Aim Guidelines

Diagnostic Imaging
Utilization Management
2009-2010 Program Guidelines
v.6.1.3
Effective Date: January 1, 2010
Proprietary and Confidential
Medical Management
8600 West Bryn Mawr Avenue
Suite 800
Chicago, IL 60631
Phone: 773-864-4600
Fax: 773-864-4601
www.americanimaging.net
Copyright 2009, American Imaging Management, Inc. All Rights Reserved.
Table of Contents
Use of AIMs Diagnostic Imaging Guidelines
Use of AIMs Diagnostic Imaging Guidelines ............................................................................................. 2
Administrative Guidelines
Guideline: Simultaneous Ordering of Multiple Imaging Tests.................................................................. 3
CLINICAL GUIDELINES
Head & Neck Imaging
CT of the Head................................................................................................................................................ 5
CTA of the Head: Cerebrovascular ............................................................................................................ 11
MRI of the Head............................................................................................................................................ 15
MRA of the Head: Cerebrovascular ........................................................................................................... 22
Functional Brain MRI................................................................................................................................... 25
Positron Emission Tomography - Brain Imaging ..................................................................................... 27
CT of the Orbit, Sella Turcica, Posterior Fossa and the Temporal Bone, including the Mastoids ..... 29
MRI of the Orbit, Face and Neck (Soft Tissue).......................................................................................... 32
CT of the Paranasal Sinuses and Maxillofacial Area ............................................................................... 35
MRI of the Temporomandibular Joints ...................................................................................................... 38
CT of the Neck for Soft Tissue Evaluation ................................................................................................ 40
CTA of the Neck ........................................................................................................................................... 43
MRA of the Neck .......................................................................................................................................... 46
Chest Imaging
CT of the Chest ............................................................................................................................................ 49
CTA of the Chest.......................................................................................................................................... 55
MRI of the Chest........................................................................................................................................... 59
MRA of the Chest ......................................................................................................................................... 62
MRI of the Breast ......................................................................................................................................... 66
Cardiac Imaging
Nuclear Cardiology Myocardial Perfusion Imaging .............................................................................. 69
Nuclear Cardiology Cardiac Blood Pool Imaging.................................................................................. 76
Nuclear Cardiology Infarct Imaging ........................................................................................................ 80
Stress Echocardiography ........................................................................................................................... 82
Transesophageal Echocardiography......................................................................................................... 89
Resting Transthoracic Echocardiography ................................................................................................ 91
CT Cardiac (Structure) ................................................................................................................................ 99
CCTA Coronary Artery .............................................................................................................................. 103
i
CT Cardiac (Quantitative Evaluation of Coronary Calcification) ......................................................... 106

MRI Cardiac ................................................................................................................................................ 108
Positron Emission Tomography (PET) Cardiac................................................................................... 113
Abdominal & Pelvic Imaging

CT of the Abdomen.................................................................................................................................... 115
MRI of the Abdomen .................................................................................................................................. 122
CTA/MRA of the Abdomen........................................................................................................................ 126
CTA of the Abdominal Aorta- Lower Extremity Run-Off........................................................................ 130
CT of the Pelvis .......................................................................................................................................... 133
MRI of the Pelvis ........................................................................................................................................ 139
CTA/MRA of the Pelvis .............................................................................................................................. 143
CT of the Abdomen & Pelvis..................................................................................................................... 146
CT Colonography (Virtual Colonoscopy) ................................................................................................ 152
Spine Imaging
CT of the Cervical Spine ........................................................................................................................... 154
MRI of the Cervical Spine.......................................................................................................................... 157
CT of the Thoracic Spine .......................................................................................................................... 160
MRI of the Thoracic Spine......................................................................................................................... 163
CT of the Lumbar Spine ............................................................................................................................ 166
MRI of the Lumbar Spine .......................................................................................................................... 169
MRA of the Spinal Canal ........................................................................................................................... 173
Upper Extremity Imaging

CT of the Upper Extremity ........................................................................................................................ 174
MRI of the Upper Extremity (Any Joint)................................................................................................... 176
MRI of the Upper Extremity (Non-Joint) .................................................................................................. 180
CTA/MRA of the Upper Extremity............................................................................................................. 183
Lower Extremity Imaging

CT of the Lower Extremity ........................................................................................................................ 185
MRI of the Lower Extremity (Joint & Non-Joint)..................................................................................... 187
CTA/MRA of the Lower Extremity ............................................................................................................ 192
PET Imaging - Other Including Oncologic

Positron Emission Tomography Other Including Oncology (excluding brain and cardiac PET) .. 195
Other
Magnetic Resonance Spectroscopy ........................................................................................................ 201
MRI Bone Marrow Blood Supply ........................................................................................................... 202
Quantitative CT Bone Mineral Densitometry ....................................................................................... 204
ii
CLINICAL GUIDELINES
WEBSITE DISCLAIMER
BY ACCEPTING THESE DOCUMENTS, I ACKNOWLEDGE ACCEPTANCE OF THE FOLLOWING
TERMS AND CONDITIONS FOR ACCESS AND USE OF THE CLINICAL GUIDELINES:
American Imaging Management, Inc. (AIM) has developed proprietary Diagnostic Imaging Utilization
Management Clinical Guidelines (together with any updates, referred to collectively as the
Guidelines). The Guidelines are designed to evaluate and direct the appropriate utilization of high
technology diagnostic imaging services. They are based on data from the peer-reviewed scientific
literature, from criteria developed by specialty societies and from guidelines adopted by other health
care organizations. Access to these Guidelines is being provided for informational purposes only.
AIM is under no obligation to update its Guidelines. Therefore, these Guidelines may be out of date.
The Guidelines are protected by copyright of AIM as permitted by and to the full extent of the law.
These rights are not released, transferred, or assigned as a result of allowing access. You agree that
you do not have any ownership rights to the Guidelines and you are expressly prohibited from selling,
assigning, leasing, licensing, reproducing or distributing the Guidelines, unless authorized in writing
by AIM.
The Guidelines do not constitute medical advice and/or medical care, and do not guarantee results or
outcomes. The Guidelines are not a substitute for the experience and judgment of a physician or
other health care professionals. Any clinician seeking to apply or consult the Guidelines is expected
to use independent medical judgment in the context of individual clinical circumstances to determine
any patients care or treatment.
The Guidelines do not address coverage, benefit or other plan
specific issues.
The Guidelines are provided as is without warranty of any kind, either expressed or implied. AIM
disclaims all responsibility for any consequences or liability attributable or related to any use, non-use
or interpretation of information contained in the Guidelines.
1
AIMs Practice Guidelines Define the Optimal Approaches for

Diagnostic Imaging Utilization during Individualized Case
Review
Use of AIMs Diagnostic Imaging Guidelines:
AIMs 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
AIM Guideline Development Process and Resources:

The development of AIMs proprietary practice guidelines involves integration of medical information from
multiple sources, to support the reproducible use of high quality and state-of-the-art advanced diagnostic
imaging services. The process for criteria development is based on technology assessment, peer-reviewed
medical literature including clinical outcomes research and consensus opinion in medical practice.
The primary resources used for AIM guideline development include:
American College of Radiology (ACR) Appropriateness Criteria

American College of Cardiology (ACC) Appropriateness Criteria
American Heart Association (AHA)
American Institute of Ultrasound in Medicine (AIUM)
American Cancer Society (ACS)
American Academy of Neurology (AAN)
American Academy of Pediatrics (AAP)
Society of Interventional Radiology (SIR)
Society of Nuclear Medicine (SNM)
Agency for Healthcare Research and Quality (AHRQ)
Centers for Medicare and Medicaid Services (CMS)
National Guideline Clearinghouse
Guideline review:
AIMs proprietary guidelines for appropriate diagnostic imaging utilization are reviewed routinely by:
(1)
(2)
(3)
(4)
Independent Physician Review Board: AIMs Physician Specialty Advisory Panel

Health Plan Medical Directors
Local Imaging Advisory Council (representing local physician communities)
Physician Review Panels, under the governance of our clients State Regulatory Agencies
2
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.
COMMON DIAGNOSTIC INDICATIONS FOR MULTIPLE SIMULTANEOUS IMAGING REQUESTS:

-
The initial diagnosis/staging or follow-up of oncology patients

Follow-up of patients who have had operative procedures on multiple anatomic sites
Patients in whom the suspected anatomic abnormality might extend into multiple regions, such as diverticulitis or
suspected syringomyelia
COMMON INAPPROPRIATE MULTIPLE SIMULTANEOUS IMAGING REQUESTS:

Brain MRA ordered routinely with brain MRI without vascular indications
Brain CT ordered simultaneously with sinus CT for headache
Multiple levels of spine MRIs or CTs for diffuse back pain or radicular symptoms
Cervical spine and shoulder MRIs ordered simultaneously for shoulder pain
Pelvic or hip MRIs ordered simultaneously with lumbar spine MRI for hip pain
Pelvic CT ordered routinely with abdominal CT for suspected upper quadrant disease processes
REFERENCES/LITERATURE REVIEW:
Kuhns M. D., Lawrence R., Thornberry M.D., John R., Freyback Ph.D., Dennis, Decision-making Imaging. YEARBOOK medical
publishers 1989
Duboulet M. D., Ph.D., Peter M. Cain, Ph.D. Kevin C. The Superiority of Sequential over Simultaneous Testing,.Medical decisionmaking volume 5 NUMBER 4 PAGES 447 451, 1985
Fryback, Ph.D. Dennis G., Thornberry, M.D. John R. The Efficacy of Diagnostic Imaging. Medical Decision-Making, volume 11,
3
Multiple Imaging Tests
number two, pages 88 94, 1991
Hollingsworth W. and Jarvik J. G. Technology Assessment in Radiology: Rutting the Evidence in Evidence-Based Radiology.
Radiology,: 244 (1) PAGES 31-38, July 1, 2007
Analysis of Diagnostic Confidence and Diagnostic Accuracy: a Unified Framework. British Journal of Radiology, March 1, 2007; (951):
pages 152-160
Dodd J. D. Radiology, Evidence-based Practice in Radiology: Steps Three and Four-Appraise and Apply Diagnostic Radiology
Literature. 242 (2): pages 342- 354, February 1, 2007;
Comparative Accuracy: Assessing New Tests Against Existing Diagnostic Pathways. British Medical Journal May 6, 2006; 332(7549):
pages 1089-1092
4
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

From the skull base to vertex, covering the entire calvarium and intra-cranial contents.
Scan coverage may vary, depending on the specific clinical indication.
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 Medicares 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.
COMMON DIAGNOSTIC INDICATIONS FOR HEAD CT:

The following diagnostic indications for Head CT are accompanied by pre-test considerations as well as clinical
supporting data and prerequisite information:
CT is the imaging modality of choice for evaluation of:
acute intra-cranial hemorrhage (parenchymal, subarachnoid, subdural and epidural hematomas);

recent head trauma;
osseous evaluation of the calvarium, skull base and facial bones, including detection of calvarial and
facial bone fractures as well as assessment of the temporal bones for conductive hearing loss and
an abnormal otoscopic exam;
calcified lesions
5
CT Head

1-2
MRI is the preferred technique for most other indications, unless contraindicated.
assessment of the cerebral parenchyma, cerebellum, brainstem and pituitary gland.
This includes
ABNORMALITIES DETECTED ON OTHER IMAGING STUDIES WHICH REQUIRE ADDITIONAL CLARIFICATION

TO DIRECT TREATMENT
CNS FINDINGS/DEFICITS NEW ONSET OR PROGRESSIVELY WORSENING NEUROLOGICAL ABNORMALITY
Including but not limited to the following clinical symptoms and findings:
- Anosmia (loss or impairment in sense of smell)
- Ataxia (inability to coordinate voluntary muscular movements)
3
- Bells Palsy
- Dysgeusia (dysfunction in sense of taste)
- Facial Numbness
- Gait Disorder
- Other Movement Disorders
- Nystagmus (rapid, involuntary, oscillating ocular movements)
- Paresis or Paralysis
- Tinnitus (ringing or roaring auditory sensation; may be either unilateral or bilateral; pulsatile or non-pulsatile;
4
transient or persistent)
- Other cranial nerve impairment
Note: Contrast-enhanced MRI, unless contraindicated, is generally recommended for evaluation of cranial nerve
impairment.
CEREBROVASCULAR ACCIDENT (CVA OR STROKE) AND TRANSIENT ISCHEMIC ATTACK (TIA)
5-6
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.
CONGENITAL ANOMALY
Including but not limited to the following conditions:

- Chiari Malformations
- Dandy-Walker Spectrum
- Encephalocele
- Holoprosencephaly
- Macrocephaly
- Microcephaly
- Schizencephaly
- Septo-optic Dysplasia
CRANIOSYNOSTOSIS
DEMENTIA
8-9
Initial evaluation, if MRI is contraindicated, or

Rapid progression, if MRI is contraindicated
DEVELOPMENTAL DELAY
10
In developmental delay, MRI is the preferred imaging modality over CT

The likelihood of making a specific neuroimaging diagnosis increases in the presence of physical exam
abnormalities such as focal motor findings or microcephaly
EVALUATION OF ABNORMAL FINDINGS DETECTED ON OTHER IMAGING STUDIES - SUCH AS A MASS
6
CT Head

LESION OR ABNORMAL INTRACRANIAL CALCIFICATION
HEADACHE IN ADULT WHEN ANY ONE OF THE FOLLOWING CRITERIA ARE MET:
11
Sudden onset and severe, including thunderclap or worst headache of life; or

Increased frequency and severity; or
With new focal neurologic signs, particularly papilledema, visual field defects and nuchal rigidity; or
New-onset headaches after age 50 years, as a recommendation; age is not an absolute requirement; or
New-onset headaches in cancer or immunodeficient patient; or
With mental status changes; or
With fever, nuchal rigidity and other meningeal signs; or
With nausea and vomiting; or
With exertion; or
Frequently awakened from sleep
Note: Current evidence does not support CT evaluation for chronic headache or migraines, when the patients neurological
status is unchanged.
HEADACHE IN PEDIATRIC PATIENT WHEN ANY ONE OF THE FOLLOWING CRITERIA ARE MET:
11-13

Associated with neurological abnormalities such as nystagmus, papilledema, gait or motor disturbances; 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;
HEMORRHAGE/HEMATOMA
Refers to non-traumatic, non-CVA and non-tumor-related intra-cranial bleed. Examples include hypertensive
hemorrhage and hemorrhage secondary to anti-coagulation or blood dyscrasia
CT is the preferred technique for evaluation of acute intra-cranial hemorrhage 14-15

MRI is usually preferred for evaluation of subacute and chronic hemorrhage
HYDROCEPHALUS (VENTRICULOMEGALY)
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.
INCREASED INTRACRANIAL PRESSURE OR HERNIATION

INFECTIOUS OR INFLAMMATORY PROCESS
16
Including but not limited to the following:

- Cerebral or Cerebellar Abscess
- Encephalitis
- Meningitis
- Neurocysticercosis
- Opportunistic Infection, particularly with AIDS or other immunodeficient condition
- Subdural Empyema
7
CT Head
MENTAL STATUS CHANGES, WITH DOCUMENTED OBJECTIVE EVIDENCE FROM NEUROLOGIC EXAM
MOVEMENT DISORDERS
Including Parkinsons disease (particularly atypical cases with poor response to levodopa, in which there may be
an underlying structural disorder producing parkinsonian features); Huntingtons disease; idiopathic sporadic
cerebellar ataxia (olivopontocerebellar atrophy); and other conditions.
MULTIPLE SCLEROSIS AND OTHER WHITE-MATTER DISEASES, WHEN MRI IS CONTRAINDICATED
17
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
- Neurofibromatosis
- Sturge-Weber Syndrome
- Tuberous Sclerosis
- Von Hippel-Lindau Disease (VHL)
NEUROENDOCRINE ABNORMALITY SUGGESTIVE OF A PITUITARY LESION
MRI is usually preferred over CT for evaluation of pituitary lesions

Relevant laboratory and clinical abnormalities are required
PAPILLEDEMA (refers to swelling and elevation of optic disc a sign of increased intracranial pressure)
PRE- AND POST-NEUROSURGICAL EVALUATION
PRIOR TO LUMBAR PUNCTURE
SEIZURE DISORDER new onset or increasing frequency and severity
18
SENSORINEURAL HEARING LOSS, DOCUMENTED BY AUDIOLOGY
As work-up for Acoustic Neuroma (Vestibular Schwannoma) also see Primary Intra-cranial Tumors
Note: Contrast-enhanced MRI, unless contraindicated, is generally recommended for evaluation of sensorineural
hearing loss.
SYNCOPE
-
19
Syncope (partial or complete loss of consciousness) and near syncope (lightheadedness) are infrequently of
primary neurological origin, particularly in the absence of abnormal neurological findings.
Neurological consultation (for assessment of possible vertebrobasilar TIAs) and cardiovascular evaluation
should be considered.

TRAUMA TO HEAD
20-21
CT is usually preferred for the initial evaluation of acute head trauma, due to the high sensitivity for hemorrhage
and ability to display fractures
Particularly when associated with:

-
Calvarial fracture (as demonstrated on plain film radiography)

Change in Mental Status or Amnesia
8
CT Head
-
Focal Neurological Deficits

Loss of Consciousness
Seizures
Signs of Increased Intracranial Pressure
Nausea / Vomiting
Worsening Headaches
TUMOR EVALUATION BENIGN AND MALIGNANT:
22
Including but not limited to the following lesions:
Primary Intra-cranial Tumors

1.
2.
Intra-axial Neoplasms of the Cerebrum and Cerebellum

Extra-axial Tumors, including Meningiomas and Schwannomas, such as:
- Cerebello-pontine Angle (CPA) and internal auditory canal (IAC) Vestibular Schwannoma of CN 8
(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
3.
CN 7 Schwannoma
Pituitary Tumors, including Macroadenomas and Microadenomas
Metastatic Disease
UNEXPLAINED MASS LESION IDENTIFIED ON PRIOR IMAGING SURVEILLANCE, WITHOUT PATHOLOGIC
TISSUE CONFIRMATION.
Examples include suspected Arachnoid Cyst or Epidermoid Cyst

VASCULAR ABNORMALITIES
Including but not limited to:

-
Aneurysm
Arterio-Venous Malformation (AVM)
Cavernous Malformation
Cerebral Vein Thrombosis
Dural Arteriovenous Fistula (DAVF)
21
Dural Venous Sinus Thrombosis
Venous Angioma
Either CTA or MRA are usually the imaging modalities of choice for some of these vascular abnormalities, such as
aneurysm evaluation.
VENTRICULAR SHUNT ASSESSMENT
VERTIGO AND DIZZINESS
With recurrent or persistent symptoms and when evaluation for other etiologies has not been revealing
Abnormal hearing test or Auditory Brainstem Response
VISUAL DISTURBANCE SUCH AS VISUAL FIELD LOSS, DIPLOPIA AND OTHER ALTERATIONS IN VISION
THAT ARE UNEXPLAINED BY OPHTHALMOLOGIC EXAM AND PATIENT HISTORY
WHEN THE PATIENTS CONDITION MEETS THE HEAD MRI GUIDELINES, BUT MRI IS EITHER
CONTRAINDICATED OR THE PATIENT IS CLAUSTROPHOBIC AND CANNOT TOLERATE MRI EXAMINATION.
1.
Morn 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.
2.
Adelman AM, Daly MP. Initial Evaluation of the Patient with Suspected Dementia. American Family Physician 2005; 71(9):
1745-1750.
3.
Petrella JR, Coleman RE, Doraiswamy PM. Neuroimaging and Early Diagnosis of Alzheimer Disease: A look to the future.
Radiology 2003; 226: 315-336.
9
CT Head
4.
Morn 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.
5.
1745-1750.
6.
Radiology 2003; 226: 315-336.
7.
Shevell M, Ashwal S, Donley D, et al. Practice Parameter: Evaluation of the child with global developmental delay.
Neurology 2003; 60: 367-380.
8.
Medina LS, DSouza B, Vasconcellos E. Adults and Children with Headache: Evidence-based diagnostic evaluation.
Neuroimaging Clinics of North America 2003; 13: 225-235.
9.
Strain JD. ACR Appropriateness Criteria on Headache-Child. J Am Coll Radoil 2007; 4: 18-23.
10. Lewis DW, Ashwal S, Dahl G, et al. Practice Parameter: Evaluation of Children and Adolescents with Recurrent Headaches.
Neurology 2002; 59: 490-498.
11. Qureshi AI, Tuhrim S, Broderick JP, et al. Spontaneous Intracerebral Hemorrhage. N Engl J Med 2001; 344: 1450-1460.
12. Edlow JA, Caplan LR. Avoiding Pitfalls in the Diagnosis of Subarachnoid Hemorrhage. N Engl J Med 2000; 342: 29-36.
13. Osborn, Anne G., Editor. Diagnostic Imaging: Brain. Salt Lake City, Utah: Amirsys; 2004.
14. 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.
15. Bernal B, Altman NR. Evidence-Based Medicine: Neuroimaging of Seizures. Neuroimaging Clinics of North America 2003;
13: 211-224.
16. Hauer KE. Discovering the Cause of Syncope: A Guide to the Focused Evaluation. Postgraduate Medicine 2003; 113(1): 3138.
17. 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.
18. Gean, Alisa D. Imaging of Head Trauma. New York: Raven Press; 1994.
19. Provenzale JM. CT and MR Imaging of Nontraumatic Neurologic Emergencies. AJR 2000; 174: 289-299.
10
CT Angiography (CTA)
Head: Cerebrovascular
CPT CODES:
70496........Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if
performed, and image postprocessing

CTA may be performed to assess the major intra-cranial arteries of the anterior and posterior circulations
(including the Circle of Willis) as well as the venous structures (major veins and dural venous sinuses).
For specific clinical indications, exams may be tailored to the region of interest.
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
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.
COMMON DIAGNOSTIC INDICATIONS FOR HEAD CTA:

The following diagnostic indications for Head CTA are accompanied by pre-test considerations as well as clinical supporting data and
prerequisite information:
ANEURYSM
1-5
Follow-up of known or suspected intra-cranial aneurysm, or

Family history of intra-cranial aneurysm, or
Associated hereditary disorders, such as autosomal dominant Polycystic Kidney Disease (10-20% occurrence of
aneurysm), Ehlers Danlos syndrome type IV and Neurofibromatosis type 1
ARTERIOVENOUS MALFORMATION (AVM)
6-7
CONGENITAL ANOMALIES OF THE CEREBRAL CIRCULATION

DURAL ARTERIOVENOUS FISTULA (DAVF)
DISSECTION
ENDOVASCULAR NEURO-INTERVENTIONAL PROCEDURE FOR INTRA-CRANIAL ANEURYSM,
ARTERIOVENOUS MALFORMATION (AVM) AND DURAL ARTERIOVENOUS FISTULA (DAVF): FOR POSTTREATMENT EVALUATION
11
CTA Head: Cerebrovascular
COMMON DIAGNOSTIC INDICATIONS FOR HEAD CTA:

HEADACHE: WORST HEADACHE OF LIFE; EXERTIONAL HEADACHE; POSITIONAL HEADACHE
INTRA-CRANIAL HEMORRHAGE
For identification of the source of hemorrhage
INTRAMURAL HEMATOMA
PRE-PROCEDURE FOR NEUROSURGICAL OPERATIVE OR PERCUTANEOUS VASCULAR INTERVENTION
Requires referral from a Neurosurgeon or Neurologist

PULSATILE TINNITUS, FOR VASCULAR ETIOLOGY
RECENT CEREBROVASCULAR ACCIDENT (CVA)
Demonstrated on head CT or MRI

STENOSIS OR OCCLUSION OF CAROTID AND CEREBRAL ARTERIES
In patients with clinically suspected or known (from prior imaging) steno-occlusive disease
In adult patients (atherosclerotic disease being a common etiology) and pediatric population (etiologies include
Moyamoya or idiopathic progressive arteriopathy of childhood)
Common clinical manifestations may include:

-
Confusion
Difficulty speaking or understanding speech
Dizziness
Gait Disturbance
Loss of Balance or Coordination
Numbness, weakness or paralysis of the face, arm or leg, on one side of the body
Sudden severe headache, that is unexplained
Visual disturbance, particularly in one eye
STENOSIS OR OCCLUSION OF VERTEBRAL AND BASILAR ARTERIES
In patients with signs and symptoms of Vertebrobasilar Insufficiency (VBI) or Vertebral Basilar Ischemia.
Symptoms of VBI are usually temporary, due to diminished blood flow in the posterior circulation of the brain.
-
Acute Sensorineural Hearing Loss

Ataxia
Diplopia
Dysarthria
Dysphagia
Facial Numbness and Paresthesias
Limb and Trunk Sensory Deficits
Loss of Taste Sensation
Motor Paresis
Nystagmus
Syncope
Vertigo
Visual Field Defects
THROMBOEMBOLIC DISEASE OF MAJOR INTRA-CRANIAL ARTERIAL AND/OR VENOUS SYSTEMS,

11
INCLUDING DURAL VENOUS SINUS THROMBOSIS
12
CTA Head: Cerebrovascular

TRAUMATIC VASCULAR INJURY
VASCULAR ABNORMALITIES ASSOCIATED WITH SICKLE CELL DISEASE IN CHILDREN
VASCULAR SUPPLY TO TUMORS
VASCULITIS
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, Kstner 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
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

From skull base to vertex, covering the entire calvarium and intra-cranial contents, including the internal auditory
canals.
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, 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.
Patient Compatibility Issues:
Artifact due to patient motion may have a particularly significant impact on exam quality.
Breath hold requirements:
-
Some imaging sequences require breath holding and this may be difficult or impossible for some patients.
Claustrophobic patients:
- Patients with claustrophobia may need to be premedicated in order to tolerate the imaging procedure. Rarely patients
with severe claustrophobia will not be suitable candidates for imaging
15
MRI Head
Biosafety Issues:
Ordering and imaging providers are responsible for considering biosafety issues prior to MRI examination, to ensure patient
safety. Among the generally recognized contraindications to MRI exam performance are permanent pacemakers (some
newer models are MRI compatible) or implantable cardioverter-defibrillators (ICD), intracranial aneurysm surgical clips that
are not compatible with MR imaging, as well as other devices considered unsafe in MRI scanners (including certain
implanted materials in the patient as well as external equipment, such as portable oxygen tanks).
Contrast utilization is at the discretion of the ordering and imaging providers.

Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to MRI of the head.
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.
COMMON DIAGNOSTIC INDICATIONS FOR HEAD MRI:

The following diagnostic indications for Head MRI are accompanied by pre-test considerations as well as supporting clinical data
and prerequisite information:
MRI is the modality of choice for most advanced neuroimaging indications in the head.
Situations in which CT is the preferred technique include:
1-2
Acute intra-cranial hemorrhage (parenchymal, subarachnoid, subdural and epidural hematomas)

Recent head trauma
Skull base and facial bone assessment, including detection of calvarial and facial bone fractures as well
as assessment of the temporal bones for conductive hearing loss and an abnormal otoscopic exam
Calcified lesions
ABNORMALITIES DETECTED ON OTHER IMAGING STUDIES WHICH REQUIRE ADDITIONAL CLARIFICATION
TO DIRECT TREATMENT
ARNOLD CHIARI I AND II MALFORMATIONS
CEREBRAL PALSY
CNS FINDING/DEFICIT NEW ONSET OR PROGRESSIVE NEUROLOGICAL ABNORMALITIES
Including but not limited to the following clinical symptoms and findings:
- Anosmia (loss or impairment in sense of smell)
- Ataxia (inability to coordinate voluntary muscular movements)
3
- Bells Palsy
- Dysgeusia (dysfunction in sense of taste)
- Facial Numbness
- Gait Disorder
- Other Movement Disorders
- Nystagmus (rapid, involuntary, oscillating ocular movements)
- Paresis or Paralysis
4
- Tinnitus (ringing or roaring auditory sensation; may be unilateral or bilateral; either pulsatile or non-pulsatile)
- Any other cranial nerve impairment
CEREBROVASCULAR ACCIDENT (CVA OR STROKE) AND TRANSIENT ISCHEMIC ATTACK (TIA)
5-6
May present with a variety of signs and symptoms, including sudden onset of weakness, focal sensory loss or
speech disorder
16
MRI Head

CONGENITAL ANOMALY
- Chiari Malformations
- Dandy-Walker Spectrum
- Encephalocele
- Holoprosencephaly
- Macrocephaly
- Microcephaly
- Schizencephaly
- Septo-optic Dysplasia
DEMENTIA
7-8
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

HEADACHE IN ADULT WHEN ANY ONE OF THE FOLLOWING CRITERIA ARE MET:
10

Increased frequency and severity; or
With new focal neurologic signs, particularly papilledema, visual field defects and nuchal rigidity; or
New-onset headaches after age 50 years; age is not an absolute requirement; or
New-onset headaches in cancer or immunodeficient patient; or
With mental status changes; or
With nausea and vomiting; or
With exertion; or
Frequently awakened from sleep
Note: Current evidence does not support CT evaluation for chronic headache or migraines, when the patients
neurological status is unchanged.
HEADACHE IN PEDIATRIC PATIENT WHEN ANY ONE OF THE FOLLOWING CRITERIA ARE MET:
10-11

Associated with neurological abnormalities such as nystagmus, papilledema, gait or motor disturbances; 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
17
MRI Head

suggest CNS involvement
HEARING LOSS - PROGRESSIVE ASYMMETRICAL HEARING DEFICIT, ASSOCIATED WITH:
Abnormal neurological evaluation; and/or

Abnormal ear, nose and throat (ENT) evaluation such as, audiometry or auditory brainstem response (ABR)
HEMORRHAGE/HEMATOMA
12-13
Refers to non-traumatic, non-CVA and non-tumor-related intra-cranial bleed. Examples include hypertensive
hemorrhage and hemorrhage secondary to anti-coagulation or blood dyscrasia
MRI is usually preferred for evaluation of subacute and chronic hemorrhage

CT is the preferred technique for evaluation of acute intra-cranial hemorrhage
HYDROCEPHALUS (VENTRICULOMEGALY)
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.
HYPOXIC ISCHEMIC ENCEPHALOPATHY
14

- Cerebral or Cerebellar Abscess
- Encephalitis
- Meningitis
- Neurocysticercosis
- Opportunistic Infection, particularly with AIDS or other immunodeficient condition
- Subdural Empyema
MENTAL STATUS CHANGES, WITH DOCUMENTED OBJECTIVE EVIDENCE FROM NEUROLOGIC EXAM

MOVEMENT DISORDERS
Including Parkinsons disease (particularly atypical cases with poor response to levodopa, in which there may be an
underlying structural disorder producing parkinsonian features); Huntingtons disease; idiopathic sporadic cerebellar
ataxia (olivopontocerebellar atrophy); hemifacial spasm; and other conditions.
MULTIPLE SCLEROSIS AND OTHER WHITE-MATTER DISEASES
15-18
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
- Neurofibromatosis
- Sturge-Weber Syndrome
- Tuberous Sclerosis
- Von Hippel-Lindau Disease (VHL)
18
MRI Head

NEUROENDOCRINE ABNORMALITY SUGGESTIVE OF A PITUITARY LESION
Relevant laboratory and clinical abnormalities are required

PAPILLEDEMA (refers to swelling and elevation of optic disc a sign of increased intracranial pressure)
PRE- AND POST-NEUROSURGICAL EVALUATION
SEIZURE DISORDER new onset or increasing frequency and severity
19-20
SENSORINEURAL HEARING LOSS, DOCUMENTED BY AUDIOLOGY
SYNCOPE
-
21
With persistent symptoms and when evaluation for other etiologies (e.g., cardiac disease, metabolic disorder)
have not been revealing.
Syncope (partial or complete loss of consciousness) and near syncope (lightheadedness) are infrequently of
primary neurological origin, particularly in the absence of abnormal neurological findings.
Neurological consultation (for assessment of possible vertebrobasilar TIAs) and cardiovascular evaluation
should be considered.
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
Seizures
Signs of Increased Intracranial Pressure
Nausea / 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
Including but not limited to the following lesions:

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 8
CN 7 Schwannoma
3. Pituitary Tumors, including Macroadenomas and Microadenomas
Metastatic Disease
UNEXPLAINED MASS LESION IDENTIFIED ON PRIOR IMAGING SURVEILLANCE, WITHOUT PATHOLOGIC
19
MRI Head

TISSUE CONFIRMATION.
Examples include suspected Arachnoid Cyst or Epidermoid Cyst

VASCULAR ABNORMALITIES
- Aneurysm
- Arterio-Venous Malformation (AVM)
- Cavernous Malformation
- Cerebral Vein Thrombosis
- Dural Arteriovenous Fistula (DAVF)
22
- Dural Venous Sinus Thrombosis
- Venous Angioma
- Dural Arteriovenous Fistula (DAVF)
Either CTA or MRA are usually the imaging modalities of choice for some of the vascular abnormalities, such as
aneurysm evaluation.
VENTRICULAR SHUNT ASSESSMENT
VISUAL DISTURBANCE - SUCH AS VISUAL FIELD LOSS, DIPLOPIA AND OTHER ALTERATIONS IN VISION
THAT ARE UNEXPLAINED BY OPHTHALMOLOGIC EXAM AND PATIENT HISTORY
VASCULITIS
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. Bells 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.
Radiology 2003; 226: 315-336.
8.
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, DSouza 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
20
MRI Head
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): 3138.
22. Provenzale JM. CT and MR Imaging of Nontraumatic Neurologic Emergencies. AJR 2000; 174: 289-299
21
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

MRA may be performed to assess the major intra-cranial arteries of the anterior and posterior circulations
(including the Circle of Willis)
3-5
sinuses).
1-2
as well as the venous structures (major cerebral veins and dural venous
For specific clinical indications, exams may be tailored to the region of interest.
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.
COMMON DIAGNOSTIC INDICATIONS FOR HEAD MRA:

The following diagnostic indications for Head MRA are accompanied by pre-test considerations as well as supporting clinical data and
ANEURYSM
6-9
Follow-up of known or suspected intra-cranial aneurysm, or

Family history of intra-cranial aneurysm, or
Associated hereditary disorders, such as autosomal dominant Polycystic Kidney Disease (10-20% occurrence of
aneurysm), Ehlers Danlos syndrome type IV and Neurofibromatosis type 1.
10-11
CONGENITAL ANOMALIES OF THE CEREBRAL CIRCULATION

DURAL ARTERIOVENOUS FISTULA (DAVF)
12-13
DISSECTION
22
MRI Head: Cerebrovascular

ENDOVASCULAR NEURO-INTERVENTIONAL PROCEDURE FOR INTRA-CRANIAL ANEURYSM,
ARTERIOVENOUS MALFORMATION (AVM) AND DURAL ARTERIOVENOUS FISTULA (DAVF): FOR POSTTREATMENT EVALUATION
HEADACHE: WORST HEADACHE OF LIFE; EXERTIONAL HEADACHE; POSITIONAL HEADACHE
INTRA-CRANIAL HEMORRHAGE
For identification of the source of hemorrhage
INTRAMURAL HEMATOMA
PRE-PROCEDURE FOR NEUROSURGICAL OPERATIVE OR PERCUTANEOUS VASCULAR INTERVENTIONS
Requires referral from a Neurosurgeon or Neurologist

PULSATILE TINNITUS, FOR VASCULAR ETIOLOGY
14
RECENT CEREBROVASCULAR ACCIDENT
Demonstrated on head CT or MRI

STENOSIS OR OCCLUSION OF CAROTID AND CEREBRAL ARTERIES
In patients with clinically suspected or known (from prior imaging) steno-occlusive disease
In adult patients (atherosclerotic disease being a common etiology) and pediatric population (etiologies include
Moyamoya or idiopathic progressive arteriopathy of childhood)

-
Confusion
Dizziness
Gait Disturbance
STENOSIS OR OCCLUSION OF VERTEBRAL AND BASILAR ARTERIES
In patients with signs and symptoms of Vertebrobasilar Insufficiency (VBI) or Vertebral Basilar Ischemia
-

Ataxia
Diplopia
Dysarthria
Dysphagia
Motor Paresis
Nystagmus
Syncope
Vertigo
23
MRI Head: Cerebrovascular

ARTERIAL THROMBOEMBOLIC DISEASE
VENOUS THOMBOSIS (INCLUDING DURAL VENOUS SINUS THROMBOSIS) OR VENOUS COMPRESSION
15

VASCULAR ABNORMALITIES ASSOCIATED WITH SICKLE CELL DISEASE IN CHILDREN
VASCULAR SUPPLY TO TUMORS
VASCULITIS
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 DetectionProspective 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-ofFlight 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.
24
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

From the skull base to vertex, covering the intra-cranial contents.
Functional MRI of the brain may be used to localize eloquent areas in the brain, prior to resection of neoplasm or
medically intractable epileptogenic foci.
Studies have shown excellent agreement in language localization, when comparing functional brain MRI with the
Wada test and direct electrical stimulation.
Advantages of functional brain MRI over a Wada test include the non-invasive technique (not requiring catheter
placement and contrast injection), lack of ionizing radiation, shorter time-requirement, lower cost and quicker
post-procedural recovery. Additionally, the Wada test is considered limited in right hemisphere dominance.
Advantages of functional brain MRI over intraoperative electrocortical stimulation include its non-invasive
technique and more extensive anatomic brain mapping. Direct electrical stimulation is an invasive procedure,
which usually evaluates only one hemisphere (limiting assessment for partial or bilateral language dominance)
and usually identifies only eloquent brain regions on the surface of the brain.
Functional MRI may successfully map primary brain activities related to motor, sensory and language functions.
Examples of tasks which may be used include sentence completion (to map language) and bilateral hand
squeeze task (for sensory motor mapping).
-
Biosafety Issues:
Ordering and imaging providers are responsible for considering biosafety issues prior to MRI examination, to ensure
patient safety. Among the generally recognized contraindications to MRI exam performance are permanent pacemakers
(some newer models are MRI compatible) or implantable cardioverter-defibrillators (ICD), intracranial aneurysm surgical
clips that are not compatible with MR imaging, as well as other devices considered unsafe in MRI scanners (including
certain implanted materials in the patient as well as external equipment, such as portable oxygen tanks).

Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to Functional Brain MRI
There are uncommon circumstances when both CT and MRI exams should be ordered for the same clinical
25
Functional Brain MRI
presentation. The specific rationale for each study must be delineated at the time of request.
symptoms.
INDICATIONS FOR FUNCTIONAL BRAIN MRI:

The following diagnostic indications for Functional MRI (fMRI) of the Brain are accompanied by
pre-test considerations and supporting clinical data
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
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 of 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.
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.
26
Positron Emission Tomography (PET)

Brain Imaging
CPT CODES:
78608........PET brain, metabolic evaluation
78609........PET brain, perfusion, single study
COMMONLY USED RADIOPHARMACEUTICAL:

2-(fluorine-18) fluoro-2-deoxy-d-glucose (FDG)
This guideline does not supersede the enrollees health plan medical policy specific to PET Neuroimaging.
Enrollee coverage for PET imaging of Alzheimers 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.
COMMON DIAGNOSTIC INDICATIONS FOR BRAIN PET:

The following diagnostic indications for Brain PET are accompanied by pre-test considerations as well as supporting clinical data and
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.
FRONTO-TEMPORAL LOBE DEMENTIA AND ALZHEIMERS DISEASE
Use of PET is approved only to differentiate between Fronto-Temporal Dementia (FTD) and Alzheimers Disease,
when the patients clinical presentation fits both diagnoses and other conventional testing has been unable to
reveal a definitive diagnosis and when all of the following conditions are met; or
Use of PET is approved when part of a CMS approved clinical trial specific to diagnosis and treatment of
dementing neurodegenerative disease.
CONDITIONS:
The use of FDG-PET scan in the diagnosis of Alzheimers 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 Alzheimers disease or frontal-temporal lobe dementia and a documented
cognitive decline of at least six (6) months duration and meets the diagnostic criteria for Alzheimers disease or
fronto-temporal lobe dementia.
The patients clinical presentation includes such symptoms as:

-
Social disinhibition
Awkwardness
Difficulties with language, or
Loss of Executive Function
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 patients cognitive decline for a minimum of
six (6) months; and
27
PET - Brain
CONDITIONS:
-
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 Alzheimers 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 Alzheimers 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 Alzheimers disease or frontotemporal lobe dementia
Results of a mini-mental status exam (MMSE) or similar test score
Differential diagnosis of Alzheimers 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
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. Alzheimers 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.
28

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

The anatomic coverage and protocol specifications will vary, depending on the clinical indication. Anatomic
evaluation includes the internal auditory canals (IACs), posterior fossa, sella turcica, orbits and temporal bone,
with the mastoid air cells.
Targeted evaluation, such as CT of the temporal bones, involves collimated views through the region of interest,
often in two imaging planes: axial images (petrous bones through mastoid tips) and coronal views (temporomandibular joints through temporal bones).
CT is often the preferred study for suspected fracture or follow-up of a known fracture, foreign body detection,
assessment of calcified lesions and temporal bone evaluation.
With capability for high-resolution osseous imaging, CT can provide detailed anatomic depiction of the temporal
bone anatomy, including the middle and inner ear structures.
MRI (unless contraindicated) is usually preferred over CT for evaluation of the sella turcica, internal auditory canal
regions and visual pathways, as well as for most soft tissue tumor evaluation.
Bony changes from a sellar, para-sellar or orbital mass or infectious process are usually well demonstrated by CT.
Duplicative testing of the same anatomic area with MRI and CT may be subject to high-level review, for evaluation
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 Medicares Correct Coding Edits, CT of the head and CT of the orbits are mutually exclusive
procedures.
This exam is inherently 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
Includes both acquired and congenital types of Cholesteatoma 1

Acquired (Secondary) Cholesteatoma: more common form (98%), presenting as a mass comprised of keratin
debris and lined by squamous epithelium
Congenital (Primary) Cholesteatoma (Epidermoid): uncommon lesion (2%), arising from aberrant embryonic
ectodermal rests in middle ear, mastoids or petrous bone
29
CT - Orbit, Sella Turcica, Posterior Fossa & Temporal Bone, including the
Mastoids
COCHLEAR IMPLANT PRE-OPERATIVE EVALUATION
CONDUCTIVE HEARING LOSS
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
Unresponsive to medical treatment

-
Abscess
Cellulitis (for example, Orbital Cellulitis)
Malignant Otitis Externa
Osteomyelitis
Otomastoiditis
ORBITAL/OCULAR EVALUATION OF SYMPTOMS AND OBJECTIVE FINDINGS

Including but not limited to evaluation of the following:
- Exophthalmos abnormal protrusion of the eyeball
- Extraocular myopathy
- Nystagmus rapid, involuntary, oscillating ocular movements
- Optic Neuritis
- Papilledema
- Proptosis forward displacement of the eyeball
- Strabismus inability of one eye to accomplish binocular vision with the other, due to extra-ocular muscle
imbalance
- Thyroid ophthalmopathy
- Visual Field Defect
- Visual loss unexplained by ophthalmic evaluation
ORBITAL PSEUDOTUMOR
OSSEOUS LESION EVALUATION
Such as Fibrous Dysplasia, Pagets disease and Otosclerosis
LOCALIZED FACIAL PAIN WHEN PERSISTENT AND UNEXPLAINED

PRE-OPERATIVE EVALUATION, PRIOR TO MASTOIDECTOMY
SENSORINEURAL HEARING LOSS
Documented by audiology
-
SKULL BASE EVALUATION for suspected or known tumors

TINNITUS
30
CT - Orbit, Sella Turcica, Posterior Fossa & Temporal Bone, including the
Mastoids
TRAUMA
- Soft tissue injury
- Fracture
1, 3-6
For diagnosis, staging, evaluation of response to treatment and pre-operative assessment of the following lesions:

1.
2.
3.
Intra-axial Neoplasms of the Cerebrum and Cerebellum

Extra-axial Tumors, including Meningiomas and Schwannomas, such as:
- Cerebello-pontine Angle (CPA) and internal auditory canal (IAC) Vestibular Schwannoma of CN VIII
CN VII Schwannoma
Pituitary Tumors, including Macroadenomas and Microadenomas
Metastatic Disease
ABNORMALITIES NOTED ON OTHER IMAGING STUDIES WHICH REQUIRE ADDITIONAL CLARIFICATION

SUCH AS SURVEILLANCE OF AN UNEXPLAINED MASS LESION, WITHOUT PATHOLOGIC TISSUE
CONFIRMATION
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: 231236.
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.
31
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

Scan coverage is dependent on the specific anatomic area of clinical interest. Exams usually include multi-planar
imaging, using different pulse sequences.
MRI is usually preferred over CT for evaluation of the sella turcica and visual pathways, unless contraindicated.
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.
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).
-
Biosafety Issues:

Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to MRI Orbit, Face and Neck.
Request for re-imaging due to technically limited exams is the responsibility of the imaging providers
32
MRI - Orbit, Face and Neck (Soft Tissues)
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:
CONGENITAL ANOMALIES
GLOTTIC LESION
Further assessment following endoscopic detection

When unresponsive to medical treatment

-
Abscess
Cellulitis (for example, Orbital Cellulitis)
Osteomyelitis
LYMPHADENOPATHY suspected or known
When persistent and unexplained

NASAL INDICATIONS NOT LISTED ELSEWHERE:
-
Anosmia
Recurrent Epistaxis
Nasal airway obstruction or polyposis refractory to medical therapy
MASS LESION PALPABLE ON PHYSICAL EXAM

MASS LESION NON-PALPABLE AND UNEXPLAINED ON PRIOR IMAGING EXAM FOR SURVEILLANCE,
WITHOUT PATHOLOGIC TISSUE CONFIRMATION
NECK MASSES IN THE PEDIATRIC POPULATION, SUCH AS BRANCHIAL CLEFT CYST, THYROGLOSSAL DUCT
1
CYST AND LYMPHANGIOMA / CYSTIC HYGROMA
OBSTRUCTIVE THYROID NODULE OR THYROMEGALY (GOITER)
Following thyroid US or thyroid scintigraphy

When associated with mass effect on the upper airway or esophagus
For pre-operative evaluation
ORBITAL INDICATIONS NOT LISTED ELSEWHERE:
- Extraocular Myopathy
- Extraocular Weakness or Non-conjugate Eye Movements
- Nystagmus
2
Optic Neuritis
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
2,10
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)
33
MRI - Orbit, Face and Neck (Soft Tissues)
COMMON DIAGNOSTIC INDICATIONS FOR ORBIT, FACE & NECK (SOFT TISSUE) MRI:
PERSISTENT PAIN, DESPITE NEGATIVE PHYSICAL AND ENDOSCOPIC EXAMS
STRIDOR
For subacute and chronic stridor, advanced imaging may follow neck (soft tissue) radiographs and ENT evaluation
2-9
TUMOR EVALUATION PRIMARY NEOPLASM AND METASTATIC DISEASE

Including but not limited to the following anatomic structures:
- Facial Structures
- Larynx and Subglottic Regions
- Nasopharynx, Oropharynx and Hypopharynx
- Neck Soft Tissues, surrounding the airway and glands
- Optic Nerve
- Orbit
- Salivary Glands
- Sella Turcica (Pituitary tumors including Macroadenoma and Microadenoma)
- Sinuses
- Thyroid and Parathyroid Glands
TRAUMA TO THE SOFT TISSUES OF THE NECK
TRAUMA TO THE ORBIT AND FACE
CT preferable for bony assessment

UPPER AIRWAY OBSTRUCTION
VOCAL CORD PARALYSIS
Unexplained, following endoscopic diagnosis

May be unilateral or bilateral
WEGENERS GRANULOMATOSIS suspected or known
Initial diagnosis may be established with an elevated cANCA (cytoplasmic pattern - antineutrophil cytoplasmic
antibody) and biopsy showing non-caseating, multinucleated, giant cell granulomas
ABNORMALITIES DETECTED ON OTHER DIAGNOSTIC EXAMS, WHICH REQUIRE FURTHER EVALUATION
1.
Castellote A, Vzquez E, Vera J, et al. Cervicothoracic Lesions in Infants and Children. RadioGraphics 199; 19: 583-600.
2.
Belden CJ. MR Imaging of the Globe and Optic Nerve. Magn Reson Imaging Clin N Am 2002; 10: 663-678.
3.
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.
4.
Ljumanovi 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.
5.
Som PM, Curtin HD, Mancuso AA. Imaging-Based Nodal Classification for Evaluation of Neck Metastatic Adenopathy. AJR
2000; 174: 837-844.
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.
Schlechte JA. Prolactinoma. N Engl J Med 2003; 349: 2035-2041.
8.
Yousem DM, Kraut MA, Chalian AA. Major Salivary Gland Imaging. Radiology 2000; 216: 19-29.
9.
Gotway MB, Higgins CB. MR Imaging of the Thyroid and Parathyroid Glands. MRI Clin N Am 2000; 8(1): 163-182.
10. Narla LD, Newman B, Spottwood SS, et al. Inflammatory Pseudotumor. RadioGraphics 2003; 23: 719-729.
34

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

Includes the sinuses, facial structures and maxillary regions. Individual scan coverage depends on the specific
clinical request, but generally includes images through the entire frontal, ethmoid, maxillary and sphenoid sinuses.
CT sections may be obtained in one or two (usually coronal and axial) planes.
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
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
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.
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.
35
CT Paranasal Sinuses & Maxillofacial Area
COMMON DIAGNOSTIC INDICATIONS FOR SINUS CT:

The following diagnostic indications for Sinus CT are accompanied by pre-test considerations as well as supporting clinical data and
SINUSITIS / RHINOSINUSITIS
1-4
Acute, Uncomplicated Sinusitis / Rhinosinusitis
Defined as symptoms that last for less than 4 weeks. Common symptoms include purulent rhinorrhea,
postnasal drainage, anosmia, nasal congestion, facial pain, headache, fever, cough, purulent
discharge and/or findings of an upper respiratory tract infection.
No radiographic imaging is usually necessary for immunocompetent patients with acute rhinosinusitis, unless a
complication or alternative diagnosis is suspected that requires imaging
CT may be performed if symptoms persist beyond 3-4 weeks of adequate treatment, which may include
antibiotics, nasal steroids and/or decongestants. Under these circumstances, a complication of acute
sinusitis/rhinosinusitis or an alternative diagnosis may warrant CT imaging of the paranasal sinuses.
Acute Recurrent Sinusitis / Rhinosinusitis
Defined as 3 or more separate episodes of sinusitis during the past year

Imaging used to corroborate the diagnosis and/or investigate for underlying causes of acute recurrent sinusitis
Clinicians should assess patients with recurrent acute sinusitis / rhinosinusitis for factors that modify management,
such as allergic rhinitis, cystic fibrosis, immunocompromised states, ciliary dyskinesia and anatomic variations
Chronic Sinusitis / Rhinosinusitis
Defined as signs and symptoms of sinusitis that last for 12 weeks or longer
Imaging used to corroborate the diagnosis and/or investigate for underlying causes of chronic sinusitis
Clinicians should assess patients with chronic sinusitis / rhinosinusitis for factors that modify management, such
as allergic rhinitis, cystic fibrosis, immunocompromised states, ciliary dyskinesia and anatomic variations
Peri-Orbital Swelling Associated with Sinus Infection
Barosinusitis / Headache Refractory to Antibiotics and Responding only to Decongestants / Oral Steroids
ANOSMIA
CONGENITAL ANOMALIES
FOREIGN BODY IN THE MAXILLOFACIAL REGION
FUNGAL AND OTHER COMPLEX SINUS INFECTIONS
MUCOCELE OF PARANASAL SINUSES
NASAL AIRWAY OBSTRUCTION REFRACTORY TO MEDICAL THERAPY
OSTEOMYELITIS OF THE FACIAL BONES
POLYPOSIS
Following direct visualization or endoscopic examination demonstrating evidence of polyps
PRE-OPERATIVE EVALUATION FOR SINUS SURGERY
POST-OPERATIVE SINUS SURGERY, WITH NEW OR WORSENING SYMPTOMS AND CLINICAL FINDINGS
RECURRENT EPISTAXIS
TRAUMA TO THE FACIAL BONES SIGNIFICANT INJURY
TUMOR OR MASS LESION IN THE SINO-NASAL REGION

36
CT Paranasal Sinuses & Maxillofacial Area
COMMON DIAGNOSTIC INDICATIONS FOR SINUS CT:

WEGENERS GRANULOMATOSIS
Initial diagnosis may be established with an elevated cANCA (cytoplasmic pattern antineutrophil cytoplasmic
antibody) and biopsy showing non-caseating, multinucleated, giant cell granulomas
ABNORMALITIES IDENTIFIED ON ENDOSCOPIC OR OTHER IMAGING STUDIES, REQUIRING FURTHER
EVALUATION WITH CT
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): 18821886.
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.
37

Temporomandibular Joints (TMJ)
CPT CODES:
70336........MRI of Temporomandibular Joint(s)

Bilateral study, including open and closed mouth views, often performed with surface coils.
Images may be obtained in axial, (oblique) sagittal and (oblique) coronal planes.
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.
MRI of the temporomandibular joint(s) is inherently a bilateral procedure. Separate entries for the right and left
temporomandibular joints are not allowed.
-
Biosafety Issues:

Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to MRI of Temporomandibular
Joint(s).
symptoms.
38
MRI-TMJ
COMMON DIAGNOSTIC INDICATIONS FOR TEMPOROMANDIBULAR JOINT (TMJ) MRI:

The following diagnostic indications for Temporomandibular Joint (TMJ) MRI are accompanied by pre-test considerations as
well as supporting clinical data and prerequisite information:
PERSISTENT SYMPTOMS OF TEMPOROMANDIBULAR JOINT DYSFUNCTION, AFTER FAILED CONSERVATIVE

TREATMENT WITH NSAIDS AND/OR ACETAMINOPHEN, A SHORT-TERM TRIAL OF SOFT DIET AND PROPER
CHEWING TECHNIQUES AS WELL AS AN ORAL APPLIANCE (SUCH AS A BITE BLOCK).
Common symptoms include but are not limited to the following:

-
2-3
Clicking sensation, particularly during jaw movement

Persistent orofacial pain
Locking
Facial asymmetry and/or deformity (stable or changing)
Unstable occlusion, with or without other symptoms
Other functional impairments with mastication
Often preceded by conventional radiographs and/or Panorex views of the TMJs

FROZEN JAW
PRE-OPERATIVE EVALUATION OF INTERNAL TMJ DERANGEMENT
From an Oral Surgeon or Otolaryngologist (ENT Specialist)

POST-OPERATIVE EVALUATION
With new or recurrent signs and symptoms

TRAUMA TO THE TEMPOROMANDIBULAR JOINTS
For assessment of meniscal position and integrity

Often preceded by conventional radiographs, Panorex views and/or CT of the TMJs
ARTHROPATHY OF THE TEMPOROMANDIBULAR JOINTS
Often preceded by conventional radiographs and/or Panorex views of the TMJs

-
Inflammatory arthritis (rheumatoid arthritis is the most common)

Infectious arthritis
Post-traumatic arthritis
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.
39

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

Axial images from the skull base to the clavicles.
CT of the neck for soft tissue evaluation generally includes imaging of the following anatomic structures:
- Pharynx, Larynx and Upper Trachea
- Salivary Glands
- Thyroid Gland
- Cervical lymph nodes in the neck
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. For spine imaging,
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.
COMMON DIAGNOSTIC INDICATIONS FOR NECK CT:

The following diagnostic indications for Neck CT are accompanied by pre-test considerations as well as supporting clinical data and
FOREIGN BODY IN THE UPPER AERO-DIGESTIVE TRACT OR SURROUNDING NECK TISSUES
Following neck radiographs (for soft tissue evaluation)

GLOTTIC LESION
Further assessment following endoscopic detection

Unresponsive to medical treatment

-
Abscess
Cellulitis
Osteomyelitis
40
CT Neck for Soft Tissue Evaluation
COMMON DIAGNOSTIC INDICATIONS FOR NECK CT:

LARYNGEAL EDEMA
Often follows initial radiographic evaluation

LYMPHADENOPATHY
1-4
When persistent and/or unexplained

MASS LESION PALPABLE NECK MASS
MASS LESION NON-PALPABLE AND UNEXPLAINED ON PRIOR IMAGING EXAM FOR SURVEILLANCE,
WITHOUT PATHOLOGIC TISSUE CONFIRMATION
NECK MASSES IN THE PEDIATRIC POPULATION, SUCH AS BRANCHIAL CLEFT CYST, THYROGLOSSAL DUCT
5
CYST AND LYMPHANGIOMA / CYSTIC HYGROMA
OBSTRUCTIVE THYROID NODULE OR THYROMEGALY (GOITER)
Following thyroid US or thyroid scintigraphy

When associated with mass effect on the upper airway or esophagus
For pre-operative 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)
PERSISTENT PAIN, DESPITE NEGATIVE PHYSICAL AND ENDOSCOPIC EXAMS
SALIVARY / PAROTID GLAND DUCTAL CALCULI (SIALOLITHIASIS)
STRIDOR
For subacute and chronic stridor, advanced imaging may follow neck (soft tissue) radiographs and ENT evaluation
TRAUMATIC INJURY TO THE SOFT TISSUES OF THE NECK
TUMOR EVALUATION BENIGN AND MALIGNANT (PRIMARY NEOPLASM AND METASTATIC DISEASE):
For diagnosis, staging, evaluation of response to treatment and pre-operative assessment

UPPER AIRWAY OBSTRUCTION
VOCAL CORD PARALYSIS
Unexplained, following endoscopic diagnosis

May be unilateral or bilateral; CT may aid in localizing the side and level of vocal cord paralysis 7
ABNORMALITIES DETECTED ON OTHER DIAGNOSTIC EXAMS, WHICH REQUIRE FURTHER EVALUATION
1.
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.
2.
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.
3.
Sumi M, Ohki M, Nakamura T. Comparison of Sonography and CT for Differentiating Benign from Malignant Cervical Lymph
Nodes in Patients with Squamous Cell Carcinoma of the Head and Neck. AJR 2001; 176: 1019-1024.
4.
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.
41
CT Neck for Soft Tissue Evaluation

5.
Castellote A, Vzquez E, Vera J, et al. Cervicothoracic Lesions in Infants and Children. RadioGraphics 199; 19: 583-600.
6.
Som PM, Curtin HD, Mancuso AA. Imaging-Based Nodal Classification for Evaluation of Neck Metastatic Adenopathy. AJR
2000; 174: 837-844.
7.
Chin S-C, Edelstein S, Chen CY, et al. Using CT to Localize Side and Level of Vocal Cord Paralysis. AJR 2003; 180: 11651170.
42
Neck
CPT CODES:
70498 ...... CTA of Neck, with contrast material(s), including noncontrast images, if performed, and image
postprocessing

CTA of the neck involves image acquisition from the aortic arch to the skull base, to visualize major vessels which
include the extracranial carotid arteries and vertebral arteries. The major venous structures may also be
interrogated with CT angiographic technique.
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
multiple myeloma.
CT Angiography (CTA) utilizes imaging data from standard CT acquisitions. 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.
COMMON DIAGNOSTIC INDICATIONS FOR NECK CTA:

The following diagnostic indications for Neck CTA are accompanied by pre-test considerations as well as supporting clinical data and
STENOSIS OR OCCLUSION OF THE EXTRACRANIAL CAROTID ARTERIES
Following work-up with duplex Doppler examination of the carotid arteries, unless diagnosis is substantiated by
clinical exam findings

-
Confusion
Dizziness
Gait Disturbance
43
CTA - Neck
COMMON DIAGNOSTIC INDICATIONS FOR NECK CTA:

STENOSIS OR OCCLUSION OF VERTEBRAL ARTERIES
In patients with signs and symptoms of Vertebrobasilar Insufficiency (VBI) or Vertebral Basilar Ischemia.
-

Ataxia
Diplopia
Dysarthria
Dysphagia
Motor Paresis
Nystagmus
Syncope
Vertigo
FOLLOW-UP OF ABNORMAL OR INCONCLUSIVE FINDINGS ON CAROTID DOPPLER ULTRASOUND,

PARTICULARLY WHEN VASCULAR CALCIFICATIONS PRECLUDE ADEQUATE VISUALIZATION OF THE LUMEN
ANEURYSM
ARTERIOVENOUS MALFORMATION
CONGENITAL ANOMALIES OF THE CAROTID AND VERTEBROBASILAR CIRCULATIONS
DISSECTION
INTRAMURAL HEMATOMA
ARTERIAL THROMBOEMBOLISM
VENOUS THOMBOSIS OR COMPRESSION
VASCULOPATHY, INCLUDING FIBROMUSCULAR DYSPLASIA (FMD)
TRAUMATIC VASCULAR INJURY TO THE EXTRACRANIAL CAROTID AND VERTEBRAL ARTERIES
5-7
PRE-OPERATIVE VASCULAR DELINEATION OF BLOOD SUPPLY TO TUMORS, SUCH AS CAROTID BODY

(GLOMUS) TUMORS
POST-OPERATIVE EVALUATION, FOLLOWING CAROTID ENDARTERECTOMY
With new sign and symptoms

As a substitute for catheter angiography, when otherwise indicated
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 Volumerendering Technique. Radiology 1999; 211: 775-780.
3.
Randoux B, Marro B, Koskas F, et al. Carotid Artery Stenosis: Prospective Comparison of CT, Three-dimensional Gadoliniumenhanced MR, and Conventional Angiography. Radiology 2001; 220: 179-185.
44
CTA - Neck
4.
Schievink W. Spontaneous Dissection of the Carotid and Vertebral Arteries. N Engl J Med 2001; 344(12): 898-906.
5.
Nez DB, Torres-Len M, Mnera F. Vascular Injuries of the Neck and Thoracic Inlet: Helical CT Angiographic Correlation.
RadioGraphics 2004; 24: 1087-1098.
6.
Mnera F, Soto JA, Palacio DM, et al. Penetrating Neck Injuries: Helical CT Angiography for Initial Evaluation. Radiology 2002;
224: 366-372.
7.
LeBlang S, Nez DB. Noninvasive Imaging of Cervical Vascular Injuries. AJR 2000; 174: 1269-1278.
45
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

Acquisitions from the aortic arch to the skull base, to visualize the major vessels including the extracranial carotid
1-2
arteries and vertebral arteries.

techniques.
The major venous structures may also be interrogated with MR angiographic
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.
not compatible with MR imaging, as well as other devices considered unsafe in MRI scanners (including certain
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.
COMMON DIAGNOSTIC INDICATIONS FOR NECK MRA:

The following diagnostic indications for Neck MRA are accompanied by pre-test considerations as well as supporting clinical data and
STENOSIS OR OCCLUSION OF THE EXTRACRANIAL CAROTID ARTERIES
Following work-up with duplex Doppler examination of the carotid arteries 5, unless diagnosis is substantiated by
clinical exam findings

-
Confusion
Dizziness
Gait Disturbance
46
MRA - Neck
COMMON DIAGNOSTIC INDICATIONS FOR NECK MRA:

STENOSIS OR OCCLUSION OF THE VERTEBRAL ARTERIES
Symptoms of Vertebrobasilar Insufficiency are usually temporary, due to diminished blood flow to the posterior
circulation of the brain.

-

Ataxia
Diplopia
Dysarthria
Dysphagia
Motor Paresis
Nystagmus
Syncope
Vertigo
FOLLOW-UP OF ABNORMAL OR INCONCLUSIVE FINDINGS ON CAROTID DOPPLER ULTRASOUND,

PARTICULARLY WHEN VASCULAR CALCIFICATIONS PRECLUDE ADEQUATE VISUALIZATION OF THE LUMEN
ANEURYSM
ARTERIOVENOUS MALFORMATION
CONGENITAL ANOMALIES OF THE CAROTID AND VERTEBROBASILAR CIRCULATIONS
DISSECTION
6-7
INTRAMURAL HEMATOMA
ARTERIAL THROMBOEMBOLISM
VENOUS THOMBOSIS OR COMPRESSION
VASCULOPATHY, INCLUDING FIBROMUSCULAR DYSPLASIA (FMD)
TRAUMATIC VASCULAR INJURY TO THE EXTRACRANIAL CAROTID AND VERTEBRAL ARTERIES
PRE-OPERATIVE VASCULAR DELINEATION OF BLOOD SUPPLY TO TUMORS, SUCH AS CAROTID BODY

(GLOMUS) TUMORS
POST-OPERATIVE EVALUATION, FOLLOWING CAROTID ENDARTERECTOMY:
With new sign and symptoms

Instead of catheter angiography, when otherwise indicated
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 Contrastenhanced 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.
47
MRA - Neck
4.
Randoux B, Marro B, Koskas F, et al. Carotid Artery Stenosis: Prospective Comparison of CT, Three-dimensional Gadoliniumenhanced 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, Nez DB. Noninvasive Imaging of Cervical Vascular Injuries. AJR 2000; 174: 1269-1278.
48
Computerized Tomography (CT)

Chest
CPT CODES:
71250........Chest CT without contrast
71260........Chest CT with contrast
71270........Chest CT without contrast, followed by re-imaging with contrast

Lung apices through costophrenic sulci
Scan coverage may vary, depending on the specific clinical indication
In the majority of clinical situations, Chest Radiographs should be performed prior to advanced imaging with CT,
preferably within 30 days of the Chest CT exam request.
Most health plans do not currently provide benefit coverage for screening studies using advanced imaging. For
Chest CT imaging, this may include lung cancer screening.
1-2
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.
COMMON DIAGNOSTIC INDICATIONS FOR CHEST CT:

The following diagnostic indications for Chest CT are accompanied by pre-test considerations as well as supporting clinical data and
prerequisite information.
This section contains:
Common Chest Indications

Additional Pulmonary Indications
Additional Mediastinal and Hilar Indications
Additional Cardiac and Pericardial Indications
Additional Pleural, Chest Wall and Diaphragmatic Indications
Common Thoracic Indications

PULMONARY EMBOLISM
3-4
HEMOPTYSIS (COUGHING UP BLOOD)
Initial evaluation should be performed with Chest X-Ray

SUBACUTE COUGH (LASTING 3-8 WEEKS) OR CHRONIC COUGH (PERSISTING FOR OVER 8 WEEKS)
In immuno-competent individuals, with a normal Chest X-Ray:

Requires Chest X-Ray since the onset of symptoms and evaluation for other causes which are described below.
Work-up may include other diagnostic studies such as pulmonary function tests or gastroesophageal reflux
assessment, as these procedures relate to the patients presentation:
- Peer-reviewed literature indicates that the majority of chronic cough cases are attributable to the following
6-7
causes: post-nasal drainage, cough-variant asthma and gastroesophageal reflux disease
49
CT - Chest

- Other etiologies for chronic cough include, but are not limited to: smoking, chronic bronchitis, cough-inducing
medications (e.g., ACE Inhibitors), exposure to an environmental irritant, respiratory infection and neoplasm
- In immuno-compromised individuals, a higher level of suspicion is warranted
PERSISTENT PNEUMONIA ON CHEST X-RAY, AFTER 4-6 WEEKS OF ANTIBIOTIC TREATMENT
RECURRENT PNEUMONIA IN THE SAME LOCATION, WITHIN 6 MONTHS
As documented on Chest Radiographs

INFECTIOUS AND INFLAMMATORY PROCESSES
INCLUDING COMPLICATIONS OF PNEUMONIA
For initial evaluation and surveillance

Including but not limited to the following thoracic abnormalities:
-
Lung Abscess
Mediastinitis
Sternal Infection (particularly following cardiac surgery)
Empyema
Mediastinal Abscess
Other infectious processes
FEVER OF UNKNOWN ORIGIN
Following standard work-up to localize the source

STRUCTURAL ABNORMALITIES ON CHEST XRAY, WHICH REQUIRE FURTHER CLARIFICATION WITH CT
POSITIVE SPUTUM CYTOLOGY FOR MALIGNANCY
DOCUMENTED MALIGNANCY PRIMARY NEOPLASM AND METASTATIC DISEASE
9-10
For staging and periodic follow-up

PRE-OPERATIVE EVALUATION FOR THORACIC SURGERY
POST-OPERATIVE COMPLICATIONS
For suspected or known operative complications, particularly during the initial 6-8 weeks following cardio-thoracic
surgery
CONGENITAL THORACIC ANOMALIES
SARCOIDOSIS
Initial evaluation and periodic follow-up

TRAUMA
Injury involving the Chest Wall, Cardiomediastinal Structures and/or Lungs

UNEXPLAINED WEIGHT LOSS SIGNIFICANT WEIGHT LOSS EXCEEDING 10% OF DESIRABLE BODY
WEIGHT, OVER A SHORT TIME INTERVAL
Additional Pulmonary Indications:

PULMONARY NODULE(S) WITH SUSPICION OF UNDERLYING MALIGNANCY
Initial evaluation and periodic surveillance of stable lesions for up to 2 years 11-13
Nodules are generally defined as < 3 cm in size
50
CT - Chest

PULMONARY MASS OR SUSPICIOUS PARENCHYMAL ABNORMALITY ON RECENT CHEST X-RAY OR OTHER
IMAGING EXAM
BULLOUS EMPHYSEMA
Following initial evaluation with Chest Radiographs

Consider High Resolution Chest CT (HRCT) Technique 14
BRONCHIECTASIS

Consider High Resolution Chest CT (HRCT) Technique 14
INTERSTITIAL LUNG DISEASE/PULMONARY FIBROSIS

Consider High Resolution Chest CT (HRCT) Technique 14-15
HYPERLUCENT LUNG LESIONS IN PEDIATRIC PATIENTS
Including but not limited to the following thoracic abnormalities:
- Congenital Lobar Emphysema
- Congenital Cystic Adenomatoid Malformation
PULMONARY SEQUESTRATION
ASBESTOS-RELATED BENIGN AND MALIGNANT LESIONS, involving the lungs and pleura:
-
16-17
Pleural plaques
Interstitial lung disease
Malignant Mesothelioma
Pleural effusion
Lung cancer
OTHER PNEUMOCONIOSES
Additional Mediastinal and Hilar Indications

EVALUATION OF THE THORACIC AORTA ANEURYSM AND DISSECTION:
18-19
In patients with suspected aortic aneurysm who have not undergone imaging of the thoracic aorta within the
preceding 60 days
or
In patients with confirmed thoracic aortic aneurysm with new or worsening signs/symptoms
or
For ongoing surveillance of stable patients with confirmed thoracic aortic aneurysm who have not undergone
imaging of the thoracic aorta within the preceding six months
or
In patients with suspected aortic dissection

or
In patients with confirmed aortic dissection who have new or worsening symptoms
or
In patients with confirmed aortic dissection in whom surgical repair is anticipated (to assist in preoperative
planning)
or
For ongoing surveillance of stable patients with confirmed aortic dissection who have not undergone imaging of
51
CT - Chest

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
PENETRATING ATHEROSCLEROTIC AORTIC ULCER
TRAUMATIC AORTIC INJURY
19-20
VASCULITIS OF THE THORACIC AORTA OR BRANCH VESSEL

SUPERIOR VENA CAVA (SVC) SYNDROME
MEDIASTINAL WIDENING ON RECENT CHEST X-RAY
HILAR ENLARGEMENT ON RECENT CHEST X-RAY
KNOWN HILAR AND/OR MEDIASTINAL LYMPHADENOPATHY / MASS
Periodic follow-up
HOARSENESS OR VOCAL CORD WEAKNESS - SUSPECTED TO RESULT FROM RECURRENT LARYNGEAL
NERVE INJURY
Chest X-ray and laryngoscopy must precede CT imaging, except for unusual clinical circumstances such as an
anatomic situation in which attempted laryngoscopy might be unsafe
THYMOMA
Note that approximately 15% of patients with Myasthenia Gravis will have a Thymoma 21
TRACHEOBRONCHIAL LESION EVALUATION
Additional Cardiac and Pericardial Indications

CONGENITAL HEART DISEASE
22
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
To assist in surgical planning for patients with complex congenital heart disease
or
52
CT - Chest

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
Note: Cardiac MRI or transesophageal echocardiography may be preferable to chest CT in order to avoid radiation
exposure
CARDIAC ANEURYSM AND PSEUDOANEURYSM
INTRA-CARDIAC AND PARA-CARDIAC MASS(ES)
Usually performed following echocardiography

EVALUATION OF PERICARDIAL CONDITIONS (PERICARDIAL EFFUSION, CONSTRICTIVE PERICARDITIS, OR
CONGENITAL PERICARDIAL DISEASES)
In patients with suspected pericardial constriction

or
In patients with suspected congenital pericardial disease

or
In patients with suspected pericardial effusion (including hemopericardium) who have undergone echocardiography
deemed to be technically suboptimal in evaluation of the effusion
or
In patients whose echocardiogram shows a complex pericardial effusion (loculated, containing solid material)
Additional Pleural, Chest Wall and Diaphragmatic Indications

ABNORMAL PLEURAL FLUID COLLECTION, INCLUDING EFFUSION, HEMOTHORAX, EMPYEMA AND
CHYLOTHORAX persistent and unexplained, following thoracentesis
CHEST WALL MASS
PLEURAL MASS
PNEUMOTHORAX unexplained or recurrent
THORACIC OUTLET SYNDROME
DIAPHRAGMATIC HERNIA
UNEXPLAINED DIAPHRAGMATIC ELEVATION OR IMMOBILITY
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.
5.
Revel MP, Fournier L S, Hennebicque AS, et al. Can CT Replace Bronchoscopy in the Detection of the Site and Cause of
53
CT - Chest
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.
54
Chest (Non-Coronary)
CPT CODES:
71275........CTA of Chest (noncoronary) ,with contrast material(s), including noncontrast images, if performed, and
image postprocessing

Scan coverage varies depending on the clinical indication. This exam does not include cardiac and coronary
artery indications.
Chest CTA may be used for anatomic depiction from the pulmonary apices through the costophrenic sulci.
Advantages of CTA:
Rapidly acquired exam, with excellent anatomic detail afforded by most multidetector CT scanners.
Disadvantages of CTA:
Potential complications from use of intravascular iodinated contrast administration (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.
Other Comments:
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.
COMMON DIAGNOSTIC INDICATIONS FOR CHEST CTA:

The following diagnostic indications for Chest CTA are accompanied by pre-test considerations as well as supporting clinical data
and prerequisite information.
General Chest CTA Indications
Additional Thoracic Aorta and Great Vessel Indications
Additional Pulmonary Artery and Vein Indication
55
CTA Chest (Non-Coronary)
General Chest CTA Indications:

VASCULAR INVOLVEMENT FROM NEOPLASM IN THE CHEST
SYSTEMIC VENOUS THROMBOSIS OR OCCLUSION, INCLUDING SUPERIOR VENA CAVA (SVC) SYNDROME
SUBCLAVIAN STEAL SYNDROME
DEVELOPMENTAL ANOMALIES OF THE THORACIC VASCULATURE
Examples of congenital thoracic vascular anomalies include but are not limited to the following:
- Aortic coarctation
- Double aortic arch
- Hypoplastic or atretic pulmonary arteries
- Inferior vena caval interruption
- Partial anomalous pulmonary venous return
- Patent ductus arteriosus
- Persistent left-sided superior vena cava
- Right-sided aortic arch
- Total anomalous pulmonary venous return
- Transposition of the Great Vessels
- Truncus arteriosus
POST-TRAUMATIC VASCULAR INJURY
Additional Thoracic Aorta and Great Vessel Indications: 4-7

preceding 60 days
or
or
or

or
or
planning)
or
or
INTRAMURAL HEMATOMA
56

ATHEROMATOUS DISEASE, INCLUDING PENETRATING ATHEROSCLEROTIC AORTIC ULCER
4,6
VASCULITIS
STENT GRAFT EVALUATION, INCLUDING DETECTION OF AN ENDOLEAK
Pre-Procedure Assessment and Post-Procedure Follow-up

POST-OPERATIVE OR POST-INTERVENTIONAL VASCULAR PROCEDURE FOR LUMINAL PATENCY VERSUS
STENOSIS / OCCLUSION, AS WELL AS POST-PROCEDURE COMPLICATION
Potential complications include but are not limited to the following:

Infection, such as abscess
Peri-anastomotic leak
Pseudoaneurysm
Additional Pulmonary Artery and Vein Indications: 4,8-13

PULMONARY EMBOLISM
4, 8-10
For clinically suspected pulmonary embolism or follow-up when recurrent thromboembolism is a concern in
patients on adequate medical therapy
PULMONARY ARTERIAL HYPERTENSION

PULMONARY ARTERIOVENOUS MALFORMATION (AVM)
EVALUATION OF CARDIAC VENOUS ANATOMY
11-13
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

Note: Chest CTA for these indications requires referral from a cardiologist, electrophysiologist or cardiothoracic
surgeon
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: MultiDetector 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
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: 11191125.
57
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; 230:329337.
10. Kruip MJ, Leclercq MGL, van der Heul C, Prins MH, Bller 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.
58

Chest
CPT CODES:
71550 ...... MRI chest, without contrast
71551........MRI chest, with contrast
71552........MRI chest, without contrast, followed by re-imaging with contrast

Chest MRI studies are often performed as problem-solving exams, following Chest CT. In these circumstances,
anatomic coverage will depend on the specific indication for the study.
This Guideline excludes cardiac indications, which are covered under the Cardiac MRI section and corresponding
CPT codes (75557-75564).
Advantages of Chest MRI:
Chest MRI may be helpful after a CT in the following scenarios:

Defining mediastinal and hilar lymphadenopathy (particularly after an unenhanced chest CT exam)
Determining direct lung tumor invasion into the mediastinum and hilar structures, without the need for iodinated
contrast material in CT
Assessing spinal canal extension from a postero-medially located thoracic mass

Evaluating a suspected Pancoast tumor (also referred to as apical pleuro-pulmonary groove or superior pulmonary
sulcus tumors) for direct chest wall extension, given the multiplanar capability of MRI
Disadvantages of Chest MRI:
Lung lesions are usually better imaged with CT when compared with MRI, given the superior spatial resolution of
CT.
MRI should not be performed in patients with certain implanted devices that are not MRI compatible, such as
pacemakers (see biosafety issues below).
-
Biosafety Issues:

Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to chest MRI.
For initial evaluation of most thoracic lesions, such as pulmonary nodules and masses, chest CT is considered the
59
MRI - Chest
study of choice.
Contrast utilization for Chest MRI is at the discretion of the ordering and imaging providers.
In general, follow-up CT and MRI exams should be performed only when there is a clinical change with new signs
or symptoms or as surveillance after treatment.
Other Comments:
An MRI of the chest should not be entered for imaging of the heart, which is examined using the Cardiac MRI CPT
codes 75557-75564.
COMMON DIAGNOSTIC INDICATIONS FOR CHEST MRI:

The following diagnostic indications for Chest MRI are accompanied by pre-test considerations as well as
supporting clinical data and prerequisite information:
DOCUMENTED MALIGNANCY PRIMARY NEOPLASM AND METASTATIC DISEASE
For staging and periodic surveillance

To evaluate the mediastinum, hila, pericardium, heart, chest wall and paraspinal region
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
THYMOMA EVALUATION OR HISTORY OF MYASTHENIA GRAVIS
-
Note that approximately 15% of patients with Myasthenia Gravis will have a thymoma
In patients with suspected aortic aneurysm who have not undergone imaging of the thoracic aorta within the preceding
60 days
or
or
For ongoing surveillance of stable patients with confirmed thoracic aortic aneurysm who have not undergone imaging of
the thoracic aorta within the preceding six months
or

or
or
In patients with confirmed aortic dissection in whom surgical repair is anticipated (to assist in preoperative planning)
60
MRI - Chest
COMMON DIAGNOSTIC INDICATIONS FOR CHEST MRI:

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
2,4
SUPERIOR VENA CAVA SYNDROME
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.
61
Chest
CPT CODES:
71555........MRA of Chest (excluding the myocardium) without contrast, followed by re-imaging with contrast

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

With MRA, artifact due to patient motion may have a particularly significant impact on exam quality.
MRA cannot be performed in patients with certain implanted devices that are not MRI compatible, such as
pacemakers (see biosafety issues below).
Biosafety Issues:
not compatible with MR imaging, as well as other devices considered unsafe in MRI scanners (including implanted
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
COMMON DIAGNOSTIC INDICATIONS FOR CHEST MRA:

The following diagnostic indicatins for Chest MRA are accompanied by pre-test considerations as well as supporting clinical data
and prerequisite information.
General Chest MRA Indications
Additional Thoracic Aorta and Great Vessel Indications
Additional Pulmonary Artery and Vein Indications
Common Chest MRA Indications:
1-3
VASCULAR INVOLVEMENT FROM NEOPLASM IN THE CHEST

SYSTEMIC VENOUS THROMBOSIS OR OCCLUSION, INCLUDING SUPERIOR VENA CAVA (SVC) SYNDROME
62
MRA - Chest

SUBCLAVIAN STEAL

POST-TRAUMATIC VASCULAR INJURY

or

or
or
Additional Thoracic Aorta and Great Vessel Indications: 4-7

preceding 60 days
or
or
or

or
or
planning)
63
MRA - Chest

or
or
INTRAMURAL HEMATOMA
ATHEROMATOUS DISEASE, INCLUDING PENETRATING ATHEROSCLEROTIC AORTIC ULCER
VASCULITIS
STENT GRAFT EVALUATION, INCLUDING DETECTION OF AN ENDOLEAK
Pre-Procedure Assessment and Post-Procedure Follow-up

POST-OPERATIVE OR POST-INTERVENTIONAL VASCULAR PROCEDURE FOR LUMINAL PATENCY VERSUS
STENOSIS / OCCLUSION AS WELL AS POST-PROCEDURE COMPLICATIONS
Potential complications include but are not limited to the following:
- Infection, such as abscess
- Peri-anastomotic leak
- Pseudoaneurysm
Additional Pulmonary Artery and Vein Indications: 8-11

PULMONARY EMBOLISM
8-9
Rarely requested and used only in selected cases, for example when intravenous iodinated contrast material for a
CTA is contraindicated due to significant iodinated contrast allergy, and a diagnostic ventilation/perfusion (V/Q) study
cannot be obtained.
PULMONARY ARTERIAL HYPERTENSION
PULMONARY ARTERIOVENOUS MALFORMATION (AVM)
10
11
or
or
or

Note: Chest MRA for these indications requires referral from a cardiologist or electrophysioligist or cardiothoracic
Surgeon
64
MRA - Chest
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-Tllez 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 GadoliniumEnhanced 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.
65

Breast - Also referred to as MR Mammography (MRM)
CPT CODES:
77058 ......MRI of Breast, without and/or with contrast material(s); Unilateral
77059 ......MRI of Breast, without and/or with contrast material(s); Bilateral
Technique:
It is strongly recommended that Breast MRI examinations be performed with a dedicated breast coil.
Limitations:
Breast MRI is not recommended as a screening technique in patients with average-risk for breast cancer
Breast MRI is not recommended to assess suspicious breast lesions in order to avoid a biopsy
Breast MRI should not be used to differentiate cysts from solid lesions, which is well evaluated with ultrasound
-
Biosafety Issues:

Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to breast MRI.
symptoms.
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.
66
MRI- Breast
COMMON DIAGNOSTIC INDICATIONS FOR BREAST MRI:

For Breast Carcinoma: Diagnostic Evaluation
LESION CHARACTERIZATION, WHEN OTHER IMAGING EXAMINATIONS, SUCH AS ULTRASOUND AND
MAMMOGRAPHY, AND PHYSICAL EXAMINATION ARE INCONCLUSIVE FOR THE PRESENCE OF BREAST
CANCER, AND BIOPSY COULD NOT BE PERFORMED (E.G., POSSIBLE DISTORTION ON ONLY ONE
1
MAMMOGRAPHIC VIEW WITHOUT A SONOGRAPHIC CORRELATE)
INVASIVE CARCINOMA AND DUCTAL CARCINOMA IN SITU (DCIS) TO DETERMINE THE EXTENT OF DISEASE
1
AND THE PRESENCE OF MULTIFOCALITY AND MULTICENTRICITY
INVASION OF BREAST CANCER DEEP TO FASCIA MRI EVALUATION OF BREAST PRIOR TO SURGICAL
TREATMENT MAY BE USEFUL IN BOTH MASTECTOMY AND BREAST CONSERVATION CANDIDATES TO
DEFINE THE RELATIONSHIP OF THE TUMOR TO THE FASCIA AND ITS EXTENSION INTO PECTORALIS
MAJOR, SERRATUS ANTERIOR, AND/OR INTERCOSTAL MUSCLES
METASTATIC CANCER WHEN THE PRIMARY IS UNKNOWN AND SUSPECTED TO BE OF BREAST ORIGIN IN
PATIENTS PRESENTING WITH METASTATIC DISEASE AND/OR AXILLARY ADENOPATHY AND NO
MAMMOGRAPHIC OR PHYSICAL FINDINGS OF PRIMARY BREAST CARCINOMA
NEOADJUVANT CHEMOTHERAPY MR MAMMOGRAPHY MAY BE PERFORMED BEFORE, DURING AND
AFTER CHEMOTHERAPY, TO ASSESS RESPONSE TO TREATMENT AND EXTENT OF RESIDUAL DISEASE,
PRIOR TO SURGERY
RECURRENCE OF BREAST CANCER IN WOMEN WITH A PRIOR HISTORY OF BREAST CANCER AND
SUSPICION OF RECURRENCE WHEN CLINICAL, MAMMOGRAPHIC, AND/OR SONOGRAPHIC FINDINGS ARE
1
INCONCLUSIVE
POST-LUMPECTOMY WITH POSITIVE MARGINS TO EVALUATE FOR RESIDUAL DISEASE IN PATIENTS
1
WHOSE PATHOLOGY SPECIMENS DEMONSTRATE CLOSE OR POSITIVE MARGINS FOR RESIDUAL DISEASE
POST-OPERATIVE TISSUE RECONSTRUCTION TO EVALUATE SUSPECTED CANCER RECURRENCE IN
PATIENTS WITH TISSUE TRANSFER FLAPS (RECTUS, LATISSIMUS DORSI, AND GLUTEAL)
DIFFERENTIATION OF PALPABLE MASS(ES) FROM SURGICAL SCAR TISSUE FOLLOWING BREAST
SURGERY, BREAST RECONSTRUCTION OR RADIATION THERAPY
For Breast Carcinoma: Annual Screening

HIGH-RISK INDIVIDUALS WITH A BREAST CANCER GENETIC MUTATION, WHICH INCLUDE THE FOLLOWING:
1,18
BRCA1 AND BRCA2 including BRCA mutation or 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
18
DEPENDENT ON FAMILY HISTORY
HISTORY OF LOBULAR CARCINOMA IN SITU (LCIS) ON BIOPSY OR DUCTAL CARCINOMA IN SITU (DCIS) ON
3,6,16
BIOPSY
FOR AN INDIVIDUAL WHO RECEIVED RADIATION TO CHEST BETWEEN THE AGES 10-30 YEARS
18
For Breast Implant Rupture:

(Not requiring breast carcinoma diagnosis)
EVALUATION OF SYMPTOMATIC PATIENTS WITH BREAST IMPLANTS, FOR DETECTION OF IMPLANT
67
MRI- Breast
RUPTURE
References/Literature Review:
1.
ACR Practice Guideline for the Performance of Contrast-Enhanced Magnetic Resonance Imaging (MRI) of the Breast. ACR
Website. Revised 2008.
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.
Bouwman, Afonso N. Eur J. Cancer Prev. 2008 Aug; 17 (4); 312-6.
4.
Hlawatsch A, Teifke A, Schmidt M, Thelan M. Preoperative Assessment of Breast Cancer: Sonography Versus MR Imaging.
AJR 2002; 179: 1493-1501.
5.
Lee CH. Problem Solving MR Imaging of the Breast. Radiol Clin N Am. 2004; 42: 919-934.
6.
Haagensen CD, Lane N. Lattes R, Bodian C. Lobular neoplasia (so-called lobular carcinoma in situ) of the breast. Cancer
1978;42:737-769.
7.
Huang W, Fisher PR, Dulaimy K, et al. Detection of Breast Malignancy: Diagnostic MR Protocol for Improved Specificity.
Radiology 2004; 232: 585-591.
8.
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.
9.
Kuhl CK. Current Status of Breast MR Imaging. Part 2. Clinical Applications. Radiology 2007; 244(3): 672-691.
10. Lee JM, Orel SG, Czerniecki BJ, et al. MRI Before Reexcision Surgery in Patients with Breast Cancer. AJR 2004; 182: 473-480.
11. 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.
12. 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.
13. 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.
14. Middleton MS. Magnetic resonance evaluation of breast implants and soft-tissue silicone. Top Magn Reson Imaging 1998; 9(2):
92-137.
15. Orel SG, Schnall MD. MR Imaging of the Breast for the Detection, Diagnosis, and Staging of Breast Cancer. Radiology 2001;
220: 13-30.
16. Rosen PP, Lieberman PH, Braun DW, Kosloff C, Adair F. Lobular carcinoma in situ of the breast: detailed analysis of 99 patients
with average follow-up of 24 years. Am J Surg Pathol 1978;2:225-251.
17. Schnall MD. Breast MR Imaging. Radiol Clin N Am 2003; 41: 43-50.
18. Schnall MD, Orel SG, Ed. Breast MR Imaging. Magnetic Resonance Imaging Clinics of North America. Philadelphia: W.B.
Saunders Company; May, 2001.
19. American Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography. CA Cancer J Clin 2007;
57: 75-89.
68
Nuclear Cardiology
Myocardial Perfusion Imaging (MPI)
CPT CODES:
78451..Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or
quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when
performed); single study, at rest or stress (exercise or pharmacologic)
78452. Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or
quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when
performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution
and/or rest reinjection
78453. Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by
first pass or gated technique, additional quantification, when performed); single study, at rest or stress
(exercise or pharmacologic)
78454..Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by
first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or
stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
COMMONLY USED RADIOPHARMACEUTICALS:

Thallium-201 Chloride
Technetium-99m Sestamibi
Technetium-99m Tetrofosmin
USES OF MYOCARDIAL PERFUSION IMAGING (MPI):

The primary use of MPI is in the diagnosis, exclusion or evaluation of obstructive Coronary Artery Disease (CAD)
MPI is also used for risk stratification with established coronary artery disease.
MPI may be used for assessment of myocardial viability in patients who have had myocardial infarction.
This guideline does not supersede the enrollees health plan medical policy specific to myocardial perfusion
imaging
A recent EKG is strongly recommended, preferably within 30 days of request for a Myocardial Perfusion Imaging
Exam. The findings on the resting EKG may be important in determining the need for imaging, the selection of the
appropriate imaging protocol and may also show evidence of ischemia at rest or interval myocardial infarction.
Age, gender and the character of the chest pain provide useful predictors of CAD, as stratified in Table 1 below.
Table 1*: Pre-Test Probability of Coronary Artery Disease by Age, Gender and Symptoms.
Age (yr)
30-39
40-49
50-59
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.
Gender
Typical/Definite
Atypical/Probable
Non-Anginal
Angina Pectoris
Angina Pectoris
Chest Pain
Asymptomatic
Men
Intermediate
Intermediate
Low
Very Low
Women
Intermediate
Very Low
Very Low
Very Low
Men
High
Intermediate
Intermediate
Low
Women
Intermediate
Low
Very Low
Very Low
Men
High
Intermediate
Intermediate
Low
69
Nuclear Cardiology - MPI
60-69
Men
High
Intermediate
Intermediate
Low
Women
High
Intermediate
Intermediate
Low
Myocardial Perfusion Imaging and Stress Echocardiography may provide useful information on Coronary Heart
Disease. Comparison data on Sensitivity and Specificity are provided in Table 2 below. Due to regional variation in
technical expertise and interpretive proficiency, the clinician should use the diagnostic imaging modality that has
been proven most accurate in his/her practices.
Table 2**: Comparison of Non-Invasive Diagnostic Imaging
** Reference for Table 2: Barry L. Zaret and George A. Bellar. Clinical Nuclear Cardiology. 3rd Edition.
Philadelphia: Elsevier Mosby Publishers; 2005, page 539.
Nuclear Imaging
Stress Echo
Nuclear Imaging
Stress Echo
Sensitivity (%)
Sensitivity (%)
Specificity (%)
Specificity (%)
Exercise (7 studies)
83%
78%
83%
91%
Dobutamine (8 studies)
86%
80%
73%
86%
Adenosine (3 studies)
89%
63%
73%
86%
Dipyridamole (4 studies)
83%
68%
88%
89%
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
Other coronary risk factors such as family history of premature CAD, coronary artery calcification, C
reactive protein levels, obesity etc. are not included in the standard methods of risk assessment but are
thought to contribute to coronary artery disease risk.
Selection of the optimal diagnostic work-up for evaluation or exclusion of coronary artery disease should be made
within the context of available studies (which include treadmill stress test, stress myocardial perfusion imaging,
stress echocardiography, cardiac PET imaging and invasive cardiac/coronary angiography), so that the resulting
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.
It is anticipated that the evaluation of patients with acute chest pain will occur in the emergency room or in an
inpatient setting and MPI performed in these locations is not included in the AIM preauthorization program.
70
COMMON DIAGNOSTIC INDICATIONS FOR MYOCARDIAL PERFUSION IMAGING:

The following diagnostic indications for Myocardial Perfusion Imaging may be accompanied by pre-test considerations as well
as supporting clinical data and prerequisite information
SUSPECTED CORONARY ARTERY DISEASE IN SYMPTOMATIC PATIENTS who have not had evaluation of
coronary artery disease (MPI, stress echo, coronary CTA or cardiac catheterization) within the preceding sixty (60)
days:
Chest pain
- with intermediate or high pretest probability of CAD (Table 1)
Or
with low pretest probability of CAD (table 1) and moderate or high risk of CAD (SCORE)
Or
- with very low pretest probability of CAD and high risk of CAD (SCORE)
Atypical symptoms: shortness of breath (dyspnea), neck, jaw, arm, epigastric or back pain, sweating (diaphoresis).
- with moderate or high risk of CAD (SCORE)
Other symptoms; palpitation, dizziness, lightheadedness, syncope, near syncope, nausea, vomiting, anxiety,
weakness, fatigue etc
with high risk of CAD (SCORE)
Patients with any cardiac symptom who have diseases/conditions with which coronary artery disease commonly
coexistS such as:
diabetes mellitus
Or
abdominal aortic aneurysm

Or
established and symptomatic peripheral vascular disease

Or
prior history of cerebrovascular accident (CVA), transient ischemic attack (TIA) or carotid endarterectomy (CEA)
Or
chronic renal insufficiency or renal failure
Patients who have undergone cardiac transplantation
SUSPECTED CORONARY ARTERY DISEASE IN ASYMPTOMATIC PATIENTS
Patients with high-risk of CAD (SCORE) who have not had evaluation of coronary artery disease (MPI, stress echo,
coronary CTA or cardiac catheterization) within the preceding two years
Or
Patients with moderate or high risk of CAD (SCORE) who have a high risk occupation that would endanger others in
the event of a myocardial infarction, for example: airline pilot, law-enforcement officer, firefighter, mass transit
operator, bus driver) who have not had evaluation of coronary artery disease (MPI, stress echo, coronary CTA or
cardiac catheterization) within the preceding two (2) years
Or
Patients with diseases/conditions with which coronary artery disease commonly coexist and who have not had
evaluation of coronary artery disease (MPI, stress echo, coronary CTA or cardiac catheterization) within the
preceding two (2) years:
diabetes mellitus
Or

Or

Or
71

Or
- chronic renal insufficiency or renal failure

Patients who have undergone cardiac transplantation and have had no evaluation for coronary artery disease within
the preceding one (1) year
ESTABLISHED CORONARY ARTERY DISEASE (DIAGNOSED BY PREVIOUS CARDIAC CATHETERIZATION,
MPI, OR STRESS ECHO) IN PATIENTS WHO HAVE NO SYMPTOMS OR STABLE SYMPTOMS)
No evaluation of CAD (MPI, stress echo, coronary CTA or cardiac catheterization) within the preceding two (2)
years
Or
If the patient is diabetic, no evaluation of CAD (MPI, stress echo, coronary CTA or cardiac catheterization) within
MPI, OR STRESS ECHO) IN PATIENTS WHO HAVE NEW OR WORSENING SYMPTOMS
Note: if symptoms are typical of myocardial ischemia cardiac catheterization may be more appropriate than MPI
PATIENTS WITH NEW ONSET ARRHYTHMIAS (PATIENT CAN BE SYMPTOMATIC OR ASYMPTOMATIC)
This guideline applies to patients with suspected or established CAD
Patients with ventricular tachycardia

Or
Patients with atrial fibrillation or flutter and high or moderate risk of CAD (SCORE)
Or
Patients with atrial fibrillation or flutter and established CAD

PATIENTS WITH NEW ONSET CONGESTIVE HEART FAILURE OR RECENTLY RECOGNIZED LEFT
VENTRICULAR DYSFUNCTION (PATIENT CAN BE SYMPTOMATIC OR ASYMPTOMATIC)

For patients in this category whose CAD risk (SCORE) is high, cardiac catheterization may be more appropriate
than noninvasive evaluation
Provided that CAD has not been excluded as the cause of LV dysfunction/ CHF by any of the following tests: MPI,
stress echo, coronary CTA or cardiac catheterization
PATIENTS WITH ABNORMAL EXERCISE TREADMILL TEST (PERFORMED WITHOUT IMAGING)
Abnormal findings on an exercise treadmill test include (chest pain, ST segment change, abnormal BP response or
complex ventricular arrhythmias)
PATIENTS WITH ABNORMAL FINDINGS ON CARDIAC CT / CORONARY CTA
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 coronary CTA

Note: If symptoms are typical of myocardial ischemia cardiac catheterization may be more appropriate than MPI
Asymptomatic patients who have not had MPI, stress echo or cardiac catheterization within the preceding
two (2) years:

Or
Or
72
Intermediate severity coronary stenosis coronary CTA

PATIENTS WITH ABNORMAL FINDINGS ON CARDIAC CATHETERIZATION
To determine flow limiting significance of intermediate coronary stenosis

MYOCARDIAL VIABILITY EVALUATION
MPI may be used to evaluate myocardial viability in patients who
have established coronary artery disease

And
have left ventricular systolic dysfunction

And
are candidates for revascularization

And
do not have evidence ov viability using other imaging modalities (for example: Stress Echo, MRI, PET)
PREOPERATIVE CARDIAC EVALUATION OF PATIENTS UNDERGOING NON-CARDIAC SURGERY
- This guideline applies to patients undergoing non-emergency surgery.
- It is assumed that those who require emergency surgery will undergo inpatient preoperative evaluation.
Patients with active cardiac conditions such as unstable coronary syndromes (unstable angina),
decompensated heart failure (NYHA function of class IV, worsening or new onset heart failure), significant
arrhythmias (third degree AV block Mobitz II AV block, uncontrolled supraventricular arrhythmia, symptomatic
ventricular arrhythmias, ventricular tachycardia) or severe stenotic valvular lesions. It is recommended that these
conditions be evaluated and managed per ACC/AHA guidelines prior to considering elective surgery. That
evaluation may include MPI.
Low-risk surgery (endoscopic procedures, superficial procedures, cataract surgery, breast surgery, ambulatory
surgery)
provided that there are no active cardiac conditions (as outlined above) MPI prior to low-risk surgery is considered
not medically necessary
Intermediate risk surgery (intraperitoneal and intrathoracic surgery, carotid endarterectomy, head and neck
surgery, orthopedic surgery, prostate surgery, gastric bypass surgery) or High-risk surgery (aortic and other major
vascular surgery, peripheral vascular surgery)
in patients who are unable to walk on a treadmill

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 (CHF)\

Or
diabetes mellitus
Or

Or
history of cerebrovascular disease (TIA, CVA or documented carotid stenosis requiring carotid
endarterectomy)
ABNORMAL EKG FINDINGS

Some patients have resting EKG findings which would render the interpretation of an exercise EKG test difficult or
impossible. In these situations patients who, in the absence of the EKG abnormality, would not meet approval
criteria for MPI, may be approved for MPI because exercise EKG testing without imaging would provide little clinically
useful data. Patients with the following resting EKG abnormalities are included this category:
73
Left bundle branch block

Or
Ventricular paced rhythm

Or
Left ventricular hypertrophy with repolarization abnormality

Or
Digoxin effect
Or
1 mm ST depression or more on a recent EKG (within the past 30 days)

Or
Pre-excitation syndromes (E.G. WPW syndrome)

UNABLE TO WALK ON A TREADMILL FOR REASONS OTHER THAN OBESITY
including but not limited to orthopedic impairment, claudication, neurological conditions, advanced lung
disease etc.
in these situations patients may not achieve an adequate exercise level to yield clinically useful information
pharmacological stress testing should be performed and therefore echo or nuclear imaging is appropriate.
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., OLeary 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
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
74
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/NonST-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
75
Nuclear Cardiology
Cardiac Blood Pool Imaging
Blood Pool Imaging includes MUGA (Multi-Gated Acquisition) &
First Pass Radionuclide Ventriculography
CPT CODES:
78472........Gated equilibrium; planar, single study, wall motion plus ejection fraction
78473........Gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction
78481........First pass technique; single study, wall motion study plus ejection fraction
78483........First pass technique; multiple studies, wall motion study plus ejection fraction
78494........Gated equilibrium: SPECT, at rest, wall motion study plus ejection fraction
78496........This code is an add-on code to be used in conjunction with 78472. As such, this code does not require
separate review
COMMONLY USED RADIOPHARMACEUTICALS:

Technetium-99m
This guideline does not supersede the enrollees health plan medical policy specific to cardiac blood pool imaging.
Primarily used to evaluate global and regional ventricular function and to determine ejection fraction(s)
May be used in the evaluation of intracardiac shunting or diastolic function
First-pass studies display initial transit of the radiotracer bolus passing through the cardiopulmonary and central
systemic circulations. Right and/or left ventricular function may be evaluated.
Equilibrium studies display gated data (MUGA) which is acquired over many cardiac cycles, using a blood pool
radiotracer. Both right and left ventricles may be evaluated
First pass studies should be acquired on a high count-rate camera in order that images have sufficient temporal
resolution. High count-rate cameras are not required for MUGA.
Studies may be performed at rest and/or during exercise.

MUGA studies are technically more difficult in patients with irregular heart rhythms. Imaging times may have to be
prolonged to acquire adequate data.
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.
COMMON DIAGNOSTIC INDICATIONS FOR CARDIAC BLOOD POOL IMAGING:

The following diagnostic indications for Cardiac Blood Pool Imaging are accompanied by pre-test considerations as well as supporting
clinical data and prerequisite information:
EVALUATION OF LEFT VENTRICULAR FUNCTION

Note: it is assumed that left ventricular function will be evaluated using a single imaging modality. Thus, if left
ventricular function has been evaluated recently by echocardiography reevaluation using blood pool imaging
is not necessary except in the situations outlined below
Initial evaluation of known or suspected heart failure (systolic or diastolic)

Or
Reevaluation of patients with known heart failure (systolic or diastolic) in a patient with the change in clinical
status
76
Nuclear Cardiology Blood Pool Imaging

Or
Reevaluation of LV function at 6 month intervals in patients who are within 1 year of diagnosis even if clinically
stable
Or
Reevaluation of asymptomatic, clinically stable patients with left ventricular systolic dysfunction (Left Ventricular
ejection fraction <55%) at yearly intervals.
Or
Baseline and serial reevaluation in patients undergoing, planning to undergo or who have undergone therapy
with cardiotoxic agents agents (examples including but not limited to some chemotherapeutic agents for cancer,
novantrone {mitoxanthone} for multiple sclerosis)
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 cardiac resynchronization therapy (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 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
77

transplantation
CORONARY ARTERY DISEASE (CAD)
Recent myocardial infarction (< 3 weeks) for initial assessment of LV function

- this study is usually done prior to discharge
- not required if left ventricular function has been assessed using another imaging modality
Or
Prior myocardial infarction for reevaluation of ventricular function during recovery phase (up to three months
following myocardial infarction)
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 (CRT)
For detection and localization of shunts {Ventricular Septal Defect (VSD), Atrial Septal Defect (ASD), Patent
Ductus Arteriosus (PDA), Anomalous Pulmonary Venous Drainage}
echocardiography is generally considered to be a preferable imaging modality in this clinical situation
For evaluation of RV and/or LV function in a patient with established complex congenital heart disease
VALVULAR HEART DISEASE
Established valvular heart disease in patients with new or worsening signs or symptoms
- in patients with suspected valvular heart disease echocardiography is the appropriate initial imaging modality
Or
Established moderate or severe valvular heart disease in patients who have not undergone evaluation of
ventricular
Or
function within the preceding year
Patients with severe asymptomatic aortic regurgitation to assist in optimal timing of aortic valve replacement
- rest and stress studies are appropriate in this clinical situation
Or
Evaluation of RV and/or LV function in patients who have undergone valve replacement or repair and who have
symptoms or signs suggestive of right or left ventricular dysfunction
echocardiography is generally considered to be preferable in this clinical situation in that it also facilitates
evaluation of valvular function and estimation of pulmonary artery pressure
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
78
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
79
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
This guideline does not supersede the enrollees health plan medical policy specific to infarct imaging
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
available studies (which include treadmill stress test, stress myocardial perfusion imaging, stress
COMMON DIAGNOSTIC INDICATIONS FOR INFARCT IMAGING:

The following diagnostic indications for Infarct Imaging are accompanied by pre-test considerations as well as supporting clinical
data and prerequisite information:
SUSPECTED ACUTE MYOCARDIAL INFARCTION, WHICH LIKELY OCCURRED WITHIN THE LAST 7 DAYS
Including interrogation of the following:

-
Negative (past expected peak) cardiac enzymes

Abnormal baseline ECG, due to prior myocardial infarction
DIFFERENTIATION OF SUBENDOCARDIAL (NON-Q-WAVE) INFARCTION VERSUS ISCHEMIA

POST-CARDIOVERSION
FOLLOWING SIGNIFICANT CHEST TRAUMA OR MAJOR SURGICAL PROCEDURE, WITH CHEST PAIN
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.
80
Nuclear Cardiology Infarct Imaging
3.
Zaret, Barry L. and Bellar, George A. Clinical Nuclear Cardiology. 3rd Edition. Philadelphia: Elsevier Mosby; 2005.
81
Cardiac Echocardiography
Stress Echocardiography (SE)
CPT CODES:
93350........Echocardiography, transthoracic during rest and cardiovascular stress test using treadmill, bicycle exer
and/or pharmacologically induced stress, with interpretation and report;
93351........Echocardiography, transthoracic during rest and cardiovascular stress test using treadmill, bicycle exer
and/or pharmacologically induced stress, with interpretation and report; including performance of
continuous electrocardiographic monitoring with physician supervision
93320........This code is an add-on code to be used in conjunction with 93350, 93351. As such, this code does not
require separate review
USES OF STRESS ECHOCARDIOGRAPHY (SE):

The primary use of SE is in the diagnosis or exclusion of obstructive Coronary Artery Disease (CAD).
SE is also used for risk stratification with established coronary artery disease.
SE may be used for assessment of myocardial viability in patients who have had myocardial infarction.
SE is occasionally used in the evaluation of valvular heart disease, and for the detection and management of
occult pulmonary hypertension.
This guideline does not supersede the enrollees health paln medical policy specific to stress echocardiography.
A recent EKG is strongly recommended, preferably within 7 days of request for Stress Echocardiogram. The
findings on the resting EKG may help to determine the need for imaging and may also show evidence of ischemia
at rest or interval myocardial infarction.
Unlike MPI, stress echocardiography does not expose the patient to ionizing radiation
Age, gender and the character of the chest pain provide useful predictors of CAD, as stratified in Table 1 below.
Table 1*: Pre-Test Probability of Coronary Artery Disease by Age, Gender and Symptoms.
Age (yr)
30-39
40-49
50-59
60-69
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.
Gender
Typical/Definite
Atypical/Probable
Non-Anginal
Angina Pectoris
Angina Pectoris
Chest Pain
Asymptomatic
Men
Intermediate
Intermediate
Low
Very Low
Women
Intermediate
Very Low
Very Low
Very Low
Men
High
Intermediate
Intermediate
Low
Women
Intermediate
Low
Very Low
Very Low
Men
High
Intermediate
Intermediate
Low
Women
Intermediate
Intermediate
Low
Very Low
Men
High
Intermediate
Intermediate
Low
Women
High
Intermediate
Intermediate
Low
Stress Echocardiography and Myocardial Perfusion Imaging (MPI) may provide useful information on Coronary
Heart Disease. Comparison data on Sensitivity and Specificity is provided in Table 2 below. Due to regional
82
Stress Echocardiography - SE
variation in technical expertise and interpretive proficiency, clinicians should use the diagnostic imaging modality that
has been proven most accurate in their practices.
Table 2**: Comparison of Non-Invasive Diagnostic Imaging
rd
** Reference for Table 2: Barry L. Zaret and George A. Bellar. Clinical Nuclear Cardiology. 3 Edition.
Philadelphia: Elsevier Mosby Publishers; 2005, page 539.
Nuclear Imaging
Stress Echo
Nuclear Imaging
Stress Echo
Sensitivity (%)
Sensitivity (%)
Specificity (%)
Specificity (%)
Exercise (7 studies)
83%
78%
83%
91%
Dobutamine (8 studies)
86%
80%
73%
86%
Adenosine (3 studies)
89%
63%
73%
86%
Dipyridamole (4 studies)
83%
68%
88%
89%
Several clinical indications listed for SE include standard methods of risk assessment such as the SCORE
(Systematic Coronary Risk Evaluation ). These risk calculation systems include consideration of the following
factors:
Age
Sex
Hypertension
Diabetes Mellitus
Cigarette smoking
Other coronary risk factors such as family history of premature CAD, coronary artery calcification, C
reactive protein levels, obesity etc. are not included in the standard methods of risk assessment but are
thought to contribute to coronary artery disease risk.
Selection of the optimal diagnostic work-up for evaluation or exclusion of coronary artery disease should be made
within the context of available studies (which include treadmill stress test, stress myocardial perfusion imaging,
stress echocardiography, cardiac PET imaging and invasive cardiac/coronary angiography), so that the resulting
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.
SE may be performed using either physical or pharmacologic stress. If physical stress is used, the choice rests
between treadmill exercise test and bicycle exercise test. While it is possible to acquire images during exercise in
patients undergoing bicycle exercise testing, image quality during treadmill exercise is suboptimal. In this situation,
the "stress" images are actually acquired immediately following peak exercise. Thus, the laboratory must be set up
in a manner that allows imaging to be completed within 45 to 60 seconds after peak exercise.
Some patients may not be suitable candidates for SE. Image quality is frequently suboptimal in morbidly obese
patients and in those with advanced lung disease. If image quality at rest is inadequate, the test should be canceled
and consideration given to an alternative imaging modality.
For patients who are unable to walk on a treadmill for non cardiac reasons (orthopedic limitations, claudication,
neurological conditions, advanced lung disease, etc) exercise stress testing is not an option. These patients will
require pharmacological testing with echo or nuclear imaging.
It is anticipated that the evaluation of patients with acute chest pain will occur in the emergency room or in an
inpatient setting and stress echo performed in these locations is not included in the AIM preauthorization program.
COMMON DIAGNOSTIC INDICATIONS FOR STRESS ECHOCARDIOGRAPHY:

The following diagnostic indications for stress echocardiography may be accompanied by pre-test considerations as well as
supporting clinical data and prerequisite information
SUSPECTED CORONARY ARTERY DISEASE IN ASYMPTOMATIC PATIENTS
Patients with high-risk of CAD (SCORE) who have not had evaluation of coronary artery disease (MPI, stress echo,
coronary CTA or cardiac catheterization) within the preceding two years
Or
Patients with moderate or high risk of CAD (SCORE) who have a high risk occupation that would endanger others in
the event of a myocardial infarction (for example: airline pilot, law-enforcement officer, firefighter, mass transit
operator, bus driver) who have not had evaluation of coronary artery disease (MPI, stress echo, coronary CTA or
83

cardiac catheterization) within the preceding two (2) years
Or
Patients with diseases/conditions with which coronary artery disease commonly coexists and who have not had
evaluation of coronary artery disease (MPI, stress echo, coronary CTA or cardiac catheterization) within the
preceding two (2) years:
diabetes mellitus
Or

Or

Or
Or
chronic renal insufficiency

Patients who have undergone cardiac transplantation and have had no evaluation for coronary artery disease
within the preceding one (1) year
SUSPECTED CORONARY ARTERY DISEASE IN SYMPTOMATIC PATIENTS
Chest pain
- with intermediate or high pretest probability of CAD (Table 1)
Or
with low pretest probability of CAD (table 1) and moderate or high risk of CAD (SCORE)
Or
with very low pretest probability of CAD and high risk of CAD (SCORE)
Atypical symptoms: shortness of breath (dyspnea), neck, jaw, arm, epigastric or back pain, sweating (diaphoresis).
- with moderate or high risk of CAD (SCORE)
Other symptoms; palpitation, dizziness, lightheadedness, syncope, near syncope, nausea, vomiting, anxiety,
weakness, fatigue etc
- with high risk of CAD (SCORE)

Patients with any cardiac symptom who have diseases/conditions with which coronary artery disease commonly
coexist such as:
diabetes mellitus
Or

Or

Or
Or
- chronic renal insufficiency or renal failure

Patients who have undergone cardiac transplantation
MPI, OR STRESS ECHO) IN PATIENTS WHO HAVE NO SYMPTOMS OR STABLE SYMPTOMS)
No evaluation of CAD (MPI, stress echo, coronary CTA or cardiac catheterization) within the preceding two (2)
years
Or
If the patient is diabetic, no evaluation of CAD (MPI, stress echo, coronary CTA or cardiac catheterization) within
84

MPI, OR STRESS ECHO) IN PATIENTS WHO HAVE NEW OR WORSENING SYMPTOMS
Note: if symptoms are typical of myocardial ischemia cardiac catheterization may be more appropriate than stress
echo
PATIENTS WITH NEW ONSET ARRHYTHMIAS (PATIENT CAN BE SYMPTOMATIC OR ASYMPTOMATIC)
Patients with ventricular tachycardia

Or
Patients with atrial fibrillation or flutter and high or moderate risk of CAD (SCORE)
Or
Patients with atrial fibrillation or flutter and established CAD

PATIENTS WITH NEW ONSET CONGESTIVE HEART FAILURE OR RECENTLY RECOGNIZED LEFT
VENTRICULAR DYSFUNCTION (PATIENT CAN BE SYMPTOMATIC OR ASYMPTOMATIC)
- This guideline applies to patients with suspected or established CAD
Provided that CAD has not been excluded as the cause of LV dysfunction/ CHF by any of the following tests: MPI,
stress echo, coronary CTA or cardiac catheterization
PATIENTS WITH ABNORMAL EXERCISE TREADMILL TEST (PERFORMED WITHOUT IMAGING)
- This guideline applies to patients with suspected or established CAD
Abnormal findings on an exercise treadmill test (chest pain, ST segment change, abnormal BP response or complex
ventricular arrhythmias)
PATIENTS WITH ABNORMAL FINDINGS ON CARDIAC CT / CORONARY CTA
Symptomatic Patients:

Or
Or
Intermediate severity coronary stenosis on coronary CTA

- if symptoms are typical of myocardial ischemia cardiac catheterization may be more appropriate than Stress Echo
Asymptomatic patients who have not had MPI, stress echo or cardiac catheterization within the preceding
two (2) years

Or
Or
Intermediate severity coronary stenosis coronary CTA

And
PATIENTS WITH ABNORMAL FINDINGS ON CARDIAC CATHETERIZATION
To determine flow limiting significance of intermediate coronary stenosis

MYOCARDIAL VIABILITY EVALUATION
MPI may be used to evaluate myocardial viability in patients who
have established coronary artery disease

And
85

have left ventricular systolic dysfunction
And
are candidates for revascularization

And
do not have evidence of viability using other imaging modalities (for example: MPI, MRI, PET)
Note: pharmacologic stress echocardiography with a drug such as dobutamine that increases myocardial contractility
is the preferred form
PREOPERATIVE CARDIAC EVALUATION OF PATIENTS UNDERGOING NON-CARDIAC SURGERY
- This guideline applies to patients undergoing non-emergency surgery.
- It is assumed that those who require emergency surgery will undergo inpatient preoperative evaluation.
Patients with active cardiac conditions such as unstable coronary syndromes (unstable angina),
decompensated heart failure (NYHA function of class IV, worsening or new onset heart failure), significant
arrhythmias (third degree AV block Mobitz II AV block, uncontrolled supraventricular arrhythmia, symptomatic
ventricular arrhythmias, ventricular tachycardia) or severe stenotic valvular lesions. It is recommended that these
conditions be evaluated and managed per ACC/AHA guidelines prior to considering elective surgery. That
evaluation may include Stress echo.
Low-risk surgery (endoscopic procedures, superficial procedures, cataract surgery, breast surgery, ambulatory
surgery)
provided that there are no active cardiac conditions (as outlined above) Stress Echo prior to low-risk surgery is
considered not medically necessary
Intermediate risk surgery (intraperitoneal and intrathoracic surgery, carotid endarterectomy, head and neck
surgery, orthopedic surgery, prostate surgery, gastric bypass surgery) or High-risk surgery (aortic and other major
vascular surgery, peripheral vascular surgery)
in patients who are unable to walk on a treadmill

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 (CHF)\

Or
diabetes mellitus
Or

Or
history of cerebrovascular disease (TIA, CVA or documented carotid stenosis requiring carotid
endarterectomy)
Mitral regurgitation
- Patients who have symptoms out of proportion to the degree of regurgitation documented on resting
echocardiography
Or
Patients with 3+ mitral regurgitation (or more) who are asymptomatic but who are undergoing evaluation for
potential mitral valve repair
AORTIC VALVE DISEASE
Patients who have apparently severe aortic stenosis and left ventricular systolic dysfunction in whom calculation of
the degree of stenosis may be affected by the low flow state
For timing of surgery in patients with moderate of severe aortic stenosis or regurgitation
86

PULMONARY HYPERTENSION
For evaluation or exclusion of exercise induced pulmonary hypertension

Or
For evaluation of right and/or left ventricular function during exercise in patients with established pulmonary
hypertension
HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY
For the evaluation of dynamic changes during exercise in patients with an established diagnosis of Hypertrophic
Obstructive Cardiomyopathy
ABNORMAL EKG FINDINGS
Some patients have resting EKG findings which would render the interpretation of an exercise EKG test difficult or
impossible. In these situations patients who, in the absence of the EKG abnormality, would not meet approval
criteria for MPI, may be approved for MPI because exercise EKG testing without imaging would provide little clinically
useful data. Patients with the following resting EKG abnormalities are included this category:

Or
Ventricular paced rhythm

Or
Left ventricular hypertrophy with repolarization abnormality

Or
Digoxin effect
Or
1 mm ST depression or more on a recent EKG (within the past 30 days)

Or
Pre-excitation syndromes (E.G. WPW syndrome)

UNABLE TO WALK ON A TREADMILL FOR REASONS OTHER THAN OBESITY
Including but not limited to orthopedic impairment, claudication, neurological conditions, advanced lung disease
etc.
In these situations patients may not achieve an adequate exercise level to yield clinically useful information
Pharmacological stress testing should be performed and therefore echo or nuclear imaging is appropriate.
1.
Pellikka, P et al. American Society of Echocardiography Recommendations for Performance, Interpretation, and Application of
Stress Echocardiography. J Am Soc Echocardiogr. 2007 Sep;20(9):1021-41
2.
Douglas P et al. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 Appropriateness Criteria for Stress Echocardiography.

J Am Coll Cardiol 2008;51:1127-47
3.
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
4.
Armstrong W., Zoghbi W. Stress Echocardiography-Current Methodology and Clinical Applications. J Am Coll Cardiol 2005;45:
1739-47
5.
Armstrong W. et al. ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography. J. Am. Coll.
Cardiol., Sep 2003; 42: 954 - 970
6.
American College of Cardiology Foundation. ACCF/ASNC Appropriateness Criteria for Single-Photon Emission Computed
Tomography Myocardial Pergusion Imaging (SPECT MPI). J Am Coll Cardiol 2005; 46(8): 1588-1605.
7.
Elhendy A., OLeary 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
8.
Fleischmann K., Hunink M., Kuntz K, et al. Exercise Echocardiography or Exercise SPECT Imaging? JAMA 1998;280:913-920
9.
Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA/ASNC Guideline Update for Exercise Testing: A Report of the American
87
College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing).2002
10. 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
11. 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
12. 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
13. 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
14. 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
15. 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
16. 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
17. Eagle K, et al. ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery.
www.acc.org/clinical/guidelines/perio/update/periupdate index.htm
18. Anderson J et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/NonST-Elevation
Myocardial Infarction. J Am Coll Cardiol, 2007; 50:1-157
19. 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
20. Mieres J, et al. Rule of Noninvasive Testing in the Clinical Evaluation of Women with Suspected Coronary Artery Disease.
Circulation. 2005; 111;682-696
88
Transesophageal Echocardiography
(TEE)
CPT CODES:
93312 .......TEE real-time with image documentation (2-D) (with or without M-mode recording)
93313........Placement of transesophageal probe only
93314........Image acquisition, interpretation and report only
93315........TEE for congenital cardiac anomalies
93316........Placement of transesophageal probe only
93317........Image acquisition, interpretation and report only
93320........This code is an add-on code to be used in conjunction with 93312, 93314, 93315, 93317. As such, this
code does not require separate review

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

The following diagnostic indications for TEE are accompanied by pre-test considerations as well as supporting clinical data and
IN PATIENTS WHO HAVE, OR ARE LIKELY TO HAVE SUBOPTIMAL TRANSTHORACIC IMAGING
When image quality is suboptimal such that the clinical question(s) prompting the TEE has/have not been
adequately answered
Or
When it is likely that transthoracic imaging will be suboptimal in the following situations:
- previous transthoracic echocardiograms were of suboptimal quality
- in patients with severe abnormalities of thoracic contour (Pectus deformities, severe kyphoscoliosis
- in patients who have recently had thoracic surgery where postoperative tenderness or the location of dressings
or incisions would preclude imaging from the usual transthoracic locations
following severe chest trauma

following extensive burns to the thorax
89
TEE
COMMON DIAGNOSTIC INDICATIONS FOR TEE:

IN PATIENTS WHOSE CLINICAL SITUATION SUGGESTS THAT TEE MAY BE A PREFERABLE TO
TRANSTHORACIC ECHOCARDIOGRAPHY AS AN INITIAL IMAGING TEST
In evaluation of suspected acute aortic pathology

To determine mechanism of valvular regurgitation and suitability for valve repair
Or
To diagnose/manage endocarditis with a moderate or high pretest probability (e.g. bacteremia, especially staph
bacteremia or fungemia)
Or
To diagnose/manage endocarditis involving prosthetic heart valves

Or
In evaluation of persistent fever in a patient with an intracardiac device

Or
In evaluation of a patient with atrial fibrillation/flutter to facilitate clinical decision-making with regards to
anticoagulation and/or cardioversion and/or radiofrequency ablation
Or
In evaluation for cardiovascular source of embolic event in a patient who has no history of atrial fibrillation/flutter
Or
In evaluation of a patient who has undergone surgical correction of complex congenital heart disease for the
exclusion of intracardiac thrombus
1.
2.
Douglas et al. ACC/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 Appropriateness Criteria for Transthoracic and

Transesophageal Echocardiography. J Am Coll Cardiol 2007
Chetlin M et al. ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography available at
www.acc.org
3.
Bonow R et al. ACC/AHA 2006 Guidelines for the Management of Patients with Valvular Heart Disease. J Am Coll Cardiol
2006; 48: e1-148
4.
Klein AL et al. Role of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation. J Am Coll
Cardiol, 2001; 37:691-704
5.
Willens HJ et al. Transesophageal Echocardiography in the Diagnosis of Diseases of the Thoracic Aorta. Part 1. Aortic
Dissection, Aortic Intramural Hematoma, and Penetrating Atherosclerotic Ulcer of the Aorta. Chest. 1999;116:1772-1779
90
Resting Transthoracic
Echocardiography
(TTE)
CPT CODES:
93303........Transthoracic echocardiography or congenital cardiac anomalies; complete
93304........Transthoracic echocardiography or congenital cardiac anomalies; follow-up or limited study
93306........Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording,
when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler
echocardiography
93303........Transthoracic echocardiography or congenital cardiac anomalies; complete
93307.Transthoracic echocardiography; complete, without spectral Doppler echocardiography, or color flow Doppler
echocardiography.
93308........Transthoracic echocardiography; complete, without spectral Doppler echocardiography, or color flow Doppler
echocardiography follow-up or limited study
93320........This code is an add-on code to be used in conjunction with 93303, 93304 93308. As such, this code does
not require separate review

Heart, proximal great vessels, pericardium
Advantages of transthoracic echocardiography:
No risk to the patient

Minimal patient discomfort
Widely available
Extremely portable
No exposure to ionizing radiation
Disadvantages of transthoracic echocardiography:
Image quality suboptimal in some patients

Less sensitive than transesophageal echocardiography in some clinical situations
Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to transthoracic
echocardiography
Transthoracic echocardiography should only be acquired on equipment which has the capability to perform Doppler
echocardiography (pulsed-wave and continuous wave with spectral display) and color flow velocity mapping.
91
TTE
COMMON DIAGNOSTIC INDICATIONS FOR TRANSTHORACIC ECHOCARDIOGRAPHY

The following diagnostic indications for Transthoracic Echocardiography are accompanied by pre-test considerations as well
as supporting clinical data and prerequisite information:
Valvular Heart Disease

SUSPECTED VALVULAR HEART DISEASE
Evaluation of cardiac murmurs when the diagnosis of valvular heart disease has not been established.
-
after the diagnosis of valvular heart disease has been established, follow the guidelines for the specific
valvular lesion (eg, established aortic stenosis)
Initial evaluation for mitral valve prolapse when signs or symptoms of mitral valve prolapse are present
Initial evaluation for bicuspid aortic valve when there is a family history (established diagnosis in a first-degree
relative
ESTABLISHED AORTIC STENOSIS OR PULMONIC STENOSIS
And
Changing symptoms or signs

Or
Reevaluation of asymptomatic patients with severe stenosis on three (3) occasions at six (6) monthly intervals
following initial diagnosis then annually
Or
Reevaluation of asymptomatic patients with moderate stenosis every two (2) years
Or
Reevaluation of asymptomatic patients with mild stenosis every three (3) years
Or
Assessment of changes in hemodynamic severity and left ventricular function in patients with known aortic stenosis
during pregnancy
ESTABLISHED AORTIC OR PULMONIC REGURGITATION
And
Changing symptoms or signs

Or
Reevaluation of asymptomatic patients with moderate or severe regurgitation annually

Or
Reevaluation of mild regurgitation every three (3) years

ESTABLISHED BICUSPID AORTIC VALVE
And
Changing signs or symptoms suggesting the development of aortic valve dysfunction

Or
Dilated aortic root (annual echocardiography is indicated)

ESTABLISHED MITRAL OR TRICUSPID STENOSIS
And
Changing signs or symptoms

Or
Reevaluation of asymptomatic patients with moderate or severe stenosis annually, or mild stenosis every three
(3) years
92
TTE

ESTABLISHED MITRAL OR TRICUSPID REGURGITATION
And

Or
Reevaluation in asymptomatic patients with moderate regurgitation annually

Or
Reevaluation in asymptomatic patients with severe regurgitation every six (6) months
ESTABLISHED MITRAL VALVE PROLAPSE
And

PROSTHETIC CARDIAC VALVES AND PATIENTS WHO HAVE UNDERGONE VALVE REPAIR
And
Initial postoperative evaluation of valve function (baseline study)

Or
Reevaluation, at two (2) yearly intervals, of asymptomatic adults (age 19 years or older) whose clinical
examination reveals no new or worsening findings suggesting dysfunction of the repaired or replaced valve.
Or
Annual reevaluation of asymptomatic non adult patients (less than or equal to 18 years old) whose clinical
examination reveals no new or worsening findings suggesting dysfunction of the repaired or replaced valve.
Or
Signs and/or symptoms suggesting dysfunction of the repaired or replaced valve.

EVALUATION OF PATIENTS WITH CONGENITAL HEART DISEASE
Evaluation of patients in whom congenital heart disease is suspected based on signs and symptoms (including
murmur, cyanosis, unexplained arterial desaturation, abnormal arterial pulses) abnormal EKG, abnormal chest xray
Or
Patients with chromosomal abnormalities or major extra cardiac abnormality associated with a high incidence of
coexisting cardiac abnormality
Or
Patients with established congenital heart disease (repaired or unrepaired) in whom there is a change in clinical
status
Or
Adult patients with a childhood history of congenital heart disease (with or without prior surgical repair) in whom
the original diagnosis is uncertain or when the precise nature of the structural abnormalities or hemodynamics is
unclear
Or
Bi-annual (every 2 years) echocardiography is appropriate in clinically stable patients age 7 years or older with
established complex congenital heart disease (with or without prior surgical repair) in whom surveillance for
ventricular function, AV valvular regurgitation or pulmonary artery pressure is important in clinical decision-making.
this does not include patients with successfully repaired patent ductus arteriosus, small atrial or ventricular
septal defects, bicuspid aortic valve or mitral valve prolapse
93
TTE

Or
Semiannual (every six months) echocardiography is appropriate in clinically stable patients age 6 years or younger
with established congenital heart disease (with or without prior surgical repair) in whom surveillance for ventricular
function, AV valvular regurgitation or pulmonary artery pressure is important in clinical decision-making.
Or
Initial outpatient postoperative evaluation of patients who have undergone surgical or catheter-based procedures
to correct congenital heart disease (within 60 days of the procedure).
Or
Non adult patients (less than or equal to 18 years old) who are undergoing staged surgical correction of congenital
heart disease.
Or
Patients in whom a decision to perform surgical or catherter based repair of congenital heart disease has been
made and in whom exhocardiography will be used to assist with procedural planning.
EVALUATION OF VENTRICULAR FUNCTION
Initial evaluation of hypertensive patients with suspected hypertensive heart disease

Or
Annual evaluation of non adult patients (less than or equal to 18 years old) with an established diagnosis of
hypertension
Or
Initial evaluation of known or suspected heart failure (systolic or diastolic)

Or
Evaluation of patients with resting EKG abnormalities (LBBB, RBBB with left anterior or posterior hemiblock, LVH,
RVH, Q waves suggestive of prior infarction)
Or
Reevaluation of asymptomatic and/or clinically stable patients with left ventricular systolic dysfunction (Left
Ventricular ejection fraction <55%) at yearly intervals
Or
Reevaluation of patients with known heart failure (systolic or diastolic) in a patient with the change in clinical status
Or
Baseline and serial reevaluation in patients undergoing, planning to undergo or who have undergone therapy with
cardiotoxic agents (examples including but not limited to some chemotherapeutic agents for cancer, novantrone
{mitoxanthone} for multiple
Or
Screening study for left ventricular dysfunction every two (2) years in clinically stable first-degree relatives of
patients with inherited cardiomyopath
Or
Evaluation of suspected restrictive, infiltrative or genetic cardiomyopathy

Or
Initial evaluation of known or suspected hypertrophic obstructive cardiomyopathy (HOCM)

Or
Reevaluation of known hypertrophic obstructive cardiomyopathy (HOCM) in a patient with a change in clinical
status to guide or evaluate therapy
Or
94
TTE

Annual reevaluation of asymptomatic patients with known hypertrophic obstructive cardiomyopathy (HOCM)
Or
Evaluation for dyssynchrony in a patient being considered for cardiac resynchronization therapy (CRT)
Or
Evaluation of a patient being treated with cardiac resynchronization therapy (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) and LV function has
not been evaluated by another modality since that testing was performed
Or
Where a significant discrepancy (more than would be expected for the range of error of the methods) exists in the
evaluation of left ventricular dysfunction by two other imaging modalities, echocardiography can be used as an
arbiter
Or
Pre and post cardiac transplant evaluation

Or
Echocardiography to evaluate right ventricular function in patients with disease likely to affect right ventricular
function including but not limited to chronic lung diseases and sleep apnea syndrome
EVALUATION OF PATIENTS WITH CARDIAC ARRHYTHMIAS
In patients who have sustained (lasting more than 30 seconds) or nonsustained (more than 3 beats but
terminating within 30 seconds) ventricular tachycardia
In patients who have sustained (lasting more than 30 seconds) or nonsustained (more than 3 beats but
terminating within 30 seconds) supraventricular tachycardia (including but not limited to atrial fibrillation, atrial
flutter, atrial tachycardia, AV node reentrant tachycardia etc)
It is not appropriate to perform echocardiography for evaluation of premature atrial or ventricular

depolarizations
EVALUATION OF INFECTIVE ENDOCARDITIS
Patients with suspected endocarditis

And
Positive blood cultures

Or
A new murmur on physical examination

Patients with established endocarditis
And
Virulent organism
Or
Severe hemodynamic lesion

Or
Aortic involvement
Or
Persistent bacteremia
95
TTE

Or
Clinical deterioration
Or
Post-treatment reevaluation of clinically stable patients within 6 months of completion of therapy

EVALUATION OF PATIENTS WITH KNOWN OR SUSPECTED CORONARY ARTERY DISEASE
Patients with known coronary artery disease

And
Recent (<3 weeks)myocardial infarction and hemodynamic instability or signs or symptoms suggesting a
complication of myocardial infarction including but not limited to acute mitral regurgitation, hypoxemia, abnormal
chest x-ray, acute ventricular septal rupture, free wall rupture/tamponade, shock, right ventricular involvement,
heart failure, or thrombus
this study is usually requested on an inpatient
Or
Recent myocardial infarction (< 3 weeks) for initial assessment of LV function

-
this study is usually done prior to discharge
not required if left ventricular function has been assessed using a different imaging modality
Or
Prior myocardial infarction for reevaluation of ventricular function during recovery phase {up to six (6) months
following myocardial infarction}
Or
Prior myocardial infarction for reevaluation of ventricular function after the recovery phase {more than six (6)
months} in patients who develop new symptoms or signs suggestive of heart failure
Or
Patients who have undergone revascularization may reasonably undergo echocardiography for evaluation of post
revascularization left ventricular function even if clinically stable.
Limited to one study within 12 months of revascularization (usually performed between 3 and 12 months
following a revascularization procedure)
Or
Annual echocardiography is appropriate in non adult patients (less than or equal to 18 years old) with an
established diagnosis of, aberrant or anomalous coronary origins or coronary artery fistula if the findings on
echocardiography will impact clinical decision making
Or
Echocardiography is appropriate in patients with an established diagnosis of Kawasaki disease at 6-8 weeks
following diagnosis in patients who have had coronary artery involvement at the time of diagnosis. If this study
shows no coronary artery abnormalities, no subsequent echocardiograms are necessary.
Or
Annual echocardiography is appropriate in patients with an established diagnosis of Kawasaki disease who have
small or medium sized coronary artery aneurysms
Or
Semiannual (every six months) echocardiography is appropriate in patients with an established diagnosis of
Kawasaki disease who have large or giant coronary artery aneurysms or coronary artery obstruction
Patients with suspected coronary artery disease

And
96
TTE

Chest pain
-
resting echocardiography may suggest a cause for the chest pain other than myocardial ischemia (mitral valve
prolapse) and is therefore a reasonable imaging procedure in patients with chest pain
If coronary artery disease is a likely diagnosis and if a resting echocardiogram cannot be performed while the
patient is experiencing the pain, a provocative test (exercise or pharmacological stress test with or without
imaging as appropriate) is preferable
- resting echocardiography has no role in screening for coronary artery disease in asymptomatic patients
Or
Echocardiography is appropriate in the evaluation of patients with suspected aberrant or anomalous coronary
origins or coronary artery fistula
Or
Echocardiography is appropriate in the evaluation of patients with suspected Kawasaki disease

EVALUATION OF SIGNS, SYMPTOMS OR ABNORMAL TESTING
Echocardiography is appropriate in the evaluation of chest pain, dyspnea, lightheadedness, syncope, transient
ischemic attack (TIA) or cerebrovascular attack (CVA)
Or
echocardiography is appropriate in the evaluation of a newly recognized murmur suggesting structural heart
disease (valvular, congenital etc)
Or
Echocardiography is appropriate in the evaluation of patients who are hemodynamically unstable or hypotensive
for unknown reasons
Or
Echocardiography is appropriate in further evaluation of abnormal results from other testing which suggests
underlying cardiac disease {abnormal chest X ray suggesting cardiac chamber enlargement, valvular or congenital
heart disease or congestive heart failure, abnormal EKG suggesting chamber hypertrophy, valvular or congenital
heart disease or abnormal laboratory results suggesting congestive heart failure such as elevated B-type
natriuretic peptide (BNP).
When other cardiac testing raises concerns of underlying coronary artery disease, provocative testing is
recommended over resting echocardiography
Or
Echocardiography is appropriate in the evaluation of respiratory failure of unknown cause

Or
Echocardiography is appropriate annually in the evaluation of patients with syndromes which place them at
increased risk for the development of acquired myocardial or aortic diseases (for example, Marfan Syndrome,
Ehlers Danlos Syndrome, Turner Syndrome, etc)
Or
Echocardiography is appropriate in the evaluation of suspected acute rheumatic fever

EVALUATION OF PATIENTS WITH PULMONARY EMBOLUS
In patients with known or suspected acute pulmonary embolus, echocardiography is useful in guiding initial
decision making (thrombectomy, thrombolysis)
echocardiography is not indicated in the initial evaluation of a patient with suspected pulmonary embolism in
order to establish the diagnosis
Or
In patients who have had a pulmonary embolus, echocardiography may be performed to evaluate right ventricular
97
TTE

function. If right ventricular function is abnormal, repeated studies may be necessary
EVALUATION OF PATIENTS WITH PULMONARY HYPERTENSION
Echocardiography is indicated for evaluation of suspected pulmonary hypertension

Or
Echocardiography is indicated in follow-up of pulmonary arterial pressures in patients with pulmonary hypertension
to evaluate response to treatment
Or
Echocardiography may be performed at 2 yearly intervals in asymptomatic adults (age 19 years or older) with an
established diagnosis of pulmonary hypertension
Or
Echocardiography may be performed annually in asymptomatic non adult patients (less than or equal to 18 years
old) with an established diagnosis of pulmonary hypertension
Echocardiography may be performed to evaluate signs or symptoms which may be attributable to worsened
pulmonary hypertension
EVALUATION OF AORTIC DISEASE
Echocardiography is indicated in the preoperative or postoperative evaluation of pathology of the ascending aorta
(aneurysm/dissection) although transesophageal echocardiography (TEE) is often preferable in this situation
Annual echocardiographic evaluation is usually sufficient in clinically stable patients but more frequent testing
may be appropriate in some situations (e.g. in longitudinal follow-up of large or enlarging thoracic aneurysms,
in follow-up of recently diagnosed thoracic aneurysms until stability is established)
Or
Echocardiography may be performed annually in patients with other disease entities which predispose them to
diseases of the aorta including but not limited to Marfan syndrome, Ehlers-Danlos syndrome and Familial Aortic
Dilation
EVALUATION OF PERICARDIAL DISEASES
Echocardiography is indicated in the evaluation of pericardial conditions including but not limited to pericardial
effusion, pericardial mass, constrictive pericarditis, effusive-constrictive conditions, patients post cardiac surgery or
suspected pericardial tamponade.
EVALUATION OF CARDIAC MASSES OR CARDIAC SOURCE OF EMBOLUS
Echocardiography is indicated in the diagnosis or exclusion of a cardiac source of embolus in a patient who has
had or appears to have had a systemic embolic event (although transesophageal echocardiography (TEE) is often
preferable in this situation).
Echocardiography is indicated in the pre and post treatment evaluation of cardiac masses (tumor or thrombus).
-
Annual echocardiographic evaluation is usually sufficient in clinically stable patients with cardiac masses/
(tumors/thrombus) but more frequent testing may be appropriate in some situations (e.g. in longitudinal followup of enlarging masses , or , in followup of recently diagnosed masses until stability is established)
1.
Douglas et al. ACC/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 Appropriateness Criteria for Transthoracic and

Transesophageal Echocardiography. J Am Coll Cardiol 2007
2.
Chetlin M et al. ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography available at:
www.acc.org
3.
Bonow R et al. ACC/AHA 2006 Guidelines for the Management of Patients with Valvular Heart Disease. J Am Coll Cardiol
2006; 48: e1-148
98
TTE
4.
Zoghbi W et al Recommendations for Evaluation of the Severity of Native Valvular Regurgitation with Two-dimensional and
Doppler Echocardiography. J Am Soc Echocardiogr 2003;16:777-802
5.
Otto C. Valvular Aortic Stenosis. Disease Severity and timing of Intervention. J Am Coll Cardiol 2006;47:2141-51
6.
Newberger JW et al. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease A Statement for Health
Professionals From the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular
Disease in the Young, American Heart Association Endorsed by the American Academy of Pediatrics. Circulation
2004;110:2747-2771
Computerized Tomography
Cardiac (Structure)
CPT CODES:
75572.Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology
(including 3-D image postprocessing, assessment of cardiac function, and evaluation of venous structures if
performed)
75573..Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in
the setting of congenital heart disease (including 3-D postprocessing, assessment of left ventricular cardiac
function, right ventricular structure and function and evaluation of venous structures, if performed)

Heart and great vessels within the thorax
Advantages of Cardiac CT
Rapidly acquired exams, with excellent anatomic detail afforded by most multidetector CT scanners with 16 or
more active detector rows.
Disadvantages of Cardiac CT include:
-
Potential complications from use of intravascular iodinated contrast administration (see biosafety issues, below)
Exposure to ionizing radiation
Potential factors that may limit the image quality during acquisition of Cardiac CT such as:
1. uncontrolled atrial or ventricular arrhythmias
2. inability to image at a desired heart rate, which may occur despite beta blocker administration
3. 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)
4. not a suitable imaging modality for morbidly obese patients (BMI > 40)
5. because of the radiation exposure issues careful consideration should be given to other imaging
modalities in pregnant women and children
Biosafety Issues:
Ordering and imaging providers are responsible for considering safety issues prior to the CTA exam. One of the
individuals with renal impairment, who are at greater risk for contrast-induced nephropathy. In addition, radiation
safety issues including cumulative exposure to ionizing radiation should be considered.
Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to cardiac CT structure and
coronary CTA
This guideline does not apply to coronary CT angiography (CCTA)

This guideline does not apply to Cardiac CT for quantitation of coronary artery calcification
Selection of the optimal diagnostic work-up for cardiac evaluation should be made within the context of other
available studies (which include transthoracic and transesophageal echocardiographyand cardiac MRI,), so that the
There are uncommon circumstances when both Cardiac CT and Cardiac MRI should be ordered for the same
clinical presentation. The specific rationale must be delineated at the time of request.
In general, follow-up Cardiac CT exams should be performed only when there is a clinical change, with new signs or
99
CT Cardiac (Structure)
COMMON DIAGNOSTIC INDICATIONS FOR CARDIAC CT:

The following diagnostic indications for Cardiac CT are accompanied by pre-test considerations as well as supporting clinical
nondiagnostic
Or
For further evaluation of complex congenital heart disease in patients who have undergone echocardiography
Or
Or
For evaluation of complex congenital heart disease in patients who have new or worsening symptoms and/or a
change in physical examination
Or
Or
cardiac MRI or cardiac CT within the preceding year
Cardiac MRI or transesophageal echocardiography may be preferable to cardiac CT in order to avoid radiation
exposure
INTRA-CARDIAC AND PARA-CARDIAC MASSES AND TUMORS
In patients with a suspected cardiac or para-cardiac mass (thrombus, tumor, etc.) suggested by transthoracic
echocardiography, transesophageal echocardiography, blood pool imaging or contrast ventriculography who have
not undergone cardiac CT or cardiac MRI within the preceding 60 days
Or
In patients with established cardiac or para-cardiac mass (thrombus, tumor, etc.) who are clinically unstable
Or
In patients with established cardiac or para-cardiac mass (thrombus, tumor, etc.) who are clinically stable and have
not undergone cardiac CT or cardiac MRI within the preceding year
Or
In patients with established cardiac or para-cardiac mass (thrombus, tumor, etc.) who have undergone treatment
(chemotherapy, radiation therapy, thrombolysis, anticoagulation or surgery) within the preceding year and have not
had cardiac CT or cardiac MRI within the preceding 60 days
CARDIAC ANEURYSM AND PSEUDOANEURYSM

Or

Or
In patients with suspected pericardial effusion who have undergone echocardiography deemed to be technically
suboptimal in evaluation of the effusion
100
COMMON DIAGNOSTIC INDICATIONS FOR CARDIAC CT:

Or
Or
Or
Or

- Cardiac CT for these indications requires referral from a cardiologist, electrophysiologist or cardiothoracic
surgeon
preceding 60 days
Or
Or
Or

Or
Or
planning)
Or
Or
In patients who have sustained blunt chest trauma, penetrating aortic trauma or iatrogenic trauma as a result of
aortic instrumentation.
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.
4.
Goo HWG, Park I-S, Ko JKK, et al. CT of Congenital Heart Disease: Normal Anatomy and Typical Pathologic Conditions.
101
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.
102
Computerized Tomographic
Angiographic
Coronary Arteries (CCTA)
CPT CODES:
75574. Computed tomographic angiography, heart, coronary arteries and bypass grafts (where present), with
contrast material, including 3-D image postprocessing (including evaluation of cardiac structure and
morphology, assessment of cardiac function, and evaluation of venous structures, if performed)

Coronary Artery Imaging: Coverage may vary, depending on the specific clinical indication as well as prior history
of coronary artery bypass graft placement.
Advantages of CTA:
Advantages of 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 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 CT/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. CCTA images the coronary arteries directly. Therefore the information provided is anatomical. The
presence coronary stenosis on CCTA (particularly if deemed to be of intermediate severity) does not
establish that the lesion has flow limiting significance. Thus, following abnormal CCTA, functional testing
may be required to assist in clinical decision-making.
Biosafety Issues:
Ordering and imaging providers are responsible for considering safety issues prior to the CCTA exam. One of the
individuals with renal impairment, who are at greater risk for contrast-induced nephropathy. In addition, radiation
safety issues including cumulative exposure to ionizing radiation should be considered.
Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to cardiac CCTA
CCTA exams are not covered by most healthcare insurers as a screening study, in the absence of signs, symptoms
or known disease.
103
CCTA - Coronary Artery
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.
In general, follow-up CCTA exams should be performed only when there is a clinical change, with new signs or
This guideline does not apply to cardiac CT for quantitation of coronary artery calcification.
Several clinical indications listed for CCTA 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
Hypertension
COMMON DIAGNOSTIC INDICATIONS FOR CCTA:

The following diagnostic indications for CCTA are accompanied by pre-test considerations as well as supporting clinical data
CONGENITAL CORONARY ARTERY ANOMALIES
For evaluation of suspected congenital anomalies of the coronary arteries

CONGESTIVE HEART FAILURE/CARDIOMYOPATHY
For exclusion of coronary artery disease in patients with low or moderate Coronary Heart Disease Risk (using
standard methods of risk assessment, such as the SCORE risk calculation) in whom coronary artery disease has
not been excluded as the etiology of the cardiomyopathy
patients with high Coronary Heart Disease Risk should undergo cardiac catheterization
Or
For coronary vein mapping patients with cardiomyopathy for whom cardiac resynchronization therapy (CRT) is
planned
EVALUATION OF PATIENTS WITH PRIOR ABNORMAL CARDIAC TESTING (MPI OR STRESS ECHO)
Patients with abnormal MPI or stress echo within the preceding 60 days suspected to be false positive on the basis
of low Coronary Heart
calculation).
Disease Risk (using standard methods of risk assessment such as the SCORE risk
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 within the preceding 60 days 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.
CORONARY ARTERY DISEASE (SYMPTOMATIC OR ASYMPTOMATIC):
Further evaluation of patients with low Coronary Heart Disease Risk (using standard methods of risk assessment
such as the SCORE risk calculation) who have had abnormal stress echocardiogram or myocardial perfusion
imaging thought to be a false positive result
104
CCTA - Coronary Artery
COMMON DIAGNOSTIC INDICATIONS FOR CCTA:

Or
Further evaluation of patients with low or moderate Coronary Heart Disease Risk (using standard methods of risk
assessment such as the SCORE risk calculation) who have had equivocal stress echocardiogram or myocardial
perfusion imaging.
Or
Noninvasive coronary arterial mapping (including internal mammary artery) in patients with established coronary
artery disease undergoing repeat surgical revascularization
Or
Patients at low or intermediate coronary heart disease risk (using standard methods of risk assessment, such as the
SCORE risk calculation) being evaluated for non-coronary artery cardiac surgery (including valvular and ascending
aortic surgery) to avoid an invasive angiogram, where all the necessary preoperative information can be obtained
using cardiac CT
1.

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.
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.
4.
5.
Hoffmann U, Ferencik M, Cury R et al. Coronary CT Angiography. J Nucl Med 2006; 47:797-806
6.
DiCarli MF. CT coronary angiography: where does it fit? J Nucl Med. 2006;47:13971399.
7.
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
8.
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
9.
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
105
Cardiac Computerized Tomography

for Quantitative Evaluation of
Coronary Calcification
CPT CODES:
75571.Computed tomography, heart, without contrast material, with quantitative evaluation of coronary artery
calcium

Coronary Artery Imaging:
Advantages of Cardiac CT for quantitative evaluation of coronary artery calcification.
-
Rapidly acquired exams.

Coronary artery calcification has been shown to correlate with the presence of atheromatous coronary artery
disease
Disadvantages of Cardiac CT for quantitative evaluation of coronary artery calcification.
Exposure to ionizing radiation

No role in the evaluation of patients with symptoms potentially due to coronary artery disease
Not clear that risk stratification data provided by quantitative evaluation of coronary artery calcification impacts
patient outcomes
Biosafety Issues:
Ordering and imaging providers are responsible for considering safety issues prior to performing quantitative
evaluation of coronary artery calcification
Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to cardiac CT for quantitative
evaluation of coronary artery calcification
Cardiac CT for quantitative evaluation of coronary artery calcification is not covered by most healthcare insurers as a
screening study
This guideline pertains to cardiac CT for quantitative evaluation of coronary artery calcification using either Electron
Beam CT (EBCT) or Multi-Detector CT (MDCT)
This guideline does not apply to coronary CT angiography (CCTA)

This guideline does not apply to cardiac CT with contrast for evaluation of cardiac structure and function
COMMON DIAGNOSTIC INDICATIONS FOR CARDIAC CT FOR QUANTITATIVE EVALUATION

OF CORONARY ARTERY CALCIFICATION:
The use of Cardiac CT for quantitative evaluation of coronary artery calcification has not been conclusively shown to
impact patient outcomes and is therefore considered to be not medically necessary in all clinical situations.
1.

106
CT Cardiac (Quantitative Evaluation of Coronary Calcification)

2.
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
107

Cardiac
CPT CODES:
75557........Cardiac MRI for morphology and function, without contrast material
75559........Cardiac MRI for morphology and function, without contrast material, with stress imaging
75561........Cardiac MRI for morphology and function, without contrast material, followed by contrast material
75563. Cardiac MRI for morphology and function, without contrast material, followed by contrast material with
stress imaging
75565. This code is an add-on code to be used in conjunction with 75557, 75559, 75561 and 75563. As such, this
CODING CONSIDERATIONS:
Only one procedure in the series 75557-75563 is appropriately reported per session. This code series is not to be used
to report cardiac MRA (see unlisted code 76598)
-
Gating Issues:
- As with other cardiac imaging modalities, the acquisition of images is frequently gated to the electrocardiogram.
- Thus, in patients with irregular heart rhythms, image quality may be suboptimal.
- Patients with claustrophobia may need to be premedicated in order to tolerate the imaging procedure. Rarely
patients with severe claustrophobia will not be suitable candidates for imaging
Biosafety Issues:
Contrast utilization is at the discretion of the ordering and imaging providers

Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to cardiac MRI
108
MRI - Cardiac
symptoms.
COMMON DIAGNOSTIC INDICATIONS FOR CARDIAC MRI:

The following diagnostic indications for Cardiac MRI are accompanied by pre-test
considerations as well as supporting clinical data and prerequisite information:
CORONARY ARTERY DISEASE

Patients who have had a myocardial infarction
To assess viability of the infarcted myocardium utilizing delayed hyperenhancement (contrast studies) when other
studies (myocardial perfusion imaging or stress echocardiography) have yielded equivocal or indeterminate results
Or
To assess LV function post myocardial infarction when there is discordant information from other studies or when
other studies are technically suboptimal
Or
To assess mitral valve regurgitation post-myocardial infarction when echocardiography is technically suboptimal.
Or
To assess ventricular septal defects post-myocardial infarction when echocardiography is technically suboptimal.
Or
To delineate pericardial effusions associated with acute myocardial infarction when echocardiography is technically
suboptimal.
Patients with suspected coronary artery disease
For evaluation of patients with suspected congenital coronary anomalies

MYOCARDITIS
For the evaluation of patients with suspected myocarditis
Or
For followup evaluation LV function of patients with an established diagnosis of myocarditis
And
Technically suboptimal transthoracic echocardiogram
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 Obstructive Cardiomyopathy (HOCM)
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 (CRT) is
planned
CARDIAC ANEURYSM OR PSEUDOANEURYSM
109
MRI - Cardiac

nondiagnostic
Or
For further evaluation of complex congenital heart disease in patients who have undergone echocardiography
Or
Or
For evaluation of complex congenital heart disease in patients who have new or worsening symptoms and/or a
change in physical examination
Or
Or
cardiac CT or cardiac MRI within the preceding year
Following inconclusive echocardiography or when echocardiography is not feasible

Or
When moderate or severe valvular disease diagnosed using other imaging modalities requires further definition
and that information is likely to affect subsequent management of the patient
- to assess valvular lesions and measure regurgitant volume, regurgitant fraction, ejection fraction and ventricular
volumes
- to help determine the timing for valvular surgery
INTRA-CARDIAC AND PARA-CARDIAC MASSES AND TUMORS
In patients with a suspected cardiac or para-cardiac mass (thrombus, tumor, etc.) suggested by transthoracic
echocardiography, transesophageal echocardiography, blood pool imaging or contrast ventriculography who have
not undergone cardiac MRI or cardiac CT within the preceding 60 days
Or
In patients with established cardiac or para-cardiac mass (thrombus, tumor, etc.) who are clinically unstable
Or
In patients with established cardiac or para-cardiac mass (thrombus, tumor, etc.) who are clinically stable and have
not undergone cardiac MRI or cardiac CT within the preceding year
Or
In patients with established cardiac or para-cardiac mass (thrombus, tumor, etc.) who have undergone treatment
(chemotherapy, radiation therapy, thrombolysis, anticoagulation or surgery) within the preceding year and have not
had cardiac MRI or cardiac CT within the preceding 60 days.
Or
Or
Or

- Cardiac MRI for these indications requires referral from a cardiologist, electrophysiologist or cardiothoracic
surgeon
110
MRI - Cardiac


Or

Or
Or
EVALUATION OF THE THORACIC AORTA - ANEURYSM AND DISSECTION:
preceding 60 days
Or
Or
Or

Or
Or
planning)
Or
Or
In patients who have sustained blunt chest trauma, penetrating aortic trauma or iatrogenic trauma as a result of
aortic instrumentation.
1.

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.
111
MRI - Cardiac
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,
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. Rienmller R, Grll 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
112

Myocardial Imaging
CPT CODES:
78491.PET myocardial perfusion, single study
78492.PET myocardial perfusion, multiple studies
78459.PET myocardial, metabolic evaluation
COMMONLY USED RADIOPHARMACEUTICALS

Ammonia (13NH3)
Rubidium Chloride (82 RbCl)
2-(18F) FLURO-2DEOXY-D-GLUCOSE (FDG)
IMAGING CONSIDERATIONS
This guideline does not supersede the enrollees 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 occasionally be appropriate in the evaluation of myocardial
pathologic processes other than coronary artery disease.
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
available modalities (which include treadmill stress test, stress myocardial perfusion imaging, stress
REQUIREMENTS FOR MYOCARDIAL PET IMAGING:

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
myocardium.
113
Myocardial Imaging - PET
COMMON DIAGNOSTIC INDICATIONS FOR CARDIAC PET:

The following diagnostic indications for Cardiac PET are accompanied by pre-test considerations as well as supporting clinical data
PERFUSION PET IMAGING FOR 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 moderate or high risk of coronary artery
disease.
PERFUSION PET IMAGING FOR PATIENTS WHO ARE < 65 YRS OLD AND HAVE BMI <40:
Further evaluation of patients who have had an equivocal nuclear stress test (MPI) or stress echo within the past 60
days
METABOLIC PET IMAGING FOR EVALUATION OF MYOCARDIAL VIABILITY WHEN ALL FOUR OF THE
FOLLOWING CONDITIONS ARE MET:
The patient has established coronary artery disease

And
Left ventricular systolic dysfunction

And
Viability status is not defined by other testing

And
Revascularization is being considered

PERFUSION PET IMAGING AND / OR METABOLIC PET IMAGING
May be considered in the evaluation of some myopathic processes excluding coronary artery disease (for example;
sarcoidosis)
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
114

Abdomen
CPT CODES:
74150........CT Abdomen; without contrast
74160........CT Abdomen; with contrast
74170........CT Abdomen; without contrast, followed by re-imaging with contrast

Diaphragmatic Dome to Iliac Crests
CT of the abdomen generally includes imaging of the following anatomic structures:
- Liver and Biliary Tract, including the Gallbladder
- Pancreas
- Gastrointestinal tract
- Spleen
- Kidneys
- Adrenal Glands
- Abdominal Aorta
- Inferior Vena Cava
- Abdominal Lymph Nodes
- Other Retroperitoneal Structures
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 7415074170 with 0066T or 0067T.
115
CT - Abdomen
COMMON DIAGNOSTIC INDICATIONS FOR ABDOMINAL CT:

The following diagnostic indications for Abdominal CT are accompanied by pre-test considerations as well as supporting clinical data and
General Abdominal CT Indications

Additional Hepatobiliary Indications
Additional Pancreatic Indications
Additional Gastrointestinal Indications
Additional Genitourinary Indications
Additional Splenic Indications
Additional Vascular Indications
General Abdominal CT Indications:

ABDOMINAL PAIN UNEXPLAINED BY CLINICAL FINDINGS, INCLUDING 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; age pediatric versus
adult patient).
The following studies represent alternative imaging for abdominopelvic 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 for evaluation of the Gallbladder and Biliary Tract
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
Barium Examination or Endoscopy: For symptoms related to the gastrointestinal tract, such as epigastric pain
secondary to peptic ulcer disease
In many other circumstances, abdominal CT may be indicated for evaluation of unexplained abdominal pain.
ABNORMAL FINDINGS ON OTHER IMAGING EXAMS THAT REQUIRE FURTHER EVALUATION
For example, abdominal radiographs demonstrating abnormal calcifications suspicious for urinary tract calculus
disease
ASCITES
Following preliminary evaluation on an Abdominal Ultrasound

CONGENITAL ANOMALY
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

HERNIA, WITH SUSPECTED COMPLICATIONS OR PRE-SURGICAL PLANNING
Suspected complications of an abdominal hernia, which include incarceration, intestinal strangulation and gangrene
Including but not limited to the following types of hernia:
-
Incisional
Internal
Spigelian (through semilunar line, lateral to rectus abdominis muscle)
116
CT - Abdomen

-
Ventral

- Abscess
- Diffuse Inflammation / Phlegmon
- Fistula
DIFFUSE, UNEXPLAINED LOWER EXTREMITY EDEMA
Advanced imaging may be used to exclude an occult pelvic tumor or lesion causing mass effect, not identified by
pelvic ultrasound, as the cause of vascular compression and resultant lower extremity edema
LYMPHADENOPATHY
For initial detection and follow-up

PALPABLE ABDOMINAL MASS
POST-OPERATIVE EVALUATION FOR COMPLICATIONS
For suspected or known operative complications, particularly during the initial 6-8 weeks following open or
laparoscopic abdomino-pelvic surgery
PRE-OPERATIVE PLANNING FOR BARIATRIC SURGERY
RETROPERITONEAL ABNORMALITY FIBROSIS, INFLAMMATION AND NEOPLASM
TRAUMA
Following significant blunt or penetrating injury to the Abdomen and Pelvis

TUMOR EVALUATION: PRIMARY ABDOMINAL OR PELVIC NEOPLASM
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.
TUMOR EVALUATION: METASTATIC DISEASE
For diagnosis
Initial staging
Periodic follow-up after treatment
May involve the following anatomic structures:
Adrenal Glands
Biliary Tract
Kidneys
Liver
Lymph Nodes
Other abdominal and retroperitoneal structures
Pancreas
Spleen
117
CT - Abdomen

-
Stomach, Small Intestines and Colo-rectum
UNEXPLAINED WEIGHT LOSS SIGNIFICANT WEIGHT LOSS EXCEEDING 10% OF DESIRABLE BODY WEIGHT,
OVER SHORT TIME INTERVAL
Additional Hepatobiliary Indications:

ELEVATED LIVER TRANSAMINASES:
Including alanine transaminase (ALT) and aspartate transaminase (AST)

Following an abnormal or inconclusive Abdominal Ultrasound
In patients on medications known to cause liver transaminase elevation, such as statins for hyperlipidemia,
acetaminophen, non-steroidal anti-inflammatory drugs, Dilantin, protease inhibitors and sulfonamides. These
medications should be stopped, whenever possible, and liver chemistries repeated, before performing advanced
imaging.
Other causes for elevated liver transaminases include excessive alcohol intake, cirrhosis, hepatitis, hepatic
steatosis as well as other hepatic and non-hepatic disorders. Consider additional diagnostic labs such as hepatitis
2
panel and serum alpha fetoprotein, as appropriate.
CIRRHOSIS AND EVALUATION FOR HEPATOCELLULAR CARCINOMA
FOCAL LIVER LESION CHARACTERIZATION
Complex or solid, including but not limited to:

5
Focal Nodular Hyperplasia

4
- Hemangioma
6
- Hepatic Adenoma
- Other focal pathologic abnormalities in the liver
-
JAUNDICE
With abnormal liver function tests (transaminases) and unexplained icterus, following an Abdominal Ultrasound
CT imaging used to evaluate for diffuse or multifocal parenchymal liver disease as well as biliary obstruction
HEPATOMEGALY
For clinically suspected or worsening hepatic enlargement
Additional Pancreatic Indications:

ACUTE PANCREATITIS, WITH SUSPECTED COMPLICATIONS INCLUDING PANCREATIC NECROSIS, ABSCESS,
8
PSEUDOCYST(S) AND/OR PERI-PANCREATIC EFFUSIONS:
Note that patients with mild acute, uncomplicated pancreatitis usually do not require cross-sectional imaging, aside
from Ultrasound identification of gallstones and/or biliary ductal calculi, as a potential cause.
PANCREATIC PSEUDOCYST
With prior history of pancreatitis or pancreatic trauma

PANCREATIC MASS
Additional Gastrointestinal Indications:

APPENDICITIS
APPENDICEAL OR PERI-APPENDICEAL MASS UNEXPLAINED ON PHYSICAL EXAM AND OTHER IMAGING

STUDIES
BOWEL OBSTRUCTION OF UNKNOWN ETIOLOGY
When the results will affect patient management decisions

118
CT - Abdomen

ENTERITIS AND/OR COLITIS
DIVERTICULITIS
10
11-12
INFLAMMATORY BOWEL DISEASE (IBD)

13
Crohns Disease
- Ulcerative Colitis
-
For suspected IBD, following endoscopic and/or barium examination

For follow-up of known IBD, with new signs/symptoms suggesting exacerbation
ISCHEMIC BOWEL
14
Additional Genitourinary Indications:

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
PERSISTENT, UNEXPLAINED HEMATURIA
Consider obtaining urine culture and/or renal ultrasound, prior to advanced imaging
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
URINARY TRACT CALCULUS DISEASE
16
UNDESCENDED (CRYPTORCHID) TESTICLE
Following attempted localization with Ultrasound
Additional Splenic Indications:

INDETERMINATE SPLENIC LESION ON PRIOR IMAGING, SUCH AS ULTRASOUND
SPLENIC PARENCHYMAL, SUBCAPSULAR OR PERI-SPLENIC HEMATOMA
SPLENOMEGALY
For clinically suspected or worsening splenic enlargement
Additional Vascular Abnormalities:

ANEURYSM OF ABDOMINAL AORTA OR BRANCH VESSEL
For initial diagnosis, particularly in obese patients

For follow-up imaging may be performed with Ultrasound in non-surgical and non-obese patients, who are
asymptomatic and have aneurysms < 5 cm in diameter
119
CT - Abdomen

For pre-operative assessment or prior to percutaneous endovascular stent graft placement
For post-operative surveillance
For suspected complication of an aneurysm, such as aneurismal rupture or infection requiring urgent imaging
AORTIC DISSECTION
May evaluate with either CT or CTA

-
Usually results from subdiaphragmatic extension of a Thoracic Aortic Dissection
ENDOVASCULAR STENT GRAFT PLACEMENT FOR ABDOMINAL AORTIC ANEURYSM
17-19

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
THROMBOSIS IN THE SYSTEMIC AND PORTAL VENOUS CIRCULATIONS
May follow initial evaluation with Doppler Ultrasound
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;21:877894.
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;94:31103121.
12. Ferzoco, LB., Raptopoulos, V., Silen, W., Acute Diverticulitis. N Engl J Med 1998;338:1521-1526.
13. Hanauer SB, Sandborn W. Management of Crohns Disease in Adults. The American Journal of Gastroenterology 2001;96:635643
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
120
CT - Abdomen
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.
121

Abdomen
CPT CODES:
74181 ......MRI of Abdomen, without contrast
74182 ......MRI of Abdomen, with contrast
74183 ......MRI of Abdomen, without contrast, followed by re-imaging with contrast

Scan coverage depends on the specific clinical indication for the abdominal MRI. General landmarks extend from
the diaphragmatic dome to the iliac crests.
Anatomic structures may include the liver, pancreas, spleen, adrenal glands, kidneys and remainder of the
abdomen.
Magnetic Resonance Cholangiopancreatography (MRCP) is used to evaluate the biliary and pancreatic ductal
systems non-invasively and is coved under CPT code 74181, Abdominal MRI without contrast.
Abdominal MRI studies are usually targeted for further evaluation of indeterminate or questionable findings,
identified on more standard imaging exams such as Ultrasound and CT.
For evaluation of vascular abnormalities such as renal artery stenosis and celiac/superior mesenteric artery
stenosis (in chronic mesenteric ischemia), Doppler Ultrasound, MRA or CTA should be considered as the
preferred imaging modalities.
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.
-
Biosafety Issues:
newer models are MRI compatible) or implantable cardioverter-defibrillators (ICD), intracranial aneurysm surgical clips
that are not compatible with MR imaging, as well as other devices considered unsafe in MRI scanners (including certain

Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to abdominal MRI.
122
MRI - Abdomen
symptoms.
COMMON DIAGNOSTIC INDICATIONS FOR ABDOMINAL MRI:

The following diagnostic indications for Abdominal MRI are accompanied by pre-test considerations as well as supporting clinical
INDETERMINATE ABDOMINAL MASS
For further evaluation and characterization of indeterminate lesions arising in the solid abdominal viscera and
surrounding anatomic structures, including but not limited to the following anatomic sites:
- Liver Characterization of focal hepatic lesions, both benign (e.g., cavernous hemangioma; focal nodular
1
hyperplasia) and malignant (e.g., hepatocellular carcinoma; liver metastases) in etiology
- Pancreas
- Spleen
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
TUMOR EVALUATION: PRIMARY NEOPLASM AND METASTATIC DISEASE
MRI staging and follow-up evaluation for biopsy-proven malignancies of the following structures:
-
Liver
Pancreas
Spleen
2
Kidney
2
Adrenal
Lymph Nodes
Other Abdominal and Retroperitoneal Neoplasms
DISSEMINATED INTRA-PERITONEAL TUMOR

LYMPHADENOPATHY
When Abdominal CT is non-diagnostic

May be useful for differentiating enlarged lymph nodes from vascular structures (with flow void on MRI), as followup from an unenhanced abdominal CT exam
DIFFUSE LIVER DISEASE
Following an inconclusive or abnormal Abdominal Ultrasound or CT

Including the following hepatic disorders:
-
Cirrhosis
Chronic Hepatitis
Hemochromatosis
CT is usually the initial imaging modality of choice for infectious and inflammatory conditions
Including but are not limited to the following:
-
Abscess
Diffuse Inflammation / Phlegmon
CONGENITAL ANOMALY
123
MRI - Abdomen
COMMON DIAGNOSTIC INDICATIONS FOR ABDOMINAL MRI:

When further evaluation is recommended after Ultrasound or CT
IN PATIENTS WITH APPROPRIATE AIM GUIDELINE INDICATIONS FOR ABDOMINAL CT, WHEN CT IS
EXPECTED TO BE LIMITED, DUE TO CONTRAINDICATIONS (SUCH AS A HISTORY OF ALLERGIC REACTION
TO IODINATED RADIOGRAPHIC CONTRAST MATERIAL)
FOR CLARIFICATION OF QUESTIONABLE OR ABNORMAL FINDINGS ON OTHER ABDOMINAL IMAGING
STUDIES
MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP) DIAGNOSTIC

INDICATIONS:
Covered by CPT Code 74181 MRI of Abdomen, without contrast
MRCP is performed using heavily T2-weighted images to display hyperintense signal from static or slowly-moving
fluid-filled structures
3-9
Advantages of MRCP, when compared with ERCP, include: non-invasive imaging technique; no ionizing
radiation; no anesthesia required; often better anatomic visualization proximal to a ductal obstruction; may detect
extra-ductal abnormalities not evident by ERCP
Disadvantages of MRCP, when compared with ERCP, include: limited spatial resolution and therefore, less
sensitive exam for detection of more subtle abnormalities; only provides diagnostic information, compared with
ERCP which has both diagnostic and therapeutic capabilities; as a consequence, MRCP may result in a delay for
needed therapeutic interventions performed with ERCP (such as sphincterotomy, stone extraction, stent
placement); susceptibility artifact on MRI may occur (for example, from metallic foreign bodies/surgical clips in the
right upper abdominal quadrant) and result in image degradation
Significant upper abdominal ascites and large cystic/fluid-filled structures may impede visualization of the
pancreatic and biliary ductal systems with MRCP.
COMMON INDICATIONS:
IN PATIENTS WITH SUSPECTED BILIARY AND/OR PANCREATIC DUCTAL ABNORMALITIES, FOLLOWING
INCOMPLETE OR FAILED ERCP, OR WHEN ERCP CANNOT BE SAFELY PERFORMED (for example, a
significant allergy to iodinated contrast material which would complicate performance of an ERCP)
WHEN ERCP IS PRECLUDED BY ANATOMIC CONSIDERATIONS, SUCH AS A BILIARY-ENTERIC SURGICAL
ANASTOMOSIS (for example, from previous choledochojejunostomy and partial gastrectomy with Billroth II
anastomosis)
TO EVALUATE PATIENTS WITH BILIARY TRACT DILATATION, BIOCHEMICAL EVIDENCE OF BILIARY
OBSTRUCTION AND/OR UNEXPLAINED RUQ PAIN, INCLUDING DETECTION OF CHOLEDOCHOLITHIASIS,
BENIGN STRICTURE, MASS LESION (BENIGN OR MALIGNANT), FISTULA AND OTHER PATHOLOGIC
PROCESSES
STATUS POST CHOLECYSTECTOMY AND HIGH CLINICAL SUSPICION FOR CHOLEDOCHOLITHIASIS
FOLLOWING PANCREATIC DUCTAL TRAUMA, WHEN ERCP IS CONTRAINDICATED, TO ASSESS DUCTAL
INTEGRITY AND PSEUDOCYST FORMATION
IN RECURRENT ACUTE PANCREATITIS OF UNKNOWN ETIOLOGY, TO IDENTIFY POSSIBLE CAUSES SUCH AS
CONGENITALLY ABERRANT DUCTAL ANATOMY (for example, Choledochal Cyst, Pancreas Divisum and
Annular Pancreas)
PRIMARY SCLEROSING CHOLANGITIS
1.
Kamel IR, Bluemke DA. MR Imaging of Liver Tumors. Radiol Clin N Am 2003; 41: 51-65.
124
MRI - Abdomen
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.
125
CT Angiography (CTA) and

Abdomen
CPT CODES:
74175........ Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if
74185........ Magnetic resonance angiography, abdomen; without or with contrast

Anatomic coverage for CPT codes 74175 (CTA) and 74184 (MRA) includes the major arterial and/or venous
structures in the abdomen, from the diaphragmatic dome through the iliac crests.
For CTA of the abdominal aorta and iliofemoral vasculature with lower extremity runoff, use CPT code 75635.
For MRA of the abdominal aorta and iliofemoral vasculature, with lower extremity runoff, use the following CPT
codes:
CPT 74185 MRA Abdomen x 1

and
- CPT 73725 MRA Lower Extremities x 2

Doppler Ultrasound examination is an excellent means to identify a wide range of vascular abnormalities, both
arterial and venous in origin. This well-established modality should be considered in the initial evaluation of many
vascular disorders listed below.
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 cardioverterdefibrillators (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.
COMMON DIAGNOSTIC INDICATIONS FOR ABDOMINAL CTA/MRA:

The following diagnostic indications for Abdominal CTA and MRA are accompanied by pre-test considerations as well as supporting
ANEURYSM
1-2
Of the Abdominal Aorta and/or Branch Vessel

PSEUDOANEURYSM
DISSECTION

INTRAMURAL HEMATOMA
ARTERIOVENOUS MALFORMATION (AVM) OR FISTULA (AVF)
126
CTA/MRA - Abdomen

STENOSIS OR OCCLUSION OF THE ABDOMINAL AORTA OR BRANCH VESSELS
Due to:
-
Atherosclerosis
Thromboembolism
Other causes
MESENTERIC ISCHEMIA
May have an acute or chronic and progressive (Intestinal or Abdominal Angina) presentation 5
VENOUS THROMBOSIS OR OCCLUSION
Consider initial evaluation with Doppler Ultrasound

-
Portal and Mesenteric Venous Systems

Systemic Venous System:
1. IVC Thrombosis or Extrinsic Compression /Occlusion, for example by tumor
2. Hepatic Vein Thrombosis (Budd-Chiari Syndrome)
3. Renal Vein Thrombosis
4. Other major abdominal vessels
VASCULAR EVALUATION OF LOWER EXTREMITY CLAUDICATION
6-7
CPT Coding for Abdominal Aortic and Run-Off evaluation, which involves image post-processing for threedimensional reconstructions, should follow:
1. For CTA: 75635 - CTA of Abdominal Aorta and Bilateral Iliofemoral Lower Extremity Run-Off without
contrast, followed by re-imaging with contrast
2. For MRA: 74185 - Abdominal MRA and 73725 - Bilateral Lower Extremity MRAs
Either CTA or MRA is indicated in a patient with classic presenting symptoms of claudication from peripheral arterial
disease, such as diminished/absent peripheral pulses and cramping pain in the legs (particularly in the thighs and
calves) when walking, which disappears at rest. Other clinical findings which support non-invasive assessment with
CTA or MRA include lower extremity cutaneous ulcers and gangrene.
In the absence of classic peripheral symptoms of claudication, then obtain a vascular surgical consultation and
perform lower extremity non-invasive arterial evaluation, which may include the following: segmental systolic
pressure measurements, segmental limb plethysmography, Continuous wave Doppler and duplex ultrasonography.
Ankle brachial indices (ABI) of < 0.9 may undergo advanced imaging. Rest pain or severe occlusive disease
typically occurs with ABI < 0.5.
RENAL ARTERY STENOSIS
8-13
For suspected Renovascular Hypertension from Renal Artery Stenosis, required clinical information includes at least
2-3 serial blood pressure measurements and a list of current anti-hypertensive medications. Renal Artery CTA or
8-12
MRA may be performed in the following clinical scenarios:
Refractory hypertension, in patients on therapeutic doses of 3 or more anti-hypertensive medications. Note that for
hypertension easily managed on 1-2 anti-hypertensive medications, imaging may not be required.
Hypertension with renal failure or progressive renal insufficiency

Accelerated or malignant hypertension
Abrupt onset of hypertension
Hypertension developing in patients younger than 35 years of age 13
Deteriorating renal function on angiotensin converting enzyme inhibition
Abdominal bruit, suspected to originate in the renal artery
Generalized arteriosclerotic occlusive disease with hypertension 13
Unilateral small renal size (> 1.5 cm difference in renal size on Ultrasound)
Following an abnormal renal Doppler Ultrasound suggestive of renal artery stenosis
Recurrent, unexplained episodes of flash pulmonary edema
Note: Doppler Ultrasound examination of the renal arteries has been shown in the peer-reviewed literature to be
efficacious and cost-efficient in detecting renal artery stenosis. However, it is less sensitive than MRA for detection of
127
CTA/MRA - Abdomen

renovascular hypertension.
12
PORTAL HYPERTENSION
PRE-OPERATIVE EVALUATION PRIOR TO LIVER RESECTION OR LIVER TRANSPLANTATION
VASCULITIS
SUSPECTED LEAK FOLLOWING ABDOMINAL AORTIC SURGERY
ENDOVASCULAR STENT GRAFT PLACEMENT FOR ABDOMINAL AORTIC ANEURYSM REPAIR
13-15
Stent grafts must be documented as MR-compatible prior to MRA

Post-procedure follow-up in asymptomatic patients: 13
- 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.
VASCULAR ANATOMIC DELINEATION FOR OTHER SURGICAL AND INTERVENTIONAL PROCEDURES
Including but not limited to the following clinical scenarios:
16
- For surgical porto-systemic shunt placement or TIPS (transjugular intrahepatic porto-systemic shunt)
- For hepatic chemo-embolization procedure
17-18
- For vascular delineation prior to operative resection of an abdominal neoplasm
- For pre- and post-procedure evaluation of bypass grafts, stents and vascular anastomoses
VASCULAR INVASION OR COMPRESSION BY AN ABDOMINAL TUMOR
UNEXPLAINED BLOOD LOSS IN THE ABDOMEN
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
128
CTA/MRA - Abdomen
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.
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 Vascular 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.
129
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.

CPT code 75635 (CTA) includes imaging of the abdominal aorta and bilateral iliofemoral vasculature, in addition to
lower extremity run-off to the level of the popliteal regions at the knees and often extending through the calf
vasculature to the ankle and foot regions.
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.
Duplicative services, such as CTA and MRA, are subject to high level review to evaluate for medical necessity.
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 Arteries with Lower Extremity Run-Off are
accompanied by pre-test considerations as well as supporting clinical data and prerequisite information:
ANEURYSM
1-2

PSEUDOANEURYSM
DISSECTION

STENOSIS OR OCCLUSION OF THE ABDOMINAL AORTA OR BRANCH VESSELS
Due to:
- Atherosclerosis
130
CTA - Abdominal Aorta and Bilateral Iliofemoral Runoff
COMMON DIAGNOSTIC INDICATIONS FOR CTA OF THE ABDOMINAL AORTA AND BILATERAL
ILIOFEMORAL ARTERIES WITH LOWER EXTREMITY RUN-OFF:
-
Thromboembolism
Other causes
VASCULAR EVALUATION OF LOWER EXTREMITY CLAUDICATION
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.
CRITICAL ISCHEMIA OF LOWER EXTREMITIES
For example, in diabetic vascular disease with ischemic ulcers or gangrene

PRE- AND POST-OPERATIVE OR INTERVENTIONAL VASCULAR PROCEDURE FOR LUMINAL PATENCY
VERSUS RE-STENOSIS (DUE TO ATHEROSCLEROSIS, THROMBOEMBOLISM, INTIMAL HYPERPLASIA OR
OTHER CAUSE) AS WELL AS POST-PROCEDURAL COMPLICATIONS (SUCH AS PSEUDOANEURYSMS
RELATED TO SURGICAL BYPASS GRAFTS OR VASCULAR STENTS)
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.
131

Pelvis
CPT CODES:
72192 ....... CT of Pelvis, without contrast
72193 ....... CT of Pelvis, with contrast
72194 ....... CT of Pelvis without contrast, followed by re-imaging with contrast

Iliac Crests to Ischial Tuberosities
Pelvic CT may include imaging of the following anatomic structures:
- Urinary Bladder
- Lower Retroperitoneum
- Iliofemoral Lymph Nodes
- Sacrum and Iliac Bones
- Sacroiliac (SI) Joints
- Prostate Gland and Seminal Vesicles in Males
- Uterus, Cervix, Vagina and Ovaries in Females
Coverage may vary, depending on the specific clinical indication for the exam
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 patients 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.

Duplicative services, such as pelvic CT and MRI, are subject to high level review to evaluate for medical necessity.
For CT Colonography see Category III codes 0066T or 0067T. Codes 72192-72194 are not reported with 0066T or
0067T.
133
CT - Pelvis
COMMON DIAGNOSTIC INDICATIONS FOR PELVIC CT:

The following diagnostic indications for Pelvic CT are accompanied by pre-test considerations as well as supporting clinical data and
General Pelvic CT Indications

Additional Intestinal Indications
Additional Osseous Indications
General Pelvic CT Indications:

For example, pelvic radiographs demonstrating abnormal calcifications suspicious for urinary tract calculus disease
ASCITES
Following preliminary evaluation on a pelvic Ultrasound

CONGENITAL ANOMALY
Often performed when further evaluation is recommended after Ultrasound or other imaging exam


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
performed, given the high sensitivity and specificity for hernia detection

- Abscess
- Recto-vaginal Fistula or other Fistula
134
CT - Pelvis

pelvic ultrasound, as the cause of vascular compression and resultant lower extremity edema
Following duplex Doppler examination for lower extremity deep venous thrombosis (DVT)
LYMPHADENOPATHY

PALPABLE PELVIC MASS
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.
TUMOR EVALUATION: PRIMARY NEOPLASM OR METASTATIC DISEASE
2-6
For initial staging and periodic follow-up

May involve:
-
Colo-rectum
Gynecologic structures: Uterus, Cervix or Ovaries
Lymph Nodes
Prostate Gland
Small Intestines
Testicles
Urinary Bladder
Other pelvic and lower retroperitoneal structures
TRAUMA SIGNIFICANT PELVIC INJURY

UNEXPLAINED WEIGHT LOSS SIGNIFICANT WEIGHT LOSS EXCEEDING 10% OF DESIRABLE BODY
WEIGHT, OVER SHORT TIME INTERVAL
Additional Intestinal Indications:

APPENDICITIS
135
CT - Pelvis

STUDIES

DIVERTICULITIS
10-11

-
Crohns Disease
Ulcerative Colitis
12
For suspected IBD, following endoscopic and/or barium examination or

ISCHEMIC BOWEL
13-14
Additional Genitourinary Tract Indications:

HYDRONEPHROSIS

Consider obtaining urine culture and/or renal/bladder ultrasound, prior to advanced imaging
Following attempted localization with Ultrasound

ANEURYSM OF LOWER ABDOMINAL AORTA, ILIAC ARTERIES OR BRANCH VESSELS
Initial diagnosis, particularly in obese patients

Follow-up imaging with Ultrasound in non-surgical and non-obese patients, who are asymptomatic and have
aneurysms < 5 cm in diameter
Suspected complication of an aneurysm, such as rupture or infection16 requiring urgent imaging

AORTO-ILIAC DISSECTION
-
ENDOVASCULAR REPAIR OF ABDOMINAL AORTIC ANEURYSM
17-20
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
136
CT - Pelvis

CTA or MRA are the modalities of choice for evaluating these vascular lesions
Additional Osseous Indications:

STRESS / INSUFFICIENCY FRACTURE IN THE PELVIS
Radiographs are a required first step, before other imaging is performed 21

ACUTE PELVIC TRAUMA, FOR FRACTURE EVALUATION
Radiographs should be performed prior to CT in most circumstances

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,
to define the location and extent of disease in patients with painful hips
22
OSSEOUS TUMOR EVALUATION IN THE PELVIS
Radionuclide Bone Scintigraphy is a frequently used imaging modality for detection of skeletal metastases from
most primary tumors and usually preceeds request for CT.
23
When an abnormality is detected on bone scanning, radiographs of the anatomic area are usually performed to
document whether finding(s) may be secondary to a benign process, such as osteoarthritis or fracture.
CHRONIC HIP PAIN, WITH NEGATIVE X-RAY AND SUSPECTED OSTEOID OSTEOMA
24
Requires negative or inconclusive hip radiographs prior to CT imaging

SACROILIITIS
Following sacroiliac joint radiographs

SUSPICION OF PELVIC OSTEOMYELITIS OR SEPTIC ARTHRITIS
When the patient is unable to undergo Hip MRI or Radionuclide Bone Scintigraphy
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.
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.
137
CT - Pelvis
12. Hanauer SB, Sandborn W. Management of Crohns 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.
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.
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.
138

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

Pelvic MRI may include imaging of the following anatomic structures:
- Urinary Bladder
- Lower Retroperitoneum
- Iliofemoral Lymph Nodes
- Sacrum and Iliac Bones
- Sacroiliac (SI) Joint
- Prostate Gland and Seminal Vesicles in Males
- Uterus, Cervix, Vagina and Ovaries in Females
Coverage may vary, depending on the specific clinical indication for the exam
Depending on the patients 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.

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.
-
139
MRI - Pelvis
Biosafety Issues:
are not compatible with MR imaging, as well as other devices considered unsafe in MRI scanners (including certain implanted

Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to pelvic MRI.
symptoms.
COMMON DIAGNOSTIC INDICATIONS FOR PELVIC MRI:

The following diagnostic indications for Pelvic MRI are accompanied by pre-test considerations as well as supporting clinical data and
ADENOMYOSIS OF THE UTERUS

ADNEXAL MASS(ES)
1-2
1,3-5
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

CONGENITAL UTERINE ANOMALY
Following abnormal pelvic imaging with Ultrasound or CT

DISSEMINATED INTRA-PERITONEAL TUMOR
ENDOMETRIOSIS
Following pelvic ultrasound

INFECTIOUS OR INFLAMMATORY PROCESS OF THE SOFT TISSUES
CT is usually the imaging modality of choice for infectious and inflammatory conditions
1,4
- Abscess
- Diffuse Inflammation
OSTEOMYELITIS OR SEPTIC ARTHRITIS
BILATERAL HIP OSTEONECROSIS (AVASCULAR NECROSIS; ASEPTIC NECROSIS)
MRI is the modality of choice for evaluation of osteonecrosis, particularly when there is clinical suspicion with hip
pain and negative or inconclusive hip radiographs
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
140
MRI - Pelvis
from an unenhanced pelvic CT exam
OBSTETRICAL ABNORMALITIES, FOLLOWING AN ABNORMAL OR EQUIVOCAL PRE-NATAL (OBSTETRICAL)
ULTRASOUND
TUMOR EVALUATION: PRIMARY NEOPLASM OR METASTATIC DISEASE
MRI staging and follow-up evaluation for biopsy-proven malignancies of the following structures: 1,3-4,7-11
-
Uterus, Cervix, Vagina or Vulva

Rectum
Testicles
Ovaries
Urinary Bladder
Prostate
Musculoskeletal Tumor
UTERINE ARTERY EMBOLIZATION PROCEDURES
12
Often performed for treatment of persistent bleeding from uterine fibroids

Following pelvic ultrasound for confirmation of masses
PELVIC FLOOR DISORDERS ASSOCIATED WITH URINARY OR BOWEL INCONTINENCE
COMMON DIAGNOSTIC INDICATIONS FOR PELVIC MRI:

PELVIC VENOUS THROMBOSIS EVALUATION
Following non-diagnostic or failed Doppler Ultrasound examination

SACROILIAC JOINT IMAGING FOR SACROILIITIS
Following sacro-iliac joint radiographs

SACRAL INSUFFICIENCY FRACTURE
Following pelvic or sacral radiographs

SIGNIFICANT PELVIC INJURY
Following pelvic or sacral radiographs

Following attempted localization with ultrasound

IN PATIENTS WITH APPROPRIATE AIM GUIDELINE INDICATIONS FOR PELVIC CT, WHEN CT IS EXPECTED
TO BE LIMITED, DUE TO CONTRAINDICATIONS (SUCH AS A HISTORY OF ALLERGIC REACTION TO
IODINATED RADIOGRAPHIC CONTRAST MATERIAL)
FOR CLARIFICATION OF QUESTIONABLE OR ABNORMAL FINDINGS ON OTHER PELVIC IMAGING STUDIES
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;403424.
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:
141
MRI - Pelvis
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.
142

Pelvis
CPT CODES:
72191 .........Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if
72198 .........Magnetic resonance angiography, pelvis; without contrast, followed by re-imaging with contrast

Scan coverage may vary, depending on the specific clinical indication for the exam.
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.
Duplicative services, such as CTA and MRA of the same anatomic area, are subject to high level review to
evaluate for medical necessity.
COMMON DIAGNOSTIC INDICATIONS FOR PELVIC CTA/MRA:

The following diagnostic indications for Pelvic CTA and MRA are accompanied by pre-test considerations as well as supporting
ANEURYSM
Of the Lower Abdominal Aorta, Iliac Arteries or Other Pelvic Branch Vessel
PSEUDOANEURYSM
DISSECTION
INTRAMURAL HEMATOMA
143
CTA/MRA- Pelvis
COMMON DIAGNOSTIC INDICATIONS FOR PELVIC CTA/MRA:

ARTERIOVENOUS MALFORMATION (AVM) OR FISTULA (AVF)
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
-
MESENTERIC ISCHEMIA
May have an acute or chronic and progressive (intestinal or abdominal angina) presentation
VENOUS THROMBOSIS OR OCCLUSION
Consider initial evaluation with Doppler Ultrasound

-
Systemic Venous System, including Lower IVC and/or Ilio-femoral Luminal Thrombosis
Mesenteric Venous System in Pelvis

SUSPECTED LEAK FOLLOWING ABDOMINAL AORTIC SURGERY
ENDOVASCULAR STENT GRAFT PLACEMENT FOR ABDOMINAL AORTIC ANEURYSM REPAIR
4-6
Stent grafts must be documented as MR-compatible prior to MRA

Primary concerns are in monitoring aneurysm size, identifying stent migration and detecting endoleaks.
Prior to and surveillance following placement of a Stent Graft
Society of Interventional Radiology: Post-procedure recommended follow-up in asymptomatic patients: 4
- If there are no problems related to the stent graft, then scans are obtained at 6 month intervals for 2 years
VASCULAR ANATOMIC DELINEATION FOR OTHER SURGICAL AND INTERVENTIONAL PROCEDURES:
For vascular delineation prior to operative resection of a pelvic neoplasm

For pre- and post-procedure evaluation of bypass grafts, stents and vascular anastomoses
VASCULAR INVASION OR COMPRESSION BY A PELVIC TUMOR
VASCULITIS
UNEXPLAINED BLOOD LOSS IN THE PELVIS
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 ContrastEnhanced 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
144
CTA/MRA- Pelvis
6.
Tolia M.D, Anuj J. Type II Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysms: Natural History. Radiology
2005;235:683-686
145

Abdomen and Pelvis Combination
CPT CODES:
74150........ CT of Abdomen, without contrast
74160........ CT of Abdomen, with contrast
74170........ CT of Abdomen, without contrast, followed by re-imaging with contrast
and
72192........ CT of Pelvis, without contrast
72193........ CT of Pelvis, with contrast
72194........ CT of Pelvis without contrast, followed by re-imaging with contrast

Diaphragmatic Dome through Pubic Symphysis
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.
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.
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
146
CT Abdomen and Pelvis Combination
COMMON DIAGNOSTIC INDICATIONS FOR ABDOMINAL & PELVIC COMBINATION CT:

The following diagnostic indications for Combined Abdominal and Pelvic CT Exams are accompanied by pre-test considerations as
well as supporting clinical data and prerequisite information
General Abdominal and Pelvic CT Indications

Additional Hepatobiliary Indications
Additional Gastrointestinal Indications
Additional Splenic Indications
General Abdominal and Pelvic CT Indications:

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:
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
1.
For example, abdominal radiographs demonstrating abnormal calcifications suspicious for urinary tract calculus
disease
ASCITES
Following preliminary evaluation on an Abdominal Ultrasound

CONGENITAL ANOMALY
Often performed when further evaluation is recommended after Ultrasound or other imaging exam


HERNIA
For diagnosis of a hernia suspected from surgical consultation

Including but not limited to the following types of hernia:
- Femoral
- Incisional
- Internal
- Inguinal
- Spigelian (through semilunar line, lateral to rectus abdominis muscle)
Ventral
147

For complications of hernias:
-
Bowel Obstruction
Incarceration
Gangrene
Intestinal Strangulation

- Abscess
- Fistula
pelvic ultrasound, as the cause of vascular compression and resultant lower extremity edema.
Following duplex Doppler examination for lower extremity deep venous thrombosis (DVT)
LYMPHADENOPATHY

PALPABLE ABDOMINAL / PELVIC MASS
RETROPERITONEAL ABNORMALITY - FIBROSIS, INFLAMMATION AND NEOPLASM
TRAUMA
Following significant blunt or penetrating injury to the Abdomen and Pelvis

TUMOR EVALUATION: PRIMARY NEOPLASM
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.
TUMOR EVALUATION: METASTATIC DISEASE
For diagnosis
Initial staging
Periodic follow-up after treatment
2-6
May involve the following anatomic areas:

- Adrenal Glands
- Biliary Tract
- Gynecologic Structures: Uterus, Cervix or Ovaries
- Kidneys
- Liver
148

-
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
Additional Gastrointestinal Indications:

APPENDICITIS

STUDIES
DIVERTICULITIS
9-10

11
Crohns Disease
- Ulcerative Colitis
-
For suspected IBD, following endoscopic and/or barium examination


ISCHEMIC BOWEL
12
13
Additional Pancreatic Indications:

ACUTE PANCREATITIS, WITH SUSPECTED COMPLICATIONS INCLUDING PANCREATIC NECROSIS, ABSCESS,
8
PSEUDOCYST(S) AND/OR PERI-PANCREATIC EFFUSIONS:
-
Note that patients with mild acute, uncomplicated pancreatitis usually do not require cross-sectional imaging,
aside from Ultrasound identification of gallstones and/or biliary ductal calculi, as a potential cause.
PANCREATIC PSEUDOCYST
With prior history of pancreatitis or pancreatic trauma

PANCREATIC MASS
Additional Genitourinary Tract Indications:

14
HYDRONEPHROSIS

When ultrasound is non-diagnostic or abnormal and unexplained, requiring further evaluation
Consider obtaining urine culture and/or renal/bladder ultrasound, prior to advanced imaging
149

RENAL NEOPLASM
For diagnosis, initial staging and pre-operative evaluation, re-staging and treatment monitoring
Following attempted localization with ultrasound

ANEURYSM OF ABDOMINAL AORTA OR BRANCH VESSEL
Initial diagnosis, particularly in obese patients

Follow-up imaging may be performed with ultrasound in non-surgical and non-obese patients, who are
asymptomatic and have aneurysms < 5 cm in diameter
Pre-operative assessment or prior to percutaneous endovascular stent graft placement

Post-operative surveillance
Suspected complication of an aneurysm, such as aneurysmal rupture or infection requiring urgent imaging
AORTIC DISSECTION

Usually results from subdiaphragmatic extension of a Thoracic Aortic Dissection
ENDOVASCULAR STENT GRAFT PLACEMENT FOR ABDOMINAL AORTIC ANEURYSM
15-17

Prior to and as surveillance following placement of Stent Graft
Society of Interventional Radiology: Post-procedure recommended follow-up in asymptomatic patients:
- If there are no problems related to the stent graft, then scans are obtained at 6 month intervals, for 2 years
CTA or MRA are the modalities of choice for evaluating these vascular lesions
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.
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: 603613.
150
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 Crohns 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 Diagnosis 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.
151

CT Colonography
(Virtual Colonoscopy)
CPT CODES:
74263........Screening CT Colonography including image post processing
74261........Diagnostic CT Colonography without contrast
74262........Diagnostic CT Colonography with contrast including non-contrast images if performed

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

The following diagnostic indication for Diagnostic CT Colonography is accompanied by
Indications for Diagnostic CT Colonography (74261, 74262):

FAILED OR INCOMPLETE FIBEROPTIC COLONOSCOPY OF THE ENTIRE COLON, DUE TO INABILITY TO
PASS THE COLONOSCOPE PROXIMALLY. FAILURE TO ADVANCE THE COLONOSCOPE MAY BE
SECONDARY TO:
Obstructing neoplasm
Spasm
Redundant colon
Altered anatomy or scarring from previous surgery
Stricture
Extrinsic compression
COAGULOPATHY
LIFETIME OR LONG-TERM ANTICOAGULATION, WITH INCREASED PATIENT RISK IF DISCONTINUED
COMPLICATIONS FROM PRIOR FIBEROPTIC COLONOSCOPY
152
CT Colonography
COMMON DIAGNOSTIC INDICATIONS FOR DIAGNOSTIC CT COLONOGRAPHY:

DIVERTICULITIS, WITH INCREASED RISK OF PERFORATION
INCREASED SEDATION RISK
For example, COPD or previous adverse reaction to anesthesia

KNOWN COLONIC OBSTRUCTION, WHEN STANDARD FIBEROPTIC COLONOSCOPY IS CONTRAINDICATED
Indications for Screening CT Colonography (74263):

AS AN ALTERNATIVE TO EITHER CONVENTIONAL (OPTICAL) COLONOSCOPY OR DOUBLE CONTRAST BARIUM
ENEMA FOR COLORECTAL CANCER SCREENING, IN INDIVIDUALS BEGINNING AT THE AGE OF 50 YEARS AND AT A
7
FREQUENCY OF EVERY 5 YEARS
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.
153

Cervical Spine
CPT CODES:
72125........ CT of Cervical Spine, without contrast
72126........ CT of Cervical Spine, with contrast
72127........ CT of Cervical Spine, without contrast, followed by re-imaging with contrast

Entire cervical spine (C1-C7), from the craniocervical junction through the T1 vertebra.
Axial images are routinely obtained, with capability for coronal and sagittal reconstructions.
MRI is the modality of choice for most cervical spine imaging indications, unless contraindicated or not tolerated by
the patient (for example, secondary to claustrophobia).
CT is the preferred technique for certain clinical scenarios such as suspected fracture, follow-up of known fracture,
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
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.
COMMON DIAGNOSTIC INDICATIONS FOR CERVICAL SPINE CT:

The following diagnostic indications for Cervical Spine CT are accompanied by pre-test considerations as well as supporting clinical
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.
FRACTURE EVALUATION
1-2
SIGNIFICANT ACUTE TRAUMA TO THE CERVICAL SPINE REGION
3-4
LESS SEVERE CERVICAL SPINE TRAUMA AND NEW NEUROLOGIC FINDING(S) OR PROGRESSIVELY
WORSENING NECK PAIN
ABNORMAL CERVICAL SPINE RADIOGRAPHS, WITH RECOMMENDED CT FOLLOW-UP
POST-MYELOGRAM CT
CONGENITAL VERTEBRAL DEFECTS IN PEDIATRIC POPULATION, FOR ASSESSMENT OF BONY DEFECTS
SUCH AS SEGMENTATION AND FUSION ANOMALIES
Following abnormal or non-diagnostic cervical spine radiographs

WHEN THE PATIENTS 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).
154
CT Cervical Spine

For most other indications, MRI is the preferred modality for advanced cervical spine imaging,
unless contra-indicated.
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:
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 cervical spine region may not require completion of the 3-4 week course of conservative treatment.
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 (FOR EXAMPLE: REFLEX ABNORMALITY;
MUSCLE WEAKNESS; OBJECTIVE SENSORY ABNORMALITY IN THE CERVICAL DERMATOME DISTRIBUTION)
DEMYELINATING DISORDERS, SUCH AS MULTIPLE SCLEROSIS, WHEN MRI IS CONTRAINDICATED
MYELOPATHY
SPINAL CORD INFARCT
POST-MYELOGRAM CT OR CT FOLLOWING OTHER INTERVENTIONAL PROCEDURE
POST-OPERATIVE EVALUATION, WITH NEW NEUROLOGIC FINDINGS OR WITH PERSISTENT OR RECURRENT
NECK/RADICULAR PAIN
- Abscess
- Osteomyelitis
- Discitis
TUMOR EVALUATION

- Primary or Metastatic Neoplasm involving the Vertebrae
- Tumor Spread within the Spinal Canal
- Spinal Cord Neoplasm
ARNOLD CHIARI MALFORMATION
CERVICAL SPINE DYSRAPHISM AND OTHER CONGENITAL ANOMALIES INVOLVING THE CERVICAL SPINE
AND/OR SPINAL CORD
SYRINGOHYDROMYELIA (SYRINX)
SEVERE SCOLIOSIS, FOR THE FOLLOWING PATIENT POPULATIONS:
155
CT Cervical Spine

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
-
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
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.
6.
Jaramillo D, Poussaint TY, Grottkau BE, et al. Scoliosis: Evidence-Based Diagnostic Evaluation. Neuroimag Clin N Am 2003; 13:
335-341.
156

Cervical Spine
CPT CODES:
72141........MRI of Cervical Spine, without contrast
72142........MRI of Cervical Spine, with contrast
72156........MRI of Cervical Spine, without contrast, followed by re-imaging with contrast

Entire cervical spine (C1-C7), from the craniocervical junction through the T1 vertebra.
Axial images are routinely obtained, with capability for coronal and sagittal reconstructions.
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.
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
-
Biosafety Issues:

Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to MRI of the cervical spine.
symptoms.
157
MRI Cervical Spine

The following diagnostic indications for Cervical Spine CT are accompanied by pre-test considerations as well as supporting clinical
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.
PERSISTENT PAIN / RADICULOPATHY IN THE CERVICAL DISTRIBUTION
In Adults, persistent symptoms despite > 3-4 weeks of conservative therapy and failed or inadequate response to
1. Medications, such as NSAIDs and muscle relaxants
2. Steroids
3. Physical therapy/exercises
Severe neck 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 cervical spine region may not require completion of the 3-4 week course of conservative treatment.
NECK OR SHOULDER PAIN AND NEW NEUROLOGIC FINDINGS RELATED TO THE CERVICAL SPINE OR
MUSCLE WEAKNESS; OBJECTIVE SENSORY ABNORMALITY IN THE CERVICAL DERMATOME DISTRIBUTION)
CERVICAL SPINAL STENOSIS OR DISC HERNIATION)
- Muscle Weakness
- Sensory Loss
- Spasticity
MYELOPATHY
SPINAL CORD INFARCT
DEMYELINATING DISORDERS, SUCH AS MULTIPLE SCLEROSIS

- Abscess
- Osteomyelitis
- Discitis
TUMOR EVALUATION

- Tumor Spread within the Spinal Canal
- Spinal Cord Neoplasm
FRACTURE EVALUATION
SIGNIFICANT ACUTE TRAUMA TO THE CERVICAL SPINE REGION
4-5
LESS SEVERE CERVICAL SPINE TRAUMA AND NEW NEUROLOGIC FINDING(S) OR PROGRESSIVELY
WORSENING NECK PAIN
158
MRI Cervical Spine

ABNORMAL CERVICAL SPINE RADIOGRAPHS, WITH RECOMMENDED MRI FOLLOW-UP
NECK/RADICULAR PAIN
ARNOLD CHIARI MALFORMATION
signs/symptoms); or

CERVICAL SPINE DYSRAPHISM AND OTHER CONGENITAL ANOMALIES INVOLVING THE CERVICAL SPINE
AND/OR SPINAL CORD
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
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.
159

Thoracic Spine
CPT CODES:
72128........CT of Thoracic Spine, without contrast
72129........CT of Thoracic Spine, with contrast
72130........CT of Thoracic Spine, without contrast, followed by re-imaging with contrast

Entire thoracic spine (T1-T12), from the cervicothoracic region through the thoracolumbar junction
Axial images are routinely obtained, with capability for coronal and sagittal reconstructions
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
COMMON DIAGNOSTIC INDICATIONS FOR THORACIC SPINE CT:

The following diagnostic indications for Thoracic Spine CT are accompanied by pre-test considerations as well as supporting clinical
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.
FRACTURE EVALUATION
SIGNIFICANT ACUTE TRAUMA TO THE THORACIC SPINE REGION

LESS SEVERE THORACIC SPINE TRAUMA AND NEW NEUROLOGIC FINDING(S) OR PROGRESSIVELY
WORSENING BACK PAIN
ABNORMAL THORACIC SPINE RADIOGRAPHS, WITH RECOMMENDED CT FOLLOW-UP
POST-MYELOGRAM CT OR CT FOLLOWING OTHER THORACIC INTERVENTIONAL PROCEDURE
CONGENITAL VERTEBRAL DEFECTS IN PEDIATRIC POPULATION, FOR ASSESSMENT OF BONY DEFECTS
SUCH AS SEGMENTATION AND FUSION ANOMALIES
Following non-diagnostic or abnormal thoracic spine radiographs

WHEN THE PATIENTS CONDITION MEETS THE THORACIC SPINE MRI GUIDELINES, BUT THERE IS EITHER A
160
CT Thoracic Spine

TO CLAUSTROPHOBIA).
For most other indications, MRI is the preferred modality for advanced thoracic spine imaging,
PERSISTENT PAIN / RADICULOPATHY IN THE THORACIC DISTRIBUTION

Steroids
in the thoracic spine region may not require completion of the 4-6 week course of conservative treatment.
THORACIC SPINAL STENOSIS OR DISC HERNIATION)
- Muscle Weakness
- Sensory Loss
- Spasticity
BACK PAIN AND NEW NEUROLOGIC FINDINGS RELATED TO THE THORACIC SPINE OR DOCUMENTED
NEUROLOGIC DEFICIT ON PHYSICAL EXAM (FOR EXAMPLE: REFLEX ABNORMALITY; MUSCLE WEAKNESS;
OBJECTIVE SENSORY ABNORMALITY IN THE THORACIC DERMATOME DISTRIBUTION)
DEMYELINATING DISORDERS, SUCH AS MULTIPLE SCLEROSIS, WHEN MRI IS CONTRAINDICATED
MYELOPATHY
SPINAL CORD INFARCT
BACK/RADICULAR PAIN
- Abscess
- Osteomyelitis
- Discitis
TUMOR EVALUATION
Including but not limited to the following neoplasms:
Tumor Spread within the Spinal Canal

Spinal Cord Neoplasm
THORACIC SPINE DYSRAPHISM AND OTHER CONGENITAL ANOMALIES INVOLVING THE THORACIC SPINE
AND/OR SPINAL CORD
SEVERE SCOLIOSIS, INCLUDING THE FOLLOWING PATIENT POPULATIONS:
161
CT Thoracic Spine

signs/symptoms); or

-
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.
162

Thoracic Spine
CPT CODES:
72146........MRI of Thoracic Spine, without contrast
72147........MRI of Thoracic Spine, with contrast
72157........MRI of Thoracic Spine, without contrast, followed by re-imaging with contrast

Entire thoracic spine (T1-T12), from the cervicothoracic region through the thoracolumbar junction.
Imaging planes generally include sagittal and axial/oblique axial (parallel with the disc spaces) views.
Advanced imaging of the thoracic spine is indicated in selected clinical scenarios and is performed significantly
less often than in the cervical and lumbar regions.
CT is the preferred technique for certain indications, including fracture detection, follow-up of a known fracture,
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
-
Biosafety Issues:

Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to MRI of the thoracic spine.
symptoms.
163
MRI Thoracic Spine
COMMON DIAGNOSTIC INDICATIONS FOR THORACIC SPINE MRI:

The following diagnostic indications for Thoracic Spine MRI are accompanied by pre-test considerations as well as supporting clinical
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.
PERSISTENT PAIN / RADICULOPATHY IN THE THORACIC DISTRIBUTION

Steroids
in the thoracic spine region may not require completion of the 4-6 week course of conservative treatment.
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
THORACIC SPINAL STENOSIS OR DISC HERNIATION)
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 (FOR EXAMPLE: REFLEX ABNORMALITY; MUSCLE WEAKNESS;
OBJECTIVE SENSORY ABNORMALITY IN THE THORACIC DERMATOME DISTRIBUTION)
MYELOPATHY
SPINAL CORD INFARCT
Abscess
Osteomyelitis
Discitis
TUMOR EVALUATION
Primary or Metastatic Neoplasm involving the Vertebrae

Spinal Cord Neoplasm
Tumor Spread in the Spinal Canal
FRACTURE EVALUATION
POST-TRAUMATIC NEUROLOGIC DEFICIT AND POSSIBLE SPINAL CORD INJURY
164
MRI Thoracic Spine
COMMON DIAGNOSTIC INDICATIONS FOR THORACIC SPINE MRI:

POST-OPERATIVE EVALUATION, WITH NEW NEUROLOGIC FINDINGS OR CONTINUED BACK/RADICULAR
PAIN
ABNORMAL THORACIC SPINE RADIOGRAPHS, WITH RECOMMENDED MRI FOLLOW-UP
With high risk for neural axis abnormalities, such as infantile and juvenile idiopathic scoliosis and congenital
scoliosis; or
signs/symptoms); or
With scoliosis related to other pathologic processes, such as neurofibromatosis; or

SPINAL DYSRAPHISM AND OTHER CONGENITAL ANOMALIES INVOLVING THE THORACIC SPINE AND/OR
SPINAL CORD
1.
Bot JCJ, Blezer ELA, Kamphorst W, et al. The Spinal Cord in Multiple Sclerosis: Relationship of High-Spatial-Resolution
2.
Koeller KK, Rosenblum RS, Morrison AL. Neoplasms of the Spinal Cord and Filum Terminale: Radiologic-Pathologic
3.
Jaramillo D, Poussaint TY, Grottka BE. Scoliosis: Evidence-Based Diagnostic Evaluation. Neuroimag Clin N Am 2003; 13:
335-341.
165

Lumbar Spine
CPT CODES:
72131........CT of Lumbar Spine, without contrast
72132........CT of Lumbar Spine, with contrast
72133........CT of Lumbar Spine, without contrast, followed by re-imaging with contrast

Entire lumbar spine (L1-L5), from the thoracolumbar region through the lumbosacral junction.
Axial images are routinely obtained, with capability for coronal and sagittal reconstructions
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
Duplicative services, such as concurrent requests for lumbar spine CT and MRI, are subject to high level review
COMMON DIAGNOSTIC INDICATIONS FOR LUMBAR SPINE CT:

The following diagnostic indications for Lumbar Spine CT are accompanied by pre-test considerations as well as supporting clinical
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
SIGNIFICANT ACUTE TRAUMA TO THE LUMBAR SPINE REGION
LESS SEVERE LUMBAR SPINE TRAUMA AND NEW NEUROLOGIC FINDING(S) OR PROGRESSIVELY
WORSENING LOW BACK PAIN
ABNORMAL LUMBAR SPINE RADIOGRAPHS, WITH RECOMMENDED CT FOLLOW-UP
SPONDYLOLYSIS AND SPONDYLOLISTHESIS
Following non-diagnostic or abnormal lumbar spine radiographs (including oblique views), in an operative
candidate
CONGENITAL VERTEBRAL DEFECTS IN THE PEDIATRIC POPULATION, FOR ASSESSMENT OF BONY
DEFECTS SUCH AS SEGMENTATION AND FUSION ANOMALIES
Following non-diagnostic or abnormal lumbar spine radiographs

CT FOLLOWING MYELOGRAPHY, DISCOGRAPHY OR OTHER LUMBAR INTERVENTIONAL PROCEDURE
166
1-2
CT Lumbar Spine

WHEN THE PATIENTS CONDITION MEETS THE LUMBAR SPINE MRI GUIDELINES, BUT THERE IS EITHER A
TO CLAUSTROPHOBIA).
For most other indications, MRI is the preferred modality for advanced lumbar spine imaging,
PERSISTENT PAIN / RADICULOPATHY IN THE LUMBAR DISTRIBUTION
3-8

Steroids
in the lumbar spine region may not require completion of the 4-6 week course of conservative treatment.
LUMBAR SPINAL STENOSIS OR DISC HERNIATION)
- Muscle Weakness
- Sensory Loss
- Spasticity
LOWER BACK OR LEG PAIN AND NEW NEUROLOGIC FINDINGS RELATED TO THE LUMBAR SPINE OR
MUSCLE WEAKNESS; OBJECTIVE SENSORY ABNORMALITY IN THE LUMBAR DERMATOME DISTRIBUTION)
DEMYELINATING DISORDERS, SUCH AS MULTIPLE SCLEROSIS, WHEN MRI IS CONTRAINDICATED AND
THERE ARE SYMPTOMS REFERABLE TO THE LOWER LUMBAR REGION
MYELOPATHY INVOLVING THE LOWER SPINAL CORD
SPINAL CORD INFARCT
CAUDA EQUINA SYNDROME
Signs and symptoms may include:

-
Bilateral radiculopathy
Saddle anesthesia
Urinary retention or incontinence
Bowel dysfunction

- Abscess
- Arachnoiditis
- Discitis
- Osteomyelitis
TUMOR EVALUATION

167
CT Lumbar Spine

-
Spinal cord neoplasm

Tumor spread in spinal canal
LUMBAR SPINE DYSRAPHISM AND OTHER CONGENITAL ANOMALIES INVOLVING THE LUMBAR SPINE
AND/OR LOWER SPINAL CORD (CONUS MEDULLARIS), FILUM TERMINALE OR NERVE ROOTS
10
scoliosis; or
signs/symptoms); or

-

LOWER BACK/RADICULAR PAIN
- Differentiation of recurrent disc herniation from scarring
- Evaluation for post-surgical complications, such as epidural hematoma/abscess
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;137:586597.
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 OutcomeMulticenter Randomized Trial. Radiology 2004; 231: 343-351.
9.
Koeller KK, Rosenblum RS, Morrison AL. Neoplasms of the Spinal Cord and Filum Terminale: Radiologic-Pathologic
10. Jaramillo D, Poussaint TY, Grottkau BE, et al. Scoliosis: Evidence-Based Diagnostic Evaluation. Neuroimag Clin N Am 2003;
13: 335-341.
168

Lumbar Spine
CPT CODES:
72148........MRI of Lumbar Spine, without contrast
72149........MRI of Lumbar Spine, with contrast
72158........MRI of Lumbar Spine, without contrast, followed by re-imaging with contrast

Entire lumbar spine (L1-L5), from the thoracolumbar region through the lumbosacral junction.
Imaging planes generally include sagittal and axial/oblique axial (parallel with disc spaces) views.
For most other lumbar spine abnormalities, MRI is the modality of choice, unless contraindicated or not tolerated
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
-
Biosafety Issues:

Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to MRI of the lumbar spine.
symptoms.
169
MRI Lumbar Spine
COMMON DIAGNOSTIC INDICATIONS FOR LUMBAR SPINE MRI:

The following diagnostic indications for Lumbar Spine MRI are accompanied by pre-test considerations as well as supporting clinical
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.
PERSISTENT PAIN / RADICULOPATHY IN LUMBAR DISTRIBUTION
2-10

Steroids
Severe low back pain and an abnormal EMG exam

in the lumbar spine region may not require completion of the 4-6 week course of conservative treatment.
LUMBAR SPINAL STENOSIS OR DISC HERNIATION)
Muscle Weakness
Sensory Loss
Spasticity
LOWER BACK OR LEG PAIN AND NEW NEUROLOGIC FINDINGS RELATED TO THE LUMBAR SPINE OR
MUSCLE WEAKNESS; OBJECTIVE SENSORY ABNORMALITY IN THE LUMBAR DERMATOME DISTRIBUTION)
12
MYELOPATHY INVOLVING THE LOWER SPINAL CORD

SPINAL CORD INFARCT
CAUDA EQUINA SYNDROME
Including but are not limited to the following signs and symptoms:
- Bilateral radiculopathy
- Bowel dysfunction
- Saddle anesthesia
- Urinary retention or incontinence
- Abscess
- Arachnoiditis
- Discitis
170
MRI Lumbar Spine
COMMON DIAGNOSTIC INDICATIONS FOR LUMBAR SPINE MRI:

-
Osteomyelitis
TUMOR EVALUATION
13

- Spinal cord neoplasm
- Tumor spread in spinal canal
FRACTURE EVALUATION
POST-TRAUMATIC NEUROLOGIC DEFICIT AND POSSIBLE SPINAL CORD INJURY
BACK/RADICULAR PAIN
- Differentiation of recurrent disc herniation from scarring
- Evaluation for post-surgical complications, such as epidural hematoma/abscess
ABNORMAL LUMBAR SPINE RADIOGRAPHS, WITH RECOMMENDED MRI FOLLOW-UP
14
scoliosis; or
signs/symptoms); or

LUMBAR SPINAL DYSRAPHISM
TETHERED CORD AND OTHER CONGENITAL ANOMALIES INVOLVING THE LUMBAR SPINE AND/OR LOWER
SPINAL CORD (CONUS MEDULLARIS), FILUM TERMINALE OR NERVE ROOTS
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
171
MRI Lumbar Spine
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
13. Koeller KK, Rosenblum RS, Morrision AL. Neoplasms of the Spinal Cord and Filum Terminale: Radiologic-Pathologic
14. Jaramillo D, Poussaint TY, Grottkau BE. Scoliosis: Evidence-Based Diagnostic Evaluation. Neuroimag Clin N Am 2003; 13:
335-341.
172
Spinal Canal
CPT CODES:
72159 ........Magnetic Resonance Angiography of Spinal Canal

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

MR Angiography (MRA) of the spinal canal is an evolving technology under clinical development. This clinical
application of MRA and its impact on health outcomes will continue to undergo review, as new evidence-based
studies are published. Interval routine coverage for MR angiography of the spinal canal is not generally available
and is not considered the standard of care at this time.
173

Upper Extremity
CPT CODES:
73200........CT upper extremity, without contrast
73201........CT upper extremity, with contrast
73202........CT upper extremity, without contrast, followed by re-imaging with contrast

Scan coverage depends on the specific clinical indication for the exam and varies considerably, based on
anatomic considerations (from shoulder through fingers) and clinical manifestations.
Depending on the protocol used, the CT data acquisition(s) may allow for diagnostic multi-planar reconstructions
through the region of interest.
Conventional radiographs should be obtained before advanced imaging 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 patients 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.
COMMON DIAGNOSTIC INDICATIONS FOR UPPER EXTREMITY CT:

The following diagnostic indications for Upper Extremity CT are accompanied by pre-test considerations as well as supporting clinical
INFECTIOUS AND INFLAMMATORY PROCESS

- Abscess
- Septic Arthritis
- Osteomyelitis when MRI is contraindicated or when defining a suspected bone sequestra
PALPABLE MASS ON PHYSICAL EXAM
PRIMARY (BENIGN AND MALIGNANT) BONE TUMOR
174
CT Upper Extremity
COMMON DIAGNOSTIC INDICATIONS FOR UPPER EXTREMITY CT:

METASTATIC TUMOR
Involving the soft tissues and/or osseous structures

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
NEUROPATHIC OSTEODYSTROPHY (CHARCOT JOINT)
Following conventional radiographs, when there is need for additional diagnostic information from a CT exam to
direct treatment decisions (such as concern for an underlying infectious process)
PRE- AND POST-OPERATIVE EVALUATION
When ordered by a Specialty Consultant (e.g., Orthopedic Surgery and Sports Medicine)
ABNORMALITY ON X-RAY OR BONE SCINTIGRAPHY, WITH RECOMMENDED CT FOLLOW-UP
PERSISTENT UPPER EXTREMITY PAIN UNRESPONSIVE TO 4-6 WEEKS OF CONSERVATIVE TREATMENT
Following initial assessment with conventional radiographs

OSTEONECROSIS [AVASCULAR NECROSIS (AVN); ASEPTIC NECROSIS]
Requires initial plain films, prior to advanced imaging

MRI is often the preferred imaging modality, particularly for evaluation in the early stages of Osteonecrosis
Common anatomic locations for Osteonecrosis in the Upper Extremity are:
-
Humeral Head
Radial Head
Carpal Navicular Bone
Lunate Bone (lunate osteonecrosis also referred to as Kienbocks disease)
INTRA-ARTICULAR LOOSE BODY, INCLUDING SYNOVIAL OSTEOCHONDROMATOSIS

CT ACCOMPANYING AN ARTHROGRAM (CT ARTHROGRAPHY)
HEMARTHROSIS (BLOODY JOINT EFFUSION), DOCUMENTED BY ARTHROCENTESIS
WHEN THE PATIENTS CONDITION MEETS THE UPPER EXTREMITY MRI GUIDELINES, BUT THERE IS EITHER A
TO CLAUSTROPHOBIA)
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.
175

Upper Extremity (Any Joint)
CPT CODES:
73221........MRI upper extremity, any joint, without contrast
73222........MRI upper extremity, any joint, with contrast
73223........MRI upper extremity, any joint, without contrast, followed by re-imaging with contrast
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.
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.
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
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
176
MRI Upper Extremity (Any Joint)
-
Biosafety Issues:

Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to MRI of the upper extremity
(any joint).
symptoms.
COMMON DIAGNOSTIC INDICATIONS FOR UPPER EXTREMITY MRI:

The following diagnostic indications for Upper Extremity MRI are accompanied by pre-test considerations as well as supporting clinical
data and prerequisite information.
General Indications for Upper Extremity Joint MRI

Additional Indications for Shoulder MRI
Additional Indications for Elbow MRI
Additional Indications for Wrist and Hand MRI
General Indications for Upper Extremity MRI in Joint Evaluation:

SIGNIFICANT TRAUMA

FRACTURE EVALUATION

To define the extent of an acute fracture and position of fracture fragments
Following conventional radiographs, when there is need for additional diagnostic information from an MRI exam to
LIGAMENT AND TENDON INJURIES
If no response to 4-6 weeks of conservative treatment

JOINT LOCKING
JOINT INSTABILITY (SENSATION OF JOINT GIVING WAY)
177


Common anatomic locations for Osteonecrosis in the Upper Extremity are:
-
Humeral Head
Radial Head
Carpal Navicular Bone
Lunate Bone (lunate osteonecrosis also referred to as Kienbocks disease)
OSTEOCHONDRAL LESION
MRI ACCOMPANYING AN ARTHROGRAM (MR ARTHROGRAPHY)
- Abscess
- Septic Arthritis
- Osteomyelitis
PRIMARY (BENIGN AND MALIGNANT) BONE TUMOR suspected or known
METASTATIC TUMOR
-
ABNORMALITY ON X-RAY OR BONE SCINTIGRAPHY, WITH RECOMMENDED MRI FOLLOW-UP

Following initial assessment on conventional radiographs

Additional Indications for the Shoulder Joint:

ROTATOR CUFF TEAR
When the diagnosis is uncertain, conservative treatment should be instituted for 4-6 weeks, to monitor response to
therapy
GLENOID LABRAL TEAR
-
Usually associated with pain and decreased range of motion
OTHER GLENOID LABRAL AND ASSOCIATED LIGAMENTOUS LESIONS

- Bankart Lesion
- Bankart Variation Lesions
- ALPSA (Anterior Labroligamentous Periosteal Sleeve Avulsion) Lesion
- HAGL (Humeral Avulsion of the Inferior Glenohumeral Ligament) Lesion
178

SUSPECTED OCCULT SHOULDER FRACTURE
With high clinical suspicion and negative or inconclusive shoulder radiographs
ADHESIVE CAPSULITIS
Following Orthopedic consultation
Additional Indications for Elbow Imaging:

EPICONDYLITIS
Generally considered a clinical diagnosis

If unresponsive to conservative treatment, specialist evaluation should be obtained prior to advanced imaging
BICEPS TENDON RUPTURE
At insertion onto radial tuberosity

TRICEPS TENDON RUPTURE
From olecranon insertion site

MEDIAL COLLATERAL LIGAMENT TEAR
CAPITELLAR OSTEOCHONDRITIS
SUSPECTED OCCULT ELBOW FRACTURE
With high clinical suspicion and negative or inconclusive elbow radiographs
Additional Indications for Wrist and Hand Imaging:

TRIANGULAR FIBROCARTILAGE COMPLEX (TFCC) TEAR
SCAPHOID FRACTURE
ULNAR COLLATERAL LIGAMENT TEAR (GAMEKEEPERS THUMB)
CARPAL TUNNEL SYNDROME FOR UNEXPLAINED SYMPTOMS FOLLOWING CONSERVATIVE TREATMENT
AND NERVE CONDUCTION STUDIES
Does not usually require advanced imaging for diagnosis
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;58:15831584.
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.
179

Upper Extremity (Non-Joint)
CPT CODES:
73218........MRI upper extremity, other than joint, without contrast
73219........MRI upper extremity, other than joint, with contrast
73220........MRI upper extremity, other than joint, without contrast, following by re-imaging with contrast

Scan coverage depends on the specific clinical indication and varies considerably, based on anatomic and clinical
considerations.
MRI routinely provides multi-planar imaging of the region of interest.
Conventional radiographs should be obtained before advanced diagnostic imaging is performed, in the majority of
cases.
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
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.
-
180
MRI Upper Extremity (Non-Joint)
Biosafety Issues:

Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to MRI of the upper extremity
(non-joint).
symptoms.
COMMON DIAGNOSTIC INDICATIONS FOR UPPER EXTREMITY MRI (NON-JOINT):

The following diagnostic indications for Upper Extremity MRI (Non-Joint) are accompanied by pre-test considerations as well as

- Abscess
- Osteomyelitis
- Inflammatory Myopathy
- Myositis
PRIMARY (BENIGN AND MALIGNANT) BONE TUMOR
METASTATIC TUMOR

SIGNIFICANT TRAUMA

FRACTURE EVALUATION

ABNORMALITY ON X-RAY OR BONE SCINTIGRAPHY, WITH RECOMMENDED MRI FOLLOW-UP
Following initial radiographic assessment

SUSPECTED ENTRAPMENT NEUROPATHY
181
MRI Upper Extremity (Non-Joint)
BRACHIAL PLEXOPATHY
BRACHIAL PLEXUS MASS
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.
4.
Wittenberg KH, Adkins MC. MR Imaging of Nontraumatic Brachial Plexopathies: Frequency and Spectrum of Findings.
182

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)

Depends on the specific anatomic area of interest, from the axillary region through the hand and digits.
CT and MR angiographic techniques include arterial and/or venous assessment, depending on the clinical
indication.
Other generally available non-invasive arterial studies of the upper extremity circulation should be considered
prior to advanced diagnostic imaging with CTA or MRA. These include segmental systolic pressure
measurements, plethysmographic analysis, Continuous wave Doppler and/or duplex ultrasonography.
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.
COMMON DIAGNOSTIC INDICATIONS FOR UPPER EXTREMITY CTA AND MRA:

The following diagnostic indications for Upper Extremity CTA and MRA are accompanied by pre-test considerations as well as
STENO-OCCLUSIVE DISEASE
Usually atherosclerotic in origin

THROMBOEMBOLIC DISEASE ARTERIAL OR VENOUS
ANEURYSM
ARTERIO-VENOUS MALFORMATION (AVM) OR FISTULA (AVF)
DISSECTION
INTRAMURAL HEMATOMA
DIALYSIS GRAFT EVALUATION
183
CTA/MRA Upper Extremity
COMMON DIAGNOSTIC INDICATIONS FOR UPPER EXTREMITY CTA AND MRA:

Following duplex Doppler assessment
RAYNAUDS SYNDROME
VASCULITIS
ARTERIAL ENTRAPMENT SYNDROME
VASCULAR INVASION OR COMPRESSION BY A MUSCULOSKELETAL NEOPLASM
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.
184

Lower Extremity
CPT CODES:
73700........CT lower extremity without contrast
73701........CT lower extremity with contrast
73702........CT lower extremity without contrast, followed by re-imaging with contrast

Scan coverage depends on the anatomic area of concern and varies considerably, based on anatomic (from hip
through toes) and clinical considerations.
Depending on the protocol used, the CT data acquisition(s) may allow for diagnostic multi-planar reconstructions
through the region of interest.
and some incomplete and non-displaced fractures may be better imaged with MRI or Radionuclide Bone
Scintigraphy.
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
Request for re-imaging, due to technically limited exams, is the responsibility of the imaging provider.
COMMON DIAGNOSTIC INDICATIONS FOR LOWER EXTREMITY CT:

The following diagnostic indications for Lower Extremity CT are accompanied by pre-test considerations as well as supporting clinical

- Abscess
- Septic Arthritis
- Osteomyelitis when MRI is contraindicated or when defining a suspected bone sequestra
TUMOR EVALUATION
When MRI is contraindicated or when evaluating osseous involvement by tumor
185
CT Lower Extremity
COMMON DIAGNOSTIC INDICATIONS FOR LOWER EXTREMITY CT:

SIGNIFICANT TRAUMA

FRACTURE EVALUATION

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

MRI is often the preferred imaging modality, particularly for evaluation during the early stages of Osteonecrosis
BONE SCINTIGRAPHY ABNORMALITY
PERSISTENT LOWER EXTREMITY PAIN UNRESPONSIVE TO 4-6 WEEKS OF CONSERVATIVE TREATMENT
Initial assessment on conventional radiographs should be performed

For hip to assess femoro-acetabular impingement (FAI)
TARSAL COALITION
Following foot radiographs

Following conventional radiographs, when there is need for additional diagnostic information from a CT exam to
When ordered by a Specialty Consultant (e.g., Orthopedic Surgeon, Sports Medicine or Podiatrist)
CT ACCOMPANYING AN ARTHROGRAM (CT ARTHROGRAPHY)
WHEN THE PATIENTS CONDITION MEETS THE LOWER EXTREMITY MRI GUIDELINES, BUT MRI IS EITHER
CONTRAINDICATED OR THE PATIENT IS CLAUSTROPHOBIC AND CANNOT TOLERATE MRI EXAMINATION.
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.
186

Lower Extremity (Joint & Non-Joint)
CPT CODES:
73718........MRI lower extremity, other than joint, without contrast
73719........MRI lower extremity, other than joint, with contrast
73720........MRI lower extremity, other than joint, without contrast followed by re-imaging with contrast
73721........MRI lower extremity, any joint, without contrast
73722........MRI lower extremity, any joint, with contrast
73723........MRI lower extremity, any joint, without contrast followed by re-imaging with contrast

Scan coverage depends on the specific clinical indication and varies considerably, based on anatomic and clinical
considerations.
If medically appropriate, an MRI exam may be requested for each major area of the right and left lower
extremities:
Hip
Thigh
Knee
Lower Leg (calf)
Ankle
Foot (includes toes)
Routine MRI examinations provide multi-planar imaging of the joint or non-joint region(s) of interest.
Use of contrast (intravenous and intra-articular) is at the discretion of both the ordering and imaging physicians.
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.
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 Bakers cysts, ultrasound should be performed before advanced imaging exams.
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.
Conservative treatment includes 4-6 weeks of physical therapy, temporarily joint rest or immobilization and
187
MRI Lower Extremity (Joint & Non-Joint)
-
Biosafety Issues:

Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to MRI of the lower exteemity
(joint and non-joint)
symptoms.
COMMON DIAGNOSTIC INDICATIONS FOR LOWER EXTREMITY MRI:

The following diagnostic indications for Lower Extremity MRI are accompanied by pre-test considerations as well as supporting clinical
General Indications for Lower Extremity MRI

Additional Indications for the Hip Joint
Additional Indications for Knee Imaging
Additional Indications for Ankle and/or Foot Imaging
General Indications for Lower Extremity MRI:

SIGNIFICANT TRAUMA

FRACTURE EVALUATION

Requires initial plain films prior to advanced imaging

For femoral head osteonecrosis, pelvic MRI may be used to image both hips simultaneously
OSTEOCHONDRAL LESION (OCD)
188

-
Abscess
Inflammatory Myopathy
Myositis
Osteomyelitis
Septic Arthritis

JOINT LOCKING
JOINT INSTABILITY (SENSATION OF JOINT GIVING WAY)
Excluding a suspected Bakers cysts (in popliteal regions), which should be imaged initially with Ultrasound
TUMOR EVALUATION

BONE SCINTIGRAPHY ABNORMALITY
PERSISTENT LOWER EXTREMITY PAIN UNRESPONSIVE TO 4-6 WEEKS OF CONSERVATIVE TREATMENT
Initial assessment on conventional radiographs should be performed

MRI ACCOMPANYING AN ARTHROGRAM (MR ARTHROGRAPHY)
When ordered by a Specialty Consultant (e.g., Orthopedic Surgery, Sports Medicine and Podiatry)
Additional Indications for the Hip Joint:

OCCULT HIP FRACTURE
With high clinical suspicion and negative or inconclusive hip radiographs

LEGG-CALV PERTHES DISEASE
Eponym for osteonecrosis (infarction) of bony epiphysis in femoral heads, usually in 4-8 year old age range
Requires initial radiographic evaluation
SLIPPED CAPITAL FEMORAL EPIPHYSIS
Atraumatic fracture through the physeal plate; affected population is often overweight teenagers
Requires initial radiographic evaluation
LABRAL TEAR
Associated with pain, decreased range of motion and clicking in the hip joint
Additional Indications for Knee Imaging:

MENISCAL TEAR/INJURY
Suspected pre-operatively, based on physical exam findings which include but are not limited to:
-
McMurray test
Locking
189

-
Buckling sensation
Medial and/or lateral joint line tenderness
CRUCIATE (ANTERIOR AND/OR POSTERIOR) LIGAMENT TEAR
Suspected pre-operatively, based on physical exam findings which include but are not limited to:
-
Lachman test
Anterior and posterior drawer tests
COLLATERAL (MEDIAL AND LATERAL) LIGAMENTOUS TEAR

POSTEROLATERAL COMPLEX INJURY
POST-OPERATIVE EVALUATION FOLLOWING REPAIR OF A LIGAMENTOUS OR TENDINOUS TEAR, WITH NEW
SYMPTOMS
CHONDROMALACIA PATELLA
OSTEOCHONDRITIS DISSECANS
Marginal fracture involving the subchondral bone and/or adjacent cartilage

Medial femoral epicondyle is a frequent location
Additional Indications for Hip, Knee, Ankle and/or Foot Imaging:

LIGAMENT AND TENDON INJURIES
Including but not limited to the following tendons:
- Hamstring
- Quadriceps
- Achilles Tendon
- Posterior Tibial Tendon
- Anterior Tibial Tendon
- Peroneus Tendons
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
MORTONS NEUROMA
Following foot radiographs, when there is need for additional diagnostic information from an MRI exam to direct
treatment decisions (such as concern for an underlying infectious process)
DIABETIC FOOT DISEASE
Evaluation with advanced imaging is performed for infection (MRI) or ischemia (MRA)
For suspected osteomyelitis, radiographs should be performed prior to advanced imaging:
-
If findings are positive for osteomyelitis, the patient should be treated and advanced imaging may not be
190

-
required
If radiographs are negative and the clinical probability for osteomyelitis is low, scintigraphy may be performed
with either a triple-phase Technetium-99m bone scan or Indium-111 leukocyte scan
If radiographs are negative and clinical suspicion for osteomyelitis is high, MRI should be performed. Use of
intravenous contrast for MRI evaluation of the diabetic foot may be helpful, if not contraindicated.
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;40:289312.
6.
Helms CA. The Meniscus: Recent Advances in MR Imaging of the Knee. AJR 2002;179:1115-112.
7.
Jackson JL, OMalley 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.
10. Yu WD, Shapiro MS. Cysts and Other Masses About the Knee. Phys Sport Med 1999;27(7):59-68.
191

Lower Extremity
CPT CODES:
73706........ Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast
images, if performed, and image postprocessing
73725........ Magnetic resonance angiography, lower extremity, without and with contrast

Depends on the area of interest and may extend from the iliofemoral regions through the feet.
Other generally available non-invasive arterial studies of the lower extremity circulation should be considered prior
to advanced diagnostic imaging with CTA or MRA. These may include segmental systolic pressure measurements,
plethysmographic analysis, Continuous wave Doppler and/or duplex ultrasonography of the lower extremity arterial
or venous circulations.
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.
COMMON DIAGNOSTIC INDICATIONS FOR LOWER EXTREMITY CTA AND MRA:

The following diagnostic indications for Lower Extremity CTA and MRA are accompanied by pre-test considerations as well as supporting
Arterial Disorders:
VASCULAR ASSESSMENT FOR LOWER EXTREMITY CLAUDICATION
CPT Coding for Abdominal Aortic and Run-Off evaluation, which involves image post-processing for threedimensional reconstructions, should follow:
For CTA: 75635 - CTA of Abdominal Aorta and Bilateral Iliofemoral Lower Extremity Run-Off without contrast,
followed by re-imaging with contrast
- For MRA: 74185 - Abdominal MRA and 73725 - Bilateral Lower Extremity MRAs
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.
192
CTA/MRA Lower Extremity
PRE-OPERATIVE EVALUATION FOR KNOWN LOWER EXTREMITY PERIPHERAL ARTERIAL DISEASE
When conventional angiography is contraindicated and lower extremity ultrasound indicates significant disease,
but is insufficient for surgical planning
CRITICAL ISCHEMIA
For example, in diabetic vascular disease with ischemic ulcers or gangrene

ANEURYSM
DISSECTION
INTRAMURAL HEMATOMA
RAYNAUDS SYNDROME
VASCULITIS
ARTERIAL ENTRAPMENT SYNDROME
Venous Disorders:
VENOUS THROMBOSIS
VENOUS COMPRESSION, DUE TO SURROUNDING MASS EFFECT
Arterial and Venous Disorders:

ARTERIO-VENOUS MALFORMATION (AVM) OR FISTULA (AVF)
THROMBOEMBOLIC DISEASE Arterial or Venous
VASCULAR INVASION OR COMPRESSION BY A MUSCULOSKELETAL NEOPLASM
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
193
CTA/MRA Lower Extremity
Performance of MR Angiography. Radiology 2000; 217: 105-114.
11. Rofsky NM, Adelman MA. MR Angiography in the Evaluation of Atherosclerotic Peripheral Vascular Disease. Radiology
2000; 214: 325-338.
12. Ruehm SG, Wiesner W, Debatin JF. Pelvic and Lower Extremity Veins: Contrast-enhanced Three-dimensional MR
Venography with a Dedicated Vascular Coil-Initial Experience. Radiology 2000; 215: 421-427.
13. Swan JS, Carroll TJ, Kennell TW, et al. Time-Resolved Three-Dimensional Contrast-Enhanced MR Angiography of the
Peripheral Vessels. Radiology 2002;225:43-52.
14. Zhang HL, Khilnani NM, Prince MR, et al. Diagnostic Accuracy of Time-Resolved 2D Projection MR Angiography for
Symptomatic Infrapopliteal Arterial Occlusive Disease. AJR 2005; 184: 938-947.
194

Other PET Applications, including
Oncologic (Tumor) Imaging
CPT CODES:
DEDICATED PET IMAGING:
78811........PET imaging, limited area
78812........PET imaging, skull to mid-thigh
78813........PET imaging, whole body
PET/CT IMAGING:
78814 .......PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization;
limited area
skull base to mid-thigh
whole body
COMMONLY USED RADIOPHARMACEUTICAL/SCANNER:

2-(fluorine-18) fluoro-2-deoxy-d-glucose (FDG), performed on a dedicated PET or integrated (hybrid) PET/CT
scanner.
IMAGING CONSIDERATIONS FOR TUMOR IMAGING:

For PET tumor imaging, AIMs Guidelines will use the definitions for INITIAL TREATMENT STRATEGY (diagnosis,
staging), and SUBSEQUENT TREATMENT STRATEGY (restaging and treatment response monitoring) as provided
in the CMS National Coverage Determination for PET Scans. PET for tumor staging is covered subject to the
conditions below.
COMMON DIAGNOSTIC INDICATIONS FOR ONCOLOGIC PET:

The following diagnostic indications for PET Tumor Imaging (which includes Dedicated PET and PET/CT Exams) are accompanied by
pre-test considerations as well as supporting clinical data and prerequisite information:
AIMs Guidelines do not supersede the enrollees health plan specific medical policy for PET
usage.
AIMs Guidelines do not imply enrollee benefit coverage for all diagnoses and/or indications.
Benefit coverage is determined solely by the enrollees health plan.
PET or PET /CT is considered medically necessary when used for the following oncologic indications:
ONE INITIAL TREATMENT STRATEGY PET or PET/CT for a member with a biopsy-proven solid tumor listed
below or myeloma, or one of the tumors listed below which is strongly suspected based on other diagnostic testing
AND imaging results are required to determine at least one of the following:
Whether the patient is a candidate for an invasive diagnostic or therapeutic procedure, such as biopsy;
Or
The optimal anatomic location for an invasive procedure;

Or
The anatomic extent of malignancy when recommended therapy reasonably depends upon the extent of
malignancy;
195
PET - Applications including Oncologic

List of malignancies appropriate for Initial Treatment Strategy PET or PET/CT (with exceptions/special
considerations noted in parentheses for Melanoma, Breast, and Cervix):
Head and Neck, including:

- Lip, Oral Cavity, and Pharynx
- Nasal cavity, Ear, and Sinuses
- Eye
- Larynx
Brain and Spinal Cord
Digestive System, including:
- Esophagus
- Stomach
- Small Intestine
- Liver and Intrahepatic Bile Ducts
- Gallbladder & Extrahepatic Bile Ducts
- Pancreas
- Retroperitoneum and Peritoneum
- Colon and Rectum
- Anus
Thorax, including:
- Lung, Non-small Cell
- Lung, Small Cell
- Pleura
- Thymus, Heart, Mediastinum
Bone/cartilage and Connective/other Soft Tissue
Skin, including:
- Melanoma (PET or PET/CT is non-covered for initial staging of regional lymph nodes in patients with
melanoma, but is covered for detection of distant metastatic disease in high-risk patients with melanoma)
Non-melanoma skin (includes Basal Cell and Squamous Cell)
Kaposi's Sarcoma
Female and male breast (PET or PET/CT is non-covered for diagnosis of breast cancer to evaluate a
suspicious breast mass or for initial staging of axillary lymph nodes in patients with breast cancer. However,
PET or PET/CT is covered for initial treatment strategy evaluation of a patient with axillary nodal metastasis of
unknown primary origin, in a patient with a paraneoplastic syndrome potentially caused by an occult breast
cancer, and for detection of distant metastatic disease in high-risk patients with known breast cancer)
Urogenital organs, including:
- Uterus and Adnexa
- Cervix (only if a prior CT or MRI has been negative for extrapelvic metastatic disease)
- Placenta
- Ovary
- Other Female Genitalia
- Testis
- Penis and other Male Genitalia
- Bladder
- Kidney
Thyroid and other endocrine glands and related structures (includes Pituitary and Adrenal)
Cancer of unknown primary origin
Lymphoma (Hodgkins and Non-Hodgkins)
Myeloma
Neuroendocrine tumor
Other solid tumor not listed except Prostate and Leukemia which are not medically necessary
PET or PET/CT for SUBSEQUENT TREATMENT STRATEGY (to assist the physician in the determination of
optimal subsequent anti-tumor treatment strategies) is medically necessary only for the following malignancies
Head and Neck (non-CNS) including:

- Lip, Oral Cavity, and Pharynx
- Nasal Cavity, Ear, and Sinuses
- Larynx
Esophagus
196
Colon and Rectum

Lung, Non-Small Cell only
Melanoma
Female and Male Breast
Cervix
Ovary
Lymphoma
Myeloma
Thyroid (follicular cell origin only, having been previously treated by thyroidectomy and radioiodine ablation, with
a current serum thyroglobuilin > 10 ng/mL, and with a negative whole-body I-131 scan within the previous 60
days)
SURVEILLANCE OF ASYMPTOMATIC PATIENTS AFTER THERAPY FOR MALIGNANCY
PET or PET/CT is considered not medically necessary for patients who have completed therapy twelve (12) or
more months ago for lymphoma or six (6) or more months ago for all other malignancies unless the patient
demonstrates signs, symptoms, laboratory or other objective findings suggestive of recurrence or spread of the
original malignancy
SCREENING: PET or PET/CT IS NOT COVERED AS A SCREENING TEST (I.E., FOR EVALUATION OF
PATIENTS WITHOUT SPECIFIC SIGNS AND SYMPTOMS OF DISEASE).
COMMON DIAGNOSTIC INDICATIONS FOR PET IMAGING OF INFECTIOUS

PROCESSES:
FOR DIAGNOSIS OF CHRONIC OSTEOMYELITIS INVOLVING THE AXIAL SKELETON
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Aassar OS, Fischbein NJ, et al. Metastatic head and neck cancer: role and usefulness of FDG PET in locating occult
primary tumors. Rad. 1999; 210(1):177-181.
Adams E, Asua J, Conde Olasagasti J, et al. Positron emission tomography: experience with PET and synthesis of the
evidence (INAHTA Joint Project). Boston, MA: U.S. Department of Veterans Affairs.1999: 41.
Albernini JL, Belhocine T, Hustinx R, et al. Whole-body positron emission tomography using fluorodeoxyglucose in
patients with metastases of unknown primary tumors (CUP syndrome). Nuclear Medicine Communications. 2003;
24:1081-1086.
Alavi A, Editor. PET Imaging I. Radiologic Clinics of North America; 42(6). Philadelphia: W.B. Saunders; 2004.
Alavi A, Editor. PET Imaging II. Radiologic Clinics of North America; 43(1). Philadelphia: W.B. Saunders; 2005.
Antoch G, Beyer T et al. PET/CT or CT/PET? A radiologists perspective. Electromedica. 2003; 71(1):64-69.
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.
Avril NE, Weber WA. Monitoring response to treatment in patients utilizing PET. Radiol Clin N Am. 2005; 43:189-204.
Bastiaannet E, Groen H, Jager PL, et al. The value of FDG-PET in the detection, grading and response to therapy of soft
tissue and bone sarcomas; a systematic review and meta-analysis. Cancer Treatment Reviews. 2004; 30:83-101.
Berberat P, Friess H, et al. Diagnosis and staging of pancreatic cancer by positron emission tomography. World J Surg.
1999; 23(9):882-887.
Bernal B, Altman NR. Evidence-based medicine: neuroimaging of seizures. Neuroimag Clin N Am. 2003; 13:211-224.
Beyer L. et al. Dual-modality PET/CT tomography for clinical oncology. Q J Nucl Med. 2002 Mar; 46(1):24-34.
Bohuslavizki KH, Klutmann, Kroger S, et al. FDG PET detection of unknown primary tumors. J Nucl Med. 2000; 41(5):
816-822.
Brandt-Mainz K, Muller ST, et al. The value of flourine-18 fluorodeoxyglucose PET in patients with medullary thyroid
cancer. Eur J Nuc Med. 2000; 27:490-496.
Bristow RE, Simpkins F, et al. Positron emission tomography for detecting clinically occult surgically resectable metastatic
ovarian cancer. Gynecologic Oncology. 2002; 85:196-200.
Bristow RE, et al. Clinically occult recurrent ovarian cancer: patient selection for secondary cytoreductive surgery using
combined PET/CT. Gynecol Oncol. 2003 Sep; 90(3):519-528.
Brucher BL. Neoadjuvant therapy of esophageal squamous cell carcinoma: response evaluation by positron emission
tomography. Ann Surg. 2001; 233(3):300-309.
Burcombe RJ, et al. Evaluation of good clinical response to neoadjuvant chemotherapy in primary breast cancer using F18 flurodeoxyglucose positron emission tomography. Eur J Cancer. 2002: 38:375-379.
Caputo FM, Buquicchio GL. Esophageal cancer staging: the role of radiology. Rays. 2005; 30(4):309-314.
Castro P, Bourge R, Foster R. Evaluation of hibernating myocardium in patients with ischemic heart disease. Am J of
Med. 1998; 104(1): 69-77.Chang CH, Shiau YC, Shen YY, et al. Differentiating solitary pulmonary metastases in patients
with renal cell carcinomas by 18F-Fluoro-2-Deoxyglucose positron emission tomography a preliminary report. Urologia
Int. 2003; 71:306-309.
Crymes WB, Demos H, Gordon L. Detection of musculoskeletal infection with 18F-FDG PET: review of the current
197
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
literature. J Nucl Med Technol. 2004; 32:12-15.

Delbeke D. Oncological applications of FDG PET imaging: Brain tumors, colorectal cancer lymphoma and melanoma. J
Nucl Med. 1999; 40:591-603.
Delbeke D, Martin WH. Positron emission tomography imaging in oncology. Radiol Clin North Am. 2001; 39(5):883-917.
Delbeke D, Rose DM, et al. Optimal interpretation of FDG PET in the diagnosis, staging and management of pancreatic
carcinoma. J Nucl Med. 1999; 40(11):1784-1791.
de Leon MJ, McRae T, Rusinek H, et al. Cortisol reduces hippocampal glucose metabolism in normal elderly, but not in
Alzheimer's disease. J Clin Endocrinol Metab. 1997; 82(10):3251-3259.
Delgado-Bolton RC, Fernandez-Perez C, Gonzalez-Mate A, et al. Meta-analysis of the performance of 18-FFDG PET in
primary tumor detection in unknown primary tumors. J Nucl Med. 2003; 44:1301-1314.
De Winter F, Van de Wiele C, Vogelaers D, et al. Fluorine-18 fluorodeoxyglucose positron emission tomography: a
highly accurate imaging modality for the diagnosis of chronic musculoskeletal infections. J Bone Joint Surg. 2001;
83:651-660.
Di Carli M, Maddahi J, et al. Long-term survival of patients with coronary artery disease and left ventricular dysfunction:
implications for the role of myocardial viability assessment in management decisions. J Thor Cardiovasc Surg. 1998;
116(6):997-1004.
Diehl M, Risse JH, Brandt-Mainz K, et al. Fourine-18 flurodeoxyglucose positron emission tomography in medullary
thyroid cancer: results of a multicenter study. Eur J Nuc Med. 2001; 28:1671-1676.
Eubank WB, et al. 18-Flurodeoxyglucose positron emission tomography to detect mediastinal or internal mammary
metastases in breast cancer. J Clin Oncol. 2001; 19:3516-3523.
Flamen P, Stroobants S, et al. Additional value of whole-body positron emission tomography with Fluorine-18-2-fluoro-2deoxy-D-glucose in recurrent colorectal cancer. J Clin Oncol. 1999: 17(3):894-901.
Flamen P, Lerut A, et al. The utility of positron emission tomography for the diagnosis and staging of recurrent
esophageal cancer. J Thorac Cardiovasc Surg. 2000; 120(6):1085-1092.
Frilling A, et al. Preoperative diagnostic value of F-18 Flurodeoxyglucose positron emission tomography in patients with
radioiodine-negative recurrent well-differentiated thyroid carcinoma. Ann Surg. 2001; 234(6): 804-811.
Gill SS, Rochon PA, Guttman M, et al. The value of positron emission tomography in the clinical evaluation of dementia. J
Am Geriatr Soc. 2003; 51:258-264.
Goldstein D, Tan BS, Rossleigh M, et al. Gastrointestinal stromal tumors: correlation of F-FDG gamma camera-based
coincidence positron emission tomography with CT for the assessment of treatment response an AGITG Study.
Oncology. 2005; 69:326-332.
Gould MK, Maclean CC et al. Accuracy of positron emission tomography for diagnosis of pulmonary nodules and mass
lesions. JAMA. 2001; 285(7):914-924.
Greco M, Crippa F, Agresti R, et al. Axillary lymph node staging in breast cancer by 2-fluoro-2-deoxy-Dglucose-positron
emission tomography: clinical evaluation and alternative management. J Natl Cancer Inst. 2001; 93(8):630-635.
Gyorke T, Zajic T, Lange A, et al. Impact of FDG PET for staging of Ewing sarcomas and primitive neuroectodermal
tumours. Nucl Med Communications. 2006; 27:17-24.
Hartmann A, Eid K, Dora C, et al. Diagnostic value of 18F-FDG PET/CT in trauma patients with suspected chronic
osteomyelitis. Eur J Nucl Med Mol Imaging. 2006.
Holder W, White R, et al. Effectiveness of positron emission tomography for the detection of melanoma metastases. Ann
Surg. 1998; 227(5):764-771.
Hustinx R, Pourdehnad M, Kaschten B, Alavi A. PET imaging for differentiating recurrent brain tumor from radiation
necrosis. Radiol Clin N Am. 2005; 43:35-47.
Ilknur A, Stokkel MPM, Pauwels EKJ. Positron emission tomography with 1-18-Fluro-2-deoxy-D-glucose in oncology: part
II the clinical value in detecting and staging primary tumors. J Cancer Res Clin Oncol. 2000; 126:560-574.
Imdahl A, Nitzsche E. et al. Evaluation of positron emission tomography with 2-[(18) F] fluoro-2-deoxy-Dglucose for the
differentiation of chronic pancreatitis and pancreatic cancer. The Br J Surg. 1999; 86(2):194-199.
Jeong YJ, Yi CA, Lee KS. Solitary Pulmonary Nodules: Detection, Characterization, and Guidance for Further Diagnostic
Workup and Treatment. AJR 2007; 188: 57-68.
Jerusalem G, Beguin Y, et al. Whole-body positron emission tomography using F-fluorodeoxyglucose for post -treatment
evaluation in Hodgkins disease and non-Hodgkins lymphoma has higher diagnostic and prognostic value than classical
computed tomography scan imaging. Blood. 1999: 94 (2):429-433.
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.
Johnson GR, Zhuang H, Khan J, et al. Roles of positron emission tomography with fluorine-18-deoxyglucose in the
detection of local recurrent and distant metastatic sarcoma. Clinical Nuclear Medicine. 2003; 28:815- 820.
Juweid ME, Cheson BD. Positron-emission tomography and assessment of cancer therapy. N Engl J Med. 2006;
354:496-507.
Kato H, Kuwana H, et al. Usefulness of positron emission tomography for assessing the responsiveness of neoadjuvant
chemoradiotherapy in patients with esophageal cancer. Am J Surg. 2002; 184(3).
Kattlove H, Winn RJ. Ongoing care of patients after primary treatment for their cancers. CA Cancer J Clin. 2003; 54:172196.
Keogan MT, Lowe VJ, Baker ME, et al. Local recurrence of rectal cancer: Evaluation with F-18 flurodeoxyglucose PET
imaging. Abdom Imaging. 1997; 22:332-337.
Khalkhali I, Vargas HI. The role of nuclear medicine in breast cancer detection. Rad Clin North Am. 2001; 39(5):10531068.
Khandani AH, Wahl RL. Applications of PET in liver imaging. Radiol Clin N Am. 2005; 43:849-60.
Kim, EE, Lee M-C, Inoue T, et al, Editors. Clinical PET Principles and Applications. New York: Springer-Verlag; 2004.
Kim TS, Moon WK, Lee DS, Chung JK, Lee MC, Youn YK, Oh SK, Choe KJ, Noh DY. Fluorodeoxyglucose positron
emission tomography for detection of recurrent or metastatic breast cancer. World J Surg. 2001; 25(7):829-834.
198
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
Kipper MS. Clinical applications of positron emission tomography. Applied Radiology. November 2002. Available at:
www.appliedradiology.com. Accessed on March 31, 2009.
Kole AC, Wieweg OE, Pruim J, et al. Detection of unknown occult primary tumors using positron emission tomography.
Cancer. 1998; 82(6) 1160-1166.Kostakoglu L, Leonard JP, et al. Comparison of flourine-18 fluorodeoxyglucose positron
emission tomography and GA-67 scintigraphy in evaluation of lymphoma. Cancer. 200
Kostakoglu L, Agress H, Goldsmith SJ. Clinical Role of FDG PET in Evaluation of Cancer Patients. RadioGraphics 2003;
23: 315-340.
Kumar R, Maillard I, Schuster SJ, Alavi A. Utility of fluorodeoxyglucose-PET imaging in the management of patients with
Hodgkins and non-Hodgkins lymphomas. Radiol Clin N Am. 2004; 42:1083-1100.
Kumar R, Chauhan A, Zhuang H, et al. Clinicopathologic factors associated with false negative FDG-PET in primary
breast cancer. Breast Can Res Treat. 2006; 98:267-274.
Lardinois D, et al. Staging of Non-Small-Cell Lung Cancer with Integrated Positron Emission Tomography and Computed
Tomography. NEJM. 2003; 25(348); 2500-2507.
Lassen U, Daugaard G, et al. 18F-FDG whole body positron emission tomography in patients with unknown primary
tumors (UPT). Eur J Cancer. 1999; 35(7) 1076- 1085.
Leitch MA. Whats new in surgical oncology? Journal of the American College of Surgeons. 2001; 192:624-639.
Lerut T, Flamen P, et al. Histopathologic validation of lymph node staging with FDG-PET scans in cancer of the
esophagus and gastroesophageal junction: a prospective study based on primary surgery with extensive
lymphadenectomy. Ann Surg. 2000; 232(6):742-752.
Leung JWT. New modalities in breast imaging: Digital mammography, positron emission tomography, and sestamibi
scintimammography. Radiol Clin N Am. 2002; 40:467-482.
Line BR, Maragh MR, Ahamed T. Positron emission tomography imaging of lung and esophageal cancer. Applied
Radiology. June 2002. Available at: www.appliedradiology.com. Accessed on March 31, 2009.
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
Makhija S, Howden N, et al. Positron emission tomography/computed tomography imaging for the detection of recurrent
ovarian and fallopian tube carcinoma: a retrospective review. Gynecologic Oncology. 2003; 85:53-58.
Mankoff DA, Shields AF, Krohn KA. PET imaging of cellular proliferation. Radiol Clin N Am. 2005; 43:153-167.
Mantaka P, Baum RP, Hertel A, et al. PET with 2-[F-18]-fluoro-2-deoxy-D-glucose (FDG) in patients with cancer of
unknown primary (CUP): influence on patients diagnostic and therapeutic management. Cancer Biotherapy &
Radiopharmaceuticals. 2003; 18:47-58.
Mavi A, Lakhani P, Zhuang H, et al. Fluorodeoxyglucose-PET in characterizing solitary pulmonary nodules, assessing
pleural diseases, and the initial staging, restaging, therapy planning and monitoring response of lung cancer. Radiol Clin
N Am. 2005; 43:1-21.
McCarville MB, Christie R, Daw NC, et al. PET/CT in the evaluation of childhood sarcomas. Am J Rad. 2005; 184:12931304.
McDougall IR, Davidson J, Segall GM. Positron emissions tomography of the thyroid, with an emphasis on thyroid cancer.
Nuclear Med Comm. 2001; 22:485-492.
Meller J, Koster G, Liersch T, et al. Chronic bacterial osteomyelitis: prospective comparison of 18F-FDG imaging with a
dual-head coincidence camera and 111In-labeled autologous leucocyte scintigraphy. Eur J Nucl Med. 2002; 29:53-60.
Meltzer CC, Luketich JD, et al. Whole-body FDG positron emission tomographic imaging for staging esophageal cancer
comparison with computed tomography. Clin Nucl Med. 2000; 25(11): 882-887.
Mester U, Goor O, Lerman H, et al. PET-CT of Extranodal Lymphoma. AJR 2004; 182: 1579-1586.
Menzel C, Gratchen S, et al. Monitoring the efficacy of Iodine-131-MIBG therapy using Flourine-18-FDGPET. Acta Med
Austriaca. 2003; 30:37-40.
Moog F, Kotzerke J, Reske SN. FDG PET can replace bone scintigraphy in primary staging of malignant lymphoma. J
Nucl Med. 1999; 40(9):1407-1413.
Nakamoto Y, Higashi T. et al. Evaluation of pancreatic islet cell tumors by fluorine-18 fluorodeoxyglucose positron
emission tomography: comparison with other modalities. Clin Nuclear Med. 2000; 25(2):115-119.
Ost D, Fein AM, Feinsilver SH. The solitary pulmonary nodule. N Engl J Med. 2003; 348:2535-2542.
Ott K, Fink U, Becker K, et al. Prediction of response to preoperative chemotherapy in gastric carcinoma by metabolic
imaging: results of a prospective trial. J Clin Oncol. 2003; 21:4604-4610.
Papos M, et al. The possible role of F-18 FDG positron emission tomography in the differential diagnosis of focal
pancreatic lesions. Clin Nuclear Med. 2002; 27 (3):197-201.
Port JL, Kent MS, Korst RJ, et al. Positron emission tomography scanning poorly predicts response to preoperative
chemotherapy in non-small cell lung cancer. Ann Thorac Surg. 2004; 77:254-259.
Rajendran J. Positron emission tomography in head and neck cancer. Applied Radiology. June 2003. Available at:
www.appliedradiology.com. Accessed on March 31, 2009.
Reske SN, Kotzerke J. FDG-PET for clinical use: results of the 3rd German interdisciplinary consensus conference
Onko-PET III, 21 July and 19 September 2001. Eur J Nuc Med. 2001; 28(11):1707-1723.
Rohren EM, Turkinton TG, Coleman RE. Clinical Applications of PET in Oncology. Radiology 2004; 231: 305-332.
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.
Safa AA, Tran LM, Rege S, et al. The role of positron emission tomography in occult primary head and neck cancers.
Cancer J Sci Am. 1999; 5(4):214-218.
Schiesser M, Stumpe KDM, Trentz O, et al. Detection of metallic implant-associated infections with FDG PET in patients
with trauma: correlation with microbiologic results. Radiology. 2003; 226:391-398.
Schirrmeister H, Kuhn T, Guhlmann A, et al. Fluorine-18 2-deoxy-2-fluoro-D-glucose PET in the preoperative staging of
breast cancer: comparison with the standard staging procedures. Eur J Nucl Med. 2001; 28(3):351-358.
Schoder H, et al. PET/CT in Oncology: Integration into clinical management of lymphoma, melanoma, and
199
92.
93.
94.
95.
96.
97.
98.
99.
100.
101.
102.
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
114.
115.
116.
117.
118.
119.
120.
121.
122.
123.
gastrointestinal malignancies. Journal of Nuclear Medicine. 2004; 45:72S-81S.

Schoder H., et al. Head and Neck Cancer: Clinical usefulness and accuracy of PET/CT image fusion. Radiology. 2004;
31(1):65-72.
Schuhmacher J, Kaul S, et al. Immunoscintigraphy with positron emission tomography: gallium-68 chelate imaging of
breast cancer pretargeted with bispecific anti-muci/anti-ga chelate antibodies. Cancer Research. 2001; 61:3712-3717.
Serafini AN, Klein JL, et al. Radioimmunoscintigraphy of recurrent, metastatic, or occult colorectal cancer with technetium
99m-labeled totally human monoclonal antibody 88BV59: results of pivotal, phase III multicenter studies. JCO. 1998;
16(5):1777-1787.
Shiraki N, Hara M, Ogino H, et al. False-positive and true-negative hilar and mediastinal lymph nodes on FDG-PET:
radiological-pathological correlation. Annals of Nuclear Medicine. 2004; 18:23-28.
Shvarts O, Han K, et al. Positron emission tomography in urologic oncology. Cancer Control. 2002; 9(4):335-342.
Silverman DHS, Small GW, Chang CT, et al. Positron emission tomography in evaluation of dementia: regional brain
metabolism and long term outcome. JAMA. 2001; 2120-2127.
Smith GT, Habner KF, et al. Cost analysis of FDG PET for managing patients with ovarian cancer. Clinical Positron
Imaging. 1999; 2(2):63-70.
Smith IC, Ogston KN, Whitford P, et al. Staging of the axilla in breast cancer. Ann Surg. 1998; 228(2):220-227.
Sperti C, et al. Value of 18-flurodeoxyglucose positron emission tomography in the management of patients with cystic
tumors of the pancreas. Ann Surg. 2001; 234(5):675-680.
Stokkel MP, Broek FW, et al. Preoperative evaluation of patients with primary head and neck cancer using dual-head
18fluorodeoxyglucose positron emission tomography. Ann of Surg. 2000; 231(2):229-234.
Sugawara Y, Zasadny K, et al. Germ cell tumor: differentiation of viable tumor, mature teratoma, and necrotic tissue with
FDG PET and kinetic modeling. Radiology. 1999; 211(1):249-256.
Tai YF, Piccini P. Applications of positron emission tomography (PET) in neurology. J Neurol Neurosurg Psychiatry. 2004;
75:669-676.
Takeuchi O, Saito O, Koda K, et al. Clinical assessment of positron emission tomography for the diagnosis of local
recurrence in colorectal cancer. Br J Surg. 1999; 85:932-937.
Tamaki N, Kawamoto M, et al. Coronary heart disease/myocardial infarction: prediction of reversible ischemia after
revascularization: perfusion and metabolic studies with positron emission tomography. Circulation. 1995; 91(6):16971705.
Termaat MF, Raijmakers PGHM, Scholten HJ, et al. The accuracy of diagnostic imaging for the assessment of chronic
osteomyelitis: a systematic review and meta-analysis. J Bone Joint Surg. 2005; 87(11):2464-2471.
Thiel A, Pietrzyk U, et al. Enhanced accuracy in differential diagnosis of radiation necrosis by positron emission
tomography-magnetic resonance imaging co-registration: technical case report. Neurosurg. 2000; 46(1):232-234.
Townsend DW, Beyer T, Blodgett T. PET/CT scanners: a hardware approach to image fusion. Seminars in Nuclear
Medicine. 2003; 33(3):193-204.
Valk P, et al. Whole-body PET imaging with (18 F) fluorodeoxyglucose in management of recurrent colorectal cancer.
Arch Surg. 1999; 134(5):503-511.
Vansteenkiste J, Fischer BM, Dooms C, Mortensen J. Positron-emission tomography in prognostic and therapeutic
assessment of lung cancer: systematic review. Lancet Oncol. 2004; 5:531-540.
Vansteenkiste JF, Stroobants SG. Positron emission tomography in the management of non-small cell lung cancer.
Hematol Oncol Clin N Am. 2004; 18:269-288.
Vitola JZ, Delbeke D, et al. Positron emission tomography to stage suspected metastatic colorectal carcinoma to the liver.
Am J Surg. 1996; 171 (1):21-26.
Vranjesevic D, et al. Whole body F-18 FDG PET and conventional imaging for predicting outcome in previously treated
breast cancer patients. J Nucl Med. 2002; 43:325-329.
Wahl RL. Current Status of PET in breast cancer imaging, staging and therapy. Sem in Roentgenology. 2001; 36(3):250260.
Wahl RL, Siegel BA, Coleman RE, et al. Prospective multicenter study of axillary nodal staging by positron emission
tomography in breast cancer: a report of the staging breast cancer with PET study group. J Clin Oncol. 2004; 22:277-285.
Weber WA, Petersen V, Schmidt B, et al. Positron emission tomography in non-small-cell lung cancer: prediction of
response to chemotherapy by quantitative assessment of glucose use. J Clin Oncol. 2003; 21:2651-2657.
Whiteford MH, et al. Usefulness of FDG PET scan in the assessment of suspected metastatic or recurrent
adenocarcinoma of the colon and rectum. Dis Colon Rectum. 2000; 43(6):759-770.
Yang SN, Liang JA, Lin FJ, et al. Comparing whole body (18)F-2-deoxyglucose positron emission tomography and
technetium-99m methylene diphosphonate bone scan to detect bone metastases in patients with breast cancer. J Cancer
Res Clin Oncol. 2002; 128(6):325-328.
Yen RF, Sun SS, Shen YY, et al. Whole body positron emission tomography with 18F-fluoro-2-deoxyglucose for the
detection of recurrent ovarian cancer. Anticancer Res. 2001; 21(5):3691-3694.
Yeo JS, et al. F-18 flurodeoxyglucose positron emissions tomography as a presurgical evaluation modality for 1-131 scan
negative thyroid carcinoma patients in cervical lymph nodes. Head Neck. 2001; 23:94-103.
Yoshida Y, Kurokawa T, Kawahara K, et al. Incremental benefits of FDG positron emission tomography over CT alone for
the preoperative staging of ovarian cancer. AJR. 2004; 182:227-233.
Zimny M, Siggelkow W, Schroder W, et al. 2-[Fluorine-18]-fluoro-2-deoxy-d-glucose positron emission tomography in the
diagnosis of recurrent ovarian cancer. Gynecol Oncol. 2001; 83(2):310-315.
Zhuang H, Kumar R, Mandel S, Alavi A. Investigation of thyroid, head and neck cancers with PET. Radiol Clin N Am.
2004; 42:1101-1111.
200
Magnetic Resonance
Spectroscopy (MRS)
CPT CODES:
76390 ..... Magnetic Resonance Spectroscopy (MRS)

Application of MRS has been described in multiple anatomic areas, to further evaluate the biochemical properties
of specific tissues.
BACKGROUND:
MR Spectroscopy is not currently a covered benefit by the Centers for Medicare and Medicaid Services, through
a National Coverage Determination.
MR spectroscopy provides a biochemical profile of different metabolic constituents in tissues. When MRS is
performed, metabolites which may be measured include Choline (Cho), N-Acetyl Aspartate (NAA), Creatine (Cr),
lactate and lipid.
Certain ratios of metabolites have been described as suggestive of high grade malignancy. An example is a
Choline/Creatine ratio greater the 2:1, compared with the normal ratio from spectroscopic data of approximately
1.
When performed, MRS usually accompanies an MRI exam.

Potential uses of MRS that have been described include neuroimaging of brain tissue (for brain tumor
differentiation from non-tumor conditions such as necrosis and abscess; cerebrovascular accident; dementia;
epilepsy; Parkinsons disease; mitochondrial disorders), breast lesion assessment and evaluation of lower
extremity ischemia.
MAGNETIC RESONANCE SPECTROSCOPY:

MR Spectroscopy is an evolving technology under clinical development. This technology and its impact on
health outcomes will continue to undergo review, as new evidence-based studies are published. Interval
routine coverage for MR spectroscopy is not generally available and is not considered the standard of care at
this time.
201

Bone Marrow Blood Supply
CPT CODES:
77084 ........MRI of Bone Marrow Blood Supply

MRI of the Bone Marrow Blood Supply is used to image multiple anatomic areas in the axial and appendicular
skeleton.
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
-
Biosafety Issues:

Ordering Issues:
This guideline does not supersede the enrollees health plan medical policy specific to bone marrow blood supply
MRI.
symptoms.
MRI OF THE BONE MARROW BLOOD SUPPLY:

Indications for MRI of the Bone Marrow:
HEMATOLOGICAL MALIGNANCIES ARISING IN THE BONE MARROW, INCLUDING MULTIPLE MYELOMA AND
LEUKEMIA
202
MRI - Bone Marrow Blood Supply
MRI OF THE BONE MARROW BLOOD SUPPLY:

To evaluate initial tumor burden within the bone marrow, from neoplastic infiltration and marrow replacement
To assess post-treatment response to therapy
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 Imaging of the Bone Marrow in the
Determination of Prognosis. Radiology 1996; 201: 243-246.
203
Quantitative CT (QCT)
Bone Mineral Densitometry
CPT CODES:
77078 ..... Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips,
pelvis, spine)
77079 ..... Computed tomography, bone mineral density study, 1 or more sites; appendicular skeleton
(peripheral) (e.g., radius, wrist, heel)

For central QCT, spine and hip measurements are obtained
For peripheral QCT, forearm, wrist (distal radius and ulna) and/or heel measurements are usually acquired
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.
COMMON DIAGNOSTIC INDICATIONS FOR QUANTITATIVE CT FOR BONE MINERAL

DENSITY:
The following diagnostic indications for Quantitative CT to assess Bone Mineral Density are accompanied by
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
- Cushings syndrome
- Delayed menarche or untreated premature menopause
- Heavy alcohol consumption
- Hypercalciuria
- Hypogonadism
- Inflammatory bowel disease
204
QCT Bone Mineral Densitometry
COMMON DIAGNOSTIC INDICATIONS FOR QUANTITATIVE CT FOR BONE MINERAL

DENSITY:
-
Low trauma fractures or vertebral fractures

Malabsorption syndromes
Primary hyperparathyroidism
Prolonged immobilization
Radiographic evidence of osteopenia
Rheumatoid arthritis
Thyroid disease
Anyone on a medication associated with development of osteoporosis.

Including but not limited to the following medications:
- Glucocorticoids (e.g., prednisone, prednisolone, decadron, 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 (e.g., adjuvant chemotherapy in many premenopausal females with
breast cancer)
- Proton Pump Inhibitors (PPI) and Histamine-2 (H2) receptor blockers for Gastroesophageal Reflux Disease
in patients over 50 years of age, under treatment for > 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
Indications for Peripheral (Appendicular) Quantitative CT (pQCT)

EVALUATION OF BONE MINERAL DENSITY WHEN THE FOLLOWING CRITERIA IS MET:
Evaluation of anyone with asymptomatic primary hyperparathyroidism
1.
Lentle BC, Prior JC. Prior Osteoporosis: What a Clinical Expects to learn from a Patients 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). Physicians 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.
205
QCT Bone Mineral Densitometry
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.
206

Aim Guidelines

Hochgeladen von

Dokumentinformationen

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Aim Guidelines

Hochgeladen von

Copyright:

Verfügbare Formate

Diagnostic Imaging

Proprietary and Confidential

Copyright 2009, American Imaging Management, Inc. All Rights Reserved.

CT Cardiac (Quantitative Evaluation of Coronary Calcification) ......................................................... 106

Abdominal & Pelvic Imaging

Upper Extremity Imaging

Lower Extremity Imaging

PET Imaging - Other Including Oncologic

The Guidelines do not address coverage, benefit or other plan

AIMs Practice Guidelines Define the Optimal Approaches for

To assist the practitioner as an educational tool

To curtail the performance of inappropriate, elective diagnostic imaging studies

To reduce the performance of duplicative diagnostic imaging studies

AIM Guideline Development Process and Resources:

American College of Radiology (ACR) Appropriateness Criteria

Independent Physician Review Board: AIMs Physician Specialty Advisory Panel

Guideline: Simultaneous Ordering of

COMMON DIAGNOSTIC INDICATIONS FOR MULTIPLE SIMULTANEOUS IMAGING REQUESTS:

The initial diagnosis/staging or follow-up of oncology patients

COMMON INAPPROPRIATE MULTIPLE SIMULTANEOUS IMAGING REQUESTS:

Multiple Imaging Tests

Computed Tomography (CT)

STANDARD ANATOMIC COVERAGE:

Contrast-enhanced CT may be contraindicated in certain circumstances, such as a documented allergy to

COMMON DIAGNOSTIC INDICATIONS FOR HEAD CT:

CT is the imaging modality of choice for evaluation of:

acute intra-cranial hemorrhage (parenchymal, subarachnoid, subdural and epidural hematomas);

COMMON DIAGNOSTIC INDICATIONS FOR HEAD CT:

ABNORMALITIES DETECTED ON OTHER IMAGING STUDIES WHICH REQUIRE ADDITIONAL CLARIFICATION

Including but not limited to the following conditions:

Initial evaluation, if MRI is contraindicated, or

In developmental delay, MRI is the preferred imaging modality over CT

COMMON DIAGNOSTIC INDICATIONS FOR HEAD CT:

Sudden onset and severe, including thunderclap or worst headache of life; or

Sudden onset and severe, including thunderclap or worst headache of life; or

CT is the preferred technique for evaluation of acute intra-cranial hemorrhage 14-15

COMMON DIAGNOSTIC INDICATIONS FOR HEAD CT:

Including but not limited to the following:

Ataxia (loss of coordination) and Spasticity

MRI is usually preferred over CT for evaluation of pituitary lesions

SENSORINEURAL HEARING LOSS, DOCUMENTED BY AUDIOLOGY

COMMON DIAGNOSTIC INDICATIONS FOR HEAD CT:

Particularly when associated with:

Calvarial fracture (as demonstrated on plain film radiography)

Focal Neurological Deficits

TUMOR EVALUATION BENIGN AND MALIGNANT:

Including but not limited to the following lesions:

Primary Intra-cranial Tumors

Intra-axial Neoplasms of the Cerebrum and Cerebellum

Examples include suspected Arachnoid Cyst or Epidermoid Cyst

Including but not limited to:

Abnormal hearing test or Auditory Brainstem Response

STANDARD ANATOMIC COVERAGE:

COMMON DIAGNOSTIC INDICATIONS FOR HEAD CTA:

Including but not limited to:

Follow-up of known or suspected intra-cranial aneurysm, or

CONGENITAL ANOMALIES OF THE CEREBRAL CIRCULATION

CTA Head: Cerebrovascular

COMMON DIAGNOSTIC INDICATIONS FOR HEAD CTA:

For identification of the source of hemorrhage

Requires referral from a Neurosurgeon or Neurologist

RECENT CEREBROVASCULAR ACCIDENT (CVA)

Demonstrated on head CT or MRI

Common clinical manifestations may include: