Académique Documents
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Utilization Management
2008 Program Guidelines
v.1.0
Effective Date: June 16, 2008
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Table of Contents
Use of AIM’s Diagnostic Imaging Guidelines
Use of AIM’s Diagnostic Imaging Guidelines ............................................................................................. 2
Administrative Guidelines
Guideline: Simultaneous Ordering of Multiple Imaging Test .................................................................... 3
Clinical Guidelines
Chest Imaging
CT of the Chest ............................................................................................................................................ 47
CTA of the Chest.......................................................................................................................................... 53
MRI of the Chest........................................................................................................................................... 57
MRA of the Chest ......................................................................................................................................... 60
MRI of the Breast ......................................................................................................................................... 64
Cardiac Imaging
Nuclear Cardiology - Myocardial Perfusion Imaging ............................................................................... 67
Nuclear Cardiology - Cardiac Blood Pool Imaging .................................................................................. 74
Nuclear Cardiology – Infarct Imaging ........................................................................................................ 77
MRI - Cardiac ................................................................................................................................................ 78
CT/CTA Cardiac and Coronary Artery ....................................................................................................... 83
Positron Emission Tomography (PET) - Cardiac ..................................................................................... 89
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Abdominal & Pelvic Imaging
CT of the Abdomen...................................................................................................................................... 91
MRI of the Abdomen .................................................................................................................................... 97
CTA/MRA of the Abdomen........................................................................................................................ 100
CTA of the Abdominal Aorta- Lower Extremity Run-Off........................................................................ 104
CT of the Pelvis .......................................................................................................................................... 106
MRI of the Pelvis ........................................................................................................................................ 113
CTA/MRA of the Pelvis .............................................................................................................................. 116
CT of the Abdomen & Pelvis..................................................................................................................... 118
CT Colonography (Virtual Colonoscopy) ................................................................................................ 124
Spine Imaging
CT of the Cervical Spine ........................................................................................................................... 126
MRI of the Cervical Spine.......................................................................................................................... 129
CT of the Thoracic Spine .......................................................................................................................... 132
MRI of the Thoracic Spine......................................................................................................................... 135
CT of the Lumbar Spine ............................................................................................................................ 138
MRI of the Lumbar Spine .......................................................................................................................... 141
MRA of the Spinal Canal ........................................................................................................................... 144
Other
Magnetic Resonance Spectroscopy ....................................................................................................... 172
MRI – Bone Marrow Blood Supply ........................................................................................................... 173
Quantitative CT – Bone Mineral Densitometry ....................................................................................... 174
ii
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CLINICAL GUIDELINES
WEBSITE DISCLAIMER
1
Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
AIM’s Practice Guidelines Define the Optimal Approaches for
Diagnostic Imaging Utilization during Individualized Case
Review
Use of AIM’s Diagnostic Imaging Guidelines:
AIM’s Proprietary Clinical Practice Guidelines are designed to evaluate and direct the appropriate utilization of
elective, high technology diagnostic imaging services. In the process, multiple functions are accomplished:
To promote the most efficient and cost-effective use of diagnostic imaging services
To assist the practitioner as an educational tool
To encourage standardization of medical practice patterns and reduce variation in clinical evaluation
To curtail the performance of inappropriate, elective diagnostic imaging studies
To reduce the performance of duplicative diagnostic imaging studies
To advocate biosafety issues, including unnecessary radiation exposure (for CT and plain film
radiography) and MRI safety concerns
To enhance quality of healthcare for elective diagnostic imaging studies, using evidence-based
medicine and outcomes research from numerous resources
Guideline review:
AIM’s proprietary guidelines for appropriate diagnostic imaging utilization are reviewed routinely by:
(1) Independent Physician Review Board: AIM’s Physician Specialty Advisory Panel
(2) Health Plan Medical Directors
(3) Local Imaging Advisory Council (representing local physician communities)
(4) Physician Review Panels, under the governance of our clients’ State Regulatory Agencies
2
Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
Guideline: Simultaneous Ordering of
Multiple Imaging Tests
Modality: All
Body Part: All
CPT Codes: All
STANDARD ANATOMIC COVERAGE:
The major area of concern is contiguous body parts where clinical signs and symptoms may be coming from abnormalities
involving either region, or different modalities can be considered to evaluate the same anatomy for the same clinical
problem. These are areas where ordering multiple tests before the results of any of the tests are known lead to
inappropriate imaging.
GENERAL CONSIDERATIONS:
• Rapid breakthroughs in technology, with attendant rise of new imaging tests available to improve patient management,
have created a dilemma for clinicians. Many factors in choosing the right test now come into play. One must consider
basic data in the decision-making process. Considerations include the possible effect on patient management, the
pretest probability that the patient is affected by a particular disease, the prevalence of the disease in the population,
and the accuracy [sensitivity\specificity] of the test. When a screening approach is adopted, rather than targeting the
particular test or anatomic site with the highest pretest probability of success, the possibility of one or more of the tests
being superfluous and not contributing meaningfully to patient management increases to an unacceptable level.
For this reason, simultaneous ordering of multiple examinations may subject these examinations to more intensive
levels of review, than would be the case if these same tests were ordered sequentially. Depending on the clinical
situation,one or more of the requested studies might not meet medical necessity criteria until the results of the
lead study are known.
REFERENCES/LITERATURE REVIEW:
1. Kuhns M. D., Lawrence R., Thornberry M.D., John R., Freyback Ph.D., Dennis, Decision-making Imaging. YEARBOOK medical
publishers 1989
2. Duboulet M. D., Ph.D., Peter M. Cain, Ph.D. Kevin C. The Superiority of Sequential over Simultaneous Testing,.Medical decision-
making volume 5 NUMBER 4 PAGES 447 – 451, 1985
3. Fryback, Ph.D. Dennis G., Thornberry, M.D. John R. The Efficacy of Diagnostic Imaging. Medical Decision-Making, volume 11,
3
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Multiple Imagings Tests
4
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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
IMAGING CONSIDERATIONS:
• Radiation Dosimetry: CT of Head, either without or with contrast, has a typical effective dose of approximately
2.3 milliSieverts (mSv) or 115 Chest X-Ray equivalents.
• 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). Notable exceptions to the use of head MRI as the neuroimaging procedure of
choice are: acute intra-cranial hemorrhage (parenchymal, subarachnoid; subdural; epidural); initial evaluation of
recent craniocerebral trauma; osseous assessment of the calvarium, skull base and maxillofacial bones, including
detection of calvarial and facial bone fractures; and evaluation of calcified intracranial lesions.
• CT of the head is an alternative exam in patients who cannot undergo MRI. 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 indwelling pacemakers or implantable
cardioverter-defibrillators (ICD), intracranial aneurysm surgical clips that are not compatible with MR imaging, as
well as other devices that are unsafe in MRI scanners (including implanted materials in the patient as well as
external equipment, such as portable oxygen tanks).
• Contrast-enhanced CT may be contraindicated in certain circumstances, such as a documented allergy to
intravenous contrast material and renal insufficiency. Special consideration should also be given to patients with
multiple myeloma.
• For CT imaging of the orbits, internal auditory canals (IACs) or temporal bones, see CPT codes 70480-70482.
• According to Medicare’s Correct Coding Edits, a CT of the Head is not usually performed with a CT of the Orbits.
These studies are generally considered mutually exclusive procedures.
• Imaging studies of the head and neck are inherently bilateral. Duplicate requests for bilateral studies to image the
right and left side of the head are inappropriate.
• Duplicative testing of the same anatomic area with MRI and CT may be subject to high-level review, for
evaluation of medical necessity.
• Request for re-imaging due to technically limited exams is the responsibility of the imaging providers.
5
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CT-Head
Note: Contrast-enhanced MRI, unless contraindicated, is generally recommended for evaluation of cranial nerve
impairment.
5-6
CEREBROVASCULAR ACCIDENT (CVA OR STROKE) AND TRANSIENT ISCHEMIC ATTACK (TIA)
• May present with a variety of signs and symptoms, including sudden onset of weakness, focal sensory loss or
speech disorder
• Among patients being evaluated for CVA and possible thrombolytic therapy, unenhanced CT is often performed as
the initial modality (within the initial 24 hours after symptom onset), to detect a possible hemorrhagic stroke or mass
lesion.
7
CONGENITAL ANOMALY
Including but not limited to the following conditions:
- Chiari Malformations
- Dandy-Walker Spectrum
- Encephalocele
- Holoprosencephaly
- Macrocephaly
- Microcephaly
- Schizencephaly
- Septo-optic Dysplasia
CRANIOSYNOSTOSIS
8-9
DEMENTIA
• Initial evaluation, if MRI is contraindicated, or
• Rapid progression, if MRI is contraindicated
6
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CT-Head
Note: Current evidence does not support CT evaluation for chronic headache or migraines, when the patient’s neurological
status is unchanged.
11-13
HEADACHE IN PEDIATRIC PATIENT – WHEN ANY ONE OF THE FOLLOWING CRITERIA ARE MET:
• Sudden onset and severe, including thunderclap or worst headache of life; or
• Associated with neurological abnormalities such as nystagmus, papilledema, gait or motor disturbances; or
• With fever, nuchal rigidity and other meningeal signs; or
• Awakened repeatedly from sleep or develop upon awakening; or
• Persistent headache with confusion, disorientation or vomiting; or
• Persistent headaches of < 6 months duration and not responsive to medical treatment; or
• Persistent headaches, without a family history of migraines; or
• Familial or personal history of disorders with predisposition to CNS lesions and clinical/laboratory findings that
suggest CNS involvement;
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CT-Head
MENTAL STATUS CHANGES, WITH DOCUMENTED OBJECTIVE EVIDENCE FROM NEUROLOGIC EXAM
MOVEMENT DISORDERS
• Including Parkinson’s disease (particularly atypical cases with poor response to levodopa, in which there may be
an underlying structural disorder producing parkinsonian features); Huntington’s disease; idiopathic sporadic
cerebellar ataxia (olivopontocerebellar atrophy); and other conditions.
17
MULTIPLE SCLEROSIS AND OTHER WHITE-MATTER DISEASES, WHEN MRI IS CONTRAINDICATED
• Multiple Sclerosis may manifest a diverse range of symptoms, including but not limited to the following:
- Ataxia (loss of coordination) and Spasticity
- Cognitive Dysfunction
- Muscle Weakness
- Paresthesias
- Speech (dysarthria, or slurred speech)
- Visual Disturbances (diplopia; nystagmus; evidence of optic neuritis)
NEUROCUTANEOUS DISORDERS
• Including but not limited to the following:
- Neurofibromatosis
- Sturge-Weber Syndrome
- Tuberous Sclerosis
- Von Hippel-Lindau Disease (VHL)
VISUAL DISTURBANCE – SUCH AS VISUAL FIELD LOSS, DIPLOPIA AND OTHER ALTERATIONS IN VISION
THAT ARE UNEXPLAINED BY OPHTHALMOLOGIC EXAM AND PATIENT HISTORY
WHEN THE PATIENT’S CONDITION MEETS THE HEAD MRI GUIDELINES, BUT MRI IS EITHER
CONTRAINDICATED OR THE PATIENT IS CLAUSTROPHOBIC AND CANNOT TOLERATE MRI EXAMINATION.
9
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CT-Head
REFERENCES/LITERATURE REVIEW:
1. Gilman S. Imaging the Brain: First of two parts. N Engl J Med 1998; 338(12): 812-820.
2. Gilman S. Imaging the Brain: Second of two parts. N Engl J Med 1998; 338(13): 889-896.
3. Gilden DH. Bell’s Palsy. N Engl J Med 2003; 351: 1323-1331.
4. Weissman J L, Hirsch B E. Imaging of Tinnitus: A review. Radiology 2000; 216: 342-349.
5. Johnston SC. Transient Ischemic Attack. N Engl J Med 2002; 347: 1687-1692.
6. Culebras A, Kase CS, Masdeu JC, et al. Practice Guidelines for the Use of Imaging in Transient Ischemic Attacks and Acute
Stroke. American Heart Association 1997; 28: 1480-1497.
7. Morón FE, Morriss MC, Jones JJ, Hunter JV. Lumps and Bumps on the Head in Children: Use of CT and MR Imaging in
Solving the Clinical Diagnostic Dilemma. RadioGraphics 2004; 24: 1655-1674.
8. Adelman AM, Daly MP. Initial Evaluation of the Patient with Suspected Dementia. American Family Physician 2005; 71(9):
1745-1750.
9. Petrella JR, Coleman RE, Doraiswamy PM. Neuroimaging and Early Diagnosis of Alzheimer Disease: A look to the future.
Radiology 2003; 226: 315-336.
10. Shevell M, Ashwal S, Donley D, et al. Practice Parameter: Evaluation of the child with global developmental delay.
Neurology 2003; 60: 367-380.
11. Medina LS, D’Souza B, Vasconcellos E. Adults and Children with Headache: Evidence-based diagnostic evaluation.
Neuroimaging Clinics of North America 2003; 13: 225-235.
12. Strain JD. ACR Appropriateness Criteria on Headache-Child. J Am Coll Radoil 2007; 4: 18-23.
13. Lewis DW, Ashwal S, Dahl G, et al. Practice Parameter: Evaluation of Children and Adolescents with Recurrent Headaches.
Neurology 2002; 59: 490-498.
14. Qureshi AI, Tuhrim S, Broderick JP, et al. Spontaneous Intracerebral Hemorrhage. N Engl J Med 2001; 344: 1450-1460.
15. Edlow JA, Caplan LR. Avoiding Pitfalls in the Diagnosis of Subarachnoid Hemorrhage. N Engl J Med 2000; 342: 29-36.
16. Osborn, Anne G., Editor. Diagnostic Imaging: Brain. Salt Lake City, Utah: Amirsys; 2004.
17. McDonald WI, Compston A, Edan G, et al. Recommended Diagnostic Criteria for Multiple Sclerosis: Guidelines from the
International Panel on the Diagnosis of Multiple Sclerosis. Annals of Neurology 2001; 50(1): 121-127.
18. Bernal B, Altman NR. Evidence-Based Medicine: Neuroimaging of Seizures. Neuroimaging Clinics of North America 2003;
13: 211-224.
19. Hauer KE. Discovering the Cause of Syncope: A Guide to the Focused Evaluation. Postgraduate Medicine 2003; 113(1): 31-
38.
20. Haydel MJ, Preston CA, Mills TJ, et al. Indications for Computed Tomography in Patient with Minor Head Injury. N Engl J
Med 2000; 343(2): 100-105.
21. Gean, Alisa D. Imaging of Head Trauma. New York: Raven Press; 1994.
22. Provenzale JM. CT and MR Imaging of Nontraumatic Neurologic Emergencies. AJR 2000; 174: 289-299.
10
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CT Angiography (CTA)
Head: Cerebrovascular
CPT CODES:
70496........Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if
performed, and image postprocessing
IMAGING CONSIDERATIONS:
• CTA studies are typically performed through acquisition of thin CT sections, during intravenous bolus infusion of
iodinated contrast material.
• During diagnostic interpretation, it is extremely useful to have images displayed on a workstation capable of
multiplanar reformations and three-dimensional reconstructions.
• Multi-detector row CT is preferred but not required in the performance of CTA, when compared with single
detector CT.
• Contrast-enhancement for CTA may be contraindicated in certain circumstances, such as a documented allergy to
intravenous contrast material and renal insufficiency. Special consideration should also be given to patients with
multiple myeloma.
• CT Angiography (CTA) utilizes the data obtained from standard CT imaging. Request for a CT exam, in addition
to a CT Angiography of the same anatomic area and during the same imaging session, is inappropriate.
• Duplicative services, such as sequential ordering of CTA and MRA, are subject to high-level review for evaluation
of medical necessity.
• Request for re-imaging due to technically limited exams is the responsibility of the imaging provider.
DISSECTION
TREATMENT EVALUATION
INTRA-CRANIAL HEMORRHAGE
- Identification of the source of hemorrhage, when conventional angiography is contraindicated
INTRAMURAL HEMATOMA
12
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CTA – Head: Cerebrovascular
VASCULITIS
REFERENCES/LITERATURE REVIEW:
1. Schievink WI. Intracranial Aneurysms. N Engl J Med 1997; 336: 28-40.
2. Michell P, Gholkar A, Vindlacheruvu RR, Mendelow AD. Unruptured Intracranial Aneurysms: Benign Curiosity or Ticking Time
Bomb? Neurology 2004; 3: 85-92.
3. Jayaraman MV, Mayo-Smith WW, Tung GA, et al. Detection of Intracranial Aneurysms: Multi-Detector Row CT Angiography
Compared with DSA. Radiology 2004; 230: 510-518.
4. Tomandl BF, Köstner NC, Schempershofe M, et al. CT Angiography of Intracranial Aneurysms: A Focus on Post processing.
RadioGraphics 2004; 24: 637-655.
5. White PM, Teasdale EM, Wardlaw JM, Easton V. Intracranial Aneurysms: CT Angiography and MR Angiography for Detection
– Prospective Blinded Comparison in a Large Patient Cohort. Radiology 2001; 219: 739-749.
6. The Arteriovenous Malformation Study Group. Arteriovenous Malformations of the Brain in Adults. N Engl J Med 1999; 340:
1812-1818.
7. Sanelli PC, Mifsud, Stieg PE. Role of CT Angiography in Guiding Management Decisions of Newly Diagnosed and Residual
Arteriovenous Malformations. AJR 2004; 183: 1123-1126.
8. Meckel S, Lovblad K-O, Abdo G, et al. Arterialization of Cerebral Veins on Dynamic MDCT Angiography: A Possible Sign of a
Dural Arteriovenous Fistula. AJR 2005; 184: 1313-1316.
9. Weissman JL, Hirsch BE. Imaging of Tinnitus: A Review. Radiology 2000; 216: 342-349.
10. Verro P, Tanenbaum LN, Borden NM, et al. CT Angiography in Acute Ischemic Stroke. Preliminary Results. Stroke 2002; 33:
276-278.
11. Stam J. Thrombosis of the Cerebral Veins and Sinuses. N Engl J Med 2005; 253: 1791-1798.
13
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Magnetic Resonance Imaging
(MRI)
Head
CPT CODES:
70551........MRI Head, without contrast
70552........MRI Head, with contrast
70553........MRI Head, without contrast, followed by re-imaging with contrast
IMAGING 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 with preferred head imaging using CT include: osseous assessment of the calvarium, skull base and
maxillofacial bones, including detection of calvarial and facial bone fractures; calcified lesions; initial evaluation of
recent craniocerebral trauma; and acute intra-cranial hemorrhage (parenchymal; subarachnoid; subdural;
epidural).
• MRI is more sensitive for detection of shearing trauma to the brain and diffuse axonal injury. It is also the preferred
technique for assessment of subacute and chronic intra-cranial hemorrhage.
• CT of the head is an alternative exam in patients who cannot undergo MRI. 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 indwelling pacemakers 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 implanted materials in the patient as well as
external equipment, such as portable oxygen tanks). Performance of an MRI examination may also be
unsuccessful, for example secondary to claustrophobia.
• The CPT code assignment for an MRI procedure is based on the anatomic area imaged. Requests for multiple
MRI exams 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.
• Images of the pituitary gland, orbits, maxillary sinuses or internal auditory canals (IACs) are included within the
single assigned CPT code for MRI imaging of the head and are not separately billable as multiple concurrent head
MRI exams.
• MRI studies of the head and neck are inherently bilateral. Duplicate imaging requests for these studies are
inappropriate.
• Duplicative testing of the same anatomic area with MRI and CT may be subject to high-level review to evaluate for
medical necessity.
• Request for re-imaging due to technically limited exams is the responsibility of the imaging providers.
The following diagnostic indications for Head MRI are accompanied by pre-test considerations as well as supporting clinical data
and prerequisite information:
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MRI – Head
CEREBRAL PALSY
5-6
CEREBROVASCULAR ACCIDENT (CVA OR STROKE) AND TRANSIENT ISCHEMIC ATTACK (TIA)
• May present with a variety of signs and symptoms, including sudden onset of weakness, focal sensory loss or
speech disorder
CONGENITAL ANOMALY
Including but not limited to the following conditions:
- Chiari Malformations
- Dandy-Walker Spectrum
- Encephalocele
- Holoprosencephaly
- Macrocephaly
- Microcephaly
- Schizencephaly
- Septo-optic Dysplasia
7-8
DEMENTIA
• Initial evaluation, or
• Rapid progression
DEVELOPMENTAL DELAY
• MRI is the preferred imaging modality over CT, in developmental delay 9
- The likelihood of making a specific neuroimaging diagnosis increases in the presence of physical exam
abnormalities such as focal motor findings or microcephaly
ENCEPHALOPATHY
15
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MRI – Head
• MRI is often the preferred for initial evaluation of patients with hydrocephalus. For patients with an indwelling shunt,
CT is usually adequate in the diagnostic follow-up of hydrocephalus.
MENTAL STATUS CHANGES, WITH DOCUMENTED OBJECTIVE EVIDENCE FROM NEUROLOGIC EXAM
16
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MRI – Head
MOVEMENT DISORDERS
• Including Parkinson’s disease (particularly atypical cases with poor response to levodopa, in which there may be an
underlying structural disorder producing parkinsonian features); Huntington’s disease; idiopathic sporadic cerebellar
ataxia (olivopontocerebellar atrophy); hemifacial spasm; and other conditions.
15-18
MULTIPLE SCLEROSIS AND OTHER WHITE-MATTER DISEASES
• Multiple Sclerosis may manifest a diverse range of symptoms, including but not limited to the following:
- Muscle Weakness
- Ataxia (loss of coordination) and Spasticity
- Paresthesias
- Speech (dysarthria, or slurred speech)
- Visual Disturbances (diplopia; nystagmus; evidence of optic neuritis)
- Cognitive Dysfunction
NEUROCUTANEOUS DISORDERS
Including but not limited to the following:
- Neurofibromatosis
- Sturge-Weber Syndrome
- Tuberous Sclerosis
- Von Hippel-Lindau Disease (VHL)
PAPILLEDEMA (refers to swelling and elevation of optic disc – a sign of increased intracranial pressure)
17
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MRI – Head
TRAUMA TO HEAD
• MRI is generally used to evaluate suspected shearing lesions and diffuse axonal injury in closed head trauma as
well as assessment of the subacute or chronic sequelae of head injury
• CT is often performed as the initial imaging exam in acute head trauma, particularly when associated with:
- Calvarial Fracture
- Change in Mental Status or Amnesia
- Focal Neurological Deficits
- Loss of Consciousness
- Seizures
- Signs of Increased Intracranial Pressure
- Vomiting
- Worsening Headaches
TRIGEMINAL NEURALGIA (PARTICULARLY WHEN ATYPICAL) OR ATYPICAL FACIAL PAIN WITHOUT FOCAL
OBJECTIVE SIGNS
• Atypical manifestations of trigeminal neuralgia include facial burning, boring crushing or pulsating sensations, which
may be relatively constant.
• Typical features of trigeminal neuralgia include the sudden, extremely sharp, stabbing, shock-like or throbbing pain
in the facial region.
14
TUMOR EVALUATION – BENIGN AND MALIGNANT:
Including but not limited to the following lesions:
• Primary Intra-cranial Tumors – suspected or known
1. Intra-axial Neoplasms of the Cerebrum and Cerebellum
2. Extra-axial Tumors, including Meningiomas and Schwannomas, such as:
- Cerebello-pontine Angle (CPA) and internal auditory canal (IAC) Vestibular Schwannoma of CN VIII
(also referred to as an Acoustic Neuroma), and
- Non-Acoustic Neuromas at the CPA involving cranial nerves (CN) 5, 7, 9, 10, 11 and 12, such as a
CN VII Schwannoma
3. Pituitary Tumors, including Macroadenomas and Microadenomas
• Metastatic Disease – suspected or known
• Either CTA or MRA are usually the imaging modalities of choice for some of the vascular abnormalities, such as
aneurysm evaluation.
18
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MRI – Head
With recurrent or persistent symptoms and when evaluation for other etiologies has not been revealing
VISUAL DISTURBANCE - SUCH AS VISUAL FIELD LOSS, DIPLOPIA AND OTHER ALTERATIONS IN VISION
THAT ARE UNEXPLAINED BY OPHTHALMOLOGIC EXAM AND PATIENT HISTORY
VASCULITIS
REFERENCES/LITERATURE REVIEW:
1. Gilman, Sid. Imaging the Brain: First of two parts. N Engl J Med 1998; 338(12): 812-820.
2. Gilman, Sid. Imaging the Brain: Second of two parts. N Engl J Med 1998; 338(13): 889-896.
3. Gilden DH. Bell’s Palsy. N Engl J Med 2003; 351: 1323-1331.
4. Weissman JL, Hirsch BE. Imaging of Tinnitus: A review. Radiology 2000; 216: 342-349.
5. Johnston SC. Transient Ischemic Attack. N Engl J Med 2002; 347: 1687-1692.
6. Culebras A, Kase CS, Masdeu JC, et al. Practice Guidelines for the Use of Imaging in Transient Ischemic Attacks and Acute
Stroke. American Heart Association 1997; 28: 1480-1497.
7. Petrella JR, Coleman RE, Doraiswamy PM. Neuroimaging and Early Diagnosis of Alzheimer Disease: A look to the future.
Radiolgy 2003; 226: 315-336.
8. Adelman AM, Daly MP. Initial Evaluation of the Patient with Suspected Dementia. American Family Physician 2005; 71(9):
1745-1750.
9. Shevell M, Ashwal S, Donley D, et al. Practice Parameter: Evaluation of the child with global developmental delay. Neurology
2003; 60: 367-380.
10. Medina LS, D’Souza B, Vasconcellos E. Adults and Children with Headache: Evidence-based diagnostic evaluation.
Neuroimaging Clinics of North America 2003; 13: 225-235.
11. Strain JD. ACR Appropriateness Criteria on Headache-Child. J Am Coll Radiol 2007; 4: 18-23.
12. Qureshi AI, Tuhrim S, Broderick JP, et al. Spontaneous Intracerebral Hemorrhage. N Engl J Med 2001; 344: 1450-1460.
13. Edlow JA, Caplan LR. Avoiding Pitfalls in the Diagnosis of Subarachnoid Hemorrhage. N Engl J Med 2000; 342: 29-36.
14. Osborn, Anne G., Editor. Diagnostic Imaging: Brain. Salt Lake City, Utah: Amirsys; 2004.
15. Noseworthy JH, Lucchinetti C, Rodriguez M, et al. Multiple Sclerosis. N Engl J Med 2000; 343: 938-952.
16. Frohman EM, Goodin DS, Calabresi PA, et al. The Utility of the MRI in Suspected MS. Neurology 2003; 61: 602-611.
17. McDonald WI, Compston A, Edan G, et al. Recommended Diagnostic Criteria for Multiple Sclerosis: Guidelines from the
International Panel on the Diagnosis of Multiple Sclerosis. Annals of Neurology 2001; 50(1): 121-127.
18. Kido DK, Tong K, Giang DW. How Different MR Imaging Criteria Relate to the Diagnosis of Multiple Sclerosis and its
Outcome. Neuroimaging Clinics of North America 2003; 13: 265-272.
19. Vattipally VR, Bronen RA. MR Imaging of Epilepsy: Strategies for Successful Interpretation. Neuroimaging Clinics of North
America 2004; 14: 349-372.
20. Bernal B, Altman NR. Evidence-Based Medicine: Neuroimaging of Seizures. Neuroimaging Clinics of North America 2003;
13: 211-224.
21. Hauer KE. Discovering the Cause of Syncope: A Guide to the Focused Evaluation. Postgraduate Medicine 2003; 113(1): 31-
38.
22. Provenzale JM. CT and MR Imaging of Nontraumatic Neurologic Emergencies. AJR 2000; 174: 289-299
19
Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
MR Angiography (MRA)
Head: Cerebrovascular
CPT CODES:
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
IMAGING CONSIDERATIONS:
• MRA refers to a group of diverse MR pulse sequences. These include Time-of-Flight (TOF) imaging, Phase
Contrast (PC) techniques and Three-Dimensional (3-D), T1-weighted gradient echo acquisitions obtained during
intravenous bolus infusion of a paramagnetic contrast agent (Gadolinium chelate).
• A workstation is necessary for most MRA studies, to acquire multiplanar reformations, shaded surface displays,
volume renderings and maximum intensity projection (MIP) images. Post-processing of MRA data with a MIP
reconstruction algorithm allows for 3-dimensional images to be rotated and viewed in different planes, improving
visualization of superimposed vessels.
• Ordering and imaging providers are responsible for considering biosafety issues prior to MRA examination, to
ensure patient safety. Among the generally recognized contraindications to MRA exam performance are
indwelling pacemakers 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 implanted
materials in the patient as well as external equipment, such as portable oxygen tanks).
• An MRA 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 not appropriate.
• Duplicative services, such as sequential ordering of MRA and CTA, are subject to high-level review to evaluate for
medical necessity.
• Request for re-imaging due to technically limited exams is the responsibility of the imaging provider.
20
Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
MRI – Head (Cerebrovascular)
DISSECTION
INTRA-CRANIAL HEMORRHAGE
- Identification of the source of hemorrhage, when conventional angiography is contraindicated
INTRAMURAL HEMATOMA
- Vertigo
- Visual Field Defects
VASCULITIS
REFERENCES/LITERATURE REVIEW:
1. Carr JC, Ma J, Desphande V, et al. High-Resolution Breath-Hold Contrast-Enhanced MR Angiography of the Entire Carotid
Circulation. AJR 2002; 178; 543-549.
2. Isoda H, Takehara Y, Isogai S, et al. Software-Triggered Contrast-Enhanced Three-Dimensional MR Angiography of the
Intracranial Arteries. AJR 2000; 174: 371-375.
3. Liauw L, van Buchem MA, Spilt A, et al. MR Angiography of the Intracranial Venous System. Radiology 2000; 214: 678-682.
4. Kirchhof K, Welzel T, Jansen O, Sartor K. More Reliable Noninvasive Visualization of the Cerebral Veins and Dural Sinuses:
Comparison of Three MR Angiographic Techniques. Radiology 2002; 224: 804-810.
5. Farb RI, Scott JN, Willinsky RA, et al. Intracranial Venous System: Gadolinium-enhanced Three-dimensional MR Venography
with Auto-triggered Elliptic Centric-ordered Sequence-Initial Experience. Radiology 2003; 226: 203-209.
6. Schievink WI. Intracranial Aneurysms. N Engl J Med 1997; 336: 28-40.
7. Mitchell P, Gholkar A, Vindlacheruvu RR, Mendelow AD. Unruptured Intracranial Aneurysms: Benign Curiosity or Ticking Time
Bomb? Neurology 2004;3: 85-92.
8. Mallouhi A, Felber S, Chemelli A, et al. Detection and Characterization of Intracranial Aneurysms with MR Angiography:
Comparison of Volume-Rendering and Maximum-Intensity-Projection Algorithms. AJR 2003; 180: 55-64.
9. White PM, Teasdale EM, Wardlaw JM, Easton V. Intracranial Aneurysms: CT Angiography and MR Angiography for Detection-
Prospective Blinded Comparison in a Large Patient Cohort. Radiology 2001; 219: 739-749.
10. The Arteriovenous Malformation Study Group. Arteriovenous Malformations of the Brain in Adults. N Engl J Med 1999; 340:
1812-1818.
11. Farb RI, McGregor C, Kim JK, et al. Intracranial Arteriovenous Malformations: Real-Time Auto-triggered Elliptic centric-ordered
3D Gadolinium-enhanced MR Angiography - Initial Assessment. Radiology 2001; 220: 244-251.
12. Wetzel SG, Bilecen D, Lyrer P, et al. Cerebral Dural Arteriovenous Fistulas: Detection by Dynamic MR Projection Angiography.
AJR 2000; 174: 1293-1295.
13. Noguchi K, Melhem ER, Kanazawa T, et al. Intracranial Dural Arteriovenous Fistulas: Evaluation with Combined 3D Time-of-
Flight MR Angiography and MR Digital Subtraction Angiography. AJR 2004; 182: 183-190.
14. Weissman JL, Hirsch BE. Imaging of Tinnitus: A Review. Radiology 2000; 216: 342-349.
15. Stam J. Thrombosis of the Cerebral Veins and Sinuses. N Engl J Med 2005; 253: 1791-1798.
22
Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
Functional Magnetic Resonance
Imaging (fMRI)
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
IMAGING CONSIDERATIONS:
• 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).
• For Pre-operative Neurosurgical Planning in Patients with Brain Tumors, as a replacement for a Wada test or
direct electrical stimulation mapping
• For Pre-operative Neurosurgical Planning in Patients with Seizures Refractory to Medical Treatment, as a
replacement for a Wada test or direct electrical stimulation mapping
REFERENCES/LITERATURE REVIEW:
1. Archten E. Jackson GD, Cameron JA. Presurgical Evaluation of the Motor Hand Area with Functional MR Imaging in Patients
with Tumors and Dysplastic Lesions. Radiology 1999; 210:529-538.
2. Korvenoja A, Kirveskari E, Aronen HJ. Sensorimotor Cortex Localization: Comparison of Magnetoencephalography,
Functional MR Imaging, and Intraoperative Cortical Mapping. Radiology 2006; 241: 213-222.
3. Medina LS, Benal B, Ruiz, J. Role fo Functional MR in Determining Language Dominance in Epilepsy and Nonepilepsy
Populations: A Bayesian Analysis. Radiology 2007; 242: 94-100.
4. Medina LS, Bernal B, Dunoyer C. Seizure Disorders: Functional MR Imaging for Diagnostic Evaluation and Surgical
Treatment – Prospective Study. Radiology 2005; 236: 247-253.
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Functional Brain MRI
5. Medina LS, Aguirre E, Bernal B. Functional MR Imaging versus Wada Test for Evaluation of Language lateralization: Cost
Analysis. Radiology 2004; 230: 49-54.
6. Petrella J, Shah L, Harris K. Preoperative Functional MR Imaging Localization of Language and Motor Areas: Effect on
Therapeutic Decision Making in Patients with Potentially Resectable Brain Tumors. Radiology 2006; 240: 793-802.
24
Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
Positron Emission Tomography (PET)
Brain Imaging
CPT CODES:
78608........PET brain, metabolic evaluation
78609........PET brain, perfusion, single study
IMAGING CONSIDERATIONS:
• This guideline does not supersede the enrollee’s health plan medical policy specific to PET Neuroimaging.
• Enrollee coverage for PET imaging of Alzheimer’s disease or Fronto-Temporal Lobe Dementia may be limited to
one (1) per lifetime.
• Duplicative testing of the same anatomic area may be subject to high-level review, for evaluation of medical
necessity.
REFRACTORY SEIZURES/EPILEPSY
• Pre-surgical evaluation to locate the foci of intractable seizure activity, in patients who have failed conventional
medical therapy and who are undergoing pre-surgical evaluation.
CONDITIONS:
The use of FDG-PET scan in the diagnosis of Alzheimer’s disease and Fronto-Temporal Lobe Dementia is
medically necessary and appropriate provided all of the following conditions are met:
• The patient has a recent diagnosis of Alzheimer’s disease or frontal-temporal lobe dementia and a documented
cognitive decline of at least six (6) months duration and meets the diagnostic criteria for Alzheimer’s disease or
fronto-temporal lobe dementia.
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Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
PET - Brain
CONDITIONS:
• The patient has had a comprehensive clinical evaluation which has included:
- A comprehensive medical history including an assessment of activities of daily living from a well-acquainted
informant other than the patient;
- A physical and mental status examination formally documenting the patient’s cognitive decline for a minimum of
six (6) months; and
- Cognitive scales or neuropsychological testing, laboratory testing, and structural imaging such as MRI or CT, to
aid in identifying structural, metabolic, and chemical abnormalities as a cause for cognitive impairment.
• The patient is evaluated by a physician experienced in the diagnosis and assessment of Alzheimer’s disease and
fronto-temporal lobe dementia.
• The results of previous physical and mental examinations, laboratory testing, and structural imaging have not
clearly determined either a specific neurodegenerative disease or other cause for the clinical symptoms and the
results of the FDG-PET will help clarify the diagnosis of Alzheimer’s disease or fronto-temporal lobe dementia, to
guide future treatment.
• A brain SPECT scan has not been obtained for the same indication.
• The referring (ordering) provider submits the following medical information regarding the enrollee:
- Date of onset of the cognitive decline
- Clinical documentation supporting the diagnosis of a clinical syndrome such as Alzheimer’s disease or fronto-
temporal lobe dementia
- Results of a mini-mental status exam (MMSE) or similar test score
- Differential diagnosis of Alzheimer’s disease or fronto-temporal lobe dementia
- Results of all neuropsychological testing performed
- Results of all CT and/or MRI structural imaging performed
- Results of recent B12 and Thyroid Hormone laboratory blood tests
- Name(s) of currently prescribed medications
REFERENCES/LITERATURE REVIEW:
1. Adelman AM, Daly MP. Initial Evaluation of the Patient with Suspected Dementia. Am Fam Physician 2005;71:1745-1750.
2. CMS National Coverage Indication for PET for Dementia and Neurodegenerative Diseases (NCD 220.6.13), effective 04/18/2005
3. Newberg AB, Alavi A. PET in Seizure Disorders. Radiol Clin N Am 2005;43:79-92.
4. Norfray JF, Provenzale JM. Alzheimer’s Disease: Neuropathologic Findings and Recent Advances in Imaging. AJR 2004; 182:
3-13.
5. Petrella JR, Coleman RE, Doraiswamy PM. Neuroimaging and Early Diagnosis of Alzheimer Disease: A Look to the Future.
Radiology 2003;226:315-336.
6. Patwardhan MB, McCrory DC, Matchar DB, et al. Alzheimer Disease: Operating Characteristics of PET – A Meta Analysis.
Radiology 2004;231:73-80.
7. Silverman DHS, Alavi A. PET Imaging in the Assessment of Normal and Impaired Cognitive Function. Radiol Clin N Am
2005;43:67-77.
26
Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
Computed Tomography (CT)
Orbit, Sella Turcica, Posterior Fossa
& Temporal Bone, including the 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
IMAGING CONSIDERATIONS:
• 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 contra-indicated) 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.
• Duplicative testing of the same anatomic area with MRI and CT may be subject to high-level review, for evaluation
of medical necessity.
• Ordering a CT of the head (CPT codes 70450-70470) in addition to a CT of the orbits is not necessary in most
cases. According to Medicare’s Correct Coding Edits, CT of the head and CT of the orbits are mutually exclusive
procedures.
• This is a bilateral procedure. Duplicate requests for imaging the right and left orbits should not be authorized.
COMMON DIAGNOSTIC INDICATIONS FOR ORBIT, SELLA TURCICA, POSTERIOR FOSSA, &
TEMPORAL BONE (INCLUDING THE MASTOIDS) CT:
The following diagnostic indications for CT of the Orbit, Sella, Posterior Fossa and Temporal Bone are accompanied by pre-test
considerations as well as supporting clinical data and prerequisite information:
CHOLESTEATOMA
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Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
CT - Orbit, Sella Turcica, Posterior Fossa & Temporal Bone, including the
Mastoids
COMMON DIAGNOSTIC INDICATIONS FOR ORBIT, SELLA TURCICA, POSTERIOR FOSSA, &
TEMPORAL BONE (INCLUDING THE MASTOIDS) CT:
CONGENITAL ANOMALIES OF THE ORBIT, TEMPORAL BONE, SELLA TURCICA AND POSTERIOR FOSSA
FOREIGN BODY:
• Evaluation for metallic foreign bodies in the orbits should be initiated with conventional radiographs, which detect
the majority of radiopaque foreign bodies
• CT may be performed if radiographs are inconclusive or if there remains high clinical suspicion for a foreign body
1-2
INFECTIOUS OR INFLAMMATORY PROCESS
• Unresponsive to medical treatment
• Including but not limited to the following:
- Abscess
- Cellulitis (for example, Orbital Cellulitis)
- Malignant Otitis Externa
- Osteomyelitis
- Otomastoiditis
ORBITAL PSEUDOTUMOR
TINNITUS
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Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
CT - Orbit, Sella Turcica, Posterior Fossa & Temporal Bone, including the
Mastoids
COMMON DIAGNOSTIC INDICATIONS FOR ORBIT, SELLA TURCICA, POSTERIOR FOSSA, &
TEMPORAL BONE (INCLUDING THE MASTOIDS) CT:
TRAUMA
Including but not limited to the following:
- Soft tissue injury
- Fracture
1, 3-6
TUMOR EVALUATION – BENIGN AND MALIGNANT:
Including but not limited to the following lesions:
• Primary Intra-cranial Tumors – suspected or known
1. Intra-axial Neoplasms of the Cerebrum and Cerebellum
2. Extra-axial Tumors, including Meningiomas and Schwannomas, such as:
- Cerebello-pontine Angle (CPA) and internal auditory canal (IAC) Vestibular Schwannoma of CN VIII
(also referred to as an Acoustic Neuroma), and
- Non-Acoustic Neuromas at the CPA involving cranial nerves (CN) 5, 7, 9, 10, 11 and 12, such as a
CN VII Schwannoma
3. Pituitary Tumors, including Macroadenomas and Microadenomas
• Metastatic Disease – suspected or known
OSSEOUS LESION EVALUATION
- Such as Fibrous Dysplasia, Paget’s disease and Otosclerosis
REFERENCES/LITERATURE REVIEW:
1. Som PM, Curtin HD. Head and Neck Imaging. St. Louis, Missouri: Mosby Publishers; 2003.
2. Vazquez E, Castellote A, Piqueras J, et al. Imaging of Complications of Acute Mastoiditis in Children. RadioGraphics 2003;
23: 359-372.
3. Choi DS, Na DGN, Byun HS, et al. Salivary Gland Tumors: Evaluation with Two-Phase Helical CT. Radiology 2000; 214: 231-
236.
4. Dammann F, Horger M, Mueller-Berg M, et al. Rational Diagnosis of Squamous Cell Carcinoma of the Head and Neck
Region: Comparative Evaluation of CT, MRI, and 18FDG PET. AJR 205; 184: 1326-1331.
5. Mukherji SK, Isaacs DL, Creager A. CT Detection of Mandibular Invasion by Squamous Cell Carcinoma of the Oral Cavity.
AJR 2001; 177: 237-243.
6. Yousem DM, Kraut MA, Chalian AA. Major Salivary Gland Imaging. Radiology 2000; 216;19-29.
29
Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
Magnetic Resonance Imaging (MRI)
Orbit, Face and 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
IMAGING CONSIDERATIONS:
• MRI is usually preferred over CT for evaluation of the sella turcica and visual pathways, unless contra-indicated.
• 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, after initial radiographic evaluation for
a radiopaque foreign body.
• 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 indwelling
pacemakers 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 implanted
materials in the patient as well as external equipment, such as portable oxygen tanks).
• 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 authorization
request.
• Duplicate exam requests for two or more MRI studies of the head (for eample, bilateral head MRIs for right and left
orbital evaluation) or neck are inappropriate. These exams are inherently bilateral.
• Duplicative testing of the same anatomic area with MRI and CT may be subject to high-level review to evaluate for
medical necessity.
• An MRI of the orbit, face and neck is not allowed for imaging the IACs. See MRI of the brain (CPT codes 70551 –
70553).
• Request for re-imaging due to technically limited exams is the responsibility of the imaging providers.
COMMON DIAGNOSTIC INDICATIONS FOR ORBIT, FACE & NECK (SOFT TISSUE) MRI:
The following diagnostic indications for MRI of the Orbit, Face and Neck (Soft Tissues) are accompanied by pre-test considerations as
well as supporting clinical data and prerequisite information:
NECK MASSES IN THE PEDIATRIC POPULATION, SUCH AS BRANCHIAL CLEFT CYST, THYROGLOSSAL DUCT
9
CYST AND LYMPHANGIOMA / CYSTIC HYGROMA
CONGENITAL ANOMALIES
• Initial diagnosis may be established with an elevated cANCA (cytoplasmic pattern - antineutrophil cytoplasmic
antibody) and biopsy showing non-caseating, multinucleated, giant cell granulomas
HOARSENESS
• Unexplained, following endoscopic examination and/or prior non-diagnostic imaging of neck/upper chest
(extending along the course of the recurrent laryngeal nerves)
GLOTTIC LESION
• Further assessment following endoscopic detection
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MRI - Orbit, Face and Neck (Soft Tissues)
COMMON DIAGNOSTIC INDICATIONS FOR ORBIT, FACE & NECK (SOFT TISSUE) MRI:
ORBITAL INDICATIONS:
Including but not limited to:
- Extraocular Myopathy
- Extraocular Weakness or Non-conjugate Eye Movements
- Nystagmus
1
- Optic Neuritis
1,10
- Orbital Pseudotumor
- Papilledema (refers to swelling and elevation of optic disc – a sign of increased intracranial pressure)
- Proptosis
- Strabismus
- Thyroid Ophthalmopathy
- Visual loss unexplained by ophthalmic evaluation
NASAL INDICATIONS:
- Anosmia
- Recurrent Epistaxis
- Nasal Obstruction
REFERENCES/LITERATURE REVIEW:
1. Belden CJ. MR Imaging of the Globe and Optic Nerve. Magn Reson Imaging Clin N Am 2002; 10: 663-678.
2. Damman F, Horger M, Mueller-Berg M, et al. Rationale Diagnosis of Squamous Cell Carcinoma of the Head and Neck:
Comparative Evaluation of CT, MRI, and 18FDG PET. AJR 2005; 184: 1326-1331.
3. Ljumanović R, Langendijk JA, Schenk B, et al. Supraglottic Carcinoma Treated with Curative Radiation Therapy: Identification
of Prognostic Groups with MR Imaging. Radiology 2004; 232: 440-448.
4. Som PM, Curtin HD, Mancuso AA. Imaging-Based Nodal Classification for Evaluation of Neck Metastatic Adenopathy. AJR
2000; 174: 837-844.
5. King AD, Tse GMK, Ahuja AT, et al. Necrosis in Metastatic Neck Nodes: Diagnostic Accuracy of CT, MR Imaging, and US.
Radiology 2004; 230: 720-726.
6. Schlechte JA. Prolactinoma. N Engl J Med 2003; 349: 2035-2041.
7. Yousem DM, Kraut MA, Chalian AA. Major Salivary Gland Imaging. Radiology 2000; 216: 19-29.
8. Gotway MB, Higgins CB. MR Imaging of the Thyroid and Parathyroid Glands. MRI Clin N Am 2000; 8(1): 163-182.
9. Castellote A, Vázquez E, Vera J, et al. Cervicothoracic Lesions in Infants and Children. RadioGraphics 199; 19: 583-600.
10. Narla LD, Newman B, Spottwood SS, et al. Inflammatory Pseudotumor. RadioGraphics 2003; 23: 719-729.
32
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Computed Tomography (CT)
Paranasal Sinuses & 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
IMAGING CONSIDERATIONS:
• Radiation Dosimetry: Approximately 50 Chest X-Ray equivalent dosage
• The prevalence of sinus inflammatory disease is high, estimated to affect approximately 33 million US citizens.1
• This guideline includes reference to rhinosinusitis in the evaluation of sinus inflammatory disease, since sinusitis
2
usually involves the nasal passage as well as the paranasal sinuses.
• A common classification of sinusitis / rhinosinusitis is based on duration of symptoms, as follows:
- Acute sinusitis / rhinosinusitis – symptoms last for less than 4 weeks and include persistent
symptoms of an upper respiratory tract infection, purulent rhinorrhea, postnasal drainage, anosmia,
nasal congestion, facial pain, headache, fever, cough, and/or purulent discharge.
- Subacute sinusitis / rhinosinusitis – symptoms last from 4 to 12 weeks.
- Chronic sinusitis / rhinosinusitis – the same symptoms as in acute sinusitis that persist for at least 12
weeks, with varying severity. Chronic sinusitis may sometimes present with vague or insidious
symptoms.
- Recurrent sinusitis / rhinosinusitis – 3 or more episodes of acute sinusitis per year; individual
episodes may be caused by different organisms.
• Clinicians should distinguish presumed acute bacterial rhinosinusitis from acute rhinosinusitis due to viral upper
2
respiratory infections and noninfectious conditions.
• Acute sinusitis is considered a self-limiting disease, since most patients improve within 2 weeks, despite the
etiology and treatment option used.
• Chronic sinusitis is reported by the Centers for Disease Control and Prevention (CDC) to be the most commonly
encountered condition below the age of 45 years and the second most common condition between 45-64 years,
1
following hypertension.
• Sinus CT is not usually performed at the time of initial clinical presentation with acute uncomplicated sinusitis.
• Sinus CT is often reserved for difficult cases or delineation of anatomy prior to planned sinus surgery, as follows:
- Limited (coronal) Sinus CT – typically used for recurrent or refractory sinus inflammatory disease, or if the
diagnosis is in doubt.
- Full Sinus CT – generally performed for surgical planning to interrogate for osteomeatal obstruction, fungal
sinusitis, facial or orbital cellulitis complicating sinusitis and suspected malignancy.
• Duplicative testing of the same anatomic area with MRI and CT may be subject to high-level review, for evaluation
of medical necessity.
• CT of the paranasal sinuses is appropriately coded to CPT 70486. There are no required number of slices or
phases for contrast-enhanced exams that constitute a paranasal sinus and maxillofacial CT study. This code may
be used to describe limited or complete imaging of the sinuses.
• CT of the maxillofacial area is a bilateral study. Separate requests to image the right and left facial area are not
allowed.
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Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
CT – Paranasal Sinuses & Maxillofacial Area
ANOSMIA
POLYPOSIS
• Following direct visualization or endoscopic examination demonstrating evidence of polyps
5
TRAUMA TO THE FACIAL BONES – SIGNIFICANT INJURY
RECURRENT EPISTAXIS
CONGENITAL ANOMALIES
POST-OPERATIVE SINUS SURGERY, WITH NEW OR WORSENING SYMPTOMS AND CLINICAL FINDINGS
34
Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
CT – Paranasal Sinuses & Maxillofacial Area
REFERENCES/LITERATURE REVIEW:
1. Anzai Y, Yueh B. Imaging evaluation of sinusitis: diagnostic performance and impact on health outcome. Neuroimag Clin N Am
2003; 13: 251-263.
2. Rosenfeld RM, Andes D, Bhattacharyya N, et al. Clinical Practice Guideline: Adult Sinusitis. Otolaryngology-Head and Neck
Surgery. 2007; 137: S1-S31.
3. Okuyemi KS, Tsue TT. Radiologic Imaging in the Management of Sinusitis. American Family Physician. 2002; 66(10): 1882-
1886.
4. Poole MD. Difficulties in Diagnosis and Treatment of Sinusitis. The American Journal of Managed Care. 1999; 5(11)Sup.:
S670-S676.
5. Turner BG, Rhea JT, Thrall JH, Small AB, Novelline RA. Trends in the use of CT and Radiography in the Evaluation of Facial
Trauma, 1992-2002: Implications for Current Costs. AJR 2004; 183: 751-754.
35
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Magnetic Resonance Imaging (MRI)
Temporomandibular Joints (TMJ)
CPT CODES:
70336........MRI of Temporomandibular Joint(s)
IMAGING CONSIDERATIONS:
• Conventional radiographs and/or Panorex films should be used for initial evaluation of bony abnormalities.
• Some of the common causes for temporomandibular joint dysfunction include direct trauma, habitual misuse of the
TMJs and various arthritides, including degenerative joint disease.
• For a known or suspected fracture of the mandibular condyles and TMJ regions, further evaluation following initial
radiographs is usually undertaken with CT.
• MRI may be used to evaluate for internal derangements and articular disc dysfunction in the TMJs.
• Dynamic Ultrasound is an alternative technique for detecting disc displacement in the TMJs.
1
• 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 indwelling
pacemakers 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 implanted
materials in the patient as well as external equipment, such as portable oxygen tanks).
• MRI of the temporomandibular joint(s) is inherently a bilateral procedure. Separate entries for the right and left
temporomandibular joints are not allowed.
• Duplicative testing of the same anatomic area with MRI and CT may be subject to high-level review, for evaluation
of medical necessity.
FROZEN JAW
36
Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
MRI-TMJ
POST-OPERATIVE EVALUATION
• With new or recurrent signs and symptoms
REFERENCES/LITERATURE REVIEW:
1. Emshoff R, Jank, S, Bertram S, et al. Disk Displacement of the Temporomandibular Joint: Sonography versus MR Imaging. AJR
2002; 178: 1557-1562.
2. Larheim TA, Westesson P-L, Sano T. Temporomandibular Joint Disc Displacement: Comparison in Asymptomatic Volunteers
and Patients. Radiology 2001; 218: 428-432.
3. Sommer OJ, Aigner F, Rudisch A, et al. Cross Sectional and Functional Imaging of the Temporomandibular Joint: Radiology,
Pathology, and Basic Biomechanics of the Jaw. RadioGraphics 2003; 23: e14.
37
Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
Computed Tomography (CT)
Neck for Soft Tissue Evaluation
CPT CODES:
70490........CT Soft Tissues of Neck, without contrast
70491........CT Soft Tissues of Neck, with contrast
70492........CT Soft Tissues of Neck without contrast, followed by re-imaging with contrast
IMAGING CONSIDERATIONS:
• Radiation Dosimetry is approximately 200 Chest X-Ray equivalent dosage
• 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.
• For many other soft tissue abnormalities of the neck, MRI is preferred, unless there is a contraindication to this
imaging modality [due to pacemaker, implantable cardioverter-defibrillator (ICD), and other non-compatible device
unsafe for use in an MRI scanner] or if MRI is not tolerated by the patient (usually secondary to claustrophobia).
• CT of the neck for soft tissue evaluation is not used for targeted imaging of the cervical spine. See CT of the
cervical spine (72125-72127).
• CT soft tissue neck is inherently a bilateral study. Separate requests to image both sides of the neck are not
allowed.
• Duplicative testing of the same anatomic area with MRI and CT may be subject to high-level review, for evaluation
of medical necessity.
The following diagnostic indications for Neck CT are accompanied by pre-test considerations as well as supporting clinical data and
prerequisite information:
NECK MASSES IN THE PEDIATRIC POPULATION, SUCH AS BRANCHIAL CLEFT CYST, THYROGLOSSAL DUCT
1
CYST AND LYMPHANGIOMA / CYSTIC HYGROMA
2
TUMOR EVALUATION – PRIMARY NEOPLASM AND METASTATIC DISEASE
38
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CT – Neck for Soft Tissue Evaluation
STRIDOR
• For subacute and chronic stridor, advanced imaging may follow neck (soft tissue) radiographs and ENT evaluation
PERSISTENT HOARSENESS
• Unexplained, following endoscopic examination and/or prior non-diagnostic imaging of neck/upper chest
(extending along the course of the recurrent laryngeal nerves)
GLOTTIC LESION
• Further assessment following endoscopic detection
UPPER TRACHEAL STENOSIS OR COMPRESSION – suspected or known
REFERENCES/LITERATURE REVIEW:
1. Castellote A, Vázquez E, Vera J, et al. Cervicothoracic Lesions in Infants and Children. RadioGraphics 199; 19: 583-600.
2. Som PM, Curtin HD, Mancuso AA. Imaging-Based Nodal Classification for Evaluation of Neck Metastatic Adenopathy. AJR
2000; 174: 837-844.
3. Fultz PJ, Feins RH, Strang JG, et al. Detection and Diagnosis of Nonpalpable Supraclavicular Lymph Nodes in Lung Cancer at
CT and US. Radiology 2002; 222: 245-251.
4. van Overhagen H, Brakel K, Heijenbrok MW, et al. Metastases in Supraclavicular Lymph Nodes in Lung Cancer: Assessment
with Palpation, US and CT. Radiology 2004; 232: 75-80.
5. Sumi M, Ohki M, Nakamura T. Comparison of Sonography and CT for Differentiating Benign from Malignant Cervical Lymph
39
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CT – Neck for Soft Tissue Evaluation
Nodes in Patients with Squamous Cell Carcinoma of the Head and Neck. AJR 2001; 176: 1019-1024.
6. King AD, Tse GMK, Ahuja AT, et al. Necrosis in Metastatic Neck Nodes: Diagnostic Accuracy of CT, MR Imaging, and US.
Radiology 2004; 230: 720-726.
7. Chin S-C, Edelstein S, Chen CY, et al. Using CT to Localize Side and Level of Vocal Cord Paralysis. AJR 2003; 180: 1165-
1170.
40
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CT Angiography (CTA)
Neck
CPT CODES:
70498 ...... CTA of Neck,with contrast material(s), including noncontrast images, if performed, and image
postprocessing
IMAGING CONSIDERATIONS:
• Duplex Doppler examination of the extracranial carotid arteries is often performed prior to CTA.
• Advantages of CTA over MRA include higher sensitivity for detection of mural calcification; usually shorter scan
time, which results in less motion, pulsation and turbulent flow artifact; avoidance of MRA in-plane flow as a cause
of apparent exaggerated stenosis; more facile detection of surgical clips and stents.
• Disadvantages of CTA include radiation exposure and use of intravascular iodinated contrast material.
• Contrast-enhancement for CTA may be contraindicated in certain circumstances, such as a documented allergy to
intravenous contrast material and renal insufficiency. Special consideration should also be given to patients with
multiple myeloma.
• CT Angiography (CTA) utilizes imaging data from standard CTacquisitions. Request for a CT exam, in addition to
CT Angiography of the same anatomic area during the same imaging session, is inappropriate.
• Duplicative services, such as CTA and MRA, are subject to high-level review for evaluation of medical necessity.
• Request for re-imaging due to technically limited exams is the responsibility of the imaging providers.
41
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CTA - Neck
ANEURYSM
ARTERIOVENOUS MALFORMATION
INTRAMURAL HEMATOMA
ARTERIAL THROMBOEMBOLISM
REFERENCES/LITERATURE REVIEW:
1. Phillips CD, Bubas LA. CT Angiography and MR Angiography in the Evaluation of Extracranial Carotid Vascular Disease. Radiol
Clin N Am 2002; 40(4): 783-798.
2. Marcus CD, Ladam-Marcus VJ, Bigot J-L, et al. Carotid Arterial Stenosis: Evaluation at CT Angiography with the Volume-
rendering Technique. Radiology 1999; 211: 775-780.
3. Randoux B, Marro B, Koskas F, et al. Carotid Artery Stenosis: Prospective Comparison of CT, Three-dimensional Gadolinium-
enhanced MR, and Conventional Angiography. Radiology 2001; 220: 179-185.
42
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CTA - Neck
4. Schievink W. Spontaneous Dissection of the Carotid and Vertebral Arteries. N Engl J Med 2001; 344(12): 898-906.
5. Núñez DB, Torres-León M, Múnera F. Vascular Injuries of the Neck and Thoracic Inlet: Helical CT – Angiographic Correlation.
RadioGraphics 2004; 24: 1087-1098.
6. Múnera F, Soto JA, Palacio DM, et al. Penetrating Neck Injuries: Helical CT Angiography for Initial Evaluation. Radiology 2002;
224: 366-372.
7. LeBlang S, Núñez DB. Noninvasive Imaging of Cervical Vascular Injuries. AJR 2000; 174: 1269-1278.
43
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MR Angiography (MRA)
Neck
CPT CODES:
70547........MRA of Neck without contrast
70548........MRA of Neck with contrast
70549........MRA of Neck without contrast, followed by re-imaging with contrast
IMAGING CONSIDERATIONS:
• Duplex Doppler examination of the extracranial carotid arteries is often performed prior to MRA.
• Advantages of MRA, compared with CTA include avoidance of radiation exposure as well as intravascular
administration of iodinated contrast material.+
• Disadvantages of MRA, compared with CTA, include lower sensitivity for detection of mural calcification; usually
longer scanning time, with potential for greater motion, pulsation and turbulent flow artifact; in-plane flow causing
apparent exaggerated stenosis; greater difficulty in identifying surgical clips and stents.
• Ordering and imaging providers are responsible for considering biosafety issues prior to MRA examination, to
ensure patient safety. Among the generally recognized contraindications to MRA exam performance are
indwelling pacemakers 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).
• An MRA of the neck is inherently bilateral. Duplicate requests to image the right and left side of the neck are not
allowed.
• Duplicative services, such as MRA and CTA, are subject to high-level review for evaluation of medical necessity.
• Request for re-imaging due to technically limited exams is the responsibility of the imaging providers.
44
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MRA - Neck
ARTERIOVENOUS MALFORMATION
INTRAMURAL HEMATOMA
ARTERIAL THROMBOEMBOLISM
45
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MRA - Neck
REFERENCES/LITERATURE REVIEW:
1. Carr JC, Ma J, Desphande V, et al. High Resolution Breath-Hold Contrast-Enhanced MR Angiography of the Entire Carotid
Circulation. AJR 2002; 178: 543-549.
2. Carroll FR, Korosec FR, Petermann GM, et al. Carotid Bifurcation: Evaluation of Time-resolved Three-dimensional Contrast-
enhanced MR Angiography. Radiology 2001; 220: 525-532.
3. Phillips CD, Bubas LA. CT Angiography and MR Angiography in the Evaluation of Extracranial Carotid Vascular Disease.
Radiol Clin N Am 2002; 40(4): 783-798.
4. Randoux B, Marro B, Koskas F, et al. Carotid Artery Stenosis: Prospective Comparison of CT, Three-dimensional Gadolinium-
enhanced MR, and Conventional Angiography. Radiology 2001; 220: 179-185.
5. Serfaty JM, Chirossel P, Chevallier JM, et al. Accuracy of Three-Dimensional Gadolinium-Enhanced MR Angiography in the
Assessment of Extracranial Carotid Artery Disease. AJR 2000; 175: 455-463.
6. Djouhri H, Guillon B, Brunereau L, et al. MR Angiography for the Long-Term Follow-Up of Dissecting Aneurysms of the
Extracranial Internal Carotid Artery. AJR 2000; 174: 1137-1140.
7. Schievink W. Spontaneous Dissection of the Carotid and Vertebral Arteries. N Engl J Med 2001;344(12): 898-906.
8. LeBlang S, Núñez DB. Noninvasive Imaging of Cervical Vascular Injuries. AJR 2000; 174: 1269-1278.
46
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Computerized Tomography (CT)
Chest
CPT CODES:
IMAGING CONSIDERATIONS:
• In the majority of clinical situations, Chest Radiographs should be performed prior to request for advanced
imaging with CT.
• Most health plans do not currently provide benefit coverage for screening studies using advanced imaging. For
1-2
Chest CT imaging, this may include lung cancer screening.
• Radiation Dosimetry: For a conventional chest CT exam, the typical effective radiation dose is around 8
milliSieverts (mSv) or 400 Chest X-Ray equivalents.
• 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 using the category III CTA codes 0144T – 0150T.
• Duplicative services, such as Chest CT and MRI, are subject to a high level review to evaluate for medical
necessity.
• Request for re-imaging due to technically limited exams is the responsibility of the imaging providers.
5
HEMOPTYSIS (COUGHING UP BLOOD)
• Initial evaluation should be performed with Chest X-Ray
47
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CT - Chest
9-10
DOCUMENTED MALIGNANCY – PRIMARY NEOPLASM AND METASTATIC DISEASE
• For staging and periodic follow-up
POST-OPERATIVE COMPLICATIONS
• For suspected or known operative complications, particularly during the initial 6-8 weeks following cardio-thoracic
surgery
SARCOIDOSIS
• Initial evaluation and periodic follow-up
TRAUMA – Injury involving the Chest Wall, Cardiomediastinal Structures and/or Lungs
48
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CT - Chest
BULLOUS EMPHYSEMA
• Following initial evaluation with Chest Radiographs
14
- Consider High Resolution Chest CT (HRCT) Technique
BRONCHIECTASIS
• Following initial evaluation with Chest Radiographs
14
- Consider High Resolution Chest CT (HRCT) Technique
16-17
ASBESTOS-RELATED BENIGN AND MALIGNANT LESIONS, involving the lungs and pleura:
- Pleural plaques
- Interstitial lung disease
- Malignant Mesothelioma
- Pleural effusion
- Lung cancer
OTHER PNEUMOCONIOSES
49
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CT - Chest
or
• In patients with confirmed aortic dissection in whom surgical repair is anticipated (to assist in preoperative
planning)
or
• For ongoing surveillance of stable patients with confirmed aortic dissection who have not undergone imaging of
the thoracic aorta within the preceding year
or
• 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
19-20
TRAUMATIC AORTIC INJURY
22
CONGENITAL HEART DISEASE
• For evaluation of suspected congenital heart disease in patients whose echocardiogram is technically limited or
nondiagnostic
or
• For initial evaluation of complex congenital heart disease in patients who have undergone echocardiography
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
or
• For evaluation of complex congenital heart disease in patients with a change in physical examination
or
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CT - Chest
• To assist in surgical planning for patients with complex congenital heart disease
or
• For surveillance in asymptomatic patients with complex congenital heart disease in patients who have not had
cardiac MRI or cardiac CT within the preceding year
- Cardiac MRI or transesophageal echocardiography may be preferable to chest CT in order to avoid radiation
exposure
REFERENCES/LITERATURE REVIEW:
1. Swensen SJ. CT Screening for Lung Cancer. AJR 2002; 179: 833-836
2. Mahadevia PJ, Fleisher L A, Frick, Kevin A. Lung Cancer Screening with Helical Computed Tomography in Older Adult
Smokers: A Decision and Cost-Effective Analysis. JAMA 2003; 289: 313-322.
3. Fedullo PF, Tapson VF. Evaluation of Suspected Pulmonary Embolism. N Engl J Med 2003; 349: 1247-1256.
4. Quiroz R, Kucher Zhou, Kelly. Clinical Validity of a Negative Computed Tomography Scan in Patients with Suspected
Pulmonary Embolism. JAMA 2005; 293 (16): 2012-2017.
51
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CT - Chest
5. Revel MP, Fournier L S, Hennebicque AS, et al. Can CT Replace Bronchoscopy in the Detection of the Site and Cause of
Bleeding in Patients with Large or Massive Hemoptysis? AJR 2002; 179: 1217-1224.
6. Irwin RS. Madison JM. Diagnosis and Treatment of Cough. N Engl J Med 2000; 343(23): 1715-1721.
7. Morice AH, Kastelik JA. Chronic Cough in Adults. Thorax 2003; 58: 901-907.
8. Tarver RD, Teague SD, Heitkamp DE, Conces DJ. Radiology of Community-Acquired Pneumonia. Radiol Clin N Am 2005;
43: 497-512.
9. Munden RF, Bruzzi J. Imaging of Non-Small Cell Lung Cancer. Radiol Clin N Am 2005; 43: 467-480.
10. Aquino SL. Imaging of Metastatic Disease to the Thorax. Radiol Clin N Am 2005; 43: 481-495.
11. Tan BB, Flaherty KR, Kazerooni EA, et al. The Solitary Pulmonary Nodule. Chest 2003; 123(1): 89S-96S.
12. Ost D, Fein AM, Feinsilver SH. The Solitary Pulmonary Nodule. N Engl J Med 2003; 348: 2535-2542.
13. Hartman TE. Radiologic Evaluation of the Solitary Pulmonary Nodule. Radiol Clin N Am 2005; 43: 459-465.
14. Kazerooni EA. High-Resolution CT of the Lungs. AJR 2001; 177: 501-519.
15. Pipavath S, Godwin JD. Imaging of Interstitial Lung Disease. Radiol Clin N Am 2005; 43: 589-599.
16. American Thoracic Society. Diagnosis and Initial Management of Nonmalignant Diseases Related to Asbestos. American
Journal of Respiratory and Critical Care Medicine. 2004; 170: 691-715.
17. Akira M, Yamamoto S, Inoue Y, Sakatani M. High-Resolution CT of Asbestosis and Idiopathic Pulmonary Fibrosis. AJR
2003; 181: 163-169.
18. Chiles C, Carr JJ. Vascular Diseases of the Thorax: Evaluation with Multidetector CT. Radiol Clin N Am 2005; 43: 543-569.
19. Macura KJ, Corl FM, Fishman EK, Bluemke DA. Pathogenesis in Acute Aortic Syndromes: Aortic Aneurysm Leak and
Rupture and Traumatic Aortic Transection. AJR 2003; 181: 303-307.
20. Parker MS, Matheson TL, Rao AV, et al. Making the Transition: The Role of Helical CT in the Evaluation of Potentially Acute
Thoracic Aortic Injuries. AJR 2001; 176: 1267-1272.
21. Truong MT, Sabloff BS, Gladish GW, et al. Invasive Thymoma. AJR 2003; 181: 1504.
22. Gilkeson RC, Ciancibello L, Zahka K. Multidetector CT Evaluation of Congenital Heart Disease in Pediatric and Adult
Patients. AJR 2003; 180: 973-980.
52
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CT Angiography (CTA)
Chest (Non-Coronary)
CPT CODES:
71275........CTA of Chest (noncoronary) ,with contrast material(s), including noncontrast images, if performed, and
image postprocessing
IMAGING CONSIDERATIONS:
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 (see biosafety issues, below)
and ionizing radiation.
Biosafety Issues:
• Ordering and imaging providers are responsible for considering safety issues prior to the CTA exam. One of the
1
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:
• Chest CTA does not cover cardiac and coronary artery imaging. Refer to the specific CPT codes for Cardiac and
Coronary Artery CT/CTA evaluation.
• There are uncommon circumstances when both CTA and MRA of the chest should be ordered for the same
clinical presentation. The specific rationale must be delineated at the time of request.
• In general, follow-up CTA exams should be performed only when there is a clinical change, with new signs or
symptoms, or specific finding(s) requiring imaging surveillance.
• Request for re-imaging due to technically limited exams is the responsibility of the imaging providers.
Other Comments:
• Duplicative testing of the same anatomic area with MRI and CT may be subject to high-level review, for evaluation
of medical necessity.
• CT Angiography (CTA) utilizes the data obtained from standard CT imaging. Request for a CT exam, in addition
to CT Angiography of the same anatomic area AND during the same imaging session, is inappropriate.
• For coronary artery imaging, see Category III codes 0144T-0150T.
53
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CTA – Chest (Non-Coronary)
SYSTEMIC VENOUS THROMBOSIS OR OCCLUSION, INCLUDING SUPERIOR VENA CAVA (SVC) SYNDROME
3
POST-TRAUMATIC VASCULAR INJURY
54
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CTA – Chest (Non-Coronary)
or
• 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
INTRAMURAL HEMATOMA
4,6
ATHEROMATOUS DISEASE, INCLUDING PENETRATING ATHEROSCLEROTIC AORTIC ULCER
VASCULITIS
7
STENT GRAFT EVALUATION, INCLUDING DETECTION OF AN ENDOLEAK
• Pre-Procedure Assessment and Post-Procedure Follow-up
PULMONARY SEQUESTRATION
11-13
EVALUATION OF CARDIAC VENOUS ANATOMY
• For localization of the pulmonary veins in patients with chronic or paroxysmal atrial fibrillation/flutter who have
been evaluated by electrophysiology and who are being considered for first radiofrequency ablation.
or
• For reevaluation of the pulmonary veins on one occasion following radiofrequency ablation
or
• For re-evaluation of the pulmonary venous anatomy prior to repeat radiofrequency ablation provided that the
patient has not had evaluation of the pulmonary veins following the previous radiofrequency ablation
or
• Coronary venous localization to establish candidacy for a biventricular pacemaker
- Chest CTA for these indications requires referral from a cardiologist or electrophysioligist or cardiothoracic
Surgeon
REFERENCES/LITERATURE REVIEW:
1. Weinreb JC, Larson PA, Woodard PK, et al. American College of Radiology Clinical Statement on Noninvasive Cardiac
Imaging. Radiology 2005; 235: 723-727.
2. Siegel MJ. Multiplanar and Three-dimensional Multi-Detector Row CT of Thoracic Vessels and Airways in the Pediatric
Population. Radiology 2003;229:641-650.
3. Alkadhi MD, Wildermuth S, Desbiolles L, et al. Vascular Emergencies of the Thorax after Blunt and Iatrogenic Trauma: Multi-
Detector Row CT and Three-dimensional Imaging. RadioGraphics. 2004;24:1239-1255.
4. Chiles C, Carr JJ. Vascular Diseases of the Thorax: Evaluation with Multidetector CT. Radiol Clin N Am 2005; 43: 543-569.
5. Tatli S, Yucel EK, Lipton MJ. CT and MR Imaging of the Thoracic Aorta: Current Techniques and Clinical Applications. Radiol
55
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CTA – Chest (Non-Coronary)
REFERENCES/LITERATURE REVIEW:
Clin N Am 2004; 42: 565-585.
6. Tunnick PA, Krinsky GA, Lee VS, Kronzon I. Diagnostic Imaging of Thoracic Aortic Atherosclerosis. AJR 2000; 174: 1119-
1125.
7. Therasse E,Soulez G, Giroux M-F, et al. Stent-Graft Placement for the Treatment of Thoracic Aortic Diseases. RadioGraphics.
2005;25:157-173.
8. Fedullo PF, Tapson V F. The Evaluation of Suspected Pulmonary Embolism. N Engl J Med 2003; 349(13): 1247-1256.
9. Schoepf UJ, Costello P. CT Angiography for Diagnosis of Pulmonary Embolism: State of the Art. Radiology 2004; 230:329-
337.
10. Kruip MJ, Leclercq MGL, van der Heul C, Prins MH, Büller HR. Diagnostic Strategies for Excluding Pulmonary Embolism in
Clinical Outcome Studies. Ann Intern Med 2003;138:941-951.
11. Ghaye B, Szapiro D, Dacher J-N, et al. Percutaneous Ablation for Atrial Fibrillation: The Role of Cross-sectional Imaging.
RadioGraphics 2003;23:S19-S33.
12. Jongbloed MR, Dirksen MS, Bax JJ, et al. Atrial Fibrillation: Multi-detector Row CT of Pulmonary Vein Anatomy prior to
Radiofrequency Catheter Ablation – Initial Experience. Radiology 2005; 234: 702-709.
13. Cronin P, Sneider MB, Kazerooni SM, et al. MDCT of the Left Atrium and Pulmonary Veins in planning Radiofrequency Ablation
for Atrial Fibrillation. AJR 2004; 183: 767-778.
56
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Magnetic Resonance Imaging (MRI)
Chest
CPT CODES:
71550 ......MRI chest, without contrast
71551 ......MRI chest, with contrast
71552 ......MRI chest, without contrast, followed by re-imaging with contrast
IMAGING CONSIDERATIONS:
• An MRI of the chest should not be entered for the imaging of the heart, which is examined using the Cardiac MRI
CPT codes 75557-75564.
• Duplicative testing of the same anatomic area with MRI and CT may be subject to high-level review, for evaluation
of medical necessity.
57
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MRI - Chest
PANCOAST TUMOR
• To evaluate for chest wall extension at the superior pulmonary sulcus
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
58
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MRI - Chest
REFERENCES/LITERATURE REVIEW:
1. Truong MT, Sabloff BS, Gladish GW, et al. Invasive Thymoma. AJR 2003; 181: 1504.
2. Tatle S, Yucel EK, Lipton MJ. CT and MR Imaging of the Thoracic Aorta: Current Techniques and Clinical Applications. Radiol Clin
N Am 2004; 42: 565-585.
3. Tunnick PA, Krinsky GA, Lee VS, Kronzon I. Diagnostic Imaging of Thoracic Aortic Atherosclerosis. AJR 2000; 174: 1119-1125.
4. Konen E, Merchant N, Provost Y, et al. Coarctation of the Aorta Before and After Correction: The Role of Cardiovascular MRI. AJR
2004; 182: 1333-1339.
59
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MR Angiography (MRA)
Chest
CPT CODES:
71555........MRA of Chest (excluding the myocardium) without contrast, followed by re-imaging with contrast
IMAGING CONSIDERATIONS:
Biosafety Issues:
• Ordering and imaging providers are responsible for considering biosafety issues prior to MRA examination, to
ensure patient safety. Among the generally recognized contraindications to MRA exam performance are
indwelling pacemakers 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 implanted
materials in the patient as well as external equipment, such as portable oxygen tanks).
Ordering Issues:
• There are uncommon circumstances when both MRA and CTA should be ordered for the same clinical
presentation. The specific rationale must be delineated at the time of request.
• In general, follow-up MRA exams should be performed only when there is a clinical change, with new signs or
symptoms, or specific finding(s) requiring imaging surveillance.
• Request for re-imaging due to technically limited exams is the responsibility of the imaging providers.
• Duplicative testing of the same anatomic area with MRI and CT may be subject to high-level review, for evaluation
of medical necessity.
1-3
Common Chest MRA Indications:
60
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MRA – Chest
SYSTEMIC VENOUS THROMBOSIS OR OCCLUSION, INCLUDING SUPERIOR VENA CAVA (SVC) SYNDROME
3
SUBCLAVIAN STEAL
61
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MRA – Chest
• In patients with confirmed aortic dissection in whom surgical repair is anticipated (to assist in preoperative
planning)
or
• For ongoing surveillance of stable patients with confirmed aortic dissection who have not undergone imaging of
the thoracic aorta within the preceding year
or
• 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
INTRAMURAL HEMATOMA
6
ATHEROMATOUS DISEASE, INCLUDING PENETRATING ATHEROSCLEROTIC AORTIC ULCER
VASCULITIS
PULMONARY SEQUESTRATION
11
EVALUATION OF CARDIAC VENOUS ANATOMY
• For localization of the pulmonary veins in patients with chronic or paroxysmal atrial fibrillation/flutter who have
been evaluated by electrophysiology and who are being considered for first radiofrequency ablation.
or
• For reevaluation of the pulmonary veins on one occasion following radiofrequency ablation
or
• For re-evaluation of the pulmonary venous anatomy prior to repeat radiofrequency ablation provided that the
patient has not had evaluation of the pulmonary veins following the previous radiofrequency ablation
or
• Coronary venous localization to establish candidacy for a biventricular pacemaker
- Chest MRA for these indications requires referral from a cardiologist or electrophysioligist or cardiothoracic
Surgeon
62
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MRA – Chest
REFERENCES/LITERATURE REVIEW:
1. Ho VB, Corse WR, Hood MN, Rowedder WR. Magnetic Resonance Angiography of the Thoracic Vessels. Magn Reson
Imaging Clin N Am. 2004;12:727-747.
2. Talti S, Yucel EK, Lipton MJ. CT and MR Imaging of the Thoracic Aorta: Current Techniques and Clinical Applications. Radiol
Clin N Am. 2004;42:565-585.
3. Wu C, Zhang J, Babb JS, et al. Subclavian Steal Syndrome: Diagnosis with Perfusion Metrics from Contrast-Enhanced MR
Angiographic Bolus-Timing Examination – Initial Experience. Radiology. 2005;235:927-933.
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;223:270-274.
5. Kunz RP, Oberholzer K, Kuroczynski W, et al. Assessment of Chronic Aortic Dissection: Contribution of Different ECG-Gated
Breath-Hold MRI Techniques. AJR 2004;182:1319-1326.
6. Tunick PA, Krinsky GA, Lee VS, Kronzon I. Diagnostic Imaging of Thoracic Aortic Atherosclerosis. AJR 2000;174:119-1125.
7. Konen E, Merchant N, Provost Y, et al. Coarctation of the Aorta Before the Correction: The Role of Cardiovascular MRI. AJR.
2004;182:1333-1339.
8. 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 2002;179:159-165.
9. Kreitner K-FJ, Ley S, Kauczor HU, et al. Chronic Thromboembolic Pulmonary Hypertension: Pre- and Postoperative
Assessment with Breath-Hold MRI Imaging Techniques. Radiology 2004;232:535-543.
10. Maki DD, Siegelman ES, Roberts DA, et al. Pulmonary Arteriovenous Malformations: Three-Dimensional Gadolinium-
Enhanced MR Angiography-Initial Experience. Radiology 2001;219:243-246.
11. Ghaye B, Szapiro D, Dacher J-N, et al. Percutaneous Ablation for Atrial Fibrillation: The Role of Cross-Sectional Imaging.
RadioGraphics. 2003;23:S19-S33.
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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
IMAGING CONSIDERATIONS:
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.
• Duplicative testing of the same anatomic area with MRI and CT may be subject to high-level review, for evaluation
of medical necessity.
FASCIAL EXTENSION OF BREAST CARCINOMAS ARISING NEAR THE PECTORALIS, SERRATUS ANTERIOR
AND INTERCOSTAL MUSCULATURE
LOCATE AN OCCULT BREAST CANCER WITH POSITIVE LYMPH NODES FOR METASTATIC DISEASE AND NO
IDENTIFIABLE PRIMARY BREAST LESION BY PHYSICAL EXAMINATION, MAMMOGRAPHY AND BREAST
ULTRASOUND
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MRI – Breast
HIGH-RISK INDIVIDUALS WITH A BREAST CANCER GENETIC MUTATION, WHICH INCLUDE THE FOLLOWING:
1,15
• BRCA1 AND BRCA2 – including BRCA mutation and first degree relative of BRCA carrier
• LI-FRAUMENI SYNDROME – including first degree relatives
• COWDEN SYNDROME – including first degree relatives
• BANNAYAN-RILEY-RUVALCABA SYNDROME – including first degree relatives
LIFETIME RISK ~ 20-25% OR GREATER, AS DEFINED BY BRCAPRO OR OTHER MODELS THAT ARE LARGELY
15
DEPENDENT ON FAMILY HISTORY
15
RADIATION TO CHEST BETWEEN AGES 10-30 YEARS
References/Literature Review:
1. ACR Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the Breast. ACR Website. Effective
10/1/04.
2. 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: 830-849.
3. Hlawatsch A, Teifke A, Schmidt M, Thelan M. Preoperative Assessment of Breast Cancer: Sonography Versus MR Imaging.
AJR 2002; 179: 1493-1501.
4. Lee CH. Problem Solving MR Imaging of the Breast. Radiol Clin N Am. 2004; 42: 919-934.
5. Huang W, Fisher PR, Dulaimy K, et al. Detection of Breast Malignancy: Diagnostic MR Protocol for Improved Specificity.
Radiology 2004; 232: 585-591.
6. Kriege M, Brekelmans CTM, 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 :427-437.
7. Lee JM, Orel SG, Czerniecki BJ, et al. MRI Before Reexcision Surgery in Patients with Breast Cancer. AJR 2004; 182: 473-480.
8. 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: 773-778.
9. Liberman L, Morris EA, Kim CM, et al. MR Imaging Findings in the Contralateral Breast of Women with Recently Diagnosed
Breast Cancer. AJR 2003; 180: 333-341.
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MRI – Breast
10. Liberman L, Morris EA, Dershaw DD, et al. MR Imaging of the Ipsilateral Breast in Women with Percutaneously Proven Breast
Cancer. AJR 2003; 180: 901-910.
11. Middleton MS. Magnetic resonance evaluation of breast implants and soft-tissue silicone. Top Magn Reson Imaging 1998; 9(2):
92-137.
12. Orel SG, Schnall MD. MR Imaging of the Breast for the Detection, Diagnosis, and Staging of Breast Cancer. Radiology 2001;
220: 13-30.
13. Schnall MD. Breast MR Imaging. Radiol Clin N Am 2003; 41: 43-50.
14. Schnall MD, Orel SG, Ed. Breast MR Imaging. Magnetic Resonance Imaging Clinics of North America. Philadelphia: W.B.
Saunders Company; May, 2001.
15. American Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography. CA Cancer J Clin 2007;
57: 75-89.
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Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
Nuclear Cardiology
Myocardial Perfusion Imaging (MPI)
CPT CODES:
78460........Planar, single study at rest or stress
78461........Planar, multiple studies at rest and/or stress
78464........SPECT, single study at rest or stress
78465........SPECT, multiple studies at rest and/or stress
IMAGING CONSIDERATIONS:
• A recent ECG is strongly recommended, preferably within 30 days of request for a Myocardial Perfusion Imaging
Exam. The ECG may be useful in selecting the type of stress exam 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
• 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 their practices.
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Nuclear Cardiology - MPI
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 • Cigarette smoking
Another factor in coronary heart disease risk assessment is a family history of premature coronary artery
disease in first degree relatives (males < 50 years old and females < 60 years old).
• The following baseline ECG changes could render a treadmill exercise ECG test uninterpretable:
- Complete Left Bundle Branch Block
- Pre-excitation (Wolff-Parkinson-White) Syndrome
- Digoxin Effect
- Ventricular Paced Rhythm
- Left Ventricular Hypertrophy, with Repolarization Abnormalities
- Baseline ST Segment Depression of 1 mm or more
• Individuals with these baseline ECG findings and additional indications as listed below are candidates for stress
imaging modalities (e.g., Myocardial Perfusion Imaging or Stress Echocardiography).
• 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 noninvasive 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.
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Nuclear Cardiology - MPI
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Nuclear Cardiology - MPI
or
2
- chronic renal insufficiency (creatinine clearance <60 mL/min/1.73 m for 3 or more months)
and
- have had no evaluation for coronary artery disease in the preceding two (2) years
• Patients who have undergone cardiac transplantation and have had no evaluation for coronary artery disease within
the preceding one (1) year
• Patients with new onset congestive heart failure or recently recognized left ventricular dysfunction (symptomatic or
asymptomatic)
- provided that there has been no evaluation for coronary artery disease (MPI, stress echo, coronary CTA or
cardiac catheterization) within the preceding sixty (60) days
and
- no cardiac catheterization is planned
• Patients with new onset arrhythmias (symptomatic or asymptomatic)
• Patients with ventricular tachycardia
or
• Patients with atrial fibrillation and high or moderate risk of CAD (SCORE)
• Patients with Abnormal Exercise Treadmill test (performed without imaging)
• Patients with a low or moderate risk of CAD (SCORE)
While MPI may be appropriate in the patients at high risk of cad (score consideration should be given to cardiac
catherterization rather than further noninvasive testing
Symptomatic Patients:
• With coronary artery calcium score > 400 Agatston units
or
• Coronary calcium score > 70th percentile for age and sex
or
• Intermediate severity coronary stenosis on CT coronary angiography
Note: if symptoms are typical of myocardial ischemia cardiac catheterization may be more appropriate than MPI
Asymptomatic patients:
• With coronary artery calcium score > 400 Agatston units
or
• Coronary calcium score > 70th percentile for age and sex
or
• Intermediate severity coronary stenosis CT coronary angiography
and
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Nuclear Cardiology - MPI
• No MPI, stress echo or cardiac catheterization within the preceding two year
• Patients with abnormal findings on cardiac catheterization
- to determine flow limiting significance of intermediate coronary stenosis
This guideline applies to patients undergoing non-emergency surgery. It is assumed that those who require
emergency surgery will undergo inpatient preoperative evaluation. Furthermore, for patients with active cardiac
conditions such as unstable coronary syndromes, decompensated heart failure (NYHA function of class IV, worsening
our new onset heart failure), significant arrhythmias (third degree AV block Mobitz II AV block, uncontrolled
supraventricular arrhythmia, symptomatic ventricular arrhythmias, ventricular tachycardia) or severe stenotic valvular
lesions is recommended that these conditions be evaluated and managed per ACC/AHA guidelines prior to
considering elective surgery.
Low-risk surgery (endoscopic procedures, superficial procedures common 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 (intraperitoneal and intrathoracic surgery, carotid endarterectomy, head and neck surgery,
orthopedic surgery, prostate surgery, gastric bypass surgery)
• in patients whose functional capacity is <4 METS
or
• the patient has at least one of the following clinical risk factors
- CAD including history of MI or Q waves on EKG, revascularization or angina
or
- compensated heart failure or prior history of heart failure\
or
- diabetes mellitus
or
- renal insufficiency (elevated serum creatinine) or renal failure
or
- prior history of cerebrovascular disease (TIA, CVA or carotid endarterectomy)
High-risk surgery (aortic and other major vascular surgery, peripheral vascular surgery)
• in patients whose functional capacity is <4 METS
or
• the patient has at least one of the following clinical risk factors
- CAD including history of MI or Q waves on EKG, revascularization or angina
or
- compensated heart failure or prior history of heart failure\
or
- diabetes mellitus
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Nuclear Cardiology - MPI
or
- renal insufficiency (elevated serum creatinine) or renal failure
or
- prior history of cerebrovascular disease (TIA, CVA or carotid endarterectomy)
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:
REFERENCES/LITERATURE REVIEW:
1. American College of Cardiology Foundation. ACCF/ASNC Appropriateness Criteria for Single-Photon Emission Computed
Tomography Myocardial Perfusion Imaging (SPECT MPI). J Am Coll Cardiol 2005; 46(8): 1588-1605.
2. Balady, G., Larson, M., Vasan, R., Usefulness of Exercise Testing in the Prediction of Coronary Disease Risk Among
Asymptomatic Persons as a Function of the Framingham Risk Score. Circulation 2004:110:1920-1925
3. Barry L. Zaret and George A. Bellar. Clinical Nuclear Cardiology. 3rd Edition. Philadelphia: Elsevier Mosby Publishers; 2005.
4. Crean A., Dutka D. Coulden, R., Cardiac Imaging Using Nuclear Medicine and Positron Emission Tomography. Radiol Clin N
Am 2004;42:619-634
5. Elhendy A., O’Leary E., Xie F, et al. Comparative Accuracy of Real-Time Myocardial Contrast Perfusion Imaging and Wall
Motion Analysis During Dobutamine Stress Echocardiography for the Diagnosis or Coronary Artery Disease. J Am Coll Cardiol
2004:44:2185-2191
6. Fleischmann K., Hunink M., Kuntz K, et al. Exercise Echocardiography or Exercise SPECT Imaging? JAMA 1998;280:913-920
7. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA/ASNC Guideline Update for Exercise Testing: A Report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing).2002
8. Hachamovitch R, Hayes ., Friedman J, et al. Determinants of Risk and its Temporal Variation in Patients with Normal Stress
Myocardial Perfusion Scans. J Am Coll Cardiol 2003;41:1329-1340
9. Hachamovitch R, Hayes S, Friedman, J, et al. Stress Myocardial Perfusion Single-Photon Emission Computed Tomography Is
Clinically Effective and Cost Effective in Risk Stratification of Patients with a High Likeihood or Coronary Artery Disease (CAD)
But No Known CAD. J Am Coll Cardiol 2004;43:200-208
10. Conroy R et al, Estimation of 10 year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J
2003;24:987-1003
11. Klocke FJ, Baird MG, Bateman TM, et al. ACC/AHA/ASNC Guidelines for the Clinical Use of Cardiac Radionuclide Imaging: A
Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC
Committee To Revise the 1995 Guideline for the Clinical Use of Cardiac Radionuclide Imaging) 2003
12. Maganti K, Rigolin V, Stress Echocardiography Versus Myocardial SPECT for Risk Stratification of Patients with Coronary
Artery Disease. Curr Opin Cardiol 2003;18:486-493
13. Marwick T, Williams MJ, Haluska B, et al. Exercise Echocardiography Is an Accurate and Cost-Efficient Technique for
Detection of Coronary Artery Disease in Women. J Am Coll Cardiol 1995;26:355-341
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Nuclear Cardiology - MPI
REFERENCES/LITERATURE REVIEW:
14. Olmos L, Dakik H, Gordon R, et al. Long-Term Prognostic Value of Exercise Echocardiography Compared with Exercise 201Tl,
ECG, and Clinical Variables in Patients Evaluated for Coronary Artery Disease. Circulation 1998; 98: 2679-2686
15. Poornima I, Miller T, Christian T, et al. Utility of Myocardial Perfusion Imaging in Patients with Low-Risk Treadmill Scores. J Am
Coll cardiol 2004;43:194-199
16. Schinkel, AFL, Bax, JJ, Geleijnse, ML, Noninvasive Evaluation of Ischaemic Heart Disease: Myocardial Perfusion Imaging or
Stress Echocardiography? European Heart Journal 2003;24:789-800
17. Senior R, Monaghan M, Becher H, et al. Stress Echocardiography for the Diagnosis and Risk Stratification of Patients with
Suspected or known Coronary Artery Disease: A Critical Appraisal. Supported by the British Society of Echocardiography.
Heart 2005;91:427-436
18. Strauss HW, Miller DD, Wittry MD, Society of Nuclear Medicine Procedure Guideline for Myocardial Perfusion Imaging. Society
of Nuclear Medicine Procedure Guidelines Manual. 2002 v. 3
19. Travin, Mark I, Bergmann S. Assessment of Myocardial Viability. Semin Nucl Med 2005;36:2-16
20. Yao SS, Qureshi E, Sherrid, M, et al. Practical Applications in Stress Echocardiography: Risk Stratification and Prognosis in
Patients with Known or Suspected Ischemic Heart Disease. J Am Coll Cardiol 2003;42:1084-1090
21. Grundy SM, Pasternak R, et al. Assessment of Cardiovascular Risk Using Multiple-Risk-Factor Assessment Equations: A
Statement for Healthcare Professionals from the Ametican Heart Association and the American College of Cardiology.
Circulation. 1999; 100:1481-1492
22. Fleisher et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery.
Executive Summary. JACC, 2007; 50:1707-32
23. Anderson J et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation
Myocardial Infarction. J Am Coll Cardiol, 2007; 50:1-157
24. Antman E, et al. ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction. J Am Coll
Cardiol 2004;44:671-719
25. Mieres J, et al. Rule of Noninvasive Testing in the Clinical Evaluation of Women with Suspected Coronary Artery Disease.
Circulation. 2005; 111;682-696
26. Zellweger M, et al. When to Stress Patients after Coronary Artery Bypass Surgery. J Am Coll Cardiol, 2001; 37:144-152
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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
IMAGING CONSIDERATIONS:
• 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 (78494 is used as an add-on code if RV function is
reported).
• First pass studies should be acquired on a high count-rate camera in order that images have sufficient temporal
resolution.
• 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.
• Some disease states and medications interfere with red blood cell labeling. These should be taken into account
when selecting the optimal imaging modality.
• 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.
stable
or
• Reevaluation of LV function at 2 year intervals in stable patients with established LV dysfunction
• Baseline and serial reevaluation in patients undergoing therapy with cardiotoxic agents
or
• Screening study for left ventricular dysfunction and first-degree relatives of patients with inherited cardiomyopathy
or
• Evaluation of suspected restrictive, infiltrative or genetic cardiomyopathy
or
• Evaluation on patients with diagnosed or suspected myocarditis
or
• Evaluation for dyssynchrony in a patient being considered for cardiac resynchronization therapy (CRT)
or
• Evaluation of a patient being treated with CRT with persistent or new symptoms with a view to device optimization
or
• When left ventricular dysfunction is suggested by other testing (chest x-ray, elevated BNP, abnormal baseline
scout imaging for stress echocardiography).
- If left ventricular function has been evaluated using another modality, MUGA/First Pass is not be necessary in
this situation.
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, MUGA/First Pass can be used as an
arbiter
or
• Periodic screening for ventricular dysfunction in patients who have undergone 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 a patient with the 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
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Nuclear Cardiology - Blood Pool Imaging
or
• Prior myocardial infarction for reevaluation of ventricular function after the recovery phase (more than three
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
REFERENCES/LITERATURE REVIEW:
1. DePuey et al. Imaging Guidelines for Nuclear Cardiology Procedures - A Report of the American Society of Nuclear
Cardiology Quality Assurance Committee. J Nucl Cardiol 2006;13:e21-171
2. Barry L. Zaret and George A. Bellar. Clinical Nuclear Cardiology. 3rd Edition. Philadelphia: Elsevier Mosby Publishers; 2005.
3. Gurusher Singh P, Diwakar J. Monitoring Chemotherapy Induced Cardiotoxicity: Role of Cardiac Nuclear Imaging. J Nucl
Cardiol 2006;13:415-26
4. DePuey EG et al. Non-perfusion Applications in Nuclear Cardiology. J Nucl Cardiol 1998;5:218-31
5. Williams KA. Measurement of Ventricular Function with Scintigraphic Techniques: Part 1 - Imaging Hardware,
Radiopharmaceuticals, and First Pass Radionuclide Angiography. J Nucl Cardiol 2005;12:86-95
6. Williams KA. A Historical Perspective on Measurement of Ventricular Function with Scintigraphic Techniques: Part II -
Ventricular Function with Gated Techniques for Blood Pool and Perfusion Imaging. J Nucl Cardiol 2005;12:208-15
7. Vallejo E et al. Assessment of Left Ventricular Ejection Fraction with Quantitative Gated SPECT: Accuracy and Correlation
with First Pass Radionuclide Angiography. J Nucl Cardiol 2000;7:461-70
8. Botvinick EH. Scintigraphic Blood Pool and Phase Image Analysis: The Optimal Tool for Evaluation of Resynchronization
Therapy. J Nucl Cardiol 2003;10:424-28
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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
RADIOPHARMACEUTICAL:
• Technetium-99m Pyrophosphate
IMAGING CONSIDERATIONS:
• Infarct imaging is typically optimal at 48-72 hours post-event 1
• False positive findings have been attributed to the following conditions: 1
- Amyloidosis
- Cardiac valvular and pericardial calcification
- Cardiomyopathy
- Doxorubicin (Adriamycin) Treatment
- Myocarditis and Pericarditis
- Prior myocardial infarction, that remains persistently positive
- Radiation Therapy
- Ventricular aneurysm
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 infarctions
- Left bundle branch block
POST-CARDIOVERSION
FOLLOWING SIGNIFICANT CHEST TRAUMA OR MAJOR SURGICAL PROCEDURE, WITH CHEST PAIN
References/Literature Review:
1. Thrall JH, Ziessman HA. Nuclear Medicine. The Requisites. 2nd Edition. St. Louis, Missouri: Elsevier Mosby Publishers, 2001,
pages 105-109.
2. Kim SC, Adams SC, Hendel RC. Role of Nuclear Cardiology in the Evaluation of Acute Coronary Syndromes. Annals of Emerg
Med 1997; 30 (2): 210-218.
3. Zaret, Barry L. and Bellar, George A. Clinical Nuclear Cardiology. 3rd Edition. Philadelphia: Elsevier Mosby; 2005.
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Magnetic Resonance Imaging (MRI)
Cardiac
CPT CODES:
75557........Cardiac MRI for morphology and function, without contrast material
75558........Cardiac MRI for morphology and function, without contrast material, with flow/velocity quantification
75559........Cardiac MRI for morphology and function, without contrast material, with stress imaging
75560........Cardiac MRI for morphology and function, without contrast material, with flow/velocity quantification and
stress imaging
75561........Cardiac MRI for morphology and function, without contrast material, followed by contrast material
75562…….Cardiac MRI for morphology and function, without contrast material, followed by contrast material with
flow/velocity quantification
75563……. Cardiac MRI for morphology and function, without contrast material, followed by contrast material with
stress imaging
75564……. Cardiac MRI for morphology and function, without contrast material, followed by contrast material with
flow/velocity quantification and stress imaging
CODING CONSIDERATIONS:
Only one procedure in the series 75557-75564 is appropriately reported per session. This code series is not to be used
to report cardiac MRA (see unlisted code 76598)
IMAGING CONSIDERATIONS:
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 indwelling pacemakers 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:
• Selection of the optimal diagnostic work-up 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.
• There are uncommon circumstances when both CT and MRI exams should be ordered for the same clinical presentation.
The specific rationale for each study must be delineated at the time of request.
• In general, follow-up CT and MRI exams should be performed only when there is a clinical change, with new signs or
symptoms.
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MRI - Cardiac
• Request for re-imaging due to technically limited exams is the responsibility of the imaging providers.
CARDIOMYOPATHY
• To assess LV function in patients with cardiomyopathy when there is discordant information from other studies or
when other studies are technically suboptimal
or
• Evaluation of patients with chronic and progressive diseases of the myocardium which result in cardiomyopathy
including but not limited to the following:
- Infiltrative Cardiomyopathy – Sarcoidosis; Amyloidosis; Hemochromatosis
- Hypertrophic Cardiomyopathy
- Non-compaction Cardiomyopathy
or
● Evaluation of patients with suspected arrhythmogenic right ventricular dysplasia
or
● For coronary vein mapping patients with cardiomyopathy for whom cardiac resynchronization therapy is
planned
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MRI - Cardiac
or
• For evaluation of complex congenital heart disease in patients with 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 IN
PATIENTS WHO HAVE NOT HAD CARDIAC CT OR CARDIAC MRI WITHIN THE PRECEDING YEAR
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MRI - Cardiac
• In patients whose echocardiogram shows a complex pericardial effusion (loculated, containing solid material)
REFERENCES/LITERATURE REVIEW:
1. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR Appropriateness Criteria for Cardiac Computed Tomography and Cardiac
Magnetic Resonance Imaging. JACC 2006; 48(7): 1-23. 7.
2. Pennell D, Udo S, et al. Clinical Indications for Cardiovascular Magnetic Resonance (CMR): Consensus Panel Report.
European Heart Journal 20004: 25 (21): 1940-1965
3. Edelman RR. Contrast-enhanced MR Imaging of the Heart: Overview of the Literature. Radiology 2004; 232: 653-668.
4. Reader S, Du Y, Lima,J, et al. Advanced Cardiac MR Imaging of Ischemic Heart Disease. RadioGraphics 2001;21:1047-1074.
5. Dembo L, Shifrin R, Wolff S. MR Imaging in Ischemic Heart Disease. Radiol Clin N Am 2004; 42: 651-673.
6. Schwitter J, Nanz D, Kneifel S, et al. Assessment of Myocardial Perfusion in Coronary Artery Disease by Magnetic Resonance.
Circulation 2001:103:2230-2235.
7. Beek A, Kuhl H, Bondarenko O, et al. Delayed Contrast-Enhanced Magnetic Resonance Imaging for the Prediction of Regional
Functional Improvement After Acute Myocardial Infarction. JACC 2003;42:895-904.
8. Hunold P, Schlosser T, Vogt F, et al. Myocardial Late Enhancement in Contrast-Enhanced Cardiac MRI: Distinction Between
Infarction Scar and Non-Infarction-Related Disease. AJR 2005;184:1420-1426.
9. Higgins CB, de Roos A. MRI and CT of the Cardiovascular System. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
10. Kayser H, van der Wall E, Sivananthan M. Diagnosis of Arrhythmogenic Right Ventricular Dysplasia: A Review. RadioGraphics
2002;22:639-648.
11. Hirsch R, Kilner P, Connelly M, et al. Diagnosis in Adolescents and Adults with Congenital Heart Disease. Circulation
1994;90:2937-2951.
12. Glockner JF, Johnston DL, McGee KP. Evaluation of Cardiac Valvular Disease with MR Imaging: Qualitative and Quantitative
Techniques. RadioGraphics 2003; 23; e9.
13. Hundley WG, Li H, Willard J, Magnetic Resonance Imaging Assessment of the Severity of Mitral Regurgitation. Circulation 1995;
92: 1151-1158.
14. Grebenc M, Rosado de Christenson M, Burke A, et al. Primary Cardiac and Pericardial Neoplasms: Radiologic-Pathologic
Correlation. RadioGraphics 2000;20:1073-1103.
15. DiBaise L, Fahmy TS. Pulmonary Vein Total Occlusion Following Caheter Ablation for Atrial Fibrillation. J Am Coll Cardiol,
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MRI - Cardiac
2006;48:2493-2499
16. Purerfellner H. Pulmonary Vein Stenosis: Still the Achilles Heel of Ablation for Artial Fibrillation. European Heart Journal. 2005;
26 (14): 1355-1357
17. Rienmuller R, Groll R, Lipton M. CT and MR Imaging of Pericardial Disease. Radiol Clin N Am 2004;42:587-601.
18. Wang ZF, Reddy GP, Gotway MB, et al. CT and MR Imaging of Pericardial Disease. RadioGraphics 2003; 23: S167-S180.
19. Rienmüller R, Gröll R, Lipton M. CT and MR Imaging of Pericardial Disease. Radiol Clin N Am 2004; 42: 587-601.
20. Weinreb JC, Larson PA, Woodard PK, et al. American College of Radiology Clinical Statement on Noninvasive Cardiac
Imaging. Radiology 2005; 235: 723-72
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Computerized Tomography and
Computerized Tomographic
Angiographic
Cardiac and Coronary Arteries (CCTA)
CPT CODES:
0144T .......CT heart, without contrast material, including image post-processing and quantitative evaluation of coronary
calcium
0145T .......CT heart, without contrast material, followed by contrast material(s) and further sections, including cardiac
gating and 3D image post-processing; cardiac structure and morphology
0146T........CTA of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts),
without quantitative evaluation of coronary calcium
0147T........CTA of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), with
quantitative evaluation of coronary calcium
0148T........Cardiac structure and morphology and CTA of coronary arteries (including native and anomalous coronary
arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium
0149T........Cardiac structure and morphology and CTA of coronary arteries (including native and anomalous coronary
arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium
0150T........Cardiac structure and morphology in congenital heart disease
IMAGING CONSIDERATIONS:
Advantages of CTA:
• Advantages of Cardiac and Coronary Artery CTA – Rapidly acquired exams, with excellent anatomic detail afforded
by most multidetector CT scanners with 16 or more active detector rows.
• CTA has a very high negative predictive value (93 to 100%)
Disadvantages of CTA:
• Disadvantages of Cardiac and Coronary Artery CTA include:
- Potential complications from use of intravascular iodinated contrast administration (see biosafety issues, below)
- Exposure to ionizing radiation (2-3 times higher than the average radiation dose administered to patients
undergoing cardiac catheterization)
- Potential factors that may limit the image quality during a Cardiac/Coronary Artery CTA exam, such as:
1. uncontrolled atrial or ventricular arrhythmias
2. extensive coronary artery calcification which may produce artifact
3. coronary stent evaluation for possible restenosis, as the stent material itself as well as the quality of the
scan and scanner may produce artifacts, limiting the exam
4. inability to image at a desired heart rate, which may occur despite beta blocker administration
5. 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)
6. not a suitable imaging modality for morbidly obese patients (BMI > 40)
7. because of the radiation exposure issues careful consideration should be given to other imaging
modalities in pregnant women and children
8. because CCTA images the coronary arteries directly, the information provided is anatomical. The
presence coronary stenosis on CCTA (particularly if deemed to be of intermediate severity) does not
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CT/CTA Cardiac & Coronary Artery
establish that the lesion is a flow limiting significance. Thus, following abnormal CCTA functional testing
may be required prior to clinical decision-making.
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. In addition, radiation
safety issues including cumulative exposure to ionizing radiation should be considered.
Ordering Issues:
• Cardiac and Coronary Artery CT/CTA exams are not covered by most healthcare insurers as a screening study, in
the absence of signs, symptoms or known disease.
• Selection of the optimal diagnostic work-up 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.
• There are uncommon circumstances when both Cardiac CT/CTA 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 and Coronary Artery CT/CTA exams should be performed only when there is a clinical
change, with new signs or symptoms, or specific finding(s) requiring imaging surveillance.
• This guideline does not pertain to ultrafast or electron beam computed tomography (EBCT) for coronary artery
evaluation.
• Request for re-imaging due to technically limited exams is the responsibility of the imaging providers.
The Pre-Test Probability of Coronary Artery Disease is stratified in the table below by age, gender and the
character of the chest pain, and provides useful predictors for underlying CAD.
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
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CT/CTA Cardiac & Coronary Artery
Several clinical indications listed for Cardiac CT/CCTA 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
• Diabetes Mellitus • Cigarette smoking
• Abnormal Lipid Profile • Hypertension
Another factor in coronary heart disease risk assessment is a family history of premature coronary artery disease
(males < 50 years old and females < 60 years old).
EVALUATION OF PATIENTS WITH PRIOR ABNORMAL CARDIAC TESTING (MPI OR STRESS ECHO)
• Patients with abnormal MPI or stress echo suspected to be false positive on the basis of low Coronary Heart
Disease Risk (using standard methods of risk assessment such as the SCORE risk calculation).
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CT/CTA Cardiac & Coronary Artery
- In the absence of a contraindication (excluding renal impairment and iodinated contrast agent hypersensitivity)
patients with moderate or high Coronary Heart Disease Risk should be referred for coronary arteriography.
or
• Patients with equivocal MPI or stress echo who have low or moderate Coronary Heart Disease Risk (using standard
methods of risk assessment such as the SCORE risk calculation.
- In the absence of a contraindication (excluding renal impairment and iodinated contrast agent hypersensitivity)
patients with high Coronary Heart Disease Risk should be referred for coronary arteriography.
- The resulting information from the CCTA should facilitate management decisions and not merely add a new
layer of testing.
• In patients with a suspected cardiac or para-cardiac mass (thrombus, tumor, etc.) suggested by transthoracic
echocardiography, transesophageal echocardiography, blood pool imaging or contrast vetriculography 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 or surgery) within the preceding year and have not had cardiac CT or cardiac MRI
within the preceding 60 days
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CT/CTA Cardiac & Coronary Artery
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 have
been evaluated by electrophysiology and who are being considered for first radiofrequency ablation.
or
• For reevaluation of the pulmonary veins on one occasion following radiofrequency ablation
or
• For re-evaluation of the pulmonary venous anatomy prior to repeat radiofrequency ablation provided that the
patient has not had evaluation of the pulmonary veins following the previous radiofrequency ablation
or
• Coronary venous localization to establish candidacy for a biventricular pacemaker
- Cardiac CT for these indications requires referral from a cardiologist or electrophysioligist or cardiothoracic
Surgeon
OTHER INDICATIONS FOR CARDIAC AND CORONARY ARTERY CT/CTA (CCTA) WILL CONTINUE TO
UNDERGO REVIEW, AS NEW EVIDENCE-BASED STUDIES ARE PUBLISHED. AT THE PRESENT TIME,
INDICATIONS OTHER THAN THOSE LISTED ABOVE ARE NOT INCLUDED IN THE CURRENT GUIDELINES.
This includes quantitative evaluation of coronary artery calcification (applicable to the Category III CPT codes 0144T,
0147T and 0149T).
REFERENCES/LITERATURE REVIEW:
1. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR Appropriateness Criteria for Cardiac Computed Tomography and Cardiac
Magnetic Resonance Imaging. JACC 2006; 48(7): 1-23.
2. Model Local Coverage Determination (LCD) Work Group for Cardiac Computed Tomography (CCT) and Computed
Tomography Coronary Angiography (CTCA), comprising of the American College of Cardiology (ACC), Carrier Advisory
Committee (CAC), American College of Radiology (ACR), American Society of Nuclear Cardiology (ASNC), North American
Society for Cardiac Imaging (NASCI) Society of Cardiac Angiography and Intervention (SCAI) and Society of Cardiovascular CT
(SCCT).
3. Gilkeson RC, Ciancibello L, Zahka K. Multidetector CT Evaluation of Congenital Heart Disease in Pediatric and Adult Patients.
AJR 2003; 180: 973-980.
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CT/CTA Cardiac & Coronary Artery
4. Goo HWG, Park I-S, Ko JKK, et al. CT of Congenital Heart Disease: Normal Anatomy and Typical Pathologic Conditions.
RadioGraphics 2003; 23: S147-S165.
5. Datta J, White CS, Gikleson RC, et al. Anomalous Coronary Arteries in Adults: Depiction at Multi-Detector Row CT
Angiography. Radiology 2005; 235: 812-818.
6. Chiles C, Carr JJ. Vascular Diseases of the Thorax: Evaluation with Multidetector CT. Radiol Clin N Am 2005; 43: 543-569.
7. ACC/ AHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring by Computed Tomography In
Global Cardiovascular Risk Assesment and in Evaluation of Patients with Chest Pain. J. Am Coll Cardiol 2007;49: 378-402
8. Hoffmann U, Ferencik M, Cury R et al. Coronary CT Angiography. J Nucl Med 2006; 47:797-806
9. DiCarli MF. CT coronary angiography: where does it fit? J Nucl Med. 2006;47:1397–1399.
10. Conroy R et al, Estimation of 10 year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J
2003;24:987-1003
11. Meyer T, Martinoff S, Hadamitsky M, et al. Improved Noninvasive Assessment of Coronary Artery Bypass Grafts with 64-Slice
Computed Tomographic Angiography in an Unselected Patient Population. J Am Coll Cardiol 2007; 49:946-50
12. Ehara M, Kawai M, Surmely JF et al. Diagnostic Accuracy of Coronary In-Stent Restenosis Using 64-Slice Computed
Tomography. J Am Coll Cardiol 2007; 49:951-9
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Positron Emission Tomography (PET)
Myocardial Imaging
CPT CODES:
78491…….PET myocardial perfusion, single study
78492…….PET myocardial perfusion, multiple studies
78459…….PET myocardial, metabolic evaluation
IMAGING CONSIDERATIONS
• This guideline does not supersede the enrollee’s health plan medical policy specific to myocardial PET imaging.
• Perfusion 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 stress Perfusion PET imaging can be performed.
• Metabolic evaluation (to determine myocardial viability) is performed using PET Flurodeoxyglucose (FDG) imaging.
Metabolic PET imaging has been shown to be useful in selection of patients who are likely to benefit from
revascularization
• Perfusion PET imaging and Metabolic PET imaging may be may be appropriate.
• Isotopes used in PET imaging require special handling arrangements because of their short half-lives.
• While Rubidium may be produced in a commercially available on-site generator Ammonia requires cyclotron
production
• Selection of the optimal diagnostic imaging for cardiac evaluation should be made within the context of other
available modalities (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.
• Perfusion PET imaging is generally (exceptions noted below) to be considered only when a patient has undergone
recent nuclear stress testing or stress echocardiography with equivocal results.
• In morbidly obese patients (BMI > 40) Perfusion PET imaging can 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).
• In keeping with CMS guidelines, Perfusion PET myocardial imaging may be considered as an alternative to nuclear
stress testing or stress echocardiography in symptomatic (or asymptomatic intermediate/high risk) patients greater
than 65 years old.
• Perfusion PET myocardial imaging is not appropriate for screening for coronary artery disease in asymptomatic low
risk patients regardless of age or body habitus.
• PET metabolic imaging is used in patients with established coronary artery disease and left ventricular systolic
dysfunction when determination of myocardial viability will influence the decision regarding revascularization
• PET metabolic imaging of the myocardium provides clinically useful information only when the myocardium is
deemed to be nonviable using other imaging modalities (perfusion imaging using thallium / technetium isotopes or
echocardiography) or when such imaging modalities are inconclusive regarding the viability status of the
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Myocardial Imaging - PET
myocardium.
• Perfusion PET imaging (patients who are at least 65 yrs old or have BMI >40)
• Evaluation of symptoms consistent with myocardial ischemia to diagnose or exclude coronary artery disease
or
• Established coronary artery disease with recurrent atypical symptoms
or
• Evaluation of regional myocardial blood flow in the patient with multiple vessel coronary artery disease with a view to
identifying a “culprit” lesion for revascularization
or
• Evaluation of asymptomatic patients who by virtue of risk factor status are at intermediate or high risk of coronary
artery disease.
• Perfusion PET imaging (patients who are < 65 yrs old and have BMI <40)
• Further evaluation of patients who have had an equivocal nuclear stress test or stress echo within the past 60 days
References/Literature Review:
1. Marwick TH, Zuchowski C, et al. Functional Status and Quality of Life in Patients with Heart Failure Undergoing Coronary
Bypass Surgery after Assessment of Myocardial Viability. JACC 1999; 33: 750
2. Sato H, Iwasaki T, et al. Prediction of Functional Recovery after Revascularization in Coronary Artery Disease Using 18 FDG
and 123I BMIPP SPECT. Chest 2000;117(1):65
3. Bacharach SL, Bax JJ, et al. PET Myocardial Glucose Metabolism and Perfusion Imaging: Part 1- Guidelines for Patient
Preparation and Data Acquisition and Part 2- Guidelines for Interpretation and Reporting. J Nucl Cardiol 2003; 10: 543-554
(Part 1) and 557-571 (Part 2)
4. National Coverage Determination for Myocardial Viability (220.6.8), Publication Number 100-3, Implementation Date
04/18/2005
5. Zaret BL, Bellar GA, Editors. Clinical Nuclear Cardiology. 3rd Edition. Philadelphia: Elsevier Mosby; 2005.
6. National Coverage Determination for PET for Perfusion of the Heart (220.6.1), Publication Number 100-3, Implementation
Date 04/18/2005
7. ACC/AHA/ASNC Guidelines for the Clinical Use of Cardiac Radionuclide Imaging. www.acc.org
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Computerized Tomography (CT)
Abdomen
CPT CODES:
74150........CT Abdomen; without contrast
74160........CT Abdomen; with contrast
74170........CT Abdomen; without contrast, followed by re-imaging with contrast
IMAGING CONSIDERATIONS:
• Radiation dosimetry: For abdominal CT exams, the typical effective radiation dose is approximately 10 milliSieverts
(mSv). This dosage correlates with an estimated 500 Chest X-Ray equivalents or approximately 4.5 years of natural
background radiation.
• When ordering an abdominal CT exam, consideration should be given to the benefits as well as the risks from
radiation exposure and ramifications of false positive studies (both financial and psychological), which may require
further work-up with other imaging modalities or follow-up surveillance with CT.
• Many health plans do not currently provide benefit coverage for screening exams (in patients without signs and
symptoms of disease) that use advanced imaging.
• Depending on the presenting signs and symptoms, other diagnostic studies, including Ultrasound, Barium
Examinations and Endoscopy, may be useful to help focus on the most appropriate advanced imaging exam (such
as CT, CTA, MRI, MRA, MRCP, PET and Radionuclide Imaging).
• Contrast-enhanced CT may be contraindicated in certain circumstances, such as a documented severe allergic
reaction to intravenous contrast material and renal insufficiency.
• For most gallbladder and hepatobiliary conditions, ascites evaluation and certain renal abnormalities (such as
detection of 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.
• Duplicative services, such as abdominal CT and MRI, are subject to high level review, to evaluate for medical
necessity.
• Request for re-imaging due to a technically limited exam is the responsibility of the imaging provider.
• For CT Colonography, see Category III codes 0066T or 0067T. Do not report Abdominal CT CPT Codes 74150-
74170 with 0066T or 0067T.
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CT - Abdomen
ASCITES
• Following preliminary evaluation on an Abdominal Ultrasound
CONGENITAL ANOMALY – known or suspected
• Often performed following initial evaluation with Ultrasound or other imaging studies
HEMATOMA / HEMORRHAGE
• For detection or surveillance of a recent intra-abdominal or retroperitoneal bleed
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CT - Abdomen
- Ventral
LYMPHADENOPATHY
• For initial detection and follow-up
TRAUMA
• Following significant blunt or penetrating injury to the Abdomen and Pelvis
TUMOR EVALUATION: PRIMARY ABDOMINAL OR PELVIC NEOPLASM – known or suspected
• Diagnosis
• Initial staging
• Periodic follow-up
Note: For colorectal cancer surveillance, the American Society of Clinical Oncology (ASCO) recommends the following
2005 practice guideline regarding use of CT:
“Panel recommends annual computed tomography (CT) of the chest and abdomen for 3 years after primary
therapy for patients who are at higher risk of recurrence and who could be candidates for curative-intent surgery;
pelvic CT scan for rectal cancer surveillance, especially for patients with several poor prognostic factors, including
those who have not been treated with radiation.”
UNEXPLAINED WEIGHT LOSS – Significant weight loss exceeding 10% of desirable body weight, over short time
interval
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CT - Abdomen
3
CIRRHOSIS AND EVALUATION FOR HEPATOCELLULAR CARCINOMA
JAUNDICE
• With abnormal liver function tests (transaminases) and unexplained icterus, following an Abdominal Ultrasound 7
• CT imaging used to evaluate for diffuse or multifocal parenchymal liver disease as well as biliary obstruction
HEPATOMEGALY
• For clinically suspected or worsening hepatic enlargement
PANCREATIC PSEUDOCYST
• With prior history of pancreatitis or pancreatic trauma
PANCREATIC MASS – suspected or known
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CT - Abdomen
- Ulcerative Colitis
• For suspected IBD, following endoscopic and/or barium examination
• For follow-up of known IBD, with new signs/symptoms suggesting exacerbation
14
ISCHEMIC BOWEL – suspected or known
ADRENAL LESION
• For characterization of an indeterminate adrenal mass identified on prior imaging
15
– such as a benign adenoma
versus a metastatic deposit
or
• When there is biochemical evidence of an adrenal endocrine abnormality
HYDRONEPHROSIS
• Evaluation for possible obstructing ureteral or urinary bladder lesion
• When ultrasound is non-diagnostic or abnormal and unexplained, requiring further evaluation
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
16
URINARY TRACT CALCULUS DISEASE - suspected or known
SPLENOMEGALY
• For clinically suspected or worsening splenic enlargement
AORTIC DISSECTION
• May evaluate with either CT or CTA
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CT - Abdomen
17-19
ENDOVASCULAR STENT GRAFT PLACEMENT FOR ABDOMINAL AORTIC ANEURYSM
• May evaluate with either CT or CTA
• Primary concerns are for monitoring the aneurysm size, identifying stent migration and detecting endoleaks.
• Prior to and as surveillance following placement of stent gaft
• Society of Interventional Radiology - Post-procedure recommended follow-up in asymptomatic patients:
1. Initial baseline CTA is recommended in less than 1 month post-stent graft placement
2. If there are no problems related to the stent graft, then scans are obtained at 6 month intervals, for 2 years
3. Thereafter, an annual follow-up CTA may be performed
• If symptoms/problems related to the stent graft occur, then more frequent imaging may be needed
REFERENCES/LITERATURE REVIEW:
1. Hopper KD, Singapuri K, Finkel A, Body CT and Oncologic Imaging. Radiology 2000; 215:27-40.
2. Giboney Paul T. Mildly Elevated Liver Transaminase Levels in the Asymtomatic Patient. American Academy of Family
Physicians. March 2005;71: .
3. Arguedas Miguel R, Chen VK, Eloubeidi MA, et al. Screening for Hepatocellular Carcinoma in Patients with Hepatitis C
Cirrhosis: A Cost-Utility Analysis. American Journal of Gastroenterology. 2003;98:679-690.
4. Kim T, Federie MP, Baron RL, Peterson MS. Et al. Discrimination of Small Hepatic Hemangiomas from Hypervascular Malignant
Tumors Smaller than 3 cm with Three-Phase Helical CT. Radiology 2001;219:699-706.
5. Brancatelli G, Federle MP, Grazioli L, et al. Focal Nodular Hyperplasia:CT Findings with Emphasis on Multiphasic Helical CT in
78 Patients. Radiology 2001;219:61-68.
6. Grazioli L, Federle MP, Brancatelli G, et al. Hepatic Adenomas:Imaging and Pathologic Findings. RadioGraphics 2001;21:877-
894.
7. Saini S, Imaging of the Hepatobiliary Tract. N Eng J Med 1997;336:1889-1894.
8. Balthazar EJ, Acute Pancreatitis:Assessment of Severity with Clinical and CT Evaluation. Radiology 2002;223:603-68.
9. Paulson EK, Kalady MF, Pappas TN, Suspected Appendicitis. N Engl J Med 2003;348:236-242.
10. Kirkpatrick IDC, Greenberg HM. Evaluating the CT Diagnosis of Clostridium Difficile Colitis: Should CT Guide Therapy?
AJR2001;176:635-639
11. Stollman NH, Raskin JB. Diagnosis and Management of Diverticular Disease of the Colon in Adults. Am J Gastro 1999;94:3110-
3121.
12. Ferzoco, LB., Raptopoulos, V., Silen, W., Acute Diverticulitis. N Engl J Med 1998;338:1521-1526.
13. Hanauer SB, Sandborn W. Management of Crohn’s Disease in Adults. The American Journal of Gastroenterology 2001;96:635-
643
14. Wiesner W, Khurana B, Ji H, et al. CT of Acute Bowel Ischemia. Radiology 2003;226:635-650.
15. Mayo-Smith WW, Boland GW, Noto RB, et al. From the RSNA Refresher Courses. State-of-the-Art Adrenal Imaging.
RadioGraphics 2001;21:995-1012.
16. Teichman JMH, Acute Renal Colic from Ureteral Calculus. N Engl J Med 2004;350:684-693.
17. Geller SC. Imaging Guidelines for Abdominal Aortic Aneurysm Repair with Endovascular Stent Grafts. J Vasc Interv Radiol
2003; 14: S263-S264.
18. Armerding MD, Rubin GD, Beaulieu CF, et al. Aortic Aneurysmal Disease: Assessment of Stent-Graft Treatment – CT versus
Conventional Angiography. Radiology 2000; 215: 138-146.
19. Tolia AJ, Landis R, Lamparello P, et al. Type II Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysms: Natural
History. Radiology 2005;235:683-686.
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Magnetic Resonance Imaging (MRI)
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
IMAGING CONSIDERATIONS:
• 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
stneosis (in chronic mesenteric ischemia), Doppler Ultrasound, MRA or CTA should be considered as the
preferred imaging modalities.
• 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
indwelling pacemakers 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
implanted materials in the patient as well as external equipment, such as portable oxygen tanks).
• 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.
• 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.
• Duplicative services, such as abdominal CT and MRI, are subject to high level review to evaluate for medical
necessity.
• Request for re-imaging due to a technically limited exam is the responsibility of the imaging provider.
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MRI - Abdomen
2
- Kidney – Evaluation of an indeterminate renal mass
2
- Adrenal – Characterization of an adrenal mass, including differentiation of adrenal adenoma from metastasis
- Other Abdominal and Retroperitoneal anatomic structures
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
IN PATIENTS WITH APPROPRIATE AIM GUIDELINE INDICATIONS FOR ABDOMINAL CT, WHEN CT IS
EXPECTED TO BE LIMITED, DUE TO CONTRA-INDICATIONS (SUCH AS A HISTORY OF ALLERGIC REACTION
TO IODINATED RADIOGRAPHIC CONTRAST MATERIAL)
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MRI - Abdomen
COMMON INDICATIONS:
REFERENCES/LITERATURE REVIEW:
1. Kamel IR, Bluemke DA. MR Imaging of Liver Tumors. Radiol Clin N Am 2003; 41: 51-65.
2. Israel GM, Krinsky GA. MR Imaging of the Kidneys and Adrenal Glands. Radiol Clin N Am 2003; 41: 145-159.
3. Keogan MT, Edelman RR. Technologic Advances in Abdominal MR Imaging. Radiology 2001; 200: 310-320.
4. Motohara T, Semelka RC, Bader TR. MR Cholangiopancreatography. Radiol Clin N Am 2003; 41: 89-96.
5. Barish MA, Yucel EK, Ferrucci JT. Magnetic Resonance Cholangiopancreatography. N Engl J Med 1999; 341: 258-264.
6. Park M-S, Kim TK, Kim KW, et al. Differentiation of Extrahepatic Bile Duct Cholangiocarcinoma from Benign Stricture: Findings
at MRCP versus ERCP. Radiology 2004; 223: 234-240.
7. Vitellas KM, Keogan MT, Spritzer CE, Nelson RC. MR Cholangiopancreatography of Bile and Pancreatic Duct Abnormalities
with Emphasis on the Single-Shot Fast Spin-Echo Technique. RadioGraphics 2000; 20: 939-957.
8. Adamek H, Weiz M, Breer H. et al. Value of Magnetic-Resonance Cholangiopancreatography (MRCP) after Unsuccessful
Endoscopic-Retrograde Cholangiopancreatography (ERCP). Endoscopy 1999; 29: 741-744.
9. Fayad LM, Kowalski T, Mitchell DG. MR Cholangiopancreatography : Evaluation of Common Pancreatic Disease. Radiol Clin N
Am 2003; 41: 97-114.
99
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CT Angiography (CTA) and
MR Angiography (MRA)
Abdomen
CPT CODES:
74175........ Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if
performed, and image postprocessing
74185........ Magnetic resonance angiography, abdomen; without or with contrast
IMAGING CONSIDERATIONS:
• 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.
• 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 should be considered, unless contraindicated, in patients who cannot undergo MRA, due to either an inability
to tolerate MRA examination (for example, secondary to claustrophobia) or biosafety issues. Among the generally
recognized contraindications to MRI exam performance are indwelling pacemakers 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 implanted materials in the patient as well as external
equipment, such as portable oxygen tanks).
• Duplicative services, such as CTA and MRA, are subject to high level review to evaluate for medical necessity.
• Request for re-imaging due to technically limited exams is the responsibility of the imaging provider.
1-2
ANEURYSM
Of the Abdominal Aorta and/or Branch Vessel
PSEUDOANEURYSM
Of the Abdominal Aorta and/or Branch Vessel
3
DISSECTION
Of the Abdominal Aorta and/or Branch Vessel
INTRAMURAL HEMATOMA
Of the Abdominal Aorta and/or Branch Vessel
4
STENOSIS OR OCCLUSION OF THE ABDOMINAL AORTA OR BRANCH VESSELS
• Due to:
- Atherosclerosis
- Thromboembolism
- Other causes
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 MRA for detection of
12
renovascular hypertension.
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CTA/MRA - Abdomen
PORTAL HYPERTENSION
VASCULITIS
REFERENCES/LITERATURE REVIEW:
1. Glockner JF. Three Dimensional Galdolinium-Enhanced MR Angiography: Applications for Abdominal Imaging. RadioGraphics
2001;21:357-370
2. 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;24:481-496.
3. Talti S, Lipton MJ, Davison BD, et al. MR Imaging of Aortic and Peripheral Vascular Disease. Radiograhics 2003; 23: S59-S78.
4. Martin ML, Tay KH, Flak B, et al. Multidetector CT Angiography of the Aortoiliac System and Lower Extemities: A Prospective
Comparison with Digital Subtraction Angiography. AJR 2003; 180 :1085-1091.
5. Cademartiri F, Raaijmakers RHJM, Kuiper JW, et al. Multi-Detector Row CT Angiography in Patients with Abdominal Angina.
RadioGraphics 2001;.24:.969-984.
6. Visser K, Kock MCJM, Kuntz KM, et al. Cost-Effectiveness Targets for Multi-Detector Row CT Angiography in the Work-Up of
Patients with Intermittent Claudication. Radiology 2003; 227: 647-656.
7. Leiner T, Kessels,AGH, Nelemans PJ, et al. Peripheral Arterial disease: comparison of color Duplex US and Contrast-Enhanced
MR Angiography for Diagnosis. Radiology 2005; 235: 699-708.
8. Safian RD, Textor SC. Renal-Artery Stenosis. N Engl J Med 2001; 344(6): 431-442.
9. Soulez G, Olivia VL, Turpin S, et al. Imaging of Renovascular Hypertension: Respective Values of Renal Scintigraphy, Renal
Doppler US, and MR Angiography. Radiographics 2000; 20: 1355-1368.
10. Masunaga H, Takehara Y, Isoda H, et al. Assessment of Gadolinium-Enhanced Time-Resolved Three Dimensional MR
Angiography for Evaluating Renal Artery Stenosis. AJR 2001; 176: 1213-1219.
11. 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 2000; 174: 629-634.
12. Bolduc JP, Oliva VL, Therasse E. Diagnosis and Treatment of Renovascular Hypertension: A Cost Benefit Analysis. AJR 2005;
184: 931-937.
13. ACR Appropriateness Criteria for Renovascular Hypertension. Accessed from the ACR website on January 20, 2008. Last review
date for this ACR Appropriateness Criteria: 2007.
14. Geller SC. Imaging Guidelines for Abdominal Aortic Aneurysm Repair with Endovascular Stent Grafts. J Vasc Interv Radiol 2003;
14: S263-S264.
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CTA/MRA - Abdomen
15. Armerding MD, Rubin GD, Beaulieu CF, et al. Aortic Aneurysmal Disease: Assessment of Stent-Graft Treatment – CT versus
Conventional Angiography. Radiology 2000; 215: 138-146.
16. Tolia AJ, Landis R, Lamparello P, et al. Type II Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysms: Natural
History. Radiology 2005;235:683-686.
17. Chopra S, Dodd GD, Chintapalli KN, et al. Transjugular Intrahepatic Portosystemic Shunt: Accuracy of Helical CT Angiography in
the Detection of Shunt Abnormalities. Radiology 2000; 215: 115-122.
18. Sahani D, Saini S, Pena C, et al. Using Multidetector CT for Preoperative Vasucular Evaluation of Liver Neoplasms: Technique
and Results. AJR 2002; 179: 53-59.
19. 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 2004; 183: 145-151.
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CT Angiography (CTA)
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 noncontrast images, if performed, and image postprocessing.
CODING CONSIDERATIONS:
Special guidance regarding CPT 75635
• CT Angiography utilizes the data obtained from standard CT imaging. A request for a CT exam, in addition to a
CTA of the same anatomic area during the same imaging session, is inappropriate.
• Additional, separate requests for a CTA of the pelvis and/or the lower extremities, along with CPT code 75635, are
inappropriate.
IMAGING CONSIDERATIONS:
• 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 should be considered, unless contraindicated, in patients who cannot undergo MRA, due to either an inability
to tolerate MRA examination (for example, secondary to claustrophobia) or biosafety issues. Among the generally
recognized contraindications to MRI exam performance are indwelling pacemakers 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 implanted materials in the patient as well as external
equipment, such as portable oxygen tanks).
• Duplicative services, such as CTA and MRA, are subject to high level review to evaluate for medical necessity.
• Request for re-imaging due to technically limited exams is the responsibility of the imaging provider.
COMMON DIAGNOSTIC INDICATIONS FOR CTA OF THE ABDOMINAL AORTA AND BILATERAL
ILIOFEMORAL ARTERIES WITH LOWER EXTREMITY RUN-OFF:
The following diagnostic indications for CTA of the Abdominal Aorta and Bilateral Iliofemoral Arteies with Lower Extremity Run-Off are
accompanied by pre-test considerations as well as supporting clinical data and prerequisite information:
1-2
ANEURYSM
Of the Abdominal Aorta and/or Branch Vessel
PSEUDOANEURYSM
Of the Abdominal Aorta and/or Branch Vessel
3
DISSECTION
Of the Abdominal Aorta and/or Branch Vessel
4
STENOSIS OR OCCLUSION OF THE ABDOMINAL AORTA OR BRANCH VESSELS
Due to:
- Atherosclerosis
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CTA - Abdominal Aorta and Bilateral Iliofemoral Runoff
- Thromboembolism
- Other causes
5
VASCULAR EVALUATION OF LOWER EXTREMITY CLAUDICATION
• 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.
REFERENCES/LITERATURE REVIEW:
1. Glockner JF. Three Dimensional Galdolinium-Enhanced MR Angiography: Applications for Abdominal Imaging. RadioGraphics
2001;21:357-370.
2. 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: 481-496.
3. Talti S, Lipton MJ, Davison BD, et al. MR Imaging of Aortic and Peripheral Vascular Disease. Radiograhics 2003; 23: S59-S78.
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 2003; 180; 1085-1091.
5. Visser K, Kock MC, Kuntz KM, et al. Cost-Effectiveness Targets for Multi-Detector Row CT Angiography in the Work-Up of
Patients with Intermittent Claudication. Radiology 2003; 227: 647-656.
105
Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
Computerized Tomography (CT)
Pelvis
CPT CODES:
72192 ....... CT of Pelvis, without contrast
72193 ....... CT of Pelvis, with contrast
72194 ....... CT of Pelvis without contrast, followed by re-imaging with contrast
IMAGING CONSIDERATIONS:
• Radiation Dosimetry: For Pelvic CT scans performed without contrast, the typical effective radiation dose is 10
milli-Sieverts (mSv). This dosage correlates with an estimated 500 Chest X-Ray equivalents or approximately 4.5
years of natural background radiation.
• When ordering a Pelvic CT exam, consideration should be given to the benefits as well as the risks from radiation
exposure and ramifications of false positive studies (both financial and psychological), which may require further
work-up with other imaging modalities or follow-up surveillance with CT.
• Most health plans do not currently provide benefit coverage for screening exams that use advanced imaging.
• Depending on the patient’s presenting signs and symptoms, pelvic imaging should be directed to the most
appropriate modality for clinical work-up. Techniques available for diagnostic evaluation of the pelvis include the
following:
- Pelvic ultrasound (trans-abdominal and trans-vaginal) as 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
- Pelvic MRI
• 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.
• Ultrasound studies may be limited in obese patients.
• Duplicative services, such as pelvic CT and MRI, are subject to high level review to evaluate for medical necessity.
• Request for re-imaging due to technically limited exams is the responsibility of the imaging provider.
• For CT Colonography see Category III codes 0066T or 0067T. Codes 72192-72194 are not reported with 0066T or
0067T.
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CT - Pelvis
ASCITES
• Following preliminary evaluation on a pelvic Ultrasound
HEMATOMA / HEMORRHAGE
• For detection or surveillance of a recent intra-abdominal or retroperitoneal bleed
HERNIA
• For diagnosis of a hernia suspected from surgical consultation
or
• For complications of hernias, such as:
- Bowel obstruction
- Gangrene
- Incarceration
- Intestinal strangulation
• Types of hernias include but not limited to the following:
- Femoral
- Incisional
- Inguinal
- Internal
- Spigelian (through semilunar line)
- Ventral
• In non-operated cases with suspected inguinal and femoral hernias, initial Ultrasound evaluation should be
1
performed, given the high sensitivity and specificity for hernia detection
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CT - Pelvis
LYMPHADENOPATHY
• For initial detection and follow-up
PELVIC PAIN – UNEXPLAINED BY CLINICAL FINDINGS, PHYSICAL EXAMINATION AND OTHER IMAGING
STUDIES
• Choice of the best diagnostic imaging exam to evaluate pelvic pain is dependent on the location of the pain as
well as other factors (such as severity of pain; associated symptoms; laboratory findings; and age - pediatric
versus adult patient).
• The following studies represent alternative imaging, in specific clinical scenarios
- Ultrasound:
1. For pelvic symptoms in the pediatric population – Ultrasound frequently provides diagnostic information,
without incurring radiation exposure from CT
2. For pelvic symptoms in females with non-specific lower pelvic pain– Pelvic Ultrasound (trans-abdominal
and trans-vaginal scans) usually provides excellent anatomic depiction of the uterus, adnexal structures
and cul-de-sac
- Barium examination or Endoscopy: For symptoms related to the intestinal tract, such as pelvic pain secondary to
inflammatory bowel disease
• In other circumstances, pelvic CT may be indicated for evaluation of unexplained pelvic pain.
UNEXPLAINED WEIGHT LOSS – SIGNIFICANT WEIGHT LOSS EXCEEDING 10% OF DESIRABLE BODY
WEIGHT, OVER SHORT TIME INTERVAL
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CT - Pelvis
HYDRONEPHROSIS
• Evaluation for possible obstructing ureteral or uninary bladder lesion
AORTO-ILIAC DISSECTION
- May evaluate with either CT or CTA
17-20
ENDOVASCULAR REPAIR OF ABDOMINAL AORTIC ANEURYSM
• May evaluate with CT or CTA
• Primary concerns are in monitoring aneurysm size, identifying stent migration and detecting endoleaks.
• Prior to and surveillance following placement of Stent Graft
• Society of Interventional Radiology: Post-procedure recommended follow-up in asymptomatic patients: 18
- Initial baseline CTA is recommended in less than 1 month post-stent graft placement
- If there are no problems related to the stent graft, then scans are obtained at 6 month intervals for 2 years
- Thereafter, an annual follow-up CTA may be performed
• If symptoms/problems related to the stent graft occur, then more frequent imaging may be needed
ARTERIOVENOUS MALFORMATION (AVM)
• CTA or MRA are the modalities of choice for evaluating these vascular lesions
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CT - Pelvis
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
22
osteonecrosis
• In known hip osteonecrosis and femoral head collapse by radiography, CT may help in the pre-operative planning,
22
to define the location and extent of disease in patients with painful hips
SACROILIITIS
• Following sacroiliac joint radiographs
REFERENCES/LITERATURE REVIEW:
1. Van den Berg, Jos C. Inguinal hernias:MRI and ultrasound. Magn Reson Imaging Clin N Am 2004;12:689-705.
2. Hopper KD, Singapuri K, Finkel A. Body CT and Oncologic Imaging. Radiology 2000; 215:27-40.
3. Jeong YY, Kang HK, Chung TW, et al. Uterine Cervical Carcinoma After Therapy: CT and MR Imaging Findings.
RadioGraphics 2003;23:969-981.
4. Cannistra S. Cancer of the Ovary. N Engl J Med 2004;351:2519-2529.
5. Jung SE. Lee JM, Rha SE, et al. CT and MR Imaging of Ovarian Tumors with Emphasis on Differential Diagnosis
6. Bosl GJ, Motzer RJ. Testicular Germ-Cell Cancer. N Engl J Med 1997;337:242-254.
7. Paulson EK, Kalady MF, Pappas TN. Suspected Appendicitis. N Engl J Med 2003;348:236-242.
8. Maglinte DT, Heitkamp DE, Howard TJ, et al. Current Concepts in Imaging of Small Bowel Obstruction. Radiol Clinics N Am
2003; 31(2): 263-283.
9. Kirkpatrick IDC, Greenberg HM. Evaluating the CT Diagnosis of Clostridium Difficile Colitis: Should CT Guide Therapy? AJR
2001;176:635-639.
10. Ferzoco, LB, Raptopoulos, V, Silen W. Acute Diverticulitis. N Engl J Med 1998;338:1521-1526.
11. Stollman NH, Raskin JB. Diagnosis and Management of Diverticular Disease of the Colon in Adults. Am J Gastroenterology
1999 94: 3110-3121.
12. Hanauer SB, Sandborn W. Management of Crohn’s Disease in Adults. Am J Gastroenterology 2001;96:635-643
13. Wiesner W, Khurana B, Ji H, et al. CT of Acute Bowel Ischemia. Radiology 2003; 226: 635-650.
14. Kim AY, Ha HK. Evaluation of Suspected Mesenteric Ischemia: Efficacy of Radiologic Studies. Radiol Clinics N Am 2003;
41(2): 327-342.
15. Teichman JMH. Acute Renal Colic from Ureteral Calculus. N Engl J Med 2004; 350: 684-693.
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CT - Pelvis
REFERENCES/LITERATURE REVIEW:
16. Macedo TA, Stanson AW, Oderich GS, et al. Infected Aortic Aneurysms: Imaging Findings. Radiology 2004; 231: 250-257.
17. Rozenbilt AM, Patlas M, Rosenbaum AT, et al. Detection of Endoleaks after Endovascular Repair of Abdominal Aortic
Aneurysm: Value of Unenhanced and Delayed Helical CT Acquisitions. Radiology 2003; 227: 426-433.
18. Geller SC. Imaging Guidelines for Abdominal Aortic Aneurysm Repair with Endovascular Stent Grafts. J Vasc Interv Radiol
2003; 14: S263-S264.
19. Armerding MD, Rubin GD, Beaulieu CF, et al. Aortic Aneurysmal Disease: Assessment of Stent-Graft Treatment – CT versus
Conventional Angiography. Radiology 2000; 215: 138-146.
20. Tolia AJ, Landis R, Lamparello P, et al. Type II Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysms:
Natural History. Radiology 2005;235:683-686.
21. ACR Appropriateness Criteria. Musculoskeletal Imaging. For Clinical Condition: Stress/Insufficiency Fracture, Including
Sacrum, Excluding Other Vertebrae (Variant 1: Suspect Stress/Insufficiency Fracture. First Imaging Modality). 2006.
22. ACR Appropriateness Criteria. Musculoskeletal Imaging. For Clinical Condition: Unilateral and Bilateral Hip Pain. 2006.
23. ACR Appropriateness Criteria. Musculoskeletal Imaging. For Clinical Condition: Metastatic Bone Disease. 2006.
24. ACR Appropriateness Criteria. Musculoskeletal Imaging. For Clinical Condition: Chronic Hip Pain (Variant 3: X-Ray negative,
suspect osteoid osteoma). 2006.
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Magnetic Resonance Imaging (MRI)
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
IMAGING CONSIDERATIONS:
• 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
- Pelvic MRI
• Verification of cystic lesions in the pelvis is usually well-established with Ultrasound.
• Ultrasound studies may be limited in obese patients.
• 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 indwelling
pacemakers 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 implanted
materials in the patient as well as external equipment, such as portable oxygen tanks).
• 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.
• Duplicative services, such as pelvic CT and MRI, are subject to high level review to evaluate for medical necessity.
• Request for re-imaging due to technically limited exams is the responsibility of the imaging provider.
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MRI - Pelvis
1-2
ADENOMYOSIS OF THE UTERUS
1,3-5
ADNEXAL MASS(ES)
• 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
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
REFERENCES/LITERATURE REVIEW:
1. Fielding JR. MR Imaging of the Female Pelvis. Radiol Clin N Am 2003; 41: 179-192.
2. Tami K, Kaori T, Ito T, et al. MR Imaging Findings of Adenomyosis: Correlation with Histopathologic Features and Diagnostic
Pitfalls. RadioGraphics 2005:25:21-40.
3. Kinkel K, Lu Y, Mehdizade A, et al. Intermediate Ovarian Mass at US: Incremental Value of Second Imaging Test for
Characterization – Meta-analysis and Bayesian Analysis. Radiology (published online before print) 2005;10:1148.
4. Szklaruk J, Tamm EP, Choi H, et al. MR Imaging of Common and Uncommon Large Pelvic Masses. RadioGraphics 2003;403-
424.
5. Andrews CL. Evaluation of the Marrow Space of the Adult Hip. RadioGraphics 2000; 20: S27-S42.
6. Dohke M, Watanabe Y, Okumura A, et al. Comprehensive MR Imaging of Acute Gynecologic Diseases. RadioGraphics 2000; 20:
1555-1566.
7. Scheidler J, Heuck AF. Imaging of Cancer of the Cervix. Radiol Clinics N Am 2002; 40: 577-590.
8. Jeong YY, Kang HK, Chung TW, et al. Uterine Cervical Carcinoma After Therapy: CT and MR Imaging Findings. RadioGraphics
2003; 23: 969-981.
9. Ascher SM, Reinhold C. Imaging of Cancer of the Endometrium. Radiol Clinics N Am 2002; 40: 563-576.
10. Cannistra SA. Cancer of the Ovary. N Engl J Med 2004; 351: 2519-2529.
11. Jung SE, Lee JM, Rha SE, et al. CT and MR Imaging of Ovarian Tumors with Emphasis on Differential Diagnosis. RadioGraphics
2002; 22: 1305-1325.
12. Pinto I, Chimeno P, Romo A, et al. Uterine Fibroids: Uterine Artery Embolization versus Abdominal Hysterectomy for Treatment –
A Prospective, Randomized, and Controlled Clinical Trial. Radiology 2003; 226: 425-431.
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CT Angiography (CTA) and
MR Angiography (MRA)
Pelvis
CPT CODES:
72191 .........Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if
performed, and image postprocessing
72198 .........Magnetic resonance angiography, pelvis; without contrast, followed by re-imaging with contrast
CODING CONSIDERATIONS:
• 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.
• 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.
IMAGING CONSIDERATIONS:
• 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.
• 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 should be considered, unless contraindicated, in patients who cannot undergo MRA, due to either an inability
to tolerate MRA examination (for example, secondary to claustrophobia) or biosafety issues. Among the generally
recognized contraindications to MRI exam performance are indwelling pacemakers 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 implanted materials in the patient as well as external
equipment, such as portable oxygen tanks).
• Duplicative services, such as CTA and MRA of the same anatomic area, are subject to high level review to
evaluate for medical necessity.
• Request for re-imaging due to technically limited exams is the responsibility of the imaging provider.
ANEURYSM
Of the Lower Abdominal Aorta, Iliac Arteries or Other Pelvic Branch Vessel
PSEUDOANEURYSM
Of the Lower Abdominal Aorta, Iliac Arteries or Other Pelvic Branch Vessel
1
DISSECTION
Of the Lower Abdominal Aorta, Iliac Arteries or Other Pelvic Branch Vessel
INTRAMURAL HEMATOMA
Of the Lower Abdominal Aorta, Iliac Arteries or Other Pelvic Branch Vessel
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CTA/MRA- Pelvis
STENOSIS OR OCCLUSION OF THE LOWER ABDOMINAL AORTA, ILIAC ARTERIES OR OTHER BRANCH
2-3
VESSELS IN THE PELVIS
Due to:
- Atherosclerosis
- Thromboembolism
- Other Causes
REFERENCES/LITERATURE REVIEW:
1. Frauenfelder MD, Thomas et al. Nontraumatic Emergent Abdominal Vascular Conditions: Advantages of Multi-Detector Row CT
and Three-Dimensional Imaging. RadioGraphics. 2004;24:496
2. Martin Michael L. Multidector CT angiography of the Aortoiliac System and Lower Extremities: A Prospective Comparison with
Digital Subtraction Angiography. AJR, April 2003;180:1085-1091
3. Ruehm Stefan G, et al. Pelvic and Lower Extremity Arterial Imaging: Diagnostic Performance of Three-Dimensional Contrast-
Enhanced MR Angiography. AJR, 2000. 174:1127-1135
4. Gellar M.D, Stuart C, et al. Imaging Guidelines for Abdominal Aortic Aneurysm Repair with Endovascular Stent Grafts. J. Vasc
Interv Radiol 2003; 14:S263-S264
5. Armerding MD, Mark D, et al. Aortic Aneurysmal Disease: Assessment of Stent-Graft Treatment-CT versus Conventional
Angiography. Radiology. 2000;215:138-146
6. Tolia M.D, Anuj J. Type II Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysms: Natural History. Radiology
2005;235:683-686
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Computerized Tomography (CT)
Abdomen and Pelvis Combination
CPT CODES:
CODING CONSIDERATIONS:
• For CT Colonography see Category III codes 0066T or 0067T. Do not report codes 74150-74170 (CT abdomen)
and 72192 – 72194 (CT Pelvis) with 0066T – 0067T.
IMAGING CONSIDERATIONS:
• Radiation dosimetry: For abdominal and pelvic CT combinations, the typical effective radiation dose is
approximately 10 milliSieverts (mSv) for each individual component, or 20 mSv for the combination study. For
both exams, this dosage correlates with an estimated 1,000 Chest X-Ray equivalents or approximately 9 years of
natural background radiation.
• When ordering abdominal and pelvic CT exams, consideration should be given to the benefits as well as the risks
from radiation exposure and ramifications of false positive studies (both financial and psychological), which may
require further work-up with other imaging modalities or follow-up surveillance with CT.
• Many health plans do not currently provide benefit coverage for screening exams (in patients without signs and
symptoms of disease) that use advanced imaging.
• Contrast-enhanced CT may be contraindicated in certain circumstances, such as a documented severe allergic
reaction to intravenous contrast material and renal insufficiency.
• Depending on the presenting signs and symptoms, other diagnostic studies including Ultrasound, Barium
Examinations and Endoscopy may be useful.
• For most gallbladder and hepatobiliary conditions, certain renal abnormalities (for example, detection of
hydronephrosis and differentiation of cystic, complex and solid lesions) and ascites evaluation, initial imaging
should be considered using Ultrasound.
• Verification of cystic lesions in the abdominal and pelvis is usually well-established with Ultrasound.
• Ultrasound studies may be limited in obese patients.
• Duplicative services, such as abdomino-pelvic CT and MRI, are subject to high level review to evaluate for medical
necessity.
• Request for re-imaging due to a technically limited exam is the responsibility of the imaging
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CT – Abdomen and Pelvis Combination
ABDOMINAL / PELVIC PAIN – unexplained by clinical findings, physical examination and other imaging studies
• Choice of the best diagnostic imaging exam to evaluate abdominal pain is dependent on the location of the pain
as well as other factors (such as severity of pain; associated symptoms; laboratory findings; and age - pediatric
versus adult patient).
• The following studies represent alternative imaging of abdomino-pelvic pain, in specific clinical scenarios
- Ultrasound:
1. For right upper quadrant pain, in all age groups – Abdominal Ultrasound is often the initial study of
choice
2. For abdominal symptoms in the pediatric population – Abdominal Ultrasound frequently provides
diagnostic information, without incurring radiation exposure from CT
3. For pelvic symptoms in females – Pelvic Ultrasound (trans-abdominal and trans-vaginal scans) usually
provides excellent anatomic depiction of the uterus, adnexal structures and cul-de-sac
- Plain Abdominal Radiographs: For initial evaluation of the bowel gas pattern, abnormal abdominal calcifications,
pneumoperitoneum and other abnormalities
- Upper or Lower Endoscopy: For symptoms related to the gastrointestinal tract, such as epigastric pain
secondary to peptic ulcer disease
• In other circumstances, abdomino-pelvic CT may be indicated for evaluation of unexplained pain in the abdomen
and pelvis.
ASCITES
• Following preliminary evaluation on an Abdominal Ultrasound
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CT – Abdomen and Pelvis Combination
HERNIA
• For diagnosis of a hernia suspected from surgical consultation
Including but not limited to the following types of hernia:
- Incisional
- Internal
- Inguinal
- Spigelian (through semilunar line, lateral to rectus abdominis muscle)
- Ventral
• For complications of hernias:
- Bowel Obstruction
- Incarceration
- Gangrene
- Intestinal Strangulation
TRAUMA
• Following significant blunt or penetrating injury to the Abdomen and Pelvis
TUMOR EVALUATION: PRIMARY NEOPLASM – suspected or known
• For diagnosis
• Initial staging
• Periodic follow-up
Note: For colorectal cancer surveillance, the American Society of Clinical Oncology (ASCO) recommends the following
2005 practice guideline regarding use of CT:
“Panel recommends annual computed tomography (CT) of the chest and abdomen for 3 years after primary therapy
for patients who are at higher risk of recurrence and who could be candidates for curative-intent surgery; pelvic CT
scan for rectal cancer surveillance, especially for patients with several poor prognostic factors, including those who
have not been treated with radiation.”
- Adrenal Glands
- Biliary Tract
- Gynecologic Structures: Uterus, Cervix or Ovaries
- Kidneys
- Liver
- Lymph Nodes
- Other abdomino-pelvic and retroperitoneal structures
- Pancreas
- Spleen
- Stomach, Small Intestines or Colo-rectum
- Urinary Bladder
UNEXPLAINED WEIGHT LOSS – Significant weight loss exceeding 10% of desirable body weight, over short
time interval
PANCREATIC PSEUDOCYST
• With prior history of pancreatitis or pancreatic trauma
PANCREATIC MASS – suspected or known
HYDRONEPHROSIS
• Evaluation for possible obstructing ureteral or urinary bladder lesion
• When ultrasound is non-diagnostic or abnormal and unexplained, requiring further evaluation
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CT – Abdomen and Pelvis Combination
RENAL NEOPLASM
• For diagnosis, initial staging and pre-operative evaluation, re-staging and treatment monitoring
AORTIC DISSECTION
• May evaluate with either CT or CTA
• Usually results from subdiaphragmatic extension of a Thoracic Aortic Dissection
15-17
ENDOVASCULAR STENT GRAFT PLACEMENT FOR ABDOMINAL AORTIC ANEURYSM
• May evaluate with either CT or CTA
• Primary concerns are for monitoring the aneurysm size, identifying stent migration and detecting endoleaks.
• Prior to and as surveillance following placement of Stent Graft
• Society of Interventional Radiology: Post-procedure recommended follow-up in asymptomatic patients:
- Initial baseline CTA is recommended in less than 1 month post-stent graft placement
- If there are no problems related to the stent graft, then scans are obtained at 6 month intervals, for 2 years
- Thereafter, an annual follow-up CTA may be performed
• If symptoms/problems related to the stent graft occur, then more frequent imaging may be needed
REFERENCES/LITERATURE REVIEW:
1. Van den Berg, Jos C. Inguinal Hernias: MRI and Ultrasound. Seminars in Ultrasound, CT and MRI 2002; 23: 156-73.
2. Hopper, Kenneth D., Singapuri, Kishor, Finkel, Arkady. Body CT and Oncologic Imaging. Radiology 2000; 215: 27-40.
3. Jeong, Yong Yeon, Kang, Heoung Keun, Chung, Tae Woong, et al. Uterine Cervical Carcinoma after Therapy: CT and MR
Imaging Findings. RadioGraphics 2003; 23: 969-981.
4. Cannistra, Stephen A. Cancer of the Ovary. New England Journal of Medicine 2004; 351: 2519-2529.
5. Jung, Seung Eun, Lee, Jae Mun, Rha, Sung Eun, et al. CT and MR Imaging of Ovarian Tumors with Emphasis on
Differential Diagnosis. RadioGraphics 2002; 22: 1305-1325.
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CT – Abdomen and Pelvis Combination
6. Bosl, George J., Motzer, Robert J. Testicular Germ-Cell Cancer. New England Journal of Medicine 1997; 337: 242-254.
7. Balthazar, Emil J. Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation. Radiology 2002; 223: 603-
613.
8. Paulson, Erik K., Kalady, Matthew F., Pappas, Theodore N. Suspected Appendicitis. New England Journal of Medicine
2003; 348(3): 236-242.
9. Stollman, Neill H., Baskin, Jeffrey B. Diagnosis and Management of Diverticular Disease of the Colon in Adults. American
Journal of Gastroenterology 1999; 94(4): 3110-3121.
10. Ferzoco, L.B., Raptopoulos, V., Silen, W. Acute Diverticulitis. New England Journal of Medicine 1998; 338: 1521-1526.
11. Hanauer, Stephen B., Sandborn, William. Management of Crohn’s Disease in Adults. American Journal of Gastroenterology
2001; 96(3): 635-43.
12. Wiesner, Walter, Khurana, Bharti, Ji, Hoon, et al. CT of Acute Bowel Ischemia. Radiology 2003; 226: 635-650.
13. Kirkpatrick I, Greenberg H. Evaluating the CT Diganosis of Clostridium difficile Colitis: Should CT Guide Therapy? AJR
2001; 176: 635-639.
14. Teichman, Joel M.H. Acute Renal Colic from Ureteral Calculus. New England Journal of Medicine 2004; 350: 684-693.
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Computerized Tomography (CT)
CT Colonography
(Virtual Colonoscopy)
CPT CODES:
0066T........Screening CT Colonography
0067T........Diagnostic CT Colonography
CODING CONSIDERATIONS:
• A CT of the abdomen (74150-74170) and a CT of the Pelvis (72192 – 72194) should not be requested for a CT
Colonography.
IMAGING CONSIDERATIONS:
• Radiation dosimetry: If standard (versus low dose) technique is used for the abdominal and pelvic CT exams, the
typical effective radiation dose is approximately 10 milliSieverts (mSv) for each individual component, or 20 mSv
for the combination study. For both exams, this dosage correlates with an estimated 1,000 Chest X-Ray
equivalents or approximately 9 years of natural background radiation. This dosage will be higher if both supine
and prone imaging is performed.
• When ordering an abdominal or pelvic CT exam, consideration should be given to the benefits as well as the risks
from radiation exposure and ramifications of false positive studies (both financial and psychological), which may
require further work-up with other imaging modalities or follow-up surveillance with CT.
• Many health plans do not currently provide benefit coverage for CT Colonography when used as a screening
exam, in the absence of signs or symptoms of a colonic abnormality, a positive family history for colorectal
carcinoma or other risk factors for the development of colonic disease.
• Depending on the presenting signs and symptoms, other studies such as fiberoptic colonoscopy and barium
examination may be helpful to evaluate the colon.
• CT Colonography requires cleansing bowel preparation and air insufflation for colonic distention, similar to
fiberoptic colonoscopy.
• Duplicative services are subject to high level review to evaluate for medical necessity.
• Authorization request for re-imaging due to a technically limited exam is the responsibility of the imaging provider.
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CT – Colonography
• Redundant colon
• Altered anatomy or scarring from previous surgery
• Stricture
• Extrinsic compression
COAGULOPATHY
REFERENCES/LITERATURE REVIEW:
1. Chung DJ, Huh KC, Choi WJ, Kim JK. CT Colonography Using 16-MDCT in the Evaluation of Colorectal Cancer. AJR 2005;
184: 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 2004; 183: 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: 893-904.
4. Macari M, Bini EJ. CT Colonography: Where Have We Been and Where Are We Going? Radiology 2005; 237 (3): 819-833.
5. Neri E, Giusti P, Battolla L, et al. Colorectal Cancer: Role of CT Colonography in Preoperative Evaluation after Incomplete
Colonoscopy. Radiology 2002; 223 (3): 615-619.
6. Van Gelder RE, Birnie E. Florie J, et al. CT Colonography and Colonoscopy: Assessment of Patient Preference in a 5-week
Follow-up Study. Radiology 2004; 233: 328-337.
7. Bernard Levin, MD, David A. Lieberman, MD, Beth McFarland, MD, Robert A. Smith, PhD, Durado Brooks, MD, MPH, Kimberly
S. Andrews, Chiranjeev Dash, MD, MPH, Francis M. Giardiello, MD, Seth Glick, MD, Theodore R. Levin, MD, Perry Pickhardt,
MD, Douglas K. Rex, MD, Alan Thorson, MD, Sidney J. Winawer, MD and the American Cancer Society Colorectal Cancer
Advisory Group, the US Multi-Society Task Force, and the American College of Radiology Colon Cancer Committee.
Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline
from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of
Radiology. CA Cancer J Clin 2008. Accessed through the internet at “caonline.amcancersoc.org”, under ACS Guidelines for
Cancer Prevention and Early Detection, on March 10, 2008.
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Computerized Tomography (CT)
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
IMAGING CONSIDERATIONS:
• 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,
occasional osseous tumor evaluation and congenital vertebral defects in the pediatric population, as well as
procedures such as cervical spine CT myelography.
• Duplicative services, such as concurrent requests for cervical spine CT and MRI, are subject to high level review for
evaluation of medical necessity.
• Authorization request for re-imaging, due to technically limited exams, is the responsibility of the imaging provider.
• 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;
occasional osseous tumor assessment; developmental vertebral abnormalities) and CT
myelography.
1-2
FRACTURE EVALUATION
3-4
SIGNIFICANT ACUTE TRAUMA TO THE CERVICAL SPINE REGION
LESS SEVERE CERVICAL SPINE TRAUMA AND NEW NEUROLOGIC FINDING(S) OR PROGRESSIVELY
WORSENING NECK PAIN
POST-MYELOGRAM CT
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).
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CT – Cervical Spine
For most other indications, MRI is the preferred modality for advanced cervical spine imaging, unless contra-
indicated.
SIGNS AND SYMPTOMS OF SPINAL CORD AND/OR NERVE ROOT COMPRESSION, FOR EXAMPLE DUE TO
CERVICAL SPINE STENOSIS OR DISC HERNIATION
Including but not limited to the following signs and symptoms:
- Hyperactive Reflexes
- Muscle Weakness
- Sensory Loss
- Spasticity
NECK OR SHOULDER PAIN AND NEW NEUROLOGIC FINDINGS RELATED TO THE CERVICAL SPINE OR
DOCUMENTED NEUROLOGIC DEFICIT ON PHYSICAL EXAM (e.g., reflex abnormality; muscle weakness;
objective sensory abnormality in the cervical dermatome distribution)
MYELOPATHY
5
TUMOR EVALUATION – suspected or known
Including but not limited to the following:
- Primary or Metastatic Neoplasm involving the Vertebrae
- Tumor Spread within the Spinal Canal
- Spinal Cord Neoplasm
CERVICAL SPINE DYSRAPHISM AND OTHER CONGENITAL ANOMALIES INVOLVING THE CERVICAL SPINE
AND/OR SPINAL CORD
SYRINGOHYDROMYELIA (SYRINX)
6
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
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CT – Cervical Spine
signs/symptoms); or
• With scoliosis related to other pathologic processes such as neurofibromatosis; or
• For pre-operative evaluation of severe scoliosis
- Note: For Pediatric patients, who may require imaging of significant portions of the spine or the entire spine, MRI
should be considered to minimize radiation exposure
REFERENCES/LITERATURE REVIEW:
1. 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.
2. 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.
3. 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 2000;174:713-717
4. Keenan HT, Hollingshead MC, Chung CJ, Ziglar MK. Using CT of the Cervical Spine for Early Evaluation of Pediatric Patients with
Head Trauma. AJR 2001;177:1405-1409.
5. Koeller KK, Rosenblum RS, Morrison AL. Neoplasms of the Spinal Cord and Filum Terminale: Radiologic-Pathologic Correlation.
RadioGraphics 2000;20:1721-1749.
6. Jaramillo D, Poussaint TY, Grottkau BE, et al. Scoliosis: Evidence-Based Diagnostic Evaluation. Neuroimag Clin N Am 2003; 13:
335-341.
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Magnetic Resonance Imaging (MRI)
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
IMAGING CONSIDERATIONS:
• 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, occasional
osseous tumor evaluation, congenital vertebral defects in the pediatric population 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 device unsafe for use in
an MRI scanner] or not tolerated by the patient (usually secondary to claustrophobia).
• Duplicative services, such as concurrent requests for cervical spine CT and MRI, are subject to high level review
for evaluation of medical necessity.
• Authorization request for re-imaging, due to technically limited exams, is the responsibility of the imaging provider.
• 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
Unless contraindicated, 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; occasional osseous tumor assessment; developmental vertebral abnormalities)
and CT myelography.
1
PERSISTENT PAIN / RADICULOPATHY – IN THE CERVICAL DISTRIBUTION
• In Adults, persistent symptoms despite > 3-4 weeks of conservative therapy and failed or inadequate response to
treatment, which may include the following:
1. Medications, such as NSAIDs and muscle relaxants
2. Steroids
3. Physical therapy/exercises
NECK OR SHOULDER PAIN AND NEW NEUROLOGIC FINDINGS RELATED TO THE CERVICAL SPINE OR
DOCUMENTED NEUROLOGIC DEFICIT ON PHYSICAL EXAM (e.g., reflex abnormality; muscle weakness;
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MRI – Cervical Spine
SIGNS AND SYMPTOMS OF SPINAL CORD AND/OR NERVE ROOT COMPRESSION, FOR EXAMPLE DUE TO
CERVICAL SPINAL STENOSIS OR DISC HERNIATION
Including but not limited to the following signs and symptoms:
- Hyperactive Reflexes
- Muscle Weakness
- Sensory Loss
- Spasticity
MYELOPATHY
3
TUMOR EVALUATION – suspected or known
Including but not limited to the following:
- Primary or Metastatic Neoplasm involving the Vertebrae
- Tumor Spread within the Spinal Canal
- Spinal Cord Neoplasm
FRACTURE EVALUATION
4-5
SIGNIFICANT ACUTE TRAUMA TO THE CERVICAL SPINE REGION
LESS SEVERE CERVICAL SPINE TRAUMA AND NEW NEUROLOGIC FINDING(S) OR PROGRESSIVELY
WORSENING NECK PAIN
SYRINGOHYDROMYELIA (SYRINX)
6
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
CERVICAL SPINE DYSRAPHISM AND OTHER CONGENITAL ANOMALIES INVOLVING THE CERVICAL SPINE
AND/OR SPINAL CORD
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MRI – Cervical Spine
REFERENCES/LITERATURE REVIEW:
1. Atchison J, Lafayette-Lucey A. How to Diagnose and Manage Neck Pain. Internal Medicine 1998;19:10-22.
2. Bot J, Blezer E, 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.
3. Koeller K, Rosenblum RS, Morrison A. Neoplasms of the Spinal Cord and Filum Terminale: Radiologic-Pathologic
Correlation. RadioGraphics 2000;20:1721-1749.
4. Sliker C, Mirvis S, Shanmuganathan K. Assessing Cervical Spine Stability in Obtunded Blunt Trauma Patients: Review of
Medical Literature. Radiology 2005;234:733-739.
5. Benedetti P, Fahr L, Kuhns L, et al. MR Imaging Findings in Spinal Ligamentous Injury. AJR 2000; 175:661-665.
6. Jaramillo D, Poussaint TY, Grottkau BE, et al. Scoliosis: Evidence-Based Diagnostic Evaluation. Neuroimag Clin N Am 2003;
13: 335-341.
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Computed Tomography (CT)
Thoracic Spine
CPT CODES:
IMAGING CONSIDERATIONS:
• 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 the patient (for example, secondary to claustrophobia).
• CT is the preferred technique for certain clinical scenarios such as suspected fracture, follow-up of a known
fracture, occasional osseous tumor evaluation, congenital vertebral defects in the pediatric population and
interventional procedures such as CT Myelography.
• Duplicative services, such as concurrent requests for thoracic spine CT and MRI, are subject to high level review
for evaluation of medical necessity.
• 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.
1
FRACTURE EVALUATION
LESS SEVERE THORACIC SPINE TRAUMA AND NEW NEUROLOGIC FINDING(S) OR PROGRESSIVELY
WORSENING BACK PAIN
POST-MYELOGRAM CT
WHEN THE PATIENT’S CONDITION MEETS THE THORACIC SPINE MRI GUIDELINES, BUT THERE IS EITHER A
CONTRAINDICATION TO MRI OR THE PATIENT CANNOT TOLERATE MRI EXAMINATION (FOR EXAMPLE, DUE
TO CLAUSTROPHOBIA).
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CT – Thoracic Spine
For most other indications, MRI is the preferred modality for advanced thoracic spine imaging, unless
contra-indicated.
SIGNS AND SYMPTOMS OF SPINAL CORD AND/OR NERVE ROOT COMPRESSION, FOR EXAMPLE DUE TO
THORACIC SPINAL STENOSIS OR DISC HERNIATION
Including but not limited to the following signs and symptoms:
- Hyperactive Reflexes
- Muscle Weakness
- Sensory Loss
- Spasticity
BACK PAIN AND NEW NEUROLOGIC FINDINGS RELATED TO THE THORACIC SPINE OR DOCUMENTED
NEUROLOGIC DEFICIT ON PHYSICAL EXAM (e.g., reflex abnormality; muscle weakness; objective sensory
abnormality in the thoracic dermatome distribution)
2
DEMYELINATING DISORDERS, SUCH AS MULTIPLE SCLEROSIS , WHEN MRI IS CONTRAINDICATED
MYELOPATHY
THORACIC SPINE DYSRAPHISM AND OTHER CONGENITAL ANOMALIES INVOLVING THE THORACIC SPINE
AND/OR SPINAL CORD
SYRINGOHYDROMYELIA (SYRINX)
3
SEVERE SCOLIOSIS, INCLUDING 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
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CT – Thoracic Spine
REFERENCES/LITERATURE REVIEW:
1. 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.
2. Koeller KK, Rosenblum RS, Morrison AL. Neoplasms of the Spinal Cord and Filum Terminale: Radiologic-Pathologic Correlation.
RadioGraphics 2000; 20: 1721-1749.
3. Jaramillo D, Poussaint TY, Grottkau BE, et al. Scoliosis: Evidence-Based Diagnostic Evaluation. Neuroimag Clin N Am 2003;
13: 335-341.
134
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Magnetic Resonance Imaging (MRI)
Thoracic Spine
CPT CODES:
IMAGING CONSIDERATIONS:
• 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,
occasional osseous tumor assessment, congenital vertebral defects in the pediatric population 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).
• Duplicative services, such as concurrent requests for thoracic spine CT and MRI, are subject to high level review
for evaluation of medical necessity.
• Authorization request for re-imaging, due to technically limited exams, is the responsibility of the imaging
providers.
• 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.
Unless contraindicated, 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.
NEW NEUROLOGIC FINDINGS RELATED TO THE THORACIC SPINE OR PROGRESSIVE NEUROLOGIC DEFICIT,
PARTICULARLY UNDER TREATMENT
• For example, progressive weakness or objective sensory abnormality in thoracic dermatome distribution
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MRI – Thoracic Spine
SIGNS AND SYMPTOMS OF SPINAL CORD AND/OR NERVE ROOT COMPRESSION, FOR EXAMPLE DUE TO
THORACIC SPINAL STENOSIS OR DISC HERNIATION
Including but not limited to the following signs and symptoms:
- Hyperactive Reflexes
- Muscle Weakness
- Sensory Loss
- Spasticity
BACK PAIN AND NEW NEUROLOGIC FINDINGS RELATED TO THE THORACIC SPINE OR DOCUMENTED
NEUROLOGIC DEFICIT ON PHYSICAL EXAM (e.g., reflex abnormality; muscle weakness; objective sensory
abnormality in the thoracic dermatome distribution)
1
DEMYELINATING DISORDERS, SUCH AS MULTIPLE SCLEROSIS
MYELOPATHY
SPINAL DYSRAPHISM AND OTHER CONGENITAL ANOMALIES INVOLVING THE THORACIC SPINE AND/OR
SPINAL CORD
SYRINGOHYDROMYELIA (SYRINX)
REFERENCES/LITERATURE REVIEW:
1. Bot JCJ, Blezer ELA, 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.
2. Koeller KK, Rosenblum RS, Morrison AL. Neoplasms of the Spinal Cord and Filum Terminale: Radiologic-Pathologic
136
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MRI – Thoracic Spine
137
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Computed Tomography (CT)
Lumbar Spine
CPT CODES:
IMAGING CONSIDERATIONS:
• 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 in
the pediatric population, occasional osseous tumor evaluation, and procedures such as Lumbar CT Myelography
and Discography.
• For most other lumbar spine abnormalities, MRI is the modality of choice, unless contraindicated or not tolerated
by the patient (for example, secondary to claustrophobia).
• Duplicative services, such as concurrent requests for lumbar spine CT and MRI, are subject to high level review
for evaluation of medical necessity.
• Authorization request for re-imaging, due to technically limited exams, is the responsibility of the imaging provider.
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; occasional
osseous tumor assessment; developmental vertebral abnormalities) as well as Lumbar CT
myelography and discography.
FRACTURE EVALUATION
LESS SEVERE LUMBAR SPINE TRAUMA AND NEW NEUROLOGIC FINDING(S) OR PROGRESSIVELY
WORSENING LOW BACK PAIN
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CT – Lumbar Spine
WHEN THE PATIENT’S CONDITION MEETS THE LUMBAR 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 lumbar spine imaging, unless
contra-indicated
3-8
PERSISTENT PAIN / RADICULOPATHY – IN THE LUMBAR DISTRIBUTION
• In Adults, persistent symptoms despite > 4-6 weeks of conservative therapy and failed or inadequate response to
treatment, which may include the following:
- Medications, such as NSAIDs and muscle relaxants
- Steroids
- Physical therapy/exercises
• In the Pediatric population, as well as in patients with documented rheumatologic disease afflicting the joints, pain
in the lumbar spine region may not require completion of the 4-6 week course of conservative treatment.
SIGNS AND SYMPTOMS OF SPINAL CORD AND/OR NERVE ROOT COMPRESSION, FOR EXAMPLE DUE TO
LUMBAR SPINAL STENOSIS OR DISC HERNIATION
Including but not limited to the following signs and symptoms:
- Hyperactive Reflexes
- Muscle Weakness
- Sensory Loss
- Spasticity
LOWER BACK OR LEG PAIN AND NEW NEUROLOGIC FINDINGS RELATED TO THE LUMBAR SPINE OR
DOCUMENTED NEUROLOGIC DEFICIT ON PHYSICAL EXAM (e.g., reflex abnormality; muscle weakness;
objective sensory abnormality in the lumbar dermatome distribution)
9
TUMOR EVALUATION – suspected or confirmed
Including but not limited to the following:
- Primary or Metastatic Neoplasm involving the Vertebrae
- Spinal cord neoplasm
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CT – Lumbar Spine
LUMBAR SPINE DYSRAPHISM AND OTHER CONGENITAL ANOMALIES INVOLVING THE LUMBAR SPINE
AND/OR LOWER SPINAL CORD (CONUS MEDULLARIS), FILUM TERMINALE OR NERVE ROOTS
SYRINGOHYDROMYELIA (SYRINX)
10
SEVERE SCOLIOSIS, FOR THE FOLLOWING PATIENT POPULATIONS:
• With 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
- Note: For Pediatric patients, who may require imaging of significant portions of the spine or the entire spine, MRI
should be considered to minimize radiation exposure
REFERENCES/LITERATURE REVIEW:
1. 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.
2. Guyer RD, Ohnmeiss DD. Contemporary Concepts in Spine Care Lumbar Discography. Spine 1995; 20(18): 2048-2059.
3. Deyo RA, Weinstein JN. Low Back Pain. N Engl J Med 2001;344 (5):363-370.
4. 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: 478-491.
5. Brant-Zawadzki MN, Dennis SC, Gade GF, Weinstein MP. Low Back Pain – What the Clinician Wants to Know. Radiology
2000;217:231-330.
6. Jarvik JG, Deyo RA. Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging. Ann of Intern Med 2002;137:586-
597.
7. Gillan MGC, 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.
8. 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.
9. Koeller KK, Rosenblum RS, Morrison AL. Neoplasms of the Spinal Cord and Filum Terminale: Radiologic-Pathologic
Correlation. RadioGraphics 2000;20:1721-1749.
10. Jaramillo D, Poussaint TY, Grottkau BE, et al. Scoliosis: Evidence-Based Diagnostic Evaluation. Neuroimag Clin N Am 2003;
13: 335-341.
140
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Magnetic Resonance Imaging (MRI)
Lumbar Spine
CPT CODES:
IMAGING CONSIDERATIONS:
• For most other lumbar spine abnormalities, MRI is the modality of choice, unless contraindicated or not tolerated
by the patient (for example, secondary to claustrophobia).
• 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 in the pediatric
population, occasional osseous tumor evaluation, and procedures such as Lumbar CT Myelography and
Discography.
• For the majority of patients with acute low back pain, symptoms and/or physical exam findings will improve or
1
resolve during a trial of conservative treatment and diagnostic imaging is not necessary
• Definitive diagnosis is not achieved in as many as 85% of patients with low pack pain1
• Duplicative services, such as concurrent requests for lumbar spine CT and MRI, are subject to high level review
for evaluation of medical necessity.
• Authorization request for re-imaging, due to technically limited exams, is the responsibility of the imaging provider.
• 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.
Unless contraindicated, 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 including spondylolisthesis in operative candidates; occasional
osseous tumor assessment; and developmental vertebral abnormalities) as well as CT myelography
and discography.
2-10
PERSISTENT PAIN / RADICULOPATHY – IN LUMBAR DISTRIBUTION
• In Adults, persistent symptoms despite > 4-6 weeks of conservative therapy and failed or inadequate response to
treatment, which may include the following:
- Medications, such as NSAIDs and muscle relaxants
- Steroids
- Physical therapy/exercises
• Severe low back pain and an abnormal EMG exam
• In the Pediatric population, as well as in patients with documented rheumatologic disease afflicting the joints, pain
in the lumbar spine region may not require completion of the 4-6 week course of conservative treatment.
SIGNS AND SYMPTOMS OF SPINAL CORD AND/OR NERVE ROOT COMPRESSION, FOR EXAMPLE DUE TO
141
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MRI – Lumbar Spine
LOWER BACK OR LEG PAIN AND NEW NEUROLOGIC FINDINGS RELATED TO THE LUMBAR SPINE OR
DOCUMENTED NEUROLOGIC DEFICIT ON PHYSICAL EXAM (e.g., reflex abnormality; muscle weakness;
objective sensory abnormality in the lumbar dermatome distribution)
12
DEMYELINATING DISORDERS, SUCH AS MULTIPLE SCLEROSIS
13
TUMOR EVALUATION – suspected or confirmed
Including but not limited to the following:
- Primary or Metastatic Neoplasm involving the Vertebrae
- Spinal cord neoplasm
- Tumor spread in spinal canal
TETHERED CORD AND OTHER CONGENITAL ANOMALIES INVOLVING THE LUMBAR SPINE AND/OR LOWER
SPINAL CORD (CONUS MEDULLARIS), FILUM TERMINALE OR NERVE ROOTS
SYRINGOHYDROMYELIA (SYRINX)
REFERENCES/LITERATURE REVIEW:
1. Jarvik J. Imaging of adults with low back pain in the primary care setting. Neuroimag Clin N Am 2003; 13: 293-305.
2. 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: 478-491.
3. Deyo RA, Weinstein JN. Low Back Pain. N Engl J Med 2001;344:363-370.
4. Brant-Zawadzki MN, Dennis SC, Gade GF, Weinstein MP. Low Back Pain. What the Clinician Wants to Know. Radiology
2000;217:321-330.
5. Staiger TO, Paauw DS, Deyo RA, Jarvik JG. Imaging studies for acute low back pain. When and when not to order them.
Postgraduate Medicine Online 1999;105(4).
6. 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.
7. Jarvik JG, Deyo RA. Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging. Ann Intern Med 2002;137:586-597.
8. Gillan MGC, 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.
9. 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.
10. 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.
11. Mazanec DJ, Podichetty,VK, Hsia A. Lumbar Canal Stenosis: Start with Nonsurgical Therapy. Cleveland Clinic Journal of
Medicine. 2002;69(11):909-917.
12. Bot JCJ, Blezer ELA, Kamphorst W, et al. The Spinal Cord in Multiple Sclerosis: Relationship of High-Spatial-Resolution
Quantitative MR Imaging Findings to Histopathologic Results. Radiology 2004;223:531-540.
13. Koeller KK, Rosenblum RS, Morrision AL. Neoplasms of the Spinal Cord and Filum Terminale: Radiologic-Pathologic
Correlation. RadioGraphics 200;20:1721-1749.
14. Jaramillo D, Poussaint TY, Grottkau BE. Scoliosis: Evidence-Based Diagnostic Evaluation. Neuroimag Clin N Am 2003; 13:
335-341.
143
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MR Angiography (MRA)
Spinal Canal
CPT CODES:
72159 ........Magnetic Resonance Angiography of Spinal Canal
IMAGING CONSIDERATIONS:
• 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.
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Computed Tomography (CT)
Upper Extremity
CPT CODES:
IMAGING CONSIDERATIONS:
• Conventional radiographs should be obtained before advanced imaging in the majority of cases.
• 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 bony sequestra.
• For evaluation of musculoskeletal tumors, MRI is generally preferred over CT, unless there is a contraindication
to performance of an MRI exam.
• Conservative treatment includes 4-6 weeks of physical therapy, temporary joint rest or immobilization and
medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), as directed by the patient’s Physician.
• Use of contrast (intravenous or intra-articular for CT arthrogram) is at the discretion of both the ordering and
imaging physicians.
• Duplicative services, such as concurrent requests for upper extremity CT and MRI, are subject to high level
review for evaluation of medical necessity.
• Authorization request for re-imaging, due to technically limited exams, is the responsibility of the imaging
provider.
• A complete CT of the upper extremity includes imaging of the entire arm. When imaging is requested for the
right and left extremity, a maximum of two CT exams is allowed.
• Brachial Plexus imaging: 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.
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CT – Upper Extremity
SIGNIFICANT TRAUMA
• Usually preceded by initial plain film radiographs
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 callous formation and solid bony union
WHEN THE PATIENT’S CONDITION MEETS THE UPPER EXTREMITY MRI GUIDELINES, BUT THERE IS EITHER A
CONTRAINDICATION TO MRI OR THE PATIENT CANNOT TOLERATE MRI EXAMINATION (for example, due to
claustrophobia).
REFERENCES/LITERATURE REVIEW:
1. Buckwalter KA, Rydberg J, Kopecky KK, et al. Musculoskeletal Imaging with Multislice CT. AJR 2001; 176: 979-986.
2. Chiles C, Davis KW, Williams DW. Navigating the Thoracic Inlet. RadioGraphics 1999;19:1161-1176.
3. Fayad LM, Johnston P, Fishman EK. Multidetector CT of Musculoskeletal Disease in the Pediatric Patient: Principles,
Techniques, and Clinical Applications. RadioGraphics 2005; 25: 603-618.
4. Pretorius ES, Fishman EK. Volume-rendered Three-dimensional Spiral CT: Musculoskeletal Applications. RadioGraphics 1999;
19: 1143-1160.
146
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Magnetic Resonance Imaging (MRI)
Upper Extremity (Any Joint)
CPT CODES:
CODING CONSIDERATIONS:
• Scan coverage depends on the specific clinical indication for the exam and varies considerably, based on
anatomic (from shoulder joint through hand/digits) and clinical considerations.
• MRI routinely provides multi-planar imaging through the region of interest.
IMAGING CONSIDERATIONS:
• Conventional radiographs of the upper extremity should be obtained before advanced diagnostic imaging is
performed, in the majority of cases.
• Use of contrast (intravenous or intra-articular) is at the discretion of both the ordering and imaging physicians.
• 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.
• 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.
• If radiographic findings are typical of osteomyelitis, advanced imaging may not be necessary.
• 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.
• Duplicative services, such as concurrent requests for upper extremity CT and MRI, are subject to high level review
for evaluation of medical necessity.
• Request for re-imaging, due to technically limited exams, is the responsibility of the imaging provider.
• Conservative treatment includes 4-6 weeks of physical therapy, temporary joint rest or immobilization and
medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), as directed by the patient’s Physician.
• 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.
• When a request is received for a MR arthrogram of the shoulder, enter CPT codes 73221, MRI upper extremity,
any joint. Do not enter the MR Angiography (MRA) CPT code 73225.
• When requested, a code for an MRI of the upper extremity, any joint, may be entered for each major joint area of
the arm.
- Shoulder
- Elbow
- Wrist
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MRI – Upper Extremity (Any Joint)
SIGNIFICANT TRAUMA
• Usually preceded by initial plain film radiographs
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
JOINT LOCKING
OSTEOCHONDRAL LESION
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MRI – Upper Extremity (Any Joint)
ADHESIVE CAPSULITIS
• Following Orthopedic consultation and Physical Therapy
EPICONDYLITIS
• Generally considered a clinical diagnosis
• If unresponsive to conservative treatment, specialist evaluation should be obtained prior to advanced imaging
CAPITELLAR OSTEOCHONDRITIS
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MRI – Upper Extremity (Any Joint)
REFERENCES/LITERATURE REVIEW:
1. Farbar JM, Buckwalther KA. Sports-Related Injuries of the Shoulder: Instability. Radiol Clin N Am 2002;40:235-249.
2. Fleckenstein JL, Wolfe GI. MRI vs EMG: Which has the Upper Hand in Carpal Tunnel Syndrome? Neurology 2002;58:1583-
1584.
3. Fritz RC. Magnetic Resonance Imaging of Sports-Related Injuries to the Shoulder: Impingement and Rotator Cuff. Radiol Clin
N Am 2002;40:217-234.
4. Jarvik JG, Yuen E, Haynor DR, et al. MR Nerve Imaging in a Prospective Cohort of Patients with Suspected Carpal Tunnel
Syndrome. Neurology 2002;58:1597-1602.
5. Jbara M, Chen Q, Marten P, et al. Shoulder MR Arthrography: How, Why, When. Radiol Clin N Am 2005;43:683-692.
6. Katz JN, Simmons BP. Carpal Tunnel Syndrome. N Eng J Med 2002;346:1807-1812.
7. Mohana-Borges AVR, Chung CB, Resnick D. MR Imaging and MR Arthrography of the Postoperative Shoulder: Spectrum of
Normal and Abnormal Findings. RadioGraphics 2004; 24: 69-85.
8. Sofka CM, Potter HG. Imaging of Elbow Injuries in the Child and Adult Athelete. Radiol Clin N Am 2002;40:251-265.
9. Stoller DW, Tirman PFJ, Bredella MA. Diagnostic Imaging: Orthopedics. Salt Lake City, Utah: Amirsys; 2004.
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Magnetic Resonance Imaging (MRI)
Upper Extremity (Non-Joint)
CPT CODES:
IMAGING CONSIDERATIONS:
• Conventional radiographs should be obtained before advanced diagnostic imaging is performed, in the majority of
cases.
• CT is often the preferred modality for evaluation of displaced fractures and subluxations, whereas stress fractures
and some incomplete or non-displaced fractures may be better imaged with MRI or Radionuclide Bone
Scintigraphy.
• 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.
• Duplicative services, such as concurrent requests for upper extremity CT and MRI, are subject to high level review
for evaluation of medical necessity.
• 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.
• When requested, a code for a MRI of the upper extremity, non-joint may be entered for each major area of the
arm.
- Upper arm
- Lower arm (forearm)
- Hand
• Brachial Plexus Imaging: 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.
• Authorization request for re-imaging, due to technically limited exams, is the responsibility of the imaging provider.
• Conservative treatment includes 4-6 weeks of physical therapy, temporary joint rest or immobilization and
medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), as directed by the patient’s Physician.
151
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MRI – Upper Extremity (Non-Joint)
SIGNIFICANT TRAUMA
• Usually preceded by initial plain film radiographs
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
BRACHIAL PLEXOPATHY
REFERENCES/LITERATURE REVIEW:
1. Demondion X, Bacqueville E, Paul C, et al. Thoracic Outlet: Assessment with MR Imaging in Asymptomatic and Symptomatic
Populations. Radiology 2003;227:461-468.
2. Qayyum A, MacVicar AD, Padhani AR, et al. Symptomatic Brachial Plexopathy following Treatment for Breast Cancer: Utility of
MR Imaging with Surface-Coil Techniques. Radiology 2000;214:837-842.
3. Stoller DW, Tirman PFJ, Bredella MA. Diagnostic Imaging: Orthopedics. Salt Lake City, Utah: Amirsys; 2004.
4. Wittenberg KH, Adkins MC. MR Imaging of Nontraumatic Brachial Plexopathies: Frequency and Spectrum of Findings.
RadioGraphics 2000;20:1023-1032.
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CT Angiography (CTA) and
MR Angiography (MRA)
Upper Extremity
CPT CODES:
73206........Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast
images, if performed, and image postprocessing
73225........Magnetic resonance angiography, upper extremity, without and with contrast (Note: Upper Extremity MRA
is not currently a covered benefit by the Centers for Medicare and Medicaid Services, through a National
Coverage Determination)
IMAGING CONSIDERATIONS:
• 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.
• Duplicative services, such as concurrent requests for CTA and MRA in the same anatomic area, are subject to
high-level review for evaluation of medical necessity.
• Request for re-imaging, due to a technically limited exam, is the responsibility of the imaging provider.
• 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.
STENO-OCCLUSIVE DISEASE
- Usually atherosclerotic in origin
ANEURYSM
DISSECTION
INTRAMURAL HEMATOMA
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CTA/MRA– Upper Extremity
RAYNAUD’S SYNDROME
VASCULITIS
REFERENCES/LITERATURE REVIEW:
1. Bilecen D, Aschwanden M, Heidecker HG, Bongartz G. Optimized Assessment of Hand Vascularization on Contrast-Enhanced
MR Angiography with a Subsystolic Continuous Compression Technique. AJR 2004; 182: 180-182.
2. Froger CL, Duijm LEM, Liem YS, et al. Stenosis Detection with MR Angiography and Digital Subtraction Angiography in
Dysfunctional Hemodialysis Access Fistulas and Grafts. Radiology 2005; 234: 284-291.
3. Karcaaltincaba M, Akata D, Aydingoz U, et al. Three Dimensional MDCT Angiography of the Extremities: Clinical Application
with Emphasis on Musculoskeletal Uses. AJR 2004; 183: 113-117.
4. Loewe C. Peripheral MR Angiography. Magn Reson Imaging Clin N Am 2004;.12:.749-479.
154
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Computed Tomography (CT)
Lower Extremity
CPT CODES:
IMAGING CONSIDERATIONS:
• Conventional radiographs should be obtained before advanced imaging in the majority of cases.
• 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 bony sequestra.
• Use of contrast (intravenous and intra-articular) is at the discretion of both the ordering and imaging physicians.
• A complete CT of the Lower Extremity includes imaging of the entire leg. When imaging is requested for the right
and left extremity, a maximum of two CT exams is allowed.
• Duplicative services, such as concurrent requests for lower extremity CT and MRI, are subject to high level review
for evaluation of medical necessity.
• Request for re-imaging, due to technically limited exams, is the responsibility of the imaging provider.
• Conservative treatment includes 4-6 weeks of physical therapy, temporary joint rest or immobilization and
medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), as directed by the patient’s Physician.
The following diagnostic indications for Lower Extremity CT are accompanied by pre-test considerations as well as supporting clinical
data and prerequisite information:
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CT – Lower Extremity
SIGNIFICANT TRAUMA
• Usually preceded by initial plain film radiographs
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 callous formation and solid bony union
TARSAL COALITION
• Following foot radiographs
WHEN THE PATIENT’S CONDITION MEETS THE LOWER EXTREMITY MRI GUIDELINES, BUT MRI IS EITHER
CONTRAINDICATED OR THE PATIENT IS CLAUSTROPHOBIC AND CANNOT TOLERATE MRI EXAMINATION.
REFERENCES/LITERATURE REVIEW:
1. Buckwalter KA, Rydberg J, Kopecky KK, et al. Musculoskeletal Imaging with Multislice CT. AJR 2001; 176: 979-986.
2. Fayad LM, Johnston P, Fishman EK. Multidetector CT of Musculoskeletal Disease in the Pediatric Patient: Principles,
Techniques, and Clinical Applications. RadioGraphics 2005; 25: 603-618.
3. Mutschler C, Vande Berg BC, Lecouvet FE, et al. Postoperative Meniscus: Assessment at Dual-Detector Row Spiral CT
Arthrography of the Knee. Radiology 2003; 228: 635-641.
4. Pretorius ES, Fishman EK. Volume-rendered Three-dimensional Spiral CT: Musculoskeletal Applications. RadioGraphics 1999;
19: 1143-1160.
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Magnetic Resonance Imaging (MRI)
Lower Extremity (Joint & Non-Joint)
CPT CODES:
IMAGING CONSIDERATIONS:
• Conventional radiographs should be obtained before advanced imaging in the majority of cases.
• Use of contrast (intravenous and intra-articular) is at the discretion of both the ordering and imaging physicians.
• 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.
• 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.
• If radiographic findings are typical of osteomyelitis, advanced imaging may not be necessary.
• 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.
• 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.
• MRI lower extremity (joint or non-joint) is appropriate for imaging the hip joint. For imaging both hips, a MRI of
the pelvis may be sufficient to answer the diagnostic question. See CPT codes 72195-72197.
• Duplicative services, such as concurrent requests for lower extremity CT and MRI, are subject to high level
review for evaluation of medical necessity.
• Request for re-imaging, due to technically limited exams, is the responsibility of the imaging provider.
• Conservative treatment includes 4-6 weeks of physical therapy, temporarily joint rest or immobilization and
medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), as directed by the patient’s Physician.
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MRI – Lower Extremity (Joint & Non-Joint)
SIGNIFICANT TRAUMA
• Usually preceded by initial plain film radiographs
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
JOINT LOCKING
LABRAL TEAR
• Associated with pain, decreased range of motion and clicking in the hip joint
MENISCAL TEAR/INJURY
• Suspected pre-operatively, based on physical exam findings which include but are not limited to:
- McMurray test
- Locking
- Buckling sensation
- Medial and/or lateral joint line tenderness
CHONDROMALACIA PATELLA
OSTEOCHONDRITIS DISSECANS
• Marginal fracture involving the subchondral bone and/or adjacent cartilage
• Medial femoral epicondyle is a frequent location
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MRI – Lower Extremity (Joint & Non-Joint)
TARSAL COALITION
• Following foot radiographs
- Coalition may be partial or complete, as well as bony, cartilaginous or fibrous
- CT may be preferred for bony coalition
- Calcaneonavicular and talocalcaneal are the most common locations
TARSAL TUNNEL
• Neuropathy secondary to entrapment or compression of the posterior tibial nerve or its branches in the fibro-osseous
tunnel, deep to the flexor retinaculum
MORTON’S NEUROMA
REFERENCES/LITERATURE REVIEW:
1. Bencardino JT, Palmer WP. Imaging of Hip Disorders in Athletes. Radiol Clin N Am 2002;40:267-287.
2. Carrino JA, Schweitzer ME. Imaging of Sports Related Knee Injuries. Radiol Clin N Am 2002;40:181-202.
3. Chatha DS, Cunningham PM, Schweitzer ME. MR Imaging of the Diabetic Foot: Diagnostic Challenges. Radiol Clin N Am
2005;43:747-759.
4. Chung CB, Lektrakul N, Resnick D. Straight and Rotational Instability Patterns of the Knee: Concepts and Magnetic
Resonance Imaging. Radiol Clin N Am 2002;40:203-216.
5. Dunfee WR, Dalinka MK, Kneeland JB. Imaging of Athletic Injuries to the Ankle and Foot. Radiol Clin N Am 2002;40:289-
312.
6. Helms CA. The Meniscus: Recent Advances in MR Imaging of the Knee. AJR 2002;179:1115-112.
7. Jackson JL, O’Malley PG, Kroenke K. Evaluation of Acute Knee Pain in Primary Care. Ann Intern Med. 2003; 575-588.
8. Manaster BJ. Adult Chronic Hip Pain: Radiographic Evaluation. RadioGraphics 2000; 20: S3-S25.
9. Stoller DW, Tirman PFJ, Bredella MA. Diagnostic Imaging: Orthopedics. Salt Lake City, Utah: Amirsys; 2004.
10. Yu WD, Shapiro MS. Cysts and Other Masses About the Knee. Phys Sport Med 1999;27(7):59-68.
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CT Angiography (CTA) and
MR Angiography (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
IMAGING CONSIDERATIONS:
• 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.
• Duplicative services, such as concurrent requests for CTA and MRA in the same anatomic area, are subject to
high-level review for evaluation of medical necessity.
• Authorization request for re-imaging, due to technically limited exams, is the responsibility of the imaging provider.
Arterial Disorders:
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 72725 - 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.
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CTA/MRA – Lower Extremity
CRITICAL ISCHEMIA
• For example, in diabetic vascular disease with ischemic ulcers or gangrene
ANEURYSM
DISSECTION
INTRAMURAL HEMATOMA
RAYNAUD’S SYNDROME
VASCULITIS
Venous Disorders:
VENOUS THROMBOSIS
REFERENCES/LITERATURE REVIEW:
1. Bezooijen R, van den Bosch HCM, Tielbeek AV, et al. Peripheral Arterial Disease: Sensitivity-encoded Multiposition MR
Angiography Compared with Intraarterial Angiography and Conventional Multiposition MR Angiography. Radiology 2004; 231:
263-271.
2. Chow LC, Rubin GD. CT Angiography of the Arterial System. Radiol Clin N Am 2002;40:729-749.
3. Goyen M, Ruehm SG, Debatin JF. MR Angiography for Assessment of Peripheral Vascular Disease. Radiol Clin N Am
2002;40:835-846.
4. Hirsch AT, Criqui MH, Terat-Jacobson D, et al. Peripheral Arterial Disease Detection, Awareness, and Treatment in Primary
Care. JAMA 2001;286:1317-1324.
5. Ho VB, Corse WR. MR Angiography of the Abdominal Aorta and Peripheral Vessels. Radiol Clin N Am 2003;41:115-144.
6. Janka R, Fellner C, Wenkel E, et al. Contrast-enhanced MR Angiography of Peripheral Arteries including Pedal Vessels at
1.0T: Feasibility Study with Dedicated Peripheral Angiography Coil. Radiology 2005; 235: 319-326.
7. Karcaaltincaba M, Akata D, Aydingoz U, et al. Three Dimensional MDCT Angiography of the Extremities: Clinical Applications
with Emphasis on Musculoskeletal Uses. AJR 2004;183:113-117.
8. Loewe C. Peripheral MR Angiography. Radiol Clin N Am 2004;12:479-499.
9. Meissner OA, Reiger J, Weber C, et al. Critical Limb Ischemia: Hybrid MR Angiography Compared with DSA. Radiology
2005;235:308-318.
10. Nelemans PJ, Leiner T, de Vet HCW, van Engelshoven JMA. Peripheral Arterial Disease Meta-analysis of the Diagnostic
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CTA/MRA – Lower Extremity
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Positron Emission Tomography (PET)
Oncologic (Tumor) Imaging
CPT CODES:
Dedicated PET Imaging:
78811........PET tumor imaging, limited
78812........PET tumor imaging, skull to mid-thigh
78813........PET tumor imaging, whole body
PET/CT Imaging:
78814 .......PET, with concurrently acquired CT for attenuation correction and anatomic localization; limited area
78815 .......PET, with concurrently acquired CT for attenuation correction and anatomic localization; skull base to
mid-thigh
78816 .......PET, with concurrently acquired CT for attenuation correction and anatomic localization; whole body
AIM’s Guidelines do not supersede the enrollee’s health plan specific medical policy for PET usage.
AIM’s Guidelines do not imply enrollee benefit coverage for all diagnoses and/or indications. Benefit
coverage is determined solely by the enrollee’s health plan.
BRAIN CANCER
• To differentiate radiation necrosis from recurrent brain tumor in patients with a confirmed brain cancer diagnosis,
who have been treated with radiation therapy.
• For all clinical indications other than those listed above, limited benefit coverage may be available, consistent with
the following requirements the Centers for Medicare and Medicaid Services (CMS)*:
1. The patient must be participating in an FDA approved clinical trial; and
2. The use of this diagnostic imaging technology is in accordance with the clinical trial’s approved patient
protocols; and
3. The use of this diagnostic imaging technology is medically necessary.
*Source: Medicare Part B Investigational Device Exemption, September 2004
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PET – Oncologic (Tumor) Imaging
BREAST CANCER
• Diagnosis
- Non-covered for initial diagnosis of breast cancer and staging of axillary lymph nodes
• Staging
- As an adjunct to standard imaging modalities (e.g., CT, MRI, and/or Ultrasound) in the staging of breast cancer
with distant metastases, excluding staging of axillary nodes.
• Restaging – after completion of treatment
- As an adjunct to standard imaging modalities (e.g., CT, MRI, and/or Ultrasound) in the restaging of loco-regional
recurrence or metastases.
• Monitoring Tumor Response to Treatment
- As an adjunct to standard imaging modalities (e.g., CT, MRI, and/or Ultrasound) in monitoring tumor response to
treatment, for women with locally advanced and metastatic breast cancer, when a change in therapy is
contemplated.
COLORECTAL CANCER
• Diagnosis
- PET results may assist in avoiding an invasive diagnostic procedure, or
- PET results may assist in determining the optimal anatomical location to perform an invasive diagnostic
procedure
- Diagnosis has not been confirmed by tissue biopsy
• Staging
- The stage of cancer remains in doubt after completion of a standard diagnostic work-up, including CT, MRI,
and/or Ultrasound; or
- The use of PET could potentially replace one or more conventional imaging studies, when it is expected that
conventional study information is insufficient for the clinical management of the patient, and
- Clinical management of the patient would differ depending on the stage of cancer identified.
• Restaging – after completion of treatment, for the purpose of:
- Detecting residual disease; or
- Detecting suspected recurrence (ex: rising CEA level and/or clinical sign/symptoms suspicious for recurrence);
or
- Determination of the extent of a known recurrence; or
- Potentially replacing one or more conventional imaging studies (e.g., CT, MRI, and/or Ultrasound), when it is
expected that the conventional imaging study information is insufficient for the clinical management of the
patient.
- The use of PET for restaging purposes typically does not occur at intervals of less than 50 calendar days
• Monitoring Tumor Response to Treatment
Limited benefit coverage may be available, consistent with the following requirements from the Centers for Medicare
and Medicaid Services (CMS)*:
1. The patient must be participating in an FDA approved clinical trial; and
2. The use of this diagnostic imaging technology is in accordance with the clinical trial’s approved patient
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PET – Oncologic (Tumor) Imaging
protocols; and
3. The use of this diagnostic imaging technology is medically necessary.
*Source: Medicare Part B Investigational Device Exemption, September 2004
ESOPHAGEAL CANCER
• Diagnosis
- PET results may assist in avoiding an invasive diagnostic procedure; or
- PET results may assist in determining the optimal anatomical location to perform an invasive procedure
- The diagnosis has not been confirmed by tissue biopsy
• Staging
- The stage of cancer remains in doubt after completion of a standard diagnostic work-up, including CT, MRI,
and/or Ultrasound; or
- The use of PET could potentially replace one or more conventional imaging studies, when it is expected that
conventional study information is insufficient for the clinical management of the patient, and
- Clinical management of the patient would differ depending on the stage of cancer identified.
• Restaging – after completion of treatment, for the purpose of:
- Detecting residual disease (upon completion of surgery, chemotherapy and/or radiation treatment); or
- Detecting suspected recurrence, in the presence of clinical symptoms suggestive of recurrent tumor; or
- Determination of the extent of a known recurrence; or
- Potentially replacing one or more conventional imaging studies (e.g., CT, MRI, and/or Ultrasound), when it is
expected that the conventional imaging study information is insufficient for the clinical management of the
patient.
- The use of PET for restaging purposes is typically not performed at intervals of less than 50 calendar days.
• Monitoring Tumor Response to Treatment
Limited benefit coverage may be available, consistent with the following requirements from the Centers for Medicare
and Medicaid Services (CMS)*:
1. The patient must be participating in an FDA approved clinical trial; and
2. The use of this diagnostic imaging technology is in accordance with the clinical trial’s approved patient
protocols; and
3. The use of this diagnostic imaging technology is medically necessary.
*Source: Medicare Part B Investigational Device Exemption, September 2004
LYMPHOMA
• Diagnosis
- The PET results may assist in avoiding an invasive diagnostic procedure; or
- The PET results may assist in determining the optimal anatomical location to perform an invasive procedure.
- The diagnosis has not been confirmed by tissue biopsy
• Staging
- The stage of cancer remains in doubt after completion of a standard diagnostic work-up, including CT, MRI,
and/or Ultrasound; or
- The use of PET could potentially replace one or more conventional imaging studies, when it is expected that
conventional study information is insufficient for the clinical management of the patient; and
- Clinical management of the patient would differ depending on the stage of cancer identified.
• Restaging – after completion of treatment, for the purpose of:
- Detecting residual disease (upon completion of surgery, chemotherapy and/or radiation treatment); or
- Detecting suspected recurrence (in the presence of clinical symptoms suggestive of recurrent tumor); or
- Determining the extent of a known recurrence; or
- Potentially replacing one or more conventional imaging studies (e.g., CT, MRI, and/or Ultrasound), when it is
expected that conventional imaging study information is insufficient for the clinical management of the patient.
- The use of PET for restaging purposes is typically not performed at intervals of less than 50 calendar days.
• Monitoring Tumor Response to Treatment
Limited benefit coverage may be available, consistent with the following requirements from the Centers for Medicare
and Medicaid Services (CMS)*:
1. The patient must be participating in an FDA approved clinical trial; and
2. The use of this diagnostic imaging technology is in accordance with the clinical trial’s approved
patient protocols; and
3. The use of this diagnostic imaging technology is medically necessary.
*Source: Medicare Part B Investigational Device Exemption, September 2004
MELANOMA
• Diagnosis
- PET results may assist in avoiding an invasive diagnostic procedure; or
- PET results may assist in determining the optimal anatomical location to perform an invasive procedure.
- The diagnosis has not been confirmed by tissue biopsy
• Staging
- The stage of cancer remains in doubt after completion of a standard diagnostic work-up, including CT, MRI,
and/or Ultrasound, or
- The use of PET could potentially replace one or more conventional imaging studies, when it is expected that
conventional study information is insufficient for the clinical management of the patient, and
- Clinical management of the patient would differ depending on the stage of cancer identified.
- Note: FDG-PET is not covered for evaluation of regional lymph nodes.
• Restaging – after completion of treatment, for the purpose of:
- Detecting residual disease (upon completion of surgery, chemotherapy and/or radiation treatment); or
- Detecting suspected recurrence (in the presence of clinical symptoms suggestive of recurrent tumor); or
- Determining the extent of a known recurrence; or
- Potentially replacing one or more conventional imaging studies (e.g., CT, MRI, and/or Ultrasound), when it is
expected that conventional imaging study information is insufficient for the clinical management of the patient.
- The use of PET for restaging purposes is typically not performed at intervals of less than 50 calendar days
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PET – Oncologic (Tumor) Imaging
SOLITARY PULMONARY NODULE CHARACTERIZATION – WHEN THE FOLLOWING CONDITIONS ARE MET:
• Evidence of the pulmonary nodules being evaluated by CT scan and the CT scan results were positive for an
indeterminate or possible malignant lesion, not exceeding 4 cm in diameter, or
• For serial evaluation of solitary pulmonary nodules, the request is not being performed within ninety (90) days
following a negative PET scan.
• Additional Comments:
- Most peer-reviewed literature indicates that PET imaging is limited for characterization of subcentimeter (< 10
1,8,21
mm) pulmonary nodules and therefore may provide unreliable results. One study suggests inaccuracy in
13
the discrimination of nodules less than 7 mm in diameter.
- False negative results have been reported for PET imaging of pulmonary carcinoid tumors and bronchoalveolar
13,21
carcinomas.
- False positive findings have been been reported in pulmonary nodules resulting from infectious and
1,13,21
inflammatory processes such as histoplasmosis, tuberculosis and rheumatoid nodules.
TESTICULAR CANCER
• Restaging in patients with post-treatment signs, symptoms or findings suggestive of residual or recurrent disease
15
(e.g., elevated tumor markers such as alpha fetoprotein or human chorionic gonadotropin)
THYROID CANCER
• Diagnosis
Limited benefit coverage may be available in accordance with the following requirements prescribed by the Centers
for Medicare and Medicaid Services (CMS)*:
1. The patient must be participating in an FDA approved clinical trial; and
2. The use of this diagnostic imaging technology is in accordance with the clinical trial’s approved patient
protocols; and
3. The use of this diagnostic imaging technology is medically necessary.
*Source: Medicare Part B Investigational Device Exemption, September 2004
• Staging, when either of the following conditions are met:
Limited benefit coverage may be available, consistent with the following requirements from the Centers for Medicare
and Medicaid Services (CMS)*:
1. The patient must be participating in an FDA approved clinical trial; and
2. The use of this diagnostic imaging technology is in accordance with the clinical trial’s approved
patient protocols; and
3. The use of this diagnostic imaging technology is medically necessary.
*Source: Medicare Part B Investigational Device Exemption, September 2004
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PET – Oncologic (Tumor) Imaging
UNKNOWN PRIMARY NEOPLASM – PRESENTING WITH METASTATIC DISEASE OUTSIDE OF THE CERVICAL
LYMPH NODES
• When all four of the following criteria are met:
- Local or regional treatment for a single site of metastatic disease is being considered; and
- PET will be used to rule out or detect additional sites of disease that would eliminate the rationale for local or
regional treatment; and
- Standard work-up for an occult primary tumor is negative; and
- Tumor is limited to a single site of disease
ALL OTHER MALIGNANCIES NOT SPECIFIED, INCLUDING BUT NOT LIMITED TO: LIVER, OVARIAN,
PANCREATIC AND SMALL CELL LUNG CANCERS, AS WELL AS SOFT TISSUE SARCOMAS:
• Limited benefit coverage may be available, consistent with the following requirements from the Centers for
Medicare and Medicaid Services (CMS)*:
1. The patient must be participating in an FDA approved clinical trial; and
2. The use of this diagnostic imaging technology is in accordance with the clinical trial’s approved patient
protocols; and
3. The use of this diagnostic imaging technology is medically necessary.
*Source: Medicare Part B Investigational Device Exemption, September 2004
REFERENCES/LITERATURE REVIEW:
1. ACR Appropriateness Criteria for Work-up of the Solitary Pulmonary Nodule. Accessed on-line March 30, 2007.
2. Alavi A, Editor. PET Imaging I. Radiologic Clinics of North America; 42(6). Philadelphia: W.B. Saunders; 2004.
3. Alavi A, Editor. PET Imaging II. Radiologic Clinics of North America; 43(1). Philadelphia: W.B. Saunders; 2005.
4. Antoch J, Stattaus J, Nemat AT, et al. Non-Small Cell Lung Cancer: Dual-Modality PET/CT in Preoperative Staging. Radiology
2003; 229: 526-533.
5. CMS National Coverage Determination (220.6.15) for PET Scans Effective 04/18/2005.
6. Flamen P, Lerut A, Van Cutsem E, et al. Utility of Positron Emission Tomography for the Staging of Patients with Potentially
Operable Esophageal Carcinoma. J Clin Oncol 2000; 18: 3202-3210.
7. Gould M, Maclean C, Kuschner W. Accuracy or Positron Emission Tomography for Diagnosis of Pulmonary Nodules and Mass
Lesions. JAMA 2001; 285: 914-924.
8. Jeong YJ, Yi CA, Lee KS. Solitary Pulmonary Nodules: Detection, Characterization, and Guidance for Further Diagnostic
Workup and Treatment. AJR 2007; 188: 57-68.
9. Kapoor V, Fukui M, McCook B. Role of 18FFDG PET/CT in the Treatment of Head and Neck Cancers: Post-therapy Evaluation
and Pitfalls. AJR 2005; 184: 589-597.
10. Kim, EE, Lee M-C, Inoue T, et al, Editors. Clinical PET Principles and Applications. New York: Springer-Verlag; 2004.
11. Kostakoglu L, Agress H, Goldsmith SJ. Clinical Role of FDG PET in Evaluation of Cancer Patients. RadioGraphics 2003; 23:
315-340.
12. Lardinois D, Weder W, Hany TF. Staging of Non-Small-Cell Lung Cancer with Integrated Positron-Emission Tomography and
Computed Tomography. N Engl J Med 2003; 348: 2500-2507.
13. Lindell RM, Hartman TE, Swenson SJ, et al. Lung Cancer Screening Experience: A Retrospective Review of PET in 22 Non-
Small Cell Lung Carcinomas Detected on Screening Chest CT in a High-Risk Population. AJR 2005; 185: 126-131.
14. Mester U, Goor O, Lerman H, et al. PET-CT of Extranodal Lymphoma. AJR 2004; 182: 1579-1586.
15. NCCN Clinical Practice Guidelines in Oncology. Testicular Cancer.V.1.2007.
16. Ost D, Fein A, Feinsilver S. The Solitary Pulmonary Nodule. N Engl J Med 2003; 348: 2535-2542.
17. Rohren EM, Turkinton TG, Coleman RE. Clinical Applications of PET in Oncology. Radiology 2004; 231: 305-332.
18. Rohren EM, Provenzale JM, Barboriak DP, et al. Screening for Cerebral Metastases with FDG PET in Patients Undergoing
Whole-Body Staging of Non-Central Nervous System Malignancy. Radiology 2003; 226: 181-187.
19. Schaefer NG, Hany TF, Taverna C, et al. Non-Hodgkin Lymphoma and Hodgin Disease: Coregistered FDG PET and CT at
Staging and Restaging-Do We Need Contrast-enhanced CT? Radiology 2004; 232: 823-829.
20. Schöder H, Yeung HWD, Gonen M, et al. Head and Neck Cancer: Clinical Usefulness and Accuracy of PET/CT Imaging Fusion.
Radiology 2004; 231: 65-72.
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PET – Oncologic (Tumor) Imaging
21. Tan BB, Flaherty KR, Kazerooni EA, Iannettoni MD. The Solitary Pulmonary Nodule. Chest 2003; 123: 89S-96S.
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Magnetic Resonance
Spectroscopy (MRS)
CPT CODES:
76390 ..... Magnetic Resonance Spectroscopy (MRS)
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.
• 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. Interval
routine coverage for MR spectroscopy is not generally available and is not considered the standard of care at
this time.
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Magnetic Resonance Imaging (MRI)
Bone Marrow Blood Supply
CPT CODES:
77084 ........MRI of Bone Marrow Blood Supply
IMAGING CONSIDERATIONS:
• 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.
• Duplicative testing of the same anatomic area with MRI and CT may be subject to high-level review, for
evaluation of medical necessity.
HEMATOLOGICAL MALIGNANCIES ARISING IN THE BONE MARROW, INCLUDING MULTIPLE MYELOMA AND
LEUKEMIA
• To evaluate initial tumor burden within the bone marrow, from neoplastic infiltration and marrow replacement
• To assess post-treatment response to therapy
REFERENCES/LITERATURE REVIEW:
1. Angtuaco EJC, Fasses ABT, Walker r, et al. Multiple Myeloma: Clinical Review and Diagnostic Imaging. Radiology 2004;
231 (1): 11-13.
2. 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.
3. Rahmouni A, Montazel J-L, 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.
4. Vande Berg BC, Lecouvet FE, Michaux L, et al. Stage I Multiple Myeloma: Value of MR Imagign of the Bone Marrow in the
Determination of Prognosis. Radiology 1996; 201: 243-246.
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Quantitative CT (QCT)
Bone Mineral Densitometry
CPT CODES:
77078 ..... Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips,
pelvis, spine)
77079 ..... Computed tomography, bone mineral density study, 1 or more sites; appendicular skeleton
(peripheral) (eg, radius, wrist, heel)
IMAGING CONSIDERATIONS:
• Bone mineral densitometry may be performed on the central axial skeleton (i.e., spine, femoral head, proximal
femur) or peripheral appendicular skeleton (i.e., forearm, wrist, heel). The axial measurements are considered
more clinically significant and represent the standard diagnostic assessment for bone densitometry.
• 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 is not covered as a screening exam in patients at low risk for osteoporosis.
• Duplicative testing of the same anatomic area may be subject to high-level review, for evaluation of medical
necessity.
Indications for Central (Axial) Quantitative CT (QCT) Evaluation of Bone Mineral Density:
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 but not limited to 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
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- 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, dexamethosone) – treatment for > 3 months
- Phenytoin (Dilantin) – treatment for > 3 months
- Heparin – treatment for > 1 month
- Depo-Provera injectable contraceptive – long-standing use (> 2 years)
- Lithium treatment
- Lupron therapy
- Cytotoxic agents which affect bone density (eg, 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 > 3 months
• Anyone who is considering therapy for osteoporosis, if bone mineral densitometry would facilitate the
decision
Indications for Central (Axial) Quantitative CT (QCT) Evaluation of Bone Mineral Density:
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/LITERATURE REVIEW:
1. Lentle BC, Prior JC. Prior Osteoporosis: What a Clinical Expects to learn from a Patient’s Bone Density Exam. Radiology
2000; 228: 620-628.
2. Steiger P, Block JE, Steiger S, et al. Spinal Bone Mineral Density measured with Quantitative CT: Effect of Region of
Interest, Vertebral Level and Technique. Radiology 1990; 175: 537-543.
3. American College of Radiology (ACR) Appropriateness Criteria. Expert Panel for Musculoskeletal Imaging. Osteoporosis
and Bone Mineral Density. As posted on ACR website: January, 2007.
4. The International Society for Clinical Densitometry (ISCD). “Official Positions and Advocacy.” As posted on ISCD website:
January, 2007.
5. American Association of Clinical Endocrinologists. Medical Guidelines for Clinical Practice for Prevention and Treatment of
Postmenopausal Osteoporosis: 2001 Edition, with Selected Updates for 2003. Endocr Pract 2003; 9(6): 545-564.
6. National Osteoporosis Foundation (NOF). Physician’s Guide to Prevention and Treatment of Osteoporosis. As posted on
NOF Website: January, 2007.
7. 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.
8. U.S. Preventive Services Task Force. Screening for Osteoporosis in Postmenopausal Women: Recommendations and
Rationale. Ann Intern Med 2002; 137: 526-528.
9. Armstrong C. Practice Guidelines. NAMS Updates Recommendations on Diagnosis and Management of Osteoporosis in
Postmenopausal Women. Am Fam Physician 2006; 74 (9): 1630.
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