicion of recurrence
based on signs, symptoms or other imaging findings.
Kaposi’s sarcoma
●● Surveillance
Thorax, other than lung cancer, including pleural malignancies, cancers of the thymus, heart,
and mediastinum
○○ For initial staging of diagnosed or suspected cancer
●● Surveillance
Thyroid
○○ Poorly differentiated papillary
○○ Anaplastic
○○ Medullary
○○ Hurthle Cell
○○ Poorly differentiated papillary
○○ Anaplastic
○○ Medullary
○○ Hurthle Cell
○○ Well-differentiated papillary or follicular thyroid cancer
■■ For evaluation of suspected recurrence when both of the following are met:
□□ With negative I131 scan, or a history of a negative I131 scan
□□ Stimulated thyroglobulin level greater than two (2) ng/dL in the absence of antibodies.
●● Surveillance
on signs, symptoms, or other imaging findings.
Note: PET is most useful for non-iodine avid thyroid cancer. Furthermore, alternative imaging modalities should be
considered in those tumor types for which falsely negative PET or PET/CT results are commonly reported, including
medullary thyroid carcinoma. PET should be used with caution unless disease is known to be FDG-avid.
Urogenital organs, other, including uterus, placenta, other female genitalia, testis, penis, and
other male genitalia—excludes ovarian (epithelial), bladder and kidney cancers
●● Surveillance
Note: Alternative imaging modalities should be considered in those tumor types for which falsely negative PET or PET/CT
results are commonly reported, including many renal cell (kidney) carcinomas. PET should be used with caution.
Screening: PET or PET/CT is considered not medically necessary as a screening test (i.e., for
evaluation of patients without specific signs and symptoms of disease).
PET for screening or diagnosis of breast cancer is not a covered benefit by the Centers for
Medicare & Medicaid Services and multiple health plans.
Other Considerations
PET mammography is an evolving technology under clinical development. This technology and
its impact on health outcomes will continue to undergo review as new evidence-based studies
are published. Interval routine coverage for PET mammography is not generally available and is
not considered medically appropriate at this time.
PET bone scanning is currently only a covered benefit by the Centers for Medicare & Medicaid
Services with CED. PET bone scanning is an evolving technology under clinical development.
This technology and its impact on health outcomes will continue to undergo review as new
evidence-based studies are published.
PET bone scan is considered not medically necessary.
PET Imaging of Infectious Processes

For diagnosis of chronic osteomyelitis involving the axial skeleton
References
1. Alpert JB, Lowry CM, Ko JP. Imaging the Solitary Pulmonary Nodule. Clin Chest Med. 2015;36(2):161-178.
2. American Society of Clinical Oncology. Choosing Wisely: Monitoring for cancer recurrence. ABIM Foundation; October
29, 2013. Available at http://www.choosingwisely.org/clinician-lists/american-society-clinical-oncology-monitoring-for-
cancer-recurrence/ Accessed on September 29, 2016.
3. American Society of Clinical Oncology. Choosing Wisely: PET CT and radionuclide bone scans in staging early breast
cancer. ABIM Foundation; October 29, 2013. Available at http://www.choosingwisely.org/clinician-lists/american-society-
clinical-oncology-pet-ct-radionuclide-bone-scans-in-staging-early-breast-cancer/ Accessed on September 29, 2016.
4. American Society of Clinical Oncology. Choosing Wisely: PET CT and radionuclide bone scans in staging early prostate
cancer. ABIM Foundation; October 29, 2013. Available at http://www.choosingwisely.org/clinician-lists/american-society-
clinical-oncology-pet-ct-radionuclide-bone-scans-in-staging-early-prostate-cancer/ Accessed on September 29, 2016.
5. American Society of Clinical Oncology. Choosing Wisely: Surveillance testing imaging for breast cancer. ABIM
Foundation; October 29, 2013. Available at http://www.choosingwisely.org/clinician-lists/american-society-clinical-
oncology-surveillance-testing-imaging-for-breast-cancer/ Accessed on September 29, 2016.
6. Christensen JA, Nathan MA, Mullan BP, Hartman TE, Swensen SJ, Lowe VJ. Characterization of the solitary pulmonary
nodule: 18F-FDG PET versus nodule-enhancement CT. AJR Am J Roentgenol. 2006;187(5):1361-1367.
7. Fletcher JW, Djulbegovic B, Soares HP, et al. Recommendations on the use of (18F) FDG PET in oncology. J Nucl Med.
2008;49:480-508.
8. Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer?
Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical
practice guidelines. Chest. 2013;143(5 Suppl):e93S - 120S.
9. Gould MK, Maclean CC, Kuschner WG, Rydzak CE, Owens DK. Accuracy of positron emission tomography for
diagnosis of pulmonary nodules and mass lesions: a meta-analysis. JAMA. 2001;285(7):914-924.
10. Lind P, Kohlfürst S. Respective roles of thyroglobulin, radioiodine imaging, and positron emission tomography in the
assessment of thyroid cancer. Semin Nucl Med. 2006;36(3):194-205.
11. Mosci C, Iagaru A. PET/CT imaging of thyroid cancer. Clin Nucl Med. 2011;36(12):e180-e185.
12. Muros MA, Llamas-Elvira JM, Ramírez-Navarro A, et al. Utility of fluorine-18-fluorodeoxyglucose positron emission
tomography in differentiated thyroid carcinoma with negative radioiodine scans and elevated serum thyroglobulin levels.
Am J Surg. 2000;179(6):457-461.
13. National Comprehensive Cancer Network, Inc.: NCCN Imaging Appropriate Use Criteria Compendium: Clinical Practice
Guidelines for Bladder Cancer; Breast Cancer; Colon Cancer; Esophageal and Esophagogastric Junction Cancers;
References
Gastric Cancer; Head and Neck Cancers; Hodgkin Lymphoma; Kidney Cancer; Melanoma; Multiple Myeloma; Non-
Hodgkin’s Lymphomas; Non-Small Cell Lung Cancer; Ovarian Cancer Including Fallopian Tube Cancer and Primary
Peritoneal Cancer; Pancreatic Adenocarcinoma; Rectal Cancer; Small Cell Lung Cancer. Referenced with permission.
To view the most recent and complete version of the NCCN Guidelines, go online to www.nccn.org.
14. Ozkan E, Aras G, Kucuk NO. Correlation of 18F-FDG PET/CT findings with histopathological results in differentiated
thyroid cancer patients who have increased thyroglobulin or antithyroglobulin antibody levels and negative 131I whole-
body scan results. Clin Nucl Med. 2013;38(5):326-331.
15. Ozkan E, Soydal C, Araz M, Aras G, Ibis E. The additive clinical value of 18F-FDG PET/CT in defining the recurrence of
disease in patients with differentiated thyroid cancer who have isolated increased antithyroglobulin antibody levels. Clin
Nucl Med. 2012;37(8):755-758.
16. Rajkumar SV, Dimopoulos MA, Palumbo A, et al. International Myeloma Working Group updated criteria for the
diagnosis of multiple myeloma. Lancet Oncol. 2014 Nov;15(12):e538-48.
17. Salvatore B, Paone G, Klain M, et al. Fluorodeoxyglucose PET/CT in patients with differentiated thyroid cancer and
elevated thyroglobulin after total thyroidectomy and (131)I ablation. Q J Nucl Med Mol imaging. Off Publ Ital Assoc Nucl
Med [and] Int Assoc Radiopharmacol (IAR), [and] Sect Soc Radiopharm. 2008;52(1):2-8.
18. Sim YT, Goh YG, Dempsey MF, Han S, Poon FW. PET-CT evaluation of solitary pulmonary nodules: correlation with
maximum standardized uptake value and pathology. Lung. 2013;191(6):625-632.
19. Vural GU, Akkas BE, Ercakmak N, Basu S, Alavi A. Prognostic significance of FDG PET/CT on the follow-up of patients
of differentiated thyroid carcinoma with negative 131I whole-body scan andelevated thyroglobulin levels: correlation with
clinical and histopathologic characteristics and long-term follow. Clin Nucl Med. 2012;37(10):953-959.
Quantitative CT (QCT)
Bone Mineral Densitometry
CPT Codes
77078 �� Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine)

●● For central QCT, spine and hip measurements are obtained
●● Bone mineral densitometry may be performed on the central axial skeleton (i.e., spine, femoral head, proximal
femur)
●● Central dual x-ray absorptiometry (DXA), also referred to as dual-energy x-ray absorptiometry (DEXA), is the most
commonly used test to evaluate bone mineral density and is considered the technology of choice, when available.
●● QCT has a high sensitivity for detection of bone loss. However, when compared with DXA, QCT is often less readily
available, more expensive and incurs higher radiation exposure.
●● QCT may not be covered as a screening exam in patients at low risk for osteoporosis.
QCT Bone Mineral Densitometry | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 230
Initial examination – when any one of the following criteria are met
●● Menopausal or post-menopausal women – as an initial examination to screen for osteoporosis
●● Men of 70 years age or older, regardless of risk factors
●● Anyone presenting with a fragility or pathologic fracture
●● Anyone with a disease or condition associated with development of osteoporosis, including any of the following
abnormalities:
○○ Anorexia nervosa
○○ Chronic liver disease
○○ Chronic renal failure
○○ Cushing’s syndrome
○○ Delayed menarche or untreated premature menopause
○○ Heavy alcohol consumption
○○ Hypercalciuria
○○ Hypogonadism
○○ Inflammatory bowel disease
○○ Low trauma fractures or vertebral fractures
○○ Malabsorption syndromes
○○ Primary hyperparathyroidism
○○ Prolonged immobilization
○○ Radiographic evidence of osteopenia
○○ Rheumatoid arthritis
○○ Thyroid disease
●● Anyone on a medication associated with development of osteoporosis, including but not limited to the following
medications:
○○ Glucocorticoids (e.g., prednisone, prednisolone, decadron, dexamethasone) – treatment for longer than 3
months
○○ Phenytoin (Dilantin) – treatment for longer than 3 months
○○ Heparin – treatment for longer than 1 month
○○ Depo-Provera injectable contraceptive – long-standing use (longer than 2 years)
○○ Lithium treatment
○○ Lupron therapy
○○ Cytotoxic agents which affect bone density (e.g., adjuvant chemotherapy in many premenopausal females with
breast cancer)
○○ Proton pump inhibitors (PPI) and histamine-2 (H2) receptor blockers for gastroesophageal reflux disease in
patients over 50 years of age, under treatment for longer than 3 months
●● Anyone who is considering therapy for osteoporosis, if bone mineral densitometry would facilitate the decision
Repeat examination – when any one of the following criteria are met:
●● Anyone under treatment for osteoporosis, to monitor the response to therapy for bone loss – at intervals of every 2
to 3 years
●● Untreated individuals who met the criteria for initial evaluation, without significant osteopenia on prior bone
densitometry and without interval increased risk for accelerated bone loss – at intervals of every 3 to 5 years
References
1. American College of Radiology. ACR–SPR–SSR Practice Parameter for the Performance of Quantitative
Computed Tomography (QCT) Bone Densitometry. Revised 2013. Available at http://www.acr.org/~/media/
DE78D218C7A64526A821A9E8645AB46D.pdf. Accessed August 26, 2016.
2. Guglielmi G, Muscarella S, Bazzocchi A. Integrated imaging approach to osteoporosis: state-of-the-art review and
update. Radiographics. 2011;31(5):1343-1364.
3. Lentle BC, Prior JC. Prior osteoporosis: what a clinical expects to learn from a patient’s bone density exam. Radiology.
2000;228:620-628.
4. Morris CA, Cabral D, Cheng H, et al. Patterns of bone mineral density testing. current guidelines, testing rates, and
interventions. J Gen Intern Med. 2004;19:783-790.
5. North American Society Menopause Society. Management of osteoporosis in postmenopausal women: 2010 position
statement of The North American Menopause Society. Menopause. 2010 Jan-Feb;17(1):25-54.
6. The International Society for Clinical Densitometry (ISCD). Official Positions. Available at http://www.iscd.org/official-
positions/2015-iscd-official-positions-adult/. Updated 2015. Accessed November 8, 2016
7. U.S. Preventive Services Task Force. Screening for osteoporosis: U.S. Preventive Services Task Force recommendation
statement. Ann Intern Med. 2011 Aug 16;155(4):276-7.
Bone Marrow Blood Supply
CPT Codes
77084 �� MRI of bone marrow blood supply

●● MRI of the bone marrow blood supply is used to image multiple anatomic areas in the axial and appendicular
skeleton
Imaging Considerations1
●● In addition to MRI, several other imaging procedures are available to assess the bone marrow, including skeletal
radiographic survey and nuclear scintigraphy.
●● To undertake extensive coverage of the skeleton with MRI of the bone marrow blood supply, phased array MR coils
are often used.
●● Performed most often to study a specific lesion(s), based on the results of other imaging or laboratory studies, or to
evaluate focal pain or neurologic symptoms.
●● On some occasions used to survey the whole body for marrow replacement or infiltration by neoplastic cells [5–12].
In these instances, the entire body is imaged from the vertex to the heels, usually in a single plane (coronal or
sagittal) acquired with overlapping stations.

Myeloma 2, 3
●● Diagnosis when all of the following are met:
○○ No lytic bone lesions seen on whole body radiography
■■ Note: for further characterization of an equivocal bone lesion seen on whole body radiography. A dedicated
MRI of the region (i.e. cervical, thoracic, lumber spine, pelvis or extremity) should be obtained
○○ To establish the diagnosis of myeloma at least one of the following is required:
■■ Biopsy proven plasmacytoma
■■ Clonal bone marrow plasma cells greater than 10%
■■ M-protein greater than or equal to 3 g/dL and/or 10 to 60 percent bone marrow plasma cells
Note: The evidence for use of MRI in myeloma is insufficient for the evaluation of the following: Response to therapy,
prognosis, and monoclonal gammopathy of uncertain significance (MGUS). For myeloma with back pain, see tumor
evaluation (cervical, thoracic, lumbar spine).
References
1. Siegel MJ. MRI of Bone Marrow. In: Kransdorf MJ, Reinhold C, Ho VB, eds. Syllabus of the American Roentgen Ray
Society (ARRS) 2006 Categorical Course. Body MRI. ARRS; 2006:243-254.
2. Dimopoulos MA, Hillengass J, Usmani S,et al. Role of Magnetic Resonance Imaging in the Management of Patients
With Multiple Myeloma: A Consensus Statement. J Clin Oncol. 2015 Jan 20.
MRI Bone Marrow Blood Supply | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 233
MRI Bone Marrow Blood Supply
Bibliography
1. Angtuaco EJ, Fasses AB, Walker R, et al. Multiple myeloma: clinical review and diagnostic imaging. Radiology. 2004;
231(1):11-13.
2. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Magnetic Resonance Imaging
(220.2). Available at http://www.cms.gov/medicare-coverage-database/. Accessibility verified September 2, 2016.
3. Kumar J, Seith A, Kumar A, Sharma R, Bakhshi S, Kumar R, Agarwala S. Whole-body MR imaging with the use of
parallel imaging for detection of skeletal metastases in pediatric patients with small-cell neoplasms: comparison with
skeletal scintigraphy and FDG PET/CT. Pediatr Radiol. 2008;38(9):953-962.
4. Lecouvet FE, Vande Berg BC, Michaux L, et al. Stage III multiple myeloma: clinical and prognostic value of spinal bone
marrow MR imaging. Radiology. 1998; 209(3):653-660.
5. Rahmouni A, Montazel JL, Divine M, et al. Bone marrow with diffuse tumor infiltration in patients with lymphoproliferative
diseases: dynamic gadolinium-enhanced MR imaging. Radiology. 2003; 229(3):710-717.
6. Schmidt GP, Reiser MF, Baur-Melnyk A. Whole-body imaging of the musculoskeletal system: the value of MR imaging.
Skeletal Radiol. 2007;36(12):1109-1119.
7. Van de Berg BC, Lecouvet FE, Michaux L, et al. Stage I multiple myeloma: value of MR imaging of the bone marrow in
the determination of prognosis. Radiology. 1996;201:243-246.
8. Siegel MJ. MRI of Bone Marrow. In: Kransdorf MJ, Reinhold C, Ho VB, eds. Syllabus of the American Roentgen Ray
Society (ARRS) 2006 Categorical Course. Body MRI. ARRS; 2006:243-254.
9. Dimopoulos MA, Hillengass J, Usmani S,et al. Role of Magnetic Resonance Imaging in the Management of Patients
With Multiple Myeloma: A Consensus Statement. J Clin Oncol. 2015 Jan 20
MRI Bone Marrow Blood Supply Bibliography | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 234
Magnetic Resonance Spectroscopy
(MRS)
CPT Codes
76390 �� Magnetic Resonance Spectroscopy (MRS)

●● Application of MRS has been described in multiple anatomic areas to further evaluate the biochemical properties of
specific tissues.
Background
●● MR Spectroscopy is not currently a covered benefit by the Centers for Medicare and Medicaid Services, through a
National Coverage Determination.
●● MR spectroscopy provides a biochemical profile of different metabolic constituents in tissues. When MRS is performed,
metabolites which may be measured include Choline (Cho), N-Acetyl Aspartate (NAA), Creatine (Cr), lactate and lipid.
●● Certain ratios of metabolites have been described as suggestive of high grade malignancy. An example is a Choline/
Creatine ratio greater the 2:1, compared with the normal ratio from spectroscopic data of approximately 1.
●● When performed, MRS usually accompanies an MRI exam.
●● Potential uses of MRS that have been described include neuroimaging of brain tissue (for brain tumor differentiation from
non-tumor conditions such as necrosis and abscess; cerebrovascular accident; dementia; epilepsy; Parkinson’s disease;
mitochondrial disorders), breast lesion assessment and evaluation of lower extremity ischemia.
Magnetic Resonance Spectroscopy

●● MR Spectroscopy is an evolving technology under clinical development. This technology and its impact on health
outcomes will continue to undergo review, as new evidence-based studies are published. At this point, medically
necessary applications are limited (see below). Interval routine coverage for MR spectroscopy is not generally available
and is not considered medically appropriate at this time.
Diagnostic Indications
Differentiate recurrent or residual brain tumor from post-therapy changes, (e.g., delayed
radiation necrosis)
Differentiate brain tumor from other non-tumor diagnoses, (e.g., abscesses or other infectious
or inflammatory processes)
References
1. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Magnetic Resonance
Spectroscopy (220.2.1). Available at http://www.cms.gov/medicare-coverage-database/. Accessibility verified August 8,
2016.
Magnetic Resonance Spectroscopy | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 235

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Clinical Appropriateness Guidelines:

Guideline Last Revised Last Reviewed

Chest 09-07-2017 09-07-2017

Extremity 07-26-2016 07-26-2016

8600 W Bryn Mawr Avenue

Description and Application of the Guidelines.........................................................................4

Head & Neck Imaging................................................................................................................7

PET Imaging.. .........................................................................................................................218

MRI Bone Marrow Blood Supply............................................................................................233

Magnetic Resonance Spectroscopy (MRS) ..........................................................................235

Simultaneous Ordering of Multiple Studies

Standard Anatomic Coverage

Common Diagnostic Indications

Abnormal imaging findings

Congenital or developmental anomaly

CT Head | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 7

Lumbar puncture risk assessment

Multiple sclerosis and other white-matter diseases**

CT Head | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 8

Tumor (benign or malignant)

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Bell’s palsy (peripheral facial weakness)

CT Head | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 10

Headache Characteristics Associated clinical features and conditions

Patient Populations High-risk vascular patient

Vertigo and dizziness

CT Head | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 11

Cerebrovascular accident (CVA or stroke) and transient ischemic attack (TIA)

Management of CVA when imaging is required to direct treatment

Congenital or developmental vascular anomaly

CT Head | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 12

CT Head | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 13

CT Head | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 14

CT Head | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 15

CT Head | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 16

Standard Anatomic Coverage

Common Diagnostic Indications

Abnormal imaging findings

Congenital or developmental anomaly

Multiple sclerosis and other white-matter diseases

Trigeminal neuralgia and persistent idiopathic facial pain

Tumor (benign or malignant)

Neurologic Signs & Symptoms

Bell’s palsy (peripheral facial weakness)

Headache Characteristics Associated clinical features and conditions

Patient Populations High-risk vascular patient

Cerebrovascular accident (CVA or stroke) and transient ischemic attack (TIA)

Management of CVA when imaging is required to direct treatment

Congenital or developmental vascular anomaly

Standard Anatomic Coverage

Choice of Imaging Study

Combination with MRI

Common Diagnostic Indications

Cerebrovascular accident (CVA)

Congenital or developmental vascular anomaly

Management (including perioperative evaluation) of established dissection

Stenosis or occlusion of intracranial arteries

Thromboembolic disease of major intracranial arterial systems

Tumor (benign or malignant)