Cigna Medical Coverage Policies – Radiology Chest Imaging Effective November 15, 2018

______Instructions for use The following coverage policy applies to health benefit plans administered by Cigna. Coverage policies are intended to provide guidance in interpreting certain standard Cigna benefit plans and are used by medical directors and other health care professionals in making medical necessity and other coverage determinations. Please note the terms of a customer’s particular benefit plan document may differ significantly from the standard benefit plans upon which these coverage policies are based. For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a coverage policy.

In the event of a conflict, a customer’s benefit plan document always supersedes the information in the coverage policy. In the absence of federal or state coverage mandates, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of:

1. The terms of the applicable benefit plan document in effect on the date of service 2. Any applicable laws and regulations 3. Any relevant collateral source materials including coverage policies 4. The specific facts of the particular situation

Coverage policies relate exclusively to the administration of health benefit plans. Coverage policies are not recommendations for treatment and should never be used as treatment guidelines.

This evidence-based medical coverage policy has been developed by eviCore, Inc. Some information in this coverage policy may not apply to all benefit plans administered by Cigna.

These guidelines include procedures eviCore does not review for Cigna. Please refer to the Cigna CPT code list for the current list of high-tech imaging procedures that eviCore reviews for Cigna.

CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in the CPT® book. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.

Imaging Guidelines V20.0.2018

Chest Imaging Guidelines Abbreviations for Chest Guidelines ...... 3 CH-1: General Guidelines ...... 5 CH-2: Lymphadenopathy ...... 9 CH-3: Cough ...... 12 CH-4: Non-Cardiac Chest Pain ...... 14 CH-5: Dyspnea/Shortness of Breath ...... 17 CH-6: Hemoptysis ...... 19 CH-7: Bronchiectasis ...... 21 CH-8: Bronchitis ...... 23 CH-9: Asbestos Exposure ...... 25 CH-10: Chronic Obstructive Pulmonary Disease (COPD) ...... 27 CH-11: Interstitial Disease ...... 29 CH-12: Multiple Pulmonary Nodules ...... 31 CH-13: Pneumonia ...... 33 CH-14: Other Chest Infections ...... 35 CH-15: Sarcoid ...... 38 CH-16: Solitary Pulmonary Nodule (SPN) ...... 40 CH-17: Pleural-Based Nodules and Other Abnormalities ...... 46 CH-18: Pleural Effusion ...... 48 CH-19: Pneumothorax/Hemothorax ...... 50 CH-20: Mediastinal Mass ...... 52 CH-21: Chest Trauma ...... 54 CH-22: Chest Wall Mass ...... 56 CH-23: Pectus Excavatum and Pectus Carinatum ...... 58 CH-24: Pulmonary Arteriovenous Fistula (AVM) ...... 60 CH-25: Pulmonary Embolism (PE) ...... 62 CH-26: Pulmonary Hypertension ...... 67 CH-27: Subclavian Steal Syndrome ...... 68 CH-28: Superior Vena Cava (SVC) Syndrome ...... 70 CH-29: Thoracic Aorta ...... 72 CH-30: Elevated Hemidiaphragm ...... 78 CH-31: Thoracic Outlet Syndrome (TOS) ...... 80 CH-32: Newer Imaging Techniques ...... 82 CH-33: Lung Transplantation ...... 84 CH-34: Lung Cancer Screening ...... 86

Abbreviations for Chest Guidelines AAA abdominal aortic aneurysm

ACE angiotensin-converting enzyme

AVM arteriovenous malformation

BI-RADS Breast Imaging Reporting and Database System

BP blood pressure BRCA tumor suppressor gene

CAD computer-aided detection CBC Complete blood count

COPD chronic obstructive pulmonary disease

CT computed tomography

CTA computed tomography angiography

CTV computed tomography venography

DCIS ductal carcinoma in situ DVT deep venous thrombosis

ECG electrocardiogram EM electromagnetic Food and Drug EMG electromyogram FDA Administration

FDG fluorodeoxyglucose FNA fine needle aspiration

GERD gastroesophageal reflux disease

GI gastrointestinal

HRCT high resolution computed tomography

IPF idiopathic pulmonary fibrosis

LCIS lobular carcinoma in situ

LFTP localized fibrous tumor of the pleura

MRA magnetic resonance angiography

MRI magnetic resonance imaging

MRV magnetic resonance venography

NCV nerve conduction velocity

PE pulmonary embolus

PEM positron-emission mammography

PET positron emission tomography Chest Imaging

PFT pulmonary function tests

PPD purified protein derivative of tuberculin

RODEO Rotating Delivery of Excitation Off-resonance MRI

SPN solitary pulmonary nodule

SVC superior vena cava

Chest Imaging

CH-1: General Guidelines CH-1: General Guidelines 6 CH-1.2: General Guidelines – Chest Ultrasound 7 CH-1.3: General Guidelines – CT Chest 7 CH-1.4: General Guidelines – CTA Chest (CPT® 71275) 8 CH-1.5: General Guidelines – Chest MRI without and with Contrast (CPT® 71552) 8 CH-1.6: This section intentionally left blank 8

Chest Imaging

CH-1: General Guidelines  A current clinical evaluation (within 60 days) is required prior to considering advanced imaging.  A clinical evaluation should include the following:  A relevant history and physical examination.  Appropriate laboratory studies and non-advanced imaging modalities, such as plain x-ray or ultrasound.  Other meaningful contact (telephone call, electronic mail or messaging) by an established individual can substitute for a face-to-face clinical evaluation.  A Pulmonary or Thoracic Surgical Specialist can be helpful in evaluating thoracic disorders.

CH-1.1: General Guidelines – Chest X-Ray  A recent chest x-ray (generally within the last 60 days) that has been over read by a radiologist would be performed in many of these cases prior to considering advanced imaging.1,2  Identify and compare with previous chest films to determine presence and stability.  Chest x-ray can help identify previously unidentified disease and may direct proper advanced imaging for such conditions as:  Pneumothorax, (see CH-19: Pneumothorax/Hemothorax).  Pneumomediastinum, (see CH-19: Pneumothorax/Hemothorax).  Fractured ribs, (seeCH-22: Chest Wall Mass).  Acute and chronic infections, and (seeCH-13: Pneumonia and CH-14: Other Chest Infections).  Malignancies.  Exceptions to preliminary chest x-ray may include such conditions as:  Supraclavicular lymphadenopathy (see CH-2.1: Supraclavicular Region).  Known Bronchiectasis (see CH-7: Bronchiectasis).  Suspected Interstitial lung disease (see CH-11: Interstitial Disease).  Positive PPD or tuberculosis (see CH-14: Other Chest Infections).  Suspected Pulmonary AVM (see CH-26: Pulmonary Hypertension).

Chest Imaging

______© 2018 eviCore healthcare. All Rights Reserved. Page 6 of 91 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______ Notes: Coding CT Chest    CH-1.3: GeneralGuidelines –  CH-1.2: Guidelines General – Guidelines Imaging 8 © 201 be resolved. unless  set CPT set High resolution CT Chest should be reported only with anappropriate code from the diagnostic i (CPT CT Chestwithoutandwithcontrast    (CPT other imaging modalities may be further evaluated with CT Chest with contrast Intrathoracic abnormalities found on chest x    includes imaging of the mediastinum. images of the chest wall with measurements of chest wall thickness, and also Chest ultrasound (CPT  CT Chestwithoutcontrast(CPT  Low-d  HighResolutionCT(HRCT).  Follow-u  Individualhascontraindicationtocontrast.

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® . All Rights Reserved. Rights All . healthcare eviCore billable. the scan. The “high resolution” involves additional slices which are not separately  involvement with tumor and determined on a case- often in the thymic mediastinal region or determining margin (vascular/soft Clarification of some equivocal findings on previous imaging studies, which are Guidelines). Aortic ValveReplacement(TAVR)intheCardiacImaging No additional C 71552)

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Chest MRI without and with Contrast Contrast with and MRI without Chest (CPT CTA Chest : BrachialPlexus).

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging 8 © 201 CH CH CH - - - 2.3: Mediastinal Lymphadenopathy 2.3: Mediastinal Axillary2.2: Lymphadenopathy Region2.1: Supraclavicular . All Rights Reserved. Rights All . healthcare eviCore

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Supporting Information and ground . All Rights Reserved. Rights All . healthcare eviCore Excisional biopsy of most abnormal lymph node if uncertainty persists. Diagnostic work abnormal lymph node if condition persists or malignancy suspected. U No advanced imaging indicated. node if condition persists or malignancy suspected. Excisional or ultrasound directed core needle biopsy of most abnormal lymph 3- Search for adjacent hand or arm injury or infection, and abnormal lymph node if condition persists or malignancy suspected. Ultrasound directed core needle biopsy or surgical excisional biopsy of the most   possible primary sites are led by symptomatology, andrisk factors. physical exam and mammography are negative. Otherwise, imaging of other ultrasound 76942).  (CPT Breast MRI See: (CPT withcontrast Neck CT Allowssimultaneous ultrasound-

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______5. 4. 3. newly with patient the in MRI breast for Indications al. et B, Anderson W, DeMartini C, Lehman 2. 1. Refer    Bac  LymphadenopathyCH- 2.3: Mediastinal warranted). involvement from alung or chest primary is highly unusual (CT Chest not often Most axillary adenopathy is infectious in primary care settings. Guidelines Imaging 8 © 201 Crite Appropriateness ACR Radiology. on Interventional Panel Expert al. et J, Chang C, Ray B, English . http://www.sciencedirect.com/science/article/pii/S1556086415310625 - 1345 8pp Issue 6, Volume 2011, Oncology Thoracic of Journal Incidentalomas, Mediastinal A, al. et Oostdijk J, Boers J, Stigt http://www.jnccn.org/content/7/2/193.long. - 259 15: 2006; Breast The metastases. axillary as presenting cancer breast Occult al. K, et Hatanaka M, Ishikawa H, Yamaguchi 2017. cancer breast diagnosed Radiology CT. and US, palpation, with assessment cancer: lung in nodes lymph supraclavicular in al. et Metastases MW, K, Heijenbrok Brakel H, Van Overhagen 20, 2017. http://pubs.rsna.org/doi/abs/10.1148/radiol.2321030663. 2017. 20,  https://acsearch.acr.org/docs/69343/Narrative. (ACR Radiology thoracoscopy/thoracotomy. More invasive andtraditional methods are mediastinoscopy or endobronchial ultrasound, and endoscopic ultrasound- percutaneous biopsy, transbronchial biopsy, transbronchial biopsy using Less invasive methods of mediastinal biopsies are CT or ultrasound directed to histologic diagnosis. can result in a positive PET scan. Therefore, the use of PET may not be helpful prior Lymphadenopathy from neoplasms as well as from benign sources of inflammation  imaging. x chest CT Chest with contrast (CPT kground and Supporting Informat and kground

. http://www.jnccn.org/content/7/2/193.long ® Lymph node biopsy (see methods below) should be considered for: Ther Low risk or noclinical suspicion for malignancy. abnormalities; Enlarged lymph nodes are in the mediastinum with no other thoracic  

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ray (over read by aradiologist) or other non-

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______3. 2. 1. Refer   Bac   Cough CH-3.1: Guidelines Imaging 8 © 201 - http://journal.chestnet.org/article/S0012 2017. October 19, 2017. 2017. 19, October 15- 11, Med, Fam Ann (2013). literature. the of review asystematic from data with expectations patients’ Comparing last? a cough does long How S, Youngpairoi J, Lundgren MH, Ebell Chest Guidelines. Practice Clinical Based - Evidence ACCP Cough: of Management the to Approach Integrative Empiric An al. et M, Pratter, 0/fulltext (1): Chest supplement. Online report. Panel Expert and guideline CHEST cough: chronic unexplained of Treatment Panel. Cough Expert CHEST al. et L, McGarvey G, P, Wang Gibson Cough a is “almost always effective” in resolving cough in smoker. use of the angiotensin- The resolution of cough usuallywill occur at amedian time of 26 days stopping of    x chest initial CT C  cough started or changed. Initial evaluation should include arecent chest x kground and Supporting Informat and kground

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. All Rights Reserved. Rights All . healthcare eviCore 27-    can be performed according to the relevant Chest Imaging Guidelines section 1. For any abnormalities present on the initial chest x   Current or past cigarette smokers with either:  investigationafter ALLthe of following: Cough in non- Dis

hest (either with contrast [CPT . 2017 19, October Accessed 44 continue all medications known to cause coughing inhibitors). ACE (e.g. Treatment of gastroesophageal reflux disease (GERD). ofcorticost trial Empiric oxide test) and spirometry should be performed to rule out asthma. Bronchoprovocation challenge (e.g. methacholine challenge, exhaled nitric  Changed chronic cough in worsening frequency or character New cough lasting greater than 2weeks (URI based cough can be prolonged).  Antihistamine and decongestant treatment. .

fter URI (Upper Respiratory Infection) can typically last beyond 2- See: See

- raywithoutisabnormalities, for the following: : CH- http://www.annfammed.org/content/11/1/5.full HD- smoker after the following sequence for a total 3 week trial and 6: Hemoptysis6: 29: Sinusitis converting enzyme (ACE) inhibitor drug. 1, 2 1, eroids.

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging 8 © 201 Syndrome CH CH CH - - - 4.2: Costochondritis/Other Musculoskeletal Chest Wall Wall Chest Musculoskeletal Costochondritis/Other 4.2: Non 4.1: 4: Non . All Rights Reserved. Rights All . healthcare eviCore -

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______maneuver and imaging is non-specific. Costochondritis can be readily diagnosed with palpation tenderness and/or hooking chronicand infections, andmalignancies. Chest x Back  Syndrome Wall Chest Musculoskeletal Costochondritis/Other CH-4.2:  Chest Pain Non-Cardiac CH-4.1:    Chest PainCH-4: Non-Cardiac Guidelines Imaging 8 © 201 guidelines. require advanced imaging (CT or MRI) unless it meets other criteria in these Costochondritis or other suggested musculoskeletal chest wall syndrome does not    Initial evaluation should include achest x MRI is not supported in the evaluation of chest pain. improve efficiency of individual management” “Evidence is not conclusive whether Triple-     See alsothe followingguidelines:

Supporting Information and ground . All Rights Reserved. Rights All . healthcare eviCore x- CH-  CT Chest with contrast (CPT    If x CT Ches CD- CD-1 CH- c  Cardiac(ECG,echocar of painpriortoadvancedim - ontrast) including:

ray could identify pneumothorax, pneumomediastinum, fracturedribs, acute ray is abnormal. -   The initial chest x (PFT’s). Pulmonary the cause in almost 60% should be done in all after cardiac causes have beenruled out since GERD is Either abarium swallow, esophageal pH monitoring, manometry,endoscopy or esophageal manometry) GI Coronary CTA, ray is normal, individual should undergo evaluation of other possible causes 29.1: A 4: CT Heart and Coronary Computed Tomography Angiography (CCTA) Coronary Tomography and CT Heart Computed 4: Pulmonary Embolism. 25:

: General Guidelines. loss. Suspected lung mass in an individual with chest pain, cough, and weight disease cell Sickle (trial anti of t with contrast (CPT

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 2. ______1. R Guidelines Imaging 3. 8 © 201 eferences ACR Appropriateness Criteria Appropriateness ACR Imaging. Cardiac on Panel Expert al., et RC, Cury PA, Araoz S, Abbara RD, PK, White Woodard Criteria Appropriateness ACR Imaging. Cardiac on Panel Expert al. et R, White V, Venkatesh U, Hoffman American College of Radi of College American disease. h (ACR); Radiology of . http://www.aafp.org/afp/2009/0915/p617.html 2017. 19, October Accessed 617. (6): 80 15; Sep 2009 . Physician Fam Am treatment. and diagnosis Costochondritis: T. Zryd A and Proulx - 2017.http://www.jacr.org/article/S1546 ttps://acsearch.acr . All Rights Reserved. Rights All . healthcare eviCore ®

- - pain chest nonspecific acute

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ces ® ® Pulse oximetry and pulmonary function studies (PFT’s), Blood work including CBC and thyroid function tests ECG, echoc

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______1. Reference  CH-6.1: Hemoptysis Guidelines Imaging 8 © 201 https://acsearch.acr.org/docs/69449/Narrative . 2017 19, October Accessed 2014. (ACR); Radiology of College American Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria Appropriateness ACR Imaging. on Thoracic Panel Expert   (CPT Chest Ch CT

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Chest Imaging 4. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 3. 5. ______2. 1. References  CH-7.1: Bronchiectasis – Guidelines Imaging 8 © 201 Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria Appropriateness ACR Imaging. on Thoracic Panel Expert - http://www.radiologic.theclinics.com/article/S0033 2017. 7, November http://thorax.bmj.com/content/65/Suppl_1/i1 Thorax - Non for Guidelines - 3692(15)52840 Hansell D, Bronchiectasis. Bronchiectasis. D, Hansell https://acsearch.acr.org/docs/69449/Narrative/. Radiology of College American Chest - evidence ACCP bronchiectasis: to due cough Chronic M. Rosen http://pediatrics.aappublications.org/content/124/2/472?download=true. 2017. 7, Pediatrics disease. lung pediatric of evaluation diagnostic in the tomography computed chest of yield and Use al. et R, Soferman H, Blau N, Schneebaum    the following: High resolution CT Chest scan (HRCT) without contrast (CPT

. All Rights Reserved. Rights All . healthcare eviCore For hemoptysiswith known or suspected bronchiectasis. For known bronchiectasis withworsening symptoms or worsening PFT’s To con , 2006; 129: 122S 129: 2006; , , 65, Supplement 1, July 2010. Accessed November 7, 2017. 7, November Accessed 2010. July 1, Supplement 65, , firm suspected diagnosis of bronchiectasis after aninitial x

4, 5 4, 7/fulltext. CF Bronchiectasis, British Thoracic Society, Bronchiectasis Guideline Group, Guideline Bronchiectasis Society, Thoracic British Bronchiectasis, CF - - http://journal.chestnet.org/article/S0012 2017. 7, November Accessed 131S. , (1998).36(1): 107 (1998).36(1): , America North of Clinics Radiologic

(ACR); 2010. (revised 2014) Accessed November 7, 2017. 7, November Accessed 2014) (revised 2010. (ACR); Imaging

- 124:472 2009; , 8924 8924 based clinical practice guidelines. practice clinical based ®

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 2. ______1. References   Bronchitis CH-8.1: Guidelines Imaging 8 © 201 http://www.mqic.org/pdf/mqic_management_of_uncomplicated_acute_bronchitis_in_adults_cpg.pdf. http://www.mqic.org/pdf/mqic_management_of_uncomplicated_acute_bronchitis_in_adults_cpg.pdf. - South adults. in bronchitis acute uncomplicated of Management Consortium. Improvement Quality Michigan - 3692(15)52837 Chest - evidence ACCP bronchitis: acute due to cough S, Chronic Braman Chest x Advanced imaging is not needed for bronchitis. . All Rights Reserved. Rights All . healthcare eviCore

2006,129, 95S 2006,129, field (MI): Michigan Quality Improvement Consortium; 2016. 2016. Consortium; Improvement Quality Michigan (MI): field - r ay to determine if any abnormality is present.

7/fulltext. 7/fulltext. - - http://journal.chestnet.org/article/S0012 2017. 7, November Accessed 103S.

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 3. ______2. 1. References  Supporting Information and Background    AsbestosCH-9.1: Exposure Guidelines Imaging 8 © 201 . https://www.atsdr.cdc.gov/substances/toxsubstance.asp?toxid=4 2017. Disease and Substances Toxic for Agency - 3692(09)60368 - doi:10.1378/chest.08 Chest. Study, aDelphi of Results Asbestos: of Effects Health iratory Resp the on Statement Consensus Physicians Chest of College American al. et Banks, E. Daniel . https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=9995 2017. 19, October Accessed H. App 1910.1001 sur Medical Standards, Health and Safety OSHA, Occupational increases with increasing intensity and duration of exposure. lung cancer, and malignant mesothelioma. The risk of developing mesothelioma Asbestosis and asbestos    re High diseases. CT Chest should not be used to screen populations at risk for asbestos  Chest x

. All Rights Reserved. Rights All . healthcare eviCore of the chest. the of Sendrequests additional for follow progression of asbestos related interstitial fibrosis. Progressive respiratory symptoms that may indicate the development or Any chang Stable solution CT Chest (HRCT) (CPT (HRCT) Chest CT solution - ray as radiographic screening for asbestos exposure. 2 calcified pleural plaques on chest x

8/fulltext e seen on chest x 2 - http://journal.chestnet.org/article/S0012 2017. 19, October Accessed 1345. . - related diseaseinclude:s pleural effusion, pleuralplaques, - ray.

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______1. Referen  Back   CH-10.1: COPD – Guidelines Imaging 2. 8 © 201 Criteria Appropriateness ACR Imaging. Thoracic on Panel Expert al., et J, Kirsch T, Mohammed D, Dyer 5 p. Accessed October 19, 2017. 2017. 19, October 5 Accessed p. cough, and/or sputum beyond normal day indicated in COPD exacerbation, which is an acute change in baseline dyspnea, respiratory symptoms, such as dyspnea. Advanced chest imaging is not typically airflow reduction (FEV1/FVC ratio < 0.7 or FEV1 ≥ 80% predicted) in the presence of COPD includes asthmatic bronchitis, chronic bronchitis, and emphysema. COPD is  Lung cancer screening is discussed in the followingguideline:  Chest x - 212:1 1999; Radiology A http://pubs.rsna.org/doi/10.1148/radiology.212.1.r99jl521 ustin JHM. Pulmonary emphysema: Imaging assessment of lung volume reduction surgery. reduction lung volume of assessment Imaging emphysema: Pulmonary JHM. ustin

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ray should be performed initially. Lymphangitic cancer toxicity Drug Lipoid pneumonia Bronchiolitis obliterans Hypersensitivity pneumonitis Langerhans cell histiocytosis Idiopathic pul Pneumoconiosis Emphysema Sarcoidosis Bronchiectasis - 1,2, operative study for Lung Volume Reduction Surgery (LVRS).

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 6. 5. 4. 3. 2. ______1. Referen  DiseaseCH-11.1: Interstitial Guidelines Imaging 8 © 201 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2945045/. management and sis pathogene of concepts evolving diseases: tissue in connective disease lung Interstitial J. Varga and F Castelino http://www.bmj.com/content/340/bmj.c2843. BMJ disease. lung interstitial suspected with patient a investigate to How al. et H, Remmen K, Kerr O, Dempsey v1- V): 63(Suppl with in collaboration Society Thoracic British the guideline: disease lung Interstitial al. et N, A, Hirani Wells Thoracic Society Thoracic diagnosis, spectrum of abnormalities, and temporal progression temporal and abnormalities, of spectrum diagnosis, Imaging pneumonia. interstitial fibrosis/Usual pulmonary Idiopathic DA. Lynch S and Misumi Criteria Appropriateness ACR Imaging. Thoracic on Panel Expert al. et J, Kirsch T, Mohammed D, Dyer Criteria L, Bacchus - http://www.atsjournals.org/doi/abs/10.1513/pats.200602 Accessed November 7, 2017. https://acsearch.acr.org/docs/69448/Narrative/ 2017. 7, November Accessed 680/Narrative/. https://acsearch.acr.org/docs/3091 2017. 7, November Accessed 2014. (ACR);      modality of choice to evaluate for: High resolution CT Chest (HRCT) without contrast (CPT

. All Rights Reserved. Rights All . healthcare eviCore management showing progression or regression of disease will change individual Once a year in individuals with known idiopathic pulmonary fibrosis (IPF) if interstitial disease, including connective tissue diseases, Newworsening or pulmonary symptoms or worsening PFT’s i    Initial request occupational lung disease such as:    diagnosis, including: Initial request to identify interstitial disease with aconnectivetissue disease Interstitial changes identified on other imaging (including chest x (PFT’S) (see: CH- (see: (PFT’S) individual the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society. Thorax Society. Thoracic Irish the and Zealand New and Australia of Society Thoracic the

ces ® ® Coal miner’s lung disease Silicosis, Asbestosis, The myopathies Scleroderma, Rheumatoid arthritis,

- - dyspnea chronic Radiology of College American (VA): Reston publication]. [online diseases lung occupational

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ces - in ® Possible lung mass associated with the infiltrate. distress, necrotizing pneumonia, pneumothorax). Complication of pneumonia (e.g. abscess, effusion, hypoxemia, respiratory

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. All Rights Reserved. Rights All . healthcare eviCore Cerebral: Vasculitis See: Treatment change is being considered in known sarcoid. New symptoms appear after a period of being asymptomatic, or Development of worsening symptoms, Establ ces - s currently noevidence- Zannad S, Charrada L, Zidi A, et al. Value of CT scanning in the investigation of thoracic of investigation in the scanning CT of Value al. et A, Zidi L, S, Charrada Zannad CD- ish or rule out the diagnosis when suspected, 5.

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______  Back     CH-16.4: PET   CH-16.3: In Guidelines Imaging 8 © 201        to the lung or mediastinum, and/or smoking history. greater than 7- Mali linear, sheet Entities that are not nodules, and are considered benign, include non- mm in diameter A enlargement. PET studies are not appropriate infiltrate,for ground glass opacity, or hilar PET Serial  restaging/recurrence guideline for indications for PET imaging. If there is a history of malignancy, refer to the appropriate Oncology (CPT PET/CT  CT screening or surveillance. Lung nodule(s) that increase in size or number should no longer be considered for     No further advanced imaging is necessary if nodule(s)

Supporting Information and ground nodule . All Rights Reserved. Rights All . healthcare eviCore A nodule that does not grow in 6months has a <10% risk of malignancy. most of which likely resulted from prior granulomatous infection. There is decreased risk of primary cancer in individuals with 5or more nodules, The risk of primary cancer increases with the total nodule count from 1 to 4. invasivenessand metastases. The larger the solid component of asub- Three per cent of all 8 mm lung nodules are malignant. Less than 1% of <6mm lung nodules are malignant. A nodule Abnormalities Pleural nodule see tissuesampling or other rther fu diagnostic investigations shouldbe considered W Is decreasing in size calcification pattern typical for agranuloma or hamartoma) Has Has remained stable on chest x Has remained stable as described in CH- day gnant ith an s) may besampled for biopsy or resected.

classically benign characteristics by chest x

is any pulmonary or pleural lesion that is a discrete, spherical opacity 2- terval Imaging Outcomes Imaging terval

nodule features can include spiculation, abnormal calcification, size studies are not considered appropriate. increase in nodule(s) size or number, PET (see CH- -

that grows at arate consistent with cancer (doubling time 100 to 400 like, two like,

® 10 mm, interval growth, history of a cancer that tends to metastasize 78815) for a distinct lung nodule ≥ 8 mm on CT

surrounded by normal lung tissue. A larger nodule is called a mass. . . - dimensional or scarring opacities. CH- or disappearing. 17.1: Pleural 1,2,3,7 1 - ray 5years for

- 3 Based Nodules and Other and Based Nodules

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Chest Imaging 7. 6. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 2. 5. 4. ______1. Referen      Guidelines Imaging 3. 8 © 201 Safety/Resources/LungRADS. Safety & Quality - (Lung System Data and Reporting Screening CT Lung 1658- Radiographics nodule. pulmonary solitary the of evaluation the in Update al. et MT, Truong lung cancer? Diagnosis and management of management and Diagnosis cancer? lung it is when nodules: pulmonary with individuals of Evaluation al, et W, Lynch J, Donnington M, Gould http://pubs.rsna.org/doi/abs/10.1148/radiol.2423060308?journalCode=radiology. 2017. 7, November Accessed 3. Issue 242, Vol 2007, March Communications, Nodules, Pulmonary Small of Management in PET JR. Fielding, and AH Khandani, X/fulltext. - http://journal.chestnet.org/article/S0012 2017. 7, November Accessed (2003). 89S Suppl.), 123(1 Chest nodule. pulmonary solitary The al. E, et Kazerooni K, B, Flaherty Tan http://pubs.rsna.org/doi/10.1148/radiol.2017161659. Radiology , 2017 Society Fleischner the From Images: CT on Detected Nodules Pulmonary Incidental of Management for Guidelines al. et H, MacMahon .acr.org/docs/69455/Narrative/. https://acsearch 2017 7, November Accessed 2012 (ACR); Radiology of College American malignancy (80%) carcinoidtumors, and mucinous adenocarcinomas. False negative PET as bronchoalvealor or carc also False positive PET increase in nodule performed the . If Repeat P average doubling times of 3 G negative PET, and stability size of over 2years. 10% hamartoma), multiple areas of calcification, small size, multiple nodules, Benign malignancyto 14% Criteria L, Jensen J, Kanne - http://journal.chestnet.org/article/S0012 2017. 7, November Accessed Physicians evidence Physicians round glas round . All Rights Reserved. Rights All . healthcare eviCore occur with small size nodule, ground glass lesions 1679. Accessed November 7, 2017. http://pubs.rsna.org/doi/abs/10.1148/rg.346130092. 2017. 7, November Accessed 1679. ces

® of malignancy

radiographically detected solitary pulmonary nodule. [Online publication]. Reston (VA): Reston publication]. [Online nodule. pulmonary solitary detected radiographically features ET , a negative PET scan reduces the likelihood of malignancy to 1%.

is discouraged. If the original PET is positive, biopsy may be s sed November 7, 2017. https://www.acr.org/Quality 2017. 7, . November Accessed

or subsolid opacities, which can harbor indolent adenocarcinoma with

Mohammed T, et al. Expert Panel on Thoracic Imaging. ACR Appropriateness ACR Imaging. on Thoracic Panel et T, al. Expert Mohammed - in solid nodules can include benign calcification (80% granuloma, original PET is negative is PET original based clinical practice guidelines practice clinical based size . . I

can occur with infection or inflammation; false negatives can , , n an individual with alow pre- can be seen in individuals with adenocarcinoma in situ, negative findings on PET scan reduce the likelihood of , biopsy may beperformed. inoid. – 5 years.

lung cancer, 3 lung cancer, , , but subsequent CT Chest shows , Accessed November 7, 2017. 7, November Accessed , 2013; 143(5 Suppl): e93S Suppl): 143(5 2013; Chest . RADS™), RADS™), 3 rd 8924 8924

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______8. Guidelines Imaging 9. 8 © 201 Small Cell Lung Cancer, Version 3.2018 3.2018 Version Cancer, Lung Cell Small - Non for Guidelines™) (NCCN in Oncology Guidelines Practice Clinical NCCN the from permission https://www.nccn.org/professionals/physician_gls/pdf/lung_screening.pdf Cancer Screening v3.2018 v3.2018 Screening Cancer Lung for Guidelines™) (NCCN in Oncology Guidelines Practice Clinical NCCN the from permission https://www.nccn.org/professionals/physician_gls/pdf/lung_screening.pdf – 3.2018 Version Screening, Cancer Lung Guidelines, (NCCN) Network Cancer Comprehensive National al. SL et Baum EA, Kazerooni, DE, Wood the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org to online go Guidelines™, NCCN the of version complete and recent most the view To NCCN. the of permission written express the without purpose any for form any in reproduced may herein illustrations and Guidelines™ NCCN The reserved. rights All Inc. Network, Cancer - Non Guidelines, al. et DL Aisner DE, SE, Wood Ettinger NCCN.org to online go Guidelines™, NCCN the of version and complete recent most the view To NCCN. the of permission written express the without any purpose for form any in reproduced be not may herein illustrations and Guidelines™ NCCN The reserved. rights All . All Rights Reserved. Rights All . healthcare eviCore

Small Cell L Cell Small – – – 3.2018 Version Cancer, ung January 18, 2018. 2018. 18, January National Comprehensive Cancer Network (NCCN) Network Cancer Comprehensive National – February 21, 2018. 2018. 21, February

© 2018 National Comprehensive Cancer Network, Inc. Network, Cancer Comprehensive National 2018 January 18, 2018. Available at: Available 2018. 18, January February 21, 2018. Available at: Available 2018. 21, February 8924 8924 © 2018 National Comprehensive National 2018 .

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______1. Reference  Supporting Information and Background   CH-17.1 Guidelines Imaging 8 © 201 - http://journal.chestnet.org/article/S0012 e142S Suppl): (5 143 May; 2013 3 lung cancer, of management and diagnosis cancer: lung of diagnosis the Establishing al. et M, Rivera surveillance or biopsy. Pleural nodule/mass or thickening without suggestion of malignancy would undergo effusion, boneerosion, chest pain. is alikelihood of malignancy including current or previous malignancy, pleural pleuralnodule/mass defined or area of pleuralthickening (CPT PET/CT      (with contrast is preferred for initial evaluation) for pleural nodule(s). w Chest CT rd

ed: American College of Chest Physicians evidence Physicians Chest of College American ed: . All Rights Reserved. Rights All . healthcare eviCore Guidelines Pulomary (SPN) Nodule - Following the Fleischner Society Guidelines for high risk. (See Pulmonary Nodules Using presence and stability. After preliminary comparison with any available previous chest films to determine replace CT Chest as the initial dedicated study. Pleural nodule(s) identified incidentally onany dedicated chest studies can MR. Pleural : 1 Pleural (see: largest measurement of multiple nodule(s) seen on an imaging study other than a “dedicated” CT Chest or ith contrast (CPT

® CH- 78815) can be considered if dedicated CT or MRI Chest identifies a – Based Nodules and Other Abnormalities and Other Nodules -Based CT CT 1.3: General Guidelines Chest ) . .

- ) 65S. Accessed November 7, 2017. 7, November Accessed 65S. ) Imaging ® 71260) or CT Chest without contrast (CPT - 3692(13)60293 1

nodule(s). (See: – – CT Chest CT - based clinical practice guidelines. Chest guidelines. practice based clinical 7/fulltext 8924 8924 1 (see: . ) that is >8 mm when there CH-

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Chest Imaging 2. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400  ______1. References  Supporting Information and Background  Effusion Pleural CH-18.1: Guidelines Imaging 8 © 201 2010/pleural thoracic.org.uk/document Pleural Disease. Thorax 2010; 65; Suppl II. Accessed November 7, 2017. https://www.brit 2017. 7, November Accessed II. Suppl 65; 2010; Thorax Disease. Pleural of Management the for Guidelines BTS 2010: Guideline Disease Pleural Society Thoracic British exudates?volume=77&issue=4&page=507. http://annals.org/aim/article - 77:507 1972; Med Intern Ann exudates. and transudates of separation diagnostic the effusions: Pleural al. et PC Luchsinger M, MacGregor R, Light Chest ultrasound (CPT  culture, cell count, and biochemical studies. Large unilateral effusions can be malignant. Analysis of fluid may include: cytology, failure, renal failure, liver insufficiency, etc.), and advanced imaging is rarely needed. Bilateral effusions are more often systemic related transudates (congestive heart evaluate for the presence of fluid within the pleural spaces and guide thoracentesis.  CT Chest with contrast (CPT

. All Rights Reserved. Rights All . healthcare eviCore possibly amass). much as possible (this fluid can obscure the underlying lung parenchyma and Thoracentesis to determine if fluid is exudative or transudative and remove as Chest x - - disease - r ay including lateral decubitus films;

guideline

- - library/clinical - ® abstract/686932/pleural 76604) can be used as an alternative to chest x - quick ® 71260)after both: - - reference information/pleural

guide/. - effusions 13. Accessed November 7, 2017. 7, November Accessed 13. and 1,2 - 8924 8924 disease/pleural - diagnostic - - separation

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging 8 © 201 CH CH - - 19.2: Pneumomediastinum; Subcutaneous Emphysema Subcutaneous Pneumomediastinum; 19.2: Pneumothorax/Hemothorax 19.1: . All Rights Reserved. Rights All . healthcare eviCore CH-

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Chest Imaging 4. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______3. 2. 1. Referen  Back  eous Emphysema Subcutan Pneumomediastinum; CH-19.2:  Pneumothorax/Hemothorax CH-19.1: Guidelines Imaging 8 © 201 - http://www.mayoclinicproceedings.org/article/S0025 Mayo Clinic Proceedings Clinic Mayo patients adult 62consecutive of analysis pneumomediastinum: Spontaneous J. Ryu A, V, Joshi Iyer Antitrypsin - https://journal.copdfoundation.org/jcopdf/id/1115/The Dis Pulm Obst Chronic Adult. the in Deficiency Sandhaus R, Turino G, Brantly M, et al. The Diagnosis and Management of Alpha of Management and Diagnosis al. The et M, Brantly G, Turino R, Sandhaus https://insights.ovid.com/pubmed?pmid=21307755. - 510 70(2): Trauma J pneumothorax." occult and hemothorax of management for guidelines management "Practice (2011). al. et T., N. Mowery, "Pneumothorax (2002). al. et N., Manes, - http://journal.chestnet.org/article/S0012 2017. 7, November chest x chest indicated in the diagnosis or management of pneumothorax. Inspiratory/expiratory the exception of the indications above, advanced imaging of the chest is rarely pneumothorax or hemothorax who are asymptomatic or have stable symptoms. With is nodata supporting the use of serial CT Chest to follow individuals with aknown An expiration chest x  Chest x  Chest x

ces Associated pneumothorax. Suspected complications from hemothorax (e.g. empyema). Preoperativestudy treatment. for Associated pneumopericardium. Recent vomiting and/or suspected esophageal perforation. Suspected Alpha -1- Pneumothorax associated with hemothorax. P pneumothorax will affect individual treatment decisions. Diagnosis of a small pneumothorax is in doubt, and the presence of a - - - rays are helpful in defining whether a pneumothorax is present. reoperative study for treatment of pneumothorax. ray initially. ray initially. - Deficiency

- in - - 417 pp. (2009), (5) 84 ; - the - ray can enhance the evaluation of equivocal plain x Adult. Antitrypsin Deficiency (even without pneumothorax). ® ® 4,5 guidelines of action." action." of --guidelines 71260) or without contrast (CPT 71260) or without contrast (CPT

518. Accessed November 7, 2017. 7, November Accessed 518.

4,5 2016; 3:668. Accessed November 7, 2017. 7, November Accessed 3:668. 2016; 4,5 421. Accessed November 7, 2017. 7, November Accessed 421.

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Chest Imaging 3. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 2. ______1. R     Mass CH-20.1: Mediastinal Guidelines Imaging 8 © 201 eference November 7, 2017. https://www.ctsnet.org/article/pericardial 2017. 7, November Accessed 2010. August Net CTS Cyst, Pericardial M; Sukumar P, Schipper C, Komanapalli sights Imaging sights Canete S, Juanpere http://pubs.rsna.org/doi/pdf/10.1148/radiographics.14.3.8066273. http://pubs.rsna.org/doi/pdf/10.1148/radiographics.14.3.8066273. RadioGraphics wall disorders. chest of evaluation imaging andMR CT al. E, et Fishman L, Bouchardy J, Kuhlman pericardialoresophagealin  Mediastinalcystincludingbronchogenic,thymic, there isaconcernfor: For Myasthenia Gravis; see For Goiter; see-9 NECK For Adenopathy; see chest CT Chestwithcontrast(CPT - https://link.springer.com/article/10.1007/s13244 . All Rights Reserved. Rights All . healthcare eviCore  nature

x-r (CPT  CT Ch  s

ay or Preoperativeassessment New signs or symptoms, or

® - 4:29 2013; ,

- 14(3):571 May; 1994 est with contrast (CPT 71552)subsequent for evaluationsif: other non-d N, Ortuno P, Martinez S. A diagnostic approach to the mediastinal masses mediastinal the to approach diagnostic A S. Martinez P, Ortuno N, CH-2 1,2,3 52. Accessed November 7, 2017. 2017. 7, November Accessed 52. edicated chestimagingandanbedoneonceinitiallyf PN ® 71260)t 595. Accessed November 7, 2017. 2017. 7, November Accessed 595. - 6.1: Neuromuscular Disease

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 3. 2. ______1. Reference   CH-21. Guidelines Imaging 8 © 201 8/fulltext. - http://www.jshoulderelbow.org/article/S1058 2017. 7, November Accessed 16:49. Throckmorton T, Kuhn JE. Fractures of the medial end of end medial the of Fractures Kuhn JE. T, Throckmorton https://insights.ovid.com/pubmed?pmid=23114485. 2017. Surg. Care Acute Trauma J . guideline management practice Trauma of Surgery the for Association Eastern an injury: cardiac blunt for Screening Trauma. of Surgery the for Association Eastern al. et J, Bilaniuk C, Velopulos K, Clancy https://acsearch.acr.org/docs/69450/Narrative. Henry T, Kirsch J, Kanne J, et al., Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria Appropriateness ACR Imaging. on Thoracic Panel Expert al., et J, Kanne J, Kirsch T, Henry pelvic injury. pelvic trauma and no physical examination or laboratory evidence of abdominal and/or No advanced imaging of the abdomen or pelvis is indicated when there is chest  Chest X rib frac rib

1: Chest Trauma Trauma 1: Chest tures: Am tures:  Rib   Cl suspected pathologicalrib frac  s

- ray initially. avicle Fractures: X- undergo CT and MRI of the chest or shoulder Proximal (medial) 1/3 fractures or sternoclavicular dislocations can occultrib fractures areanindication NOT Chest CT for unless malignancy Uncomplicated,single fractures, multiple fractures,non - abdominal organs. flail chest, cardiovascular injury and/or injuries to solid or hollow including pneumothorax, hemothorax, pulmonary contusion, atelectasis, With associated complications identified clinically or by other imaging, 1 is

or Sternal s ray is adequate for evaluation of middle and distal 1/3 fractures.

uspected astheetiology. erican College of Radiology (ACR) Radiology of College erican 2

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______1. Referen  Back  CH-22.1: Chest Wall Mass Guidelines Imaging 2. 8 © 201 Appropriateness Criteria Appropriateness ACR Imaging. onMusculoskeletal Panel Expert al. et M, Kransdorf N, A, Weissman Zoga Appropriateness Criteria Appropriateness ACR Imaging. Musculoskeletal on Panel Expert al, et M, B, Kransdorf Weissman W, Morrison https://acsearch.acr.org/docs/69434/Narrative/. 2017. 7, November destruction as well as location and size. Chest x   indicated as the initial imaging study. Chest x https://acsearch.acr.org/docs/69421/Narrative. 2017. 7, November Accessed 2013 (ACR); Radiology of

Supporting Information and ground . All Rights Reserved. Rights All . healthcare eviCore  contrast (CPT or MRI chest without and with contrast (CPT used to assess the vascularity lesions. of also be valuable in differentiating cystic from solid lesions and has also been setting of a suspected superficial or subcutaneous lipoma. This modality may CT Chest with contrast (CPT Chest ul

ces Chest x   Obviouslipomas  Clearlybenignentity - -

rays of chest rays ca wall of masses ray is useful in the workup of a soft No mass identified (radiographically or palpated) Bo Bo trasound (CPT

ne ne). - ray completed and does not demonstrate any of the following: ).

® 71550) when the following are met: ® ®

soft primary bone tumors. [online publication]. Reston (VA): American College American (VA): Reston publication]. [online tumors. bone primary - American College of Radiology (ACR) Radiology of College American masses. tissue ® 1 (see 76604) may be useful as an initial imaging study in the

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______2. 1. Referen  Supporting Information and Background  CH-23.1: Excavatum Pectus and Carinatum Guidelines Imaging 8 © 201 https://www.ncbi.nlm.nih.gov/pubmed/15625987. - 15(3):455 Oct; 2004 . Med Clin Adolesc carinatum. pectus and excavatum pectus anomalies: wall Chest al. et D, K, Croitoru Kelly M, Goretsky https://www.ncbi.nlm.nih.gov/pubmed/15625987. Radiol excavatum pectus of evaluation the for MRI J. P, Dwek Kruk BE, LoSasso PA, Marcovici precuts deformities. for the appropriateness of operative repair prior to the development of symptomatic the thoracic surgeon in pre- Chest measurements derived from CT Chest, such as the Haller Index, are helpful to    (CPT CT Chest without contrast (CPT

ces ® , 2011; 41:7 2011; , ECG and Chest x function abnormalities. 71552)and 3- or pulmonary dysfunction has been identified

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 3. 2. ______1. Referen  Back  AVM Pulmonary CH-24.1: Guidelines Imaging 8 © 201 http:// - 632 247: 2008; Radiology anomalies. lung congenital of evaluation CT Multidector R. P, Cleveland Boiselle E, Lee http://www.atsjournals.org/doi/abs/10.1164/ajrccm.158.2.9711041. 2 no. 158 vol. 1998 1, August Med. Care Crit. Respir. J. Am. Review, Art the of aState Malformations Arteriovenous Pulmonary G. Kanj and J Gossage http://www.eurekaselect.com/56022/article. Design tical Pharmaceu Current teleangiectasia. haemorrhagic hereditary by affected in patients malformations arteriovenous cerebral and pulmonary of treatment Endovascular al. et A, Bortone N, Burdi E, Cillis De using platinum coils or detachable balloons. hilum of the lung. Treatment is often by surgery or embolization of the feeding artery peripheral,circumscribed, non- trauma, bronchiectasis). They can be identified in up to 98% of chest x usually found in the lower lobes, that can be either primary or acquired (su as ch Pulmonary AVMs are abnormal connections between pulmonary arteries and veins,    (CPT MRA wi Chest th contrast,CT CTA Chest (preferred modality) (CPT

Supporting Information and ground . All Rights Reserved. Rights All . healthcare eviCore patent foreman ovale on echocardiogram. Evaluation of individuals with paradoxical embolus/stroke and no evidence of First degree relatives of an individual with aprimary pulmonary AVM. Suspect pubs.rsna.org/doi/abs/10.1148/radiol.2473062124. ces ® ed pulmonary AVM. 71555)evaluation for of:

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging 8 © 201 Cancer activelyCancer in 6 treated last ormonths receiving palliative treatment Hemoptysis DVTPrevious of history PE or leastImmobilization 3 at days surgery in or last 4 weeks H diagnosis likely equally or likely is PE of palpation the deepveins) DVT Clinicalof minimum:(at leg signs/symptoms andpain swelling with 63% of 63% withthose ahigh pretest probability. aboveUsing the criteria, only individuals of 3% alow with probability pretest hadPE versus Low <2 Probability: Calculate eart rate >100 rate eart    

. All Rights Reserved. Rights All . healthcare eviCore  Perfusion Imaging.   to warranted Follow  Perfusion Imaging; CPT Ventilation-  Pregnant women with suspected PE are suggested to proceed with Non  

advanced imaging: Is not areplacement for CTA Chest (CPT Primary cardiac and pulmonary etiologies should be eliminated. Chest x    Can be considered in any of the following: D- Doppler studies of the lower ex V/Q preferred if Doppler negative; CTA Chest (CPT -

urgent cases which do not meet above 2

dimer and/or; - scan to evaluate intervalfor change (CPT Follow Chest is not diagnostic (CPT Suspected pulmonary embolism when a Chest x chest (ventilation- Suspected pulmonary embolism if there is acontraindication to CT or CTA up Imaging in Stable or Asymptomatic Individuals with Known PE is not ®

2,3,4,10 71555) can be performed if V/Q scanning is not available. - perfusion scans, also called V/Q, scans (CPT ray (to rule out other causes of acute chest pain). - up of up of an equivocal or positive recent ventilation-

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400        ______Back Guidelines Imaging 8 © 201 dyspnea at rest or exercise intolerance. hypertension after primary thromboembolism and only half of this latter group has pulmonary hypertension. Yet, 1/2 of all have persistent or new pulmonary recurrent PE. ECHO and Right Heart Catheterization (RHC) can identify those with Subsequent persistence or elevation of D months and 50% remains at one year. Two thirds after primary thromboembolism have residual pulmonary artery clot at 6 findings. luminal diameter and clot character poorly correlated to symptoms ECHO and Repeat studies do not allow onethe ability to distinguish new from residual clot, with risk factors. embolism (PE) with absent or stable symptoms is based on clinical evaluation and The decision to terminate anticoagulation treatment after previous pulm pathology. does not provide asubstantial cost savings, anddoes not diagnose other pulmonary CT imaging has supplanted V/Q scanning since the latter is difficult to obtain quickly,   D- incidence with leg swelling or pain just over 50%. suspicion of PE. Dyspnea, pleuritic chest pain and tachypnea occur with about 50% Pulmonary embolism is found in approximately 10% of all those that present with 

Supporting Information and ground dimer level has a high sensitivity andlow specificity diagnosingfor PE. . All Rights Reserved. Rights All . healthcare eviCore present. diabetes, pregnancy, or other conditions where fibrin products are likely to be D- has a negative predictive value approaching 100%. A negative D    71275)the any for of following indications: CT Chest with contrast with PE protocol (CPT

dimer can be falsely elevated with recent surgery, injury, malignancy, sepsis, Right heart strain or failure identified by EKG, ECHO or Heart catheterization. El Recurrent signs or symptoms such as dyspnea, or evated d-

- dimer in combination with low or moderate PE risk classification dimer which is persistent or recurrently elevated, or

- dimer is associated with increased risk of

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Chest Imaging 9. 8. 7. 6. 5. 4. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 3. 2. ______1. R Guidelines Imaging 10. 8 © 201 eference Appropriateness Crit Appropriateness ACR Imaging. Thoracic and Cardiac on Panels Expert al. et T Henry R, Brown J, Kirsch https://jamanetwork.com/journals/jama/fullarticle/202176. 172- 295 (2): gorithm combining clinical probability, D probability, clinical combining gorithm al an using embolism pulmonary suspected managing of "Effectiveness (2006). al. et A., Belle, van - http://www.annemergmed.com/article/S0196 2017. 7, November Accessed 5 03- (5): 44 Nov: 2001 . Med Ann Emerg embolism. pulmonary suspected with patients of evaluation the in Criteria of Wells validation Prospective al. et K, Feldhaus T, S. McCubbin Wolf d http://annals.org/aim/article 98- 135 (2): d- and model clinical a simple using by department emergency the to presenting embolism pulmonary suspected with patients of management imaging: diagnostic without bedside the at embolism pulmonary Excluding al. et M, Rodger D. P. Anderson Wells http://www.nejm.org/doi/full/10.1056/NEJMoa054444#t=article. - 1780 355: 2006; Med J Engl N therapy. d- al. et C, B, Legnani Cosmi G, Palareti 2017. Resolution of thromboemboli in patients with acute pulmonary embolism. pulmonary acute with in patients thromboemboli of Resolution 2017. Chest 5. review. A systematic embolism. pulmonary acute with patients in thromboemboli of Resolution al. et BL, Davidson M, Hovens M, Nijkeuter - http://journal.chestnet.org/article/S0012 2017. 7, November Chest pressure. artery pulmonary estimated in elevation subsequent or persistent of frequency embolism: pulmonary submassive acute after 6months status functional et MR, Marchick MT, Steuerwald JA, Kline http://www.nejm.org/doi/full/10.1056/NEJMra010902. Med J Engl N . hypertension pulmonary thromboembolic Chronic al. et KM, Kerr Auger WR, PF, Fedullo 2008; 336: 1227. Accessed November 7, 2017. http://www.bmj.com/content 2017. 7, November Accessed 1227. 336: 2008; - meta and review systematic women: in postmenopausal thromboembolism venous Plu M, - Canonico https://insights.ovid.com/pubmed?pmid=22343403. 2016 (ACR); Radiology of College - http://journal.chestnet.org/article/S0012 pert panel report. Chest. report. panel pert ex and guideline CHEST disease: VTE for therapy Antithrombotic al., et J, E, Ornelas Akl C, Kearon iagnostic . All Rights Reserved. Rights All . healthcare eviCore - 1465 345: 2001; s s - - imaging 107. PubMed PMID: 11453709. Accessed November 7, 2017. 7, November Accessed 11453709. PMID: PubMed 107. 179. Accessed November 7, 2017. 7, November Accessed 179.

Bureau G, Lowe G, Scarabin, P. (2008). Hormone replacement therapy and risk of risk and therapy replacement Hormone (2008). P. Scarabin, G, Lowe G, Bureau management eria 1472. Accessed November 7, 2017. 7, November Accessed 1472. ®

- 315 (2): 149 Feb; 2016

- - pain chest acute - abstract/714645/excluding - patients . 14 p. Accessed November 7, 2017. 7, November Accessed p. 14 . - - 3692(15)00335 1789. Accessed November Accessed 1789. Dimer testing to determine the duration of anticoagulation of duration the determine to testing Dimer dimer t dimer - suspected?volume=135&issue=2&page=98.

al. Prospective evaluation of right ventricular function and function ventricular right of evaluation Prospective al. suspected pulmonary embolism. Reston (VA): American (VA): Reston embolism. pulmonary suspected

esting, and computed tomography." JAMA tomography." andcomputed esting, 52 Accessed November 7, 2017. 7, November Accessed 52 2006; 129: 192- 129: 2006; - pulmonary 9/fulltext. 8924 8924 - 3692(15)31541 dimer. dimer. - embolism

7, 2017. 7, 197. Accessed November 7, November Accessed 197. - 1202 136: 2009; . 2001 Jul 17: Jul 2001 Med. Ann Intern

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CH- Subclavian Steal Syndrome Steal Subclavian

27: Subclavian Steal Syndrome

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 2. ______1. References        CH-2  Guidelines Imaging 8 © 201 November 7, 2017. http://circ.ahajournals.org/content/129/22/2320.long. 2017. 7, November - 2320 129: 2014; Circulation, syndrome. steal Subclavian D. Pinto and B Potter - JMRI17%3E3.0.CO;2 - http://onlinelibrary.wiley.com/doi/10.1002/1522 2017. 7, November Accessed 339. (2): 12 2000; Imaging. Reson Magn J syndrome. steal subclavian V    Satisfying the symptom complex. temporal resolution. the test of choice for subclavian steal syndrome given its superior spatial and While MRA does not expose the individual to radiation, CTA should be considered artery bypass gra orft, subclavianendarterectomy. Treatment options include ligation of the ipsilateral vertebral artery, aorta- Guidelines. See also a symptomatic individuals if needed to exclude pathology distal to the subclavian Upper extremity MRA (CPT angiography. indeterminate, or as preoperative studies if theywill substitute for invasive vertebrobasilar ischemia if the clinical exam and duplex study are positive, CPT MRA Neck and Chest (CPT  initial imaging with carotid duplex study (CPT Initial evaluation should include clinical findings satisfying the symptom complex and proximal subclavian or innominate artery to perfuse that arm. collateral circulation to the arm on the side and past the stenotic or occlu ded and retrograde down the ipsilateral vertebral artery (reversal of flow) to supply Occurs from blood flowing upthe contralateral vertebral artery to the basilar artery an Brimberge F, Dymarowski S, Budts W, et al. Role of magnetic resonance in the diagnosis of diagnosis the in resonance magnetic of al. et Role Budts W, S, Dymarowski F, Brimberge an rtery andif they will substitute for invasive angiography.

7.1: SubclavianStealyndrome . All Rights Reserved. Rights All . healthcare eviCore   Symptoms of cerebral ischemia may beproduced by exercise of the affected arm dysarthria occur less frequently. paresthesias. Bilateral corticalvisual disturbances, ataxia,syncope, and Symptoms include vertebral basilar artery insufficiency, vertigo, limb paresis, and bruit in the supraclavicular area on the extremities, delayed or decreased amplified pulses in the affected side, and a discrepancy of >15 mmHg in blood pressure readings taken in both upper Physical (CPT Carotid duplex study ®

71275) can be performed for diagnosis in individuals with symptoms of the Head guidelines. vertebral artery, then neurological symptoms should be evaluated accordingto theIf carotid duplex is not diagnostic for reversal of flow in the ipsilateral Reversal of flow in the ipsilateral vertebral artery. HD- examination findings suggestive subclavian of stenosis include a

21.1: Stroke/TIA 8/abstract.

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SVC Syndrome SVC

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______2. 1. Reference  Backgr   CH-2 Guidelines Imaging 8 © 201 Lepper P, Ott S, Hoppe H, et la. Superior vena cava syndrome in thoracic in syndrome cava vena Superior la. et H, Hoppe S, Ott P, Lepper http://www.nejm.org/doi/full/10.1056/NEJMcp067190. Medicine of Journal England New Causes. Malignant with Syndrome Cava Vena Superior (2007). al. et Wilson, dizziness. mediastinitis, indwelling devices). Other symptoms include dyspnea, headache and the SVC, most commonly from lung cancer (80- SVC syndrome is caused by acute the SVC is being considered. (CPT MRV based on the facial cyanosis and UE swelling without anasarca. CT Chest with contrast (CPT - 653 56: 2011; 8.1: SVCyndrome . All Rights Reserved. Rights All . healthcare eviCore Supporting Information ound and - 1862 356: , s ® 666. Accessed November 7, 2017. http://rc.rcjournal.com/content/56/5/653.short. 2017. 7, November Accessed 666. 71555) or CTV (CPT

1869. Accessed November 7, 2017. 7, November Accessed 1869.

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging 8 © 201 CH CH CH CH CH CH ------29.5: Calcified Ascending29.5: Calcified Aorta Aortic Valve Bicuspid with Aorta in Individuals Thoracic 29.4: 29.3: Screening Guidelines Familialfor Syndromes Aneurysm (TAA) Aortic Thoracic 29.2: Aortic29.1: Dissection Aor29: Thoracic . All Rights Reserved. Rights All . healthcare eviCore

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______ Supporting Information and Background   CH-29.1: Aortic dependent upon the physicians’ preference and expertise. Thoracic aortic diseases are variable and critical; selected imaging procedures are Supporting Information and Background  AortaCH-29: Thoracic Guidelines Imaging  8 © 201 MRAChest, and/or CPT CTA Chest, and/or Abdomen, and/or Pelvis (CPT contrast; MRI Chest, and/or Abdomen, and/or Pelviswithout contrast OR without and with a Chest, CT pain is seen in 96% and is best adapted to the emergent setting. Chest x Classic symptoms of sharp, severe acute onset of retrosternal or interscapular chest   Options” For femoralarteries for CTA or MRA of the entire aorta (including arch branches) and extending through the table below: Thoracic imaging in this section performed as well but has limitations. individual in the CT scanner, availability and speed of imaging. MRI can be CTA is the test of choice given its superior spatial resolution, ease of monitoring the aortic dissection present without classic symptoms. imprecise; any

llow First Year: 1month, 3 months, 6months,12 months, thenannually. Annually total if aortic diameter is <4.5 cm. Every 6 months if total aortic diameter is ≥4.5 cm.

can beperfor - nd/or Abdomen, and/or Pelvis (contrast as requested); up, any requested imaging from the “Table of Thoracic Aorta Imaging

suspicion should be considered since up to 10% of individuals with Dissection Abdomen, and/or Pelvis (CPT suspected med. Table of ThoracicAortaTable of Imaging Options

1,2,3,4,5,7,9

aortic dissection. ONE of the following the of ONE be can

1, 2,3,4,5 ® ® 71275, CPT

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______ CH-29.3: Screening G thoracic, see Background and Supporting Information. For educational information on the normal size of the aortic arch and descending      Aneurysm (TAA) Aortic Thoracic CH-29.2: Guidelines Imaging 8 © 201     Screening with Abdominal Aortic Aneurysm (AAA).    Options” For   disease. For planning of Thoracic Aorta Imaging Options” For known TAA and chest pain or back pain, any requested imaging from the “Table  Imaging Options” above: For suspected TAA, any requested imaging from the “Table of Thoracic Aorta  Suspected Screening forFamilialSyndromesandGenetic Syndromes.

 Preoperativeopenorendovascular(stent)repair Follow equivocal or donot visualize the ascending aorta adequately. Any imaging listed can be performed if these studies identify a TAA or are  Known AAA s (usually US) See: Known TAA can be screened for AAA using Abdominal Imaging Guidelines  Endovas Surgery or Stent treatment.    “Medicall 72198) MRA C 72191) or CTA Ches mediastinal) or other imaging studies (fluoroscopy, spine MRI, etc.) abnormality. Abnormalities identified on Chest –x- 1,2,3,4,5 follow

relatives (parents, siblings, children) of individuals with TAA and/or dissection. (CPT ECHO First year interval advanced imaging. >/= 3.0 cm TAA when there is concern growthfor can have a one- >/= 4.5 cm canTAA be followed every 6months. 3.5 to 4.4 cm TAA can be followed annually. 9

abovethe for following:

- - 

up, any r Up hest, and/or Abdomen, and/or Pelvis (CPT Suspicionofendoleak cular graft/ y” treated/observation. for pre

t, and/or Abdomen, and/or Pelvis (CPT

per TAA Followper TAA Aortic Familial Thoracic : creening for TAA is not supported by sufficient evidence. 1 month,1 3months, 6months,12 months, thenannually. ® equested imaging from the “Table the of Thoracicfrom Aorta imaging Imaging equested – 93306, CPT thoracic endovascular repair (TEVAR) of thoracic aorta

AB stent. uidelines for Familial Syndromes Familial for uidelines - 17.1: Abdominal Aneurysm17.1: Aortic

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 Supporting Information For more educational information on the Bicuspid Aortic Valve, see B ______ Dissection Aortic Supporting Information: and Background   AscendingCH-29.5: Calcified Aorta Congenita - PEDCD Renovascular Hypertension and Other Secondary Causes of Hypertension For Coarctation; see PEDPVD  Aortic Valve Bicuspid with Aorta in Individuals Thoracic CH-29.4: Information. For educational information on familial TAA, see Background and Supporting  Guidelines Imaging 8 © 201  There  Prior to TAVR/I (Transcatheter Aortic Valve Replacement/Implantation).  Prior to open-  Screening Bicuspid for Aortic Valve.   IV ScreeningMarfan for Syndrome or  

4, 5,6,8,9 . All Rights Reserved. Rights All . healthcare eviCore  Fo   Op diagnosis. See CT and CTA in CD the aorticwall. and/or open direct aortic palpation are used to detect atherosclerotic changes in Transesophageal echocardiography(TEE), Intraoperative ultrasonography Suspect  Follow Suspect the aorta. B: Type A: Type

2.3: Congenital Heart Disease Modality Considerations,

llow tions” are no evidence- If no dilatation of the aortic root or ascending thoracic aorta is found, there is with bicuspid aortic valve. There is noevidence- indicated. Additional imaging such as cardiac MRI, cardiac CT, or CCTA is NOT generally Up guidelines. (CPT ECHO Annual l Heart Disease Timing Considerations Timing Disease Heart l

- - two up up: ed ed

Those that begin in the ascending aorta. Those that begin from just distal to the left subclavian artery branch of and/or ECHO (CPT and/or

heart operations. per TAA Follow g , any requested imaging from the “Table of Thoracic Aorta Imaging , ECHO (CPT ECHO , eneral

10,11

based data to support continued surveillance imaging.

types - ® 4.8: ®

93306, CPT of based data to support screening relatives individuals of - - 93306, CPT 4.1: ThoracicAortic Disease, Up guidelines.

11,12,13 aortic

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______1. Referen  Valve. Aortic Bicuspid  TAA Familial  TAA     Guidelines Imaging 2. 8 © 201 - http://www.annemergmed.com/article/S0196 thoracic aortic dissection cr policy: Clinical Physicians. Emergency of College American al. et J, S, Schuur Promes D, Diercks https://acsearch.acr.org/docs/69402/Narrative/. (ACR) Radiology of College   evaluated for evidence of aortic dilatation. bicuspid aortic valve should have both the aortic root and ascending thoracic aorta concurrent ascending aortic aneurysms that needed repair. All individuals with Since 20% of individuals who underwent bicuspid aortic valve surgery had comparedto non- about Familial TAA presents at an earlier age, has a faster aortic growth rate, is seen in  root is normally 3.5 cm. The normal size of the aortic arch and descending thoracic aorta is 3 cm. The aortic they are considered precursors of aortic dissection. variant forms of aortic dissection and should follow that of aortic dissection, since Penetrating ulcer (through the intima) and intramural hematoma (no intimal tear) are lumina at higher risk. become aneurysmal in 5years and will require intervention, with less patent false Routine follow Transesophageal echo may be equally diagnostic compared to CT or MRI. flow to a vital organ, or if there is inability to control the blood pressure. is reserved for distal dissections that are leaking, ruptured, or compromising blood B Type endovascularor stent graft. A Type Criteria Appropriateness ACR Imaging. Cardiac on Panel Expert al. S, et Abbara L, Latson J, Jacobs itical issues in the evaluation and management of adult patients with suspected acute nontraumatic acute suspected with patients adult of management and evaluation the in issues itical

. All Rights Reserved. Rights All . healthcare eviCore recommended. Risk of rupture is 0% if < 4cm and 31% if > 6 cm, which is when surgery is often agemean 65. Risk factors include atherosclerosis, prolonged hypertension and trauma with ascending or arch aorta. TAA oc ces

® 20%or non-

acute chest pain -- pain chest acute

often requires urgent surgical intervention with placement of an aortic graft can usually betreated medicallywith careful blood pressure control. Surgery curs most often in the descending (50%) and then equally likely in the

- up imaging is important because 30% familial TAA. familial

Marfan TAA and has autosomal dominant inheritance, when - :32 65 (1) Jan; 2015 . Med Emerg Ann . 17. 20 7, November Accessed 2014. ;

suspected aortic dissection [online publication]. Reston (VA): American (VA): Reston publication]. [online dissection aortic suspected 4,5

- 0644(14)01478 8924 8924 4/fullt - 40% of chronic dissections will 42. Accessed November 7, 2017. 7, November Accessed 42. ext.

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 11. 10. ______9. 8. 3. Guidelines Imaging 12. 7. 6. 5. 4. 13. 8 © 201 Criteria - Appropriate ACR Radiology. Interventional and Imaging on Vascular Panels Expert KE, Dill CR, Criteria Appropriateness ACR Imaging. Vascular on Panel Expert al. et K, Dill F, Rybicki S, Kalva 355. Accessed November 7, 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1592270/. 2017. 7, November Accessed 355. Khoyne http://circ.ahajournals.org/content/119/6/880.long. - 880 119: 2009; Circulation valve. aortic bicuspid with associated dilatation aortic Ascending OM. Shapira MD, Klein TM, Tadros (AC Radiology - Meta and Review Systematic Dissection: Aortic Thoracic Suspected for Imaging Resonance Magnetic and Tomography, Computed Helical Echocardiography, Transesophageal of Accuracy Y. Diagnostic Ohe InoueT, CC, Apfel Z, T, Wajima Shiga nontraum - http://www.annalsthoracicsurgery.org/article/S0003 Surg Ann Thorac risks. nonsurgical versus surgical and surgery, for indications aneurysms: aortic thoracic of history Natural JA. Elefteriades - 4975(06)01020 - 1400 (4): 82 Oct; 2006 Surgery Thoracic of Annals patterns. phenotypic and inheritance, of modes incidence, anddissections aneurysms aortic thoracic Familial al. et M, Roberts M, Coady G, Albornoz http://circ.ahajournals.org/content/121/13/e266. 2017. 7, November Accessed e369. - e266 121: 2010; Circulation Disease Aortic Thoracic With Patients of Management and Diagnosis the for Guidelines ACCF/AHA/AATS/ACR/ASA/SCAI/SIR/STS/SVM 2010 al, et MD, Hiratzka F. Loren http://circ.ahajournals.org/content/121/13/e266. 2017. 7, diseas aortic thoracic with patients of andmanagement diagnosis the for guidelines ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM 2010 al. et JA, Beckman GL, Bakris LF, Hiratzka https://acsearch.acr.org/docs/3082597/Narrative/. 2017. 7, November Accessed 2013. 1992 Mar; 103 (3): 453 - (3): 103 Mar; 1992 Surg. Cardiovasc Thorac J and treatment. detection for A strategy operations. cardiac during aorta ascending atherosclerotic - Davila T, Wareing, - http://onlinelibrary.wiley.com/doi/10.1111/j.1540 1350- Cardiovascular Interventions Cardiovascular JACC: Approach. Transaortic the to Relevance Its and Implantation Valve Aortic Transcatheter Under Patients in Aorta Ascending in the Calcium of Distribution M. Thomas, R, Attia, V, Bapat. http://www.sciencedirect.com/science/article/pii/S1936879812002476. . All Rights Reserved. Rights All . healthcare eviCore 1356. Accessed November 7, 2017 7, November Accessed 1356. ® Tex Heart Journal Heart Tex Aorta. Diseased the in Cannulation K. Plestis, A, zhad,

thoracic aorta interventional planning and follow and planning interventional aorta thoracic atic aortic disease. [online publication]. Reston (VA): (VA): Reston publication]. [online disease. aortic atic - http://www.annalsthoracicsurgery.org/article/S0003 2017. 7, November Accessed 1405. R)

4/fulltext. ; 2017. Accessed November 7, 2017. 7, November Accessed 2017. ; Roman, V, Barzilai, B, Kouchoukos, N. Management of the s the of Management N. Kouchoukos, B, Barzilai, V, Roman, 890. Accessed November 7, 2017. 7, November Accessed 890.

2012; 5 (5); 470- 5(5); 2012; e. e. J Am Coll Cardiol Coll Am J . https://acsearch.acr.org/docs/3102329/Narrative/.

- S1877 74: 2002;

476 Acc 476 8191.1994.tb00881.x 62. Accessed November 7, 2017. 7, November Accessed 62. - 4975(02)04147 essed November 7, 2017. 7, November essed -

Med Intern Arch analysis. up. Reston (VA Reston up. - e27 55: 2010; 8924 8924 S1880. Accessed November 7, 2017. 7, November Accessed S1880. American College of Radiology (ACR) Radiology of College American 4/fulltext. /full. e129. Accessed November Accessed e129. ): American College of College American ):

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- 353 (3); 33 2006; www.eviCore.com 2006; 166 (13): 2006;

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging 8 © 201 CH - 30.1: Elevated Hemidiaphragm 30.1: . All Rights Reserved. Rights All . healthcare eviCore CH-

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400  ______2. 1. Referen      Back   Elevated Hemidiaphragm CH-30.1: Guidelines Imaging 8 © 201 - https://www.thieme 2017. 7, November Q X/fulltex - http://www.thoracic.theclinics.com/article/S1547 2017. 7, November Accessed Clin Surg Thorac diaphragm. the of paralysis Acquired 2009. GE. Darling MA, Ko Chest is negative. CT Abdomen with contrast (CPT  requested) with new diaphragmatic paralysisafter. elevation. Any loss of lung volume or increased abdominal pressure can lead to diaphragm mediastinum. Common phrenic causes are traumatic or surgical injury or malignancy involving the Any injury to the phrenic nerve from neck to diaphragm can lead to paralysis. co most “Eventration” is thin membranous replacement of muscle, usually on the right, as the The right hemidiaphragm sits about 2 cm higher than the left. indicated. Repeat adv  CT Chest with contrast (CPT Med Care Crit Respir Semin paralysis. Diaphragm A. 2009. ureshi

Supporting Information and ground . All Rights Reserved. Rights All . healthcare eviCore weakness. Fluoroscopic examination (“sniff test”) to differentiate true paralysis from diaphragmati Previ ces t. mmon cause of elevation. ous chest x anced imaging studies in the absence of new signs or symptoms are not

c elevation is a new finding, and/or 1,2 - raysare available and reviewed to determine if the ® 71260) and CT Neck with contrast (CPT ® connect.com/DOI/DOI?10.1055/s 74160) to rule out liver or abdominal process if CT

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging 8 © 201 CH - 31.1: Thoracic Outlet Syndrome Outlet Thoracic 31.1: . All Rights Reserved. Rights All . healthcare eviCore CH- : 31:

Thoracic Outlet Syndrome (TOS)

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______2. 1. Referen    Back    Syndrome Outlet Thoracic CH-31.1: Guidelines Imaging 8 © 201 Thoracic Imaging. ACR Appropriateness Criteria Appropriateness ACR Imaging. Thoracic and Imaging Neurologic Imaging, onVascular Panels Expert al. et D, Broderick D, Bandyk J, Moriarty . http://pubs.rsna.org/doi/abs/10.1148/rg.2016150221 RadioGraphics, Syndrome. Outlet Thoracic with Patient the of Imaging al. et R, Thompson S, Sridhar C, Raptis American College of Radi of College American syndrome: imaging pathway. vascular surgeon or thoracic surgeon is helpful in determining the appropriate Since this is such arare entity and diagnosis is difficult, specialist evaluation by a effort thrombosis) found in 15% and the remaining 5% being arterial in etiology. There are 3types, with neurogenic causes seen in 80%, venous causes (also called rib). first thoracic outlet of the chest (the area bounded by the two scalene muscles and the TOS refers to compression of the subclavian vessels and/or brachial plexus at the see PN Also    MR im other causes of right upper extremity pain. thereif has been a change in symptoms, since it can identify boney abnormalities or Chest X https://acsearch.acr.org/docs/69417/Narrative

Supporting Information and ground . All Rights Reserved. Rights All . healthcare eviCore MRI with suspected arterial or venous TOS.    CT Chest with contrast or CT Neck with contrast can be used in place of MRI for: a Neck MRA Che MRI

ces aging is the preferred imaging modality in individuals with suspected TOS. incompatibility. Dialysis rib. Postoperative individuals in whom there is a question regarding aremnant first definable with CT. Suspected anomalous ribs or fractures, as bone anatomy is more easily - ray should be performed initially in all cases, after the onset of symptoms or

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging 8 © 201 CH CH CH - - - 32.3: Positron Emission Mammography Emission Positron 32.3: 32.2: Navigational/EM Bronchoscopy Virtual 32.1: . All Rights Reserved. Rights All . healthcare eviCore CH-

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Mammography Emission Positron CH-32.3: Not Coding  CH-32.2: Navigational/EM   CH-32.1: Virtu Guidelines Imaging 8 © 201      guidance with aCT road map for performing biopsies of peripheral lung lesions. Peripheral bronchoscopy technology uses electromagnetic (EM) navigational flexible bronchoscope. sixththe CPT Virt investigational at this time. the use of virtual bronchoscopy, and this procedure should be considered There is insufficient data currently available to generate appropriateness criteria for

. All Rights Reserved. Rights All . healthcare eviCore ual bronchoscopy uses multidetector CT with 3D rendering (CPT See CPT 3D Rendering, (CPT procedure imaging acquisition. diagnostic CT codes should bereported for the planning phase and pre- Neither separate unlisted codes, (CPT Planning is included in the Supplementalimaging See ® 76377) to generate an image of the tracheobronchial tree down to the level of ® BR- - es 31627. to seventh-

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400   ______1. Referen   Studies Imaging -Transplant CH-33.1: Pre Guidelines Imaging 8 © 201 http://www.ajronline.org/doi/abs/10.2214/AJR.07.7061. http://www.ajronline.org/doi/abs/10.2214/AJR.07.7061. 2017. October on20 Accessed Web. (AJR).htm 3_supplement Roentgenology of Journal n America AJR. Review." Transplantation: Lung of "Imaging Al. Et and Patsios, D. Paul, N. Y. L., Ng, CT Chest with and without contrast (CPT Other studies that willbe considered include V/Q scan, Six Minute Walk Test.   See: CT Chest without contrast (CPT  not exceedthe following: undergo advanced imaging per that institution’s protocol as long as the Individuals on the waiting list or being considered thefor lung transplant can

. All Rights Reserved. Rights All . healthcare eviCore  Heart catheterization can also be done after a positive stress test. Imaging Stress Test (MPI, SE, MR) or Heart Catheterization (Right and Left); ECHO or CT Chest without contrast (CPT CT Chest with and without contrast (CPT

ce CD- Requestssubsequent for follow 1.6 :

Transplant Individuals Transplant . U.S. National Library of Medicine, Mar. 2009. Vol_ 192, No_ No_ 192, Vol_ 2009. Mar. Medicine, of Library National U.S. . ®

71250)in for post itial

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging 8 © 201 Chest (LDCT) Images (LDCT) Chest CH CH Medicaid) and (Commercial Screening CH - - - 34.3: Incidental Pulmonary Nodules Detected on Low Dose CT onLow Detected Pulmonary Nodules Incidental 34.3: 34.2: This section intentionally blank left 34.1: U.S. Preventative Services Task Force: Lung Cancer . All Rights Reserved. Rights All . healthcare eviCore CH-

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Chest Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______CH-34.2: “substantially limit life expectancy.” stable COPD and its symptoms, including cough, shortness of breath would not be examples of conditions that would from another site or a member with COPD who uses oxygenwhen ambulating, would lung cancer was discovered. For example, congesti would question the member’s ability to undergo surgical or non- *This is based on a range of chest or other organ signs, symptoms or conditions which  icaid) Med and (Commercial Screening CH-34.1: U.S. Preventative Services Task Force: Lung Cancer Guidelines Imaging 8 © 201    Medicaid Indica Screening    of the following criteriaare met: Low All criteria belowAll be criteria must met approval:for I in lessscreening than 12 months; and Currently smokes or smokes Currently quit past within the 15(

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Chest Imaging Title of Section - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______     Images (LDCT) Dose CT Chest onLow Detected Nodules Pulmonary CH-34.3: Guidelines Imaging 8 © 201 sampling is recommendedsampling and/or testing additional diagnostic tissue 4B is sampling and/or testing additional diagnostic tissue Suspicious4A : - active cancer a low becoming a of likelihood clinically ow includes nodules withfoll upsuggested; 3 : Probably benign finding(s) Primary Descriptor* Category/Category   nodule. Category4A January 1st of the following year. with aninterval LDCT done on July 1st – For exam months. 2, Category 3nodules that are unchanged on interval CT should be coded as category 3 Lung Additio LDCT, see CH- For lung nodules, including incidental findings from studies other than screening a diagnosis based on

or 4X or

Benign Appe Benign . All Rights Reserved. Rights All . healthcare eviCore If there is alow suspicion of lung cancer with these follow studies, biopsy or surgical excision should be considered. If there is a high suspicion of lung cancer with these follow studies, a annual LDCT screening -

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a larger, growing or increasingly suspicious screening if stable screening in 6LDCT months anda annual return to F solid component a8mmusedis when be there ≥ may PET/CT if unchanged.screening LDCT6 month with a annual LDCTreturn to stable. stable. is low there If suspicion lung cancer,of malignancyprobability and of depending tissue onand/or sampling the Chest withCT or PET/CT without contrast, cancer lung in 6months anda return annual screening ifto onent. solid comp a8mmusedis when be there ≥ may PET/CT up the LDCT annual screeningwould resume ollow with with - up with in LDCT with3 months another LDCT in 3LDCT withmonths LDCT another

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Chest Imaging Title of Section Appearance or Appearance - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging 8 © 201 Incomplete Category Negative Probably Probably Behavior Benign Benign Benign . All Rights Reserved. Rights All . healthcare eviCore

includes nodules nodules includes definitely benign definitely finding(s) finding(s) benign Probably No nodules and No nodules clinically active clinically active Nodules with a Nodules term follow up follow term size or lack of size cancer due to cancer likelihood of likelihood likelihood of likelihood becoming a becoming becoming a becoming Descriptor suggested; suggested; with alow Category very low low very nodules cancer growth

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diagnostic testing testing diagnostic a prior diagnosis diagnosis a prior which additional additional which individuals with individuals recommended Findings (non- Findings of lung cancer cancer lung of who return to who to return Significant or Significant and/or tissue tissue and/or lung cancer) lung Findings for for Findings Modifier for for Modifier sampling is is sampling S Potentially screening Clinically Clinically ignificant ignificant

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Chest Imaging Title of Section - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 2. 4. .Lung- 3. ______1. Referen Guidelines Imaging 8 © 201 National Coverage Determination (NCD) for Lung Cancer Screening with Low Dose Computed Dose Low with Screening Cancer Lung for (NCD) Determination Coverage National Oc 2017. 5, on October Accessed 2/5/2015. Version this of Date Effective (210.14) (LDCT) Tomography screening. Cancer Screening v3.201 Screening Cancer Lung for Guidelines™) (NCCN in Oncology Guidelines Practice Clinical NCCN the from permission https://www.nccn.org/professionals/physician_gls/pdf/lung_screening.pdf – 3.2018 Version Screening, Cancer Lung Guidelines, (NCCN) Network Cancer Comprehensive National al. SL et Baum EA, Kazerooni, DE, Wood https://www.acr.org/:/media/ACR/Documents/PDF/QualitySafety/Resources/LungRADS/Summary.pdf details.aspx?NCDId=364&ncdver=1&bc=AAAAgAAAAAAAAA%253d%253d&. https://w - https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lung 2017. 5, onOctober Accessed Force. Task Services Preventive U.S. 2013. December . Medicine Internal of Annals . n.d N.p., Force. Task Services - Screening Cancer: Lung Summary: Update Final Screening." Cancer: "Lung and complete version of the NCCN Guidelines™, go online to to online go Guidelines™, NCCN the of version and complete recent most the view To NCCN. the of permission written express the without any purpose for form any in reproduced be not may herein illustrations and Guidelines™ NCCN The reserved. rights All tober . All Rights Reserved. Rights All . healthcare eviCore RADS™ Version 1.0 Assessment Categories Release date: April 28, 2014. Accessed 2014. 28, April date: Release Categories Assessment 1.0 Version RADS™ ces 5, 2017. 5, - ww.cms.gov/medicare

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