Criteria for Imaging Effective September 25, 2009

Prepared for healthﬁ rst Provider Network. Clinical criteria for medical necessity review of outpatient diagnostic imaging. © 2009 CareCore National, LLC. All rights reserved. CareCore National Criteria for Imaging Version 2.2009

Table of Contents

0144T CT Heart Quantitative Calcium Scoring – Medicare ...... 9 0146T CTA Coronary Arteries without Calcium Scoring – Medicare ...... 9 0147T CTA Coronary Arteries with Calcium Scoring – Medicare ...... 9 0148T CTA Coronary Arteries and Structure and Morphology without Calcium Scoring – Medicare 9 0149T CTA Coronary Arteries and Structure and Morphology with Calcium Scoring – Medicare .... 9 0150T CT Heart Structure and Morphology in Congenital Heart Disease - Medicare ...... 9 0151T CT Heart for Function, Wall Motion and Ejection Fraction – Medicare ...... 9 0145T CT Heart Structure and Morphology...... 11 0145T CT Heart Structure and Morphology – Medicare ...... 12 0146T CTA Coronary Arteries without Calcium Scoring...... 13 0150T CT Heart Structure and Morphology in Congenital Heart Disease ...... 18 0151T CT Heart for Function, Wall Motion and Ejection Fraction...... 20 70336 MRI Temporomandibular Joint ...... 21 70450 CT of the Head or Brain without Contrast...... 22 70460 CT of the Head or Brain with Contrast...... 22 70470 CT of the Head or Brain without and with Contrast...... 22 70480 CT Orbit, Sella, Posterior Fossa Outer, Middle or Inner Ear without Contrast...... 29 70481 CT Orbit, Sella, Posterior Fossa Outer, Middle or Inner Ear with Contrast...... 29 70482 CT Orbit, Sella, Posterior Fossa Outer, Middle or Inner Ear without and with Contrast...... 29 70486 CT Maxillofacial Area Including Paranasal Sinuses without Contrast...... 34 70487 CT Maxillofacial Area Including Paranasal Sinuses with Contrast...... 34 70488 CT Maxillofacial Area Including Paranasal Sinuses without and with Contrast...... 34 70490 CT Soft Tissue Neck without Contrast...... 39 70491 CT Soft Tissue Neck with Contrast...... 39 70492 CT Soft Tissue Neck without and with Contrast...... 39 70496 CTA of the Head...... 43 70498 CTA of the Carotid and Vertebral Arteries...... 47 70540 MRI Orbit, Face, Neck without Gadolinium...... 49 70542 MRI Orbit, Face, Neck with Gadolinium...... 49 70543 MRI Orbit, Face, Neck without and with Gadolinium ...... 49 70544 MRA or MRV of the Brain without Gadolinium...... 53 70545 MRA or MRV of the Brain with Gadolinium...... 53 70546 MRA or MRV of the Brain without and with Gadolinium ...... 53 70547 MRA or MRV Carotid and Vertebral Arteries without Gadolinium...... 57 70551 MRI of the Brain without Gadolinium ...... 60 70552 MRI Brain with Gadolinium...... 66 70553 MRI Brain without and with Gadolinium...... 66 70554 Functional MRI of the Brain without Physician or Psychologist ...... 76 70555 Functional MRI of the Brain with Physician or Psychologist ...... 76 71250 CT of the Chest without Contrast...... 77 71260 CT of the Chest with Contrast ...... 77 Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

71270 CT of the Chest without and with Contrast ...... 77 71275 CTA of the Chest...... 90 71550 MRI of the Chest without Gadolinium ...... 93 71551 MRI of the Chest with Gadolinium ...... 93 71552 MRI of the Chest without and with Gadolinium...... 93 71555 MRA or MRV Chest without or with Gadolinium ...... 98 72125 CT of the Cervical Spine without Contrast...... 101 72126 CT of the Cervical Spine with Contrast...... 101 72127 CT of the Cervical Spine without and with Contrast...... 101 72128 CT of the Thoracic Spine without Contrast...... 105 72129 CT of the Thoracic Spine with Contrast...... 105 72130 CT of the Thoracic Spine without and with Contrast ...... 105 72131 CT of the Lumbar Spine without Contrast...... 109 72132 CT of the Lumbar Spine with Contrast...... 109 72133 CT of the Lumbar Spine without and with Contrast ...... 109 72141 MRI of the Cervical Spine without Gadolinium ...... 114 72142 MRI of the Cervical Spine with Gadolinium ...... 118 72156 MRI of the Cervical Spine without and with Gadolinium ...... 118 72146 MRI Thoracic Spine without Gadolinium...... 122 72147 MRI Thoracic Spine with Gadolinium...... 126 72157 MRI Thoracic Spine without and with Gadolinium ...... 126 72148 MRI Lumbar Spine without Gadolinium ...... 130 72149 MRI Lumbar Spine with Gadolinium ...... 134 72158 MRI Lumbar Spine without and with Gadolinium ...... 134 72159 MRA of the Spinal Canal ...... 138 72191 CTA of the Pelvis...... 139 72192 CT Pelvis without Contrast ...... 141 72193 CT Pelvis with Contrast ...... 141 72194 CT Pelvis without and with Contrast...... 141 72195 MRI of the Pelvis without Gadolinium...... 154 72196 MRI of the Pelvis with Gadolinium...... 154 72197 MRI of the Pelvis without and with Gadolinium...... 154 72198 MRA or MRV of the Pelvis without or with Gadolinium ...... 160 73200 CT of the Upper Extremity without Contrast ...... 162 73201 CT of the Upper Extremity with Contrast ...... 162 73202 CT of the Upper Extremity without and with Contrast...... 162 73206 CTA of the Upper Extremity...... 164 73218 MRI Upper Extremity Other than Joint Including Hand without Gadolinium...... 165 73219 MRI Upper Extremity Other than Joint Including Hand with Gadolinium...... 167 73220 MRI Upper Extremity Other than Joint Including Hand without and with Gadolinium ...... 167 73221 MRI Upper Extremity Joint without Gadolinium: Elbow...... 169 73222 MRI Upper Extremity Joint with Gadolinium: Elbow...... 172 73223 MRI Upper Extremity Joint without and with Gadolinium: Elbow ...... 172 73221 MRI Upper Extremity Joint without ...... 174 73222 MRI Upper Extremity Joint with Gadolinium: Shoulder...... 177

CareCore National Criteria for Imaging Version 2.2009

73223 MRI Upper Extremity Joint without and with Gadolinium: Shoulder...... 177 73221 MRI Upper Extremity Joint without Gadolinium: Wrist and Hand...... 180 73222 MRI Upper Extremity Joint with Gadolinium: Wrist and Hand...... 182 73223 MRI Upper Extremity Joint with and without Gadolinium: Wrist and Hand ...... 182 73225 MRA Upper Extremity...... 184 73700 CT Lower Extremity without Contrast ...... 185 73701 CT Lower Extremity with Contrast ...... 185 73702 CT Lower Extremity without and with Contrast...... 185 73706 CTA of the Lower Extremity...... 188 73718 MRI Lower Extremity Other than Joints without Gadolinium...... 190 73719 MRI Lower Extremity Other than Joints with Gadolinium...... 192 73720 MRI Lower Extremity Other than Joints without and with Gadolinium ...... 192 73721 MRI Lower Extremity Joint without Gadolinium: Ankle or Foot ...... 193 73722 MRI Lower Extremity Joint with Gadolinium: Ankle or Foot ...... 198 73723 MRI Lower Extremity Joint without and with Gadolinium: Ankle or Foot...... 198 73721 MRI Lower Extremity Joint without Gadolinium: Knee...... 201 73722 MRI Lower Extremity Joint with Gadolinium: Knee...... 205 73723 MRI Lower Extremity Joint without and with Gadolinium: Knee...... 205 73721 MRI Lower Extremity Joint without Gadolinium: Hip...... 208 73722 MRI Lower Extremity Joint with Gadolinium: Hip...... 211 73723 MRI Lower Extremity Joint without and with Gadolinium: Hip...... 211 73725 MRA Lower Extremity...... 214 74150 CT Abdomen without Contrast ...... 215 74160 CT Abdomen with Contrast ...... 215 74170 CT Abdomen without and with Contrast ...... 215 74175 CTA of the Abdomen...... 229 74181 MRI Abdomen without Gadolinium ...... 233 74182 MRI Abdomen with Gadolinium ...... 233 74183 MRI Abdomen without and with Gadolinium...... 233 74185 MRA of the Abdomen without or with Gadolinium ...... 239 75557 MRI of the Heart for Morphology and Function without Gadolinium ...... 243 75558 MRI of the Heart for Morphology and Function with Flow Velocity without Gadolinium ..... 247 75559 MRI of the Heart for Morphology and Function with Stress without Gadolinium...... 251 75560 MRI of the Heart for Morphology and Function with Flow Velocity and Stress without Gadolinium ...... 252 75561 MRI of the Heart for Morphology and Function without and with Gadolinium ...... 253 75562 MRI of the Heart for Morphology and Function and Flow Velocity without and with Gadolinium ...... 257 75563 MRI of the Heart for Morphology and Function with Stress without and with Gadolinium... 261 75564 MRI of the Heart for Morphology and Function with Stress with Flow Velocity without and with Gadolinium ...... 262 75635 CTA of the Abdominal Aorta and Bilateral Ileofemoral Lower Extremity Runoff ...... 263 76376 3D Rendering of Tomographic Images Not Requiring an Independent Work Station...... 265 76377 3D Rendering of Tomographic Images Requiring an Independent Work Station ...... 265 76380 CT Limited or Localized Follow-up Study ...... 267

CareCore National Criteria for Imaging Version 2.2009

76801 Ultrasound First Trimester (Up to 14 weeks) ...... 268 76802 Ultrasound First Trimester, Each Additional Gestation (Up to 14 weeks) ...... 269 76805 Ultrasound After First Trimester...... 270 76810 Ultrasound After First Trimester, Each Additional Gestation ...... 271 76811 High Risk Fetal Anatomy Ultrasound Single Gestation...... 272 76812 Ultrasound Detailed Fetal, Each Additional Gestation...... 274 76813 Ultrasound, Pregnant Uterus, Real Time with Image Documentation, Single or First Gestation ...... 276 76814 Ultrasound, Pregnant Uterus, Real Time with Image Documentation, Each Additional Gestation...... 276 76815 Limited OB Ultrasound One or More Gestations (After 14 weeks) ...... 277 76816 Follow-up OB Ultrasound (One for Each Gestation)...... 278 76817 OB Ultrasound Transvaginal ...... 279 76818 Biophysical Profile with Non-Stress Testing ...... 280 76819 Biophysical Profile without Non-Stress Testing ...... 280 76820 Doppler Velocimetry Umbilical Arteries ...... 282 76821 Doppler Velocimetry Middle Cerebral Arteries...... 282 76825 Fetal Echocardiography...... 284 76826 Fetal Echocardiography Follow-up or Repeat ...... 284 76827 Fetal Doppler Echocardiography ...... 284 76828 Fetal Doppler Echocardiography Follow-up or Repeat...... 284 77011 CT for Stereotactic Localization...... 286 77012 CT Guidance for Needle Placement...... 287 77013 CT Guidance Procedures for Ablation...... 288 77014 CT Guidance for Radiation Therapy...... 289 77021 MR Guidance Procedures ...... 290 77058 MRI of the Breast Unilateral ...... 291 77059 MRI of the Breast Bilateral ...... 291 77084 MRI Bone Marrow Blood Supply ...... 293 78000 Thyroid Uptake Single Determination...... 294 78001 Thyroid Uptake Multiple Determinations...... 294 78003 Thyroid Uptake with Stimulation or Suppression ...... 294 78006 Thyroid Imaging with Uptake Single Determination...... 294 78007 Thyroid Imaging with Uptake Multiple Determinations...... 294 78010 Thyroid Imaging Only ...... 294 78011 Thyroid Imaging with Vascular Flow...... 294 78015 Thyroid Carcinoma Metastases Imaging Limited Area ...... 294 78016 Thyroid Carcinoma Metastases Imaging with Additional Studies ...... 294 78018 Thyroid Carcinoma Metastases Imaging Whole Body...... 294 78020 Thyroid Carcinoma Metastases Uptake (Add-on Code) ...... 294 78070 Parathyroid Imaging ...... 297 78075 Adrenal Nuclear Imaging Cortex and/or Medulla...... 298 78102 Bone Marrow Imaging Limited Areas...... 301 78103 Bone Marrow Imaging Multiple Areas...... 301 78104 Bone Marrow Imaging Whole Body ...... 301

CareCore National Criteria for Imaging Version 2.2009

78185 Spleen Imaging Only with or without Vascular Flow...... 302 78195 Lymph System Imaging (Lymphoscintigraphy)...... 303 78201 Liver Imaging Static...... 304 78202 Liver Imaging with Vascular Flow ...... 304 78205 Liver Imaging SPECT...... 304 78206 Liver Imaging SPECT with Vascular Flow ...... 304 78215 Liver and Spleen Imaging Static...... 304 78216 Liver and Spleen Imaging with Vascular Flow ...... 304 78220 Liver Function withHepatobiliary Agents...... 307 78223 Bile Duct Imaging with or without CCK (HIDA Scan)...... 305 78230 Salivary Gland Nuclear Imaging ...... 306 78231 Salivary Gland Nuclear Imaging with Serial Imaging...... 306 78232 Salivary Gland Function Study ...... 306 78258 Esophageal Motility Study ...... 307 78261 Gastric Mucosa Imaging...... 308 78262 Gastroesophageal Reflux Study...... 309 78264 Gastric Emptying Study...... 310 78278 GI Bleeding Scintigraphy...... 311 78282 Gastrointestinal Protein Loss...... 312 78290 Intestinal Imaging ...... 313 78291 Peritoneal - Venous Shunt Patency...... 314 78300 Nuclear Bone Scan Limited...... 315 78305 Nuclear Bone Scan Multiple Areas...... 315 78306 Nuclear Bone Scan Whole Body ...... 315 78320 Nuclear Bone Scan SPECT...... 315 78315 Bone Scan Three Phase ...... 319 78414 Central C-V Hemodynamics (Non-imaging) Single or Multiple ...... 321 78428 Cardiac Shunt Detection...... 322 78445 Non-cardiac Vascular Flow Imaging...... 323 78456 Acute Venous Thrombosis Imaging...... 324 78457 Venous Thrombosis Imaging Unilateral...... 324 78458 Venous Thrombosis Imaging Bilateral...... 324 78459 Myocardial PET, Metabolic...... 325 78460 Myocardial Perfusion Imaging Planar Rest or Stress ...... 326 78461 Myocardial Perfusion Imaging Planar Rest and/or Stress ...... 326 78464 Myocardial Perfusion with SPECT - Single Study...... 327 78465 Myocardial Perfusion with SPECT - Multiple Studies ...... 327 78478 Myocardial Perfusion - Wall Motion ...... 327 78480 Myocardial Perfusion - Ejection Fraction ...... 327 78464 Myocardial Perfusion with SPECT – Single Study – Medicare CT and NY ...... 331 78465 Myocardial Perfusion with SPECT - Multiple Studies – Medicare CT and NY ...... 331 78478 Myocardial Perfusion - Wall Motion – Medicare CT and NY...... 331 78480 Myocardial Perfusion - Ejection Fraction – Medicare CT and NY...... 331 78466 Infarct Avid Myocardial Imaging ...... 335

CareCore National Criteria for Imaging Version 2.2009

78468 Infarct Avid Myocardial Imaging with Ejection Fraction by First Pass Technique ...... 335 78469 Infarct Avid Myocardial Imaging Tomographic SPECT...... 335 78472 Gated Cardiac Radionuclide Angiography...... 336 78473 Gated Multiple Cardiac Radionuclide Angiography ...... 337 78481 Planar First Pass Cardiac Radionuclide Angiography ...... 338 78483 Planar First Pass Multiple Cardiac Radionuclide Angiography...... 339 78491 PET Myocardial Perfusion Imaging Rest or Stress...... 340 78492 PET Myocardial Perfusion Imaging Rest and Stress...... 340 78491 PET Myocardial Perfusion Imaging Rest or Stress – Medicare CT and NY...... 344 78492 PET Myocardial Perfusion Imaging Rest and Stress – Medicare CT and NY...... 344 78494 SPECT Equilibrium Cardiac Radionuclide Angiography...... 348 78496 SPECT Equilibrium Multiple Cardiac Radionuclide Angiography...... 349 78580 Pulmonary Perfusion Imaging Particulate...... 350 78584 Pulmonary Perfusion Imaging, Particulate, with Ventilation Single Breath ...... 351 78585 Pulmonary Perfusion Imaging, Particulate, with Ventilation, without or with Single Breath 352 78586 Pulmonary Ventilation Imaging, Aerosol, Single Projection...... 353 78587 Pulmonary Ventilation Imaging, Aerosol, Multiple Projections...... 354 78588 Pulmonary Perfusion Imaging, Particulate, with Ventilation, Aerosol, Single or Multiple Projections...... 355 78591 Pulmonary Ventilation Imaging, Gaseous, Single Breath, Single Projection ...... 356 78593 Pulmonary Ventilation Imaging, Gaseous, with or without Single Breath, Single Projection357 78594 Pulmonary Ventilation Imaging, Gaseous, with or without Single Breath, Multiple Projections ...... 358 78596 Pulmonary Quantitative Differential Function Study ...... 359 78600 Brain Scintigraphy Static Limited...... 360 78601 Brain Scintigraphy Limited with Vascular Flow ...... 360 78605 Brain Scintigraphy Complete Static ...... 360 78606 Brain Scintigraphy Complete with Vascular Flow ...... 360 78607 Brain Imaging SPECT ...... 361 78608 PET Brain Metabolic...... 362 78608 PET Brain Metabolic - Medicare...... 363 78609 PET Brain Perfusion...... 364 78609 PET Brain Perfusion - Medicare...... 365 78610 Brain Imaging Vascular Flow...... 366 78630 Cisternogram...... 367 78635 Cerebrospinal Ventriculography ...... 368 78645 Shunt Evaluation ...... 369 78647 CSF Flow SPECT...... 370 78650 CSF Leakage Detection ...... 371 78660 Radiopharmaceutical Dacrocystography...... 372 78700 Kidney Imaging (Nuclear) Static ...... 373 78701 Kidney Imaging (Nuclear) with Vascular Flow ...... 374 78707 Kidney Flow and Function, Single Study without Pharmacologic Intervention...... 375 78708 Kidney Imaging with Vascular Flow and Function with Pharmacological Intervention Single376

CareCore National Criteria for Imaging Version 2.2009

78709 Kidney Imaging with Vascular Flow and Function with and without Pharmacological Intervention, Multiple ...... 377 78710 Kidney Imaging with SPECT ...... 378 78725 Nuclear Non-imaging Renal Function...... 379 78730 Urinary Bladder Residual Study...... 380 78740 Ureteral Reflux Study (Radiopharmaceutical Voiding Cystogram) ...... 381 78761 Testicular Scan – Vascular Flow and Delayed Images...... 382 78800 Radiopharmaceutical Localization of Tumor Limited Area...... 383 78801 Radiopharmaceutical Localization of Tumor Multiple Areas...... 383 78802 Radiopharmaceutical Localization of Tumor Whole Body Single Day Study ...... 383 78803 Radiopharmaceutical Localization of Tumor SPECT...... 383 78804 Radiopharmaceutical Localization of Tumor Whole Body Two or More Days ...... 383 78806 Radiopharmaceutical Imaging of Inflammatory Process Whole Body ...... 385 78807 Radiopharmaceutical Imaging of Inflammatory Process SPECT...... 385 78811 PET Limited Area ...... 387 78812 PET Skull Base to Mid-thigh...... 387 78813 PET Whole Body ...... 387 78814 PET/CT Limited Area...... 387 78815 PET/CT Skull Base to Mid-thigh ...... 387 78816 PET/CT Whole Body ...... 387 78811 PET Limited Area – Medicare ...... 396 78812 PET Skull Base to Mid-thigh – Medicare ...... 396 78813 PET Whole Body – Medicare ...... 396 78814 PET/CT Limited Area – Medicare ...... 396 78815 PET/CT Skull Base to Mid-thigh – Medicare ...... 396 78816 PET/CT Whole Body – Medicare ...... 396

CareCore National Criteria for Imaging Version 2.2009

0144T CT Heart Quantitative Calcium Scoring 0146T CTA Coronary Arteries without Calcium Scoring 0147T CTA Coronary Arteries with Calcium Scoring 0148T CTA Coronary Arteries and Structure and Morphology without Calcium Scoring 0149T CTA Coronary Arteries and Structure and Morphology with Calcium Scoring 0150T CT Heart Structure and Morphology in Congenital Heart Disease 0151T CT Heart for Function, Wall Motion and Ejection Fraction

Medicare

Medicare only

The test is never covered for screening, i.e., in the absence of signs, symptoms or disease. Electron beam tomography (EBT) is not covered.

I. 0144T Calcium scoring1-5 A. Quantitative calcium scoring is not a covered service in the Medicare Program. Calcium scoring reported in isolation is felt to be a screening service. When performed in association with CT angiography, the service is not separately payable.

II. 0146T, 0147T, 0148T, 0149T MD CCTA1-5 A. Facilitation of the diagnostic cardiac evaluation of a individual with chest pain syndrome (e.g. chest pain, anginal equivalent, angina, shortness of breath with exertion) 1. CCTA may be used in lieu of an imaging stress test if the clinician has a high degree of suspicion that CAD is high on the differential diagnosis of the symptoms (high pretest probability of disease). 2. It may be used to clarify a perfusion stress test that is non-diagnostic, equivocal, or is inadequate in explaining the patient's symptoms B. Facilitation of the management decision of a symptomatic patient with known coronary artery disease 1. New or recurrent symptoms, or 2. After prior intervention (CABG, stent, etc.) when the results of the MDCT may guide the decision for repeat invasive intervention C. Assessment of suspected congenital anomalies of coronary circulation or Great Vessels (0150T) D. Assessment of coronary or pulmonary venous anatomy (0145T and 0148T) Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

1. Prior to pacemaker insertion or transcatheter ablation for dysrhythmia E. Patient undergoing non-coronary artery cardiac surgery F. Assessment of the symptomatic patient when presentation is suspicious of pulmonary emboli or aortic dissection (see criteria for 71275) G. Assessment of mediastinal or lung parenchymal lesions, the vascularity of which is unknown or ill defined, but is critical to the diagnosis (see criteria for 71275)

III. 0151T Function analysis codes 1-5 The “function evaluation” service (0151T) should be restricted to carefully selected situations where information on left ventricular and/or right ventricular function is needed for management decision. It must not be ordered routinely with all studies. It should not be necessary to use this feature when there is available pre-test information on ventricular function from other sources such as echocardiogram, cardiac MR or LV gram on cardiac catheterization.

Reference:

1. Cardiac computed tomography and computed tomography coronary angiography, LCD L26128, accessed at http://www.umd.nycpic.com/cgi-bin/bookmgr/bookmgr.exe/BOOKS/RD018E00/FRONT August 23, 2008. 2. LCD for Cardiac computed tomography (CCT) (L27418) accessed at http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=27418&lcd_version=3&basket=lcd%3A27418%3A3%3ACardiac+Computed+Tomography+% 28CCT%29%3AFI%3AArkansas+Blue+Cross+Blue+Shield+%2D+Rhode+Island+%2800021%29%3A August 23, 2008. 3. LCD for Cardiac computed tomography (CCT) and coronary computed tomography angiography(CCTA) (L27421), accessed at http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=27421&lcd_version=2&basket=lcd%3A27421%3A2%3ACardiac+Computed+Tomography+% 28CCT%29+and+Coronary+Computed+Tomography+Angiography+%28CCTA%29%3ACarrier%3AHealthNow+++%2800801%29%3A, August 23, 2008. 4. Draft LCD for cardiac computed tomography and computed tomography angiography-revised (DL22391), accessed at http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=22390&lcd_version=5&basket=lcd%3A22390%3A5%3ACardiac+Computed+Tomography+an d+Computed+Tomography+Coronary+Angiography+%2D+Revised%3ACarrier%3AHealthNow+++%2800801%29%3A22391 August 23, 2008. 5. Cardiac computed tomography (CCT) and coronary computed tomography angiography (CCTA) (L25907) accessed at http://www.empiremedicare.com/newjpolicy/policy/l25907_final_lcd_ngs.htm August 23, 2008.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

0145T CT Heart Structure and Morphology

NOTE: This procedure is contraindicated if the member has any one of the following:

I. Contraindications A. Multifocal atrial tachycardia B. Frequent Atrial Premature Contractions (APCs) C. More than 50 Premature Ventricular Contractions hourly (PVCs) D. Inability to lie flat E. Inability to obtain a heart rate of <65 beats per minute after beta blockers F. Calcium score of >1000 G. Normal cardiac catheterization <1 year ago H. Body mass index of >40% I. Inability to breath hold for >8 seconds

Note that the contraindications for 0145T and 0148T are different from those for 0146T, 0145T and 0148T do not include atrial fibrillation.

I. Planned electrophysiologic procedure 1 This procedure is only performed prior to an electrophysiologic procedure such as ablation or cardiac resynchronization therapy such as placement of a biventricular pacemaker or an Automatic Implantable Cardioverter/Defibrillator (AICD). A. Planned pulmonary vein ablation 1. Atrial fibrillation a. Rate inadequately controlled on drug therapy 2. Paroxysmal atrial fibrillation B. Planned placement of biventricular pacemaker C. Planned placement of an AICD

References:

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

0145T CT Heart Structure and Morphology

Medicare

NOTE: This procedure is contraindicated if the member has a known calcium score of >1000

I. Pre surgical planning 1,2,3 This procedure is only performed prior to an electrophysiologic procedure such as ablation or cardiac resynchronization therapy such as placement of a biventricular pacemaker or an Automatic Implantable Cardioverter/Defibrillator (AICD). A. Planned pulmonary vein ablation 1. Atrial fibrillation a. Rate inadequately controlled on drug therapy 2. Paroxysmal atrial fibrillation B. Planned placement of biventricular pacemaker C. Planned placement of an AICD

References:

1. Hendel RC, Kramer CM, Patel MR et al, ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 Appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging, accessed at http://www.acc.org/qualityandscience/clinical/pdfs/CCT.CMR.pdf February 18, 2008. 2. National Government Services, Inc, LCD for Cardiac Computed Tomography (CCT) and Coronary Tomography Angiography (CCTA) (L25907), accessed at http://www.ngsmedicare.com/NGSMedicare/lcd/L25907_active_lcd.htm, June 8, 2009. 3.Highmark Medicare Services, LCD L27483- Computed Tomographic Angiography of the Chest, accessed at http://www.highmarkmedicareservices.com/policy/mac-ab/l27483-r4.html, June 8, 2009.

Reviewed: 6/09/2009 Posted:6/09/2009

CareCore National Criteria for Imaging Version 2.2009

0146T CTA Coronary Arteries without Calcium Scoring

NOTE: CCTA is contraindicated if the member has any one of the following: (send for physician review) 1 Atrial fibrillation Multifocal atrial tachycardia Frequent Atrial Premature Contractions (APCs) More than 50 premature ventricular contractions hourly (PVCs) Inability to lie flat Inability to obtain a heart rate of <65 beats per minute after beta blockers Calcium score of >1000 Normal cardiac catheterization <1 year ago Body mass index of >40% Inability to breath hold for >8 seconds

I. New congestive heart failure and no cardiac imaging (cardiac catheterization, CCTA, or stress test) in last 8 weeks 1 A. Chest x-ray (current) with findings of CHF B. Hospitalization for CHF with documented weight loss and improvement in symptoms with diuretics C. Outpatient CHF with documented weight loss and improvement in symptoms with diuretics D. Cardiomyopathy with ejection fraction of <50%

II. Recurrent congestive heart failure and prior CCTA or coronary artery catheterization since the onset of the diagnosis of heart failure

III. Positive routine exercise stress test A. EKG changes 1. >1 mm ST depression which is horizontal or downsloping 2. Ventricular ectopy (PVCs) induced during the stress test B. Drop in systolic blood pressure >10 mm Hg induced during the stress test C. Chest pain during exercise stress test D. Other findings 1. No prior routine stress test within 2 years 2. Coronary artery catheterization not planned 3. No chest pain syndrome †, dyspnea on exertion 4. Framingham risk <10%

IV. New EKG findings compared to a routine stress test done <2 years ago. Coronary artery catheterization not planned

CareCore National Criteria for Imaging Version 2.2009

A. Chest pain syndrome † with pretest probability low or very low (See chart 1 to determine pretest probability of disease based on chest pain) B. Prior coronary artery catheterization was normal or revealed <30% stenosis in all vessels C. Prior CCTA 1. Normal 2. <40 % stenosis in all vessels 3. Calcium score <100

V. Abnormal imaging stress test NO chest pain syndrome † A. New findings on current imaging stress test 1. Framingham risk <10% (see chart 2) 2. Coronary artery catheterization is not planned B. New findings on current imaging stress compared to one done in past two years 1. No prior evaluation or medical therapy a. No coronary angiogram is planned b. There are no symptoms of chest pain or dyspnea on exertion c. Framingham risk percentage <10% (see chart 2 below) 2. Prior coronary angiogram was normal 3. Prior CCTA was normal

VI. NEW chest pain syndrome † 1 A. Pretest probability is low or very low (See chart 1 to determine pretest probability of disease based on chest pain) and routine stress test contraindicated 1. Inability to exercise 2. Diabetes 3. Current use of digoxin or digoxin derivative 4. Wolfe-Parkinson-White Syndrome 5. Complete left bundle branch block 6. Ventricular paced rhythm 7. Poor heart rate response due to medication (beta blockers, calcium channel blockers) 8. > 1mm ST depression which is horizontal or downsloping B. Intermediate to high risk (see chart 2) normal uninterpretable or equivocal myocardial perfusion imaging including EKG (CCTA is not to be approved for a member with very low to low pre- test probability of disease.)

VII. Pre-operative assessment for high-risk non-cardiac surgery 1 A. High risk surgery†† 1. Aortic and other major vascular surgery 2. Peripheral arterial vascular surgery 3. Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss B. Framingham risk <10% C. No imaging stress test within the past year

VIII. Valvular heart disease and heart catheterization is not planned1 Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

IX. Suspected congenital anomalies of the coronary circulation 1 A. Myocardial ischemia documented on stress test and coronary angiography demonstrating a smooth vessel constriction B. Young patient (under 35) with exertional syncope or exertional chest pain and one of the following 1. Normal 12 lead EKG 2. Normal stress test 3. Normal myocardial perfusion scan

X. Failed coronary artery catheterization A. Positive myocardial perfusion scan B. Symptomatic patient after coronary artery bypass surgery or PCI including stents 1. Exertional chest pain relieved by either rest or nitroglycerin, 2. Chest tightness

†Chest pain syndrome includes chest pain, chest tightness, chest burning, dyspnea, shoulder pain, and jaw pain.

†† The following surgeries are considered to be either Intermediate Risk or Low Risk and do not qualify for preoperative evaluation by CCTA:

Carotid endarterectomy Head and neck surgery Intraperitoneal or intrathoracic surgery Orthopedic surgery (including joint replacement) Prostate surgery Endoscopic surgery Superficial procedures Cataract surgery Breast surgery Bariatric surgery

The following assessment is used to determine the pre-test probability of coronary artery disease based on a description of the character of the chest pain, member age and sex. This assessment will define the chest pain as typical angina, atypical angina, and nonanginal chest pain. To characterize the chest pain, the following questions are to be asked and scored:

1) Substernal chest pain=1 2) Arm pain=0 3) Jaw pain=0 4) Relieved by nitroglycerin or rest=1 Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

5) Shortness of breath=0 6) Nocturnal= 0 7) Pain or discomfort with inspiration= 0 8) Discomfort at rest = 0 9) Exercise induced or emotionally induced=1

A score of 3 qualifies as typical angina; a score of 2 qualifies as atypical angina, and 0-1 qualifies as non-anginal. This description then is applied to the age/sex criteria as follows:

The pre-test probability is defined as high, intermediate, low, or very low. This is applied to the criteria sets for determination of the need for CCTA. Framingham risk assessment is a calculation to predict the 10 year risk of heart disease in an individual member. The calculation is made from member age, sex, most recent lipid values and blood pressure, as well as smoking history and the presence of diabetes. A sample calculator can be found on-line at: http://www.intmed.mcw.edu/clincalc/heartrisk.html 2

CHART 1 Determination of Pretest Probability for Coronary Disease Based on Chest Pain1 The following assessment is used to determine pre-test probability of coronary artery disease based on description of the character of chest pain, member age and sex. This assessment will define the chest pain as typical angina, atypical angina, and nonanginal chest pain. This description then is applied to the age/sex criteria as follows

Age Gender Typical/Definite Atypical/Probable Angina Nonanginal Chest Asymptomatic Years Angina Pectoris Pectoris Pain 30-39 Men Intermediate Intermediate Low Very Low Women Intermediate Very Low Very Low Very Low 40-49 Men High Intermediate Intermediate Low Women Intermediate Low Very Low Very Low 50-59 Men High Intermediate Intermediate Low Women Intermediate Intermediate Low Very Low ≥60 Men High Intermediate Intermediate Low Women High Intermediate Intermediate Low High: Greater than 90% Intermediate: Between 10% Low: Between 5% and 10% Very Low: Less than 5% pre- pretest probability and 90% pre-test probability pre-test probability test probability

Typical Angina (definite): 1) Substernal chest pain or discomfort is 2) provoked by exertion or emotional stress and 3) relieved by rest and/or nitroglycerin.

Atypical angina (probable): Chest pain or discomfort that lacks one of the characteristics of definite or typical angina.

Non-anginal chest pain: Chest pain or discomfort that meets one or none of the typical angina characteristics.

CareCore National Criteria for Imaging Version 2.2009

Chart 2 Framingham Risk Assessment for Coronary Artery Disease1

Framingham risk assessment is a calculation to predict the 10-year risk of heart disease in an individual member. The calculation is made from member age, sex, most recent lipid values and blood pressure, as well as smoking history and presence of diabetes. A sample calculator can be found on-line at: http://www.intmed.mcw.edu/clincalc/heartrisk.html 2

CHD Risk Level Framingham Score Low Less than 10% Moderate Between 10% and 20% High Greater than 20%

Framingham Coronary Heart Disease (CHD) Risk: The exact Framingham risk percentage is applied, if required, to the determination of need for the requested CCTA.

References:

1. Hendel RC, Kramer CM, Patel MR, et al, ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging, accessed at http://www.acc.org/qualityandscience/clinical/pdfs/CCT.CMR.pdf February 18, 2008. 2. Coronary heart Disease Risk Calculator, Medical College of Wisconsin, accessed at http://www.intmed.mcw.edu/clincalc/heartrisk.html April 19, 2006.

Additional references:

3. Mollet NR, Cademartiri F, van Mieghem CAG, et al, High- resolution spiral computed tomography coronary angiography in members referred for diagnostic conventional coronary angiography, Circulation, 2005;112:2318-2323. 4. Leschka S, Alkadhi H, Desbiolles L et al, Accuracy of MSCT coronary angiography with 64-slice technology: first experience, Eur H J, 2005; 26:1482- 1487. 5. Nieman K, Cademartiri F, Lemos PA, et al, Reliable noninvasive coronary angiography with fast submillimeter multislice spiral computed tomography, Circulation, 2002; 106:2051-2054. 6 Nieman K, Cademartiri F, Raaijmkers R et al, Noninvasive angiographic evaluation of coronary stents with multi-slice spiral computed tomography, Herz, 2003; 28:136-142 7. Maintz D, Seifarth H, Raupach R, et al, 64-slice multidetector coronary CT angiography: in vitro evaluation of 68 different stents, Eur Radiol, 2006; 16:818-826. 8. Budoff MJ, Achenbach S, and Duerinckx A, Clinical utility of Computed tomography and magnetic resonance techniques for noninvasive coronary angiography, J Amer Coll Cardiol,, 2003; 42:1867-1878. 9. Baron BJ, Sudden Death in Young Athletes, N Eng J Med, 2003; 349:1064-1075.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

0150T CT Heart Structure and Morphology in Congenital Heart Disease

I. Suspicion of congenital obstructive cardiac lesion A. Working diagnosis 1. Coarctation of the aorta 2. Aortic valve stenosis 3. Pulmonic valve stenosis 4. Mitral valve stenosis 5. Tricuspid valve stenosis or atresia B. Prior imaging 1. Documented diagnosis by other imaging and planned surgical repair 2. Chest x-ray suggestive consistent with working diagnosis 3. Echocardiogram inadequate visualization for surgery

II. Atrial Septal Defect (ASD) including Patent Foramen Ovale (PFO) A. Prior imaging 1. Chest x-ray suggestive of ASD 2. Echocardiogram inadequate visualization for surgical repair B. Asymptomatic 1. Systolic ejection murmur with diastolic rumble 2. Echocardiogram inadequate visualization for surgical repair C. Symptomatic 1. Dyspnea or congestive heart failure 2. CVA with unknown etiology (paradoxical embolus) D. Documented diagnosis by other imaging and planned surgical repair

III. Ventricular Septal Defect (VSD) A. Documented diagnosis by other imaging and planned surgical repair

IV. Tetralogy of Fallot A. Prior imaging 1. Chest x-ray suggestive of Tetralogy of Fallot 2. Echocardiogram inadequate visualization of anatomy B. Documented diagnosis by other imaging and planned surgical repair

V. Ebstein’s anomaly A. Documented diagnosis by other imaging and planned surgical repair

VI. Other congenital heart disease A. Truncus arteriosus B. Transposition of the Great Vessels

CareCore National Criteria for Imaging Version 2.2009

C. Single left ventricle D. Total anomalous pulmonary venous return E. Endocardial cushion defect F. Vascular rings and other congenital anomalies of the great vessels G. Left sided aortic arch with aberrant right subclavian artery H. Anomalous left pulmonary artery I. Double aortic arch J. Ebstein’s anomaly K. Eisenmenger’s syndrome

VII. Syndromes with congenital heart disease (established diagnosis) A. Holt-Oram syndrome also called heart-hand B. Anomalous pulmonary venous return C. Marfan’s syndrome D. Turner’s syndrome E. William syndrome F. Trisomy 21 (Down syndrome) G. Schone’s syndrome

References: 1. Gfilkeson RC, Ciancibello L and Zahka K, Multidetector CT evaluation of congenital heart disease in pediatric and adult patients, AJR, 2003; 180:973-980. 2. Goo HW, Park I, Ko JK, et al, CT of congenital heart disease: normal anatomy and typical pathologic conditions, RadioGraphics, 2003; 23:S147-S165. 3. Siegel MJ, Bhalla S, Gutierrez FR, et al, MDCT of postoperative anatomy and complications in adults with cyanotic heart disease, AJR, 2005; 184:241-247. 4. Westra SJ, Hill JA, Alejos JC, et al, Three-dimensional helical CT of the pulmonary arteries in infants and children with congenital heart disease, AJR, 1999; 173:109-115.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

0151T CT Heart for Function, Wall Motion and Ejection Fraction

I. Certified when either 0145T, 0146T, 0148T, of 0150T have already been certified unless: A. Ejection fraction and wall motion has already been performed as part of a nuclear or echo stress test.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

70336 MRI Temporomandibular Joint

I. Clinical symptoms 1-4 A. Physical 1. Clicking, popping or grating of one or both TMJs 2. Locking of jaw when opening mouth 3. Unable to open mouth comfortably 4. Mandible (jaw) deviates to one side on opening mouth 5. Physical limitation of opening or closing mouth 6 Pain or tenderness of masseter muscle (TMJ or side of face) on direct palpation B. Facial pain or swelling [(1 or 2 or 3) and 4] 1. Pain in TMJ (side of jaw) not relieved by conservative therapy including NSAIDs, if tolerated, for 3 weeks 2. Headache or neck pain not relieved by conservative therapy including NSAIDs, if tolerated, for 3 weeks 3. Swelling on side of face not relieved by conservative therapy including NSAIDs, if tolerated, for 3 weeks 4. Pain and/or tenderness of TMJ (side of face) on direct palpation during physical examination

References:

1. Berteram S, et al, Diagnosing TMJ internal derangement and osteoarthritis with magnetic resonance imaging, J Am Dent Assoc, 2001; 132:753-761. 2. Haley, DP, DDS, et al, The relationship between clinical and MRI finding in patients with unilateral TM joint pain, JADA, 2001; 132 no. 4: 476-481. 3. Janzen DL, Connell DG, and Munk PL, Current imaging of temporomandibular 2001 joint abnormalities: a pictorial essay. (Department of Radiology, University of British Columbia, Vancouver), Can Assoc Radiol J, 1998 Feb; 49(1):21-34. 4. Schallhas KP, et al, Facial pain, headache and temporomandibular joint inflammation, Headache: The Journal of Head and Face Pain, 1989 April; 29(4):229-232.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

70450 CT of the Head or Brain without Contrast 70460 CT of the Head or Brain with Contrast 70470 CT of the Head or Brain without and with Contrast

I. Head trauma 1, 2 A. Amnesia B. Altered level of consciousness or loss of consciousness C. Vomiting D. Neurologic symptoms E. Headache F. Seizure G. Coagulopathy previously diagnosed (or current treatment with Heparin or Coumadin) H. Skull fracture I. Ataxia J. Aphasia K. Decreased sensation in a limb L. Visual field loss M. Double vision N. Memory loss

II. New neurologic signs or symptoms that suggest stroke3 or TIA A. Sudden onset of: 1. Motor weakness affecting a limb, or one side of the face or body 2. Decreased sensation affecting a limb, or one side of the face or body 3. Ataxia (unsteady and clumsy motion of the limbs or trunk) 4. Cognitive dysfunction 5. Impaired vision, including amaurosis fugax, visual field loss and diplopia 6. Aphasia (loss or impairment of the ability to produce or comprehend language due to brain damage) 7. Dysarthria (speech disorder resulting from neurological injury) 8. Dysphagia with no GI cause 9. Vertigo with either headache or nystagmus 10. Re-evaluation after documented stroke with change in neurological examination 11. Numbness, tingling, paresthesias 12. Syncope

III. Re-evaluation after stroke A. Anti-coagulation planned B. New or worsening neurologic signs and symptoms

CareCore National Criteria for Imaging Version 2.2009

IV. Headache, indications for imaging 4-6 (MRI preferred except for E, J and L) A. Syncope B. Papilledema C. Worsened by Valsalva maneuver, coughing straining or postural changes D. Wakens from sleep E. SAH 1. With sudden onset of severe, exertional, or "thunderclap" headache 2. Associated with nausea, vomiting, diplopia, seizure, mental status change or syncope 3. History of prior aneurysm or AVM F. Infection in an extracranial location G. Change in mental status, personality or level of consciousness H. Suspected carotid artery dissection 1. Rapid onset of headache with strenuous exercise or Valsalva maneuver 2. Recent minor trauma 3. Neck pain 4. Horner’s syndrome on same side as neck pain I. Head pain that spreads into the lower neck and between the shoulders (may indicate meningeal irritation due to either infection or subarachnoid blood; it is not typical of a benign process) J. Suspected subdural hematoma 1. Major head trauma 2. Minor trauma while on anti-coagulants K. Thunderclap headache L. Worst headache of life M. New headache [One] 1. Abnormal neurologic examination a. Papilledema b. Nystagmus c. Gait abnormality d. Weakness of an arm or leg e. Seizure 2. Fever >100.4 3. Stiff neck (nuchal rigidity) 4. History of cancer 5. History of HIV infection 6. History of TB 7. History of sarcoidosis 8. Age 5 years or less 9. Over age 50 10. Pregnancy 11. Headache with exertion 12. Documented infection outside the brain 13. Mental status changes 14. Extracranial malignancy Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

N. Progressive worsening of headache O. Numbness or tingling P. New onset of chronic daily headache

V. Seizure 7-9 (MRI with gadolinium is preferred) A. Initial evaluation of new onset of seizures B. In patients with a known seizure disorder who experience an increase in seizure activity or are refractory to treatment at adequate dosage

VI. Infection or abscess 10, 11 (MRI with gadolinium is preferred) A. Findings suggesting infection 1. Fever >100.4 2. Leukocytosis, WBC >12,000/cu.mm 3. Known infection elsewhere 4. Immunocompromised patient B. Other clinical findings 1. Headache 2. Drowsiness or confusion 3. Motor sensory or speech disorders 4. Vomiting 5. Seizure 6. Stiff neck 7. Photophobia 8. Recurrence of symptoms after antimicrobial therapy C. Follow-up during and after completion of therapy to assess effectiveness

VII. Brain tumor 12-18 (MR not feasible) This may include any of the following: Astrocytoma Choroid plexus papilloma Craniopharyngioma Ependymoma Gliobastoma multiforme Hematoma Hemangioblastoma Medulloblastoma Meningioma Metastases OligodendrogliomaPituitary adenoma A. Evaluation of known primary brain tumor 1. New signs and symptoms or worsening neurological condition a. New onset of headache b. New onset of vomiting

CareCore National Criteria for Imaging Version 2.2009

c. New onset of visual problems 2. Interval re-evaluation a. Anaplastic astrocytoma or oligodendroglioma, or glioblastoma multiforme may be examined at 60 to 90 day intervals after completion of therapy for three years without evidence of change in clinical condition. b. Other known primary intracranial cancers may be imaged every 90-180 days with no change in signs or symptoms B. Evaluation for brain metastases in patients with known extracranial malignancy 1. Routine initial staging for the following a. Sarcoma b. Melanoma c. Small cell lung cancer 2. New neurological signs or symptoms with any other known malignancy a. New onset of headache b. New onset of vomiting c. New onset of visual problems d. Seizure e. Visual changes f. Personality or behavioral changes 3. Follow-up assessment during or after therapy for known metastases 4. Known brain metastasis with new or worsening symptoms 5. Follow up known brain metastases after chemotherapy a. Imaging (preferably contrast MRI) every 3 months for 1 year b. After one year imaging is performed based on clinical signs and symptoms 6. Follow up known brain metastases after radiation therapy a. Imaging (preferably contrast MRI) every 3 months for 1 year b. After one year imaging is performed based on clinical signs and symptoms 7. Follow up up known brain metastases after surgery a. Imaging (preferably contrast MRI) every 3 months for 1 year b. After one year imaging is performed based on clinical signs and symptoms C. Cranial nerve palsy

VIII. Evaluation after intervention or surgery A. New or worsening neurologic condition B. Follow-up

IX. Suspected acoustic neuroma (schwannoma) or cerebellar pontine angle tumor 19, 20 (MRI preferred) A. Symptoms 1. Unilateral sensorineural hearing loss documented by audiometry 2. Headache 3. Disturbed balance or gait 4. Tinnitus B. Findings 1. Sensorineurial hearing loss Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

2. Facial weakness 3. Altered sense of taste C. Neurofibromatosis

X. Hydrocephalus21 A. Suspected obstructive hydrocephalus 1. Clinical findings a Headache b. Papilledema c. Diplopia d. Mental status changes e. Gait disturbance or ataxia (People with ataxia experience a failure of muscle control in their arms and legs, resulting in a lack of balance and coordination or a disturbance of gait.) f. Seizure 2. History of a. Arteriovenous Malformation (AVM) b. Aneurysm c. Intraventricular or SAH d. Meningitis e. Hydrocephalus B. Normal Pressure Hydrocephalus (NPH) 1. Apraxic gait (apraxia is a motor disorder in which volitional or voluntary movement is impaired without muscle weakness) 2. Motor perseveration 3. Urinary incontinence 4. Dementia 5. Known NPH with worsening symptoms

XI. Evaluation of tinnitus 22-24 (ringing, hissing, buzzing, roaring, clicking or rough sounds heard by patient) A. If tinnitus is objective and pulsatile approve MRA or CTA B. If tinnitus is objective and continuous approve (MRI of brain with gadolinium is preferred) C. If tinnitus is subjective and unilateral MRI of brain with gadolinium is preferred

XII. Arnold Chiari malformation A. Cranial nerve palsy B. Incontinence C. Lower extremity spasticity D. Lumbar myelomeningocele E. Sensory loss F. Tethered cord G. Unsteady gait H. Neck or back pain I. Follow up of known Chiari with new or changed symptoms Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

XIII. Craniosynostosis XIV. Fibrous Dysplasia XV. Macrocephaly XVI. Microcephaly XVII. Encephalocele XVIII. Cephalohematoma

References:

1. Smits M, Dippel DWJ, de Haan GG, et al, Minor head injury: guidelines for the use of CT-A multicenter validation study, Radiology, 2007, published on line before print October 2, 2007, accessed at http://radiology.rsnajnls.org/cgi/content/full/2452061509v1 November 6, 2007. 2. Vos PE, Bttistin G, Birbamer F, et al., EFNS guideline on mild traumatic brain injury: report of tan EFNS taskforce, Eur J Neuorol, 2002; 9: 207-219. 3. De La Paz RL, Seidenwurm DJ, Davis PC, et al, Expert panel on neurologic imaging, ACR Appropriateness Criteria, Cerebrovascular Disease, Variant 2, American College of Radiology,2006 accessed on line at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/CerebrovascularDiseaseD oc2.aspx November 6, 2007. 4. Yoshito T, and Endo K, MR imaging in the evaluation of chronic or recurrent headache, Radiology, 2005; 235:575-579. 5. Beithon F, Detlie E, Hult C, et al, Health care guideline: diagnosis and treatment of headache, Eighth edition, January 2007, Institute for Clinical Systems Improvement http://www.icsi.org/headache/headache__diagnosis_and_treatment_of_2609.html accessed July 10, 2007. 6. Frishberg BM, Rosenberg JH, Matchar DB, et al, Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache, accessed at http://www.aan.com/professionals/practice/pdfs/gl0088.pdf September 20, 2007. 7. Karis JP, Seidenwurm DJ, Davis PC, et al., Expert panel on neurologic imaging, ACR Appropriateness Criteria, Epilepsy, American College of Radiology, 2006 accessed on line at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/EpilepsyDoc 3.aspx November 6, 2007. 8. Marks WJ, and Garcia PA, Management of seizures and epilepsy, American Family Physician, accessed at http://www.aafp.org/afp/980401ap/marks.html November 6, 2007. 9. Scottish Intercollegiate Guidelines Network, Diagnosis and management of epilepsy in adults, a national clinical guideline, accessed on line at http://www.sign.ac.uk/pdf/sign70.pdf November 1, 2007. 10. Enzmann DR, Britt RH, Placone R, Staging of human brain abscess by computed tomography, Radiology, 1983; 146:703-708. 11. Zak IT, Altinok D, Merline JR, et al, West nile virus infection, AJR, 2005; 184:957-961. 12. Davis PC, Hudgins PA, Peterman SB, et al, Diagnosis of cerebral metastases: double-dose delayed CT vs. contrast-enhanced MR imaging, AJNR, 1991; 12(2):293-300. 13. Schaefer PW, Budzik RF Jr., Gonzalez RG, Imaging of cerebral metastases, Neurosurg Clin N Am, 1996 Jul; 7(3):393-423. 14. Aupérin A, Arriagada R, Pignon J, et al, Prophylactic cranial irradiation for patients with small-cell lung cancer in complete remission, N Eng J Med, 1999; 341(7):476 - 484. 15. NCCN Practice guidelines in Oncology v2.2006 Central nervous system cancers, p. 100 (GLIO-2). 16. Davis PC, Hudgins PA, Peterman SB, et al, Diagnosis of cerebral metastases: double-dose delayed CT vs. contrast-enhanced MR imaging, AJNR, 1991; 12(2):293-300. 17. Soffietti R, Cornu P, Delattre JY, et al, EFNS guidelines on diagnosis and treatment of brain metastases: report of an EFNS Task Force, Eur J Neuorol, 2006; 13: 674-681. 18.Brem SS, Bierman PJ, Black P et al, NCCN Central Nervous system Cancers Panel Members, NCCN Practice Guidelines in Oncology- v1.2008, Central nervous system cancers, accessed at http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf , March 10, 2009. 19.Turski PA, Seidenwurm DJ, Davis PC, et al, Expert panel on neurologic imaging, ACR Appropriateness Criteria, Vertigo and hearing loss, American College of Radiology, 2006 accessed on line at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/VertigoandH earingLossDoc14.aspx November 6, 2007.

CareCore National Criteria for Imaging Version 2.2009

20. Clinical Practice Advisory Group of the British Association of Otorhinolaryngologists Head and Neck Surgeons, Clinical effectiveness guidelines, Acoustic neuroma (vestibular schwannoma), accessed at http://www.entuk.org/members/publications/ceg_acousticneuroma.pdf October 30, 2007. 21.Dormant D, Seidenwurm DJ, Davis PC, et al, Expert panel on neurologic imaging, ACR Appropriateness Criteria, Dementia and movement disorders, Variant 7: Suspected normal pressure hydrocephalus, American College of Radiology, 2006 accessed on linehttp://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/NeurodegenerativeDis ordersUpdateinProgressDoc9.aspx October 31, 2007. 22. Lockwood AH, Salvi RJ, Burkard F, Tinnitus, N Eng J Med, 2002; 347:904-910. 23. Henry JA, Dennis KC, Schechter MA, General review of tinnitus: prevalence, mechanisms, effects, and management, J Speech Lang Hear Res, 2005; 48:1204-1235. 24. Crummer RW, Hassan GA, Diagnostic approach to tinnitus http://www.aafp.org/afp/20040101/120.html accessed on July 22, 2007.

Reviewed: 3/18/2009 Posted: 8/15/2009

CareCore National Criteria for Imaging Version 2.2009

70480 CT Orbit, Sella, Posterior Fossa Outer, Middle or Inner Ear without Contrast 70481 CT Orbit, Sella, Posterior Fossa Outer, Middle or Inner Ear with Contrast 70482 CT Orbit, Sella, Posterior Fossa Outer, Middle or Inner Ear without and with Contrast

VTI exam (studies performed to provide a virtual anatomy guide for use during surgery) are becoming increasingly more common 1, 2

I. Head and neck cancer 3-10 A. New, confirmed tissue diagnosis for initial staging B. Deteriorating clinical condition with known head and neck cancer C. Restaging during or shortly after therapy

II. Suspected orbital tumor or other pathology 11-13 A. Unilateral exophthalmos or enophthalmous B. Orbital or periorbital mass or vascular malformation C. Vision loss D. Thyroid eye disease (including myopathy) 14 1. Bilateral proptosis 2. Vision loss

III. Optic neuritis [MRI with gadolinium preferred] 15-18 A. Eye pain worsening with movement of the eye B. Visual field deficit which is mostly central C. Visual loss in one eye 1. Known MS D. Examination of the eye 1. Swelling of the optic disc 2. Blurring of disc margins 3. Distended veins E. Suspicion of multiple sclerosis, 1. Pain on eye movement or tenderness of globe 2. Impaired color perception 3. Age 15 - 50 4. Unilateral rapid visual loss 5. Visual loss Improves spontaneously Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

F. Post radiation neuritis, visual loss months or years after radiation therapy to area

IV. Bell's Palsy, with unusual presentation [MRI preferred] 19-21 A. Slow onset B. Bilateral C. Extended duration, no indication of recovery after two weeks

V. Evaluation of tinnitus, 22-24 (ringing, hissing, buzzing, roaring, clicking or rough sounds heard by patient) A. If tinnitus is objective and continuous B. If tinnitus is subjective and unilateral 1. Examination of the ear a. No evidence of wax impaction b. No evidence of otitis media c. No evidence of otitis externa

VI. Evaluation of vertigo, (MRI preferred) 25, 26 A. Progressive unilateral hearing loss B. Nystagmus C. Pain in ear or mastoid area, headache D. Nausea or vomiting E. Signs suggesting cerebrovascular or demyelinating disease [MR head may also be appropriate] 1. Weakness 2. Paresthesia 3. Other changes in sensory and motor function 4. Altered level of consciousness 5. Changes in vision 6. Ataxia or dysarthria

VII. Evaluation of congenital anomalies of the ear 27

28, 29 VIII. Suspected cholesteatoma A. Recurrent or persistent purulent otorrhea B. Hearing loss C. Tinnitus D. Retraction of the tympanic membrane

IX. Trauma 30 A. Radiographic (routine x-ray exam) evidence of fracture or not diagnostic B. Infra orbital numbness C. Enophthalmous D. Inhibited movement of eyes, e.g. diplopia E. Suspected foreign body in globe or orbit Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

F. Bleeding from ear after injury

28 X. Evaluation of severe infections of the ear (malignant otitis externa)

XI. Cochlear implant evaluation

XII. Congenital hearing loss

XIII. Visual field loss 31

XIV. Congenital anomaly of the orbit 31

XV. Otosclerosis

XVI. Suspected pituitary disease (micro-adenoma, macro-adenoma) [MRI of the brain with gadolinium is preferred] 32-36 A. Elevated pituitary hormones including precocious puberty 1. Prolactin (PRL) >20 ng/mL [g/L] 2. Growth Hormone (GH) >5 ng/mL [g/L] 3. Thyroid Stimulating Hormone (TSH) >6 U/mL [mIU/L] 4. Follicular Stimulating Hormone (FSH) a. Male: >10 mIU/mL b. Female: (mIU/mL) i. Follicular phase >13 ii. Luteal phase >13 iii. Midcycle >22 iv. Post-menopausal >138 5. Luteinizing Hormone (LH) a. Male: >10 mIU/mL b. Female: (mIU/mL) i. Follicular phase >18 ii. Luteal phase>20 iii. Midcycle peak >105 iv. Post-menopausal >62 6. Adrenocorticotropic hormone (ACTH) >200 pg/mL B. Decreased pituitary hormones or hypopituitarism 1. Pituitary apoplexy a. Acute headache with vomiting b. Ophthalmoplegia c. Amaurosis fugax (temporary vision loss) d. Depressed level of consciousness e. Bitemporal hemianopsia (visual field loss) 2. Growth hormone response of less than 3ug/L to one (except children under 1 yr)

CareCore National Criteria for Imaging Version 2.2009

a. Insulin tolerance test b. L-Dopa test c. GHRH test d. L-arginine test 3. Gonadotropin deficiency (hypogonadism) a. Decreased sexual function b. Infertility c. Loss of secondary sexual characteristics d. Menstrual disorders 4. TSH deficiency 5. ACTH deficiency C. Short stature 1. No evidence of the following: a. Crohn’s disease b. Hypothyroidism c. Malignancy d. Renal disease 2. Decreased growth hormone 3. Bone age more than 2 standard deviations below the mean for age 4. History of surgery or radiation in the pituitary or hypothalamus regions

References:

1. Haluck RS, Krummel TS, Computers and virtual reality for surgical education in the 21st century, Arch Surg, 2000; 135: 786-792. 2. Dammann F, Bode A, Schwaderer E, et al., Computer-aided surgical planning for implantation of hearing aids based on CT data in a VR environment, RadioGraphics, 2001; 21: 183-190. 3. King AD, Lam WWM, Leung SF, et al., Comparison of T2 weighted fat suppressed turbo spin-echo and contrast enhanced T1 weighted spin-echo MRI in nasopharyngeal carcinoma, BJR, 1997; 70: 1208-1214. 4. Loevner LA., Sonners, Adina I, Schulman Brian J, Reinterpretation of cross-sectional images in patients with head and neck cancer in the setting of a multidisciplinary cancer center, AJNR , 2002; 23: 1622-1626. 6. Weber AL, Montandon C, Robson CD, Neurogenic tumors of the neck, Radiol Clinic N Am 2000; 38(5): 1077-1090. 7. Tien RD, Hesselink JR, Chu PK et al., Improved detection and delineation of head and neck lesions with fat suppression spin-echo MR imaging, AJNR 1991: 12(1): 19-24. 8. Di Martino E, Nowak B, Hassan HA, et al., Diagnosis and staging of head and neck cancer: a comparison of modern imaging modalities (positron emission tomography, computed tomography, color-coded duplex sonography) with panendoscopic and histopathologic findings, Arch Otolaryngol Head Neck Surg, 2000; 126: 1457-1461. 9. Loevner LA, Sonners AI, Schulman BJ, et al., Reinterpretation of cross-sectional images in patients with head and neck cancer in the setting of a multidisciplinary cancer center, AJNR, 2002 ;23: 1622-1626. 10. Scottish Intercollegiate Guidelines Network, Diagnosis and management of head and neck cancer, a national clinical guideline, accessed at http://www.sign.ac.uk/pdf/sign90.pdf November 6, 2007. 11. Gunduz K, Shields JA, Eagle RC, Jr, et al., Malignant rhabdoid tumor of the orbit, Arch Ophthalmol 1998; 116: 243-246. 12. Tanaka A, Mihara F, Yoshiura T, et al., Differentiation of cavernous hemangioma from schwannoma of the orbit: a dynamic MRI study, AJR, 2004; 183:1799-1804. 13. Gufler H, Laubenberger J, Gerling J et al., MRI of lymphomas of the orbits and the paranasal sinuses, JCAT, 1997; 21(6): 877- 891. 14. Meyer PA., Avoiding surgery for thyroid eye disease, Eye, 2006 Oct; 20(10): 1171-1177. [abstract] 15. Beck RW, Arrington J, Murtagh FR, et al., Brain magnetic resonance imaging in acute optic neuritis. Experience of the Optic Neuritis Study Group, Arch Neurol, 1993 Aug; 50(8): 841-846. 16. Miller DH, Newton MR, van der Poel JC, et al., Magnetic resonance imaging of the optic nerve in optic neuritis. Neurology, 1988 Feb; 38(2): 175-179.

CareCore National Criteria for Imaging Version 2.2009

17. Lee AG, Lin DJ, Kaufman M, et al., Atypical features prompting neuroimaging in acute optic neuropathy in adults. Can J Ophthalmol 2000 Oct; 35(6): 325-330. 18. Balcer LJ, Optic neuritis, N Eng J Med, 2006; 354: 1273-1280. 19. Saremi F, Helmy M, Farzin S, et al., MRI of cranial nerve enhancement, AJR, 2005; 185: 1487-1497. 20. Adour KK, Byl FM, Hilsinger RL, et al., The true nature of Bell's palsy: analysis of 1,000 consecutive patients, Laryngoscope, 1978; 88(5):787-780. 21. Gilden DH, Clinical practice. Bell's palsy, N Engl J Med, 2004 Sep 23; 351(13): 1323-1331. 22. Lockwood AH, Salvi RJ, Burkard F, Tinnitus, N Eng J Med, 2002; 347: 904-910. 23. Henry JA, Dennis KC, Schechter MA, General review of tinnitus: prevalence, mechanisms, effects, and management, J Speech Lang Hear Res, 2005; 48: 1204-1235. 24. Crummer RW, Hassan GA, Diagnostic approach to tinnitus, http://www.aafp.org/afp/20040101/120.html accessed on July 22, 2007. 25. Turski PA, Seidenwurm DJ, Davis PC, et al., Expert panel on neurologic imaging, ACR Appropriateness Criteria, Vertigo and hearing loss, American College of Radiology,2006 accessed on line at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/VertigoandHearingLossDo c14.aspx November 6, 2007. 26. Labuguen RH, Initial evaluation of vertigo, Am Fam Physician, 2006 Jan 15; 73(2): 244-251. 27. Swartrz JD and Faerber EN, Congenital malformations of the external and middle ear: High-resolution CT findings of surgical import, AJR, 1985; 144:501-506. 28. Rosenfeld RM, Culpepper L, Doyle KJ, et al., Clinical practice guideline: Otitis media with effusion, Otolaryngology- Head and Neck Surgery, 2004; 130: S95-S118 29. Caldemeyer KS, Sandrasegaran D, Shinaver CN, et al., Temporal bone: comparison of isotropic helical CT and conventional direct axial and coronal CT, AJR, 1999; 172: 1675-1682. 30. Rhea JT, Rao PM, Novelline RA, Helical CT and three dimensional CT of facial and orbital injury, Radiol Clin N Am, 1999; 37: 489-513. 31. Zimmerman RD, Seidenwurm DJ, Davis PC, et al., Expert panel on neurologic imaging, ACR Appropriateness Criteria, Orbits, vision and visual loss, American College of Radiology,2006 accessed on line at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/OrbitsVisionandVisualLos sDoc11.aspx November 6, 2007. 32. Abernethy LJ, Imaging of the pituitary in children with growth disorders, European J of Radiology, 1998; 26:102-108. 33. Chalumeau M, Hadjiathanasiou CG, Ng SM, et al., Selecting girls with precocious puberty for brain imaging: validation of European evidence based diagnosis rule, J Pediatr, 2003; 143: 445-450. 34. Neely EK, Wilson DM, Lee PA, et al, Spontaneous serum Gonadotropin concentrations in the evaluation of precocious puberty, J Pediatr, 1995; 127: 47-52. 35. Wilson TA, Rose SR, Cohen P, et al, Update of guidelines for the use of growth hormone in children: the Lawson Wilkins pediatric endocrinology society drug and therapeutics committee, J Pediatr, 2003; 143: 415-421. 36. Petak SM, Nankin HR, Spark RF, et al., American Association of Clinical Endocrinologists medical Guidelines for clinical practice for the evaluation and treatment of hypogonadism in adult male patients-2002 update, Endocrine Practice, 2002; 8:439-456.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

70486 CT Maxillofacial Area Including Paranasal Sinuses without Contrast 70487 CT Maxillofacial Area Including Paranasal Sinuses with Contrast 70488 CT Maxillofacial Area Including Paranasal Sinuses without and with Contrast

The correlation between sinus findings on imaging and pain is poor or absent. Sinus imaging should be reserved for “delineating the anatomy and degree of sinus disease before surgical Intervention.”

This is especially true of pediatric patients almost all of whom will show MR evidence of sinus mucosal thickening when rhinitis is the only pathology. Even asymptomatic children examined by CT for other reasons had opacified or unidentifiable maxillary antra 72% of the time under age 1 year, and 18% if over one year of age.

I. Acute complicated rhinosinusitis1-4 A. Symptoms 1. Pain a. Headache b. Facial c. Orbital 2. Purulent nasal discharge 3. Facial swelling or erythema B. Findings 1. Orbital cellulitis 2. Facial cellulitis 3 Suspicion of intracranial infection or meningitis a. Mental status changes b. Focal neurologic findings 4. Proptosis 5. Visual disturbance 6. Focal neurologic findings C. Comorbidities 1. Diabetes 2. Immunocompromised state 3. Past history of facial trauma or surgery D. No response to medical management for 7days with no change in signs or symptoms followed by treatment with an alternative antibiotic for 7 days

CareCore National Criteria for Imaging Version 2.2009

1. Amoxicillin unless contraindicated 2. Penicillin allergic a. Bactrim b. Erythromycin c. Zithromax d. Azithromycin e. Clarithromycin E. Progression of symptoms under medical management

II. Recurrent acute rhinosinusitis >4 episodes within 1 year without symptoms between episodes1, 3, 4 A. Symptoms 1. Upper respiratory symptoms for more than a week 2. Colored nasal discharge 3. Poor response to decongestant 4. Facial or sinus pain 5. Nasal obstruction

III. Chronic rhinosinusitis (defined as inflammation of the mucosa of the nose and paranasal sinuses lasting for at least 12 consecutive weeks) 4 A. Symptoms 1. Purulent nasal discharge 2. Facial pain/pressure 3 Nasal obstruction 4 Decreased sense of smell B. Findings on physical examination 1. Nasal polyps 2. Septal deviation C. Continued symptoms and signs after antibiotic therapy more than 7 days D. Continued symptoms after maximum medical therapy

IV. Suspected sinus or nasopharyngeal tumor1, 5, 6 This may include but is not limited to the following: Inverting papilloma Olfactory neuroblastoma (esthesioneuroblastoma) Juvenile angiofibroma Squamous cell carcinoma Adenocarcinoma Adenoid cystic carcinoma Odontogenic keratocyst

A. Positive nasal endoscopy

CareCore National Criteria for Imaging Version 2.2009

B. Soft tissue mass by sinus imaging C. Clinical findings 1. Nasal obstruction 2. Posterior (Level V) neck mass 3. Epistaxis 4. Headache 5. Serous otitis media with hearing loss, and otalgia 6. Cranial nerve involvement (is indicative of skull base extension and advanced disease) 7. Facial or dental pain without obvious cause 8. Destroyed bone by x-ray 9. Mass effect on imaging D. Anosmia or dysosmia > 2 weeks E. Recurrent unilateral otitis media or recurrent sinusitis after appropriate antibiotic therapy F. Ebstein-Barr Virus (EBV) infection with positive titers G. Documented history of inverting papilloma H. Interval follow up of documented sinus or nasopharyngeal tumor

V. Salivary gland pathology 6,7 A. Mass suspected by physical examination or other testing. B. Suspected submandibular or parotid duct stone 1. Acutely swollen and painful gland 2. Ultrasound non diagnostic 3. Recurrent infections C. Interval follow up of documented salivary gland tumor

VI. Mucocele or nasal polyp(s) 6, 8 A. Mucocele suspected physical findings 1. Proptosis 2. Exophthalmos 3. Loss of vision 4. Swelling over the sinus 5. Abnormal plain films B. Follow-up of known mucocele or polyp(s) C. Nasal polyps 1. Anterior rhinoscopy demonstrating polyp(s) 2. History of cystic fibrosis 3. Inability to smell (anosmia) 4. Nasal obstruction

VII. Head and neck cancer A. New, confirmed tissue diagnosis for initial staging B. Deteriorating clinical condition with known head and neck cancer

CareCore National Criteria for Imaging Version 2.2009

C. Clinical evidence of cranial nerve involvement D. Interval follow up of documented head and neck cancer

VIII. Trauma A. Radiographic (routine x-ray exam) evidence of fracture or not diagnostic B. Facial subcutaneous air after injury C. CSF rhinorrhea (clear fluid drainage from nose) D. Clinical evidence of facial distortion after injury E. Diploplia

IX. Cough, work up of chronic (cough lasting more than 3 weeks) 9, 10 A. Recent chest x-ray ( within 1 month) 1. Treatment for any finding on CXR failed to relieve cough 2. No cause for cough suggested by CXR B. If [skip section if there is no history of smoking or ACE inhibitor use] 1. Patient smoked no response to cessation 2. Patient used ACE Inhibitors no response to discontinued use C. No response to empiric treatment of: 1. Upper airway cough syndrome (UACS preferred terminology; old terminology was post nasal drip) no response to > 1 week of first generation antihistamines and decongestants 2. GERD a. No response to anti-reflux medication b. Negative 24 hour esophageal pH monitoring 3. Asthma, no response to bronchodilators

X. Planned endoscopic sinus surgery for navigation during the procedure

References:

1. Anderson G, Avery W, Cunningham B, Institute for Clinical System Improvement, Health care guideline: diagnosis and treatment of respiratory illness in adults and children, second edition, 2008; accessed at http://www.icsi.org/respiratory_illness_in_children_and_adults__guideline_/respiratory_illness_in_children_and_adults__guideline__13116.html March 28, 2008. 2. McAlister WH, Strain JD, Cohen HL, et al, Expert Panel on Pediatric Imaging, American College of Radiology, Appropriateness Criteria- Sinusitis-Child, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonPediatricImaging/sinusitisChildDoc8.aspx March 31, 2008. 3. Rosenfeld RM, Andes D, Bhattacharyya N, et al, Clinical practice guideline: adult sinusitis, Otolaryngology-Head and Neck Surgery, 2007; 137:S1-S31. 4. Shotelersuk K, Khorparasert C, Sakdikul S, et al, Epstein-Barr virus DNA in serum/plasma as a tumor marker for nasopharyngeal cancer, Clinical Cancer Research, 2000; 6:1046-1051. 5. King AD, Vlantis AC, Tsang RKY, et al, Magnetic resonance imaging for the detection of nasopharyngeal carcinoma, AJNR, 2006; 27:1288- 1291. 6. Connor SEJ, Hussain S, and Woo EK-F, Sinonasal Imaging, Imaging, 2007; 19:39-54. 7. Liyanage SH, Spencer SP, Hogarath KM, et al, Imaging of salivary glands, Imaging, 2007; 19:14-27. 8. Zimmerman RD, Seidenwurm DJ, Davids PC, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria- Orbits, Vision and Visual Loss, accessed at

CareCore National Criteria for Imaging Version 2.2009

http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/OrbitsVisionandVisualLos sDoc11.aspx April 1, 2008. 9. Pratter MR, Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome), ACCP evidence-based clinical practice guidelines, Chest, 2006; 129:63S-71S. 10. McGarvey LPA, Polley L and MacMahon J, Review series: chronic cough: common causes and current guidelines, Chron Respir Dis, 2007; 4:215-223.

Reviewed: 3/18/2009 Posted: 8/15/2009

CareCore National Criteria for Imaging Version 2.2009

70490 CT Soft Tissue Neck without Contrast 70491 CT Soft Tissue Neck with Contrast 70492 CT Soft Tissue Neck without and with Contrast

I. Salivary gland pathology 1, 2 A. Mass suspected by physical examination or other testing 1. MRI cannot be performed B. Suspected submandibular or parotid duct stone 1. Ultrasound non diagnostic 2. Acutely swollen and painful gland 3. Recurrent infections C. Interval follow up of documented salivary gland tumor 1. MRI cannot be performed

II. Parathyroid pathology 3-5 A. Hyperparathyroidism 1. Ca >normal [> 10.6 mg/dL or 2.7 mmol/L] 2. PTH >normal [> 55 pg/mL or 5.8 pmol/L] 3. Nuclear medicine scan or ultrasound non diagnostic and surgery is planned B. Biopsy proven malignancy 1. Initial staging 2. Interval follow up

III. Neck mass 6, 7 A. New neck mass 1. Ultrasound not diagnostic a. No response to antibiotics if lymphadenitis is suspected b. Adult over age 40 c. Rock hard mass d. Rapidly expanding mass e. Mass present for more than 3 weeks B. Progressive growth C. Inflammatory mass not responding to antibiotic therapy D. Recurrence at site of previously treated tumor 1. Ultrasound non diagnostic 2. FNA E. Children: any mass detected by physical examination or other imaging F. Suspected congenital neck mass 1. Thyroglossal duct cyst a. Midline or slightly off midline mass in the anterior triangle Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

b. Ultrasound not diagnostic 2. Brachial cleft cyst 3. Lymphangioma 4. Thymic cyst

IV. Suspected nasopharyngeal tumor 8-10 A. Symptoms 1. Epistaxis 2. Recurrent sinusitis after appropriate antibiotic therapy 3. Posterior (level V) neck node or mass 4. Cranial nerve involvement (is indicative of skull base extension and advanced disease) B. Clinical findings 1. Nasal obstruction 2. Positive endoscopy 3. Headache 4. Serous otitis media with hearing loss and otalgia 5. Facial pain 6. Ebstein-Barr Virus (EBV) infection with positive titers C. Interval follow up of known nasopharyngeal cancer

V. Head and neck cancer 10, 11 Includes but not limited to; Cancer of the arytenoid cartilage Cancer of the epiglottis Cancer of the hard palate Cancer of the infraglottic region Cancer of the larynx Cancer of the oral cavity Cancer of the paranasal sinuses Cancer of the pharynx Cancer of the salivary gland(s) Cancer of the soft palate Cancer of the supraglottic region Cancer of the tongue Cancer of the tonsils Cancer of the vocal cord(s)

A. New, confirmed tissue diagnosis for initial staging B. Deteriorating clinical condition with known head and neck cancer C. Establish new baseline after completion of therapy

VI. Neck abscess A. Fever >100.4 B. Leukocytosis, WBC >12,000/cu.mm C. Pain and swelling at site

CareCore National Criteria for Imaging Version 2.2009

VII. Vocal cord paralysis or hoarseness 12 A. Unilateral 1. Dysphonia 2. Prior neck surgery 3. Neck or salivary gland mass B. Bilateral 1. Stridor 2. Prior thyroidectomy

VIII. Airway compromise by neck mass A. Evidence of upper airway obstruction (PFT) B. Known neck mass C. Enlarged thyroid

IX. Suspected laryngeal fracture 13 A. Trauma to the neck B. Clinical findings 1. Subcutaneous emphysema or crepitus 2. Dysphonia 3. Loss of the laryngeal prominence (Adam's apple) 4. Dysphagia 5. Odynophagia 6. Stridor 7. Hemoptysis 8. Cough 9. Pain over the larynx

X. Thyroid mass A. Ultrasound with incomplete evaluation of substernal extension B. Enlarged thyroid on nuclear scan

XI. Lymphoma 14,15 A. Initial staging B. New or changing cervical adenopathy with known lymphoma C. Follow up after completion of therapy 1. Immediately after completion of treatment 2. Hodgkin’s disease a. 6-12 months after completion of therapy for 3 years b. Annually after completion of therapy for up to 5 years 3. Non Hodgkin’s lymphoma a. Every 3 months for 1 year b. Every 3-6 months 4. Evidence of recurrent disease a. New neck mass with known lymphoma Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

b. Recurrence documented outside the neck c. New or recurrent night sweats d. New or recurrent fatigue e. New or recurrent unintentional weight loss

References:

1. Connor SEJ, Hussain S, and Woo EK-F, Sinonasal Imaging, Imaging, 2007; 19:39-54. 2. Liyanage SH, Spencer SP, Hogarath KM, et al, Imaging of salivary glands, Imaging, 2007; 19:14-27. 3. Kukora JS, Zeiger MA, Clark OH, et al, The American association of clinical endocrinologists and the American association of endocrine surgeons position statement of the diagnosis and management of primary hyperparathyroidism, Endocrine Practice, 2005; 11:49-54. 4. Greenspan BS, Brown ML, Dillehay GL, et al, The Society of Nuclear Medicine Procedure Guideline for Parathyroid Scintigraphy, accessed at http://interactive.snm.org/docs/Parathyroid_v3.0.pdf April 1, 2008. 5. Weber AL, Randolph G and Aksoy FG, The thyroid and parathyroid glands, Radiologic Clin N Am, 2000; 38:105-112. 6. Gleeson M, Herbert A, and Richards A, Regular review: management of lateral neck masses in adults, BMJ, 2000; 320:1521-1524. 7.Turkington JRA, Paterson A, Sweeeney LE, et al, Pictorial review, neck masses in children, BJR, 2005; 78:75-85. 8. Chang ET and Adami H-O, The enigmatic epidemiology of nasopharyngeal carcinoma, Cancer Epidemiol Biomarkers Prev, 2006; 15:1765- 1777. 9. Bar-Sela G, Kuten A, Minkov I, et al, Prevalence and relevance of EBV latency in nasopharyngeal carcinoma, Israel J Clin Pathol, 2004; 57:290-293. 10. Frastoere AA, Ang K-K, Brizel D, et al, NCCN Head and Neck Cancers Panel Members, NCCN Practice Guidelines in Oncology- v1.2007- Head and Neck Cancers, accessed at http://www.nccn.org/professionals/physician_gls/PDF/head-and-neck.pdf April 2, 2008. 11. Scottish Intercollegiate Guidelines Network, Diagnosis and management of head and neck cancer a national clinical guideline, accessed at http://www.sign.ac.uk/pdf/sign90.pdf April 2, 2008. 12. Chin S, Edelstein S, Chen C, et al, Using CT to localize side and level of vocal cord paralysis , AJR, 2003; 180:1165-1170. 13. Thevasagayam MS and Pracy P, Laryngeal trauma: a systematic approach to management, Trauma, 2005; 7:87-94. 14. Hoppe RT, Advani RH, Ambinder RF, et al, NCCN Hodgkin Disease/Lymphoma Panel Members, NCCN Practice Guidelines in Oncology- v.1.2007, Hodgkin Disease/Lymphoma, accessed at http://www.nccn.org/professionals/physician_gls/PDF/hodgkins.pdf December 27, 2007. 15. .Zelenetz AD, Advani RH, Bociek RG, et al, NCCN non-Hodgkin’s Disease Lymphomas Panel Members, NCCN Practice Guidelines in Oncology-v.1.2007, non-Hodgkin’s Disease Lymphoma’s, accessed at http://www.nccn.org/professionals/physician_gls/PDF/nhl.pdf December 27, 2007.

Reviewed: 3/18/2009 Posted: 8/15/2009

CareCore National Criteria for Imaging Version 2.2009

70496 CTA of the Head

I. Subarachnoid Hemorrhage (SAH) 1-3 A. Subarachnoid hemorrhage demonstrated on CT or MRI B. CSF equivocal, bloody or xanthochromic C. Proven subarachnoid hemorrhage with negative angiogram requiring follow up imaging

II. Proven intracerebral bleed 1,2 (hemorrhage or hematoma) A. CT or MRI positive for intracerebral bleed or hemorrhage or hematoma

III. Recent stroke by history 1, 4

IV. Cerebral aneurysm 1, 2, 5-7 A. Screening study for cerebral aneurysm first-degree family history of: 1. Cerebral aneurysm 2. Two or more relatives with a history of SAH 3. Polycystic kidney disease 4. Multiple meningiomas B. Suspected cerebral aneurysm 1. SAH or intracerebral hematoma on prior imaging 2. Isolated cranial nerve (CN) deficit C. Known cerebral aneurysm documented by CTA, MRA or angiography 1. Follow-up a. Shortly after an interventional procedure (i.e. surgery or embolization) b. Every 6 months after embolization D Neurofibromatosis E. Visual field loss F. Thunderclap headache G. Exertional headache H. Preoperative planning for cerebral aneurysm management (surgical or interventional)

V. Pre-operative study, carotid endarterectomy planned 1 A. Asymptomatic patient with carotid stenosis of 60% or more by prior imaging B. Symptomatic carotid stenosis with carotid duplex US showing 60% stenosis C. Carotid duplex showing ulcerated plaque

VI. Suspected vertebro-basilar insufficiency 1 A. Crossed neurologic deficits (i.e., ipsilateral cranial nerve deficits with contralateral motor weakness) B. Dysarthria C. Dysphagia D. Nausea

CareCore National Criteria for Imaging Version 2.2009

E. Cognitive changes 1. Memory loss 2. Disorientation F. Vestibular changes 1. Vertigo 2. Ataxic gait G. Visual changes 1. Double vision 2. Homonymous hemianopsia 3. Nystagmus 4. Conjugate gaze paralysis 5. Ophthalmoplegia H. Hearing changes 1. Tinnitus 2. Hearing loss I. Motor or sensory deficits 1. Numbness of tongue 2. Facial weakness J. Drop attacks or syncope

VII. AVM (ArterioVenous Malformation) 8 A. Known AVM documented by CTA, MRA, MRI, catheter angiogram 1. Immediate follow-up after a therapeutic procedure (i.e. surgery, embolization, radiosurgery) 2. Routine follow up after a therapeutic procedure 3. New or worsening clinical findings 4. Planning of intervention (surgical or interventional) B. Suspected AVM 1. Severe unexplained headache (thunderclap headache) 2. Altered level of consciousness 3. Focal neurologic findings 4. Subarachnoid hemorrhage on recent CT or MRI of the brain 5. Subarachnoid hemorrhage on lumbar puncture 6. Intracerebral bleed or hematoma, or hemorrhage on prior CT or MRI of the brain

VIII. Suspected cerebral venous thrombosis 9-11 (MRA is preferred) A. Symptoms 1. Papilledema 2. Headaches 3. Mental status changes 4. Calvarial mass 5. Vomiting 6. Transient visual obscurations 7. Focal or generalized seizures

CareCore National Criteria for Imaging Version 2.2009

8. Lethargy or coma 9. Alternating focal deficits 10. Hemiparesis or paraparesis B. Risk factors 1. Post Partum 2. Post operative status 3. Skull fracture over dural sinus 4. Meningitis, sinusitis or middle ear infections 5. Hypercoagulable state a. Cancer b. Marasmus c. Dehydration d. Contraceptive medications e. Other medications

IX. Evaluation of tinnitus 12 (ringing, hissing, buzzing, roaring, clicking or rough sounds heard by patient)

X. Vasculitis 13 A. Clinical presentation 1. Headache 2. Seizures 3. Focal neurologic deficit 4. Altered level of consciousness 5. Altered mood or personality 6. Autoimmune disease a. Systemic Lupus Erythematosis (SLE) b. Polyarteritis Nodosa c. Giant cell arteritis d. Sjögren’s syndrome e. Behçet’s syndrome f. Dermatomyositis B. Laboratory tests [One] 1. ESR >20 mm/hr 2. C-reactive protein >10 mg/L 3. ANA positive 4. Anticardiolipin antibodies positive

References

1. De La Paz RL, Seidenwurm DJ, Davis PC, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria –Cerebrovascular Disease, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/CerebrovascularDiseaseD oc2.aspx March 13, 2008. 2. Colen TW, Wang LC, Ghodke BV, et al, Effectiveness of MDCT angiography for the detection of intracranial aneurysms in patients with nontraumatic subarachnoid hemorrhage, AJR, 2007; 89:898-903. Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

3. Graham M. Teasdale, Joanna M. Wardlaw , Philip M. White, et al, on behalf of the Davie Cooper Scottish Aneurysm Study Group, The familial risk of subarachnoid hemorrhage, Brain, 2005; 128: 1677-1685. 4. Wippold FJ II, Lacey JL, Seidenwurm DJ, et, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria – Focal Neurologic Deficit, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/FocalNeurologicDeficitDo c4.aspx March 13, 2008. 5. Chapman AB, Rubinstein D, Hughes R, et al, Intracranial aneurysms in autosomal dominant polycystic kidney disease, N Engl J Med, 1992; 327: 916-920. 6. Juvela S, Porras M, Heiskanen O, Natural history of unruptured intracranial aneurysms: a long-term follow-up study, J Neurosurg, 1993; 79:174-182. 7. Wermer MJH, Rinkel GJE, and van Gijn J, Repeated screening for intracranial aneurysms in familial subarachnoid hemorrhage, Stroke, 2003; 34:2788-2791. 8. Al-Shahi R and Warlow C, A systematic review of the frequency and prognosis of arteriovenous malformations of the brain in adults, Brain, 2001; 124:1900-1926. 9. Sebire G, Tabarki B, Saunders DE, et al, Cerebral venous sinus thrombosis in children: risk factors, presentation, diagnosis and outcome, Brain, 2005; 128:477-489. 10. Leach JL, Fortuna RB, Jones BV, et al, Imaging of cerebral venous thrombosis: current techniques, spectrum of findings, and diagnostic pitfalls, RadioGraphics, 2006; 26:S19-S43. 11. Einhaupl K, Bousser MG, de Bruijn SFTM, et al, EFNS guideline on the treatment of cerebral venous and sinus thrombosis, Eur J Neurol, 2006; 13:553-559. 12. Lockwood A H, Salvi RJ, Burkard R F, Tinnitus, N Engl J Med, 2002; 347: 904-910. 13. Roane DW, and Griger DR, An approach to diagnosis and initial management of systemic vasculitis, American Family Physician, 1999; 60:1421-1430.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

70498 CTA of the Carotid and Vertebral Arteries

I. Suspected carotid stenosis 1-4 A. TIA in carotid distribution 1. Temporary sensory or motor changes on contralateral side 2. Amaurosis fugax 3. Transient aphasia B. Stroke in carotid distribution by PE 1. Persistent sensory or motor changes on contralateral side 2. Vision loss on ipsilateral side 3. Persistent aphasia C. Findings on carotid duplex examination 1. 60% stenosis or more 2. 50% stenosis with ulcerative plaque 3. Carotid occlusion 4. Technically inadequate/equivocal 5. Ulcerated plaque on carotid Doppler

II. Suspected vertebro-basilar insufficiency A. Dysarthria B. Dysphagia C. Nausea D. Cognitive changes 1. Memory loss 2. Disorientation E. Vestibular changes 1. Vertigo 2. Ataxic gait F. Visual changes 1. Double vision 2. Homonymous hemianopsia 3. Nystagmus 4. Conjugate gaze paralysis 5. Ophthalmoplegia G. Hearing changes 1. Tinnitus 2. Hearing loss H. Motor or sensory deficits 1. Ipsilateral paralysis of tongue 2. Contralateral motor paresis I. Drop attacks or syncope J. Strong family history of aneurysm and/or polycystic kidney disease

CareCore National Criteria for Imaging Version 2.2009

III. Suspected traumatic or spontaneous carotid dissection 5-7 A. Isolated ipsilateral neck pain B. Unilateral facial or orbital pain C. Unilateral headaches D. Horner’s syndrome, miosis and ptosis (contraction of the iris, drooping eyelid) E. Transient ischemic attacks F. Minor neck trauma (includes chiropractic manipulation) G. Rapid onset of headache with strenuous exercise or Valsalva maneuver

IV. Recent stroke by history 9

V. Carotid body tumor

VI. Pre-operative evaluation of neck mass A. CT of the neck demonstrating a mass close to the carotid artery

VII. TIA by history A. Transient change in mental status B. Transient loss of vision (amaurosis fugax) C. Transient paralysis or weakness of an extremity D. Transient slurring of speech or loss of ability to speak

References:

1. Verro P, Tannenbaum LN, Borden NM, et al, CT angiography in acute ischemic stroke, preliminary results, Stroke, 2002: 33:276-278. 2. Anderson GB, Ashforth R, Teinke DE, et al, CT angiography for the detection and characterization of carotid artery bifurcation disease, Stroke, 2000; 31:2168-2174. 3. Moore WS, Baranett HJM, Beebe HG, et al, Guidelines for carotid endarterectomy: a multidisciplinary consensus statement from the ad hoc committee, American Heart Association, Circulation, 1995; 91:566-579. 4. Toole JF, Howard VJ, and Chambless LE, The Asymptomatic Carotid Atherosclerosis Study Group, Study design for randomized prospective trial of carotid endarterectomy for asymptomatic atherosclerosis, Stroke, 1989; 20:844-849. 5. Sturzenegger M, Spontaneous internal carotid artery dissection: early diagnosis and management in 44 patients, J Neurol, 1995 Mar; 242(4):231-238. 6. Ozdoba C, Sturzenegger M, and Schroth G, Internal carotid artery dissection: MR imaging features and clinical- radiologic correlation, Radiology, 1996; 199:191-198. 7. Schievink WI, Spontaneous dissection of the carotid and vertebral arteries, N Engl J Med, 2001; 344: 898-906. 8. Schievink WI, Mokri B, and Whisnant JP, Internal carotid artery dissection in a community, Rochester, Minnesota, 1987-1992, Stroke, 1993; 24:1678-1680. 9. Shrier, DA, Tanaka, H, Numaguchi, Y, et al, CT angiography in the evaluation of acute stroke, AJNR, 1997; 18: 1011-1020.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

70540 MRI Orbit, Face, Neck without Gadolinium 70542 MRI Orbit, Face, Neck with Gadolinium 70543 MRI Orbit, Face, Neck without and with Gadolinium

I. Salivary gland pathology 1, 2 A. Mass suspected by physical examination or other testing B. Mass found on recent prior imaging such as ultrasound or CT C. Lateral facial swelling D. Interval follow-up of known mass E. Follow up after surgery and/or radiation therapy F. Surveillance after treatment

II. Parathyroid pathology 3-5 A. Hyperparathyroidism [(1 or 2) + 3] 1. Ca >normal [>10.6 mg/dL or 2.7 mmol/L] 2. PTH ≥normal [>55 pg/mL or 5.8 pmol/L] 3. Nuclear medicine scan or ultrasound non diagnostic and surgery is planned B. Biopsy proven malignancy 1. Initial staging 2. Interval follow up

III. Neck mass other than thyroid 6, 7 A. Progressive growth B. Inflammatory mass not responding to antibiotic therapy for 4-6 weeks C. Recurrence or new mass at site of previously treated tumor D. Children: any mass detected by physical examination or other imaging E. Fine needle aspiration consistent with metastatic disease (carcinoma, sarcoma) or lymphoma F. Suspected congenital neck mass [One] 1. Thyroglossal duct cyst [a and b] a. Midline or slightly off midline mass in the anterior triangle b. Ultrasound not diagnostic 2. Brachial cleft cyst 3. Lymphangioma 4. Thymic cyst G. Neck abscess [(1 or 2) +3] 1. Fever >100.4 2. Leukocytosis, WBC >12,000/cu.mm 3. Pain and swelling at the site

IV. Suspected orbital tumor or other pathology 8 A. Unilateral exophthalmos or enophthalmous Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

B. Orbital or periorbital mass or vascular malformation C. Vision loss D. Proptosis E. Uveitis F. Scleritis G. Head injury with visual loss H. Optic atrophy I. Orbital cellulitis J. Optic neuritis [gadolinium suggested] 1. Vision loss in one eye a. Known MS 2. Eye pain worsening with movement of the eye 3. Visual field deficit which is mostly central 4. Examination of the eye a. Swelling of the optic disc b. Blurring of disc margins c. Distended veins 5. Loss of color vision K. Thyroid eye disease (including myopathy) [One] 1. Bilateral proptosis 2. Vision loss L. Post-operative evaluation M. Pre-operative evaluation N. Papilledema O. Orbital tumor 1. Melanoma 2. Retinoblastoma 3. Lymphoma 4. Metastases

V. Suspected nasopharyngeal tumor 8-10 A. Symptoms 1. Epistaxis 2. Recurrent sinusitis after appropriate antibiotic therapy 3. Posterior (level V) neck node or mass 4. Cranial nerve involvement (is indicative of skull base extension and advanced disease) B. Clinical findings: 1. Nasal obstruction 2. Positive endoscopy 3. Headache 4. Serous otitis media with hearing loss and otalgia 5. Facial pain 6. Ebstein-Barr Virus (EBV) infection with positive titers C. Interval follow up of known nasopharyngeal cancer

CareCore National Criteria for Imaging Version 2.2009

VI. Head and neck cancer 10-12 Includes but not limited to; Cancer of the arytenoid cartilage Cancer of the epiglottis Cancer of the hard palate Cancer of the infraglottic region Cancer of the larynx Cancer of the oral cavity Cancer of the paranasal sinuses Cancer of the pharynx Cancer of the salivary gland(s) Cancer of the soft palate Cancer of the supraglottic region Cancer of the tongue Cancer of the tonsils Cancer of the vocal cord(s)

A. New, confirmed tissue diagnosis for initial staging B. Deteriorating clinical condition with known head and neck cancer C. Establish new baseline after completion of therapy

VII. Airway compromise by neck mass A. Evidence of upper airway obstruction on pulmonary function testing 1. Known neck mass 2. Enlarged thyroid

VIII. Neck abscess A. Fever >100.4 B. Leukocytosis, WBC >12,000/cc.mm C. Pain and swelling at site

IX. Vocal cord paralysis or hoarseness A. Must have negative chest x-ray B. Prior neck surgery (including but not limited to anterior cervical discectomy, carotid endarterectomy, thyroid surgery) C. Neck mass D. Thyroid tumor E. Trauma to the neck

X. Brachial plexus 13 A. Brachial plexus injury 1. Symptoms a. Weakness or paralysis of the shoulder and biceps b. Weakness of the wrist c. Weakness or paralysis of the forearm or hand Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

d. Horner’s syndrome 2. History a. Trauma including birth trauma b. Radiation fibrosis c. History of radiation therapy to the chest, breast or axilla d. Weakness of the shoulder and/or arm e. Personal history of malignancy B. Primary or metastatic tumor 1. Symptoms a. Pain b. Weakness of the extremity c. Numbness of the extremity d. Hyperesthesia of the extremity C. Schwannoma or neurofibroma 1. Symptoms [One] a. Palpable mass in the lower neck or supraclavicular fossa b. Weakness of the upper extremity

References:

1. Browne RFJ, Golding SJ, and Watt-Smith SR, The role of MRI in facial swelling due to presumed salivary gland disease, BJR, 2001; 74:127- 133. 2. Liyanage SH, Spencer SP, Hogarath KM, et al, Imaging of salivary glands, Imaging, 2007; 19:14-27. 3. Kukora JS, Zeiger MA, Clark OH, et al, The American association of clinical endocrinologists and the American association of endocrine surgeons position statement of the diagnosis and management of primary hyperparathyroidism, Endocrine Practice, 2005; 11:49-54. 4. Greenspan BS, Brown ML, Dillehay GL, et al, The Society of Nuclear Medicine Procedure Guideline for Parathyroid Scintigraphy, accessed at http://interactive.snm.org/docs/Parathyroid_v3.0.pdf April 1, 2008. 5. Weber AL, Randolph G and Aksoy FG, The thyroid and parathyroid glands, Radiologic Clin N Am, 2000; 38:105- 112. 6. Gleeson M, Herbert A and Richards A, Regular review Management of lateral neck masses in adults, BMJ, 2000; 320:1521-1523. 7. Schwetschenau E and Kelley DJ, The adult neck mass, Am Fam Physician, 2002; 66:831-838. 8. Zimmerman RD, Seidenwurm DJ, Davis PC, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria-orbits, vision and visual loss, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/orbitsVisionandVisualL ossDoc11.aspx April 22, 2008. 9. Chang ET and Adami H-O, The enigmatic epidemiology of nasopharyngeal carcinoma, Cancer Epidemiol Biomarkers Prev, 2006; 15:1765- 1777. 10. Bar-Sela G, Kuten A, Minkov I, et al, Prevalence and relevance of EBV latency in nasopharyngeal carcinoma, Israel J Clin Pathol, 2004; 57:290-293. 11. Frastoere AA, Ang K-K, Brizel D, et al, NCCN Head and Neck Cancers Panel Members, NCCN Practice Guidelines in Oncology- v1.2007- Head and Neck Cancers, accessed at http://www.nccn.org/professionals/physician_gls/PDF/head-and-neck.pdf April 2, 2008. 12. Scottish Intercollegiate Guidelines Network, Diagnosis and management of head and neck cancer A national clinical guideline, accessed at http://www.sign.ac.uk/pdf/sign90.pdf April 2, 2008. 13. Bowen B, Seidenwurm DJ, Davis P et al, Expert Panel on Neurologic Imaging, American College of Radiology, Appropriateness Criteria, Plexopathy, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/PlexopathyDoc12.aspx February 4, 2008

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

70544 MRA or MRV of the Brain without Gadolinium 70545 MRA or MRV of the Brain with Gadolinium 70546 MRA or MRV of the Brain without and with Gadolinium

I. Subarachnoid Hemorrhage 1 (SAH) A. Subarachnoid hemorrhage demonstrated on CT or MRI B. CSF equivocal, bloody or xanthochromic C. Proven subarachnoid hemorrhage with negative angiogram requiring follow up imaging

II. Proven intracerebral bleed 1, 2 (hemorrhage or hematoma) A. CT or MRI positive for intracerebral bleed or hemorrhage or hematoma

III. Recent stroke by history 1, 2

IV. Cerebral aneurysm 1 A. Screening study for cerebral aneurysm first-degree family history of one 1. Cerebral aneurysm 2. Two or more relatives with a history of subarachnoid hemorrhage 3. Polycystic kidney disease 4. Multiple meningiomas B. Suspected cerebral aneurysm 1. SAH or intracerebral hematoma on prior imaging 2. Isolated Cranial Nerve (CN) deficit C. Known cerebral aneurysm documented on CTA, MRA or angiography 1. Follow-up a. Shortly after an interventional procedure (i.e. surgery or embolization) b. Every 6 months after embolization 2. New or worsening clinical findings D. Neurofibromatosis E. Visual field loss F. Thunderclap headache G. Exertional headache H. Preoperative planning for cerebral aneurysm management (surgical or interventional)

V. Pre-operative study, carotid endarterectomy 1 planned A. Asymptomatic patient with carotid stenosis of 60% or more by prior imaging B. Symptomatic carotid stenosis with carotid duplex US showing 60% stenosis C. Carotid duplex showing ulcerated plaque

CareCore National Criteria for Imaging Version 2.2009

A. Crossed neurologic deficits (i.e., ipsilateral cranial nerve deficits with contralateral motor weakness) B. Dysarthria C. Dysphagia D. Nausea E. Cognitive changes 1. Memory loss 2. Disorientation F. Vestibular changes 1. Vertigo 2. Ataxic gait G. Visual changes 1. Double vision 2. Homonymous hemianopsia 3. Nystagmus 4. Conjugate gaze paralysis 5. Ophthalmoplegia H. Hearing changes 1. Tinnitus 2. Hearing loss I. Motor or sensory deficits 1. Numbness of tongue 2. Facial weakness J. Drop attacks or syncope

VII. AVM 3 (ArterioVenous Malformation) A. Known AVM documented by CTA, MRA, MRI, catheter angiogram 1. Immediate follow up after a therapeutic procedure (i.e. surgery, embolization, radiosurgery) 2. Routine follow up after a therapeutic procedure 3. New or worsening clinical findings 4. Planning of intervention (surgical or interventional) B. Suspected AVM 1. Severe unexplained headache (thunderclap headache) 2. Altered level of consciousness 3. Focal neurologic findings 4. Subarachnoid hemorrhage on recent CT or MRI of the brain 5. Subarachnoid hemorrhage on lumbar puncture 6. Intracerebral bleed or hematoma or hemorrhage on prior CT or MRI of the brain

VIII. Suspected cerebral venous thrombosis 4-6 A. Symptoms 1. Papilledema 2. Headaches 3. Mental status changes 4. Calvarial mass

CareCore National Criteria for Imaging Version 2.2009

5. Vomiting 6. Transient visual obscurations 7. Focal or generalized seizures 8. Lethargy or coma 9. Alternating focal deficits 10. Hemiparesis or paraparesis B. Risk factors 1. Post-partum 2. Post-operative status 3. Skull fracture over dural sinus 4. Meningitis, sinusitis or middle ear infections 5. Hypercoagulable state a. Cancer b. Marasmus c. Dehydration d. Contraceptive medications e. Other medications f. Sickle cell disease g. SLE h. Protein S deficiency i. Protein C deficiency 6. Ear infection 7. Brain tumor by history

IX. Evaluation of tinnitus (ringing, hissing, buzzing, roaring, clicking or rough sounds heard by patient)

X. Vasculitis 7-9 A. Clinical presentation 1. Headaches 2. Seizures 3. Focal neurologic deficit 4. Altered level of consciousness 5. Altered mood or personality 6. Autoimmune disease a. Systemic Lupus Erythematosis (SLE) b. Polyarteritis Nodosa c. Giant cell arteritis d. Sjögren’s syndrome e. Behçet’s syndrome f. Dermatomyositis B Laboratory findings 1. ESR >20 mm/hr 2. C-reactive protein >10 mg/L 3. ANA positive

CareCore National Criteria for Imaging Version 2.2009

4. Anticardiolipin antibodies positive

XI. Suspicion of trigeminal neuralgia A. Symptoms 1. Intermittent pain in the distribution of V2 and/or V3 2. Facial spasm 3. Failed Carbamazepine therapy

References:

1. De La Paz RL, Seidenwurm DJ, Davis PC, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria –cerebrovascular disease, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/CerebrovascularDisease Doc2.aspx March 13, 2008. 2. Wippold FJ II, Lacey JL, Seidenwurm DJ, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria –focal neurologic deficit, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/FocalNeurologicDeficitD oc4.aspx March 13, 2008. 3. Al-Shahi R and Warlow C, A systematic review of the frequency and prognosis of arteriovenous malformations of the brain in adults, Brain, 2001; 124:1900-1926. 4. Sebire G, Tabarki B, Saunders DE, et al, Cerebral venous sinus thrombosis in children: risk factors, presentation, diagnosis and outcome, Brain, 2005; 128:477-489. 5. Leach JL, Fortuna RB, Jones BV, et al, Imaging of cerebral venous thrombosis: current techniques, spectrum of findings, and diagnostic pitfalls, RadioGraphics, 2006; 26:S19-S43. 6. Einhaupl K, Bousser MG, de Bruijn SFTM, et al, EFNS guideline on the treatment of cerebral venous and sinus thrombosis, Eur J Neurol, 2006; 13:553-559. 7. Aviv RI, Benseler SM, Silverman SM, et al, MR imaging and angiography of primary CNS vasculitis of childhood, AJNR, 2006; 27:192-199. 8. Pomper MG, Miller TJ, Stone JH et al, CNS vasculitis in autoimmune disease: MR imaging findings and correlation with angiography, AJNR, 1999; 20:75-85. 9. Benseler S and Schneider R, Central nervous system vasculitis in children, Curr Opin Rheum, 2004; 16:43-50.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

70547 MRA or MRV Carotid and Vertebral Arteries without Gadolinium 70548 MRA or MRV Carotid and Vertebral Arteries with Gadolinium 70549 MRA or MRV Carotid and Vertebral Arteries without and with Gadolinium

I. Suspected carotid stenosis 1 A. TIA in carotid distribution 1. Temporary sensory or motor changes on contralateral side 2. Amaurosis fugax 3. Transient aphasia B. Stroke in carotid distribution by PE 1. Persistent sensory or motor changes on contralateral side 2. Vision loss on ipsilateral side 3. Persistent aphasia C. Findings on carotid duplex ultrasound 1. 60% stenosis or more 2. Ulcerative plaque on carotid Doppler 3. Carotid occlusion 4. Technically inadequate/equivocal carotid Doppler D. Asymptomatic carotid bruit 1. Inadequate carotid duplex ultrasound E. Carotid endarterectomy planned 1. Duplex carotid ultrasound demonstrating a. Stenosis of 60% or more b. Ulcerated plaque

II. Suspected vertebro-basilar insufficiency 1 A. Dysarthria B. Dysphagia C. Nausea D. Cognitive changes 1. Memory loss 2. Disorientation E. Vestibular changes 1. Vertigo 2. Ataxic gait F. Visual changes 1. Double vision

CareCore National Criteria for Imaging Version 2.2009

2. Homonymous hemianopsia 3. Nystagmus 4. Conjugate gaze paralysis 5. Ophthalmoplegia G. Hearing changes 1. Tinnitus 2. Hearing loss H. Motor or sensory deficits 1. Ipsilateral paralysis of tongue 2. Contralateral motor paresis I. Drop attacks or syncope J. Strong family history of aneurysm and/or polycystic kidney disease

III. Carotid body tumor 2-4 A. Carotid ultrasound demonstrating a solid mass at the carotid bifurcation B. Preoperative surgical planning

IV. Pre-operative evaluation of head and neck tumor for vascular invasion 4 A. CT or MRI demonstrating mass close to carotid artery

V. TIA by history 1 A. Transient change in mental status B. Transient loss of vision (amaurosis fugax) C. Transient paralysis or weakness of an extremity D. Transient slurring of speech or loss of ability to speak

VI. Suspected traumatic or spontaneous carotid dissection 5, 6 A. Neck pain B. Unilateral facial or orbital pain C. Unilateral headaches D. Horner’s syndrome, miosis and ptosis (contraction of the iris, drooping eyelid) E. Transient ischemic attacks (TIA) F. Cranial nerve palsy G. New onset of stroke H. Minor neck trauma (includes chiropractic manipulation)

VII. Recent stroke by history 1

References:

CareCore National Criteria for Imaging Version 2.2009

2. van den Berg R, Verbist BM, Mertens BJA, et al, Head and neck paragangliomas: improved tumor detection using contrast –enhanced 3D time-of-flight MR angiography as compared with fat-suppressed MR imaging techniques, AJNR, 2004; 25:863-870. 3. Arslan H, Unal O, Kutluhan A, and Sakarya E, Power Doppler scanning in the diagnosis of carotid body tumors, J Ultrasound Med, 2000; 19:367-370. 4. Colletti PM, Terk MR, and Zee C-S, Magnetic resonance angiography in neck masses, Comput Med Imaging Graph, 1996; 20:379-388. 5. Thanvi B, Munshi SK, Dawson SL, et al, Carotid and vertebral artery dissection syndrome s, Postgrad Med J, 2005; 81:383-388. 6. Davis PC, Seidenwurm DJ, Brunberg JA, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria- Head Trauma, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/HeadTraumaDoc5.aspx March 13, 2008.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

70551 MRI of the Brain without Gadolinium

I. Abrupt onset of a neurologic deficit that suggests stroke or TIA1-3 A. Motor weakness affecting a limb, or one side of the face or body B. Decreased sensation affecting a limb, or one side of the face or body C. Cognitive dysfunction 1. Memory loss 2. Confusion 3. Disorientation or 4. Behavioral changes D. Ataxia (unsteady and clumsy motion of the limbs or trunk) E. Impaired vision 1. Amaurosis fugax 2. Visual field loss 3. Diplopia F. Aphasia (loss or impairment of the ability to produce or comprehend language, due to brain damage) G. Dysarthria (speech disorder resulting from neurological injury) H. Dysphagia I. Vertigo J. Syncope K. Numbness, tingling, paresthesias

II. Reevaluation after stroke A. Change in clinical status B. Needed for treatment planning

III. Headache 4-11 A. Syncope B. Papilledema C. Worsened by Valsalva maneuver, coughing straining or postural changes D. Wakens from sleep E. Suspected subarachnoid hemorrhage [CT preferred in early phase] 1. With sudden onset of severe, exertional, or "thunderclap" headache 2. Associated with nausea, vomiting, diplopia, seizure, mental status change, or syncope 3. History of prior known (documented on CTA, MRA or angiogram) aneurysm or AVM F. Infection in an extracranial location G. Change in mental status, personality, or level of consciousness H. Suspected carotid artery dissection [One] 1. Neck pain 2. Unilateral facial or orbital pain 3. Unilateral headaches

CareCore National Criteria for Imaging Version 2.2009

4. Horner’s syndrome, miosis and ptosis (contraction of the iris, drooping eyelid) 5. Transient Ischemic Attacks (TIA) 6. Minor neck trauma (includes chiropractic manipulation) 7. Rapid onset of headache with strenuous exercise or Valsalva maneuver I. Head pain that spreads into the lower neck and between the shoulders (may indicate meningeal irritation due to either infection or subarachnoid blood; it is not typical of a benign process) J. Suspected subdural hematoma 1. Major head trauma 2. Minor trauma while on anticoagulants K. Thunderclap headache L. Worst headache of life M. New Headache [One] 1. Abnormal neurologic examination a. Papilledema b. Nystagmus c. Gait abnormality d. Weakness of an arm or leg e. Seizures f. Other focal neurologic findings 2. Fever greater than 100.4 3. Stiff neck (nuchal rigidity) 4. History of cancer 5. History of HIV infection 6. History of TB 7. History of sarcoidosis 8. Age 5 years or less 9. Over age 50 10. Pregnancy 11. Headache with exertion 12. Documented infection outside the brain 13. Mental status changes 14. Extracranial malignancy N. Progressive worsening of headache O. Numbness or tingling P. New onset of chronic daily headache

IV. Head trauma12-15 [CT preferred for first 24 hours] A. Amnesia B. Altered consciousness C. Vomiting D. Focal neurologic finding E. Headache F. Seizure G. Coagulopathy

CareCore National Criteria for Imaging Version 2.2009

V. Suspected AVM (Arteriovenous Malformation)

VI. Multiple Sclerosis (MS) 16-22 A. Suspected MS 1. Motor disturbances a. Spasticity b. Hyperreflexia c. Loss of coordination 2. Transverse myelitis 3. Sensory changes a. Numbness b. Tingling c. Itching 4. Cognitive dysfunction

VII. Chronic or progressive mental status changes23 A. Deteriorating cognitive function 1. Progressive loss of memory 2. Confusion 3. Disorientation 4. Personality changes B. No psychiatric cause C. Physiologic or drug induced causes excluded by lab studies

VIII. Hydrocephalus24-26 A. Suspected obstructive hydrocephalus 1. Clinical findings a. Headache b. Papilledema c. Diplopia d. Mental status changes e. Gait disturbance or ataxia f. Seizure 2. History of a. Arterio-Venous Malformation (AVM) b. Aneurysm c. Intraventricular or Subarachnoid Hemorrhage (SAH) d. Meningitis e. Hydrocephalus 3. Congenital aqueductal stenosis B. Normal Pressure Hydrocephalus (NPH) 1. Apraxic gait (Apraxia is a motor disorder in which volitional or voluntary movement is impaired without muscle weakness.) 2. Motor perseveration

CareCore National Criteria for Imaging Version 2.2009

3. Urinary incontinence 4. Dementia 5. Known NPH with worsening symptoms

IX. Arnold Chiari Malformation 27-29 A. Cranial nerve palsy B. Headache C. Incontinence D. Lumbar myelomeningocele E. Neck or back pain F. Sensory loss G. Syncope H. Tethered cord I. Unsteady gait J. Lower extremity spasticity K. Follow up known Chiari

X. Dandy Walker Cyst30

XI. Encephalocele30

XII. Microcephaly

XIII. Macrocephaly

XIV. Developmental delay31

XV. Multiple congenital anomalies31

XVI. Suspicion of trigeminal neuralgia A. Symptoms [One} 1. Intermittent pain in the distribution of V2 and/or V3 2. Facial spasm 3. Failed Carbamazepine therapy

Reference:

1. De La Paz RL, Seidenwurm DJ, Davis PC, et al, Expert panel on neurologic imaging, ACR Appropriateness Criteria, Cerebrovascular Disease, Variant 2, American College of Radiology, 2006 accessed on line at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/CerebrovascularDiseaseD oc2.aspx November 6, 2007.

CareCore National Criteria for Imaging Version 2.2009

2. Masdeu JC, Irimia P, Asenbaum S, et al, EFNS guideline on neuroimaging in acute stroke, Report of an EFNS task force, Eur J Neurology, 2006; 13:1271-1283. 3. Anderson D, Larson D, and Koshnick R, Health Care Guideline: Diagnosis and initial treatment of ischemic stroke, accessed at http://www.ajronline.org.elibrary.aecom.yu.edu/cgi/reprint/170/3/561 November 28, 2007. 4. Yoshito T, and Endo K, MR imaging in the evaluation of chronic or recurrent headache, Radiology, 2005; 235:575-579. 5. Beithon F, Detlie E, Hult C, et al, Health care guideline: diagnosis and treatment of headache, Eighth edition, January 2007, Institute for Clinical Systems Improvement http://www.icsi.org/headache/headache__diagnosis_and_treatment_of_2609.html accessed July 10, 2007. 6. Frishberg BM, Rosenberg JH, Matchar DB, et al, Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache, accessed at http://www.aan.com/professionals/practice/pdfs/gl0088.pdf September 20, 2007. 7. Strain JD, Cohen HL, Fordham L, et al, Expert panel on neurologic imaging, ACR Appropriateness Criteria, Headache- Child accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonPediatricimaging/headacheChildDoc3.aspx November 20, 2007. 8. Jordan, JE, Seidenwurm DJ, Davis PC, et al, Expert panel on neurologic imaging, ACR Appropriateness Criteria, Headache accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicimaging/headacheDoc6.aspx November 20, 2007. 9. Sandrin G, Friberg L, Janig W, et al, Neurophysiological tests and neuroimaging procedures in non-acute headache: guidelines and recommendations, Eur J Neurology,2004; 11:217-224. 10. Frishberg, BM, Rosenberg JH, Matachar DB, et al, Evidence-Based guidelines in the primary care setting: Neuroimaging in patients with nonacute headache, US Headache Consortium, accessed at http://www.americanheadachesociety.org/professionalresources/USHeadacheConsortiumGuidelines.asp November 20, 2007. 11. Silberstein SD, Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review), Neurology, 2000; 55:754-762. 12. Smits M, Dippel DWJ, de Haan GG, et al, Minor head injury: guidelines for the use of CT-A multicenter validation study, Radiology, 2007, published on line before print October 2, 2007, accessed at http://radiology.rsnajnls.org/cgi/content/full/2452061509v1 November 6, 2007. 13. Vos PE, Bttistin G, Birbamer F et al, EFNS guideline on mild traumatic brain injury: report of tan EFNS taskforce, Eur J Neuorol, 2002; 9:207-219. 14. Davis PC, Seidenwurm DJ, Brunberg JA, et al, Expert panel on neurologic imaging, ACR Appropriateness Criteria, Head trauma, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/headtraumaDoc5.aspx November 20, 2007. 15. National Collaborating Centre for Acute Care. Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults. London (UK): National Institute for Clinical Excellence (NICE); 2003; accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=5067&nbr=003551&string=head+AND+trauma+AND+mri November 5, 2007. 16. Filippi M, Rocca MA, Arnold DL, et al, ESFN guidelines of the use of neuroimaging in the management of multiple sclerosis, Eur J Neuro, 2006; 13:313-325.345. 17. Inglese M, Grossman RI, and Filippi M, Magnetic resonance imaging monitoring of multiple sclerosis lesion evolution, J Neuroimaging, 2005;15:22S-29S. 18. Polman CH, Reingold SC, Edan G, et al, Diagnostic criteria for multiple sclerosis:2005 revisions to the “McDonald Criteria”, Ann Neurol, 2005; 58:840-846. 19. Frohman EM, Goodin DS, Calabresis PA, et al, The utility of MRI in suspected MS: report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology, accessed at http://www.neurology.org/cgi/reprint/61/5/602.pdf February 8, 2008. 20. National Collaborating Centre for Chronic Conditions. Multiple sclerosis, National clinical guideline for diagnosis and management in primary and secondary care, National Institute for Clinical Excellence (NICE). 2004; accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=5063&nbr=003547&string=multiple+AND+sclerosis February 8, 2008. 21. Polman CH, Reingold SC, Edan G, et al, Diagnostic criteria for multiple sclerosis: 2005 revisions to the “McDonald Criteria”, Ann Neurol, 2005; 58:840-846. 22. Calabresis PA, Diagnosis and management of multiple sclerosis, Am Fam Physician, 2004; 70:1935-1944. 23. Dormont D, Seidenwurm DJ, Davis PC, et al, Expert Panel on Neurologic Imaging, American College of Radiology, Appropriateness Criteria, Dementia and movement disorders, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/NeurodegenerativeDisord ersUpdateinProgressDoc9.aspx February 8, 2008. 24. Ishikawa M, Guideline Committee for Idiopathic Normal Pressure Hydrocephalus, Japanese Society of Normal Pressure Hydrocephalus, Clinical guidelines for idiopathic normal pressure hydrocephalus, accessed at http://nels.nii.ac.jp/els/contents_disp.php?id=ART0002481949&type=pdf&lang=en&host=cinii&order_no=Z00000014297913&ppv_type=0&lang _sw=&no=1202503469&cp= February 8, 2008. 25. Bradley Jr. WG, Scalzo D, Queralt J, et al, Normal pressure hydrocephalus: evaluation with cerebrospinal fluid flow measurements at MR imaging, Radiology, 1996; 198:523-529. 26. Bradley WG, Normal pressure hydrocephalus: new concepts on etiology and diagnosis, AJNR 2000; 21:1586-1590. 27. Evaluation and treatment of adult growth hormone deficiency” An Endocrine Society Clinical Practice Guideline, accessed at http://www.endo-society.org/publications/guidelines/final/upload/042506_CG_HormoneBook.pdf February 11, 2008.

CareCore National Criteria for Imaging Version 2.2009

28. Greenlee JDW, Donovan KA, Hasan DM, et al, Chiari I malformation in the very young child: the spectrum of presentations and experience in 31 children under age 6 years, Pediatrics, 2002; 110:1212-1219. 29. Wu YW, Chin CT, Chan KM, et al, Pediatric Chiari I malformations Do clinical and radiologic features correlate? Neurology, 1999; 53:1271. 30. Poe LB, Coleman LL, and Mahmud F, Congenital central nervous system anomalies, RadioGraphics , 1989; 9:801-826. 31. Williams HJ, Imaging the child with developmental delay, Imaging, 2004; 16:174-185.

Reviewed: 3/18/2009 Posted: 8/15/2009

CareCore National Criteria for Imaging Version 2.2009

70552 MRI Brain with Gadolinium 70553 MRI Brain without and with Gadolinium

I. Suspected pseudotumor cerebri 1-3 A. Clinical findings 1. Symptoms a. Headache, worse on straining b. Visual disturbance c. Diplopia d. Level of consciousness may be impaired 2. Physical findings a. Papilledema b. Enlargement of the blind spots c. Abducens palsy (inability to deviate the eye laterally)

II. Seizure 4-7 A. Initial evaluation of new onset of seizures B. In patients with a known seizure disorder who experience an increase in seizure activity or are refractory to treatment at adequate dosage

III. CNS infection or abscess 8-10 A. Findings suggesting Infection 1. Fever >100.4 2. Leukocytosis, WBC >12,000/cu.mm 3. Known infection elsewhere 4. Immunocompromised patient B. Other clinical findings 1. Headache 2. Drowsiness or confusion 3. Focal neurological findings 4. Vomiting 5. Seizure 6. Stiff neck 7. Photophobia 8. Recurrence of symptoms after antibiotic therapy C. Follow-up during therapy to assess effectiveness and after completion are appropriate

IV. Brain tumor 11-20 A. Mass detected on CT exam or prior non contrast or contrast MRI B. Evaluation of known primary brain tumor Astrocytoma Choroid plexus papilloma

CareCore National Criteria for Imaging Version 2.2009

Ependymoma Glioblastoma multiforme Hemangioblastoma Medulloblastoma Meningioma Metastases Oligodendroglioma Pituitary Adenoma 1. New signs and symptoms or worsening neurological condition 2. Interval re-evaluation a. Anaplastic astrocytoma or oligodendroglioma, or glioblastoma multiforme may be examined at 60 to 90 day intervals after completion of therapy for three years without evidence of change in clinical condition. b. Other primary intracranial cancers may be imaged at 90 to 180 day intervals. C. Evaluation for brain metastases in patients with known extra cranial malignancy 1. Routine initial staging for the following a. Sarcoma b. Melanoma c. Lung cancer 2. New neurological signs or symptoms with any other known malignancy a. New onset of headache b. New onset of vomiting c. New onset of visual problems d. Seizure e. Visual changes f. Personality or behavioral changes 3. Known brain metastasis with new or worsening symptoms 4. Follow up known brain metastases after chemotherapy a. Imaging (preferably MRI) every 3 months for 1 year b. If stable after one year imaging is performed based on clinical signs and symptoms 5. Follow up known brain metastases after radiation therapy a. Imaging (preferably MRI) every 3 months for 1 year b. If stable after one year imaging is performed based on clinical signs and symptoms 6. Follow up up known brain metastases after surgery a. Imaging (preferably MRI) every 3 months for 1 year b. If stable after one year imaging is performed based on clinical signs and symptoms 7. Prior to the use of Avastin D. Cranial nerve palsy

V. Suspected tumor of or affecting one or more cranial nerves-21-23

1st Olfactory Loss or disturbance of the sense of smell. 2nd Optic Blindness of various types, depending on lesion location.

CareCore National Criteria for Imaging Version 2.2009

Ptosis (drooping) of eyelid, deviation of the eyeball outward, dilatation of 3rd Occulomotor the pupil, double vision. Rotation of the eyeball upward and outward, double 4th Trochlear vision. Sensory root: Pain or loss of sensation in face, forehead, temple, and eye. 5th Trigeminal Motor root: Deviation of the jaw toward paralyzed side, difficulty in chewing. 6th Abducens Deviation of the eye outward, double vision. Paralysis of all the muscles on one side of the face, inability to wrinkle the forehead, close the eye, or whistle. Deviation of the mouth toward the 7th Facial sound side.

8th Vestibulocochlear Deafness or ringing in the ears, dizziness, nausea and vomiting, reeling. 9th Glossopharyngeal Disturbance of taste. Difficulty in swallowing. Paralysis of the main trunk on one side causes hoarseness and difficulty in 10th Vagus swallowing and talking. Drooping of the shoulder. Inability to rotate the head away from the 11th Spinal accessory affected side. Paralysis of one side of the tongue. Deviation of the tongue toward the 12th Hypoglossal paralyzed side. Thick speech.

VI. Known AVM (Arteriovenous Malformation)

VII. Systemic disease affecting the brain 24-28 A. Systemic Lupus Erythematosus (SLE) or vasculitis 1. Alteration in level of consciousness 2. Cranial nerve involvement B. HIV 1. Cerebritis 2. Encephalitis 3. Meningitis 4. Vasculitis C. Sarcoidosis

VIII. Known Multiple Sclerosis (MS) 29-35 A. Known MS 1. New or worsening clinical findings 2. Follow-up to assess treatment a. For individuals with multiple sclerosis who are being treated with Natalizumab (Tysabri) or Refid MRI with gadolinium may be approved every 3-6 months for follow up. B. Annual study for known MS

CareCore National Criteria for Imaging Version 2.2009

IX. Suspected Multiple Sclerosis with visual disturbance A. Visual disturbances, optic neuritis 1. Scotoma 2. Pain with movement of the eye 3. Opthalmoplegia 4. Marcus Gunn pupil

X. Suspected acoustic neuroma (schwannoma) or cerebellar pontine angle tumor 36-40 A. Symptoms 1. Unilateral hearing loss 2. Headache 3. Disturbed balance or gait 4. Tinnitus B. Findings 1. Asymmetric sensorineural hearing loss by audiometry 2. Facial weakness 3. Altered sense of taste C. Neurofibromatosis

XI. Labyrinthitis, vestibular neuronitis 40 A. Episodes of vertigo with vomiting or nausea B. Ear normal by PE C. Continued or worsening vertigo after at least one week of medical treatment with any appropriate medication

XII. Suspected cerebral venous thrombosis 2, 41-43 A. Symptoms 1. Papilledema 2. Headaches 3. Mental status changes 4. Vomiting 5. Transient visual obscurations 6. Focal or generalized seizures 7. Lethargy or coma 8. Alternating focal deficits 9. Hemiparesis or paraparesis B. Risk factors 1. Post Partum 2. Post operative status 3. Skull fracture over dural sinus 4. Calvarial mass 5. Meningitis, sinusitis or middle ear infections 6. Hypercoagulable state

CareCore National Criteria for Imaging Version 2.2009

a. Cancer b. Marasmus c. Dehydration d. Contraceptive medications e. Other medications

XIII. Evaluation of tinnitus 44-46(ringing, hissing, buzzing, roaring, clicking, or rough sounds heard by patient) A. If tinnitus is objective and pulsatile approve MRA or CTA B. If tinnitus is objective and continuous approve C. If tinnitus is subjective and unilateral

XIV. Suspected pituitary pathology 47-51 A. Elevated pituitary hormones including precocious puberty 1. Prolactin (PRL) >20 ng/mL [g/L] 2. Growth Hormone (GH) >5 ng/mL [g/L] 3. Thyroid Stimulating Hormone (TSH) >6 U/mL [mIU/L] 4. Follicular Stimulating Hormone (FSH) a. Male: >10 mIU/mL b. Female: (mIU/mL) i. Follicular >13 ii. Luteal >13 iii. Midcycle >22 iv. Postmenopausal >138 5. Luteinizing Hormone (LH) a. Male: >10 mIU/mL b. Female: (mIU/mL) i. Follicular >18 ii. Luteal >20 iii. Midcycle peak >105 iv. Postmenopausal >62 6. Adrenocorticotropic Hormone (ACTH) >200 pg/mL B. Hypopituitarism including hypogonadism 1. Pituitary apoplexy a. Acute headache with vomiting b. Ophthalmoplegia c. Amaurosis d. Depressed level of consciousness e. Bitemporal hemianopsia 2. Acquired hypopituitarism a. Cranial irradiation b. Brain surgery c. Head trauma d. Empty sella e. Hemochromatosis Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

f. Prior brain infection g. Known pituitary tumor h. Langerhans cell histiocytosis of the pituitary 3. Gonadotropin deficiency a. Menstrual disorders b. Infertility c. Decreased sexual function d. Loss of secondary sexual characteristics 4. TSH deficiency 5. ACTH deficiency 6. Growth hormone deficiency a. Adults i. Decreased levels of 3 or more pituitary hormones (TSH, LH, FSH, ACTH, GHRH, ADH) ii. Decreased levels of IGF-I (Insulin-like growth factor I) <10ng/ml iii. Insulin tolerance test (contraindicated in individuals with history of seizures or coronary artery disease) 01. Growth hormone response < 5 micrograms/L iv. Arginine stimulating test 01. Growth hormone response < 5 micrograms/L b. Children i. Growth hormone levels below normal (<10 ng/ml) ii. Turner’s syndrome iii. Chronic renal insufficiency iv. History of intrauterine growth retardation v. Prader-Willi syndrome vi. Height deficit at puberty 01. Height 2 standard deviations below the population mean vii. Children over the age of 1 01. Insulin tolerance test positive 0a. Growth hormone response < 5 micrograms/L

XV. Encephalocele52

XVI. Suspicion of trigeminal neuralgia 53 A. Symptoms 1. Intermittent pain in the distribution of V2 and/or V3 2. Facial spasm 3. Failed Carbamazepine therapy

XVII. Neurofibromatosis21, 54-57 A. Café-au-lait spots (5 or more) B. Skin fold freckling C. First degree relative (parent sibling or child) with neurofibromatosiseither 1 or 2 D. Scoliosis Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

E. Seizure disorder F. Peripheral neurofibromas G. Hearing loss H. Brain tumor I. Spinal cord tumor J. Lisch nodules in the iris of the eye K. Bone dysplasia (sphenoid wing, bowing of long bones)

XVIII. Neurosarcoid 58-61 A. Adult 1. Known sarcoid with neurologic symptoms 2. Cranial nerve palsy 3. Headache 4. Seizure 5. Sensory deficit 6. Pituitary dysfunction 7. Vision loss 8. Cognitive changes 9. Psychiatric symptoms B. Children 1. Seizures 2. Short stature 3. Diabetes insipidus 4. Lack of sexual maturation

XIX. Short stature A. No evidence of the following 1. Hypothyroidism 2. Renal disease 3. Malignancy 4. Crohn’s disease 5. Turner’s syndrome B. Suspected growth hormone deficiency 1. Provocative testing response of Growth hormone less than 5ug/L for children over the age of 1 year (these tests are not to be used in infants) a. Insulin tolerance test b. L-Dopa test c. GHRH test d. L arginine test 2. IGFBP-3 (values vary for age and sex) abnormal C. Bone age more than 2 standard deviations below the mean for age D. History of surgery or radiation in the pituitary or hypothalamus regions

XX. Papilledema

CareCore National Criteria for Imaging Version 2.2009

XXI. Cerebral hypotension 62 A. Headache 1. Increases when the individual is upright and decreases quickly when recumbent 2. Increases with coughing, straining, sneezing

References:

1. Hershkowitz L, Hagy JA, Visual Problems, accessed at http://www.aan.com/familypractice/pdf/FINAL%20VISUAL%202.pdf November 20, 2007. 2. Ward TN, Sands GH, Shank JC, Headaches: Practical Management, accessed at http://www.aan.com/familypractice/pdf/FINAL%20HEADACHE%206.pdf November 20, 2007. 3. Beithon J, Detlie E, Hult C, et al, ICSI Health Care Guideline: Diagnosis and Treatment of Headache, accessed at http://www.icsi.org/headache/headache_diagnosisandtreatmentof2609.html November 20, 2007. 4. Bradley WG, and Shey RB, MR imaging evaluation of seizures, Radiology, 2000; 214(3):651-656. 5 Karis JP, Seidenwurm DJ, Davis PC, et al, Expert Panel on Neurologic Imaging, ACR Appropriateness Criteria, Epilepsy, American College of Radiology, 2006 accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/EpilepsyDoc3.aspx November 6, 2007. 6. Marks WJ, and Garcia PA, Management of Seizures and Epilepsy, American Family Physician, accessed at http://www.aafp.org/afp/980401ap/marks.html November 6, 2007. 7. Scottish Intercollegiate Guidelines Network, Diagnosis and management of Epilepsy in Adults, a National Clinical Guideline, accessed at http://www.sign.ac.uk/pdf/sign70.pdf November 1, 2007. 8. Enzmann DR, Britt RH, Placone R, Staging of human brain abscess by computed tomography, Radiology, 1983; 146:703-708. 9. Zak IT, Altinok D, Merline JR, et al., West Nile Virus Infection, AJR, 2005; 184:957-961. 10.Trunkel AR, Hartman BJ, Kaplan SL, et al, Practice guidelines for the management of bacteria meningitis, Clinical Infectious Diseases, 2004; 39:1267-1284. 11. Brem SS, Bierman PJ, Black P, et al, NCCN Central Nervous System Cancers Panel Members NCCN Practice guidelines in Oncology v1.2007 Central Nervous System Cancers accessed at http://www.nccn.org/professionals/physiciangls/PDF/cns.pdf February 6, 2008. 12. Albers GW, Amarenco P, Easton JD, et al, Antithrombotic and thrombolytic therapy for ischemic stroke, The seventh ACCP conference on antithrombotic and thrombolytic therapy, Chest, 2004; 126:483-512. 13. Davis PC, Hudgins PA, Peterman SB, Hoffman JC Jr., Diagnosis of cerebral metastases: double-dose delayed CT vs. contrast-enhanced MR imaging, AJNR, 1991; 12(2):293-300. 14. Schaefer PW, Budzik RF Jr., Gonzalez RG, Imaging of cerebral metastases, Neurosurg Clin N Am, 1996 Jul; 7(3):393-423. 15. Aupérin A, Arriagada R, Pignon J, et al, Prophylactic cranial irradiation for patients with small-cell lung cancer in complete remission, NEJM, 1999; 341(7):476 - 484. 16. Davis PC, Hudgins PA, Peterman SB, Hoffman JC Jr., Diagnosis of cerebral metastases: double-dose delayed CT vs. contrast-enhanced MR imaging, AJNR, 1991; 12(2):293-300. 17. Soffietti R, Cornu P, Delattre JY, et al, EFNS guidelines on diagnosis and treatment of brain metastases: report of an EFNS Task Force, Eur J Neuorol, 2006; 13:674-681. 18. Alberts WM, Diagnosis and management of lung cancer executive summary: ACC evidence-based clinical practice guidelines (2nd edition), Chest, 2007; 132:1-19. 19. Wippold FJ, Lacey JL, Seidenwurm DJ, et al, Expert panel on neurologic imaging, ACR Appropriateness Criteria, Focal Neurologic Deficit, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/FocalNeurologicDeficitDo c4.aspx November 21, 2007. 20. Webster D, Schiff D, Lee C, et al, Technology Assessment: Stereotactic RadioneuroSurgery for Brain Lesions, accessed at http://www.icsi.org/technology_assessment_reports_-_inactive/ta_stereotactic_radioneurosurgery_for_brain_lesions_- _inactivated_04_2005.html November 28, 2007. 21. Zimmerman RD, Seidenwurm DJ, Davis PC, et al, Expert Panel on Neurologic Imaging, American College of Radiology, Appropriateness Criteria, Orbits, Vision and Visual Loss, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/OrbitsVisionandVisualLos sDoc11.aspx February 6, 2008. 22. Turski PA, Seidenwurm DJ, Davis PC, et al, Expert Panel on Neurologic Imaging, American College of Radiology, Appropriateness Criteria, Vertigo and Hearing Loss, accessed at Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/VertigoandHearingLossDo c14.aspx February 6, 2008. 23. Sarem F, Helmy M, Farzin S, et al, MRI of cranial nerve enhancement, AJR, 2005; 185:1487-1497. 24. Pomper MG, Miller TJ, Stone JH, et al, CNS vasculitis in autoimmune disease: MR imaging findings and correlation with angiography, AJNR, 1999; 20:75-85. 25. Greenan TJ, Grossman RI and Goldberg HI, Cerebral vasculitis: MR imaging and angiographic correlation, Radiology, 1992; 182:65-72. 26. Dumas JL, Valeyre D, Chapelon-Abric C, et al, Central nervous system Sarcoidosis: follow up at MRI Imaging during steroid therapy, Radiology, 2000; 214:411-420. 27. Aviv RI, Nenseler SM, Silverman ED, et al, MR imaging and angiography of primary CNS vasculitis of childhood, AJNR, 2006; 27:192-199. 28. Graham JW and Jan W, I and the brain in systemic lupus erythematosus, Lupus, 2003; 12:891-896. 29. Filippi M, Rocca MA, Arnold DL, et al, ESFN guidelines of the use of neuroimaging in the management of multiple sclerosis, Eur J Neuro, 2006; 13:313-325. 30. Inglese M, Grossman RI, and Filippi M, Magnetic resonance imaging monitoring of multiple sclerosis lesion evolution, J Neuroimaging, 2005; 15:22S-29S. 31. Polman CH, Reingold SC, Edan G, et al, Diagnostic criteria for multiple sclerosis: 2005 revisions to the “McDonald Criteria”, Ann Neurol, 2005; 58:840-846. 32. Frohman EM, Goodin DS, Calabresis PA, et al, The utility of MRI in Suspected MS: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology, accessed at http://www.neurology.org/cgi/reprint/61/5/602.pdf February 8, 2008. 33. National Collaborating Centre for Chronic Conditions. Multiple sclerosis, National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care, National Institute for Clinical Excellence (NICE). 2004; accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=5063&nbr=003547&string=multiple+AND+sclerosis February 8, 2008. 34. Polman CH, Reingold SC, Edan G, et al, Diagnostic criteria for multiple sclerosis: 2005 revisions to the “McDonald Criteria”, Ann Neurol, 2005; 58:840-846. 35. Calabresis PA, Diagnosis and management of multiple sclerosis, Am Fam Physician, 2004; 70:1935-1944. 36. British Association of Otorhinolaryngologists Head and Neck Surgeons, Clinical Effectiveness Guidelines, Acoustic Neuroma (vestibular schwannoma), BAO-HNS Document 5, Spring 2002 accessed at http://www.entuk.org/members/publications/ceg_acousticneuroma.pdf November 1, 2007. 37. Nance WE, Bailey BJ, Broaddus WC, et al, Suary: Vestibular schwannoma (acoustic neuroma Consensus development conference, Neurosurgery, 1992; 30:962-964. 38. Swartz JD, Sensorineural hearing deficit: a systematic approach based on imaging findings, RadioGraphics, 1996; 16:561-574. 39. Glastonbury CM, Davidson HC, Harnsberger R, et al, Imaging findings of cochlear nerve deficiency, AJNR, 2002; 23:635-643. 40. Morley S and Beale TJ, Imaging of deafness and tinnitus, Imaging, 2007; 19:55-70. 41. Idbaih A, Boukobza M, Crassard I, et al, MRI of clot in cerebral venous thrombosis: high diagnostic value of susceptibility-weighted images, Stroke, 2006; 37:991-995; 42. Selim M, Fink J, Linfante I, et al, Diagnosis of cerebral venous thrombosis with echo-planar T2SW-weighted magnetic resonance imaging, Arch Neurol, 2002; 59:1021–1026 43. Leach JL, Fortuna RB, Jones BV, et al, Imaging of cerebral venous thrombosis: current techniques, spectrum of findings , and diagnostic pitfalls, RadioGraphics, 2006; 26:519-543. 44. Crummer RW and Hassan GA, Diagnostic approach to tinnitus, http://www.aafp.org/afp/20040101/120.html accessed on July 22, 2007. 45. Henry JA, Dennis KC, Schechter MA,. General review of tinnitus: prevalence, mechanisms, effects, and management, J Speech Lang Hear Res, 2005; 48:1204-1235. 46. Lockwood A H, Salvi RJ, Burkard RF, Tinnitus, N Engl J Med, 2002; 347:904-910. 47. Acerini CL, Tasker RC, Bellone S, Hypopituitarism in childhood and adolescence following traumatic brain injury: the case for prospective endocrine investigation, Eur J Endocrinol, 2006; 155:663 - 669. 48. Ostrov SG, Quencer RM, Hoffman, JC, Hemorrhage within pituitary adenomas: how often associated with pituitary apoplexy syndrome ? AJR, 1989; 153:153-160. 49. Seidenwurm DJ, Davis PC, Brunberg JA, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria, Neuroendocrine Imaging, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/NeuroendocrineImagingD oc10.aspx February 8, 2008. 50. Gharib H, Cook DM, Saenger PH, et al, American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for Growth Hormone Use in Adults and Children-2003 update, accessed at http://www.aace.com/pub/pdf/guidelines/hgh.pdf February 11, 2008. 51. Evaluation and treatment of adult growth hormone deficiency” An Endocrine Society Clinical Practice Guideline, accessed at http://www.endo-society.org/publications/guidelines/final/upload/042506_CG_HormoneBook.pdf February 11, 2008. 53. Rowland LP, Cranial and peripheral nerve lesions, chapter 69 in Merritt’s Neurology, 11th edition, 2005, Lippincott Williams & Wilkens, Philadelphia, 54. National Institute of Neurological Disorders and Stroke, Neurofibromatosis Fact Sheet, accessed at http://www.ninds.nih.gov/disorders/neurofibromatosis/detail_neurofibromatosis.htm?css=print February 12, 2008. 55. Nunes F, and MacColin M, Neurofibromatosis 2 in the pediatric population, J Child Neurol, 2003; 18:718-724. Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

56. Vivarelli R, Grosso S, Calbrese F, et al, Epilepsy in neurofibromatosis 1, J Child Neurol, 2003; 18:338-342. 57. Ferner RF, Huson SM, Thomas N, et al, Guidelines for the diagnosis and management of individuals with neurofibromatosis 1, J Med Genet, 2007; 44:81-88. 58. Baumann Rj, and Robertson WC Jr., Neurosarcoid presents differently in children than in adults, Pediatrics, 2003; 112:e480-e486, accessed at http://pediatrics.aappublications.org/cgi/reprint/112/6/e480 February 12, 2008. 59. Zajicek JP, Scolding NJ, Foster O, et al, Central nervous system sarcoidosis-diagnosis and management, Q J Med, 1999; 92:103-117. 60. Smith JK, Matheus MG, and Castillo M, Imaging manifestations of neurosarcoidosis, AJR, 2004; 182:289-295. 61. Joseph FG and Scolding NJ, Sarcoidosis of the nervous system, Practical Neurology, 2007; 7:234-244. 62. Sun C and Lay CL, Pathophysiology, clinical features and diagnosis of spontaneous low cerebralspinal fluid pressure headache, UpToDate online 16.3 accessed at http://www.uptodate.com/online/content/topic.do?topicKey=headache/8918&selectedTitle=1~46&source=search_result December 1, 2008.

Reviewed: 3/18/2009 Posted: 8/15/2009

CareCore National Criteria for Imaging Version 2.2009

70554 Functional MRI of the Brain without Physician or Psychologist 70555 Functional MRI of the Brain with Physician or Psychologist

I. Evaluation of patients with seizures or brain tumors who are candidates for neurosurgical therapy when the results of testing will obviate the need for either the Wada test or direct electrical stimulation. 1-3

References:

1. Medina LS, Bernal B, Dunoyer C, et al, Seizure disorders: Functional MR imaging for diagnostic evaluation and surgical treatment- prospective study, Radiology, 2005; 236: 247-253. 2. Petrella JR, Shah LM, Harris KM, et al, 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. 3. Sabsevitz DX, Swanson SJ, Hammeke TA, et al, Use of preoperative functional neuroimaging to predict language deficits from epilepsy surgery, Neurology, 2003; 60:1788-1792.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

71250 CT of the Chest without Contrast 71260 CT of the Chest with Contrast 71270 CT of the Chest without and with Contrast

I. Cough 1-4 A. Prior to CT, All of the following should be done 1. Chest x-ray within the past 4 weeks 2. Clinical exclusion (by testing, history or therapeutic trial) of all: a. Post nasal drip b. Asthma or bronchospastic disease c. Gastroesophageal reflux d. Prolonged use of Angiotensin-Converting Enzyme (ACE) inhibitor therapy e. Sinusitis

II. Hemoptysis 5-7 A. Known malignancy B. More than a single episode

III. Vocal cord paralysis or hoarseness 7-9 A. No evidence of locally infiltrating lesion causing fixation of cord(s) B. Unilateral paralysis

IV. Abnormal findings on prior chest imaging 10-26 A. Initial work up of lung nodule or mass on imaging study of the chest [One] 1. Age >30 2. Size >3 mm 3. Enlarged compared to prior exam 4. Age <30 with equivocal, eccentric or no calcifications on prior exam 5. Smoker 6. Known malignancy elsewhere B. Follow up of pulmonary nodule [1 or 2]

General Statements: A linear density is NOT a nodule.

Criteria do not apply to patients known to have or suspected of having malignant disease. Lung nodule follow-up applies only to patients over age 35. In the under 35 population the risk of radiation exposure outweighs risk of cancer. Ground glass opacities (non-solid nodules) grow more slowly therefore consideration should be given to extending the follow-up interval and length of follow-up. These may represent bronchoalveolar carcinoma

CareCore National Criteria for Imaging Version 2.2009

1. Asymptomatic patient with no history of malignancy, smoking, exposure to asbestos, uranium, or radon or history of lung cancer in first degree relative a. Nodule <3.9 mm, no follow up CT b. Nodule 4-5.9 mm follow up CT 12 months; if no change no additional imaging c. Nodule 6-7.9 mm i. Follow up CT at 6-12 months ii. Follow up CT at 18-24 months if no change on first follow up scan d. Nodule >8mm i. Follow up CT at 3, 9 and 24 months OR ii. Dynamic contrast enhanced CT OR iii. PET OR iv. Biopsy 2. Asymptomatic patient with no history of malignancy but with a history of smoking, exposure to asbestos, uranium, or radon or history of lung cancer in first degree relative a. Nodule <3.9 mm follow up at 12 months; if unchanged no further follow up b. Nodule 4-5.9 mm i. Follow up CT at 6-12 months ii. Follow up CT at 18-24 months if no change on first follow up scan c. Nodule 6-7.9 mm i. Follow up at 3-6 months then ii. Follow up at 9-12 months then iii. Follow up at 24 months d. Nodule >8mm i. Follow up CT at 3, 9 and 24 months OR ii. Dynamic contrast enhanced CT OR iii. PET OR iv. Biopsy 3. Lung nodule in patient <35 years of age, one low dose CT at 6-12 months C. Atelectasis or mass by CXR 1. Entire lung field 2. Lobar atelectasis >2 days 3. Segmental atelectasis >2 weeks D. Bleb, bulla or significant emphysema on prior imaging E. Pneumonia, persistent or recurring 1. Unimproved after 3 weeks, or not resolved by 8 weeks after antibiotics 2. Recurrent pneumonia at same site 3. Immunocompromised host F. Mediastinal mass or widening 1. New finding on chest x-ray 2. Follow-up examination after at least three months G. Hilar enlargement 1. New finding on chest x-ray 2. Follow-up examination after at least three months H. Elevated diaphragm

CareCore National Criteria for Imaging Version 2.2009

1. New finding on chest x-ray 2. Follow-up examination after at least three months I. Pleural effusion 1. Thoracentesis reveals malignant cells, primary unknown 2. Exudative pleural effusion 3. Prior to video assisted thoracoscopic or other surgery or chest tube insertion for loculated effusion 4. Initial evaluation prior to intervention 5. Following therapeutic thoracentesis J. Lung abscess or cavitating lesion on chest 1. Not previously imaged 2. Immunocompromised host 3. Follow up after >2weeks of intravenous antibiotics K. Infiltrate 1. No CXR improvement after 4 weeks 2. No change or worsening of symptoms a. Fever >100.4 b. Leukocytosis > 12,000 /cu mm

V. Lung cancer detected by bronchoscopy, cytology or other imaging7, 8, 10, 27-29

VI. Suspected Pulmonary Embolus (PE) 30-33 A. Clinical findings 1. Sudden onset of dyspnea 2. Pleuritic chest pain 3. Cough 4. Hemoptysis 5. Tachypnea 6. Known DVT by sonography 7. Known malignancy 8. Unilateral leg swelling 9. Recent surgery 10. Elevated d-dimer >250 microg/L 11. Recent immobilization of lower extremity 12. Pitting edema in the symptomatic leg B. CXR non-diagnostic for symptoms

VII. Evaluation for metastases to lung or mediastinum 28, 29, 34-49 A. Initial staging of primary cancer prior to treatment 1. Renal cell cancer (kidney) 2. Breast 3. Colon 4. Cervix

CareCore National Criteria for Imaging Version 2.2009

5. Melanoma 6. Testicular or germ cell cancer a. Must have positive abdominal CT or an abnormal chest x-ray 7. Lymphoma or Hodgkin's disease 8. Sarcoma 9. Thymoma 10. Ewing’s sarcoma 11. Osteogenic sarcoma 12. Pancreatic cancer 13. Hepatocellular cancer or hepatoma 14. Ovarian cancer a. Extensive abdominal disease b. Elevated CA-125 B. Restaging after completion of therapy C. Surveillance: Ongoing evaluation of asymptomatic patients with no known lung or mediastinal metastases 1. Renal cell carcinoma (kidney) a. May be repeated at 4- 6 month intervals for three years b. Then annually for another 6 years 2. Osteogenic sarcoma a. For any change in chest x-ray b. High grade i. Reassess after completion of chemotherapy ii. New abnormality on chest x-ray c. Every 3 months for 2 years d. Every 4 months for the 3rd year e. Every 6 months for 4th and 5th year f. Annually after the 5th year 3. Soft tissue sarcomas a. At 3-6 month intervals for 2 years b. Annually after 2 years 4. Colon cancer a. Chest/abdominal/pelvic CT scan every 3-6 months x 2 years b. Then every 6-12 months up to a total of 5 years 5. Testicular or germ cell cancer annually until lesion stabilizes if a. A chest x-ray shows a suspected lesion, or b. CT of the abdomen or pelvis reveal metastases 6. Lymphoma or Hodgkin's disease at six month intervals 7. Head and neck a. Change on chest x-ray 8. Melanoma a. Changes on chest x-ray b. Recurrence or appearance of any other metastasis 9. Thymoma 10. Ovarian cancer

CareCore National Criteria for Imaging Version 2.2009

a. Elevated CA-125 b. Abnormal chest x-ray 11. Ewing’s Sarcoma a. Restaging after chemotherapy is completed b. Surveillance every 60-90 days for 2 years c. Surveillance annually for at least 5 years 12. Uterine Leiomyosarcoma a. May be approved every 90-180 days for 2 years 13. Any known malignancy with change in chest x-ray D. Any known malignancy with change in signs or symptoms E. Known malignancy with interval evaluation on treatment 1. Breast cancer other than DCIS 2. Head and neck cancer 3. Colorectal cancer 4. Testicular or germ cell cancer a. Must have positive abdominal CT or an abnormal chest x-ray 5. Lymphoma 6. Thymoma 7. Esophageal cancer 8. Kidney or renal cell cancer

VIII. Known primary or metastatic lung or mediastinal tumor 27,50,51 A. Lung cancer 1. Initial staging 2. Restaging after completion of treatment 3. Rising tumor markers 4. Surveillance of asymptomatic individual (therapy completed and restaging at end of treatment has been performed) a. Every 4- 6 months for the first 2 years b. Annually after the first 2 years if stable 5. During treatment to establish response 6. Unresectable disease a. Initial staging b. Establish new baseline at the completion of therapy (chemotherapy or radiation therapy) c. Change in the chest x-ray d. New symptoms i. New onset hemoptysis ii. New onset cough iii. New onset chest pain iv. Other symptoms related to the chest v. Rising tumor markers vi. Hoarseness vii. Shortness of breath viii. Weight loss of 10 pounds or more

CareCore National Criteria for Imaging Version 2.2009

B. Evaluation for possible resection of known metastases C. New symptoms, findings or deteriorating clinical situation 1. Objective a. New or worsening findings on CXR b. Horner's syndrome c. Hypercalcemia d. Rising tumor markers e. Elevated hemidiaphragm f. Chylothorax g. Superior vena cava syndrome h. Weight loss of 10 pounds or more 2. Subjective a. Airway compromise b. Shortness of breath c. Hemoptysis d. Recurrent pulmonary infections e. Dysphagia f. Cough g. Chest pain h. Hoarseness

IX. Syndrome of Inappropriate ADH (SIADH)52-54 A. Decreased serum sodium (<125 mmol/l) B. Elevated ADH C. Dilute plasma osmolality

X. Esophageal cancer 40, 55-57 A. Initial evaluation with tissue diagnosis B. Following completion of radiation and/or chemotherapy and/or surgery C. New or worsening condition after treatment 1. Cervical lymph node recurrence 2. Dyspnea 3. Dysphagia 4. Chest pain 5. Cough

XI. Interstitial lung disease 58-60 A. Abnormal pulmonary function testing showing restrictive pattern B. Clinical findings 1. Progressive breathlessness with exertion (dyspnea) 2. Persistent nonproductive cough 3. Infiltrate on chest x-ray 4. Hemoptysis 5. Rapid breathing or tachypnea >16 6. Decreased oxygen saturation with exercise Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

7. Crackles on examination of the lungs 8. Digital clubbing

XII. Suspected dissection of the aorta61-65 A. Unequal blood pressure in the arms B. Rapid onset of "ripping, tearing, searing" severe chest or upper back or abdominal pain C. Pain with abnormal appearance of aorta on prior imaging 1. Chest 2. Back 3. Abdominal D. Syncope E. Shortness of breath F. Prior aortic aneurysm repair G. Chest pain with evidence of a stroke H. Loss of pulses

XIII. Thoracic or thoracoabdominal aneurysm by PE or other imaging 66-68 A. Patient with Marfan’s or Ehlers-Danlos syndrome B. Turner’s syndrome C. Asymptomatic patient with 1. Ascending aorta with diameter >3.7cm 2. Aortic arch and/or descending aorta with diameter >3.5 cm by CXR 3. Any segment dilated to twice the adjacent normal diameter 4. Bicuspid aortic valve on echocardiogram D. Known thoracic or thoracoabdominal aneurysm demonstrated on prior CT, CTA, MRI, MRA or ultrasound 1. Asymptomatic a. Follow up scan 6 months after initial diagnosis b. If no change on the 6 month follow up scan then once every 12 months unless symptoms develop 2. Symptoms a. Chest pain b. Aortic insufficiency c. Superior vena cava compression d. Left vocal cord paralysis E. Preoperative planning for endovascular repair (stent graft) F. Postoperative evaluation following endovascular repair (stent graft) 1. 1 month after repair 2. 3 months after repair 3. 6 months after repair 4. 12 months after repair

XIV. Chest trauma 62,69,70 A. Abnormal appearance of aorta or mediastinum on chest x-ray B. Suspected sternal fracture not demonstrated on x-ray Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

C. Recent history of chest trauma (<5weeks)

XV. Prior to Video Assisted Thoroscopic Surgery (VATS) for treatment of recurrent pneumothorax, pleural effusions, etc. 71,72

XVI. Thymoma, suspected in patient with myasthenia gravis 48,73,74 A. Clinical 1. Ptosis or drooping of the eyelid(s) 2. Diplopia or double vision 3. Flattening of the smile 4. Nasal speech 5. Difficulty chewing or swallowing 6. Facial paresis 7. Proximal limb weakness B. Laboratory tests 1. Positive anti-acetylcholine receptor (anti-Ach R) antibodies 2. Positive MuSK antibody assay 3. Antistriational (anti-titin and antiryanodine) receptor antibody assays

XVII. Suspected bronchiectasis 75,76 A. Clinical findings 1. Cough 2. Daily production of mucopurulent and tenacious sputum 3. Hemoptysis 4. Dyspnea 5. Wheezing or crackles 6. Pleuritic chest pain 7. Digital clubbing B. Bronchiectasis on prior CXR C. History of cystic fibrosis D. Primary ciliary dyskinesia E. Known Alpha1 Anti-Trypsin deficiency (AAT)

XVIII.Cystic fibrosis 75,76 A. Hemoptysis B. Respiratory distress C. Spontaneous pneumothorax D. Acute onset chest pain E. Inspiratory rales or crackles 1. Must have prior chest x-ray F. Bronchiectasis 1. Must have prior chest x-ray G. Chronic or recurrent respiratory infections

CareCore National Criteria for Imaging Version 2.2009

XIX. Paraneoplastic syndrome suspicious for lung cancer 52-54 A. SIADH (Syndrome of Inappropriate ADH) 1. Decreased serum sodium (less than 125 mmol/l) B. Hypercalcemia C. Carcinoid syndrome D. Glomerulonephritis E. Thrombophlebitis

XX. Fever of Unknown Origin (FUO)77 A. Fever >100.4 on several occasions over at least three weeks B. Uncertain diagnosis after lab studies 1. Two blood cultures 2. Urine culture 3. Tuberculin skin test 4. HIV antibody assay and HIV viral load for patients at high risk C. ESR >20 mm/hr D. C-reactive protein >10 mg/ml E. Associated night sweats

XXI. Interstitial lung disease (pulmonary fibrosis) 78,79 A. Symptoms 1. Cough 2. Dyspnea 3. Hemoptysis B. Chest x-ray C. Other associated diseases 1. Sarcoidosis 2. Collagen vascular disease a. Scleroderma b. Dermatomyosistis c. SLE d. Rheumatoid arthritis 3. Tuberous Sclerosis 4. Wegener’s Granulomatosis 5. Bronchiolitis oblierans organizing pneumonia (BOOP) 6. Occupational exposure a. Asbestos b. Silicosis 7. Immunocompromised individual D. Drug related diseases 1. Amiodarone 2. Nitrofurantoin 3. Procainamide 4. Hydralazine 5. Bleiomycin Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

6. Methotrexate 7. BCNU E. Pulmonary function tests or spirometry 1. Restrictive lung disease

References:

1.Pratter MR, Brightling CE, Boulet LP, et al, An empiric integrative approach to the management of cough: ACCP evidence-based clinical practice guidelines, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8674&nbr=004839&string=cough+AND+guidelines December 24, 2007. 2 McGarvey LPA, Polley L, and MacMahon J, Review series: chronic cough: common causes and current guidelines, Chronic Respiratory Disease, 2007; 4:215-223. 3. McGarvey LPA, Cough 6: Which investigations are most useful in the diagnosis of chronic cough, Thorax, 2004; 59:342-346. 4. Irwin RS, Baumann MH, Bolser DC et al, Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines, Chest, 2006; 129:1-23. 5. Winer-Muram HT, Khan A, Aquino SL et al, Expert Panel on Thoracic Imaging, American College of Radiology Appropriateness Criteria: Hemoptysis, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonThoracicImaging/hemoptysisDoc4.aspx December 24, 2007. 6.Bruzzi JF, Remy-Jardin M, Delhaye D, et al, Multi-detector row CT of Hemoptysis, RadioGraphics,2006; 26(1):3-22. 7.Baird J, Belchamber C, Bellamy D, et al, Guideline Development Group, The diagnosis and treatment of lung cancer, National collaborating center for acute care, 2005; accessed at http://www.nice.org.uk/nicemedia/pdf/cg024fullguideline.pdf December 25, 2007. 8.Scottish Intercollegiate Guidelines Network, Management of patients with lung cancer, a national clinical guideline, 2005; accessed at http://www.sign.ac.uk/pdf/sign80.pdf December 25, 2007. 9.Glazer HS, Arongerg DJ, Lee JK, et al, Extralaryngeal causes of vocal cord paralysis: CT evaluation, AJR, 1983, 141:527-531. 10.Alberts Wm, Chair, Diagnosis and management of lung cancer executive summary, ACCP evidence-based clinical practice guidelines, Chest, 2007; 132:1S-19S accessed at http://www.chestjournal.org/cgi/reprint/132/3_suppl/1S December 26, 2007. 11. MacMahon H, Austin JHM, Gamsu G, et al, Guidelines for management of small pulmonary nodules detected on CT scans: A statement from the Fleischner Society, Radiology, 2005; 237:395-400. 12. Gould, MK, Fletcher J, Iannettoni MD, et al, Evaluation of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition), Chest, 2007; 132:108-130. 13. Woodring, JH, Determining the cause of pulmonary atelectasis: a comparison of plain radiography and CT AJR, 1988; 150:757-763. 14. Ashizawa K, Hayashi K, Aso N et al, Lobar atelectasis: diagnostic pitfalls on chest radiography, BJR, 2001; 74:89-97. 15.Haramati LB, Davis SD, Goodman, PC et al, Expert Panel on Thoracic Imaging, American College of Radiology Appropriateness Guidelines, Acute respiratory Illness, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonThoracicImaging/AcuteRespiratoryIllnessDoc 1.aspx December 27, 2007. 16.Donnelly LF and Klosterman LA, The yield of CT of children who have complicated pneumonia and noncontributory chest radiography, AJR,1998; 170:1627-1631. 17. Aquino SL, Chiles C, and Halford P, Distinction of consolidative bronchio alveolar carcinoma from pneumonia: do CT criteria work? AJR, 1998; 171:359-363. 18. Gruden JF, Huang L, Turner J et al, High-resolution CT in the evaluation of clinically suspected Pneuocystis carinii pneumonia in AIDS patients with normal, equivocal or nonspecific radiographic findings, AJR, 1997; 169:967-975. 19.Holtzman SR, Bettmann MA, Casciani T, et al Expert panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria, Blunt chest trauma-suspected aortic injury, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/Vascular/BluntChestTraumaSuspeCTedAorticInjuryDoc6.as px December 27, 2007. 20. Camus P, Ask K and Foucher P, Iatrogenic respiratory diseases, accessed at http://www.chestnet.org/education/online/pccu/vol17/lessons7_8/lesson7.php December 27, 2007. 21. Baron RL, Levitt RG, Sagel SS, et al, Computed tomography in the evaluation of mediastinal widening, Radiology, 1981; 138:107-113. 22. Pugatch RD, Faling LJ, Robbins AH, et al, CT diagnosis of benign mediastinal abnormalities, AJR, 1980; 134:685-694.

CareCore National Criteria for Imaging Version 2.2009

23. Siegel MJ, Sagel SS, and Reed K, The value of computed tomography in the diagnosis and management of pediatric mediastinal abnormalities, Radiology, 1982; 149-155. 24. Alexander ES, Proto AV, and Clark RA, CT differentiation of subphrenic abscess and pleural effusion, AJR, 1983; 140:47-51. 25. Rahman NM, Chapman SJ, and Davies RJO, Pleural effusion: a structured approach to care, British Medical Bulletin, 2004; 72:31-47. 26. Light RW, Pleural Effusion, N Eng J Med, 2002; 346(25):1971-1977 27.Pfister DG, Johnson DH, Azzoli CG, et al, American Society of Clinical Oncology Treatment of unresectable non-small-cell lung cancer guideline: update 2003, Journal of Clinical Oncology, 2004; 22(2): 330-353. 28. Rozehshtein A, Davis SD, Komaki RU, et al, Expert Panels on Thoracic Imaging and Radiation Oncology-Lung Work Group, American College of Radiology Appropriateness Criteria Staging of bronchogenic carcinoma, accessed at http://www.nice.org.uk/nicemedia/pdf/cg024fullguideline.pdf December 27, 2007. 29. Thoms WW Jr, Komaki RU, Gewanter RM, et al, Expert panel on Radiation Oncology-Lung, American College of Radiology Appropriateness Criteria, Follow-up of non-small-cell lung cancer, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonRadiationOncologylungWorkGroup/FollowUp ofNonSmallCelllungcancerDoc1.aspx December 27, 2007. 30.Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected pulmonary embolism, Ann Emerg Med, 2003; 41:257-270. 31. Bettman MA, Lyders EM, Yucel K et al, Expert panel on Cardiac Imaging, American College of Radiology Appropriateness Criteria, Acute chest pain-suspected pulmonary embolism, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainSusp ectedPulmonaryEmbolismUpdateinProgressDoc4.aspx December 27, 2007. 32. Torbicki A, van Beek EJR, Charbonnier B, et al, Guidelines on diagnosis and management of pulmonary embolism, European Heart Journal, 2000; 21:1301-1336. 33. Qaseem A, Snow V, Barry P, et al, Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians, Ann Intern Med, 2007; 146:454-458. 34. Mohammed T_LH, Chowdhry AA, Khan A, et al, Expert Panel on Thoracic Imaging, American College of Radiology Appropriateness Criteria, screening for pulmonary metastateses, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonThoracicImaging/ScreeningforPulmonaryMeta stasesDoc9.aspx December 26, 2007. 35.Manaster BJ, Petersen B, Dalinka MK, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Follow-up of malignant or aggressive musculoskeletal tumors, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/FollowUpofMalignant orAggressiveMusculoskeletalTumorsDoc11.aspx December 27, 2007. 36.Javitt MC, Fleischer AC, Andreotti RF, et al, Expert Panel on Women’s Imaging, American College of Radiology, Staging and follow-up of ovarian cancer, accessed at http://www.acr.org/SecondaryMainMenuCAtegories/quality_safety/app_criteria/pdf/ExpertPanelonWomensImaging/StagingandFollowUpofOvari anCancerDoc10.aspx December 27, 2007. 37.Biermann JS, Adkins D, Benjamin R, et al, NCCN Bone Cancer Panel Members, Bone Cancer, NCCN Practice Guidelines in Oncology- v.1.2007, accessed at http://www.nccn.org/professionals/physician_gls/PDF/bone.pdf December 27, 2007. 38. Engst PF, Arnoletti JP, Benson AB, et al, NCCN Colon Cancer Panel Members, Colon Cancer, NCCN Practice Guidelines in Oncology- v.1.2008, accessed at http://www.nccn.org/professionals/physician_gls/PDF/colon.pdf December 27, 2007. 389 Benson AB, Ben-Josef E, Bloomston M, et al, NCCN Hepatobiliary Cancers Panel Members, NCCN Practice guidelines in Oncology- v2.2008, Hepatobiliary Cancers, accessed at http://www.nccn.org/professionals/physician_gls/PDF/esophageal.pdf December 27, 2007. 40.Ajani J, Bekaii-Saab T, D’Amico TA, et al, NCCN Esophageal Cancer Panel Members, Esophageal Cancer, NCCN Practice Guidelines in Oncology-v2.2007, accessed at http://www.nccn.org/professionals/physician_gls/PDF/esophageal.pdf December 27, 2007. 41.Motzer RJ, Bolger GB, Boston B et al, NCCN Kidney Cancer Panel Members, NCCN Practice Guidelines in Oncology v.1.2008, Kidney Cancer, accessed at http://www.nccn.org/professionals/physician_gls/PDF/kidney.pdf December 27, 2007. 42.Houghton AN, Bichakjian CK, Coit DG, et al, NCCN Melanoma Panel Members, NCCN Practice Guidelines in Oncology-v.2.2007, Melanoma, accessed at http://www.nccn.org/professionals/physician_gls/PDF/melanoma.pdf December 27, 2007. 43. Hoppe RT, Advani RH, Ambinder RF, et al, NCCN Hodgkin Disease/Lymphoma Panel Members, NCCN Practice Guidelines in Oncology- v.1.2007, Hodgkin Disease/Lymphoma, accessed at http://www.nccn.org/professionals/physician_gls/PDF/hodgkins.pdf December 27,2007. 44.Zelenetz AD, Advani RH, Bociek RG, et al, NCCN non-Hodgkin’s Disease Lymphomas Panel Members, NCCN Practice Guidelines in Oncology-v.1.2007, non-Hodgkin’s Disease Lymphoma’s, accessed at http://www.nccn.org/professionals/physician_gls/PDF/nhl.pdf December 27, 2007. 45.Morgan RJ, Alvarez RD, Armstrong DK, et al, Nccn Ovarian Cancer Panel Members, , NCCN Practice Guidelines in Oncology-v.1.2007, Ovarian cancer, accessed at http://www.nccn.org/professionals/physician_gls/PDF/ovarian.pdf December 27, 2007. 46.Demetri GD, Baker LH, Benjamin RS, et al, NCCN Soft Tissue Sarcoma Panel Members, NCCN Practice Guidelines in Oncology-v.3.2007, Soft tissue sarcoma, accessed at NCCN Practice Guidelines in Oncology-v.1.2007, accessed at NCCN Practice Guidelines in Oncology-v.1.2007, , December 27, 2007. 47. Motzer RJ, Bolger GB, Boston B, NCCN Testicular Cancer Panel Members, NCCN Practice Guidelines in Oncology-v.1.2008,Testicular cancer accessed at , http://www.nccn.org/professionals/physician_gls/PDF/testicular.pdf December 27, 2007.

CareCore National Criteria for Imaging Version 2.2009

48.Ettinger DS, Akerley W, Bepler G et al, NCCN Non-Small Cell Lung Cancer Panel Members, NCCN Practice Guidelines in Oncology- v.2.2008, Non-small cell lung cancer, accessed at http://www.nccn.org/professionals/physician_gls/PDF/nscl.pdf December 27, 2007. 49.Greer BE, Koh W-J, Abu-Rustum N, et al, NCCN Uterine Neoplasms Panel Members, NCCN Practice Guidelines in Oncology-v.1.2008, Uterine Neoplasms, accessed at http://www.nccn.org/professionals/physician_gls/PDF/uterine.pdf December 27, 2007. 50. Rubins J, Unger M and Colice GL, Follow-up and surveillance of the lung cancer patient following curative intent therapy: ACCP evidence- based clinical practice guideline (2nd edition), Chest, 2007; 132:355-367. 51. Walsh, GL, O'Connor, M, Willis, KM, et al. Is follow-up of lung cancer patients after resection medically indicated and cost effective?. Ann Thorac Surg 1995; 60:1563-1572. 52. Seidenwurm DJ, Davis PC, Brunberg JA, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria, Neuroendocrine Imaging, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/NeuroendocrineImagingD oc10.aspx December 28, 2007. 53. Spiro SG, Gould MK, and Colice GL, Initial Evaluation of the patient with lung cancer: symptoms, signs. Laboratory tests and paraneoplastic syndromes: ACCP evidenced-based clinical practice guidelines (2nd edition) Chest, 2007; 132:149-160. 54. Ellison DH, and Berl T, The syndrome of inappropriate antidiuresis, N Eng J Med, 2007; 356:21064-2072. 55. American Gastroenterological Association Medical Position Statement: Role of the gastroenterologist in the management of esophageal carcinoma, Gastroenterology, 2005; 128:1468-1470. 56. Vilgrain V, Mompoint D, Palazzo L et al, Staging of esophageal carcinoma: comparison of results with endoscopic sonography and CT, AJR, 1990; 155:277-281. 57. Kim TJ, Lee KL, Kim YH, et al, Postoperative imaging of esophageal cancer: what chest radiologists need to know, RadioGraphics, 2007; 27:409-429. 58 King T E Jr, Clinical advances in the diagnosis and therapy of the interstitial lung diseases, Am J Respir Crit Care Med, 2005; 172:268-279. 59. Aziz ZA, Wells AU, Bateman ED, et al, Interstitial lung disease: effects of thin-section CT on clinical decision making, Radiology, 2006; 238:725-733. 60. Copley SJ, Coren M, Nicholson AG et al, Diagnostic accuracy of the thin-=section CT and chest radiography of pediatric interstitial lung disease, AJR, 2000; 174:549-554. 61 Gomes AS, Bettmann MA, Casciani T, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-suspected aortic dissection, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainSusp ectedaorticdissectionDoc2.aspx December 28, 2007. 62Holtzman SR, Bettmann MA, Casciani T, et al, Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Blunt chest trauma suspected aortic injury, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/Vascular/BluntChestTraumaSuspectedaorticInjuryDoc6.aspx December 28, 2007. 63. Erbel R, Alfonso F, Boileau C, et al, Diagnosis and management of aortic dissection : recommendations of the task force on aortic dissection, Europena Society of Cardiology, European Heart Journal, 2001, 22:1642-1682. 64. Stanford W, Yucel EK, Bettmann MA, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-No ecg enzyme evidence of myocardial ischemia/infarction, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/Acute ChestPainNoECGorEnzymeEvidenceofMyocardialIschemiaInfarctionDoc1.aspx December 28, 2007. 65.Mulder S, Spilde P, Morrison J, et al, Health Care Guideline: Diagnosis and treatment of chest pain and acute coronary syndrome (ACS), Institute for Clinical systems Improvement, Third Edition, 2006, accessed at http://www.icsi.org/acs_acute_coronary_syndrome /acute_coronary_syndrome andchest_paindiagnosis_and_treatment_of_2.html December 28, 2007. 66. Isselbacher EM Thoracic and abdominal aortic aneurysms, Circulation, 2005; 111:816-828. 67. Elefteriades JA, Natural history of thoracic aortic aneurysms: indications for surgery, and surgical versus non surgical risks, Ann Thorac Surg, 2002; 74:1877-1880. 68. Fattori R and Russo V, Degenerative aneurysm of the descending aorta. Endovascular treatment, European Association for Cardio-thoracic Surgery, Multimedia Manual of Cardiothoracic Surgery, 2007, accessed at http://mmcts.ctsnetjournals.org/cgi/reprint/2007/1217/mmcts.2007.002824.pdf December 28, 2007. 69. van Hise ML, Primack SL, Israel RS, Muller NL, CT in blunt chest trauma: indications and limitations, RadioGraphics, 1998; 18:1071-1084. 70. Iochum S, Ludig T, Walter F, et al, Imaging of diaphragmatic injury: a diagnostic challenge, RadioGraphics, 2002; 22:S103-S118. 71. Solli P and Spaggiari, Indications and developments of video-assisted thoracic surgery in the treatment of lung cancer, Oncologist, 2007; 12:1205-1214. 72. Ciriaco P, Negri G, Puglisi A, et al, Video-assisted thoracoscopic surgery for pulmonary nodules: rationale for preoperative computed tomography-guided hookwire localization, Eur J Cardio-Thoracic Surg, 2004; 25(3):429-433. 73. Myasthenia gravis fact sheet, National Institute of Neurological Disorders and Stroke, accessed at http://www.ninds.nih.gov/disorders/myasthenia_gravis/detail_myasthenia_gravis.htm December 29, 2007. 74. de Kraker M, Kluin J, Renken N, et al, CT and myasthenia gravis: correlation between mediastinal imaging and histopathological findings, Interact CardioVasc Thorac Surg, 2005; 4:267-271. 75. Rosen MJ, Chronic cough due to bronchiectasis: ACC evidence-based clinical practice guidelines, Chest, 2006; 129:122-131. 76. Barker AF, Bronchiectasis, N Eng J Med, 2002; 346:1383-1393. Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

77. Mourad O, Palda V, Detsky AS, A comprehensive evidence-based approach to fever of unknown origin, Arch Intern Med, 2003; 163:545- 551. 78. Travis WD, King TE Jr, Capron F, et al., American Thoracic Society/European Respiratory Society International Multidisciplinary Consensus Classification of the Idiopathic Interstitial Pneumonias, Am J Respir Crit Care Med, 2002; 165:277-304. 79. Sharma S, Restrictive lung disease, accessed at Http://www.emedicine.com/MEDICARE/topic2012.htm October 4, 2008

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

71275 CTA of the Chest

I. For evaluation of suspected pulmonary embolism 1-3 [CT with contrast or CT pulmonary arteriography are both appropriate] A. Clinical findings 1. Sudden onset of dyspnea 2. Pleuritic chest pain 3. Cough 4. Hemoptysis 5. Tachypnea 6. Known DVT by sonography 7. Known malignancy B. Chest x-ray non-diagnostic

II. Developmental anomalies of the thoracic vasculature for initial evaluation, treatment planning and post-operative evaluation 4-8 A. Coarctation of the aorta B. Right-sided aortic arch C. Truncus arteriosus D. Persistent left superior vena cava E. Interrupted inferior vena cava F. Total anomalous pulmonary venous return G. Pulmonary artery atresia H. Pulmonary artery hypoplasia

III. Suspected dissection of the aorta9-13 A. Unequal blood pressure in the arms B. Rapid onset of "ripping, tearing, searing" severe chest or upper back or abdominal pain C. Pain with abnormal appearance of aorta on prior imaging 1. Chest 2. Back 3. Abdominal D. Syncope E. Shortness of breath F. Prior aortic aneurysm repair G. Chest pain with evidence of a stroke H. Loss of pulses

IV. Aneurysm of the thoracic aorta or thorocoabdominal aneurysm14-18 A. Patient with Marfan or Ehlers-Danlos syndrome B. Turner’s syndrome C. Asymptomatic patient with 1. Ascending aorta with diameter >3.7 cm

CareCore National Criteria for Imaging Version 2.2009

2. Aortic arch and/or descending aorta with diameter >3.5 cm by chest x-ray 3. Any segment dilated to twice the adjacent normal diameter 4. Bicuspid aortic valve on echocardiogram D. Known thoracic or thoracoabdominal aneurysm demonstrated by CT, CTA, MRI, MRA or ultrasound 1. Asymptomatic a. Follow up scan 6 months after initial diagnosis b. If no change on the 6 month follow up scan then once every 12 months unless symptoms develop 2. Symptoms [One] a. Chest pain b. Aortic insufficiency c. Superior vena cava compression d. Left vocal cord paralysis E. Preoperative planning for endovascular repair (stent graft) F. Postoperative evaluation following endovascular repair (stent graft) 1. 1 month after repair 2. 3 months after repair 3. 6 months after repair 4. 12 months after repair

V. Assess thoracic venous structures 19 A. Superior vena cava syndrome 1. Physical findings a. Swelling, edema or cyanosis of body cranial to heart level i. Face ii. Arms iii. Neck b. Dilated anterior chest wall veins and/or collateral veins c. Cerebral and laryngeal edema 2. Neurologic symptoms a. Headache b. Dizziness, stupor or syncope c. Visual disturbances 3. Bending over or lying down accentuates symptoms B. Mapping for venous access

VI. Trauma A. Chest pain B. Chest x-ray demonstrating abnormal mediastinal or aortic contour

CareCore National Criteria for Imaging Version 2.2009

References:

1.Bettman MA, Lyaders EM, Yucel E, et al, Expert Panel on Cardiac Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-suspected pulmonary embolism, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainSusp ectedPulmonaryEmbolismUpdateinProgressDoc4.aspx April 25, 2008. 2.Burnett B, Heit J, Larsen J, et al , Institute for Clinical Systems Improvement, Health Care Guideline: VTE thromboembolism, accessed at http://www.icsi.org/venous_thromboembolism/venous_thromboembolism_4.html April 25, 2008. 3. Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected pulmonary embolism, Ann Emerg Med, 2003; 41:257-270. 4. Ho VB, Yucel EK, Khan A, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- suspected congenital heart disease in the adult, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/SuspectedCongenital HeartDiseaseintheAdultUpdateinProgressDoc18.aspx April 25, 2008. 5. Goo HW, Par I-S, Ko JK et al, CT of congenital heart disease: normal anatomy and typical pathologic conditions, RadioGraphics, 2003; 23: S147-S165. 6. Leschka S, Oechslin E, Husmann L, et al, Pre and postoperative evaluation of congenital heart disease in children and adults with 64-section CT, RadioGraphics, 2007; 27:829-846. 7. Ou P, Celermajer DS, Calcagni G, et al, Three-dimensional CT scanning: a new diagnostic modality in congenital heart disease, Heart, 2007; 93:908-913. 8. Leonard AP, Crossley RA, Klusmann M, et al, Cardiac multidetector computed tomography (MCCT): method, indications and applications, Imaging, 2006; 18:151-159. 9. Gomes AS, Bettmann MA, Casciani T, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-suspected aortic dissection, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainSusp ectedaorticdissectionDoc2.aspx December 28, 2007. 10.Holtzman SR, Bettmann MA, Casciani T, et al, Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Blunt chest trauma suspected aortic injury, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/Vascular/BluntChestTraumaSuspectedaorticInjuryDoc6.aspx December 28, 2007. 11. Erbel R, Alfonso F, Boileau C, et al, Diagnosis and management of aortic dissection : recommendations of the task force on aortic dissection, Europena Society of Cardiology, European Heart Journal, 2001, 22:1642-1682. 12. Stanford W, Yucel EK, Bettmann MA, , Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-No ecg enzyme evidence of myocardial ischemia/infarction, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/Acute ChestPainNoECGorEnzymeEvidenceofMyocardialIschemiaInfarctionDoc1.aspx December 28, 2007. 13. .Mulder S, Spilde P, Morrison J, et al, Helath Care Guideline: Diagnosis and treatment of chest pain and acute coronary syndrome (ACS), Institute for Clinical systems Improvement, Third Edition, 2006, accessed at http://www.icsi.org/acs_acute_coronary_syndrome /acute_coronary_syndrome _and_chest_pain__diagnosis_and_treatment_of_2.html December 28, 2007. 14. Mehard WB, Heiken JP, and Sicard GA, High-attenuating crescent in abdominal aortic aneurysm wall at CT: A sign of acute or impending rupture, Radiology, 1994; 192:359-362. 15. Starvropoulos SW and Charagundla SR, Imaging techniques for detection and management of endoleaks after endovascular aortic aneurysm repair, Radiology, 2007; 243:641-655. 16. Hirsch AT, Haskal AJ, Hertzer NR, et al, ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease(lower extremity, renal, mesenteric and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for vascular surgery,society for cardiovascular angiography and intervention, society for vascular medicine and biology, society of interventional radiology and the ACC/AHA task force on practice guidelines(writing committee to develop guidelines for the management of patients with peripheral arterial disease), J Am Coll Cardiol, 2006; 47:1-192. 17. Fattori R and Russo V, Degenerative aneurysm of the descending aorta. Endovascular Treatment, European Association for Cardio- thoracic Surgery, Multimedia Manual of Cardiothoracic Surgery, 2007, accessed at http://mmcts.ctsnetjournals.org/cgi/reprint/2007/1217/mmcts.2007.002824.pdf December 28, 2007. 18. Horton KM, Smith C, and Fishman EK, MDCT and 3D CT angiography of splanchnic artery aneurysms, AJR, 2007; 189:641-647. 19. Qanadli SD, El Hajjam M, Bruckert F, et al, Helical CT phlebography of the superior vena cava: diagnosis and evaluation of venous obstruction, AJR, 1999; 172:1327-1333.

CareCore National Criteria for Imaging Version 2.2009

71550 MRI of the Chest without Gadolinium 71551 MRI of the Chest with Gadolinium 71552 MRI of the Chest without and with Gadolinium

I. Lung cancer and other neoplasms of the lung 1, 2 A. Staging of a known malignancy in the chest 1. Central tumor possibly invading the aorta or vena cava 2. Posterior tumor possibly invading the spine 3. Superior sulcus (Pancoast) tumor on prior imaging a. Arm and shoulder pain b. Horner syndrome

II. Mediastinum1, 3-5 A. Hilar enlargement with non-diagnostic CT B. Pericardial or cardiac mass by prior imaging 1. Primary cardiac masses a. Prior abnormal heart contour on chest x-ray b. Prior abnormal echocardiogram 2. Heart failure or peripheral embolization of unknown etiology C. Suspected superior vena cava obstruction 1. Edema of head and neck 2. Dilated collateral veins on torso 3. Cyanosis 4. Headache and confusion D. Suspected thymoma in patient with myasthenia gravis E. Mediastinal mass or widening suspected on prior imaging or clinical grounds 1. Spinal cord compressive syndrome 2. Vena caval obstruction 3. Pericardial tamponade 4. Congestive heart failure 5. Dysrhythmias 6. Pulmonary stenosis 7. Tracheal compression 8. Esophageal compression 9. Vocal cord paralysis 10. Horner's syndrome 11. Phrenic nerve paralysis 12. Chylothorax 13. Chylopericardium 14. Pancoast's syndrome 15. Postobstructive pneumonitis Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

III. Great Vessels 5-9 A. Anomalies of the aortic arch 1. Abnormal mediastinal contour on chest x-ray 2. Abnormal echocardiogram B. Monitoring the aorta in Marfan syndrome and annuloaortic ectasia C. Establishing the source of peripheral embolization 1. Cyanosis of a single extremity or part of an extremity 2. Abdominal angina 3. Stroke or TIA D. Diagnosis and assessment of the severity of coarctation, including postangioplasty evaluation E. Diagnosis of periaortic abscess or infectious pseudoaneurysm in bacterial endocarditis of the aortic valve F. Assessment of the origin and proximal parts of the Great Vessels for possible causes of cerebrovascular disease 1. History of stroke or TIA G. Intramural hematoma H. Aortitis 1. Upper extremity claudication 2. Stroke 3. Transient cerebral ischemia 4. Dizziness or syncope 5. Subclavian steal 6. Retinopathy 7. Raynaud's phenomenon 8. Hypertension, sometimes malignant I. Suspected thoracic aortic dissection 1. Unequal blood pressure in arms 2. Rapid onset of "ripping, tearing, searing" severe chest or upper back or abdominal pain 3. Pain with abnormal appearance of aorta on prior imaging a. Chest b. Back c. Abdominal 4. Syncope 5. Shortness of breath 6. Prior aortic aneurysm repair 7. Chest pain with evidence of a stroke 8. Loss of pulses J. Thoracic or thoracoabdominal aneurysm 1. Patient with Marfan’s or Ehlers-Danlos syndrome 2. Turner’s syndrome 3. Asymptomatic patient with a. Ascending aorta with diameter >3.7 cm b. Aortic arch and/or descending aorta with diameter >3.5 cm by CXR c. Any segment dilated to twice the adjacent normal diameter d. Bicuspid aortic valve on echocardiogram

CareCore National Criteria for Imaging Version 2.2009

4. Known thoracic or thoracoabdominal aneurysm demonstrated on prior CT, CTA, MRI, MRA or ultrasound a. Asymptomatic i. Follow up scan 6 months after initial diagnosis ii. If no change on the 6 month follow up scan then once every 12 months unless symptoms develop b. Symptoms i. Chest pain ii. Aortic insufficiency iii. Superior vena cava compression iv. Left vocal cord paralysis c. Preoperative planning for endovascular repair (stent graft)

IV. Pleura 10 A. Tumor 1. To determine if pleural lesions detected on other examinations are benign or malignant (metastases are most common) 2. Mesothelioma a. To determine extent of tumor B. To evaluate pleural fluid in high risk patients

V. Brachial plexus 11-16 A. Brachial plexus injury 1. Symptoms a. Weakness or paralysis of the shoulder and biceps b. Weakness of the wrist c. Weakness or paralysis of the forearm or hand d. Horner’s syndrome 2. History a. Trauma including birth trauma b. Radiation fibrosis c. History of radiation therapy to the chest, breast or axilla d. Weakness of the shoulder and/or arm B. Primary or metastatic tumor 1. Symptoms a. Pain b. Weakness of the extremity c. Numbness of the extremity d. Hyperesthesia of the extremity C. Schwannoma or neurofibroma 1. Symptoms a. Palpable mass in the lower neck or supraclavicular fossa b. Weakness of the upper extremity

CareCore National Criteria for Imaging Version 2.2009

VI. Suspected dissection of the thoracic aorta17-21 A. Unequal blood pressure in arms B. Rapid onset of "ripping, tearing, searing" severe chest or upper back or abdominal pain C. Pain with abnormal appearance of aorta on prior imaging 1. Chest 2. Back 3. Abdominal D. Syncope E. Shortness of breath F. Prior aortic aneurysm repair G. Chest pain with evidence of stroke H. Loss of pulses

References:

1. Shen RK, Meyers BF, Larner JM, et al, Special treatment issues in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition) Chest, 2007; 132:290-305. 2. Patz EF, Imaging bronchogenic carcinoma, Chest, 2000; 117:90-95. 3. Maisch B, Seferovic PM, Ristic AD, et al, Guidelines on the diagnosis and management of pericardial diseases full text, The Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology, accessed at http://www.escardio.org/NR/rdonlyres/177EB2C7-F1CC-4F39-9E38-C1EBE6F56816/0/guidelines_Pericardial_FT_2004.pdf May 6, 2008. 4. Brown D, Aberle DR, Batra P, et al, Current use of imaging in the evaluation of primary mediastinal masses, Chest, 1990; 98:466-473. 5. Stollo DC, Rosado de Christenson ML and Jett JR, Primary mediastinal tumors. Part 1: tumors of the anterior mediastinum, Chest, 1997; 112:511-522. 6. Gomes AS, Bettmann MA, Casciani T, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria-Acute chest pain-suspected aortic dissection, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainSusp ectedaorticdissectionDoc2.aspx May 6, 2008. 7. Mulder S, Spilde P, Morrison J, et al , Health Care Guideline” Diagnosis and treatment of chest pain and acute coronary syndrome (ACS), Institute for Clinical Systems Improvement accessed at http://www.icsi.org/acs_acute_coronary_syndrome /acute_coronary_syndrome _and_chest_pain__diagnosis_and_treatment_of_2.html May 6, 2008. 8. Grollman J, Bettman MA, Casciani T, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- pulsatile abdominal mass, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/Vascular/PulsatileAbdominalMassDoc13.aspx May 6, 2008. 9. Hi VB, Yucel EK, Khan A, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- suspected congenital heart disease in the adult, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/SuspectedCongenital HeartDiseaseintheAdultUpdateinProgressDoc18.aspx May 6, 2008. 10. Hierholzer J, Luo L, Bittner RC, et al, MRI and CT in the differential diagnosis of pleural disease, Chest, 2000; 118:604-609. 11. Bowen B, Seidenwurm DJ, Davis PC, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria- plexopathy, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/PlexopathyDoc12.aspx May 6, 2008. 12. Yoshikawa T, Hayashi N, Yamamoto S, et al, Brachial plexus injury: clinical manifestations, conventional imaging findings and the latest imaging techniques, RadioGraphics, 2006; 26:S133-S143. 13. Qayyum A, MacVicar AD, Revell P, et al, Symptomatic brachial plexopathy following treatment for breast cancer: utility of MR imaging with surface-coil techniques, Radiology, 2000; 214:837-842. 14. Maravilla KR and Bowen BC, Imaging of the peripheral nervous system: evaluation of peripheral neuropathy and plexopathy, AJNR, 1998; 19:1011-1023. 15. Todd M, Shah G and Mukherji S, MR imaging of the brachial plexus, Top in Mag Reson Imaging, 2004; 15:113-125.

CareCore National Criteria for Imaging Version 2.2009

16. Saifuddin A, Imaging tumors of the brachial plexus, Skeletal Radiol, 2003; 32:375-387. 17. Gomes AS, Bettmann MA, Casciani T, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-suspected aortic dissection, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainSusp ectedaorticdissectionDoc2.aspx December 28, 2007. 18. Holtzman SR, Bettmann MA, Casciani T, et al, Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Blunt chest trauma suspected aortic injury, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/Vascular/BluntChestTraumaSuspectedaorticInjuryDoc6.aspx December 28, 2007. 19.. Erbel R, Alfonso F, Boileau C, et al, Diagnosis and management of aortic dissection : recommendations of the task force on aortic dissection, Europena Society of Cardiology, European Heart Journal, 2001, 22:1642-1682. 20. Stanford W, Yucel EK, Bettmann MA, , Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-No ecg enzyme evidence of myocardial ischemia/infarction, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/Acute ChestPainNoECGorEnzymeEvidenceofMyocardialIschemiaInfarctionDoc1.aspx December 28, 2007. 21. Mulder S, Spilde P, Morrison J, et al, Helath Care Guideline: Diagnosis and treatment of chest pain and acute coronary syndrome (ACS), Institute for Clinical systems Improvement, Third Edition, 2006, accessed at http://www.icsi.org/acs_acute_coronary_syndrome /acute_coronary_syndrome _and_chest_pain__diagnosis_and_treatment_of_2.html December 28, 2007.I

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

71555 MRA or MRV Chest without or with Gadolinium

I. Indications for evaluation of suspected pulmonary embolism1 clinical findings if CT or CTA contraindicated because of allergy to CT contrast agents1 A. Sudden onset of dyspnea B. Pleuritic chest pain C. Cough D. Hemoptysis E. Tachypnea F. Known DVT by sonography G. Known malignancy H. CXR non-diagnostic

II. Developmental anomalies of the thoracic vasculature for initial evaluation, treatment planning and post-operative evaluation 2 A. Coarctation of the aorta B. Right-sided aortic arch C. Truncus arteriosus D. Persistent left superior vena cava E. Interrupted inferior vena cava F. Total anomalous pulmonary venous return G. Pulmonary artery atresia H. Pulmonary artery hypoplasia

III. Suspected dissection of the thoracic aorta 3-8 A. Unequal blood pressure in the arms B. Rapid onset of "ripping, tearing, searing" severe chest or upper back or abdominal pain C. Pain with abnormal appearance of aorta on prior imaging 1. Chest 2. Back 3. Abdominal D. Syncope E. Shortness of breath F. Prior aortic aneurysm repair G. Chest pain with evidence of stroke H. Loss of pulses

IV. Aneurysm of the thoracic aorta or thorocoabdominal aneurysm9-11 A. Patient with Marfan or Ehlers-Danlos syndrome B. Turner’s syndrome Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

C. Asymptomatic patient with 1. Ascending aorta with diameter >3.7 cm 2. Aortic arch and/or descending aorta with diameter >3.5 cm by chest x-ray 3. Any segment dilated to twice the adjacent normal diameter 4. Bicuspid aortic valve on echocardiogram D. Known thoracic or thoracoabdominal aneurysm 1. Asymptomatic with no repair a. Follow up scan 6 months after initial diagnosis b. If no change on the 6 month follow up scan then once every 12 months unless symptoms develop 2. Symptoms a. Chest pain b. Aortic insufficiency c. Superior vena cava compression d. Left vocal cord paralysis E. Preoperative planning for endovascular repair (stent graft)

V. Assess thoracic venous structures 12 A. Suspected occlusion B. Mapping for venous access

VI. Pulmonary vein mapping 13 A. Planned radiofrequency ablation for treatment of atrial fibrillation B. Following radiofrequency ablation if there is a suspicion of venous stenosis

VII. Aortic pathology A. Monitor known thoracic aneurysm documented on prior CT, CTA, MRI, MRA, angiogram B. Peripheral embolization C. Post traumatic 1. Widening of the mediastinum 2. Deviation of the trachea 3. Loss of pulses 4. Cyanosis of hands and/or feet

References:

1. Bettmann MA, Lyders EM, Yucel EK, et al, Expert Panel on Cardiac Imaging, American College of Radiology Appropriateness Criteria, Acute Chest Pain-Suspected Pulmonary Embolism, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/Acute chestPainSuspectedPulmonaryEmbolismUpdateinProgressDoc4.aspx March 13, 2008. 2. Ho VB, Yucel EK, Khan A, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Suspected Congenital Heart Disease in the Adult, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/SuspectedCongenital HeartDiseaseintheAdultUpdateinProgressDoc18.aspx March 13, 2008.

CareCore National Criteria for Imaging Version 2.2009

3. Gomes AS, Bettmann MA, Casciani T, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria, Acute Chest Pain-Suspected Aortic Aneurysm, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcutechestPainSuspe ctedAorticDissectionDoc2.aspx March 13, 2008. 4. Clinical Resource Efficiency Support Team, Guidelines for the Use of Magnetic Resonance Imaging in Northern Ireland, accessed at http://www.crestni.org.uk/publications/mri.pdf March 13, 2008. 5.Holtzman SR, Bettmann MA, Casciani T, et al, Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Blunt chest trauma suspected aortic injury, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/Vascular/BluntChestTraumaSuspectedaorticInjuryDoc6.aspx December 28, 2007. 6.. Erbel R, Alfonso F, Boileau C, et al, Diagnosis and management of aortic dissection : recommendations of the task force on aortic dissection, Europena Society of Cardiology, European Heart Journal, 2001, 22:1642-1682. 7..Stanford W, Yucel EK, Bettmann MA, , Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-No ecg enzyme evidence of myocardial ischemia/infarction, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/Acute ChestPainNoECGorEnzymeEvidenceofMyocardialIschemiaInfarctionDoc1.aspx , December 28, 2007. 8. .Mulder S, Spilde P, Morrison J, et al, Helath Care Guideline: Diagnosis and treatment of chest pain and acute coronary syndrome (ACS), Institute for Clinical systems Improvement, Third Edition, 2006, accessed at http://www.icsi.org/acs_acute_coronary_syndrome /acute_coronary_syndrome _and_chest_pain__diagnosis_and_treatment_of_2.html , December 28, 2007. 9. Starvropoulos SW and Charagundla SR, Imaging techniques for detection and management of endoleaks after endovascular aortic aneurysm repair, Radiology, 2007; 243:641-655. 10. Hirsch AT, Haskal AJ, Hertzer NR, et al, ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease(lower extremity, renal, mesenteric and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for vascular surgery,society for cardiovascular angiography and intervention, society for vascular medicine and biology, society of interventional radiology and the ACC/AHA task force on practice guidelines(writing committee to develop guidelines for the management of patients with peripheral arterial disease), J Am Coll Cardiol, 2006; 47:1-192. 11. Fattori R and Russo V, Degenerative aneurysm of the descending aorta. Endovascular Treatment, European Association for Cardio- thoracic Surgery, Multimedia Manual of Cardiothoracic Surgery, 2007, accessed at http://mmcts.ctsnetjournals.org/cgi/reprint/2007/1217/mmcts.2007.002824.pdf December 28, 2007. 12 Pennell DJ, Sechtem UP, Higgins CB, et al, Clinical indications for Cardiovascular Magnetic Resonance (CMR): consensus panel report, Eur H J, 2004; 25:1940-1945. 13 Wazni OM, Tsao H-M, Chen S-A, Cardiovascular imaging in the management of atrial fibrillation, J Am Coll Cardio, 2006; 48:2077-2084.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

72125 CT of the Cervical Spine without Contrast 72126 CT of the Cervical Spine with Contrast 72127 CT of the Cervical Spine without and with Contrast

Red Flags

If any of the following are part of the clinical history presented with a request for pre-certification of these CPT codes the need to meet criteria concerning prior conservative management is waived and the examinations should be pre-certified if other criteria are met:

History of cancer Unexplained weight loss Immunocompromised IV drug use Abnormal CBC, ESR, Urinary tract infections Pain increased at rest Fever Bladder and bowel dysfunction Saddle anesthesia Major motor weakness of a limb Trauma (this is age dependent, lesser trauma required in older patients)

I. Neck pain 1 A. MRI is contraindicated B. Pain lasting greater than 6 weeks C. No red flags and failure to respond to conservative medical management 1. Anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Symptoms worsening while under treatment 3. Pain severe enough to require opiates (narcotics) with no relief after 2 days

II. Trauma 2,3 A. Abnormal x-ray of the cervical spine B. Posterior midline (bony) tenderness in the cervical spine C. Focal neurologic signs

III. Suspected malignancy 4-7 A. MRI is contraindicated B. Suspected neurological symptoms caused by tumor 1. Pain or weakness in nerve root distribution C. Suspected bone metastasis [1 and 2] 1. Known malignancy

CareCore National Criteria for Imaging Version 2.2009

2. Lumbar spine pain D. Follow-up primary or metastatic bone tumor confirmed on prior imaging study E. New or worsening pain at site F. Periodic assessment during chemotherapy for bone tumor G. Re-assessment after chemotherapy, radiation therapy, or surgery has been completed

IV. Myelopathy 7,8 A. MRI is contraindicated B. Sensory, motor, or autonomic function is impaired at and below a horizontally defined level 1. Bilateral radiculopathy 2. Bowel incontinence 3. Bladder dysfunction 4. Spasticity 5. Sensory deficit confirmed by physical examination 6. Hyperreflexia 7. Clonus C. Multiple sclerosis previously diagnosed 1. Spinal imaging is indicated only if there are symptoms attributable to a specific spinal level

V. Radiculopathy or suspected spinal stenosis 9 Presence of red flags waives any conservative management requirements. A. MRI is contraindicated B. Moderate pain 1. Motor disturbances a. Hyporeflexia b. Atrophy c. Weakness 2. Sensory disturbances a. Pain in nerve root distribution b. Numbness c. Tingling sensations (paresthesias) d. Burning sensations (dysesthesias) e. Shooting pain 3. No red flags and failure to respond to conservative medical management a. Anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated b. Symptoms worsening while under treatment c. Pain severe enough to require opiates (narcotics) with no relief after 2 days C. Severe pain or weakness in nerve root distribution

VI. Infection 6 A. MRI is contraindicated B. Suspected osteomyelitis 1. Pain 2. Laboratory findings

CareCore National Criteria for Imaging Version 2.2009

a. Fever > 100.4 b. WBC > 12,000/cu.mm c. ESR > 20mm/hr d. C-reactive protein > 10 mg/L d. Blood culture positive 3. History of infection elsewhere or penetrating wound 4. History of diabetes, dialysis or peripheral vascular disease 6. X-ray suggestive of osteomyelitis C. Pre-operative evaluation of osteomyelitis D. Follow up of osteomyelitis during or after treatment E. Suspected epidural abscess or disc space infection [MRI with gadolinium is preferred] 1. Localized spine pain or tenderness to palpation 2. History of a. Trauma b. Prior spinal procedure c. Infection elsewhere 3. Laboratory findings a. Fever > 100.4 b. WBC > 12,000/cu.mm c. ESR > 20 mm/hr d. C-reactive protein > 10 mg/L e. Blood culture positive F. Follow-up during therapy for epidural abscess or disc space infection 1. New or worsening pain at site or neurologic signs or symptoms 2. Periodic evaluation of response to therapy

VII. Brachial plexus 10 A. MRI contraindicated B. Brachial plexus injury 1. Symptoms a. Weakness or paralysis of the shoulder and biceps b. Weakness of the wrist c. Weakness or paralysis of the forearm or hand d. Horner’s syndrome 2. History a. Trauma including birth trauma b. Radiation fibrosis c. History of radiation therapy to the chest, breast or axilla d. Weakness of the shoulder and/or arm C. Known malignancy 1. Pain 2. Weakness of the extremity 3. Numbness of the extremity 4. Hyperesthesia of the extremity D. Schwannoma or neurofibroma

CareCore National Criteria for Imaging Version 2.2009

1. Palpable mass in the lower neck or supraclavicular fossa 2. Weakness of the upper extremity

VIII. Discography11 A. MRI or CT have not provided sufficient diagnostic information [All] 1. No red flags and failure to respond to conservative medical management 2. Anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 3. Symptoms worsening while under treatment

References:

1. Daffner RH, Dalinka MK, Alazraki NP, et al, Expert Panels on Musculoskeletal and Neurologic Imaging, American College of Radiology Appropriateness Criteria- chronic neck pain accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ChronicNeckPainDo c9.aspx , May 7, 2008. 2. Daffner RH, Hackney DB, Dalinka MK, et al, Expert Panels on Musculoskeletal and Neurologic Imagiang, American College of Radiology Appropriateness Criteria- Suspected spine trauma, Accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/SuspeCTedcervicals pineTraumaDoc22.aspx , May 7, 2008. 3. Hoffman JR, Mower WR, Wolfson AB, et al, Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma, N Engl J Med, 2000; 343:94-99. 4. Beltran F, Noto AM, Chakeres DW, et al, Tumors of the osseous spine: staging with MR imaging versus CT, Radiology, 1987; 162:565-569. 5. Ilaslan H, Sundaram M, Unni KK, et al, Primary vertebtral osteosarcoma: imaging findings, Radiology, 2004; 230:697-702. 6. Von Lon DJ, Kellerhouse LE, Pathria MN, et al, Infection versus tumor in the spine: Criteria fro distinction with CT, Radiology, 1988; 166:851- 855. 7. Bilsk MH, Lis E, RAizer J, The diagnosis and treatment of metastatic spinal tumor, Oncologist, 1999; 4:459-469. 8. Seidenwurm DJ, Brunberg JA, Davis PC, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria- myelopathy, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/MyelopathyDoc8.aspx , May 7, 2008. 9. Tsuchiya D, Katase S, Aoki C et al, Application of multi-detector row helical scanning to postmyelographic CT, Eur Radiol, 2003; 13:1438- 1443. 10. Bowen B, Seidenwurm DJ, Davis PC, et al, Exopert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria- plexopathy, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/PlexopathyDoc12.aspx , May 6, 2008. 11. Boswell MV, Trescot A, Datta S, et al, Interventional techniques: evidenced-based practice guidelines in the management of chronic spinal pain, American Society of Interventional Pain Physicians, accessed at http://www.painphysicianjournal.com/2007/january/2007;10;7-111.pdf , May 13, 2008

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

72128 CT of the Thoracic Spine without Contrast 72129 CT of the Thoracic Spine with Contrast 72130 CT of the Thoracic Spine without and with Contrast

Red Flags

If any of the following are part of the clinical history presented with a request for pre-certification of these CPT codes, the need to meet criteria concerning prior conservative management is waived and the examinations should be pre-certified if other criteria are met:

I. Back pain confined to thoracic region A. MRI contraindicated B. Lasting longer than 6 weeks C. No red flags and failure to respond to conservative medical management 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Symptoms worsening while under treatment 3. Pain severe enough to require opiates (narcotics) with no relief after 2 days

II. Trauma 1 A. Clinical suspicion of spine fracture [1 and 2] 1. Negative radiographs and 2. Signs or symptoms suggesting a specific spine level B. Fracture by x-ray

III. Radiculopathy or suspected spinal stenosis A. Moderate pain 1. Motor disturbances Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

a. Hyporeflexia b. Atrophy c. Weakness 2. Sensory disturbances (may be band-like) a. Pain in nerve root distribution b. Numbness c. Tingling sensations (paresthesias) d. Burning sensations (dysesthesias) e. Shooting pain 3. No red flags and no relief after conservative medical management a. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated b. Symptoms worsening while under treatment c. Pain severe enough to require opiates (narcotics) with no relief after 2 days B. Severe pain or weakness 1. Weakness in nerve root distribution 2. Pain severe enough to require opiates not responding after 2 days

IV. Myelopathy 2 The spinal cord ends at about T12or L1. Therefore suspicion of lumbar myelopathy is evaluated by examing the thoracic spine A. MRI contraindicated B. Symptoms and findings 1. Pain a. May precede neurologic symptoms b. Progressively worsens c. Increases when supine 2. Motor weakness, gait ataxia or paralysis 3. Loss of bladder or bowel function 4. Profound sensory deficit 5. Bilateral radiculopathy

V. Suspected malignancy 3-6 A. MRI is contraindicated B. Suspected neurological symptoms caused by tumor 1. Pain or weakness in nerve root distribution C. Suspected bone metastasis [1 and 2] 1. Known malignancy 2. Lumbar spine pain D. Follow-up primary or metastatic bone tumor confirmed on prior imaging study E. New or worsening pain at site F. Periodic assessment during chemotherapy for bone tumor G. Re-assessment after chemotherapy, radiation therapy, or surgery has been completed

VI. Multiple sclerosis

CareCore National Criteria for Imaging Version 2.2009

A. Spinal imaging is indicated only if there are symptoms attributable to a specific spinal level.

VII. Infection 5 [MRI with gadolinium is preferred] A. Suspected osteomyelitis 1. Clinical findings a. Fever >100.4 b. Leukocytosis, WBC > 12,000/cu.mm c. ESR >20 mm/hr d. C-reactive protein > 10 mg/L e. Blood culture positive 2. Pain 3. History of infection elsewhere 4. History of diabetes, dialysis or peripheral vascular disease B. Pre-operative evaluation of osteomyelitis [MRI preferred] C. Suspected epidural abscess or disc space infection [MRI with gadolinium is preferred] [1 and 2 and 3] 1. Localized spine pain or tenderness to palpation 2. History a. Trauma b. Prior spinal procedure c. Infection elsewhere 3. Clinical findings a. ESR >20 mm/hr b. Fever > 100.4 c. Leukocytosis, WBC > 12,000/cu.mm d. C reactive protein >10 mg/L e. Blood culture positive D. Follow-up during or after therapy for osteomyelitis, epidural abscess or disc space infection 1. New or worsening pain at site or neurologic signs or symptoms 2. Periodic evaluation of response to therapy

VIII. Discography A. To confirm that patient’s symptoms are attributable to a particular disc, prior to therapeutic intervention.

IX. Evaluation for possible vertebroplasty7,8 A. Painful osteoporotic or non neoplastic compression fracture 1. No red flags and failure to respond to conservative medical management a. Continued pain after anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated b. Symptoms worsening while under treatment c. Pain severe enough to require opiates (narcotics) with no relief after 2 days

CareCore National Criteria for Imaging Version 2.2009

References:

1. Daffner RH, Hackney DB, Dalinka MK, et al, Expert Panels on Musculoskeletal and Neurologic Imaging, American College of Radiology Appropriateness Criteria- Suspected spine trauma, Accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/SuspeCTedcervicals pineTraumaDoc22.aspx , May 7, 2008. 2. Seidenwurm DJ, Brunberg JA, Davis PC, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria- myelopathy, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/MyelopathyDoc8.aspx May 7, 2008. 3. Beltran F, Noto AM, Chakeres DW, et al, Tumors of the osseous spine: staging with MR imaging versus CT, Radiology, 1987; 162:565-569. 4. Ilaslan H, Sundaram M, Unni KK, et al, Primary vertebral osteosarcoma: imaging findings, Radiology, 2004; 230:697-702. 5. Von Lon DJ, Kellerhouse LE, Pathria MN, et al, Infection versus tumor in the spine: Criteria for distinction with CT, Radiology, 1988; 166:851- 855. 6. Bilsk MH, Lis E, RAizer J, The diagnosis and treatment of metastatic spinal tumor, Oncologist, 1999; 4:459-469. 7. Kallmes DF and Jensen ME, Percutaneous vertebtroplasty, Radiology, 2003; 229:27-36. 8. Cotrten A, Boutry N, Cortet B, et al, Percutaneous vertebroplasty:state of the art, RadioGraphjcs, 1998; 18:311-320.

CareCore National Criteria for Imaging Version 2.2009

72131 CT of the Lumbar Spine without Contrast 72132 CT of the Lumbar Spine with Contrast 72133 CT of the Lumbar Spine without and with Contrast

Red Flags

History of cancer Unexplained weight loss Immunocompromised IV drug use Abnormal CBC, ESR,. Urinary tract infections Pain increased at rest Fever Bladder and bowel dysfunction Saddle anesthesia Major motor weakness of a limb Trauma (this is age dependent, lesser trauma required in older patients)

I. Back pain confined to lumbar region 1-3 A. MRI contraindicated B. Pain lasting 6 weeks or more C. No red flags and failure to respond to conservative medical management 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Symptoms worsening while under treatment 3. Pain severe enough to require opiates (narcotics) with no relief after 2 days

II. Trauma 1–4 A. Clinical suspicion of spine fracture 1. Negative radiographs and 2. Signs or symptoms suggesting a specific spine level B. Fracture by x-ray

III. Radiculopathy 1-3 A. Moderate symptoms 1. Motor disturbances Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

a. Hyporeflexia b. Atrophy c. Weakness 2. Sensory disturbances a. Unilateral pain in nerve root distribution b. Numbness c. Tingling sensations (paresthesias) d. Burning sensations (dysesthesias) and 3. No red flags and failure to respond to conservative medical management a. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated b. Symptoms worsening while under treatment c. Pain severe enough to require opiates (narcotics) with no relief after 2 days B. Severe symptoms 1. Unilateral weakness in nerve root distribution (e.g. foot drop, or bowel or bladder dysfunction)

5 IV. Suspected spinal stenosis A. Clinical findings 1. Low back or bilateral lower extremity pain 2. Pseudoclaudication, pain, numbness or weakness with walking, often bilateral 3. Pain worse with spinal extension, improved with forward flexion 4. Symptoms interfere with ADLs (i.e. washing, feeding one's self, dressing) B. No red flags and failure to respond to conservative medical management [One] 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Symptoms worsening while under treatment 3. Pain severe enough to require opiates (narcotics) with no relief after 2 days

V. Suspected cauda equina compression or cauda equina syndrome 1-3 A MRI is contraindicated B. Sudden unexplained onset of [One] 1. Saddle anesthesia 2. Profound sensory deficit 3. Bowel or bladder dysfunction 4. Leg numbness and weakness 5. Diminished rectal sphincter tone 6. Bilateral radiculopathy 7. Neurogenic claudication

VI. Suspected malignancy 6 A. MRI is contraindicated B. Suspected neurological symptoms caused by tumor 1. Pain or weakness in nerve root distribution C. Suspected bone metastasis Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

1. Known malignancy 2. Lumbar spine pain D. Follow-up primary or metastatic bone tumor confirmed on prior imaging study E. New or worsening pain at site F. Periodic assessment during chemotherapy for bone tumor G. Re-assessment after chemotherapy, radiation therapy, or surgery has been completed

VII. Conditions due to infections 1,2 A. MRI is contraindicated B. Suspected osteomyelitis 1. Clinical findings a. Fever >100.4 b. Leukocytosis, WBC >12,000/cu.mm c. ESR >20 mm/hr d. C-reactive protein >10 mg/L e. Blood culture positive 2. Pain 3. History of infection elsewhere or penetrating wound 4. History of diabetes, dialysis or peripheral vascular disease 5. X-ray suggestive of osteomyelitis C. Pre-operative evaluation of known osteomyelitis D. Suspected disc space infection with lumbar spine pain 1. ESR >20 mm/hr 2. Fever > 100.4 3. Leukocytosis, WBC >12,000/cu.mm 4. Blood culture positive 5. C-reactive protein >10 mg/L 6. Blood culture positive E. Epidural abscess 1. Progressive neurologic symptoms a. Radiating root pain b. Muscle weakness c. Sensory deficit by physical examination d. Loss of bowel or bladder control 2. Focal spinal pain and tenderness 3. Clinical studies a. Fever >100.4 b. Leukocytosis, WBC > 12,000/cu.mm c. ESR >20 mm/hr d. C-reactive protein >10 mg/L e. Blood culture positive

VIII. Suspected meningocele or myelomeningocele [MRI preferred]

CareCore National Criteria for Imaging Version 2.2009

IX. Discography 7 A. To confirm that patient’s symptoms are attributable to a particular disc, prior to therapeutic intervention.

X. Tethered cord 8 A. Documented Arnold Chiari malformation B. Symptoms 1. Low back and leg pain worst in the am 2. Spastic gait 3. Hair tuft 4. Dimple 5. Hemangioma 6. Incontinence 7. Scoliosis 8. Weakness of lower extremity

XI. Evaluation for possible vertebroplasty9,10 A. Painful osteoporotic or non neoplastic compression fracture 1. No red flags and failure to respond to conservative medical management a. Continued pain after anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated b. Symptoms worsening while under treatment c. Pain severe enough to require opiates (narcotics) with no relief after 2 days

References:

1. Bradley WG, Seidenwurm DJ, Brunber JA, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria- low back pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/lowbackpainDoc7.aspx , May 9, 2008. 2. Thorson DC, Bonsell J, Mueller B, et al, Institute for Clinical Systems Improvement, HelathCareGuideline: Adult low back pain, twelfth edition, accessed at http://www.icsi.org/low_back_pain/adult_low_back_pain__8.html , May 13, 2008. 3. Chiodo A, Alvarea D, Graziano G et al, Low Back Pain Guideline Team, University of Michigan Health System, Guidlelines for Clinical Care- Acute low back pain, accessed at http://cme.med.umich.edu/pdf/guideline/backpain03.pdf ,May 13, 2008. 4. Daffner RH, Hackney DB, Dalinka MK, et al, Expert Panels on Musculoskeletal and Neurologic Imagiang, American College of Radiology Appropriateness Criteria- Suspected spine trauma, Accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/SuspeCTedcervicals pineTraumaDoc22.aspx , May 7, 2008. 5.Watters WC III, Baisden J, Bono C, et al, NASS Clinical Guidelines Committee, Evidence-based clinical guidelilnes for multidisciplinary spine care: diagnosis and treatement of degenerative lumbar spinal stenosis, North American Spine Society, accessed at http://www.spine.org/Documents/NASSCG_Stenosis.pdf , May 13, 2008. 6.El-Khoury GY, Bennett DL, Dalinka MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria- metastatic bone disease, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/MetastaticBoneDise aseDoc14.aspx , May 13, 2008.

CareCore National Criteria for Imaging Version 2.2009

7.Boswell MV, Trescot A, Datta S, et al, Interventional techniques: evidenced-based practice guidelines in the management of chronic spinal pain, American Society of Interventional Pain Physicians, accessed at http://www.painphysicianjournal.com/2007/january/2007;10;7-111.pdf , May 13, 2008 8. Raghavan N, Barkovich AJ, Edwards M et al, MR imaging in the tethered spinal cord syndrome, AJR, 1989; 152:843-852. 9. Kallmes DF and Jensen ME, Percutaneous vertebtroplasty, Radiology, 2003; 229:27-36. 10. Cotrten A, Boutry N, Cortet B, et al, Percutaneous vertebroplasty:state of the art, RadioGraphjcs, 1998; 18:311-320.

Reviewed: 3/18/2009 Posted: 8/15/2009

CareCore National Criteria for Imaging Version 2.2009

72141 MRI of the Cervical Spine without Gadolinium

Red Flags

If any of the following are part of the clinical history presented with a request for precertification of these CPT codes the need to meet criteria concerning prior conservative management is waived and the examinations should be precertified if other criteria are met:

History of cancer Unexplained weight loss Immunocompromised IV drug use Abnormal CBC, Sed Rate, Urinary tract infections Pain increased at rest Fever Bladder and bowel dysfunction Saddle anesthesia Major motor weakness of a limb Trauma (this is age dependent, lesser trauma required in older patients)

I. Neck pain 1 A. Lasting longer than 6 weeks B. No red flags C. No response to conservative management 1. Continued pain after anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Symptoms worsening while under treatment 3. Pain severe enough to require opiates (narcotics) with no relief after 2 days

II. Trauma 2-4 [CT preferred for bone injuries] A. Suspected spinal cord injury B. Clinical suspicion of spine fracture with negative x-rays or CT but with signs or symptoms suggesting a specific spine level C. Possible unstable fracture by x-ray or CT

III. Suspected tumor of bone (for cord see 72142, 72156) 4-8 A. Primary or metastatic bone tumor [gadolinium not required if there are no neurological signs or symptoms] 1. Known malignancy 2. Cervical spine pain 3. Follow-up primary or metastatic bone tumor confirmed on prior imaging study 4. New or worsening pain at site of known bone tumor

CareCore National Criteria for Imaging Version 2.2009

5. Periodic assessment during chemotherapy, radiation Rx, or surgery for bone tumor 6. New onset scoliosis 7. New onset kyphosis

IV. Suspected or known Multiple Sclerosis [MS]9 A. Suspected MS 1. Loss of coordination 2. Numbness of the upper extremities 3. Weakness of upper extremities 4. Bowel incontinence 5. Bladder dysfunction 6. Weakness of the legs 7. Numbness of the legs 8. Lhermitte’s sign 9. New onset paresthesia 10. Spasm 11. Hyperreflexia B. Known MS 1. Baseline or follow up of treatment with Rebif 2. New or worsening of symptoms 3. Follow up of treatment including Natalizumab Tysabri 4. Annual follow up in stable individual

V. Spinal stenosis (spondylotic myelopathy) 10, 11 A. Leg spasticity B. Arm weakness or clumsiness C. Pain in neck and arms D. Other clinical indications 1. Sensory changes 2. Bilateral radiculopathy 3. Diminished spinal range of motion (ROM) 4. Bladder dysfunction E. No red flags and failure to respond to conservative therapy 1. Continued pain after anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Symptoms worsening while under treatment 3. Pain severe enough to require opiates (narcotics) with no relief after 2 days

VI. Syrinx or syringomyelia A. Known Chiari 1 malformation B. Asymmetric sensory loss and or weakness in the arms C. History of spinal cord trauma D. History of myelitis E. Spinal cord tumor

CareCore National Criteria for Imaging Version 2.2009

VII. Radiculopathy 4, 10, 11, 12 A. Moderate pain in nerve root distribution 1. Motor disturbances a. Hyporeflexia b. Atrophy c. Weakness 2. Sensory disturbances a. Numbness b. Tingling sensations (paresthesias) c. Burning sensations (dysesthesias) d. Shooting pain 3. No red flags and failure to respond to conservative therapy a. Continued pain after anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated b. Symptoms worsening while under treatment c. Pain severe enough to require opiates (narcotics) with no relief after 2 days B. Severe pain 1. Weakness in nerve root distribution 2. Pain severe enough to require opiates with no relief after 2 days

VIII. Evaluation of scoliosis 13-15 A. Preoperative assessment B. Any neurologic finding in the presence of scoliosis C. Atypical curve pattern D. Congenital scoliosis E. Neurofibromatosis F. Marfan’s syndrome

References:

1. Daffner RH, Dalinka MK, Alazraki N, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Chronic Neck Pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ChronicNeckPainDo c9.aspx February 4, 2008. 2. Daffner RA, Hackney DB, Dalinka MK, et al, Expert Panel on Musculoskeletal and Neurologic Imaging, American College of Radiology, Appropriateness Criteria, Suspected Spine Trauma, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/Suspectedcervicalspi neTraumaDoc22.aspx February 4, 2008. 3. Hadley MN, Walters BC, Grabb PA, et al, Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries, Section on Disorder of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and the Congress of Neurologic Surgeons, accessed at http://www.spineuniverse.com/pdf/traumaguide/finished1116.pdf February 4, 2008. 4. Goddard AJP and Gholkar A, Diagnostic and therapeutic radiology of the spine: an overview, Imaging, 2002; 14:355-373. 5. El-Khoury GY, Bennett DL, Dalinka MK, et al, Expert Panel on Musculoskeletal Imaging American College of Radiology Appropriateness Criteria Metastatic Bone Disease, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/MetastaticBoneDise aseDoc14.aspx February 4, 2008.

CareCore National Criteria for Imaging Version 2.2009

6. Brem SS, Bierman PJ, Black P, et al, NCCN Central Nervous System Cancers Panel Members, NCCM Practice Guidelines in Oncology v.1.2007, Central nervous System Cancers, accessed at http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf February 4, 2008. 7. Murphey MD, Andrew CL, Flemming DJ, et al, From the archives of the AFIPO Primary tumors of the spine: radiologic-pathologic correlation, RadioGraphics, 1996; 16:1131-1158. 8. Husband DJ, Grant KA and Raniuk CS, MRI in the diagnosis and treatment of suspected malignant spinal cord compression, The British Journal of Radiology, 2001; 74:15-23. 9. Bakshi R, Hutton GJ, Miller JR, et al, The use of magnetic resonance imaging in the diagnosis and long-term management of multiple sclerosis, Neurology, 2004; 63(Suppl 5):S3-S11. 10. Birchall D, Connelly D, Walker L, et al, Evaluation of magnetic resonance myelography in the investigation of cervical spondylotic radiculopathy, The British Journal of Radiology, 2003; 76:525-531. 11. Rao R, Neck pain, cervical radiculopathy, and cervical myelopathy, The J Bone & Joint Surg, 2002; 84:1872-1881. 12. Carette S, and Fehlings MG, Cervical radiculopathy, N Eng J Med, 2005; 353:392-399. 13. Evans SC, Edgar MA, Hall-Craggs MA, et al, MRI of ‘idiopathic’ juvenile scoliosis, J Bone Joint Surg [Br], 1996; 78:314-317. 14. Maiocco B, Deeney VF,Coulon R, et al, Adolescent Idiopathic scoliosis and the presence of spinal cord abnormalities: preoperative magnetic resonance imaging analysis, Spine, 1997; 22:2537-3541. 15. Alam A and The J, MRI assessment of scoliosis, Imaging, 2005; 17:226-235.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

72142 MRI of the Cervical Spine with Gadolinium 72156 MRI of the Cervical Spine without and with Gadolinium

Red Flags

History of cancer Unexplained weight loss Immunocompromised IV drug use Abnormal CBC, ESR, Urinary tract infections Pain increased at rest Fever >100.4 Bladder and bowel dysfunction Saddle anesthesia Major motor weakness of a limb Trauma (this is age dependent, lesser trauma required in older patients)

I. Suspected tumor of the cervical spinal cord or meninges 1-5 A. Suspected primary or metastatic tumor of the cervical cord or leptomeninges 1. Pain with known malignancy and neurologic findings 2. Hyperreflexia 3. Weakness of the upper or lower extremity 4. Spasticity 5. Bladder dysfunction 6. Bowel dysfunction 6. Lhermitte’s sign 7. Sensory deficit 8. New onset scoliosis 9. New onset kyphosis 10. Spastic gait 11. Bilateral radiculopathy 12. Periodic assessment during or after chemotherapy or radiation therapy for known tumor in the spinal canal

II. Medulloblastoma 4, 5 A. Initial evaluation B. Follow up intervals at 90 days Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

C. Worsening of symptoms D. Evaluation after completion of chemotherapy or radiation therapy

III. Ependymoma A. Initial evaluation B. Follow up intervals at 90 days C. Worsening of symptoms D. Evaluation after completion of chemotherapy or radiation therapy

IV. Known Multiple Sclerosis [MS] 6 A. New symptoms in an individual with an established diagnosis of MS 1. Loss of coordination 2. Numbness of the upper extremities 3. Weakness of upper extremities 4. Bowel incontinence 5. Bladder dysfunction 6. Weakness of the legs 7. Numbness of the legs 8. Lhermitte’s sign 9. New onset paresthesia 10. Spasticity 11. Hyperreflexia B. Surveillance 1. Baseline or follow up of treatment with Rebif 2. New or worsening of symptoms 3. Follow up of treatment including Natalizumab Tysabri 4. Annual follow up with no change in signs and symptoms

V. Myelopathy7 A. Sensory, motor, or autonomic function is impaired at and below a horizontally defined level 1. Bilateral radiculopathy 2. Bowel incontinence 3. Bladder dysfunction 4. Spasticity 5. Sensory deficit B. Known Multiple Sclerosis (MS) C. Syrinx or syringomyelia 1. Known Chiari type 1 malformation 2. Asymmetric sensory loss and or weakness in arms 3. Known syrinx and history or suspicion of spinal trauma, myelitis, or spinal cord tumor

VI. Osteomyelitis 8, 9 A. Suspected osteomyelitis 1. Pain Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

2. Clinical findings a. ESR >20 mm/hr b. Fever and leukocytosis, WBC >12,000/cc.mm c. C-reactive protein >10 mg/L d. Blood culture positive 3. History of infection elsewhere 4. History of diabetes, dialysis or peripheral vascular disease B. Preoperative evaluation of osteomyelitis C. Interval follow up during or after completion of treatment

VII. Epidural abscess10 A. Focal spinal pain and tenderness B. Signs of infection 1. Fever >100.4 2. Leukocytosis, WBC >12,000/cc.mm 3. ESR >20 mm/hr 4. C-reactive protein >10 mg/L 5. Blood culture positive C. Progressive neurologic symptoms D. Radiating nerve root pain 1. Muscle weakness 2. Sensory deficit E. History of 1. IV drug use 2. Diabetes 3. Immunosuppression 4. Trauma 5. Spinal surgery 6. Infection elsewhere F. Follow-up during therapy for epidural abscess or disc space infection 1. New or worsening pain at site or neurologic signs or symptoms 2. Periodic evaluation of response to therapy

VIII. Suspected disc space infection (discitis)8-12 A. Cervical spine pain B. ESR >20 mm/hr C. Fever >100.4 D. Leukocytosis, WBC >12,000/cu.mm E. Blood culture positive F. C-reactive protein >10 mg/L

IX. Brachial plexus 13 A. Brachial plexus injury 1. Symptoms a. Weakness or paralysis of the shoulder and biceps Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

b. Weakness of the wrist c. Weakness or paralysis of the forearm or hand d. Horner’s syndrome 2. History a. Trauma including birth trauma b. Radiation fibrosis c. History of radiation therapy to the chest, breast or axilla B. Primary or metastatic tumor 1. Symptoms a. Pain b. Weakness of the extremity c. Numbness of the extremity d. Hyperesthesia of the extremity C. Schwannoma or neurofibroma 1. Symptoms a. Palpable mass in the lower neck or supraclavicular fossa b. Weakness of the upper extremity

References:

1. Brem SS, Bierman PJ, Black P, et al, NCCN Central Nervous System Cancers Panel Members, NCCM Practice Guidelines in Oncology v.1.2007, Central Nervous System Cancers, accessed at http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf February 4, 2008. 2. Murphey MD, Andrew CL, Flemming DJ, et al, From the archives of the AFIPO Primary tumors of the spine: radiologic-pathologic correlation, RadioGraphics, 1996; 16:1131-1158. 3. Husband DJ, Grant KA and Raniuk CS, MRI in the diagnosis and treatment of suspected malignant spinal cord compression, The British Journal of Radiology, 2001; 74:15-23. 4. Meyers SP, Wioldenhain SL, Chang J-K, et al, Postoperative evaluation for disseminated meduloblastoma involving the spine: contrast- enhanced MRI findings, CSF cytologic analysis, timing of disease occurrence, and patient outcomes, AJNR, 2000, 21:17157-1765. 5. Bilsky MH, Lis E, Raizer J, et al, The diagnosis and treatment of metastatic spinal tumor, Oncologist, 1999; 4:459-469. 6. Bakshi R, Hutton GJ, Miller JR, et al, The use of magnetic resonance imaging in the diagnosis and long-term management of multiple sclerosis, Neurology, 2004; 63:Supplemeent 5 S3-S11. 7. Seidenwurm DJ, Brunberg JA, Davis PC, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria, Myelopathy, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/MyelopathyDoc8.aspx February 4, 2008. 8. Fernandez M, Carrol CL, and Baker CJ, Discitis and vertebral osteomyelitis in children: an 18-year review, Pediatrics, 2000; 105:1299-1304. 9. Govender S, Spinal infections, J Bone Joint Surg [Brit], 2005; 87:1454-1458. 10. Lu C-H, Chang W-N, Lui CC, et al, Adult spinal epidural abscess: clinical features and prognostic factors, Cl Neurol Neurosurg, 2002; 104:306-310 11. Brown R, Hussain M, McHugh K et al, Discitis in young children, J Bone Joint Surg [Brit], 2001; 83:106-111. 12. Sharif HS, Role of MR imaging in the management of spinal infections, AJR, 1992; 158:1333-1345. 13. Bowen B, Seidenwurm DJ, Davis P et al, Expert Panel on Neurologic Imaging, American College of Radiology, Appropriateness Criteria, Plexopathy, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/PlexopathyDoc12.aspx February 4, 2008

CareCore National Criteria for Imaging Version 2.2009

72146 MRI Thoracic Spine without Gadolinium

Red Flags

I. Back pain confined to thoracic region1, 2 A. Lasting >6 weeks B. No red flags C. No response to conservative management 1. Continued pain after anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Symptoms worsening while under treatment 3. Pain severe enough to require opiates (narcotics) with no relief after 2 days

II. Trauma3, 4 A. Suspected spinal cord injury B. Clinical suspicion of spine fracture with negative x-rays or CT but with signs or symptoms suggesting a specific spine level C. Possible unstable fracture by x-ray or CT

III. Suspected tumor 2, 5-13 A. Primary or metastatic bone tumor [gadolinium not required if there are no neurological signs or symptoms] 1. Known malignancy with thoracic spine pain 2. Follow-up primary or metastatic bone tumor confirmed on prior imaging study 3. New or worsening pain at site of known bone tumor 4. Periodic assessment during chemotherapy, radiation Rx, or surgery for bone tumor 5. Pain

CareCore National Criteria for Imaging Version 2.2009

6. New onset scoliosis 7. New onset kyphosis

IV. Suspected or known Multiple Sclerosis [MS] 14, 15 A. Suspected MS 1. Loss of coordination 2. Numbness of the upper extremities 3. Weakness of upper extremities 4. Bowel incontinence 5. Bladder dysfunction 6. Weakness of the legs 7. Numbness of the legs 8. Lhermitte’s sign 9. New onset paresthesia 10. Spasm 11. Hyperreflexia B. Known MS [One] 1. Baseline or follow up of treatment with Rebif 2. New or worsening of symptoms 3. Follow up of treatment including Natalizumab Tysabri 4. Annual follow up with no change in signs or symptoms

V. Spinal stenosis A. Leg spasticity B. Weakness or clumsiness C. Other clinical indications 1. Sensory deficit 2. Bilateral radiculopathy 3. Bladder disturbance 4. Claudication 5. Diminished spinal Range of Motion (ROM)) D. No red flags and failure to respond to conservative medical management 1. Continued pain after anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Symptoms worsening while under treatment 3. Pain severe enough to require opiates (narcotics) with no relief after 2 days

VI. Radiculopathy1 A. Moderate pain 1. Motor disturbances a. Hyporeflexia b. Atrophy c. Weakness 2. Sensory disturbances a. Pain in nerve root distribution (band like)

CareCore National Criteria for Imaging Version 2.2009

b. Numbness c. Tingling sensations (paresthesias) d. Burning sensations (dysesthesias) e. Shooting pain B. No red flags and failure to respond to conservative medical management 1. Continued pain after anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Symptoms worsening while under treatment 3. Pain severe enough to require opiates (narcotics) with no relief after 2 days

VII. Evaluation of scoliosis 16-19 A. Preoperative assessment B. Any neurologic finding in the presence of scoliosis C. Atypical curve pattern D. Congenital scoliosis E. Neurofibromatosis F. Marfan’s syndrome

VIII. Evaluation for possible vertebroplasty20,21 A. Painful osteoporotic or non neoplastic compression fracture 1. No red flags and failure to respond to conservative medical management a. Continued pain after anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated b. Symptoms worsening while under treatment c. Pain severe enough to require opiates (narcotics) with no relief after 2 days

References:

1. Rves PA and Douglass AB, Evaluation and treatment of low back pain in family practice, J Am Board Fam Pract, 2004; 17:S23-S31. 2. Teh J, Imam A, and Watts C, Imaging of back pain, Imaging, 2005; 17:171-207. 3. Daffner RH, Hackney DB, Dallinka MK, et al, Expert Panel on Musculoskeletal and Neurologic Imaging, American College of Radiology Appropriateness Criteria, Suspected spine trauma, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/SuspectedCervicalsp ineTraumaDoc22.aspx February 1, 2008. 4. Gardner A, Grannum S and Porter K, Thoracic and lumbar spine fractures, Trauma, 2005; 7:77-85. 5. El-Koury GY, Bennett DL, Dalinka MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Metastatic Bone Disease, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/MetastaticBoneDise aseDoc14.aspx January 31,2008. 6. Goddard AJP and Gholkar A, Diagnostic and therapeutic radiology of the spine: an overview, Imaging, 2002; 14:355-373. 7. Brem SS, Bierman PJ, Black P, et al, NCCN Central Nervous System Cancers Panel Members, NCCM Practice Guidelines in Oncology v.1.2007, Central Nervous System Cancers, accessed at http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf February 4, 2008. 8. Murphey MD, Andrew CL, Flemming DJ, et al, From the archives of the AFIP Primary tumors of the spine: radiologic-pathologic correlation, RadioGraphics, 1996; 16:1131-1158. 9. Husband DJ, Grant KA, and Raniuk CS, MRI in the diagnosis and treatment of suspected malignant spinal cord compression, The British Journal of Radiology, 2001; 74:15-23.

CareCore National Criteria for Imaging Version 2.2009

10. Meyers SP, Wioldenhain SL, Chang J-K, et al, Postoperative evaluation for disseminated meduloblastoma involving the spine: contrast- enhanced MRI findings, CSF cytologic analysis, timing of disease occurrence, and patient outcomes, AJNR, 2000; 21:1757-1765. 11.Bilsky MH, Lis E, Raizer J, et al, The diagnosis and treatment of metastatic spinal tumor, Oncologist, 1999; 4:459-469. 12.Kienstra GEM, Terwee CB, Dekker FW, et al, Prediction of spinal epidural metastases, Arch Neurol, 2000; 57:690-695. 13.El-Koury GY, Bennett DL, Dalinka MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Metastatic bone disease, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/MetastaticBoneDise aseDoc14.aspx January 31,2008. 14. Frohman EM, Goodin DS, Calabresi A, et al, The utility of MRI in suspected MS: report of the therapeutics and technology assessment subcommittee of the American academy of neurology, Neurology, 2003; 61:602-611. 15. Simon JH, Update on multiple sclerosis, Radiol Clin N Am, 2006; 44:79-100. 16. The management of spinal deformity in the United Kingdom guide to good practice, accessed at http://www.boa.ac.uk/site/showpublications.aspx?ID=59 March 6, 2008. 17. Wright N, Imaging in scoliosis, Arch Dis Child, 200; 82:38-40. 18. Davids JR, Chamberlin E, and Blackhurst DW, Indications for magnetic resonance imaging in presumed adolescent idiopathic scoliosis, JBJS, 2004; 86:2187-2195. 19. Alam A and The J, MRI assessment of scoliosis, Imaging, 2005; 17:226-235. 20. Lewis CA, Barr JD, Cardella JF et al, Practice guideline for the performance of Percutaneous vertebroplasty , American College of Radiology Guidelines and Standards, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/head- neck/percutaneous_vertebroplasty.aspx , March 5, 2009. 21. Anderson MW, Dalinka MK, DeSmet AA, et al, Musculoskeletal Imaging Committee of the Commission on Body Imaging, Practice guideline for the performance of magnietic resonance imaging (MRI) of the adult spine, American College of Radiology Guidelines and Standards, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/head-neck/percutaneous_vertebroplasty.aspx , March 5, 2009.

CareCore National Criteria for Imaging Version 2.2009

72147 MRI Thoracic Spine with Gadolinium 72157 MRI Thoracic Spine without and with Gadolinium

Red Flags

I. Suspected tumor of the thoracic spinal cord or leptomeninges1, 2-10 A. Suspected primary or metastatic tumor of the cervical cord or leptomeninges 1. Pain with known malignancy and neurologic findings 2. Hyperreflexia 3. Weakness of the upper or lower extremity 4. Spasticity 5. Bladder dysfunction 6. Bowel dysfunction 7. Lhermitte’s sign 8. Sensory loss 9. New onset scoliosis 10. New onset kyphosis 11. Spastic gait 12. Bilateral radiculopathy 13. Periodic assessment during or after chemotherapy or radiation therapy for known tumor in the spinal canal

II. Medulloblastoma 11, 12 A. Initial evaluation B. Follow up intervals at 90 days Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

C. Worsening of symptoms D. Evaluation after completion of chemotherapy or radiation therapy

III. Ependymoma A. Initial evaluation B. Follow up intervals at 90 days C. Worsening of symptoms D. Evaluation after completion of chemotherapy or radiation therapy

IV. Known Multiple Sclerosis [MS] 13,14 A. New symptoms in an individual with an established diagnosis of MS 1. Loss of coordination 2. Numbness of the upper extremities 3. Weakness of upper extremities 4. Bowel incontinence 5. Bladder dysfunction 6. Weakness of the legs 7. Numbness of the legs 8. Lhermitte’s sign 9. New onset paresthesia 10. Spasticity 11. Hyperreflexia B. Surveillance 1. Baseline or follow up of treatment with Rebif 2. New or worsening of symptoms 3. Follow up of treatment including Natalizumab Tysabri 4. Annual follow up with no change in signs and symptoms

V. Myelopathy 13-15 A. Sensory, motor, or autonomic function is impaired at and below a horizontally defined level 1. Bilateral radiculopathy 2. Bowel incontinence 3. Bladder dysfunction 4. Spasticity 5. Sensory deficit confirmed at PE

VI. Osteomyelitis 1, 16, 17 A. Suspected osteomyelitis 1. Pain 2. Clinical findings a. ESR >20 mm/hr b. Fever and leukocytosis, WBC >12,000/cc.mm c. C-reactive protein >10 mg/L d. Blood culture positive Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

3. History of infection elsewhere 4. History of diabetes, dialysis or peripheral vascular disease B. Preoperative evaluation of osteomyelitis C. Interval follow up during or after completion of treatment

VII. Epidural abscess 18 A. Focal spinal pain and tenderness B. Signs of infection 1. ESR >22 mm/hr 2. Fever and leukocytosis WBC >12,000/cu.mm 3. C-reactive protein >10 mg/L 4. Positive blood cultures C. Progressive neurologic symptoms 1. Radiating nerve root pain 2. Muscle weakness 3. Sensory deficit 4. Loss of bowel or bladder control D. History of 1. IV drug use 2. Diabetes 3. Immunosuppression 4. Trauma 5. Spinal surgery 6. Infection elsewhere E. Follow-up during therapy for epidural abscess or disc space infection 1. New or worsening pain at site or neurologic signs or symptoms 2. Periodic evaluation of response to therapy

VIII. Suspected disc space infection (discitis) 16, 19, 20 A. Thoracic spine pain B. ESR >20 mm/hr C. Fever > 100.4 D. Leukocytosis, WBC >12,000/cu.mm E. Blood culture positive F. C-reactive protein >10 mg/L

References:

1. Teh J, Imam A, and Watts C, Imaging of back pain, Imaging, 2005; 17:171-207. 2. El-Koury GY, Bennett DL, Dalinka MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Metastatic Bone Disease, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/MetastaticBoneDise aseDoc14.aspx January 31,2008. 3. Goddard AJP and Gholkar A, Diagnostic and therapeutic radiology of the spine: an overview, Imaging, 2002; 14:355-373.

CareCore National Criteria for Imaging Version 2.2009

4. Brem SS, Bierman PJ, Black P, et al, NCCN Central Nervous System Cancers Panel Members, NCCM Practice Guidelines in Oncology v.1.2007, Central Nervous System Cancers, accessed at http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf February 4, 2008. 5. Murphey MD, Andrew CL, Flemming DJ, et al, the archives of the AFIP Primary tumors of the spine: radiologic-pathologic correlation, RadioGraphics, 1996; 16:1131-1158. 6. Husband DJ, Grant KA and Romaniuk CS, MRI in the diagnosis and treatment of suspected malignant spinal cord compression, The British Journal of Radiology, 2001; 74:15-23. 7. Meyers SP, Wioldenhain SL, Chang J-K, et al, Postoperative evaluation for disseminated meduloblastoma involving the spine: contrast- enhanced MRI findings, CSF cytologic analysis, timing of disease occurrence, and patient outcomes, AJNR, 2000, 21:17157-1765. 8. Bilsky MH, Lis E, Raizer J, et al, The diagnosis and treatment of metastatic spinal tumor, Oncologist, 1999; 4:459-469. 9. Kienstra GEM, Terwee CB, Dekker FW, et al, Prediction of spinal epidural metastases, Arch Neurol, 2000; 57:690-695. 10.El-Koury GY, Bennett DL, Dalinka MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Metastatic bone disease, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/MetastaticBoneDise aseDoc14.aspx January 31,2008. 11. Meyers SP, Wioldenhain SL, Chang J-K, et al, Postoperative evaluation for disseminated medulloblastoma involving the spine: contrast- enhanced MRI findings, CSF cytologic analysis, timing of disease occurrence, and patient outcomes, AJNR, 2000, 21:17157-1765. 12. Koeller KK and Rushing EJ, From the archives of the AFIP Medulloblastoma: a comprehensive review with radiologic-pathologic correlation, RadioGraphics, 2003; 23:1613-1637. 13. Frohman EM, Goodin DS, Calabresi A, et al, The utility of MRI in suspected MS: report of the therapeutics and technology assessment subcommittee of the American academy of neurology, Neurology, 2003; 61:602-611. 14. Simon JH, Update on multiple sclerosis, Radiol Clin N Am, 2006; 44:79-100. 15. Seidenwurm DJ, Brunberg JA, Davis PC, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria, Myelopathy accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/MyelopathyDoc8.aspx February 1, 2008. 16 Fernandez M, Carrol CL, and Baker CJ, Discitis and vertebral osteomyelitis in children: an 18-year review, Pediatrics, 2000; 105:1299-1304. 17. Govender S, Spinal infections, JBJS 2005; 87:1454-1458. 18. Lu C-H, Chang W-N, Lui CC, et al, Adult spinal epidural abscess: clinical features and prognostic factors, Cl Neurol Neurosurg, 2002; 104:306-310. 19. Brown R, Hussain M, McHugh K, et al, Discitis in young children, JBJS, 2001; 83:106-111. 20. Sharif HS, Role of MR imaging in the management of spinal infections, AJR, 1992; 158:1333-1345.

Reviewed: 3/18/2009 Posted: 8/15/2009

CareCore National Criteria for Imaging Version 2.2009

72148 MRI Lumbar Spine without Gadolinium

Red Flags

I. Back pain1-5 [Contrast should be used if there is a history of lumbar spine surgery] A. Lasting >6 weeks B. No red flags and failure to respond to conservative medical management [One] 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Symptoms worsening while under treatment 3. Pain severe enough to require opiates (narcotics) with no relief after 2 days

II. Trauma 1-5 A. Suspected distal cord or cauda equina injury 1. Saddle anesthesia 2. Profound sensory deficit 3. Bowel or bladder dysfunction 4. Severe motor deficit 5. Diminished rectal sphincter tone 6. Bilateral radiculopathy 7. Neurogenic claudication B. Clinical suspicion of spine fracture with negative x-rays or CT but with signs or symptoms suggesting a specific spine level C. Possible unstable fracture by x-ray or CT

CareCore National Criteria for Imaging Version 2.2009

III. Radiculopathy 1-3 [Contrast should be used if there is a lumbar spine surgery] A. Moderate pain 1. Motor disturbances a. Hyporeflexia b. Atrophy c. Weakness 2. Sensory disturbances a. Pain in nerve root distribution b. Numbness c. Tingling sensations (paresthesias) d. Burning sensations (dysesthesias) e. Shooting pain 3. No red flags and failure to respond to conservative therapy a.Continued pain after treatment with NSAID or other anti-Inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated b. Worsening pain during treatment with anti-inflammatory medication and activity modification > 2 weeks c. Pain severe enough to require opiates (narcotics) with no relief after 2 days B. Severe pain 1. Weakness in nerve root distribution (e.g. foot drop, or bowel or bladder dysfunction) 2. Pain severe enough to require opiates (narcotics) not responding after 2 days

IV. Suspected spinal stenosis 6 [Contrast should be used if there is a history of lumbar spine] A. Clinical findings 1. Low back or bilateral lower extremity pain 2. Pseudoclaudication, pain, numbness or weakness with walking, often bilateral 3. Pain worse with spinal extension, improved with forward flexion 4. Symptoms interfere with ADLs (i.e. washing, dressing, eating, and sleeping) B. No red flags and failure to respond to conservative therapy 1. Continued pain after treatment with anti-Inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Symptoms worsening while under treatment 3. Pain severe enough to require opiates (narcotics) with no relief after 2 days

V. Suspected cauda equina syndrome [Contrast is indicated if there is a suspicion of tumor or infection] 1,2,4 A. Sudden unexplained onset of 1. Saddle anesthesia 2. Profound sensory deficit 3. Bowel or bladder dysfunction 4. Severe motor deficit 5. Diminished rectal sphincter tone Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

6. Bilateral radiculopathy 7. Neurogenic claudication

VI. Suspected meningocele or myelomeningocele 7 A. Congenital B. After lumbar surgery

VII. Evaluation of scoliosis 8-11 A. Preoperative assessment B. Any neurologic finding in the presence of scoliosis C. Atypical curve pattern D. Congenital scoliosis E. Neurofibromatosis F. Marfan’s syndrome

7 VIII. Tethered cord A. Documented Arnold Chiari malformation B. Symptoms 1. Low back and leg pain worst in the am 2. Spastic gait 3. Hair tuft 4. Dimple 5. Hemangioma 6. Incontinence 7. Scoliosis 8. Weakness of lower extremity

IX. Suspected tumor of vertebra or bone 12-20 A. Primary or metastatic bone tumor [gadolinium not required if there are no neurological signs or symptoms] 1. Known malignancy with lumbar spine pain 2. Follow-up primary or metastatic bone tumor confirmed on prior imaging study 3. New or worsening pain at site of known bone tumor . 4. Periodic assessment during chemotherapy, radiation therapy, or surgery for bone tumor 5. Pain 6. New onset scoliosis

X. Evaluation for possible vertebroplasty21,22 A. Painful osteoporotic or non neoplastic compression fracture 1. No red flags and failure to respond to conservative medical management a. Continued pain after anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated b. Symptoms worsening while under treatment c. Pain severe enough to require opiates (narcotics) with no relief after 2 days

CareCore National Criteria for Imaging Version 2.2009

References:

1. Bradley WG Jr, Seidenwurm DJ, Brunberg JA, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria, Low back pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/LowBackPainDoc7.aspx January 31, 2008. 2. Thorson DC, Bonsell J, Mueller B, et al, Health Care Guideline: Adult low back pain, Institute for Clinical Systems Improvement, accessed at http://www.icsi.org/low_back_pain/adult_low_back_pain__8.html January 31, 2008. 3. Bowen B, Seidenwurm DJ, Davis PC, et al Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria, Plexopathy, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/PlexopathyDoc12.aspx January 31, 2008. 4. Chiodo A, Alvarez D, Graziano G, et al, Low Back Pain Guideline Team, Acute low back pain, University of Michigan Health System, Guidelines for Clinical Care, accessed at http://cme.med.umich.edu/pdf/guideline/backpain03.pdf January 31, 2008. 5. Deyo RA and Weinstein JN, Low back pain, N Eng J Med, 2001; 344:363-370. 6. Watters WC III, Baisden J, Gilbert T, et al, NASS Clinical Guidelines Committee, Evidence-based clinical guidelines for multidisciplinary spine care, Diagnosis and treatment of degenerative lumbar spinal stenosis, North American Spine Society, accessed at http://www.spine.org/Documents/NASSCG_stenosis.pdf January 31, 2008. 7. Barnes PD, Lester PD, Yamanashi WS, et al, MRI in infants and children with spinal dysraphism, AJR, 1986; 147:339-346. 8. The management of spinal deformity in the United Kingdom guide to good practice, accessed at http://www.boa.ac.uk/site/showpublications.aspx?ID=59 , March 6, 2008. 9. Wright N, Imaging in scoliosis, Arch Dis Child, 200; 82:38-40. 10. Davids JR, Chamberlin E, and Blackhurst DW, Indications for magnetic resonance imaging in presumed adolescent idiopathic scoliosis, JBJS,2004; 86:2187-2195. 11. Alam A and The J, MRI assessment of scoliosis, Imaging, 2005; 17:226-235. 12. Goddard AJP and Gholkar A, Diagnostic and therapeutic radiology of the spine: an overview, Imaging, 2002; 14:355-373. 13. El-Khoury GY, Bennett DL, Dalinka MK et al, Expert Panel on Musculoskeletal Imaging American College of Radiology Appropriateness Criteria Metastatic bone disease, accesed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/MetastaticBoneDiseaseDoc14.aspx , February 4, 2008. 14. Brem SS, Bierman PJ, Black P, et al, NCCN Central Nervous System Cancers Panel Members, NCCM Practice Guidelines in Oncology v.1.2007, Central nervous system cancers, accessed at http://www.nccn.org/professionals/physician_gls/PDF/cns.pdf February 4, 2008. 15 .Murphey MD, Andrew CL, Flemming DJ et al, From the archives of the AFIPO Primary tumors of the spine: radiologic-pathologic correlation, RadioGraphics, 1996; 16:1131-1158 16. Husband DJ, Grant KA and Romaniuk CS, MRI in the diagnosis and treatment of suspected malignant spinal cord compression, The British Journal of Radiology, 2001; 74:15-23. 17. Meyers SP, Wioldenhain SL, Chang J-K, et al, Postoperative evaluation for disseminated meduloblastoma involving the spine: contrast-enhanced MRI findings, CSF cytologic analysis, timing of disease occurrence , and patien outcomes, AJNR, 2000, 21:17157-1765. 18. Bilsky MH, Lis E, Raizer J et al, The diagnosis and treatment of metaststic spinal tumor, Oncologist, 1999; 4:459-469. 19. Kienstra GEM, Terwee CB, Dekker FW et al, Prediction of spinal epidural metastases, Arch Neurol, 2000; 57:690-695. 20. El-Koury GY, Bennett DL, Dalinka MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Metastatic bone disease, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/MetastaticBoneDiseaseDoc14.aspx. 21. Lewis CA, Barr JD, Cardella JF et al, Practice guideline for the performance of Percutaneous vertebroplasty , American College of Radiology Guidelines and Standards, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/head-neck/percutaneous_vertebroplasty.aspx , March 5, 2009. 22. Anderson MW, Dalinka MK, DeSmet AA, et al, Musculoskeletal Imaging Committee of the Commission on Body Imaging, Practice guideline for the performance of magnietic resonance imaging (MRI) of the adult spine, American College of Radiology Guidelines and Standards, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/head-neck/percutaneous_vertebroplasty.aspx , March 5, 2009.

Reviewed 3/18/2009 Posted: 8/15/2009

CareCore National Criteria for Imaging Version 2.2009

72149 MRI Lumbar Spine with Gadolinium 72158 MRI Lumbar Spine without and with Gadolinium

Red Flags

History of cancer Unexplained weight loss Immunocompromised IV drug use Abnormal CBC, ESRUrinary tract infections Pain increased at rest Fever >100.4 Bladder and bowel dysfunction Saddle anesthesia Major motor weakness of a limb Trauma (this is age dependent, lesser trauma required in older patients)

I. Back pain1-5 with a history of lumbar spine surgery [Gadolinium should be used if there is history of lumbar spine surgery] A. Lasting >6 weeks B. No red flags and failure to respond to conservative medical management 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Symptoms worsening while under treatment 3. Pain severe enough to require opiates (narcotics) with no relief after 2 days

II. Radiculopathy 1-3 with a history of lumbar spine surgery [Gadolinium should be used if there is history of lumbar spine surgery] A. History of lumbar spine surgery B. Moderate pain 1. Motor disturbances a. Hyporeflexia b. Atrophy c. Weakness 2. Sensory disturbances a. Pain in nerve root distribution b. Numbness c. Tingling sensations (paresthesias) Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

d. Burning sensations (dysesthesias) e. Shooting pain 3. No red flags and failure to respond to conservative therapy a. Continued pain after treatment with anti-Inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated b. Worsening pain during treatment with anti-inflammatory medication c. Pain severe enough to require opiates (narcotics) with no relief after 2 days C. Severe pain 1. Weakness in nerve root distribution (e.g. foot drop or bowel or bladder dysfunction) 2. Pain severe enough to require opiates (narcotics) not responding after 2 days

III. Suspected spinal stenosis 6 [Gadolinium should be used if there is history of lumbar spine surgery] A. History of lumbar spine surgery B. Clinical findings 1. Low back or bilateral lower extremity pain 2. Pseudoclaudication, pain, numbness or weakness with walking, often bilateral 3. Pain worse with spinal extension, improved with forward flexion 4. Symptoms interfere with ADLs (i.e. washing, dressing, eating, sleeping) C. No red flags and failure to respond to conservative therapy 1. Continued pain after treatment with anti-Inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Worsening pain during treatment with anti-inflammatory medication 3. Pain severe enough to require opiates (narcotics) with no relief after 2 days

IV. Suspected cauda equina syndrome [gadolinium is indicated if there is suspicion of tumor or infection] 1, 2, 4 A. Sudden unexplained onset of 1. Saddle anesthesia 2. Profound sensory deficit 3. Bowel or bladder dysfunction 4. Severe motor deficit 5. Diminished rectal sphincter tone 6. Bilateral radiculopathy 7. Neurogenic claudication

V. Suspected tumor A. Leptomeninges or nerve roots 1. Pain with known malignancy and neurologic findings 2. Hyperreflexia 3. Weakness of the upper or lower extremity 4. Spasticity 5. Bladder or bowel dysfunction Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

6. Sensory deficit 7. New onset scoliosis 8. Spastic gait 9. Periodic assessment during or after chemotherapy or radiation therapy for known tumor in the spinal canal

VI. Suspected osteomyelitis 1, 2, 4, 8-10 A. Pain B. Clinical findings 1. Fever >100.4 2. Leukocytosis, WBC >12,000/cc.mm 3. ESR >20 mm/hr 4. C-reactive protein >10 mg/L 5. Blood culture positive C. History of infection elsewhere D. History of diabetes, dialysis of peripheral vascular disease

VII. Pre-operative or post-operative evaluation of osteomyelitis [Gadolinium]

VIII. Suspected disc space infection (discitis) A. Lumbar spine pain B. ESR >20 mm/hr C. Fever >100.4 D. Leukocytosis, WBC >12,000/cu.mm E. Blood culture positive F. C-reactive protein >10 mg/L

IX. Epidural abscess 12 A. Focal spinal pain and tenderness B. Signs of infection [One] 1. Fever >100.4 2. Leukocytosis, WBC >12,000/cu.mm 3. ESR >20 mm/hr 4. C-reactive protein >10 mg/L 5. Blood culture positive C. Progressive neurologic symptoms [One] 1. Radiating root pain 2. Muscle weakness 3. Sensory deficit 4. Loss of bowel or bladder control D. History of [One] 1. IV drug use 2. Diabetes 3. Immunosuppression E. Follow-up during therapy for epidural abscess Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

1. New or worsening pain at site or neurologic signs or symptoms 2. Periodic evaluation of response to therapy

X. Medulloblastoma [Gadolinium]13 A. Initial evaluation B. Follow-up after treatment C. New signs or symptoms

XI. Ependymoma [Gadolinium] A. Initial evaluation B. Follow up after treatment C. New signs or symptoms

References:

1. Bradley WG Jr, Seidenwurm DJ, Brunberg JA, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria, Low Back Pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/LowBackPainDoc7.aspx January 31, 2008. 2. Thorson DC, Bonsell J, Mueller B, et al, Health Care Guideline: Adult Low Back Pain, Institute for Clinical Systems Improvement, accessed at http://www.icsi.org/low_back_pain/adult_low_back_pain__8.html January 31, 2008. 3. Bowen B, Seidenwurm DJ, Davis PC, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria, Plexopathy, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/PlexopathyDoc12.aspx January 31, 2008. 4. Chiodo A, Alvarez D, Graziano G, et al, Low Back Pain Guideline Team, Acute Low Back Pain, University of Michigan Health System, Guidelines for Clinical Care, accessed at http://cme.med.umich.edu/pdf/guideline/backpain03.pdf January 31, 2008. 5. Deyo RA and Weinstein JN, Low back pain, N Eng J Med, 2001; 344:363-370. 6. Watters WC III, Baisden J, Gilbert T, et al, NASS Clinical Guidelines Committee, Evidence-based Clinical Guidelines for Multidisciplinary Spine Care, Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis, North American Spine Society, accessed at http://www.spine.org/Documents/NASSCG_stenosis.pdf January 31, 2008. 7. El-Koury GY, Bennett DL, Dalinka MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Metastatic Bone Disease, accessed at http://www.acr.org/SecondaryMainMenuCategories/qualitysafety/appcriteria/pdf/ExpertPanelonMusculoskeletalImaging/MetastaticBoneDisease Doc14.aspx January 31,2008. 8. Fernandez M, Carrol CL, and Baker CJ, Discitis and vertebral osteomyelitis in children: an 18-year review, Pediatrics, 2000; 105:1299-1304. 9. Govender S, Spinal infections, J Bone Joint Surg [Brit], 2005; 87:1454-1458. 10.Brown R, Hussain M, McHugh K, et al, Discitis in young children, J Bone Joint Surg [Brit], 2001; 83:106-111. 11. Sharif HS, Role of MR imaging in the management of spinal infections, AJR, 1992; 158:1333-1345. 12. Lu C-H, Chang W-N, Lui CC, et al, Adult spinal epidural abscess: clinical features and prognostic factors, Cl Neurol Neurosurg, 2002; 104:306-310. 13. Koeller KK, Rushing EJ, From the archives of the AFIP Medulloblastoma: a comprehensive review with radiologic-pathologic correlation, RadioGraphics, 2003; 23:1613-1637.

Reviewed: 3/18/2009 Posted: 8/15/2009

CareCore National Criteria for Imaging Version 2.2009

72159 MRA of the Spinal Canal

I. Dural ArterioVenous Fistula (DAVF) suspected on MRI 1-3 A. Must have copy of MRI report indicating the above

II. Spinal ArterioVenous Malformation (AVM) 3,4 A. Suspected on recent MRI, must have copy of report B. Follow up after treatment

References:

1. Luetmer PH, Lane JI, Gilbertson JR, et al, Preangiographic evaluation of spinal dural arteriovenous fistuals with elliptic centric contrast- enhanced MR angiography and effect on radiation dose and volume of iodinated contrast material, AJNR, 2005; 26:711-718, 2 Bowen BC, Fraser K, Kochan JP, et al, Spinal dural arteriovenous fistulas: evaluation with MR angiography, AJNR, 1995; 16:2029-2043. 3 Backes WH and Nijenhuis RJ, Advances in spinal cord MR angiography, AJM+NR, 2008; 29:619-631. 4. Mascalchi M, Bianchi MC, Quilici N, et al, MR angiography of spinal vascular malformations, AJNR, 1995; 16:289-297.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

72191 CTA of the Pelvis

Note: For evaluation of PVD, the appropriate CPT code is 75635 (CTA abdominal aorta with runoff) rather than either CTA abdomen or CTA pelvis. I. Suspected occlusion or stenosis of iliac or femoral arteries 1-4 A. ABI (Ankle Brachial Index, ankle systolic BP divided by brachial systolic BP) 1. Rest ABI <0.90 in symptomatic member 2. Exercise ABI <0.90 in symptomatic member with rest ABI >0.90 3. Toe brachial index <0.90 or pulse volume recording evidence of peripheral vascular disease if the ABI >1.30 B. Abnormal pulses C. Bruit D. Claudication E. Diabetic with 1. Skin changes 2. Loss of hair 3. Poor capillary refill 4. Thickened nails 5. Thin skin F. Known atherosclerotic occlusive disease

II. Aneurysm of the aorta or pelvic arteries 5 A. Known aortic or pelvic aneurysm 1. Periodic follow-up of known AAA will be allowed once every six months a. Inadequate ultrasound b. No surgical repair B. Pulsatile mass on abdominal, vaginal, or rectal exam C. Aneurysm detected on x-ray or US exam D. Suspected rupture of AAA 1. New onset of mid-abdominal or back pain 2. Clinical findings a. Pulsatile mass b. Abnormal x-ray of US findings suggesting aortic disease c. Falling blood pressure E. Postoperative evaluation of aneurysm following repair including endovascular repair (stent graft) 1. 1 month after repair 2. 3 months after repair 3. 6 months after repair 4. Annually after repair 5. Suspicion of endoleak

CareCore National Criteria for Imaging Version 2.2009

III. Suspected pelvic AVM A. Hematuria B. Vaginal bleeding, may be after c-section or curettage

IV. Pelvic trauma with suspected vascular injury

V. Uterine fibroid embolization A. Pre embolization evaluation

VI. Renal transplant6 A. MRI contraindicated B. Suspicion of renal artery stenosis 1. Hypertension 2. Deterioration of renal function 3. New bruit

References: 1. Pilleul F, Beuf O, Abdominal arteries should be evaluated by 3D contrast - enhanced MRA as the first step, Acta Radiologica, 2002; 43(5): 544-542. 2. Willmann JK, Wildermuth S, Pfammatter T, et al, Aortoiliac and renal arteries: prospective intraindividual comparison of contrast-enhanced three-dimensional MR angiography and multi–detector row CT angiography, Radiology, 2003; 226:798-811. 3. Frykberg RG, Zagonis T, Armstrong DG, et al, Diabetic foot disorders: a clinical practice guideline (2006 revision), Journal of Foot and Ankle Surgery, 2006; 45(5):S1-S66. 4. Hirsch AT, Haskal ZJ, Hertzer NR et al, ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic: a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines, accessed at 5Caronno R, Piffaretti G, Tozzi M et al, Endovascular treatment of isolated iliac artery aneurysms, Annals of Vascular Surgery, 2006; 20:496- 501. 6 Glockner JF and Vrtiska TJ, Renal MR and CT angiography:current concepts, Abdom Imaging, 2007; 32:407-420.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

72192 CT Pelvis without Contrast 72193 CT Pelvis with Contrast 72194 CT Pelvis without and with Contrast

I. Complaints associated with abdominal or pelvic pain 1-10 Note: A. Abdominal pain persisting for more than a few hours and any of the following: 1. Abdominal tenderness 2. Evidence of inflammatory reaction or visceral dysfunction 3. Collapse 4. Vomiting 5. Muscular rigidity - guarding 6. Abdominal distention B. Obstructive uropathy or hydronephrosis (Renal, ureteral or, bladder stone causing obstruction) 1. Pain in flank, radiating toward the groin 2. Hematuria C. Diverticulitis 1. Lower abdominal pain or mass 2. Other clinical findings a. Fever >100.4 b. Leukocytosis, WBC >12,000/cu.mm c. Diverticulosis by prior imaging study d. Symptoms worsening under treatment with antibiotics and diet restriction after 2 days or more D. Abscess 1. Suspected a. Abdominal or pelvic pain for at least a day b. Other clinical findings i. Mass on abdominal, pelvic or rectal exam ii. Fever >100.4 iii. Leukocytosis, WBC >12,000/cu.mm 2. Follow up during or after treatment a. Condition unimproved or worsening after drainage or IV antibiotics for at least two days b. Condition unimproved or worsening after IV Abx Rx >1 wk c. Routine follow-up study after treatment, including evaluation for removal of drain. E. Appendicitis 1. Pain a. Generalized through the abdomen b. Periumbilical c. Suprapubic d. Right lower quadrant Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

2. Symptoms and signs a. Nausea/vomiting b. Guarding or abdominal rigidity c. Rebound tenderness d. Tenderness RLQ e. Positive Rovsing’s sign (referred rebound -- pressure to LLQ causes pain in RLQ) f. Fever >100.4 g. Leukocytosis, WBC >12,000/cu.mm 3. Pregnancy excluded F. Crohn’s Disease and Inflammatory Bowel Disease (suspected) 1. Acute symptoms and signs a. Abdominal pain b. Liquid bowel movements, diarrhea c. Weight loss d. Anorexia e. Fever >100.4 f. Abdominal tenderness g. Abdominal mass h. Family history of Crohn’s Disease i. Extra intestinal manifestations i. Oral aphthous lesions ii. Gallstones iii. Nephrolithiasis with stones 2. Chronic inflammatory bowel disease (IBD) a. Fistulization with or without infection i. Fevers, chills, and a tender abdominal mass ii. Bladder or vagina recurrent infections iii. Cutaneous fistulas iv. Perianal disease 01. Anal fissures or fistulas 02. Abscesses b. Diarrhea, non bloody, intermittent c. Cramping or steady right lower quadrant or periumbilical pain d. Small bowel obstruction with distention, cramping abdominal pain, nausea, vomiting e. Focal tenderness, right lower quadrant f. Postprandial bloating, cramping pains, and loud borborygmi g. Palpable, tender mass in the lower abdomen G. Ulcerative colitis [bloody mucoid stools associated with 1, 2, or 3]] 1. Diarrhea 2. Pain 3. Tenesmus (straining at stool)

II. Evaluation of symptoms after abdominopelvic surgery Any intra-abdominal surgery 1. Abdominal pain or tenderness

CareCore National Criteria for Imaging Version 2.2009

a. Abscess [Any] i. Unexpected post surgical abdominal pain for at least a day ii. Mass on abdominal, pelvic or rectal exam iii. Fever >100.4 iv. Leukocytosis, WBC >12,000/cu.mm b. Subphrenic abscess i. Upper abdominal pain, worse with respiration ii. Fever >100.4 iii. Leukocytosis, WBC >12,000/cu.mm c. Intra-abdominal hemorrhage i. Risk factor for bleeding 01. Recent intra-abdominal surgery/instrumentation 02. Coagulopathy 03. Patient on coumadin, heparin or other anticoagulant 04. Abdominal/pelvic trauma ii. Findings [One] 01. Falling hematocrit 02. Hemodynamic instability • Systolic blood pressure <100 • Falling blood pressure 03. Shock by PE 04. Gross evidence of bleeding (i.e. from drain, surgical site or orifice) B. Follow up after percutaneous drainage of intra-abdominal abscess C. Post cholecystectomy 1. Clinical findings a. Pain b. Fever >100.4 c. Leukocytosis, WBC >12,000/cu.mm d. Jaundice e. Ileus f. Direct bilirubin >0.4 mg/dL g. Liver enzymes elevated D. Appendicitis after surgery [1 or 2] 1. Persistent fever >100.4 2. Leukocytosis, WBC >12,000/cu.mm

III. Aneurysm 11-18 A. Suspected rupture of AAA 1. New onset of mid-abdominal or back pain 2. Clinical findings a. Pulsatile or expansile mass b. Abnormal x-ray or US findings suggesting aortic disease c. Falling blood pressure B. Known AAA documented on prior imaging (Ultrasound, CT, CTA, MRI, MRA) 1. Periodic follow-up of known AAA will be allowed once every six months

CareCore National Criteria for Imaging Version 2.2009

a. Inadequate ultrasound b. No surgical repair C. Postoperative evaluation following endovascular repair (stent graft) 1. 1 month after repair 2. 3 months after repair 3. 6 months after repair 4. Annually after repair 5. Suspicion of endoleak D. Aneurysm of any intra abdominal artery detected on other Imaging E. Vascular insufficiency of the bowel (suspicion of) 1. Abdominal pain often starting as periumbilical and often out of proportion to exam findings 2. Other clinical findings a. Leukocytosis, WBC >12,000/cu.mm b. Stool positive for occult blood c. Nausea, vomiting or diarrhea d. History of abdominal angina (pain after eating for approximately 3 hours)

IV. Obstruction of bowel 19, 20 A. Non-diagnostic flat and upright abdominal x-ray and 1. Pain 2. Abdominal distention 3. Constipation or obstipation 4. Borborygmus, loud bowel sounds, high pitched tinkling sounds 5. Diffuse abdominal tenderness 6. Tympani 7. Nausea and vomiting 8. KUB abnormal but nonspecific

V. Patient with known cancer including lymphoma other than pelvic cancer (except head and neck cancer) 21-39 A. Initial staging B. Follow-up after Rx [without change in clinical status] 1. After surgery and before adjuvant radiation or chemotherapy 2. After treatment for metastatic or unresectable disease 3. Scheduled as: a. Initial staging and for tissue diagnosis b. Restaging during or after chemotherapy and/or radiation therapy c. Every 6-12 months for 3 years d. Annually after 3 years C. New or worsening clinical data reported 1. Anorexia 2. Weight loss 3. Jaundice 4. Abdominal or pelvic pain 5. Abdominal or pelvic mass Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

6. Hepatomegaly 7. Ascites 8. Bowel obstruction by KUB 9. Lab values elevated/increasing a. Rising CEA b. Worsening liver function tests c. Rising bilirubin d. Rising CA 19-9 (pancreatic cancer)

VI. Diverticulitis, suspected or known in a patient with lower abdominal pain and/or mass 4, 5, 40, 41 A. Fever >100.4 B. Leukocytosis, WBC >12,000/cu.mm C. Diverticulosis by prior imaging study D. Symptoms worsening under treatment with antibiotics and diet restriction after 2 days or more

VII. Appendicitis A. Pain 1. Generalized through the abdomen 2. Periumbilical 3. Suprapubic 4. Right lower quadrant B. Symptoms and signs 1. Nausea/vomiting 2. Guarding or abdominal rigidity 3. Rebound tenderness 4. Tenderness RLQ 5. Positive Rovsing’s sign (pressure to LLQ causes pain in RLQ) 6. Pregnancy excluded 7. Fever > 100.4 8. Leukocytosis, WBC >12,000/cu.mm

VIII. Suspected pelvic abscess, Pelvic Inflammatory Disease (PID)1, 43 A. Symptoms 1. Lower abdominal pain 2. Chills 3. Menstrual disturbances 4. Purulent cervical discharge 5. Cervical and adnexal tenderness B. Objective findings 1. Local pelvic tenderness 2. Fever > 100.4 3. Leukocytosis, WBC >12,000/cu.mm IX. Follow-up of known pelvic abscess or fistula during or after treatment

CareCore National Criteria for Imaging Version 2.2009

A. Condition unimproved or worsening after drainage and IV antibiotics for at least two days B. Condition unimproved or worsening after IV antibiotic treatment >1 wk C. Follow up evaluation at completion of treatment D. Evaluation prior to removal of drain

X. Known pelvic tumor for staging or restaging after completion of therapy21-39 A. Primary malignancies arising in the pelvis 1. Bladder cancer 2. Rectal cancer 3. Prostate cancer 4. Cervical cancer 5. Endometrial cancer 6. Lymphoma 7. Bone tumor arising in the pelvis 8. Transitional cell carcinoma of the ureter 9. Ovarian cancer B. New or worsening symptoms 1. Pelvic or lower extremity pain 2. Leg weakness or numbness 3. Hematuria 4. Rectal bleeding 5. Bowel obstruction 6. Vaginal bleeding 7. Ascites 8. New onset hydronephrosis 9. New onset renal insufficiency 10. Rising tumor markers C. Metastatic malignancy proven to be in the pelvis on prior imaging D. Patient with known malignancy elsewhere in the body now with 1. New pelvic mass on PE or other imaging 2. Change in bladder or bowel habits 3. Pelvic pain with nondiagnostic US 4. Rectal or vaginal bleeding 5. Hematuria 6. New onset hydronephrosis 7. New onset renal insufficiency 8. Constipation or bowel obstruction 9. Ascites

XI. Hematuria 43-46

CareCore National Criteria for Imaging Version 2.2009

XII. Complex ovarian, adnexal or other pelvic mass found on imaging or physical examination [MRI preferred, CT is useful for suspected dermoid cyst]

XIII. Urethral diverticulum 47,48 [MRI preferred, CT virtual endoscopy may be used if MRI is not feasible] A. Tender cystic swelling protruding from the vagina B. Urinary frequency, urgency, burning on urination, dysuria C. Dribbling, dyspareunia

XIV. Lumbosacral plexopathy 49-54 [see also: Known pelvic tumor for staging or restaging after therapy] LS spine imaging non-diagnostic, MRI contraindicated along with A or B A. Leg numbness or weakness in distribution of more than one nerve root B. Meralgia Paresthetica (pain, paresthesia, and sensory loss in the lateral aspect of the thigh)

XV. Suspected sacral or pubic fracture52-55 A. Suspected sacral fracture 1. Sacral pain with a single fracture of the pelvic ring 2. Sacral pain in long distance runners not responsive to NSAIDs and modification of behavior for three or more weeks B. Osteopenic or post radiation therapy patient with chronic sacral or pubic pain

XVI. Suspected inguinal hernia 56-59 A. Inguinal pain or discomfort 1. Often unilateral 2. Worsened by straining or lifting 3. Worsened by prolonged standing B. Visible or palpable groin mass 1. More prominent in upright position 2. More prominent with Valsalva maneuver C. Strangulation (more common with femoral hernias) 1. Colicky pain abdominal pain 2. Palpable mass 3. Signs of intestinal obstruction D. After previous hernia surgery with either persistent pain or suspicion of recurrent hernia

XVII. Crohn’s Disease and Inflammatory Bowel Disease A. Acute symptoms and signs 1. Abdominal pain 2. Liquid bowel movements, diarrhea 3. Weight loss 4. Anorexia

CareCore National Criteria for Imaging Version 2.2009

5. Fever >100.4 6. Abdominal tenderness 7. Abdominal mass 8. Family history of Crohn’s Disease 9. Extra intestinal manifestations a. Oral aphthous lesions b. Gallstones c. Nephrolithiasis with stones B. Chronic inflammatory disease 1. Fistulization with or without infection a. Fevers, chills, and a tender abdominal mass b. Bladder or vagina recurrent infections c. Cutaneous fistulas d. Perianal disease i. Anal fissures or fistulas ii. Abscesses C. Any evidence of clinical deterioration while on steroids or immunosuppressives

XVIII.Fever of Unknown Origin (FUO) 41 A. Fever >100.4 on several occasions over at least three weeks B. Uncertain diagnosis after lab studies 1. Two blood cultures 2. Urine culture 3. Tuberculin skin test 4. HIV antibody assay and HIV viral load for patients at high risk C. ESR >20 mm/hr D. C-reactive protein >10 mg/ml E. Associated night sweats

XIX. Abdominal and pelvic trauma42-44 A. Initial evaluation B. Follow-up for known/suspected intra-abdominal injury 1. Periodic assessment a. New or worsening symptoms or findings

XX. Cryptorchidism (undescended testicle) [MRI Preferred] 45-47 A. Testicle not palpable B. Abdominal and pelvic US nondiagnostic for undescended testicle

XXI. CT Enterography 50,51 A. Bowel obstruction B. Celiac disease C. Complications of Crohn’s Disease 1. Abscess

CareCore National Criteria for Imaging Version 2.2009

2. Fistula 3. Small bowel obstruction 4. Peri-anal fistula 5. Stenosis 6. Stricture D. Polyposis syndromes E. Small bowel tumor F. Suspected Crohn’s Disease 1. Fever >100.4 2. Diarrhea 3. Weight loss 4. Fatigue 5. Crampy abdominal pain 6. Perianal fistula or fissure 7. Enterovesical fistula 8. Enterovaginal fistula 9. Enterocutaneous fistula 10. Right lower quadrant tenderness G. Ulcerative colitis

XXII. Suspected or known dissection of the aorta 69-73 A. Unequal blood pressure in the arms B. Rapid onset of "ripping, tearing, searing" severe chest or upper back or abdominal pain C. Pain with abnormal appearance of aorta on prior imaging 1. Chest 2. Back 3. Abdominal D. Syncope E. Shortness of breath F. Prior aortic aneurysm repairs G. Chest pain with evidence of a stroke H. Loss of pulses I. Follow up of known dissection

XXIII. Weight loss 74 A. Weight loss greater than 5% total body weight (or at least a 5 pound weight loss) B. Significant change in bowel habits C. Negative colonoscopy D. Chest x-ray non diagnostic for cause of weight loss E. Normal thryroid function tests (TSH, T3 and T4) F. Normal renal function tests (BUN and creatinine) G. Abnormal liver function tests

CareCore National Criteria for Imaging Version 2.2009

XXIV. Kidney or renal stones A. Flank pain B. Hematuria or blood in the urine C. Fever, Chills D. Known renal stone for follow up E. Hydronephrosis on other imaging

XXV. Urogenital fistula (known or suspected including vesicovaginal, ureterovaginal and urethrovaginal fistulas)75,76 A. Leakage of urine from the vagina B. Recurrent urinary tract infection with urine leaking from the vagina C. History of pelvic radiation D. History of pelvic surgery E. Foreign body in the bladder F. Obstetric complication G. Pelvic trauma

XXVI.Enterovesical fistula (known or suspected)75,76 A. Pneumaturia B. Fecaluria C. History of diverticulitis D. History of inflammatory bowel disease E. Recurrent urinary tract infections with pneumaturia F. Foreign body in the bladder G. History of pelvic radiation

References:

1. Rosen MP, Bree RL, Foley WD, et al, American College of Radiology Appropriateness Criteria acute abdominal pain and fever or suspected abdominal abscess, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=9618 November 12, 2007. 2. Rosenfield AT, Choyke PL, Bluth E, et al, American College of Radiology Appropriateness Criteria, Acute onset flank pain, variant 1: Suspicion of stone disease, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8278&nbr=004610&string=hydronephrosis November 12, 2007. 3. Finnish Medical Society Duodecium, Haematuria, In EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2004 Aug 26 , accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=7382&nbr=004363&string=hydronephrosis November 12, 2007. 4. Levine MS, Bree RL, Foley WD et al, American College of Radiology Appropriateness Criteria, Left lower quadrant pain, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8586&nbr=004773&string=Diverticulitis November 12, 2007. 5. Rafferty J, Shellito P, Hyman NH, et al, Standards Committee of American Society of Colon and Rectal Surgeons. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum, 2006; 49:939-944. 6. Cincinnati Children’s Hospital Medical Center, Health Policy and Clinical Effectiveness Program, Evidence Based Clinical Practice Guideline, Emergency appendectomy, accessed at http://www.cincinnatichildrens.org/NR/rdonlyres/07312778-8D7C-4C24-8250- 11B3ACF51FD2/0/appendectomyguideline.pdf November 12, 2007. 7. Weyant MJ, Eachempati SR, Maluccio MA, et al, Interpretation of computed tomography does not correlate with laboratory or pathologic findings in surgically confirmed acute appendicitis, Surgery, 2000; 128:145-152. 8. Knutson D, Greenberg G and Cronau H, Management of Crohn’s Disease—A practical approach, American Family Physician, accessed at http://www.aafp.org/afp/20030815/707.html November 10. 2007.

CareCore National Criteria for Imaging Version 2.2009

9. Huprich JE, Bree RL, Foley WD, et al, American College of Radiology Appropriateness Criteria, Evaluation of Crohn’s disease, accessed at http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=8585&nbr=4772 November 7, 2007. 10.Carter MJ, Lobo AJ, and Travis SPL, on behalf of the IBD Section of the British Society of Gastroenterology, Gut, 2005; 53(Suppl V):v1-v16. 11. Mehard WB, Heiken JP, and Sicard GA, High-attenuating crescent in abdominal aortic aneurysm wall at CT: A sign of acute or impending rupture, Radiology, 1994; 192:359-362. 12. Lederle FA, Wilson SE, Johnson GR, et al, Immediate repair compared with surveillance of small abdominal aortic aneurysms, N Eng J Med, 2002; 346:1437-1444. 13. Starvropoulos SW and Charagundla SR, Imaging techniques for detection and; management of endoleaks after endovascular aortic aneurysm repair, Radiology, 2007; 243:641-655. 14. Hirsch AT, Haskal AJ, Hertzer NR, et al, ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease(lower extremity, renal, mesenteric and abdominal aortic): a collaborative report from the American association for vascular surgery/society for vascular surgery,society for cardiovascular angiography and interventions, society for vascular medicine and biology, society of interventional radiology and the ACC/AHA task force on practice guidelines(writing committee to develop guidelines for the management of patients with peripheral arterial disease), J Am Coll Cardiol, 2006; 47:1-192. 15. Fattori R and Russo V, Degenerative aneurysm of the descending aorta. Endovascular treatment, European Association for Cardio-thoracic Surgery, Multimedia Manual of Cardiothoracic Surgery, 2007, accessed at http://mmcts.ctsnetjournals.org/cgi/reprint/2007/1217/mmcts.2007.002824.pdf December 28, 2007. 16. Horton KM, Smith C, and Fishman EK, MDCT and 3D CT angiography of splanchnic artery aneurysms, AJR, 2007; 189:641-647. 17 Macari M, Chandarana H, Balthazar E, et al, Intestinal ischemia versus intramural hemorrhage: CT evaluation, AJR, 2002; 180:177-184. 18. Wiesner W, Khurana B, Ji H, et al, CT of acute bowel ischemia, Radiology, 2003; 226:635-650. 19. Furukawa A, Yamasaki M, Furuichi K, et al, Helical CT in the diagnosis of small bowel obstruction, RadioGraphics, 2001; 21:341-355. 20. Ros PR, Huprich JE, Bree RL, et al, American College of Radiology Appropriateness Criteria, Suspected small bowel obstruction, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonGastrointestinalimaging/SuspectedSmallbowe lobstructionDoc15.aspx November 9, 2007. 21. Scottish Intercollegiate Guidelines Network, Epithelial ovarian cancer: A national guideline accessed at http://www.sign.ac.uk/pdf/sign75.pdf February 6, 2008. 22. Zafar S, Jafri H, Shetty M, et al, American College of Radiology Appropriateness Criteria, Pretreatment stating of invasive bladder cancer, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8281&nbr=004613&string=cancer+AND+staging November 13, 2007. 23. Desch CE, Benson AB, Somerfield MR, et al, Colorectal cancer surveillance: 2005 update of an American Society of Clinical Oncology practice guideline, JCO, 2005; 23:8512-8519. 24. Diagnostic Imaging In The Assessment of Metastatic and Recurrent Ovarian Cancer, a Cancer Care Ontario Recommendations Report, April, 2006; accessed at http://www.cancercare.on.ca/pdf/pebcdiovar.pdf November 13, 2007. 25. Diagnostic Imaging in Lymphoma, a Cancer Care Ontario Recommendations Report, March, 2006, accessed at http://www.cancercare.on.ca/pdf/pebcdilymphf.pdf November 13, 2007. 26. Casalino DD, Choyke PL, Bluth EI, et al, American College of Radiology Appropriateness Criteria, Follow up of renal cell carcinoma, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8311&nbr=004643&string=kidney+AND+cancer November 12, 2007. 27. Choyke PL, Bluth EI, Bush WH Jr, et al, American College of Radiology Appropriateness Criteria, Renal cell carcinoma staging, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8284&nbr=004616&string=kidney+AND+cancer November 14, 2007. 28. Wolkov HB, Constine LS, Yahalom J, et al, American College of Radiology Appropriateness Criteria, Staging evaluation for patients with Hodgkin’s disease, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8307&nbr=004639&string=lymphoma+AND+imaging November 9, 2007. 29. Ng AK, Constine LS, Deming RL, et al, American College of Radiology Appropriateness Criteria, Routine follow-up for Hodgkin’s disease after completion of treatment and response assessment, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8306&nbr=004638&string=lymphoma+AND+imaging November 9, 2007. 30. Montie JE, Eisenberger MA, El-Galley R, et al, Bladder Cancer, NCCN practice guidelines in Oncology, v1.2008, accessed at http://www.nccn.org/professionals/physician_gls/PDF/bladder.pdf November 10, 2007. 31. Biermann JS, Adkins D, and Benjamin R, Bone cancer, NCCN practice guidelines in Oncology, v1.2008, accessed at http://www.nccn.org/professionals/physician_gls/PDF/bone.pdf November 10, 2007. 32. Ajani J, Bekaii-Saab T, D’Amico TA, et al, Gastric cancer, NCCN practice guidelines in Oncology, V2.2007, accessed at http://www.nccn.org/professionals/physician_gls/PDF/gastric.pdf November 10, 2007. 33. Hoppe RT, Advani RH, Ambinder RF, et al, Hodgkin disease/lymphoma, NCCN practice guidelines in Oncology,cV1.2007, accessed at http://www.nccn.org/professionals/physician_gls/PDF/hodgkins.pdf November 9, 2007. 34. Motzer RJ, Bolger GB, Boston B, et al, Kidney cancer, NCCN practice guidelines in Oncology, v1.2008, accessed at http://www.nccn.org/professionals/physician_gls/PDF/kidney.pdf November 9, 2007. 35. Clark OH, Ajani J, Benson AB III, et al, Neuroendocrine tumors, NCCN practice guidelines in Oncology, V1.2007, accessed at http://www.nccn.org/professionals/physician_gls/PDF/neuroendocrine.pdf November 13, 2007. 36. Zelenetz AD, Advani EH, Bociek RG, et al, Non-Hodgkin’s lymphomas, NCCN practice guidelines in Oncology, V3.2007, accessed at http://www.nccn.org/professionals/physician_gls/PDF/nhl.pdf November 13, 2007. 37. Ettinger DS, Eaton K, Gockerman JP, et al, Occult primary, NCCN practice guidelines in Oncology, V2.2007, accessed at http://www.nccn.org/professionals/physician_gls/PDF/occult.pdf November 13, 2007. Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

38. Demetri GD, Baker LH, Benjamin RS, et al, Soft tissue Sarcoma, NCCN practice guidelines in Oncology, V3.2007, accessed at http://www.nccn.org/professionals/physician_gls/PDF/sarcoma.pdf November 13, 2007. 39. Motzer RJ, Bolger GB, Boston B, et al, Testicular cancer, NCCN practice guidelines in Oncology, v1.2008, accessed at http://www.nccn.org/professionals/physician_gls/PDF/testicular.pdf November 13, 2007. 40. Levine MS, Bree RL, Foley WD et al, American College of Radiology Appropriateness Criteria, Left lower quadrant pain, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8586&nbr=004773&string=Diverticulitis November 12, 2007. 41. Rafferty J, Shellito P, Hyman NH, et al, Standards Committee of American Society of Colon and Rectal Surgeons. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum, 2006; 49:939-944. 42. Huprich JE, Bree RL, Foley WD, et al, Expert Panel on Gastrointestinal Imaging, American College of Radiology Appropriateness Criteria, Crohn’s Disease accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonGastrointestinalImaging/CrohnsDiseaseDoc5. aspx February 6, 2008. 43. Finnish Medical Society Duodecium, Haematuria, In EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2004 Aug 26, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=7382&nbr=004363&string=hydronephrosis November 12, 2007. 44. Grossfeld GD, Wolf JS, Litwin MS, et al, Asymptomatic microscopic hematuria in adults: Summary of the AUA best practice policy recommendations, Am Fam Physician, 2001; 63:1145-11154. 45. Choyke PL, Bluth EI, Bush WH Jr, et al, Expert Panel on Urologic Imaging, American College of Radiology Appropriateness Criteria, Hematuria, accessed at 49. Grossfeld GD, Wolf JS, Litwin MS, et al, Asymptomatic microscopic hematuria in adults: Summary of the AUA best practice policy recommendations, Am Fam Physician, 2001;63:1145-11154. 46. Coley BD, Gunderman R, Blatt ER, Expert Panel on Pediatric Imaging, American College of Radiology, Appropriateness Criteria, Hematuria-child, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonPediatricImaging/hematuriaChildDoc4.aspx February 6, 2008. 47. Kim, B, Hricak, H, Tanagho, EA, Diagnosis of urethral diverticula in women: value of MR imaging, AJR, 1993; 161:809-815. 48. Chou C-P, Huang J-S, Yu, Chia-Cheng P, et al, Urethral Diverticulum: Diagnosis with Virtual CT Urethroscopy AJR, 2005: 184: 1889-1890. 49. Maravilla KR, Bowen BC, Imaging of the peripheral nervous system: evaluation of peripheral neuropathy and plexopathy, AJNR, 1998; 19:1011-1023. 50. Gebarski KS, Gebarski SS, Glazer GM, et al, The lumbosacral plexus: anatomic-radiologic-pathologic correlation using CT, RadioGraphics, 1986; 6:401-425. 51. Bowem B, Seidenwurm DJ, Davis PC, et al, Expert panel on neurologic imaging, American College of Radiology Appropriateness Criteria, Plexopathy, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/plexopathyDoc12.aspx January 17, 2008. 52. Work Loss Data Institute, Hip & pelvis (acute and chronic), accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=11022&nbr=005802&string=pelvic+AND+fracture January 17, 2008. 53. Cooper, J, Pelvic ring injuries, Trauma, 2006; 8:95-100. 54. Mack LA, Harley JD, and Winquist RA, CT of acetabular fractures: analysis of fracture patterns, AJR, 1982; 138:407- 412. 55. Harley JD, Mack LA, and Winquist RA, , CT of acetabular fractures: comparison with conventional radiography , AJR, 1982; 138:4013-417. 56. Aguirre DA, Santosa AC, Casola G et al, Abdominal wall hernias: imaging features, complications and diagnostic pitfalls at multi-detector row CT, RadioGraphics, 2005; 25:1501-1530. 57. Shadbolt CL, Heinze SBJ, and Dietrich RB, Imaging of groin masses: inguinal anatomy and pathologic conditions revisited, RadioGraphics, 2001; 21:S261-S271. 58. Miller PA, Mezwa DG, Feczko PJ, et al, Imaging of abdominal hernias, RadioGraphics, 1995; 15:333-347. 59. Zarvan NP, Lee FT, Yandow DR, et al, Abdominal hernias: CT findings, AJR, 1995; 164:1391-1395. 60. 41. Mourad O, Palda V, Detsky AS, A comprehensive evidence-based approach to fever of unknown origin, Arch Intern Med, 2003;163:5454-551. 61. Shuman WP, Holtzman SR, Bree RL, et al, American College of Radiology Appropriateness Criteria, Abdominal trauma, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8270&nbr=004602&string=abdominal+AND+trauma+AND+imaging November 13, 2007. 62. Holevar M, Ebert J, Luchette F, et al, Practice management guidelines for the management of genitourinary trauma, The EAST Practice Management Guidelines Work Group accessed at http://www.east.org/tpg/GUmgmt.pdf November 7, 2007. 63. Salim A, Sangthong B, Martin M, et al, Whole body imaging in blunt multisystem trauma patients without obvious signs of injury, results of a prospective study, Arch Surg, 2006; 141:468-475. 64. Kier R, McCarthy S, Rosenfield AT, et al, Nonpalpable testes in young boys: evaluation with MR imaging, Radiology, 1988; 169:429-433. 65. Fritzsche PJ, Hricak H, Kogan BA, et al, Undescended testis: Value of MR imaging, Radiology,1987; 164:169-173. 66. Friedland GW and Chang P, The role of imaging in the management of the impalpable Undescended tests, AJR, 1988; 151:1107-1111. 67. Paulsen SR, Huprich JE, Fletcher JG, et al, CT Enterography as a diagnostic tool in evaluating small bowel disorders: Review of clinical experience with over 700 cases, RadioGraphics, 2006; 26:641-662. 68. Booya F, Fletcher JG, Huprich JE, et al, Active Crohn’s disease: CT findings and interobserver agreement for enteric phase CT Enterography, Radiology, 2006; 241:787-795. Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

69. Gomes AS, Bettmann MA, Casciani T, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-suspected aortic dissection, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainSusp ectedaorticdissectionDoc2.aspx December 28, 2007. 70.Holtzman SR, Bettmann MA, Casciani T, et al, Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Blunt chest trauma suspected aortic injury, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/Vascular/BluntChestTraumaSuspectedaorticInjuryDoc6.aspx December 28, 2007. 71. Erbel R, Alfonso F, Boileau C, et al, Diagnosis and management of aortic dissection : recommendations of the task force on aortic dissection, Europena Society of Cardiology, European Heart Journal, 2001, 22:1642-1682. 72. Stanford W, Yucel EK, Bettmann MA, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-No ecg enzyme evidence of myocardial ischemia/infarction, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/Acute ChestPainNoECGorEnzymeEvidenceofMyocardialIschemiaInfarctionDoc1.aspx December 28, 2007. 73.Mulder S, Spilde P, Morrison J, et al, Helath Care Guideline: Diagnosis and treatment of chest pain and acute coronary syndrome (ACS), Institute for Clinical systems Improvement, Third Edition, 2006, accessed at http://www.icsi.org/acs_acute_coronary_syndrome /acute_coronary_syndrome _and_chest_pain__diagnosis_and_treatment_of_2.html December 28, 2007. 74. Bouras EP, Lange SM and Scolapio JS, Rational approach to patients with unintentional weight loss, Mayo Clin Proc, 2001; 76:923-929.

Reviewed: 3/18/2009 Posted: 8/15/2009

CareCore National Criteria for Imaging Version 2.2009

72195 MRI of the Pelvis without Gadolinium 72196 MRI of the Pelvis with Gadolinium 72197 MRI of the Pelvis without and with Gadolinium

I. Pelvic mass detected by other means A. Ultrasound or CT nondiagnostic or not feasible

II. Adenomyosis 1-4 A. Abnormal uterine bleeding B. Painful menses C. Chronic pelvic pain D. Impaired fertility E. Uterine enlargement by US

III. Endometriosis 5-9 A. Symptoms 1. Severe dysmenorrhea 2. Deep dyspareunia 3. Chronic pelvic pain 4. Ovulation pain 5. Cyclical or perimenstrual symptoms (e.g. bowel or bladder associated) with or without abnormal bleeding 6. Infertility 7. Chronic fatigue B. Findings [One] 1. Pelvic tenderness 2. Fixed retroverted uterus 3. Tender utero-sacral ligaments or 4. Enlarged ovaries C. Laparoscopy nondiagnostic for endometriosis or contraindicated

IV. Suspected congenital anal, vaginal or uterine anomaly (septate, bicornate, didelphic) 10-13 A. Pelvic pain B. Irregular menses C. Dysmenorrhea D. Infertility E. Repeated spontaneous abortions F. Cervical septum

CareCore National Criteria for Imaging Version 2.2009

G. Hysterosalpingogram and US nondiagnostic or contraindicated

V. Cryptorchidism 14, 15 A. Testicle not palpable B. US nondiagnostic for undescended testicle

VI. Known pelvic tumor for staging or restaging after therapy 16-21 A. Primary malignancies arising in the pelvis 1. Bladder cancer 2. Rectal cancer 3. Prostate cancer 4. Cervical cancer 5. Endometrial cancer 6. Lymphoma 7. Bone tumor arising in the pelvis 8. Transitional cell carcinoma of the ureter 9. Ovarian cancer B. New or worsening symptoms 1. Pelvic or lower extremity pain 2. Leg weakness or numbness 3. Hematuria 4. Rectal bleeding 5. Bowel obstruction 6. Vaginal bleeding 7. Ascites 8. New onset hydronephrosis 9. New onset renal insufficiency 10. Rising tumor markers C. Metastatic malignancy proven to be in the pelvis on prior imaging D. Patient with known malignancy elsewhere in the body now with 1. New pelvic mass on PE or other imaging 2. Change in bladder or bowel habits 3. Pelvic pain with nondiagnostic US 4. Rectal or vaginal bleeding 5. Hematuria 6. New onset hydronephrosis 7. New onset renal insufficiency 8. Constipation or bowel obstruction 9. Ascites 10. Rising tumor markers

VII. Evaluation before or after uterine artery embolization (also known as Uterine Fibroid Embolization (UFE) 22-24 A. Patients selected for Uterine Artery Embolization (UAE) may be approved for preoperative MRI to allow planning of the procedure Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

B. Postoperatively if there is: 1. Bleeding 2. Fever >100.4 3. Prolonged pain C. Post embolization for evaluation of results including establish a new baseline for size of fibroids following the procedure

VIII. Evaluation before or after uterine myomectomy 25 A. Preoperative planning B. Postoperatively if there is: 1. Bleeding 2. Fever >100.4 3. Prolonged pain

IX. Urethral diverticulum 26-28 A. Tender cystic swelling protruding from the vagina B. Urinary frequency, urgency, burning on urination, dysuria C. Dribbling D. Dyspareunia

X. Suspected pelvic fracture 29 A. Suspected sacral fracture (CT nondiagnostic or contraindicated) 1. Sacral pain with a single fracture of the pelvic ring 2. Sacral pain in long distance runners a. Not responsive to NSAIDs and modification of behavior for three or more weeks B. Osteopenic or postradiation therapy patient with chronic sacral or pubic pain

XI. Suspected sacroiliitis 30-33 A. Low back pain or pain over the sacroiliac joints [One] 1. HLA B27 positive 2. Known [One] a. Ankylosing spondylitis b. Psoriatic arthritis c. Inflammatory bowel disease d. Reiter’s syndrome e. Juvenile rheumatoid arthritis f. Rheumatoid arthritis

XII. Lumbosacral plexopathy 34-37 [see also: Known pelvic tumor for staging or restaging after therapy] [Gadolinium recommended] A. Lumbar spine imaging non-diagnostic B. Leg numbness or weakness in distribution of more than one nerve root C. Meralgia paresthetica (pain, paresthesia, and sensory loss in the lateral aspect of the thigh lateral femoral cutaneous nerve)

CareCore National Criteria for Imaging Version 2.2009

XIII. Prostate cancer detection 16, 38-41 (This may be an endorectal MRI) A. Mass detected on digital rectal examination or PSA >3.5 B. Transrectal Doppler ultrasound not diagnostic or not feasible C. Biopsy is contemplated

XIV. Suspected or known dissection of the thoracic aorta 42-45 A. Unequal blood pressure in the arms B. Rapid onset of "ripping, tearing, searing" severe chest or upper back or abdominal pain C. Pain with abnormal appearance of aorta on prior imaging 1. Chest 2. Back 3. Abdominal D. Syncope E. Shortness of breath F. Prior aortic aneurysm repairs G. Chest pain with evidence of a stroke H. Loss of pulses I. Follow up of known dissection

XV. Aneurysm 46-48 A. Suspected rupture of AAA 1. New onset of pain 2. Clinical findings a. Palpable, pulsatile or expansile mass b. Abnormal x-ray or US findings suggesting aortic disease c. Falling blood pressure B. Known AAA documented on ultrasound, CT, CTA, MRI, MRA 1. Periodic follow-up of known AAA will be allowed once every six months a. Inadequate ultrasound 2. New onset of pain C. Postoperative evaluation following endovascular repair (stent graft) 1. 1 month after repair 2. 3 months after repair 3. 6 months after repair 4. Annually after repair D. Aneurysm of any intra-abdominal artery detected on other Imaging E. Vascular insufficiency of the bowel 1. Abdominal pain often starting as periumbilical 2. Other clinical findings a. Leukocytosis, WBC >12,000/cu.mm b. Stool positive for occult blood c. Nausea, vomiting or diarrhea d. History of abdominal angina (pain after eating for approximately 3 hours)

CareCore National Criteria for Imaging Version 2.2009

References:

1. Chopra S, Lev-Toff AS, Ors F, et al, Adenomyosis: Common and uncommon manifestations on sonography and magnetic resonance imaging, J Ultrasound Med, 2006; 25:617-627. 2. Kunz G, Beil, D, Huppert P, et al, Adenomyosis in endometriosis-prevalence and impact on fertility. Evidence from magnetic resonance imaging, Human Reproduction, 2005; 20(8):2309-2316. 3. Parazzini F, Verecllini P, Panazza S, et al, Risk factors for adenomyosis, Human Reproduction 12(6):1275-1279. 4. Royal College of Obstetricians and Gynaecologists, Guideline No 41, April, 2005; The initial management of chronic pelvic pain, accessed at http://www.rcog.org.uk/resources/Public/pdf/initial_%20management_chronic_pelvic_pain41.pdf December 5, 2007. 5. Woodward PJ, Sohaey R, and Mezzetti TP Jr, From the archives of the AFIP. Endometriosis: radiologic-pathologic correlation, RadioGraphics, 2001; 21:193-216. 6. Kuligowska E, Deeds L, and Kang Lu, Pelvic pain: overlooked and underdiagnosed gynecologic conditions, RadioGraphics, 2005; 25:3-20. 7. Togashi K, Nishimura K, Kimura I, et al, Endometrial cysts: diagnosis with MR imaging, Radiology, 1991; 180:73-78. 8. Royal College of Obstetricians and Gynaecologists, Green-top Guideline No 24, October, 2006; The investigation and management of endometriosis, accessed at http://www.rcog.org.uk/resources/Public/pdf/endometriosis_gt_24_2006.pdf December 5, 2007. 9. Carbognin G, Guarise A, Minelli L, et al, Pelvic endometriosis: US and MRI features, Abdom Imaging, 2004; 29:609-618. 10. Imaoka I, Wada A, Matsuo M, et al, MR imaging of disorders associated with female infertility: use in diagnosis, treatment and management, RadioGraphics, 2003; 23:1401-1421. 11.Siegeleman ES, Outwater EK, Banner MP, et al, High-resolution MR imaging of the vagina, RadioGraphics, 1997; 1183-1203. 12. Hricak H, Chang YCF, Thurnher S, Vagina: evaluation with MR imaging, Radiology, 1988; 169:169-174. 13. Pellerito JS, McCarthy SM, Doyle MB, et al Diagnosis of uterine anomalies: relative accuracy of MR imaging, endovaginal sonography and hysterosalpingography, Radiology, 1992; 173:795-800. 14. Kier R, McCarthyS, Rosenfield AT, et al. Nonpalpable testes in young boys: evaluation with MR imaging, Radiology, 1988; 169: 429-433. 15. Fritzsche PJ, Hricak H, Kogan B, et al, Undescended testis: value of MR imaging, Radiology, 1987; 164:169-173. 16.Israel, GM, Francis IR, Roach M, et al, Expert Panel on Urologic Imaging and Radiation Oncology-Prostate, American College of Radiology Appropriateness Criteria, Pretreatment and staging prostate cancer, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonUrologicImaging/PretreatmentStagingProstat eCancerDoc12.aspx December 5, 2007. 17. Zafar S, Jafri H, Dinan D, et al , Expert Panel on Urologic Imaging, American College of Radiology Appropriateness Criteria, Pretreatment and staging bladder cancer, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonUrologicImaging/PretreatmentStagingofInvasi veBladderCancerDoc11.aspx December 5, 2007. 18. Tjandra JJ, Kilkenny JW, Buie WD, et al, Practice parameters for the management of rectal cancer (revised), Dis Colon Rectum, 2005; 48:411-423. 19. Hricak H, Akin O, Sala E, et al, Expert Panel on Women’s Imaging, American College of Radiology Appropriateness Criteria, Invasive cancer of the cervix, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonWomensImaging/InvasiveCanceroftheCervix Doc5.aspx December 5, 2007. 20. Hricak H, Akin O, Sala E, et al, Expert Panel on Women’s Imaging, American College of Radiology Appropriateness Criteria, Endometrial cancer of the uterus, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonWomensImaging/EndometrialCanceroftheUte rusDoc2.aspx December 5, 2007. 21. Howard G, Kirk D, Brush J, et al, Scottish Intercollegiate Guidelines Network, Management of transitional cell carcinoma of the bladder, accessed at http://www.sign.ac.uk/pdf/sign85.pdf December 5, 2007. 22.Andrew RT, Spies JB, Sacks D, et al, Patient care and uterine artery embolization for leiomyoma, J Vasc Interv Radiol, 21004; 15:115-120. 23.Pelage JP, Guaou NG, Jha RC, et al, Uterine fibroid tumors: long-term MR imaging outcome after embolization Radiology, 2004; 230: 803-809. 24.Dietz C, Ahles BL, Polasek P, et al Institute for Clinical Systems Improvement, Technology Assessment Report, Uterine artery embolization for uterine fibroids, accessed at http://www.icsi.org/technology_assessment_reports_- _active/ta_uterine_artery_embolization_for_uterine_fibroids.html December 5, 2007. 25.Tsuji S, Takahashi K, Imaoka I, et al, MRI evaluation of the uterine structure after myomectomy, Gynecol Obstet Invest, 2006;61:106-110. 26. Kim B, Hricak H, Tanagho E., Diagnosis of urethral diverticula in women: value of MR imaging, AJR. 1993; 161: 809-815.. 27.Hahn WY, Israel GM, and Lee VS, MRI of female urethral and periurethral disorders, 2004; 182:677-682.. 28.Blaivas JG, Flisser AJ, Bleustein CB, et al, Periurethral masses: etiology and diagnosis in a large series of women, Obstetrics & Gynecology, 2004; 103(5):842-847. 29. Blake SP, and Connors AM, Pictorial review Sacral insufficiency fracture, Brit J Radiol, 2004; 77:891-896. 30.Vleeming A, Albert HB, Ostgaard HC et al, European guidelines on the diagnosis and treatment of pelvic girdle pain, accessed at http://www.backpaineurope.org/web/files/WG4_Guidelines.pdf December 6, 2007. 31.Bredella MA, Steinbach LS, Morgan S, et al, MRI of the sacroiliac joints in patients with moderate to severe anklylosing spondylitis, AJR, 2006; 187:1420-1426 Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

33.Yu W, Feng F, Dion E et al, Comparison of radiography, computed tomography and magnetic resonance imaging in the detection of sacroiliitis accompanying anklylosing spondylitis, Skeletal Radiol, 1998;27(6):311-310. 34. Murphey MD, Wetzel LH, Bramble JM, et al, Sacroiliitis: MR imaging findings. Radiolog, 1991; 180: 239-244. 35. Bowen B, Seidenwurm DJ, Davis PC, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria, Plexopathy, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/plexopathyDoc12.aspx December 7, 2007. 36. Dworkin RH, Backonja M, Rowbotham MC et al, Advances in neuropathic pain: diagnosis, mechanisms and treatment recommendations, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=4671&nbr=003405&string=lumbar+AND+plexopathy December 7, 2007. 37..Maravilla KR, Bowen B., Imaging of the peripheral nervous system: evaluation of peripheral neuropathy and plexopathy, AJNR., 1998; 19: 1011-1023. 38. Gebarski KS, Gebarski SS, Glazer GM, et al, The lumbosacral plexus: anatomic-radiologic- pathologic correlation using C., RadioGraphics, 1986; 6:401-42539. 39. Ito H, Kamoi K, Yokoyama K, et al, Visualization of prostate cancer using dynamic contrast-enhanced MRI: comparison with transrectal power Doppler ultrasound. Br J Radio, 2003; 76: 617-624. 40. Yu KK, Scheidler J, Hricak H, et al. Prostate cancer: prediction of extracapsular extension with endorectal MR imaging and three- dimensional proton MR spectroscopic imaging. Radiology, 1999; 213:481 -488. 41. Li H, Sugimura K, Kaji Y. Conventional MRI capabilities in the diagnosis of prostate cancer in the transition zone, AJR, 2006; 186(3): 729 - 742. 42 Gomes AS, Bettmann MA, Casciani T, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-suspected aortic dissection, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainSusp ectedaorticdissectionDoc2.aspx December 28, 2007. 43Holtzman SR, Bettmann MA, Casciani T, et al, Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Blunt chest trauma suspected aortic injury, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/Vascular/BluntChestTraumaSuspectedaorticInjuryDoc6.aspx December 28, 2007. 44. Erbel R, Alfonso F, Boileau C, et al, Diagnosis and management of aortic dissection : recommendations of the task force on aortic dissection, Europena Society of Cardiology, European Heart Journal, 2001, 22:1642-1682. 45. Stanford W, Yucel EK, Bettmann MA, , Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-No ecg enzyme evidence of myocardial ischemia/infarction, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/Acute ChestPainNoECGorEnzymeEvidenceofMyocardialIschemiaInfarctionDoc1.aspx , December 28, 2007. 46. Starvropoulos SW and Charagundla SR, Imaging techniques for detection and management of endoleaks after endovascular aortic aneurysm repair, Radiology, 2007; 243:641-655. 47. Hirsch AT, Haskal AJ, Hertzer NR, et al, ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease(lower extremity, renal, mesenteric and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for vascular surgery,society for cardiovascular angiography and intervention, society for vascular medicine and biology, society of interventional radiology and the ACC/AHA task force on practice guidelines(writing committee to develop guidelines for the management of patients with peripheral arterial disease), J Am Coll Cardiol, 2006; 47:1-192. 48. Fattori R and Russo V, Degenerative aneurysm of the descending aorta. Endovascular Treatment, European Association for Cardio- thoracic Surgery, Multimedia Manual of Cardiothoracic Surgery, 2007, accessed at http://mmcts.ctsnetjournals.org/cgi/reprint/2007/1217/mmcts.2007.002824.pdfDecember 28, 2007.

Reviewed: 3/18/2009 Posted: 8/15/2009

CareCore National Criteria for Imaging Version 2.2009

72198 MRA or MRV of the Pelvis without or with Gadolinium

I. Peripheral arterial vascular disease 1,12-14 A. ABI (ankle brachial index, ankle systolic BP divided by brachial systolic BP) 1. Rest ABI < 0.90 in symptomatic member 2. Exercise ABI <0.90 in symptomatic member with rest ABI >0.90 3. Toe brachial index <0.90 or pulse volume recording evidence of peripheral vascular disease if the ABI >1.30 B. Abnormal pulses C. Bruit D. Claudication E. Diabetic with 1. Skin changes 2. Loss of hair 3. Poor capillary refill 4. Thickened nails 5. Thin skin F. Known atherosclerotic occlusive disease

II. Aneurysm of the iliac arteries 2 A. Known aortic aneurysm 1. Periodic follow-up of known AAA will be allowed once every six months a. Inadequate ultrasound b. No surgical repair c. New onset of pain B. Pulsatile mass on abdominal, vaginal, or rectal exam C. Aneurysm detected on x-ray or US exam D. Suspected rupture of AAA 1. New onset of pain 2. Clinical findings a. Palpable mass b. Abnormal x-ray of US findings suggesting aortic disease c. Falling blood pressure E. Postoperative evaluation following repair including endovascular repair (stent graft) 1. 1 month after repair 2. 3 months after repair 3. 6 months after repair 4. Annually after repair 5. Suspected endoleak

III. Suspected pelvic AVM A. Hematuria

CareCore National Criteria for Imaging Version 2.2009

B. Vaginal bleeding, may be after C-section or curettage

IV. Pelvic trauma, with suspected vascular injury

V. Prior to uterine artery embolization (MRA of the abdomen or pelvis)

VI. Suspected dissection of the thoracic aorta3-7 A. Unequal blood pressure in the arms B. Rapid onset of "ripping, tearing, searing" severe chest or upper back or abdominal pain C. Pain with abnormal appearance of aorta on prior imaging 1. Chest 2. Back 3. Abdominal D. Syncope E. Shortness of breath F. Prior aortic aneurysm repair G. Chest pain with evidence of a stroke H. Loss of pulses

References:

1. Saks D, Bettman MA, Casciani T, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria, claudication, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/Vascular/ClaudicationDoc9.aspx March 12, 2008. 2. Hirsch AT, Haskal Z, Hertzer NY, et al, ACC/AHA 2005 Guidelines for the Management of Patients with Peripheral Arterial Disease (lower extremity, renal, mesenteric and abdominal aortic): A Collaborative Report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology and the ACC/AHA Task Force on Practice Guidelines, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8503&nbr=004740&string=MRA+and+aneurysm March 12, 2008. 3 Gomes AS, Bettmann MA, Casciani T, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-suspected aortic dissection, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainSusp ectedaorticdissectionDoc2.aspx December 28, 2007. 4. Holtzman SR, Bettmann MA, Casciani T, et al, Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Blunt chest trauma suspected aortic injury, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/Vascular/BluntChestTraumaSuspectedaorticInjuryDoc6.aspx December 28, 2007. 5. Erbel R, Alfonso F, Boileau C, et al, Diagnosis and management of aortic dissection : recommendations of the task force on aortic dissection, Europena Society of Cardiology, European Heart Journal, 2001, 22:1642-1682. 6. Stanford W, Yucel EK, Bettmann MA, , Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-No ecg enzyme evidence of myocardial ischemia/infarction, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/Acute ChestPainNoECGorEnzymeEvidenceofMyocardialIschemiaInfarctionDoc1.aspx December 28, 2007. 7.Mulder S, Spilde P, Morrison J, et al, Helath Care Guideline: Diagnosis and treatment of chest pain and acute coronary syndrome (ACS), Institute for Clinical systems Improvement, Third Edition, 2006, accessed at http://www.icsi.org/acs_acute_coronary_syndrome /acute_coronary_syndrome _and_chest_pain__diagnosis_and_treatment_of_2.html December 28, 2007.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

73200 CT of the Upper Extremity without Contrast 73201 CT of the Upper Extremity with Contrast 73202 CT of the Upper Extremity without and with Contrast

I. Suspected fracture (including stress fractures) 1, 2 A. Pain at site, x-ray non-diagnostic for fracture at initial evaluation 1. Pain with passive Range of Motion (ROM) or weight bearing 2. Pain unimproved after activity modification and/or immobilization ~ 2 weeks B. Two x-rays 10 days apart not diagnostic of fracture C. MRI not feasible

II. Suspected nonunion of known fracture 2 A. Failure to demonstrate progressive evidence of healing for 3 or more months B. Pain at fracture site C. Movement at fracture site by subjective sensation or by radiographic imaging

III. Suspected osteomyelitis 3-5 A. Clinical findings 1. ESR >20 mm/hr 2. Fever >100.4 3. Leukocytosis, WBC >12,000/cu.mm 4. C-reactive protein >10 mg/ml 5. Blood culture positive B. Any of the following: 1. Pain 2. X-ray non-diagnostic 3. History of infection elsewhere 4. History of diabetes, dialysis or peripheral vascular disease 5. History of penetrating injury or surgery 6. Sinus tract, poor wound or fracture healing C. Pre-operative evaluation of osteomyelitis D. Interval follow up during or after completion of treatment

IV. Tumor A. Suspected bone tumor 1. Pain 2. Bone lesion detected on prior imaging B. Follow-up primary or metastatic bone tumor proven on prior imaging 1. After radiation or chemotherapy has been completed 2. Periodic assessment 3. New or worsening symptoms at site Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

V. Mass 6 [MRI preferred] A. Palpable lesion newly discovered or growing B. Evidence of inflammation 1. Pain or tenderness at site 2. Redness 3. Associated fever >100.4 C. Recent trauma 1. Suspected hematoma 2. US not diagnostic D. Known prior lesion or underlying malignancy E. Prior surgery or radiation therapy

VI. Assessment of prosthetic positioning and alignment A. Suspicion of poor alignment of prosthesis or joint replacement B. Plain radiographs non-diagnostic

VII. Complex fracture, CT required for treatment planning

References:

1. Dalinka MK, Daffner RH, De Smet AA, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria- chronic wrist pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ChronicWristPainDo c10.aspx May 15, 2008. 2. Rubin DA, Dalinka MK, Daffner RH, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria- acute hand and wrist trauma, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/AcuteHandandWrist TraumaDoc1.aspx May 15, 2008. 3. FAyad LM, Carrino JA, Fishman EK, Musculoskeletal infection: role of CT in the emergency department, RadioGraphics, 2007; 27: 1723- 1236. 4. Auh JS, Binns HJ, and Katz BZ, Retrospective assessment of subacute or chronic osteomyelitis in children and young adults, Clin Pediatr,2004; 43:549-555. 5. Lazzarini L, Mader JT, and Calhoun JH, Osteomyelitis in long bones, J Bone Joint Surg Am, 2004:86:2305-2318. 6. Keiken JP, Lee JKT, Smathers RL et al, CT of benign soft-tissue masses of the extremities, AJR, 1984,; 142:575-580.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

73206 CTA of the Upper Extremity

I. Suspected occlusion, stenosis 1 A. Abnormal pulses: asymmetric, weak or absent B. Claudication C. Skin changes: poor capillary filling, cyanosis D. Abnormal Doppler ultrasound E. Thoracic outlet syndrome F. Reconstruction surgery planning G. Thoracic outlet syndrome [Two or more] 1. Cold extremity or digits 2. Pallor 3. Decreased pulses 4. Decreased blood pressure in one arm 5. Change in pulse or blood pressure with change in position of arm or head H. Effort thrombosis [Two or more] 1. Swelling 2. Cyanosis 3. Evidence of collateral veins

II. Aneurysm or AVM of the upper extremity arteries A. Pulsatile mass by palpation or imaging

III. Venous aneurysm A. Doppler US not diagnostic B. Asymptomatic peripheral mass

1. Stepansky F, Hecht EM, Rivera R, et al, Dynamic MR angiography of upper extremity vascular disease: pictorial review, Radiographics, 2008; 28-e28 published online October 29, 2007, accessed at http://radiographics.rsnajnls.org/cgi/content/full/28/1/e28 May 13, 2008. 2. Bogdan MA, Klein MB, Rubin GD, et al. CT Angiography in Complex Upper Extremity Reconstruction. Journal of Hand Surgery (British and European Volume), Vol. 29, No. 5, 465-469(2004), accessed at http://www.drmichaelbogdan.com/publications/bogdan_JHS04.pdf

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

73218 MRI Upper Extremity Other than Joint Including Hand without Gadolinium

I. Known or suspected fracture (including stress fractures) 1, 2 A. Pain at site, x-ray non-diagnostic for fracture at initial evaluation 1. Pain with passive Range of Motion (ROM) 2. Pain unimproved after activity modification and/or immobilization for 2 weeks B. Two x-rays 10 days apart not diagnostic of fracture C. Worsening symptoms during Immobilization or activity modification D. Scaphoid or navicular fracture 1. Normal or equivocal x-ray E. Distal radius fracture with possible extension into the joint F. Suspected fracture of the hook of the hamate 1. Normal or equivocal x-rays

II. Suspected nonunion of known fracture 2 A. Failure to demonstrate progressive evidence of healing for 3 or more months B. Pain at fracture site C. Movement by subjective sensation or by radiographic imaging

III. Suspected soft tissue injury 3-7 A. Muscle injury 1. Defect palpable 2. Pain on movement with palpable muscle swelling B. Compartment syndrome [Any Two] 1. Prior trauma with or without fracture 2. Pain on stretching of muscle 3. Pain on palpation of muscle

IV. Tendinitis 8 A. Symptoms 1. Localized pain that is reproduced with stretching of the affected tendon 2. Tenderness to palpation of tendon 3. History of repetitive overuse B. No relief after conservative medical management 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Symptoms worsening while under treatment 3. Pain severe enough to require opiates (narcotics) with no relief after 2 days

V. Evaluation of the intrinsic muscles of the hand A. Atrophy of any hand muscles

CareCore National Criteria for Imaging Version 2.2009

B. Motor and sensory deficits of the hand unexplained by physical examination and EMG

VI. Trauma 2 A. Scaphoid or navicular fracture 1. Normal or equivocal x-ray B. Distal radius fracture with possible extension into the joint C. Suspected subluxation of radioulnar joint D. Suspected fracture of the hook of the hamate 1. Normal or equivocal x-rays E. Suspected metacarpal fracture or dislocation 1. Normal or equivocal x-rays

References:

1. Dalinka MK, Daffner RH, De Smet AA, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria- chronic wrist pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ChronicWristPainDo c10.aspx May 15, 2008. 2. Rubin DA, Dalinka MK, Daffner RH, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria- acute hand and wrist trauma, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/AcuteHandandWrist TraumaDoc1.aspx May 15, 2008. 3. Anderson SE, Hertel R, Johnston JO, et al, Latissimus dorsi tendinosis and tear: imaging features of a pseudotumor of the upper limb in five patients, AJR, 2005; 185:1145-1151. 4. May DA, Disler DG, Jones EA, et al, Abnormal signal intensity in skeletal muscle at MRI imaging: patterns, pearls and pitfalls, RadioGraphics, 2000; 20:S295-S315. 5. Connell DA, Potter HG, Sherman MF, et al, Injuries of the pectoralis major muscle: evaluation with MR imaging, Radiology, 1999; 210:785- 791. 6. Beltran J and Rosenberg ZS, Diagnosis of compressive and entrapment neuropathies of the upper extremity : value of MR imaging, AJR, 1994; 163:525-531. 7. DeSmet AA, Magnetic resonance findings in skeletal muscle tears, Skeletal Radiol, 1993; 22:479-484. 8. Steele M, and Norvell JG, Tendonitis, accessed at http://www.emedicine.com/emerg/TOPIC570.HTM May 16, 2008.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

73219 MRI Upper Extremity Other than Joint Including Hand with Gadolinium 73220 MRI Upper Extremity Other than Joint Including Hand without and with Gadolinium

I. Suspected or known osteomyelitis A. Clinical findings 1. ESR >20 mm/hr 2. Fever >100.4 3. Leukocytosis WBC >12,000/cu.mm 4. C-reactive protein >10 mg/L 5. Blood culture positive B. Any of the following 1. Pain 2. X-ray non-diagnostic 3. History of infection elsewhere 4. History of diabetes, dialysis or peripheral vascular disease 5. History of penetrating injury or surgery 6. Sinus tract, poor wound or fracture healing C. Pre-operative evaluation of osteomyelitis D. Interval follow up during or after completion of treatment

II. Tumor A. Suspected bone tumor [CT or MRI] 1. Pain at site 2. Bone lesion at site by imaging (radiograph or bone scan) B. Follow-up known bone tumor [CT or MRI] 1. Prior imaging positive at site 2. After radiation or chemotherapy has been completed 3. Periodic assessment 4. New or worsening symptoms at site

III. Palpable mass of extremity A. Palpable lesion newly discovered or growing B. Evidence of inflammation 1. Pain or tenderness at site 2. Redness 3. Associated fever >100.4 C. Recent trauma, suspected hematoma, US not diagnostic D. Known prior lesion or underlying malignancy Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

E. Prior surgery or radiation therapy

IV. Brachial plexus A. Brachial plexus injury 1. Symptoms a. Weakness or paralysis of the shoulder and biceps b. Weakness of the wrist c. Weakness or paralysis of the forearm or hand d. Horner’s syndrome 2. History a. Trauma including birth trauma b. Radiation fibrosis c. History of radiation therapy to the chest, breast or axilla d. Weakness of the shoulder and/or arm B. Primary or metastatic tumor 1. Symptoms a. Pain b. Weakness of the extremity c. Numbness of the extremity d. Hyperesthesia of the extremity C. Schwannoma or neurofibroma 1. Symptoms a. Palpable mass in the lower neck or supraclavicular fossa b. Weakness of the upper extremity

CareCore National Criteria for Imaging Version 2.2009

73221 MRI Upper Extremity Joint without Gadolinium: Elbow

I. Joint complaints, etiology unknown 1,2 A. Clinical findings 1. Joint pain 2. Limited Range of Motion (ROM) 3. Crepitus 4. Locking 5. Joint line tenderness 6. Effusion by PE B. No response to conservative management 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Continued pain after physical therapy for 4 weeks or more 3. Symptoms worsening while under treatment

II. Suspected intra-articular loose body 1 A. Joint pain B. Locking C. Clicking

III. Suspected avascular necrosis (osteonecrosis, OCD, AVN, osteochondritis dissecans) A. Pain B. Pain with passive movement C. Steroid use D. Sickle Cell Disease E. Chronic pain after sprain or sprains F. No response to conservative management 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Continued pain after physical therapy for 4 weeks or more 3. Symptoms worsening while under treatment

IV. Suspected fracture (stress or occult) 1,3,4 A. Clinical findings 1. Pain and tenderness at site of suspected injury B. Negative x-ray

1, 5-8 V. Injuries to the elbow A. Suspected Ulnar (Medial) Collateral Ligament (UCL or MCL) injury

CareCore National Criteria for Imaging Version 2.2009

1. Elbow injury 2. Tenderness of medial elbow 3. Instability with valgus stress testing 4. No response to conservative management a. Continued pain after anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated b. Physical therapy for at least 4 weeks c. Symptoms worsening while under treatment B. Suspected Radial (lateral) Collateral Ligament (RCL) injury 1. Elbow injury or history of repeated heavy lifting 2. Tenderness of lateral elbow 3. Instability with varus stress testing 4. No response to conservative management a. Continued pain after anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated b. Physical therapy for at least 4 weeks c. Symptoms worsening while under treatment C. Ulnar nerve injury or entrapment 1. Symptoms a. Tenderness along the inside of the elbow b. Tingling and numbness in little and ring fingers c. Numbness in hand when the elbow is bent d. Difficulty with hand coordination (such as when typing or playing a musical instrument) e. Decreased grip and pinch strength, muscle weakness 2. No response to conservative management a. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated b. Physical therapy for at least 4 weeks c. Symptoms worsening while under treatment 3. History of fracture of or near elbow D. Biceps or triceps tendon tear 1. Reduced ability to flex or extend at elbow E. Suspected epicondylitis (tennis elbow) 1. Symptoms a. Pain b. Tenderness c. Pain on passive stretching d. Pain on resisted active contraction 2. No response to conservative management a. Continued pain after anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated b. Steroid injections c. Physical therapy for at least 4 weeks d. Symptoms worsening while under treatment

CareCore National Criteria for Imaging Version 2.2009

References:

1. Steinbach LS, Dalinka MK, and Daffner RH, American College of Radiology Appropriateness Criteria- chronic elbow pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ChronicelbowPainDo c6.aspx March 18, 2008. 2. Palmer, T and Toombs JD, Managing joint pain in primary care, J Am Board Fam Pract, 2004; 17:S32-S42. 3. Berger PE, Ofstein RA, Jackson DW, et al, MRI demonstration of radiographically occult fractures: what have we been missing? RadioGraphics 1989;9: 407-436. 4. Daffner RH and Pavlov H, Stress fractures: current concepts, AJR, 1992; 159:245-252. 5. Mackay D, Rangan A, Hide G, et al, The objective diagnosis of early tennis elbow by magnetic resonance imaging, Occupational Medicine, 2003; 53:309-312. 6. Langer P, Fadale P and Hulstyn M, Evolution of the treatment options of ulnar collateral ligament injuries of the elbow, Br J Sports Med, 2006; 40:499-506. 7. Driscoll SWM, Lawton RL, and Smith AM, The ‘moving valgus stress test’ for medial collateral ligament tears of the elbow, Am J Sports Med, 2005; 33:231-239. 8. Work Loss Data Institute, Elbow (acute & chronic), Corpus Christi(Tx), Work Loss Data Institute, 2007 Jun 11, 158p accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=11017 November 24, 2008.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

73222 MRI Upper Extremity Joint with Gadolinium: Elbow 73223 MRI Upper Extremity Joint without and with Gadolinium: Elbow

I. Suspected osteomyelitis 1 A. Clinical findings 1. Fever >100.4 2. Leukocytosis, WBC >12,000/cu.mm 3. ESR >20 mm/hr 4. C-reactive protein >10 mg/ml 5. Blood culture positive B. Any of the following: 1. Pain 2. X-ray non-diagnostic 3. History of infection elsewhere 4. History of diabetes, dialysis or peripheral vascular disease 5. History of penetrating injury or surgery 6. Sinus tract, poor wound or fracture healing C. Pre-operative study D. Post operative study to establish a new baseline E. Interval imaging of an established osteomyelitis to assess response to treatment

II. Evaluation of joints for aggressive treatment of arthritis or synovitis 2 A. Proven rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis by lab studies and clinical findings B. Intention to begin Remicade therapy or similar

III. Suspected bone tumor A. X-ray or CT evidence of bone tumor or soft tissue tumor affecting bone B. Preoperative or pretreatment planning B. Known malignancy elsewhere with new onset of bone pain 1. X-ray 2. Bone san

IV. MR arthrogram 3 (with gadolinium) A. Pain interferes with the smooth functioning of the elbow

V. Soft tissue mass4,5 A. X-ray of the area of interest B. Preoperative planning C. Post operative imaging Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

D. Surveillance with no evidence of recurrence 1. Low-grade tumor annually for 5 years 2. High grade tumor every 3-6 months for 5 years

VI. Septic joint A Symptoms 1. Acute onset of pain 2. Inability to bear weight 3. Limited Range of Motion (ROM) B Findings on physical examination 1. Swelling 2. Erythema 3. Fever >100.4 4. Leukocytosis, WBC count > 12,000/ cu. mm 5. C-reactive protein >10 mg/ml

References: 1. Unger E, Moldofsky P, Gatenby R, et al, Diagnosis of osteomyelitis by MR imaging, AJR, 1988; 150:605-610. 2. Steinbach LS, Dalinka MK and Daffner RH, American College of Radiology Appropriateness Criteria- Chronic Elbow Pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ChronicelbowPainDo c6.aspx March 18, 2008. 3. Kobelt G, Jönsson L , Young A, et al, The cost-effectiveness of infliximab (Remicade®) in the treatment of rheumatoid arthritis in Sweden and the United Kingdom based on the ATTRACT study Rheumatology, 2003; 42:326-335. 4. Morrison WB, Dalinka MK, Daffner RH, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria-Soft tissue masses, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/SoftTissueMassesD oc19.aspx , December 29, 2008. 5.Knapp EL, Kransdorf MJ and Letson D, Diagnostic imaging update: soft tissue sarcomas, Cancer Control, 2005; 12:22-26, accessed at http://medgenmed.medscape.com/viewarticle/498749_print , December 29, 2008.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

73221 MRI Upper Extremity Joint without Gadolinium: Shoulder

I. Joint complaints, etiology unknown 1-3 A. Clinical findings 1. Joint pain 2. Limited Range of Motion (ROM) 3. Crepitus 4. Locking 5. Joint line tenderness 6. Effusion by PE B. No relief after conservative medical management 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Continued pain after physical therapy for 4 weeks or more 3. Symptoms worsening while under treatment

II. Suspected intra-articular loose body A. Joint pain B. Locking C. Clicking

IV. Suspected fracture (stress or occult) 2,4,5 A. Clinical findings 1. Pain and tenderness at site of suspected injury B. Two x-rays 10 days apart not diagnostic of fracture C. Continued pain after conservative therapy greater than 2 weeks

2 V. Suspected acute rotator cuff tear A. Recent injury Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

B. Shoulder pain C. Additional findings 1. Weakness 2. Subacromial tenderness D. Shoulder x-ray non-diagnostic E. Apley’s scratch test F. Neer sign G. Apprehension sign H. Drop arm sign I. Sulcus sign J. Relocation sign K. Empty can sign

VI. Suspected chronic rotator cuff tendinitis3 A. Clinical findings 1. Dull aching in the shoulder, which may interfere with sleep 2. Severe pain when the arm is actively abducted into an overhead position 3. May be associated with subacromial bursitis 4. Symptoms after injury or overuse a. Baseball b. Tennis c. Swimming d. Occupations that require repeated elevation of the arm 5. Over age 40 6. Apley’s scratch test 7. Neer sign 8. Apprehension sign 9. Drop arm sign 10. Sulcus sign 11. Relocation sign 12. Empty can test B. Shoulder x-ray non-diagnostic C. No relief after conservative medical management 1. Steroid injection 2. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 3. Continued symptoms after physical therapy for 4 weeks or more 4. Symptoms worsening while under treatment

VII. Suspected labral tear 4 A. Pain interferes with the smooth functioning of the shoulder B. Discomfort on forced external rotation at 90 degrees of abduction C. A "pop" or "click" on forced external rotation D. Discomfort on forced horizontal adduction of the shoulder E. Weakness in the rotator cuff muscles

CareCore National Criteria for Imaging Version 2.2009

References: 1. Denniston PL Jr, Kennedy CW, et al, Work Loss Data Institute, Shoulder (acute and chronic), accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=11028&nbr=005808&string=MRI+AND+shoulder March 14, 2008. 2. American College of Occupational and Environmental Medicine, Shoulder Complaints, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/shoulderTraumaDoc 18.aspx March 14, 2008. 3. WorkCover SA, Imaging guidelines, Government of South Australia, 2007, accessed at www.workcover.com/Treat/TREATHome/Resources/Treatdocuments.aspx?fno=4968 March 17, 2008. 4. Steinbach LS, Dlinka MK, Daffner RH, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria- shoulder trauma, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/shoulderTraumaDoc 18.aspx March 14, 2008. 5. Berger PE, Ofstein RA, Jackson DW, et al, MRI demonstration of radiographically occult fractures: what have we been missing, RadioGraphics, 1989; 9:407-436.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

73222 MRI Upper Extremity Joint with Gadolinium: Shoulder 73223 MRI Upper Extremity Joint without and with Gadolinium: Shoulder

I. Suspected osteomyelitis1, 2 A. Clinical findings 1. Fever >100.4 2. Leukocytosis, WBC >12,000/cu.mm 3. ESR >20 mm/hr 4. C-reactive protein >10 mg/ml 5. Blood culture positive B. Any of the following: 1. Pain 2. History of infection elsewhere 3. History of diabetes, dialysis or peripheral vascular disease 4. History of penetrating injury or surgery 5. Sinus tract, poor wound or fracture healing C. Pre-operative study D. Post operative study to establish a new baseline E. Interval imaging of an established osteomyelitis to assess response to treatment

II. Suspected labral tear 3 (consider MR arthrogram) A. Pain interferes with the smooth functioning of the shoulder B. Discomfort on forced external rotation at 90 degrees of abduction C. A "pop" or "click" on forced external rotation D. Discomfort on forced horizontal adduction of the shoulder E. Weakness in the rotator cuff muscles

III. Evaluation of joints for aggressive treatment of arthritis or synovitis A. Proven rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis by lab studies and clinical findings B. Intention to begin Remicade therapy or similar

4 IV. Suspected bone tumor A. X-ray or CT evidence of bone tumor, or soft tissue tumor affecting bone B. Preoperative or pretreatment planning C. Known malignancy elsewhere with new onset of bone pain 1. Must have x-ray 2. Bone scan

CareCore National Criteria for Imaging Version 2.2009

V. Brachial plexus 5 A. Brachial plexus injury 1. Symptoms a. Weakness or paralysis of the shoulder and biceps b. Weakness of the wrist c. Weakness or paralysis of the forearm or hand d. Horner’s syndrome 2. History a. Trauma including birth trauma b. Radiation fibrosis c. History of radiation therapy to the chest, breast or axilla d. Weakness of the shoulder and/or arm B. Primary or metastatic tumor 1. Symptoms a. Pain b. Weakness of the extremity c. Numbness of the extremity d. Hyperesthesia of the extremity B. Schwannoma or neurofibroma 1. Palpable mass in the lower neck or supraclavicular fossa 2. Weakness of the upper extremity

VI. MR arthrogram (with gadolinium) A. Suspicion of a labral tear 1. Pain interferes with the smooth functioning of the shoulder 2. Discomfort on forced external rotation at 90 degrees of abduction 3. A "pop" or "click" on forced external rotation 4. Discomfort on forced horizontal adduction of the shoulder 5 Weakness in the rotator cuff muscles

VII. Soft tissue mass (if there is a suspicion of malignancy, imaging must be performed before a biopsy)6,7 A. X-ray of the area of interest B. Preoperative planning C. Post operative imaging D. Surveillance with no evidence of recurrence 1. Low-grade tumor annually for 5 years 2. High grade tumor every 3-6 months for 5 years

VIII. Septic joint A Symptoms 1. Acute onset of pain 2. Inability to bear weight 3. Limited Range of Motion (ROM)

CareCore National Criteria for Imaging Version 2.2009

B Findings on physical examination 1. Swelling 2. Erythema 3. Fever >100.4 4. Leukocytosis, WBC count > 12,000/ cu. mm 5. C-reactive protein >10 mg/ml

References:

1. Karchevsky M, Schweitzer ME, Morrison WB, et al, MRI findings of septic arthritis and associated osteomyelitis in adults, AJR, 2004; 182:119-122. 2. Unger E, Moldofsky P, Gatenby R, et al, Diagnosis of osteomyelitis by MR imaging, AJR, 1988; 150:605-610. 3. Steinbach LS, Dlinka MK, Daffner RH, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria- Shoulder Trauma, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/shoulderTraumaDoc 18.aspx March 14, 2008. 4. Herzog RJ, Instructional Course Lectures, the American Academy of Orthopedic Surgeons-magnetic resonance imaging of the shoulder, JBJS, 1997; 70:934-953. 5. Bowen B, Seidenwurm DJ, Davis PC, et al, Expert Panel on Neurological Imaging, American College of Radiology Appropriateness Criteria – Plexopathy accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/PlexopathyDoc12.aspx March 14, 2008. 6. Morrison WB, Dalinka MK, Daffner RH, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria-Soft tissue masses, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/SoftTissueMassesD oc19.aspx , December 29, 2008. 7.Knapp EL, Kransdorf MJ and Letson D, Diagnostic imaging update: soft tissue sarcomas, Cancer Control, 2005; 12:22-26, accessed at http://medgenmed.medscape.com/viewarticle/498749_print , December 29, 2008.

CareCore National Criteria for Imaging Version 2.2009

73221 MRI Upper Extremity Joint without Gadolinium: Wrist and Hand

I. Joint complaints, etiology unknown 1, 2, 3 A. Clinical findings 1. Joint pain 2. Limited Range of Motion (ROM) 3. Crepitus 4. Locking 5. Joint line tenderness 6. Effusion by PE B. No response to conservative medical management 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Continued pain after physical therapy for 4 weeks or more 3. Symptoms worsening while under treatment

II. Suspected intra-articular loose body A. Joint pain B. Locking C. Clicking

III. Suspected avascular necrosis (osteonecrosis, OCD, AVN, 1,3 osteochondritis dissecans) A. Pain B. Pain with passive movement C. Steroid use D. Sickle Cell Disease E. Chronic pain after sprain or sprains F. No response to conservative management 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Continued pain after physical therapy for 4 weeks or more 3. Symptoms worsening while under treatment

IV. Known or suspected fracture except scaphoid or navicular (stress or occult) 1, 3, 4 A. Clinical findings 1. Pain and tenderness at site of suspected injury B. Two x-rays 10 days apart not diagnostic of fracture

CareCore National Criteria for Imaging Version 2.2009

V. Suspected injury of wrist ligaments and cartilage including the Triangular Fibrocartilage Complex (TFCC) 3, 5 A. Twisting or other injury to wrist B. Wrist pain with movement and palpation C. Weakness (decreased grasp strength) D. Wrist x-ray non-diagnostic for etiology of pain E. No relief after conservative medical management 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Continued pain after physical therapy for 4 weeks or more 3. Symptoms worsening while under treatment

VI. Suspected navicular or scaphoid fracture 3, 6, 7 A. History of wrist injury, tenderness in ‘anatomic snuff box’ (at distal end of radius along lateral margin of the wrist) and tenderness with thumb movement B. Pain which may increase with gripping or squeezing C. One negative or non diagnostic x-ray

8 Evaluation of intrinsic muscles of the hand A. Atrophy of any hand muscles B. Motor and sensory deficits of the hand unexplained by PE and EMG

References:

1. Dalinka MK, Daffner RH, De Smet AA, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria- Chronic Wrist Pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ChronicwristPainDo c10.aspx March 19, 2008. 2. Palmer, T and Toombs JD, Managing joint pain in primary care, J Am Board Fam Pract, 2004; 17:S32-S42. 3. McAlinden PS, and The J, Imaging of the wrist, Imaging, 2003; 15:180-192. 4. Rubin DA, Dalinka MK, Daffner RH, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria-Acute Hand and Wrist Trauma, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/AcuteHandandwrist TraumaDoc1.aspx March 19, 2008. 5. Haims AH, Moore AE, Schweitzer ME, et al, MRI in the diagnosis of cartilage injury in the wrist, AJR, 2004; 182:1267-1270. 6. Phillips TG, Reibach AM, and Slomiany WP, Diagnosis and Management of Scaphoid Fractures, American Family Physician, 2004; 70: 869-884, accessed at http://www.aafp.org/afp/20040901/879.pdf March 20, 2008. 7. Brydie A and Raby N, Early MRI in the management of clinical scaphoid fracture, BJR, 2003; 76:296-300. 8. Andreisek G, Kilgus M, Burg D, et al, MRI of the intrinsic muscles of the hand: spectrum of imaging findings and clinical correlation, AJR, 2005; 185:930-939.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

73222 MRI Upper Extremity Joint with Gadolinium: Wrist and Hand 73223 MRI Upper Extremity Joint with and without Gadolinium: Wrist and Hand

I. Suspected osteomyelitis 1 A. Clinical findings 1. Fever >100.4 2. Leukocytosis, WBC >12,000/cu.mm 3. ESR >20 mm/hr 4. C-reactive protein >10 mg/ml 5. Blood culture positive B. Any of the following: 1. Pain 2. History of infection elsewhere 3. History of diabetes, dialysis or peripheral vascular disease 4. History of penetrating injury or surgery 5. Sinus tract, poor wound or fracture healing C. Pre-operative study D. Post operative evaluation to establish a new baseline E. Interval imaging of an established osteomyelitis to assess response to treatment

III. Suspected bone tumor 3 A. X-ray evidence or CT evidence of bone tumor, or soft tissue tumor affecting bone B. Preoperative or pretreatment planning B. Known malignancy elsewhere with new onset of bone pain [Both] 1. Must have x-ray 2. Bone scan C. Follow up after treatment

IV. MR arthrogram 3, 4, 5 (with gadolinium) A. TFCC injury B. Suspicion of scapholunate ligament disruption C. Suspicion of lunotriquetral ligament disruption

V. Soft tissue mass 6-9

CareCore National Criteria for Imaging Version 2.2009

A. Suspected ganglion 1. Transillumination or ultrasound demonstrating non cystic mass 2. Recurrence after aspiration 3. No response to aspiration B. Suspected soft tissue sarcoma (if there is a suspicion of malignancy imaging must be performed before a biopsy) 1. X-ray of the area of interest 2. Preoperative or pretreatment planning 2. Post operative imaging 3. Surveillance with no evidence of recurrence a. Low-grade tumor annually for 5 years b. High-grade tumor every 3-6 months for 5 years C. Preoperative or pretreatment planning D. Follow up after treatment

VI. Septic joint A. Symptoms 1. Acute onset of pain 2. Limited Range of Motion (ROM) B. Findings on examination 1. Swelling 2. Erythema 3. Fever >100.4 4. Leukocytosis, WBC count > 12,000/ cu. mm 5. C-reactive protein >10 mg/ml

References:

1. Unger E, Moldofsky P, Gatenby R, et al, Diagnosis of osteomyelitis by MR imaging, AJR, 1988; 150:605-610. 2. Kobelt G, Jönsson L , Young A, et al, The cost-effectiveness of infliximab (Remicade®) in the treatment of rheumatoid arthritis in Sweden and the United Kingdom based on the ATTRACT study, Rheumatology, 2003; 42:326-335. 3. Dalinka MK, Daffner RH, De Smet AA, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria- chronic wrist pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ChronicwristPainDoc 10.aspx March 19, 2008. 4. McAlinden PS, and The J, Imaging of the wrist, Imaging, 2003; 15:180-192. 5. Ruegger C, Schmid MR, Pfirrmann CWA, et al, Peripheral tear of the triangular fibrocartilage: depiction with MR arthrography of the distal radioulnar joint, AJR, 2007; 188:187-192. 6. Morrison WB, Dalinka MK, Daffner RH, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria- Soft Tissue Masses, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/SoftTissueMassesD oc19.aspx March 19, 2008. 7. The J and Whiteley G, MRI of soft tissue masses of the hand and wrist, BJR, 2007; 80:47-63. 8. Burke FD, Melikyan EY, Bradley MJ, et al, Primary care referral protocol for wrist ganglia, Postgrad Med J, 2003; 79:329-331 9. Knapp EL, Kransdorf MJ and Letson D, Diagnostic imaging update: soft tissue sarcomas, Cancer Control, 2005; 12:22-26, accessed at http://medgenmed.medscape.com/viewarticle/498749_print December 29, 2008.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

73225 MRA Upper Extremity

I. Suspected occlusion, stenosis 1 A. Abnormal pulses: asymmetric, weak or absent B. Claudication C. Skin changes: poor capillary filling, cyanosis D. Abnormal Doppler ultrasound

II. Aneurysm or AVM of the upper extremity arteries A. Pulsatile mass by palpation or imaging

III. Venous aneurysm A. Doppler US not diagnostic B. Asymptomatic peripheral mass

References:

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

73700 CT Lower Extremity without Contrast 73701 CT Lower Extremity with Contrast 73702 CT Lower Extremity without and with Contrast

II. Suspected nonunion of known fracture 1, 3 A. Failure to demonstrate progressive evidence of healing for 3 or more months B. Pain at fracture site C. Movement by subjective sensation or by radiographic imaging

III. Suspected osteomyelitis 4, 5 A. Clinical findings 1. Fever >100.4 2. Leukocytosis, WBC >12,000/cu.mm 3. ESR >20 mm/hr 4. C-reactive protein >10 mg/L 5. Blood culture positive B. Any of the following: 1. Pain, maybe dull or vague, x-ray non-diagnostic 2. History of infection elsewhere 3. History of diabetes, dialysis or peripheral vascular disease 4. History of penetrating injury or surgery 5. Sinus tract, poor wound or fracture healing C. Pre-operative evaluation of osteomyelitis D. Interval re-evaluation during or after treatment

IV. Suspected tarsal coalition A. Pain at site B. Rigid flatfoot with personal spasm C. Pain relieved by rest D. Personal tendon spasms E. History of ankle sprains F. X-ray non-diagnostic for tarsal coalition

V. Tumor 6 A. Suspected bone tumor

CareCore National Criteria for Imaging Version 2.2009

1. Pain at site 2. Bone lesion at site by imaging (x-ray or bone scan) B. Follow-up primary or metastatic bone tumor 1. Prior imaging positive at site 2. After radiation or chemotherapy has been completed 3. Periodic assessment (annually if no change in clinical findings) 4. New or worsening symptoms at site

VI. Palpable mass of extremity [MRI preferred] A. Palpable lesion newly discovered or growing B. Evidence of inflammation 1. Pain or tenderness at site 2. Redness 3. Associated fever >100.4 C. Recent trauma, suspected hematoma, US not diagnostic D. Known prior lesion or underlying malignancy E. Prior surgery or radiation therapy

VII. Assessment of prosthetic positioning and alignment A. Suspicion of poor alignment of prosthesis or joint replacement B. Plain x-rays non-diagnostic

VIII. Complex fracture, CT required for treatment planning

IX. Patello-femoral pathology (including patellar tracking disorder) 7 A. Symptoms and history 1. Anterior knee pain worsening with activity (e.g. running, standing up from a bent-knee position) 2. Pain on squatting 3. History of recurrent patellar dislocations or subluxations B. Clinical findings 1. Crepitus 2. Positive patellar grind test 3. Pain on palpation of the medial and/or lateral patellar 4. Positive J sign (patella displaces laterally at full knee extension) C. No relief after medical (conservative) management [(1 and 2) or 3] 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Continued pain after physical therapy for 4 weeks or more 3. Symptoms worsening while under treatment

8 X. Gaucher’s disease [MRI not available or feasible]

XI. Septic joint [MRI not available or feasible] A. Symptoms

CareCore National Criteria for Imaging Version 2.2009

1. Acute onset of pain 2. Inability to bear weight 3. Limited Range of Motion (ROM) B. Findings on physical examination 1. Swelling 2. Erythema 3. Fever >100.4 4. Leukocytosis, WBC >12,000/cu.mm 5. C-reactive protein >10 mg/L 6. ESR >20 mm/hr

XII. Synovitis [MRI not available or feasible]

XIII. Preoperative planning of joint replacement

References:

1. El-Khoury GY, Bennett DL, Dalinka MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria-chronic foot pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ChronicFootPainDoc 7.aspx May 14, 2008. 2. Gaeta M, Minutoli F, Scribano E, et al, CT and MRI imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities, Radiology, 2005; 235:553-561. 3. Stallenberg B, Madani A, Burny F, et al, The vacuum phenomenon: a CT sign of nonunited fracture, AJR, 2001; 176:1161-1164. 4. Lipsky BA, Berendt AR, Deery HG, et al, Diagnosis and treatment of diabetic foot infections, IDSA Guidelines, accessed at http://www.journals.uchicago.edu/doi/pdf/10.1086/424846?cookieSet=1 May 14, 2008. 5. Ostlere S, Imaging of the ankle and foot, Imaging, 2003;15:242-269. 6. Kneeland JB, Dalinka MK, Alazraki N, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria- chronic hip pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ChronicHipPainDoc8 .aspx May 14, 2008. 7. Dupuy DE, Hangen DH, Zachazewski JE, et al, Kinematic CT of the patellofemoral joint, AJR, 1997; 169:211-215. 8. Maas M, Poll LW, and Terk MR, Imaging and quantifying skeletal involvement in Gaucher’s disease, Brit J Radiol, 2002; 75:A13-!24.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

73706 CTA of the Lower Extremity

For aortobifemoral or aortobiiliac runoff study use CPT code 75635

I. Peripheral arterial vascular disease (PAD, PVD) 1,2 A. Intermittent claudication B. Fatigue C. Erectile dysfunction D. Diminished femoral pulses E. Non healing ulcer F. Gangrene G. Absent or weak peripheral pulses H. Rest ABI < 0.9 in symptomatic member I. Exercise ABI <0.90 in symptomatic member with rest ABI >0.90 J. Toe brachial index <0.90 or pulse volume recording evidence of peripheral vascular disease if the ABI >1.30

II. Femoral or popliteal artery aneurysm 1 A. Pulsatile mass

III. Trauma (popliteal) 1 A. Diminished peripheral pulses B. Suspected pseudoaneurysm

IV. Fibular transfer graft 3,4

V. Venous aneurysm A. Doppler US not diagnostic B. Asymptomatic peripheral mass

VI. Arteriovenous malformation

VII. Venous malformation

References:

1.Rubin G, Schmidt AJ, Logan LJ, et al, Multi-detector row CT angiography of lower extremity arterial inflow and runoff: initial experience, Radiology, 2001; 221:146-158. 2. Hirsch AT, Haskal ZJ, Hertzer NR et al, ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic: a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines, accessed at http://content.onlinejacc.org/cgi/reprint/47/6/e1 , August 23, 2008. Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

3.Winslow CP and Wax MK, Tissue transfer, fibula, accessed at http://www.emedicine.com/ent/topic661.htm May 15, 2008. 4.Chow LC, Napoli A, Klein M, et al, Vascular mapping of the leg with multi-detector row CT angiography prior to free-flap transplantation, Radiology, 2005; 237:353-360

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

73718 MRI Lower Extremity Other than Joints without Gadolinium

I. Known or suspected fracture (including stress fractures) 1 A. Pain at site, x-ray non-diagnostic for fracture at initial evaluation 1. Pain with passive Range of Motion (ROM) or weight bearing 2. Pain unimproved after activity modification or immobilization for ≥2 weeks B. Two x-rays 10 days apart not diagnostic of fracture except for suspected hip fracture C. Worsening symptoms during immobilization or activity modification

II. Suspected nonunion of known fracture A. Failure to demonstrate progressive evidence of healing for 3 or more months B. Pain at fracture site C. Movement at fracture site by subjective sensation or by radiographic imaging

III. Suspected soft tissue injury 2-4 A. Muscle Injury 1. Defect palpable 2. Pain on movement with palpable muscle swelling B. Compartment syndrome 1. Prior trauma with or without fracture 2. Pain on stretching of muscle 3. Pain on palpation of muscle

IV. Suspected tarsal coalition 5, 6 A. Pain at site B. Rigid flatfoot with peroneal spasm C. Pain relieved by rest D. Peroneal tendon spasms E. History of ankle sprains

V. Tendinitis 6, 7 A. Symptoms 1. Localized pain that is reproduced with stretching of the affected tendon 2. Tenderness on palpation of tendon 3. History of repetitive overuse B. No relief after conservative medical management 1. Continued pain after treatment with anti-Inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Continued symptoms after physical therapy for ≥4 weeks 3. Symptoms worsening while under treatment

CareCore National Criteria for Imaging Version 2.2009

VI. Plantar fasciitis 7 A. Pain on plantar aspect of foot B. Focal tenderness to palpation from heel to forefoot C. No response to conservative medical management 1. Rest and icing 2. Continued symptoms after anti-inflammatory medications for ≥4 weeks 3. Heel supports and cushioning 4. Steroid injection at points of tenderness

References:

1. Manaster BJ, Grossman JW, Dalinka, MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria- stress/insufficiency fracture including sacrum, excluding other vertebra, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/stressInsufficiencyfra cturesIncludingSacrumExcludingOtherVertebraeDoc20.aspx May 19, 2008. 2. Connel DA, Schneider-Kolsky ME, Malara F, et al, Longitudinal study comparing sonographic and MRI assessments of acute and healing hamstring injuries, AJR, 2004; 183:975-984. 3. Speer KP, Lohnes J and Garrett WE, Radiographic imaging of muscle strain injury, Am J Sports Med, 1993; 21:89-96. 4. Cross TM, Houang MR, and Cameron M, Acute quadriceps muscle strains magnetic resonance imaging features and prognosis, Am J Sports Med, 2004; 32:710-719. 5. Harris EJ, Vanore JV, Thomas JL, et al, Diagnosis and treatment of pediatric flatfoot, J Foot and Ankle Surg, 2004; 43:341-370. 6. El-Khoury GY, Bennett DL, Dalinka MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria- chronic foot pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ChronicFootPainDoc 7.aspx May 22, 2008. 7. Lee MS, Banore JV, Thomas JL, et al, Diagnosis and treatment of adult flatfoot, J Foot and Ankle Surg, 2005; 44:78-113.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

73719 MRI Lower Extremity Other than Joints with Gadolinium 73720 MRI Lower Extremity Other than Joints without and with Gadolinium

I. Suspected osteomyelitis A. Clinical findings 1. Fever >100.4 2. Leukocytosis, WBC >12,000/cu.mm 3. ESR >20 mm/hr 4. C-reactive protein >10 mg/L 5. Blood culture positive B. Any of the following: 1. Pain, may be dull or vague, x-ray non-diagnostic 2. History of infection elsewhere 3. History of diabetes, dialysis or peripheral vascular disease 4. History of penetrating injury or surgery 5. Sinus tract, poor wound or fracture healing C. Pre-operative evaluation of osteomyelitis D. Interval follow up during or after completion of treatment

II. Tumor A. Suspected bone tumor 1. Pain at site 2. Bone lesion at site by imaging (x-ray, bone scan or CT scan) B. Follow-up known bone tumor 1. Prior imaging positive at site 2. After radiation or chemotherapy has been completed 3. Periodic assessment 4. New or worsening symptoms at site

CareCore National Criteria for Imaging Version 2.2009

73721 MRI Lower Extremity Joint without Gadolinium: Ankle or Foot

I. Chronic joint pain, x-ray nondiagnostic for etiology 1-4 A. Clinical presentation 1. Locking 2. Giving way 3. Range of Motion (ROM) limited by pain 4. Crepitus 5. Tenderness 6. Joint effusion/swelling B. No response to conservative management 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Continued pain after physical therapy for 4 weeks or more 3. Symptoms worsening while under treatment

II. Suspected intra-articular loose body 5 A. Clinical presentation 1. Joint pain 2. Locking 3. Clicking 4. Giving way

III. Suspected avascular necrosis (osteonecrosis, OCD, AVN, 5 osteochondritis dissecans) A. Pain B. Pain with passive movement C. Steroid use D. Sickle Cell Disease E. Chronic pain after sprain or sprains F. No response to conservative management [(1 and 2) or 3] 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Continued pain after physical therapy for 4 weeks or more 3. Symptoms worsening while under treatment

IV. Suspected fracture (including stress fractures) 5-8 A. Pain at site, x-ray non-diagnostic for fracture at initial evaluation 1. Pain with passive Range of Motion (ROM) or weight bearing 2. Pain unimproved after activity modification or immobilization for ≥2 weeks B. Two x-rays 10 days apart not diagnostic of fracture

CareCore National Criteria for Imaging Version 2.2009

C. Worsening symptoms during immobilization or activity

V. Tarsal tunnel syndrome, posterior tibial nerve compression 6, 8 A. Clinical findings 1. Aching, burning or tingling of the sole of the foot, toes or heel 2. Positive Tinel's sign 3. Positive dorsiflexion eversion test 4. Nerve Conduction Study (NCS) consistent with compression at tarsal tunnel 5. No response to conservative management a. Continued pain after physical therapy 4 weeks or more b. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks unless contraindicated c. One inch heel, arch support for 4-6 wks d. Pain worsening during treatment

VI. Suspected tarsal coalition [CT best for bony coalition, MRI if CT nondiagnostic] 8 A. Pain at site B. Rigid flatfoot C. Pain relieved by rest D. Peroneal tendon spasms E. History of ankle sprains

4, 8-10 VII. Ankle injuries A. Achilles tendon rupture or tendinitis 1. Ultrasound is nondiagnostic 2. Clinical findings a. Posterior ankle pain b. Point tenderness over the Achilles tendon or tenderness on deep palpation c. Palpable nodule in the tender aspect of the tendon d. Inability to raise up on toes e. X-ray reveals calcification or other evidence of Achilles tendon pathology f. Hyper-dorsiflexion sign g. Positive Thompson Test h. Palpable gap in tendon B. Peroneal tendon 1. Tendinitis or tear a. Pain and tenderness behind and distal to the lateral malleolus b. No response to conservative management i. Immobilization for 2-6 weeks ii. Continued pain after physical therapy 4 weeks or more iii. Pain worsening while under treatment iv. Continued pain after treatment with anti-inflammatory medication for 4 weeks or more unless contraindicated

CareCore National Criteria for Imaging Version 2.2009

2. Subluxation a. Clinical findings i. There is often a history of acute injury with pain and swelling over the posterolateral ankle ii. Snapping along lateral ankle iii. Pain with resisted eversion and with toe walking iv. Recurrent inversion injury with instability b. No response to conservative management i. Continued pain after treatment with anti-inflammatory medication for 4 weeks or more unless contraindicated ii. Continued pain after physical therapy 4 weeks or more iii. Pain worsening while under treatment C. Anterior tibiofibular ligament injury (may be associated with proximal fracture of the fibula: 1. Physical examination a. Pain with dorsiflexion of the ankle b. Point tenderness over the anterior lateral tibiofibular joint c. Lateral ankle instability d. Positive squeeze test e. Positive external rotation stress test 2. No response to conservative management a. Continued pain after physical therapy 4 weeks or more b. Continued pain after treatment with anti-inflammatory medication for 4 weeks or more unless contraindicated c. Pain worsening while under treatment D. Deltoid ligament injury 1. Acute injury <3 weeks a. Findings on physical examination i. Pain medial side of joint ii. Edema medial side of joint b. X-ray non diagnostic for etiology of symptom c. No response to conservative management i. Continued pain after treatment with anti-inflammatory medication for 4 weeks or more unless contraindicated ii. Continued pain after physical therapy 4 weeks or more iii. Pain worsening while under treatment 2. Chronic pain >3 weeks a. Pain medial side of joint b. X-ray nondiagnostic for etiology of pain E. Anterior Talofibular Ligament (ATFL) Injury 1. History of injury 2. Findings on physical examination a. Pain anterolateral side of joint b. Edema anterolateral side of joint c. Positive anterior draw test

CareCore National Criteria for Imaging Version 2.2009

3. No response to conservative therapy a. Protected weight bearing 1-2 weeks b. Continued pain after treatment with anti-inflammatory medication for 4 weeks or more unless contraindicated c. Continued pain after physical therapy for 4 weeks or more d. Pain worsening with treatment F. Calcaneofibular ligament injury 1. Findings on physical examination a. Pain on lateral side of joint b. Swelling lateral side of joint c. Ecchymosis lateral side of joint d. Positive talar tilt test 2. X-ray nondiagnostic for etiology of symptoms 3. No response to conservative therapy a. Protected weight bearing 1-2 weeks b. Continued pain after treatment with anti-inflammatory medication for 4 weeks or more unless contraindicated c. Continued pain after physical therapy for 4 weeks or more d. Pain worsening with treatment G. Suspected posterior tibial tendon rupture 1. Pain and tenderness along tendon path (especially posterior to the medial malleolus) 2. Patient is unable to lift heel off ground when standing on one foot H. Tendonitis or tendenosis 1. Physical findings a. Swelling b. Tenderness c. Pain on passive stretching d. Pain with active motion 2. No response to conservative management a. Immobilization for 2-6 weeks b. Continued pain after physical therapy for up to 4 weeks c. Continued pain after treatment with anti-inflammatory medication for 4 weeks or more unless contraindicated d. Steroid injections or oral steroids including Medrol dose pack with persisting pain e. Pain worsening with treatment

VIII. Plantar fasciitis 5, 8, 11 A. Pain on plantar aspect of foot B. Focal tenderness to palpation from heel to forefoot C. No response to conservative management including: 1. Rest and icing 2. Continue pain after treatment with anti-inflammatory medication for 4 weeks or more unless contraindicated 3. Heel supports and cushioning 4. Steroid injection at points of tenderness

CareCore National Criteria for Imaging Version 2.2009

IX. Osteoid osteoma (CT is preferred) A. Non-diagnostic x-ray B. Clinical 1. Bone pain worse at night which is relieved by aspirin 2. Pain increases with activity C. Known diagnosis and planning for surgery D. Known diagnosis and planning for radiofrequency ablation E. Known diagnosis and post intervention evaluation to establish a new baseline

References:

1. De Smet AA, Dalinka MK, Daffner RH, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Chronic Ankle Pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ChronicanklepainDo c5.aspx January 19, 2008. 2. Fongemie A, Ddudera A, Strandemo G, et al, Health Care Guideline: Ankle Sprain, Institute for Clinical Systems Improvement, accessed at http://www.icsi.org/ankle_sprain/ankle_sprain_4.html January 19, 2008. 3. Academy of Ambulatory Foot and Ankle Surgery, Intermetatarsal Neuroma, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=4243&nbr=003243&string=ankle+AND+pain January 19, 2008. 4. Work Loss Data Institute, Ankle & Foot (acute and chronic) accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=11014&nbr=005794&string=ankle+AND+pain January 19, 2008. 5. Ostlere S, Imaging the ankle and foot, Imaging, 2003; 15:242-269. 6. Rosenberg ZS, Beltran J, and Bencardino JT, MR imaging of the ankle and foot, RadioGraphics, 2000; 20:S153-S179. 7. Daffner RH and Pavlov H, Stress fractures: current concepts, AJR, 1992; 159:245-252. 8. El-Koury GY, Bennett DL, Dalinka MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Chronic Foot Pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ChronicFootPainDoc 7.aspx January 20, 2008. 9. Kader D, Saxena A, Movin T, et al, Achilles tendinopathy: some aspects of basic science and clinical management, Br J Sports Med, 2002; 36:239-249. 10. Pavola M, Kannus P, Jarvinen TAH, et al, Achilles tendinopathy, J Bone Joint Surg Am, 2002; 84:2062-2076. 11. Cole C, Seto C, and Gazewood J, Plantar fasciitis: evidence-based review of diagnosis and therapy, American Family Physician, 2005; 72:2237-2242.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

73722 MRI Lower Extremity Joint with Gadolinium: Ankle or Foot 73723 MRI Lower Extremity Joint without and with Gadolinium: Ankle or Foot

I. Suspected osteomyelitis 1 A. Clinical findings 1. ESR >20 mm/hr 2. Fever >100.4 3. Leukocytosis, WBC >12,000/cu.mm 4. C-reactive protein >10 mg/ml 5. Blood culture positive B. Any of the following: 1. Pain with X-ray nondiagnostic 2. History of infection elsewhere 3. History of diabetes, dialysis or peripheral vascular disease 4. History of penetrating injury or surgery 5. Sinus tract, poor wound or fracture healing C. Preoperative evaluation of osteomyelitis D. Postoperative evaluation for new baseline E. Interval imaging for response to therapy of documented osteomyelitis F. Positive probe to bone test

II. Morton neuroma 2 A. Clinical findings 1. Forefoot pain 2. Aggravated by wearing tight or high-heeled shoes, relieved by barefoot walking 3. Pain radiates to the toes (usually 3rd and 4th toes) 4. Pain persists after steroid injections B. Ultrasound nondiagnostic

III. Evaluation of joints for aggressive treatment of arthritis or synovitis 3 A. Proven rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis by lab studies and clinical findings B. Intention to begin Remicade (or similar) therapy

IV. Suspected bone tumor 4 A. X-ray evidence of bone tumor, or soft tissue tumor affecting bone B. Preoperative or pre treatment planning C. Known malignancy elsewhere with new onset of bone pain

CareCore National Criteria for Imaging Version 2.2009

1. Must have x-ray 2. Bone scan

V. MR Arthrogram A. Suspected intra-articular loose body 1. Pre-operative study 2. Locking 3. Clicking 4. Giving way B. Anterior tibiofibular ligament injury 1. Failed conservative management a Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated b. Continued pain after physical therapy for 4 weeks or more c. Symptoms worsening while under treatment 2. MRI non diagnostic

VI. Soft tissue mass 5-7 A. Soft tissue mass increasing in size B. Abscess 1. Pain or tenderness at site 2. Erythema 3. Fever >100.4 4. Leukocytosis > 12,000/cu.mm C. Recent trauma, suspected hematoma, US not diagnostic D. Suspicion of a soft tissue sarcoma (imaging must be performed prior to biopsy) 1. X-ray of the area of interest 2. Post operative imaging 3 months after primary therapy 3. Surveillance with no evidence of recurrence. a. Low grade tumor annually for 5 years b. High grade tumor every 3-6 months for 5 years E. Preoperative or pretreatment planning F. Follow up

VII. Septic joint A. Symptoms 1. Acute onset 2. Inability to bear weight 3. Limited Range of motion (ROM) B. Findings on physical examination 1. Swelling 2. Erythema 3. Fever >100.4 4. Leukocytosis, WBC >12,000/cu.mm 5. C-reactive protein >10 mg/ml Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

References:

1. Rosenberg ZS, Beltran J, and Bencardino JT, MR imaging of the ankle and foot, RadioGraphics, 2000; 20:S153-S179. 2. Academy of Ambulatory Foot and Ankle Surgery, Intermetatarsal Neurangoma, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=4243&nbr=003243&string=ankle+AND+pain January 19, 2008. 3. Kobelt G, Jönsson L , Young A, et al, The cost-effectiveness of infliximab (Remicade®) in the treatment of rheumatoid arthritis in Sweden and the United Kingdom based on the ATTRACT Study, Rheumatology, 2003; 42: 326-335. 4. El-Koury GY, Bennett DL, Dalinka MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Chronic Foot Pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ChronicFootPainDoc 7.aspx January 20, 2008. 5. Blacksin MF, Ha DH, Hameed M, et al, Superficial soft-tissue masses of the extremities, RadioGraphics,2006;26:1289-1304. 6.. Morrison WB, Dalinka MK, Daffner RH, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria-Soft tissue masses, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/SoftTissueMassesD oc19.aspx December 29, 2008. 7. Knapp EL, Kransdorf MJ and Letson D, Diagnostic imaging update: soft tissue sarcomas, Cancer Control, 2005; 12:22-26, accessed at http://medgenmed.medscape.com/viewarticle/498749_print December 29, 2008.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

73721 MRI Lower Extremity Joint without Gadolinium: Knee

I. Chronic joint pain, x-ray nondiagnostic for etiology 1 A. Clinical presentation 1. Locking 2. Giving way 3. Range of Motion (ROM) limited by pain 4. Crepitus 5. Tenderness 6. Joint effusion/swelling B. No response to conservative management 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Continued pain after physical therapy for 4 weeks or more 3. Symptoms worsening while under treatment

II. Suspected intra-articular loose body 2 A. Clinical presentation 1. Joint pain 2. Locking 3. Giving way 4. Clicking

III. Suspected avascular necrosis (OCD, osteonecrosis, AVN, osteochondritis dissecans) 3 A. Pain B. History of steroid use C. Sickle Cell Disease D. No response to conservative management 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Continued pain after physical therapy for 4 weeks or more 3. Symptoms worsening while under treatment

IV. Suspected or known fracture (including stress fractures) 5,6 A. Pain at site, x-ray non-diagnostic for fracture at initial evaluation 1. Pain with passive Range of Motion (ROM) or weight bearing 2. Pain unimproved after activity modification or immobilization for ≥2 weeks B. Two x-rays 10 days apart not diagnostic of fracture C. Worsening symptoms during immobilization or activity modification

CareCore National Criteria for Imaging Version 2.2009

4, 7-9 V. Knee injuries A. Knee pain secondary to recent injury, with nondiagnostic x-ray 1. Swelling or effusion 2. Pain significantly limiting mobility or physical examination. 3. algus instability 4. arus instability 5. ositive Lachman's test 6. ositive pivot shift test B. Suspected meniscal tear 1. Findings on physical examination a. Intermittent locking, b. Unable to fully extend c. McMurray's test positive d. Joint line tenderness e. Effusion f. Pain with flexion and rotation g. A sensation of popping, clicking, or snapping 2. No response to conservative management a. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks unless contraindicated or not tolerated b. Continued pain after physical therapy for 4 weeks or more c. Symptoms worsening while under treatment C. Injuries to ligaments 1. Suspected anterior cruciate ligament injury a. Knee pain after twisting injury b. Knee buckling with quick turn or step down c. Positive anterior drawer sign d. Inability to ambulate e. Rapid acculumulation of an effusion f. Positive Lachman's sign g. Positive pivot shift test 2. Suspected posterior cruciate ligament injury a. Absent tibial step off (tibia should protrude 1 cm beyond femur at 90 degrees of flexion b. History of hyperextension or posterior displacement of tibia 3. Suspected LCL or MCL injury a. MCL i. Positive valgus stress test (knee opens medially with stress to tibia) ii. Continued instability after conservative management with brace b. LCL i. History of an injury causing varus (lateral at the knee) stress ii. Tenderness at lateral joint line iii. Laxity to varus stress D. Suspected quadriceps tendon injury 1. Palpable lesion or gap in quadriceps muscle or tendon 2. Inability to extend the knee

CareCore National Criteria for Imaging Version 2.2009

3. Palpable gap in tendon E. Tendonitis or tendonosis 1. Physical findings a. Swelling b. Tenderness c. Pain on passive stretching d. Pain with active motion 2. No response to conservative management a. Immobilization for 2-6 weeks b. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated c. Symptoms worsening while under treatment

VI. Suspected Baker's cyst 10, 11 A. US nondiagnostic for Baker's cyst B. Popliteal mass C Suspicion of meniscal tear 1. Findings on physical examination a. Intermittent locking, b. Unable to fully extend c. McMurray's test positive d. Joint line tenderness e. Effusion f. Pain with flexion and rotation g. A sensation of popping, clicking, or snapping 2. No response to conservative management a. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks unless contraindicated or not tolerated b. Continued pain after physical therapy for 4 weeks or more c. Symptoms worsening while under treatment

1, 12 VII. Patello-femoral pathology (including patellar tracking disorder) A. Symptoms and history 1. Anterior knee pain worsening with activity (e.g. running, standing up from a bent knee position) 2. Pain on squatting 3. History of recurrent patellar dislocations or subluxations B. Clinical findings 1. Crepitus 2. Positive patellar grind test 3. Pain on palpation of the medial and/or lateral patellar 4. Positive J sign (patella displaces laterally at full knee extension) C. No response to conservative management 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Continued pain after physical therapy for 4 weeks or more Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

3. Symptoms worsening while under treatment

VIII. Osteoid osteoma (CT is preferred) A. Non-diagnostic x-ray B. Clinical 1. Bone pain worse at night which is relieved by aspirin 2. Pain increases with activity C. Known diagnosis and planning for surgery D. Known diagnosis and planning for radiofrequency ablation E. Known diagnosis and post intervention evaluation to establish a new baseline

References:

1. Kiningham R, Desmond J, Fox D, et al, University of Michigan Health System, Guidelines for clinical Care, Knee Pain or Swelling: acute or chronic, accessed at http://cme.med.umich.edu/pdf/guideline/knee.pdf January 21, 2008. 2. Lee J, Thorson D, Jurisson M, et al, Institute for Clinical Systems Improvement Health Care Guideline, Diagnosis and treatment of adult degenerative joint disease (DJD)/osteoarthritis (OA) of the Knee, accessed at http://www.icsi.org/degenerative_joint_disease/diagnosis_and_treatment_of_adult_degenerative_joint_disease_of_theknee_3.html January 21, 2008. 3. Stocks G, Dennis D, Mesko W, et al, AAOS Clinical Guideline on Osteoarthritis of the Knee (phase II), accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=4584&nbr=003374&string=knee+AND+avascular+AND+necrosis , January 21, 2008. 4. Washington State Department of Labor and Industries, Medical Treatment Guidelines, Review Criteria for Knee Surgery, accessed at http://www.lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/MedTreatGuidelines.pdf January 21, 2008. 5. Berger PE, Ofstein RA, Jackson DW, et al, MRI demonstration of radiographically occult fractures: what have we been missing? RadioGraphics, 1989; 9:407-436. 6. Anderson MW and Greenspan A, Stress fractures, Radiology, 1996; 199:1-12. 7. New Zealand Guidelines Group, The diagnosis and management of soft tissue knee injuries; internal derangements, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=4337&nbr=003270&string=knee+AND+mri January 21, 2008. 7. Pavlov F, Saboeiro GR, Campbell SE, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Acute trauma to the knee, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/AcuteTraumatothekn eeDoc2.aspx January 21, 2008. 9. Pavlov H, Dalinka MK, Alazraki NP, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Nontraumatic Knee Pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/NonTraumatickneeP ainDoc15.aspx January 21, 2008. 10. Ultrasonographic examinations: indications and preparation of the patient, Finnish Medical Society Duodecim, accessed at http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=10478&nbr=5501 January 28, 2008. 11. Ward EE, Jacobson JA, Fessell DP, et al, Sonographic detection of Baker’s cyst: comparison with MR imaging, AJR, 2001; 176:373-380. 12. Shellock FG, Mink JH, Deutsch AL, et al, Patellar tracking abnormalities: clinical experience with kinematic MR imaging in 130 patients, Radiology, 1989; 172:799-804.

Reviewed: 3/18/2009 Posted: 8/15/2009

CareCore National Criteria for Imaging Version 2.2009

73722 MRI Lower Extremity Joint with Gadolinium: Knee 73723 MRI Lower Extremity Joint without and with Gadolinium: Knee

I. Suspected osteomyelitis 1-4 A. Clinical findings 1. ESR > 20 mm/hr 2. Fever >100.4 3. Leukocytosis, WBC >12,000/cu.mm 4. C-reactive protein >10 mg/ml 5. Blood culture positive B. Any of the following: 1. Pain with x-ray nondiagnostic 2. History of infection elsewhere 3. History of diabetes, dialysis or peripheral vascular disease 4. History of penetrating injury or surgery 5. Sinus tract, poor wound or fracture healing C. Preoperative evaluation of osteomyelitis D. Postoperative evaluation for new baseline E. Interval imaging for response to therapy of documented osteomyelitis

II. Suspected bone tumor 1, 5-7 A. X-Ray evidence of bone tumor, or soft tissue tumor affecting bone B. Preoperative or pretreatment planning C. Known malignancy elsewhere with new onset of bone pain 1. Must have x-ray 2. Bone scan D. Follow up after treatment

III. Evaluation of joints for aggressive treatment of arthritis or synovitis 8 A. Proven rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis by lab studies and clinical findings B. Intention to begin Remicade (or similar) therapy

IV. MR Arthrogram A. Suspected intra-articular loose body 1. Pre-operative study 2. Locking 3. Clicking Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

B. Recurrent knee pain after arthroscopic or surgical intervention

V. Soft tissue mass9-11 A. Soft tissue mass increasing in size B. Abscess 1. Pain or tenderness at site 2. Erythema 3. Fever >100.4 4. Leukocytosis > 12,000/cu.mm C. Recent trauma, suspected hematoma, US not diagnostic D. Suspicion of a soft tissue sarcoma (imaging must be performed prior to biopsy) 1. X-ray of the area of interest non-diagnostic 2. Post operative imaging 3 months after primary therapy 3. Surveillance with no evidence of recurrence. a. Low grade tumor annually for 5 years b. High grade tumor every 3-6 months for 5 years E. Preoperative or pretreatment planning F. Follow up after treatment

VI. Septic joint 9,12 A. Symptoms 1. Acute onset of pain 2. Inability to bear weight 3. Limited Range of Motion (ROM) B. Findings on physical examination 1. Swelling 2. Erythema 3. Fever > 100.4 4. Leukocytosis, WBC >12,000/cu.mm 5. C-reactive protein >10 mg/ml

References:

1. Kiningham R, Desmond J, Fox D, et al, University of Michigan Health System, Guidelines for clinical Care, Knee Pain or Swelling: Acute or Chronic, accessed at http://cme.med.umich.edu/pdf/guideline/knee.pdf January 21, 2008. 2. Unger E, Moldofsky P, Gatenby R, et al, Diagnosis of osteomyelitis by MR imaging, AJR, 1988; 150:605-610. 3. Kapoor A, Page S, LaValley M, et al, Magnetic resonance imaging for diagnosing foot osteomyelitis, Arch Intern Med, 2007; 167:125-132. 4. British Society for Children’s Orthopaedic Surgery, The Management of Acute Bone and Joint Infection in Childhood, a Guide to Good Practice, accessed at http://www.boa.ac.uk/site/showpublications.aspx?ID=59 January 28, 2008. 5. Morrison WB, Dalinka MK, Daffner RH, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Bone Tumors, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/BoneTumorsDoc4.as px January 28, 2008. 6. Nabaster BJ, Petersen B, Dalinka MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Follow-up of Malignant or Aggressive Musculoskeletal Tumors, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/FollowUpofMalignant orAggressiveMusculoskeletaltumorsDoc11.aspx January 28, 2008. Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

7. Stacy GS, Nahal RS and Peabody TD, Staging of bone tumors: a review with illustrative examples, AJR, 2006; 186:967-976. 8. Hodgson RJ, O’Connor P, and Moots R, MRI of rheumatoid arthritis- image quantitation for the assessment of disease activity, progression and response to therapy, Rheumatology, 2008; 47:13-21. 9. Morrison WB, Dalinka MK, Daffner RH, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology, Appropriateness Criteria, Soft tissue Mass, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/softtissuemassesDo c19.aspx accessed at January 29, 2008. 10. Manaster BJ, Petersen B, Dalinka MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Follow-up of malignant or aggressive musculoskeletal tumors, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/FollowUpofMalignant orAggressiveMusculoskeletalTumorsDoc11.aspx January 29, 2008. 11. Papp DR, Khanna AJ, McCarthy, EF et al, Magnetic resonance imaging of soft-tissue tumors: determinate and indeterminate lesions, J Bone Joint Surg Am, 2007; 89:103-115. 12. Karchevsky M, Schweitzer ME, Morrison WB, et al, MRI findings of septic arthritis and associated osteomyelitis in adults, AJR, 2004; 182:119-122.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

73721 MRI Lower Extremity Joint without Gadolinium: Hip

I. Chronic joint pain, x-ray nondiagnostic for etiology 1, 2 A. Clinical presentation 1. Locking 2. Giving way 3. Range of Motion (ROM) limited by pain 4. Crepitus 5. Tenderness 6. Joint effusion/swelling B. No response to conservative management 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks unless contraindicated or not tolerated 2. Continued pain after physical therapy for 4 weeks or more 3. Symptoms worsening while under treatment

II. Suspected intra-articular loose body 3 A. Joint pain B. Locking C. Giving way D. Clicking

III. Suspected or known avascular necrosis (osteonecrosis, osteochondritis dissecans, AVN, OCD)1, 4-6 A. Hip pain 1. Steroid use 2. Sickle Cell Disease 3. Pain in groin or buttocks 4. Worse with ambulation 5. Present at night 6. Pain with internal rotation of leg 7. Limited Range of Motion (ROM)

IV. Suspected fracture (including stress fractures) 7-9 A. Pain at site, x-ray non-diagnostic for fracture at initial evaluation 1. Pain with passive Range of Motion (ROM) or weight bearing 2. Pain unimproved after activity modification or immobilization for ≥2 weeks B. Worsening symptoms during immobilization or activity modificationClinical findings

V. Hip injury 10 A. Suspected nondisplaced femoral neck fracture

CareCore National Criteria for Imaging Version 2.2009

1. Hip pain increased by weight bearing/passive Range of Motion (ROM) 2. Hip x-ray nondiagnostic for fracture B. Suspected acetabular labral tear (May be a request for MR arthrogram includeh is MRI with gadolinium) 1. Pain 2. Clicking 3. Instability 4. Decreased Range of Motion (ROM) C. Tendonitis or tendenosis 1. Physical findings a. Swelling b. Tenderness c. Pain on passive stretching d. Pain with active motion D. No response to conservative management 1. Continued pain after treatment with anti-inflammatory medication for at least 4 weeks, unless contraindicated or not tolerated 2. Continued pain after physical therapy for 4 weeks or more 3. Symptoms worsening while under treatment 4. Steroid injections or oral steroincludecluding Medrol dose pak

VI. Gaucher’s disease

VII. Legg-Calve-Perthes disease 9 A. Non diagnostic x-ray

VIII. Slipped capital femoral epiphysis 9, 11 A. Non diagnostic x-ray B. Hip pain C. Limp D. External rotation of the hip

References:

CareCore National Criteria for Imaging Version 2.2009

1. Kneeland JB, Kalinka MK, Alazraki N, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology, appropriateness Criteria, Chronic Hip Pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ChronichippainDoc8. aspx January 29, 2008. 2. Fang C, and The J, Imaging of the hip, Brit Institute of Radiology, Imaging, 2003; 15:205-216. 3. Kelly BT, Williams RJ and Philppon MJ, Hip arthroscopy: current indications, treatment options and management issues, Am J of Sports Medicine, 2003; 31:1020-1037. 4. De Smet AA, Dalinka MK, Alazraki NP, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology, Appropriateness Criteria, Avascular Necrosis of the Hip, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/AvascularNecrosisoft hehipDoc3.aspx January 29, 2008. 5. Mitchell MD, Kundel HL, Stenberg ME, et al, Avascular necrosis of the hip: comparison of MR, CT and scintigraphy, AJR, 1986; 147:67-71. 6. Work Loss Data Institute Hip & pelvis (acute & chronic) accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=11022&nbr=005802&string=hip+AND+infection January 29, 2008. 7. Manaster BJ, Grossman JW, Dalinka MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology, Appropriateness Criteria, Stress/insufficiency fracture, including sacrum, excluding other vertebrae accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/StressInsufficiencyFr acturesIncludingSacrumExcludingOtherVertebraeDoc20.aspx January 29, 2008. 8. Oka M and Monu JUV, Prevalence and patterns of occult hip fractures and mimics revealed by MRI, AJR, 2004; 182:283-288. 9. Fordham L, Gunderman R, Blatt ER, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology, Appropriateness Criteria, Limping Child –Ages 0-5 years, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonPediatricImaging/LimpingChildUpdateinProgr essDoc6.aspx January 29, 2008. 10. Toomayan GA, Holman WR, Kozlowicz, SM, et al, Sensitivity of MR arthrography in the evaluation of acetabular labral tears, AJR, 2006; 186:449-453. 11. Wilson D and Allen G, Imaging of children’s hips, Imaging, 2002; 14:179-187.

CareCore National Criteria for Imaging Version 2.2009

73722 MRI Lower Extremity Joint with Gadolinium: Hip 73723 MRI Lower Extremity Joint without and with Gadolinium: Hip

I. Suspected osteomyelitis 1-3 A. Clinical findings 1. ESR >10 mm/hr 2. Fever >100.4 3. Leukocytosis, WBC >12,000/cu.mm 4. C-reactive protein >10mg/ml 5. Blood culture positive B. Any of the following: 1. Pain, with, X-ray nondiagnostic 2. History of infection elsewhere 3. History of diabetes, dialysis or peripheral vascular disease 4. History of penetrating injury or surgery 5. Sinus tract, poor wound or fracture healing C. Preoperative evaluation of osteomyelitis D. Postoperative evaluation for new baseline E. Interval imaging for response to therapy of documented osteomyelitis

II. Suspected bone tumor 2 A. X-ray or CT evidence of bone tumor, or soft tissue tumor affecting bone B. Known malignancy elsewhere with new onset of bone pain 1. Must have x-ray 2. Bone scan C. Preoperative or pretreatment planning D. Follow up after treatment

III. Evaluation of joints for aggressive treatment of arthritis or synovitis 4 A. Proven rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis by lab studies and clinical findings B. Intention to begin Remicade (or similar) therapy

IV. Septic joint 1, 3 A. Symptoms 1. Acute onset of pain 2. Inability to bear weight 3. Limited Range of Motion (ROM) B. Findings on physical examination Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

1. Swelling 2. Erythema 3. Fever >100.4 4. Leukocytosis, WBC >12,000/cu.mm 5. C-reactive protein >10 mg/ml

V. MR Arthrogram 5 A. Suspected intra-articular loose body 1. Pre-operative study 2. Locking 3. Clicking B. Recurrent hip pain after arthroscopic or surgical intervention C. Suspected labral tear

VI. Soft tissue mass 6-10 A. Soft tissue mass increasing in size B. Abscess 1. Pain or tenderness at site 2. Erythema 3. Fever >100.4 4. Leukocytosis > 12,000/cu.mm C. Recent trauma, suspected hematoma, US not diagnostic D. Suspicion of a soft tissue sarcoma (imaging must be performed prior to biopsy) 1. X-ray of the area of interest 2. Post operative imaging 3 months after primary therapy 3. Surveillance with no evidence of recurrence. a. Low grade tumor annually for 5 years b. High grade tumor every 3-6 months for 5 year E. Preoperative or pretreatment planning F. Interval follow up after treatment

References:

1. Fordham L, Gunderman R, Blatt ER, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology, appropriateness Criteria, Limping Child –Ages 0-5 years, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonPediatricImaging/LimpingChildUpdateinProgr essDoc6.aspx January 29, 2008. 2. Wilson D and Allen G, Imaging of children’s hips, Imaging, 2002; 14:179-187. 3. Karchevsky M, Schweitzer ME, Morrison WB, et al, MRI findings of septic arthritis and associated osteomyelitis in adults, AJR, 2004; 182:119-122. 4. Kobelt G, Jönsson L, Young A, The cost-effectiveness of infliximab (Remicade®) in the treatment of rheumatoid arthritis in Sweden and the United Kingdom based on the ATTRACT study, Rheumatology, 2003; 42:326-335. 5. Toomayan GA, Holman WR, Kozlowicz SM, et al, Sensitivity of MR arthrography in the evaluation of acetabular labral tears, AJR, 2006; 186: 449-453. 6. Morrison WB, Dalinka MK, Daffner RH, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology, Appropriateness Criteria, Soft Tissue Mass, accessed at

CareCore National Criteria for Imaging Version 2.2009

http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/softtissuemassesDo c19.aspx accessed at January 29, 2008. 7. Manaster BJ, Petersen B, Dalinka MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Follow-up of Malignant or Aggressive Musculoskeletal Tumors, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/FollowUpofMalignant orAggressiveMusculoskeletalTumorsDoc11.aspx January 29, 2008. 8. Papp DR, Khanna AJ, McCarthy EF, et al, Magnetic resonance imaging of soft-tissue tumors: determinate and indeterminate lesions, J Bone Joint Surg Am, 2007; 89:103-115. 9. Blacksin MF, Ha DH, Hameed M, et al, Superficial soft-tissue masses of the extremities, RadioGraphics,2006;26:1289-1304. 10.Knapp EL, Kransdorf MJ and Letson D, Diagnostic imaging update: soft tissue sarcomas, Cancer Control, 2005; 12:22-26, accessed at http://medgenmed.medscape.com/viewarticle/498749_print December 29, 2008.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

73725 MRA Lower Extremity

I. Peripheral vascular disease (PVD, occlusion or stenosis of arteries of the leg) 1 A. ABI (ankle brachial index, ankle systolic BP divided by brachial systolic BP) 1. Rest ABI <0.90 in symptomatic member 2. Exercise ABI <0.90 in symptomatic member with rest ABI >0.90 3. Toe brachial index <0.90 or pulse volume recording evidence of peripheral vascular disease if the ABI >1.30 B. Abnormal pulses C. Bruit D. Claudication E. Diabetic with 1. Skin changes 2. Loss of hair 3. Poor capillary refill 4. Thickened nails 5. Thin skin F. Known atherosclerotic occlusive disease

II. Femoral or popliteal artery aneurysm A. Pulsatile mass

III. Trauma (popliteal) A. Diminished peripheral pulses B. Suspected pseudoaneurysm

IV. Fibular transfer graft

V. Venous aneurysm

VI. Deep Venous Thrombosis (DVT) A. Venous Doppler non diagnostic

References:

1. Hirsch AT, Haskal ZJ, Hertzer NR et al, ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic: a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines, accessed at http://content.onlinejacc.org/cgi/reprint/47/6/e1 August 23, 2008.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

74150 CT Abdomen without Contrast 74160 CT Abdomen with Contrast 74170 CT Abdomen without and with Contrast

I. Complaints associated with abdominal or pelvic pain 1-10 A. Abdominal pain persisting for more than a few hours and any of the following: 1. Abdominal tenderness 2. Evidence of inflammatory reaction or visceral dysfunction 3. Collapse 4. Vomiting 5. Muscular rigidity-guarding 6. Abdominal distention B. Obstructive uropathy or hydronephrosis (Renal, ureteral or, bladder stone causing obstruction) 1. Pain in flank, radiating toward the groin 2. Hematuria C. Diverticulitis 1. Lower abdominal pain or mass 2. Other clinical findings a. Fever >100.4 b. Leukocytosis, WBC >12,000/cu.mm c. Diverticulosis by prior imaging study d. Symptoms worsening under treatment with antibiotics and diet restriction after 2 days or more D. Abscess 1. Suspected a. Abdominal or pelvic pain for at least a day b. Other clinical findings i. Mass on abdominal, pelvic or rectal exam ii. Fever >100.4 iii. Leukocytosis, WBC >12,000/cu.mm 2. Follow up during or after treatment a. Condition unimproved or worsening after drainage or IV antibiotics for at least two days b. Condition unimproved or worsening after IV Abx Rx >1 wk c. Routine follow-up study after treatment, including evaluation for removal of drain. E. Appendicitis 1. Pain a. Generalized through the abdomen b. Periumbilical c. Suprapubic d. Right lower quadrant Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

2. Symptoms and signs a. Nausea/vomiting b. Guarding or abdominal rigidity c. Rebound tenderness d. Tenderness RLQ e. Positive Rovsing’s sign (referred rebound -- pressure to LLQ causes pain in RLQ) f. Fever >100.4 g. Leukocytosis, WBC >12,000/cu.mm 3. Pregnancy excluded F. Crohn’s Disease and Inflammatory Bowel Disease (suspected) 1. Acute symptoms and signs a. Abdominal pain b. Liquid bowel movements, diarrhea c. Weight loss d. Anorexia e. Fever >100.4 f. Abdominal tenderness g. Abdominal mass h. Family history of Crohn’s Disease i. Extra intestinal manifestations i. Oral aphthous lesions ii. Gallstones iii. Nephrolithiasis with stones 2. Chronic inflammatory bowel disease (IBD) a. Fistulization with or without infection i. Fevers, chills, and a tender abdominal mass ii. Bladder or vagina recurrent infections iii. Cutaneous fistulas iv. Perianal disease 01. Anal fissures or fistulas 02. Abscesses b. Diarrhea, non bloody, intermittent c. Cramping or steady right lower quadrant or periumbilical pain d. Small bowel obstruction with distention, cramping abdominal pain, nausea, vomiting e. Focal tenderness, right lower quadrant f. Postprandial bloating, cramping pains, and loud borborygmi g. Palpable, tender mass in the lower abdomen G. Ulcerative colitis [bloody mucoid stools associated with 1,2 or 3] 1. Diarrhea 2. Pain 3. Tenesmus (straining at stool)

CareCore National Criteria for Imaging Version 2.2009

II. Evaluation of symptoms after abdominopelvic surgery As above, if meets criteria for abdomen under this category, will generally need CT pelvis as well A. Any intra-abdominal surgery 1. Abdominal pain or tenderness a. Abscess i. Unexpected post surgical abdominal pain for at least a day ii. Mass on abdominal, pelvic or rectal exam iii. Fever >100.4 iv. Leukocytosis, WBC >12,000/cu.mm b. Subphrenic abscess i. Upper abdominal pain, worse with respiration ii. Fever >100.4 iii. Leukocytosis, WBC >12,000/cu.mm c. Intra-abdominal hemorrhage i. Risk factor for bleeding 01. Recent intra-abdominal surgery/instrumentation 02. Coagulopathy 03. Patient on coumadin, heparin or other anticoagulant 04. Abdominal/pelvic trauma ii. Findings 01. Falling hematocrit 02. Hemodynamic instability • Systolic blood pressure less than 100 • Falling blood pressure 03. Shock by PE 04. Gross evidence of bleeding (i.e. from drain, surgical site or orifice) B. Follow up after percutaneous drainage of intra-abdominal or pelvic abscess C. Post cholecystectomy 1. Clinical findings a. Pain b. Fever >100.4 c. Leukocytosis, WBC >12,000/cu.mm d. Jaundice e. Ileus f. Direct bilirubin > 0.4 mg/dL g. Liver enzymes elevated D. Appendicitis after surgery 1. Persistent fever >100.4 2. Leukocytosis, WBC >12,000/cu.mm

III. Aneurysm 11-18 A. Suspected rupture of AAA 1. New onset of mid-abdominal or back pain 2. Clinical findings [any] a. Pulsatile or expansile mass Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

b. Abnormal X-ray or US findings suggesting aortic disease c. Falling blood pressure B. Known AAA documented on prior imaging (Ultrasound, CT, CTA, MRI, MRA) 1. Periodic follow-up of known AAA will be allowed once every six months if ultrasound is not adequate. 2. New onset of pain C. Postoperative evaluation following endovascular repair (stent graft) 1. 1 month after repair 2. 3 months after repair 3. 6 months after repair 4. Annually after repair 5. Suspicion of endoleak D. Aneurysm of any intraabdominal artery detected on other Imaging E. Vascular insufficiency of the bowel (suspicion of) 1. Abdominal pain often starting as periumbilical and often out of proportion to exam findings 2. Other clinical findings a. Leukocytosis, WBC >12,000/cu.mm b. Stool positive for occult blood c. Nausea, vomiting or diarrhea d. History of abdominal angina (pain after eating for approximately 3 hours)

V. Patient with known cancer including lymphoma 21-51 A. Initial staging B. Follow-up after Rx [without change in clinical status] 1. After surgery and before adjuvant radiation or chemotherapy 2. After treatment for metastatic or unresectable disease 3. Scheduled as: a. Initial staging and for tissue diagnosis b. Restaging during or after chemotherapy and/or radiation therapy c. Every 4-6 months for 3 years d. Annually after 3 years C. New or worsening clinical data reported 1. Anorexia 2. Weight loss 3. Jaundice Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

4. Abdominal or pelvic pain 5. Abdominal or pelvic mass 6. Hepatomegaly 7. Ascites 8. Bowel obstruction by KUB 9. Lab values elevated/increasing a. Rising CEA (>2.5 in non smoker and >5.0 in smoker) b. Worsening liver function tests c. Rising bilirubin (Total bilirubin >1.9mg/dL) d. Rising CA 19-9 (pancreatic cancer) (>40Ku/L)

47-53 VI. Known or suspected pancreatitis or pancreatic pseudocyst A. Suspected acute pancreatitis, (exams may be repeated at intervals if there is no improvement on therapy, or signs of complications are present.) 1. Abdominal pain and tenderness 2. Elevated Amylase >99U/L 3. Elevated Lipase >9U/L B. Known pancreatitis with any of the following allows for repeat exams if present; 1. Hemodynamic instability a. Falling hematocrit b. Falling blood pressure 2. Fever >100.4 3. Retroperitoneal air on prior CT 4. Positive blood culture 5. Signs of peritonitis (rebound tenderness) 6. Poor oxygen saturation, signs of ARDS (Adult respiratory distress syndrome) 7. Signs of renal failure 8. Initial clinical state unimproved after 5 days of therapy C. Suspected pancreatic pseudocyst 1. History [any] a. Acute pancreatitis with onset at least 4 wks earlier b. Pancreatitis secondary to trauma (time irrelevant) c. Chronic pancreatitis 2. Clinical findings a. Abdominal/back pain b. Abdominal tenderness c. Abdominal mass D. Evaluation of known pancreatic pseudocyst 1. Periodic evaluation for change in size 2. New or worsening clinical findings E. Pancreatic mass on prior imaging

VII. Pancreatic cancer or mass 47-50 A. Symptoms 1. Weight loss Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

2. Mid-epigastric pain 3. Mid-epigastric pain radiating to the back B. Elevated tumor markers 1. CA19-9 (>40Ku/L) C. Abnormal pancreas on prior ultrasound, CT or MRI D. Painless jaundice 1. Abdominal ultrasound 2. Elevated direct bilirubin >0.4mg/dL or total >1.9mg/dL

VIII. Known or suspected adrenal disease or mass 29,51,54 Note: with suspected pheochromocytoma, if meets criteria, can also approve CT pelvis as uncommon presentation of pheochromocytoma is extra-adrenal including the bladder. A. Suspected pheochromocytoma 1. Urinary VMA >7mg/24hours 2. Elevated catecholamines B. Suspected adrenal cortical tumor (cortisol secreting) 1. 24 hr urine free cortisol >100mcg/24hr 2. No suppression by dexamethasone C. Suspected aldosteronoma [One] 1. Aldosterone >30 ng/dL for adult and > 80ng/dL for children 2. Plasma renin < 1.9 ng/ml/hr 3. Hypokalemia not on diuretics a. Serum potassium less than 3.5mEq/L on 2 different samples

IX. Splenomegaly with LUQ pain

X. Renal mass detected on prior imaging55,56 A. Cystic or Solid mass detected on ultrasound 1. Simple cyst confirmed on prior CT to be simple cyst or Bosniak class I cyst – no further imaging is indicated B. Bosniak Class II cyst on prior CT (or MRI) 1. CT may be certified every 6 months for 3 years and if stable no further imaging C. Follow up of renal cell cancer 1. Following radical or partial nephrectomy a. T1 tumors no surveillance imaging b. T2 tumors annual CT scan of the abdomen c. T3 and T4 tumors i. Every 3-6 months for 3 years ii. Annually after 3 years 2. Follow up after ablative therapy (radiofrequency or cryoablation) a. Immediately after initial treatment b. Every 3 months for a year for the first year c. Every 6-12 months after the first year

CareCore National Criteria for Imaging Version 2.2009

XI. Complex or solid abdominal, hepatic, or renal mass (on prior imaging) 55-59

XII. Evaluation of painless jaundice 50 A. Direct bilirubin >0.4mg/dL or total >1.9mg/dL B. Alkaline phosphatase >133 IU/L C. Ultrasound not diagnostic

XIII. Fever of Unknown Origin (FUO) 60 A. Fever >100.4 on several occasions over at least three weeks B. Uncertain diagnosis after lab studies 1. Two blood cultures 2. Urine culture 3. Tuberculin skin test 4. HIV antibody assay and HIV viral load for patients at high risk C. ESR >20 mm/hr D. C-reactive protein >10 mg/ml E. Associated night sweats

XIV. Abdominal and pelvic trauma 61-63 A. Initial evaluation B. Follow-up for known/suspected intra-abdominal injury 1. Periodic assessment 2. New or worsening symptoms or findings

XV. Cryptorchidism (undescended testicle) [MRI Preferred] 64-66 A. Testicle not palpable B. Abdominal and pelvic US nondiagnostic for undescended testicle

XVI. Weight Loss 67 A. Weight loss greater than 5% total body weight (or at least 5 pound weight loss) B. Significant change in bowel habits C. Negative colonoscopy D. Chest x-ray non diagnostic for cause of weight loss E. Normal thyroid function tests (TSH, T3 and T4) F. Normal renal function tests (BUN and creatinine) G. Abnormal liver function tests

XVII. Hematuria 3, 68

XVIII. CT Enterography 69, 70 A. Bowel obstruction B. Celiac Disease C. Polyposis syndromes D. Small bowel tumor Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

E. Suspected Crohn’s Disease 1. Fever 2. Diarrhea 3. Weight loss 4. Fatigue 5. Crampy abdominal pain 6. Perianal fistula or fissure 7. Enterovesical fistula 8. Enterovaginal fistula 9. Enterocutaneous fistula 10. Right lower quadrant tenderness F. Complications of Crohn’s Disease 1. Abscess 2. Fistula 3. Small bowel obstruction 4. Peri-anal fistula 5. Stenosis 6. Stricture G. Ulcerative colitis

XIX. Neuroendocrine tumor 39 A. Carcinoid 1. Elevated urine 5HIAA > 15mg/24hr B. Islet cell tumor of the pancreas 1. Gastrinoma a. Elevated serum gastrin >100pg/ml 2. Insulinoma a. Elevated serum insulin >2.0ng/ml 3. Glucagonoma a. Elevated serum glucagon>100pg/ml 4. VIPoma a. Elevated Vasoactive Intestinal Polypeptide (VIP) >75pg/ml 5. Somatostatinoma a. Elevated somatostatin 6. Pheochromocytoma a. Urinary VMA >7 mg/24hours b. Elevated catecholamines

XX. Evaluation of cirrhosis and portal hypertension 71,72 A. Hepatitis B and C 1. Ultrasound demonstrating a liver mass 2. Elevated alpha feto protein >20 micrograms/L and no mass on liver ultrasound B. Cirrhosis 1. Planned TIPS (Transjugular Intrahepatic Portosystemic shunt – relatively non-invasive procedure for portal hypertension) Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

XXI. Evaluation of patients with Hepatitis B or C 73-76 A. Ultrasound demonstrating a mass >1cm B. Alpha fetoprotein >20 micrograms/L

XXII. Evaluation of patient with lung cancer 23,41,51 A. Initial staging B. Establish new baseline at the end of treatment C. Rising CEA (non smoker >2.5; smoker >5.0) D. Rising liver function tests

XXIII. Follow up of known renal abscess or complicated pyelonephritis 77

XXIV. Abscess 1,5,9 A. Suspected 1. Abdominal pain for at least a day 2. Other clinical findings a. Mass on abdominal, pelvic or rectal exam b. Fever > 100.4 c. Leukocytosis, WBC >12,000/cu.mm B. Follow up during or after treatment 1. Condition unimproved or worsening after drainage and IV antibiotics for at least two days 2. Condition unimproved or worsening after IV Abx Rx > 1 wk 3. Routine follow-up study after treatment including evaluation for removal of drain.

78, 79 XXV. Suspected abdominal wall hernia A. Abdominal pain or discomfort 1. Worsened by straining or lifting 2. Worsened by prolonged standing B. Visible or palpable mass 1. More prominent in upright position 2. More prominent with Valsalva maneuver C. Strangulation 1. Colicky pain abdominal pain 2. Palpable mass 3. Signs of intestinal obstruction D. After abdominal surgery with incisional pain associated with bulge or suspected defect

XXVI. Suspected dissection of the aorta 80-84 A. Unequal blood pressure in the arms B. Rapid onset of "ripping, tearing, searing" severe chest or upper back or abdominal pain C. Pain with abnormal appearance of aorta on prior imaging 1. Chest 2. Back 3. Abdominal

CareCore National Criteria for Imaging Version 2.2009

D. Syncope E. Shortness of breath F. Prior aortic aneurysm repair G. Chest pain with evidence of a stroke H. Loss of pulses

XXVII. Crohn’s Disease and Inflammatory Bowel Disease A. Acute symptoms and signs 1. Abdominal pain 2. Liquid bowel movements, diarrhea 3. Weight loss 4. Anorexia 5. Fever >100.4 6. Abdominal tenderness 7. Abdominal mass 8. Family history of Crohn’s Disease 9. Extra intestinal manifestations a. Oral aphthous lesions b. Gallstones c. Nephrolithiasis with stones B. Chronic inflammatory disease 1. Fistulization with or without infection a. Fevers, chills, and a tender abdominal mass b. Bladder or vagina recurrent infections c. Cutaneous fistulas d. Perianal disease i. Anal fissures or fistulas ii. Abscesses C. Any evidence of clinical deterioration while on steroids or immunosuppressives

XXVIII. Appendicitis6,7 A. Pain 1. Generalized through the abdomen 2. Periumbilical 3. Suprapubic 4. Right lower quadrant B. Symptoms and signs 1. Nausea/vomiting 2. Guarding or abdominal rigidity 3. Rebound tenderness 4. Tenderness RLQ 5. Positive Rovsing’s sign (pressure to LLQ causes pain in RLQ) 6. Pregnancy excluded 7. Fever > 100.4 8. Leukocytosis, WBC >12,000/cu.mm

CareCore National Criteria for Imaging Version 2.2009

XXIX. Diverticulitis, suspected or known in a patient with lower abdominal pain and/or mass 4,5 A. Fever >100.4 B. Leukocytosis, WBC >12,000/cu.mm C. Diverticulosis by prior imaging study D. Symptoms worsening under treatment with antibiotics and diet restriction after 2 days or more

XXX. Kidney or renal stones A. Flank pain B. Hematuria or blood in the urine C. Fever, Chills D. Known renal stone for follow up E. Hydronephrosis on other imaging

References:

1.Rosen MP, Bree RL, Foley WD, et al, American College of Radiology Appropriateness Criteria Acute Abdominal Pain and Fever or Suspected Abdominal Abscess, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=9618 November 12, 2007. 2. Rosenfield AT, Choyke PL, Bluth E, et al, American College of Radiology Appropriateness Criteria, Acute Onset Flank Pain, Variant 1: Suspicion of Stone Disease, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8278&nbr=004610&string=hydronephrosis November 12, 2007. 3. Finnish Medical Society Duodecium, Haematuria, In EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2004 Aug 26, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=7382&nbr=004363&string=hydronephrosis November 12, 2007. 4. Levine MS, Bree RL, Foley WD, et al, American College of Radiology Appropriateness Criteria, Left Lower Quadrant Pain, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8586&nbr=004773&string=Diverticulitis November 12, 2007. 5. Rafferty J, Shellito P, Hyman NH, et al. Standards Committee of American Society of Colon and Rectal Surgeons. Practice Parameters for Sigmoid Diverticulitis, Dis Colon Rectum, 2006; 49:939-944. 6. Cincinnati Children’s Hospital Medical Center, Health Policy and Clinical Effectiveness Program, Evidence Based Clinical Practice Guideline, Emergency Appendectomy, accessed at http://www.cincinnatichildrens.org/NR/rdonlyres/07312778-8D7C-4C24-8250- 11B3ACF51FD2/0/appendectomyguideline.pdf November 12, 2007. 7. Weyant MJ, Eachempati SR, Maluccio MA, et al, Interpretation of computed tomography does not correlate with laboratory or pathologic findings in surgically confirmed acute appendicitis, Surgery, 2000; 128:145-152. 8. Knutson D, Greenberg G and Cronau H, Management of Crohn’s Disease—A Practical Approach, American Family Physician, accessed at http://www.aafp.org/afp/20030815/707.html November 10, 2007. 9. Huprich JE, Bree RL, Foley WD, et al, American College of Radiology Appropriateness Criteria, Evaluation of Crohn’s disease, accessed at http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=8585&nbr=4772 November 7, 2007. 10. Carter MJ, Lobo AJ, and Travis SPL, on behalf of the IBD Section of the British Society of Gastroenterology, Gut, 2005; 53 (Suppl V):v1- v16. 11. Mehard WB, Heiken JP, and Sicard GA, High-attenuating crescent in abdominal aortic aneurysm wall at CT: A sign of acute or impending rupture, Radiology, 1994; 192:359-362. 12. . Lederle FA, Wilson SE, Johnson GR, et al, Immediate repair compared with surveillance of small abdominal aortic aneurysms, N Eng J Med, 2002; 346:1437-1444. 13. Starvropoulos SW and Charagundla SR, Imaging techniques for detection and management of endoleaks after endovascular aortic aneurysm repair, Radiology, 2007; 243:641-655. 14. Hirsch AT, Haskal AJ, Hertzer NR, et al, ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease(lower extremity, renal, mesenteric and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for vascular surgery,society for cardiovascular angiography and intervention, society for vascular medicine and biology, society of interventional

CareCore National Criteria for Imaging Version 2.2009

radiology and the ACC/AHA task force on practice guidelines(writing committee to develop guidelines for the management of patients with peripheral arterial disease), J Am Coll Cardiol, 2006; 47:1-192. 15. Fattori R and Russo V, Degenerative aneurysm of the descending aorta. Endovascular Treatment, European Association for Cardio- thoracic Surgery, Multimedia Manual of Cardiothoracic Surgery, 2007, accessed at http://mmcts.ctsnetjournals.org/cgi/reprint/2007/1217/mmcts.2007.002824.pdf December 28, 2007. 16. Horton KM, Smith C, and Fishman EK, MDCT and 3D CT angiography of splanchnic artery aneurysms, AJR, 2007; 189:641-647. 17. Macari M, Chandarana H, Balthazar E, et al, Intestinal ischemia versus intramural hemorrhage: CT evaluation, AJR, 2002; 180:177-184. 18. Wiesner W, Khurana B, Ji H et al, CT of acute bowel ischemia, Radiology, 2003; 226:635-650. 19. Furukawa A, Yamasaki M, Furuichi K, et al, Helical CT in the diagnosis of small bowel obstruction, RadioGraphics, 2001; 21:341-355. 20. Ros PR, Huprich JE, Bree RL, et al, American College of Radiology Appropriateness Criteria, Suspected Small Bowel Obstruction, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonGastrointestinalimaging/SuspectedSmallbowe lobstructionDoc15.aspx November 9, 2007. 21. Zafar S, Jafri H, Shetty M, et al, American College of Radiology Appropriateness Criteria, Pretreatment Stating of Invasive Bladder cancer, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8281&nbr=004613&string=cancer+AND+staging November 13, 2007. 22. Desch CE, Benson AB, Somerfield MR, et al, Colorectal cancer surveillance: 2005 update of an American Society of Clinical Oncology Practice Guideline, JCO, 2005; 23:8512-8519. 23. Pfister DG, Johnson DH, Azzoli CG, et al, American society of clinical oncology treatment of unresectable non-small-cell lung cancer guideline: Update 2003, JCO, 2004; 22:320-353. 24. Diagnostic Imaging in the Assessment of Metastatic and Recurrent Ovarian Cancer, a Cancer Care Ontario Recommendations Report, April, 2006; accessed at http://www.cancercare.on.ca/pdf/pebcdiovar.pdf November 13, 2007. 25 Diagnostic Imaging in Lymphoma, a Cancer Care Ontario Recommendations Report, March, 2006, accessed at http://www.cancercare.on.ca/pdf/pebcdilymphf.pdf November 13, 2007. 26. Casalino DD, Choyke PL, Bluth EI, et al, American College of Radiology Appropriateness Criteria, Follow up of Renal Cell Carcinoma, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8311&nbr=004643&string=kidney+AND+cancer November 12, 2007. 27. Francis IR, Choyke PL, Bluth E, et al, American College of Radiology Appropriateness Criteria, Indeterminate Renal Mass, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8312&nbr=004644&string=kidney+AND+cancer November 12, 2007. 28. Choyke PL, Bluth EI, Bush WH Jr, et al, American College of Radiology Appropriateness Criteria, Renal Cell Carcinoma Staging, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8284&nbr=004616&string=kidney+AND+cancer November 14, 2007. 29. Grumbach MM, Biller BMK, Braunstein GD, et al, Management of the clinically Unapparent Adrenal Mass (incidentaloma), NIH Consensus and State-of-the-Science Statements, 2002, 19(2), accessed at http://consensus.nih.gov/2002/2002AdrenalIncidentalomasos021PDF.pdf November 12, 2007. 30. Wolkov HB, Constine LS, Yahalom J, et al, American College of Radiology Appropriateness Criteria, Staging Evaluation for Patients with Hodgkin’s Disease, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8307&nbr=004639&string=lymphoma+AND+imaging November 9, 2007. 31. Ng AK, Constine LS, Deming RL, et al, American College of Radiology Appropriateness Criteria, Routine Follow-up for Hodgkin’s disease After Completion of Treatment and Response Assessment, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8306&nbr=004638&string=lymphoma+AND+imaging November 9, 2007. 32. Montie JE, Eisenberger MA, El-Galley R, et al, Bladder Cancer, NCCN Practice Guidelines in Oncology, v1.2008, accessed at http://www.nccn.org/professionals/physician_gls/PDF/bladder.pdf November 10, 2007. 33. Biermann JS, Adkins D, Benjamin R, Bone cancer, NCCN Practice Guidelines in Oncology, v1.2008, accessed at http://www.nccn.org/professionals/physician_gls/PDF/bone.pdf November 10, 2007. 34. Ajani J, Bekaii-Saab T, D’Amico TA, et al, Esophageal Cancer, NCCN Practice Guidelines in Oncology, V2.2007, accessed at http://www.nccn.org/professionals/physician_gls/PDF/esophageal.pdf November 10, 2007. 35. Ajani J, Bekaii-Saab T, D’Amico TA, et al, Gastric cancer, NCCN Practice Guidelines in Oncology, V2.2007, accessed at http://www.nccn.org/professionals/physician_gls/PDF/gastric.pdf , November 10, 2007. 36. Benson AB III, Ben-Josep E, Bloomston M, et al, Hepatobiliary Cancer NCCN Practice Guidelines in Oncology, v1.2008 accessed at http://www.nccn.org/professionals/physician_gls/PDF/hepatobiliary.pdf , November 10, 2007. 37. Hoppe RT, Advani RH, Ambinder RF, et al, Hodgkin Disease Lymphoma, NCCN Practice Guidelines in Oncology, V1.2007, accessed at http://www.nccn.org/professionals/physician_gls/PDF/hodgkins.pdf November 9, 2007. 38. Motzer RJ, Bolger GB, Boston B, et al, Kidney Cancer, NCCN Practice Guidelines in Oncology, v1.2008, accessed at http://www.nccn.org/professionals/physician_gls/PDF/kidney.pdf November 9, 2007. 39. Clark OH, Ajani J, Benson ABIII, et al, Neuroendocrine tumors, NCCN practice guidelines in Oncology, V1.2007, accessed at http://www.nccn.org/professionals/physician_gls/PDF/neuroendocrine.pdf November 13, 2007. 40. Zelenetz AD, Advani EH, Bociek RG, et al, Non-Hodgkin’s Lymphomas, NCCN Practice Guidelines in Oncology, V3.2007, accessed at http://www.nccn.org/professionals/physician_gls/PDF/nhl.pdf , November 13, 2007. 41. Ettinger DS, Akerley W, Bepler G, et al Non small Cell Lung Cancer, NCCN Practice Guidelines in Oncology, v2.2008, accessed at http://www.nccn.org/professionals/physician_gls/PDF/nscl.pdf November 13, 2007. 42. Ettinger DS, Eaton K, Gockerman JP, et al, Occult Primary, NCCN Practice Guidelines in Oncology, V2.2007, accessed at http://www.nccn.org/professionals/physician_gls/PDF/occult.pdf November 13, 2007.

CareCore National Criteria for Imaging Version 2.2009

43. Kalemkerian GP, Akerley W, Downey RJ, Small Cell Lung Cancer, NCCN Practice Guidelines in Oncology, v1.2008, accessed at http://www.nccn.org/professionals/physician_gls/PDF/sclc.pdf November 13, 2007. 44. Demetri GD, Baker LH, Benjamin RS, et al, Soft Tissue Sarcoma, NCCN Practice Guidelines in Oncology, V3.2007, accessed at http://www.nccn.org/professionals/physician_gls/PDF/sarcoma.pdf November 13, 2007. 45. Motzer RJ, Bolger GB, Boston B, et al, Testicular Cancer, NCCN Practice Guidelines in Oncology, v1.2008, accessed at http://www.nccn.org/professionals/physician_gls/PDF/testicular.pdf November 13, 2007. 46. Khan SA, Davidson BR, Goldin R, et al, Guidelines for the diagnosis and treatment of cholangiocarcinoma: consensus document, Gut, 2002; 51:1-9. 47. Tempero M, Alasadi R, Amobetti JP, et al, Pancreatic Adenocarcinoma, NCCN Practice Guidelines in Oncology, v1.2008, accessed at http://www.nccn.org/professionals/physician_gls/PDF/pancreatic.pdf November 13, 2007 48.Zeman RK, Cooper C, Zeiberg AS, et al, TNM Staging of Pancreatic Carcinoma Using Helical CT, AJR, 1997; 169:459-464. 49. Guidelines for the management of patients with pancreatic cancer periampullary and ampullary carcinomas, Pancreatic Section of the British Society of Gastroenterology, Pancreatic Society of Great Britain and Ireland, Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, Royal College of Pathologists, Special interest group for Gastro-I, Gut, 2005; 54:1-16. 50. Foley WD, Bree RL, Gay SB, et al, American College of Radiology Appropriateness Criteria, Jaundice, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8294&nbr=004626&string=painless+AND+jaundice November 13, 2007. 51..Scottish Intercollegiate Guidelines Network, Management of patients with lung cancer, a national clinical guideline, 2005; accessed at http://www.sign.ac.uk/pdf/sign80.pdf , December 25, 2007 52. AGA Institute technical review on acute pancreatitis, Gastroenterology, 2007;132:20022-2044. 53.Ros PR, Bree RL, Foley WD, et al, Expert Panel on Gastrointestinal Imaging, American College of Radiology Appropriateness Criteria, Acute pancreatitis, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonGastrointestinalImaging/AcutepancreatitisDoc 2.aspx , August 23, 2008. 54. Francis IR, Baumgarten DA, Bluth EI, et al, Expert Panel on Urologic Imaging, American College of Radiology Appropriateness criteria, incidentally discovered adrenal mass, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonUrologicImaging/IncidentallyDiscoveredadren almassDoc7.aspx , August 23, 2008. 55. Israel GM, Francis IR, Baumgarten DA, et al, Expert Panel on Urologic Imaging, American College of Radiology Appropriateness criteria, Indeterminate renal masses, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonUrologicImaging/IndeterminateRenalmasses Doc8.aspx , August 23, 2008. 56.Curry NS, Francis IR, Baumgarten DA, et al, Expert Panel on Urologic Imaging, American College of Radiology Appropriateness criteria, Renal cell carcinoma staging, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonUrologicImaging/RenalCellCarcinomaStaging Doc14.aspx , August 23, 2008. 57.Heiken JP, Bree RL, Foley WD, et al Expert Panel on Gastrointestinal Imaging, American College of Radiology Appropriateness criteria , suspected liver metastases, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonGastrointestinalImaging/SuspectedliverMetast asesDoc14.aspx , August 23, 2008. 58. Foley DW, Bree RL, Gay SB, et al, al Expert Panel on Gastrointestinal Imaging, American College of Radiology Appropriateness criteria liver lesion characterization, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonGastrointestinalImaging/liverLesionCharacteri zationDoc9.aspx , August 23, 2008. 59. Gay SB, Bree RL, Foley WD, et al, Expert Panel on Gastrointestinal Imaging, American College of Radiology Appropriateness criteria, palpable abdominal mass, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonGastrointestinalImaging/Palpableabdominalm assDoc10.aspx , August 23, 2008. 60. Mourad O, Palda V, Detsky AS, A comprehensive evidence-based approach to fever of unknown origin, Arch Intern Med, 2003; 163:545- 551. 61. Shuman WP, Holtzman SR, Bree RL, et al, American College of Radiology Appropriateness Criteria, Abdominal Trauma, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8270&nbr=004602&string=abdominal+AND+trauma+AND+imaging November 13, 2007. 62. Holevar M, Ebert J, Luchette F, et al, Practice Management Guidelines for the Management of Genitourinary Trauma, The EAST Practice Management Guidelines Work Group accessed at http://www.east.org/tpg/GUmgmt.pdf November 7, 2007. 63. Salim A, Sangthong B, Martin M, et al, Whole body imaging in blunt multisystem trauma patients without obvious signs of injury, results of a prospective study, Arch Surg, 2006; 141:468-475. 64. Kier R, McCarthy S, Rosenfield AT, et al, Nonpalpable testes in young boys: evaluation with MR imaging, Radiology,1988; 169:429-433. 65. Fritzsche PJ, Hricak H, Kogan BA, et al, Undescended testis: Value of MR imaging, Radiology,1987; 164:169-173. 66. Friedland GW and Chang P, The role of imaging in the management of the impalpable undescended tests, AJR, 1988; 151:1107-1111. 67. Bouras EP, Lange SM and Scolapio JS, Rational approach to patients with unintentional weight loss, Mayo Clin Proc, 2001; 76:923-929.

CareCore National Criteria for Imaging Version 2.2009

68. Grossfeld GD, Wolf JS, Litwin MS, et al, Asymptomatic microscopic hematuria in adults: summary of the AUA best practice policy recommendations, Am Fam Physician, 2001; 63:1145-1154. 69. Paulsen SR, Huprich JE, Fletcher JG, et al, CT Enterography as a diagnostic tool in evaluating small bowel disorders: Review of clinical experience with over 700 cases, RadioGraphics, 2006; 26:641-662. 70. Booya F, Fletcher JG, Huprich JE, et al, Active Crohn’s disease: CT findings and interobserver agreement for enteric phase CT Enterography, Radiology, 2006; 241:787-795. 71. Murray KF and Carithers RL Jr, AASLD practice guidelines: evaluation of the patient for liver transplantation, Hepatology, 2005; 41(6):1-26. 72. Boyer TD and Haskal ZJ, AASLD practice guideline The role of transjugular intrahepatic protosystemic shunt in the management of portal hypertension, Hepatology, 2005; 41(2):386-400 73. Arguedas MR, Chen VK, Eloubeidi MA, et al Screening for Hepatocellular Carcinoma in patients with Hepatitis C Cirrhosis: A Cost-Utility Analysis The American Journal of Gastroenterology, 2003; 98(3):679-690. 74. Ryder SD, Guidelines for the diagnosis and treatment of hepatocellular carcinoma (HCC) in adults, GUT, 2003; 52(Suppl III):iii1-iii8. 75. Lok AS, McMahon BJ, Chronic hepatitis B, Hepatoplogy, 2007: 45:507-509. 76. Bruix J and Sherman M, AASLD Practice Guideline, Management of hepatocellular carcinoma, Hepatology, 2005; 42:1208-1236. 77. Sandler CM, Choyke PL, Bluth E, et al, Expert Panel on Urology, American College of Radiology Appropriateness Criteria, Acute pyelonephritis, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8277&nbr=004609&string=kidney+AND+abscess November 14, 2007. 78. Aguirre DA, Santosa AC, Casola G, et al, Abdominal wall hernias: imaging features, complications and diagnostic pitfalls at multi-detector row CT, RadioGraphics, 2005; 25:1501-1530. 79. Miller PA, Mezwa DG, Feczko PJ, et al, Imaging of abdominal hernias, RadioGraphics, 1995; 15:333-347. 80. Gomes AS, Bettmann MA, Casciani T, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-suspected aortic dissection, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainSusp ectedaorticdissectionDoc2.aspx , December 28, 2007. 81.Holtzman SR, Bettmann MA, Casciani T, et al, Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Blunt chest trauma suspected aortic injury, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/Vascular/BluntChestTraumaSuspectedaorticInjuryDoc6.aspx , December 28, 2007. 82. Erbel R, Alfonso F, Boileau C, et al, Diagnosis and management of aortic dissection : recommendations of the task force on aortic dissection, Europena Society of Cardiology, European Heart Journal, 2001, 22:1642-1682. 83. Stanford W, Yucel EK, Bettmann MA, , Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-No ecg enzyme evidence of myocardial ischemia/infarction, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/Acute ChestPainNoECGorEnzymeEvidenceofMyocardialIschemiaInfarctionDoc1.aspx , December 28, 2007. 84.Mulder S, Spilde P, Morrison J, et al, Helath Care Guideline: Diagnosis and treatment of chest pain and acute coronary syndrome (ACS), Institute for Clinical systems Improvement, Third Edition, 2006, accessed at http://www.icsi.org/acs_acute_coronary_syndrome /acute_coronary_syndrome _and_chest_pain__diagnosis_and_treatment_of_2.html , December 28, 2007.

Reviewed: 3/18/2009 Posted: 8/15/2009

CareCore National Criteria for Imaging Version 2.2009

74175 CTA of the Abdomen

I. Renovascular hypertension, suspected renal artery stenosis 1-6 A. Severe hypertension (>110 diastolic) with 1. Progressive renal insufficiency or 2. Refractoriness to aggressive medical therapy B. Malignant or accelerated hypertension C. Acute worsening of previously stable hypertension D. Significant hypertension (>110 diastolic) in adult <35 years old E. New onset significant hypertension (>110 diastolic) after age 50 F. Grade III or grade IV retinopathy with significant hypertension (>110 diastolic) G. Hypertension in a patient with: 1. Diffuse atherosclerosis or 2. Incidentally detected asymmetry of kidney size H. Hypertension with an acute elevation in plasma creatinine concentration unexplained or after therapy with an ACE inhibitor I. Abdominal bruit J. Recurring acute pulmonary edema with significant hypertension (>110 diastolic) K. Hypokalemia (<3.5 mmol/L) with normal or elevated plasma renin (>1 ng/ml/Hr) levels in the absence of diuretic therapy

II. Intestinal angina (mesenteric ischemia) 1,7-9 A. Recurrent acute episodes of abdominal pain [All] 1. Dull or crampy 2. Postprandial epigastric pain, occasionally radiates to the back 3. Weight loss 4 Fear of eating

III. Evaluation of renal transplant donor 10

IV. Aneurysm on prior imaging study 1,11 (US, CT, CTA, MRI or MRA) of the abdomen A. Suspected rupture of AAA 1. New onset of pain, usually abdominal pain radiating to the back 2. Clinical findings a. Palpable, pulsatile or expansile mass b. Abnormal x-ray or US findings suggesting aortic disease c. Falling blood pressure B. Known AAA 1. Periodic follow-up of known AAA will be allowed once every six months a. Inadequate ultrasound b. No surgical repair

CareCore National Criteria for Imaging Version 2.2009

2. New onset of pain C. Postoperative evaluation following repair including endovascular repair (stent graft) 1. 1 month after repair 2. 3 months after repair 3. 6 months after repair 4. Annually after repair 5. Suspicion of endoleak D. Aneurysm of any intraabdominal artery detected on other Imaging E. Vascular insufficiency of the bowel 1. Abdominal pain often starting as periumbilical and often out of proportion to findings on exam 2. Other clinical findings a. Leukocytosis, WBC >12,000/cu.mm b. Stool positive for occult blood c. Nausea, vomiting or diarrhea d. History of abdominal angina (pain after eating for approximately 3 hours)

V. Peripheral arterial vascular disease 1,12-14 Note: For evaluation of PVD, unlike with MRA studies, the appropriate CPT code would be 75635 (CTA abdominal aorta with runoff) rather than either CTA abdomen or CTA pelvis. A. ABI (Ankle Brachial Index, ankle systolic BP divided by brachial systolic BP) 1. Rest ABI <0.90 in symptomatic member 2. Exercise ABI <0.90 in symptomatic member with rest ABI >0.90 3. Toe brachial index <0.90 or pulse volume recording evidence of peripheral vascular disease if the ABI >1.30 B. Abnormal pulses C. Bruit D. Claudication E. Diabetic with 1. Skin changes 2. Loss of hair 3. Poor capillary refill 4. Thickened nails 5. Thin skin F. Known atherosclerotic occlusive disease

VI. Suspected dissection of the aorta 15-17 A. Unequal blood pressure in the arms B. Rapid onset of "ripping, tearing, searing" severe chest or upper back or abdominal pain C. Pain with abnormal appearance of aorta on prior imaging 1. Chest 2. Back 3. Abdominal D. Syncope E. Shortness of breath Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

F. Prior aortic aneurysm repair G. Chest pain with evidence of a stroke H. Loss of pulses

VII. Evaluation of the hepatic arteries and veins (including portal vein) 1, 10, 14-16 A. Evaluation of portal and hepatic veins prior to or following TIPS (Transjugular Intrahepatic Portosystemic Shunt) B. Evaluation of portal and hepatic veins prior to or following surgical intervention for portal hypertension C. Evaluation of hepatic vasculature prior to and following embolization procedure D. Evaluation of hepatic vasculature prior to planned hepatectomy E. Evaluation of liver donor

VIII. Evaluation of abdominal veins A. Documented kidney (renal cell) carcinoma B. Nephrotic syndrome C. Suspicion of iliac vein thrombus D. Suspicion of inferior vena cava thrombus

References:

1. Pilleul F, Beuf O, Abdominal arteries should be evaluated by 3D contrast - enhanced MRA as the first step, Acta Radiologica, 2002; 43(5): 544-542. 2. Boudeqijn G, Vasbinder C, Nelemans PJ, et al, Diagnostic tests for renal artery stenosis in patients suspected of having renovascular hypertension, Annals of Int Med, 2001; 135(6):401-411. 3. Leung DA, Hagspiel KD, Angle JF, et al, MR angiography of the renal arteries, Radiol Clin N Am, 2002: 40:847-865. 4. Qanadli SD, Soulez G, Therasse E, et al, Detection of renal artery stenosis, AJR, 2001; 177:1123-1129. 5. Kawashima A, Francis IR, Baumgaraten DA, et al, Expert Panel on Urologic Imaging, American College of Radiology Appropriateness Criteria, Renovascular Hypertension, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonUrologicImaging/renovascularhypertensionDo c17.aspx December 11, 2007. 6. Chobanian AV, Bakris GL, Black HR, et al, Seventh report of the joint national committee on prevention, detection, evaluation and treatment of high blood pressure, Hypertension, 2003; 42(6):1206-1252. 7. Shih MP, and Hagspiel, CTA and MRA in mesenteric ischemia: part 1, role in diagnosis and differential diagnosis, AJR, 2007; 188:452-461. 8. Shih MP, Angle JF, Leung DA, et al, CTA and MRA in mesenteric ischemia: part 2, normal findings and complications after surgical and endovascular treatment, AJR, 2007; 188: 462-471. 9. American Gastroenterological Association medical position statement: guidelines on intestinal ischemia, Gastroenterology, 2000; 118:951- 953. 10. Lee SS, et al, Hepatic arteries in potential donors for living related liver transplantation: evaluation with multi–detector row CT angiography, Radiology, 2003; 227:391-399. 11. Hartnell GG, Imaging of aortic aneurysms and dissection: CT and MRI, J Thoracic Imaging, 2001; 16(1):35-46. 12. Willmann JK, Wildermuth S, Pfammatter T, et al, Aortoiliac and renal arteries: prospective intraindividual comparison of contrast-enhanced three-dimensional MR angiography and multi–detector row CT angiography, Radiology, 2003; 226:798-811. 13. Frykberg RG, Zagonis T, Armstrong DG, et al, Diabetic foot disorders: a clinical practice guideline (2006 revision), Journal of Foot and Ankle Surgery, 2006; 45(5):S1-S66. 14. Hirsch AT, Haskal ZJ, Hertzer NR et al, ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic: a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines, accessed at http://content.onlinejacc.org/cgi/reprint/47/6/e1 August 23, 2008. Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

15.Gomes AS, Bettmann MA, Casciani T, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-suspected aortic dissection, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainSusp ectedaorticdissectionDoc2.aspx December 28, 2007. 16.Holtzman SR, Bettmann MA, Casciani T, et al, Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Blunt chest trauma suspected aortic injury, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/Vascular/BluntChestTraumaSuspectedaorticInjuryDoc6.aspx December 28, 2007. 17.Erbel R, Alfonso F, Boileau C, et al, Diagnosis and management of aortic dissection : recommendations of the task force on aortic dissection, Europena Society of Cardiology, European Heart Journal, 2001, 22:1642-1682.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

74181 MRI Abdomen without Gadolinium 74182 MRI Abdomen with Gadolinium 74183 MRI Abdomen without and with Gadolinium

As a general rule, MRI is not used for the initial examination of abdominal pain with the exception of suspected pancreatitis. CT or US would be the initial study.

I. Hepatic, renal, pancreatic or other abdominal mass 1-4 A. Detected on other imaging, further characterization required B. Suspected hepatic, renal, or pancreatic abscess 1. Fever >100.4 2. Leukocytosis, WBC >12,000/cu.mm 3. Positive blood culture 4. Abdominal pain 5. Palpable mass 6. Hiccup 7. Ileus

II. Known or suspected adrenal disease5-7 A. Suspected pheochromocytoma 1. Urinary VMA >7mg/24 hours 2. Elevated catecholamines B. Suspected adrenal cortical tumor (cortisol secreting) 1. 24 hour urine free cortisol >100mcg.24hr 2. Dexamethasone suppression test negative C. Suspected aldosteronoma 1. Aldosterone >30ng/dL for adult and >80ng/dL for children 2. Plasma renin <1.9ng/hr 3. Hypokalemia not on diuretics a. Serum potassium less than 3.5 mEq/L on 2 different samples D. Suspected neuroblastoma 1. Abdominal mass 2. Urinary VMA >7mg/24hours 3. Urinary VMA and homovanillic acid E. Suspicion of ganglioneuroma, ganglioneuroblastoma or paraganglioneuroma F. Periodic assessment of non-functioning adrenal mass 3 and 6 months after initial diagnosis

III. Hemochromatosis 9,10 A. Elevated iron saturation B. Elevated serum ferritin

CareCore National Criteria for Imaging Version 2.2009

A. For evaluation of findings on CT or US

V. Evaluation of patients with Hepatitis B or C 14-18 A. Ultrasound demonstrating a mass >1cm C. Alpha fetoprotein >20 µgµ/L

VI. Pancreatitis 19-21 For suspected pancreatitis, if meets criteria, either MRI or MRCP is acceptable. A. Suspected acute pancreatitis (Exams may be repeated at intervals if there is no improvement on therapy or signs of complications are present.) 1. Abdominal pain and tenderness 2. Amylase >99U 3. Lipase >160IU/L B. Anticipated multiple follow up abdominal exams [to minimize radiation exposure] C. Known pancreatitis with any of the following allows for repeat exams if present 1. Hemodynamic instability a. Falling hematocrit b. Falling blood pressure 2. Fever >100.4 3. Retroperitoneal air on prior CT 4. Positive blood culture 5. Signs of peritonitis (rebound tenderness) 6. Poor oxygen saturation, signs of Adult Respiratory Distress Syndrome (ARDS) 7. Signs of renal failure 8. Initial clinical state unimproved after 5 days of therapy D. Abscess E. Suspected pseudocyst 1. History a. Acute pancreatitis with onset at least 4 weeks earlier b. Pancreatitis secondary to trauma (time irrelevant) c. Chronic pancreatitis 2. Clinical findings a. Abdominal/back pain b. Abdominal tenderness c. Abdominal mass

VII. Pancreatic cancer or mass 22,23 A. Symptoms 1. Weight loss 2. Mid-epigastric pain 3. Mid-epigastric pain radiating to the back B. Elevated tumor markers 1. CEA >2.5 2. CA19-9 >40KU/L C. Abnormal pancreas on prior ultrasound, CT or MRI Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

D. Painless jaundice 1. Direct bilirubin >0.4 mg/dL 2. Total bilirubin > 1.9 mg/dL E. Abdominal ultrasound with pancreatic mass or equivocal pancreatic findings

VIII. As an alternative to CT A. Anticipated lifelong abdominal exams (long-term follow up of any disease process) B. Allergy to iodinated contrast material in patient meeting guidelines for abdominal CT

IX. Findings on CT requiring further evaluation

X. MR Cholangiopancreatography (MRCP) 24 A. Suspected obstruction to flow of bile 1. Biliary duct dilatation on US or other imaging 2. Jaundice direct bilirubin >0.4 mg/dL 3. Acalculous cholecystitis B. Pancreatitis 1. Clinical findings ] a. Abdominal pain and tenderness b. Amylase >99U c. Lipase >160IU/L 2. Recurrent or chronic without obvious cause 3. Occurring after trauma, surgery or instrumentation (including prior cholecystectomy or ERCP) C. Evaluation of pseudocyst detected on prior imaging (The status of the pancreatic duct is a key determinant of how a pseudocyst is treated. If the pancreatic duct is intact, percutaneous drainage is likely to be effective. If the duct is disrupted percutaneous drainage will not provide definitive therapy and will convert the pseudocyst to a fistula). D. Tumor 1. Evaluation of pancreatic or biliary ducts with known tumors of the pancreas, liver or suspected tumors of the biliary or pancreatic ducts on prior imaging 2. Biliary cystadenoma or cystadenocarcinoma

XI. Neuroendocrine tumor 25-28 A. Carcinoid 1. Elevated 5HIAA15mg/24hr B. Islet cell tumor of the pancreas 1. Gastrinoma a. Elevated serum gastrin >100pg/ml 2. Insulinoma a. Elevated serum insulin >2.0ng/ml 3. Glucagonoma a. Elevated serum glucagon>100pg/ml 4. VIPoma

CareCore National Criteria for Imaging Version 2.2009

a. Elevated Vasoactive Intestinal Polypeptide (VIP) >75pg/ml 5. Somatostatinoma a. Elevated somatostatin C. Pheochromocytoma (see Known or Suspected Adrenal Disease, above) 1. Elevated VMA or metanephrine 2. Elevated catecholamines

XII. Aneurysm A. Suspected rupture of AAA 1. New onset of pain 2. Clinical findings a. Palpable, pulsatile or expansile mass b. Abnormal X-ray or US findings suggesting aortic disease c. Falling Blood Pressure B. Known AAA 1. Periodic follow-up of known AAA will be allowed once every six months a. Inadequate ultrasound 2. New onset of pain C. Postoperative evaluation following endovascular repair (stent graft) 1. 1 month after repair 2. 3 months after repair 3. 6 months after repair 4. Annually after repair D. Aneurysm of any intraabdominal artery detected on other Imaging E. Vascular insufficiency of the bowel 1. Abdominal pain often starting as periumbilical 2. Other clinical findings a. Leukocytosis, WBC >12,000/cu.mm b. Stool positive for occult blood c. Nausea, vomiting or diarrhea d. History of abdominal angina (pain after eating for approximately 3 hours)

XIII. Suspected dissection of the aorta 29-33 A. Unequal blood pressure in the arms B. Rapid onset of "ripping, tearing, searing" severe chest or upper back or abdominal pain C. Pain with abnormal appearance of aorta on prior imaging 1. Chest 2. Back 3. Abdominal D. Syncope E. Shortness of breath F. Prior aortic aneurysm repair G. Chest pain with evidence of a stroke H. Loss of pulses

CareCore National Criteria for Imaging Version 2.2009

References:

1. Koenraad J, Mortelé, Ros PR, Cystic focal liver lesions in the adult: differential CT and MR imaging features, RadioGraphics, 2001; 21: 895- 910. 2. Garcia-Eulate R, Hussain N, Heller T, CT and MRI of hepatic abscess in patients with chronic granulomatous disease, AJR, 2006; 187: 482- 490. 3. Beer AJ, Dobritz M, Zantl N, Comparison of 16-MDCT and MRI for characterization of kidney lesions, AJR, 2006; 186: 1639-1650. 4. Miller FH, Keppke AL, Dalal K, et al., MRI of pancreatitis and its complications: Part 1, acute pancreatitis, AJR, 2004 Dec 1; 183(6): 1637- 1644. 5.Israel GM, Krinsky GA, MR imaging of the kidneys and adrenal glands, Radiol Clin N Am, 2003; 41: 145-159. 6.Mayo-Smith WW, Boland GW, Noto RB, et al., State of the art adrenal imaging, Radio-Graphics, 2001; 21: 995-1012. 7. Bae KT, Fuangtharnthip P, Prasad SR, et al., Adrenal masses: CT characterization with histogram analysis method, Radiology, 2003; 228: 735-742. 8. Bravo EL, Evolving concepts in the pathophysiology, diagnosis, and treatment of pheochromocytoma, Endocr Rev, 1994; 15: 356.\ 9.Alustiza JM, Artetxe J, Castiella A, et al., MR quantification of hepatic iron concentration, Radiology, 2004; 230: 479-484. 10. Mortele KJ and Ros PR, Imaging of diffuse liver disease, Semin Liver Dis, 2001; 21: 195-212. 11. Gupta AA, Kim DC, Krinsky GA, et al., CT and MRI of cirrhosis and its mimics, AJR, 2004; 183: 1595-1601. 12. Baron RL, Peterson MS, Screening the cirrhotic liver for hepatocellular carcinoma with CT and MR imaging: opportunities and pitfalls, RadioGraphics, 2001; 21: S117-S132. 13. de LeÂ dinghen V, Laharie D, Lecesne R, et al., Detection of nodules in liver cirrhosis: spiral computed tomography or magnetic resonance imaging? A prospective study of 88 nodules in 34 patients, European Journal of Gastroenterology & Hepatology, 2002; 14: 159-165. 14. Arguedas MR, Chen VK, Eloubeidi MA, et al., Screening for hepatocellular carcinoma in patients with hepatitis C cirrhosis: a cost-utility analysis, Am J Gastroenter, 2003; 98(3): 679-690. 15. Marrero JA, Hepatocellular carcinoma, Current Opinion in Gastroenterology, 2003; 19: 243–249. 16. Gebo KA, Jenckes MW, Chander G, et al., Management of Chronic Hepatitis C, Agency for Healthcare Research and Quality, Evidence Report/Technology Assessment Number 60, 2002, accessed at http://www.ahrq.gov/downloads/pub/evidence/pdf/hepc/hepc.pdf , November 5, 2007. 17. Ryder SD, Guidelines for the diagnosis and treatment of hepatocellular carcinoma (HCC) in adults, Gut, 2003; 52(Suppl III): iii1-iii8. 18. Bruix J and Sherman M, AASLD Practice Guideline, Management of hepatocellular carcinoma, Hepatology, 2005; 42:1208-1236. 19. Miller FH, Keppke AL, Dalal K, et al., MRI of pancreatitis and its complications: Part 1, acute pancreatitis, AJR, 2004 Dec 1; 183(6): 1637- 1644. 20. Pitchumoni CS, Sonnenshein M, Candido FM, et al., Nutrition in the pathogenesis of alcoholic pancreatitis, Am J Clinical Nutrition, 1980 Mar; 33: 631. 21. Morgan DE, Baron TH, Smith JK, et al., Pancreatic fluid collections prior to intervention: evaluation with MR imaging compared with CT and US, Radiology, 1997; 203: 773 –778. 22. Tamm EP, Silverman PM, Charnsangevej C, et al., Diagnosis, staging and surveillance of pancreatic cancer, AJR, 2003; 180: 23. Sahani DV, Kadavigere R, Blake M, et al., Intraductal papillary mucinous neoplasm of pancreas: multi–detector row CT with 2D curved reformations—correlation with MRCP, Radiology, 2006; 238: 560-569. 311-1323. 24. Vitellas KM, Keogan MT, Spritzer CE, et al., MR cholangiopancreatography of bile and pancreatic duct abnormalities with emphasis on the single-shot fast spin-echo technique, RadioGraphics, 2000; 20: 939-957. 25. Owen NJ, Sohaib SAA, Peppercorn PD, et al, MRI of pancreatic neuroendocrine tumors, BJR, 2001; 74: 968-973. 26. Herwick S, Miller FH, Keppke AL, MRI of islet cell tumors of the pancreas, AJR, 2006; 187: W472-W480. 27. Plockinger U, Rindi G, Eriksson B, et al., Guidelines of the diagnosis and treatment of neuroendocrine gastrointestinal tumours, A consensus statement on behalf of the European neuroendocrine tumour society (ENETS), Neuroendocrinology, 2004; 80: 394-424.39. 28. Clark OH, Ajani J, Benson A BIII, et al, Neuroendocrine tumors, NCCN practice guidelines in Oncology, V1.2007, accessed at http://www.nccn.org/professionals/physician_gls/PDF/neuroendocrine.pdf November 13, 2007. 29. Gomes AS, Bettmann MA, Casciani T, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-suspected aortic dissection, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainSuspe ctedaorticdissectionDoc2.aspx , December 28, 2007. 30. Holtzman SR, Bettmann MA, Casciani T, et al, Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Blunt chest trauma suspected aortic injury, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/Vascular/BluntChestTraumaSuspectedaorticInjuryDoc6.aspx December 28, 2007 31. Erbel R, Alfonso F, Boileau C, et al, Diagnosis and management of aortic dissection : recommendations of the task force on aortic dissection, Europena Society of Cardiology, European Heart Journal, 2001, 22:1642-1682. 32. Stanford W, Yucel EK, Bettmann MA, , Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-No ecg enzyme evidence of myocardial ischemia/infarction, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/Acute ChestPainNoECGorEnzymeEvidenceofMyocardialIschemiaInfarctionDoc1.aspx December 28, 2007.

CareCore National Criteria for Imaging Version 2.2009

33. Mulder S, Spilde P, Morrison J, et al, Helath Care Guideline: Diagnosis and treatment of chest pain and acute coronary syndrome (ACS), Institute for Clinical systems Improvement, Third Edition, 2006, accessed at http://www.icsi.org/acs_acute_coronary_syndrome /acute_coronary_syndrome _and_chest_pain__diagnosis_and_treatment_of_2.html December 28, 2007.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

74185 MRA of the Abdomen without or with Gadolinium

I. Renovascular hypertension, suspected renal artery stenosis 1-6 A. Severe hypertension (diastolic > 110) with 1. Progressive renal insufficiency or 2. Refractoriness to aggressive medical therapy B. Malignant or accelerated hypertension C. Acute worsening of previously stable hypertension D. Significant hypertension (diastolic >110) in adult <35 years old E. New onset significant hypertension (diastolic >110) after age 50 F. Grade III or grade IV retinopathy with significant hypertension (>110 diastolic). G. Hypertension in a patient with: 1. Diffuse atherosclerosis 2. Incidentally detected asymmetry of kidney size H. Hypertension in a patient with an acute elevation in plasma creatinine concentration unexplained or after therapy with an ACE inhibitor I. Abdominal bruit J. Recurring acute pulmonary edema with significant hypertension (diastolic > 110) K. Hypokalemia (decreased plasma potassium level) with normal or elevated plasma renin levels in the absence of diuretic therapy

II. Intestinal angina or mesenteric ischemia 1, 7-9 A. Recurrent acute episodes of abdominal pain 1. Dull or crampy 2. Postprandial epigastric pain, occasionally radiates to the back 3. Weight loss 4 Fear of eating

III. Evaluation of renal transplant donor 10

IV. Aneurysm on prior imaging study (US, CT or MRI) of the abdomen1,11 A. Suspected rupture of AAA 1. New onset of pain, usually abdominal pain radiating to the back 2. Clinical findings a. Palpable, pulsatile or expansile mass b. Abnormal x-ray or US findings suggesting aortic disease c. Falling blood pressure B. Known AAA 1. Periodic follow-up of known AAA will be allowed once every six months a. Inadequate ultrasound b. No surgical repair Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

2. New onset of pain C. Postoperative evaluation following repair including endovascular repair (stent graft) 1. 1 month after repair 2. 3 months after repair 3. 6 months after repair 4. Annually after repair 5. Suspicion of endoleak D. Aneurysm of any intraabdominal artery detected on other imaging E. Vascular insufficiency of the bowel 1. Abdominal pain often starting as periumbilical and often out of proportion to findings on exam 2. Other clinical findings a. Leukocytosis, WBC >12,000/cu.mm b. Stool positive for occult blood c. Nausea, vomiting or diarrhea d. History of abdominal angina (pain after eating for approximately 3 hours)

V. Peripheral arterial vascular disease 1,12-14 A. ABI (ankle brachial index, ankle systolic BP divided by brachial systolic BP) 1. Rest ABI < 0.90 in symptomatic member 2. Exercise ABI <0.90 in symptomatic member with rest ABI >0.90 3. Toe brachial index <0.90 or pulse volume recording evidence of peripheral vascular disease if the ABI >1.30 B. Abnormal pulses C. Bruit D. Claudication E. Diabetic with 1. Skin changes 2. Loss of hair 3. Poor capillary refill 4. Thickened nails 5. Thin skin F. Known atherosclerotic occlusive disease

VI. Evaluation of the hepatic arteries and veins (including portal vein) 1, 10, 15,16 A. Evaluation of portal and hepatic veins prior to or following TIPS (transjugular intrahepatic portosystemic shunt) B. Evaluation of portal and hepatic veins prior to or following surgical intervention for portal hypertension C. Evaluation of hepatic vasculature prior to and following embolization procedure D. Evaluation of hepatic vasculature prior to planned hepatectomy E. Evaluation of liver donor

VII. Evaluation of abdominal veins 17 A. Documented kidney (renal cell) carcinoma Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

B. Nephrotic syndrome C. Suspicion of iliac vein thrombus D. Suspicion of inferior vena cava thrombus

VIII. Malignant neoplasm of the kidney (renal cell) 17 A. Contraindication to the use of iodinated contrast

IX. Suspected dissection of the aorta 18-20 A. Unequal blood pressure in the arms B. Rapid onset of "ripping, tearing, searing" severe chest or upper back or abdominal pain C. Pain with abnormal appearance of aorta on prior imaging 1. Chest 2. Back 3. Abdominal D. Syncope E. Shortness of breath F. Prior aortic aneurysm repairs G. Chest pain with evidence of a stroke H. Loss of pulses

References:

CareCore National Criteria for Imaging Version 2.2009

Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines, accessed at http://content.onlinejacc.org/cgi/reprint/47/6/e1 , August 23, 2008. 15. Lim JS, Kim M-J, Kim JH, et al, Preoperative MRI of potential living-donor-related liver transplantation using a single dose of gadobenate dimeglumine, AJR, 2005; 185:424-431. 16. Nghiem HV, Winter TC III, Mountford MC, et al, Evaluation of the portal venous system before liver transplantation: value of phase-contrast MR angiography, AJR, 1995; 164:871-878. 17 Curry NS, Francis IR, Baumgarten DA, et al, Expert Panel on Urologic Imaging, American College of Radiology Appropriateness Criteria— Renal Cell Carcinoma Staging, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonUrologicImaging/renalcellCarcinomaStagingD oc14.aspx March 14, 2008. 18. Gomes AS, Bettmann MA, Casciani T, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Acute chest pain-suspected aortic dissection, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainSusp ectedaorticdissectionDoc2.aspx , December 28, 2007. 19.Holtzman SR, Bettmann MA, Casciani T, et al, Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Blunt chest trauma suspected aortic injury, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/Vascular/BluntChestTraumaSuspectedaorticInjuryDoc6.aspx , December 28, 2007. 20. Erbel R, Alfonso F, Boileau C, et al, Diagnosis and management of aortic dissection : recommendations of the task force on aortic dissection, Europena Society of Cardiology, European Heart Journal, 2001, 22:1642-1682.

CareCore National Criteria for Imaging Version 2.2009

75557 MRI of the Heart for Morphology and Function without Gadolinium

I. Suspicion of congenital obstructive cardiac lesion 1-5 A. Working diagnosis 1. Coarctation of the aorta 2. Aortic valve stenosis 3. Pulmonic valve stenosis 4. Mitral valve stenosis 5. Tricuspid valve stenosis or atresia

II. Atrial Septal Defect 1-5 (ASD) A. Asymptomatic 1. Systolic ejection murmur with diastolic rumble 2. Echocardiogram inadequate visualization for surgical repair B. Symptomatic 1. Dyspnea or Congestive Heart Failure 2. CVA with unknown etiology (paradoxical embolus) C. Documented diagnosis by other imaging and planned surgical repair

III. Ventricular Septal Defect 1-5 (VSD) A. Documented diagnosis by other imaging and planned surgical repair

IV. Tetralogy of Fallot 1-5 A. Prior imaging 1. Chest x-ray suggestive of Tetralogy of Fallot 2. Echocardiogram suboptimal for diagnosis B. Documented diagnosis by other imaging and planned surgical repair

V. Ebstein’s anomaly 1-5 A. Documented diagnosis by other imaging and planned surgical repair B. Prior imaging inadequate for diagnosis

VI. Other congenital heart disease 1-5 A. Truncus arteriosus B. Transposition of the Great Vessels C. Single left ventricle D. Total anomalous pulmonary venous return E. Endocardial cushion defect F. Vascular rings and other congenital anomalies of the Great Vessels

CareCore National Criteria for Imaging Version 2.2009

G. Left sided aortic arch with aberrant right subclavian artery H. Anomalous left pulmonary artery I. Double aortic arch J. Ebstein’s anomaly K. Eisenmenger’s syndrome

VII. Syndromes with congenital heart disease 1-5 (established diagnosis) A. Holt-Oram syndrome B. Anomalous pulmonary venous return C. Marfan’s syndrome D. Turner’s syndrome E. William syndrome F. Trisomy 21 (Down’ syndrome) G. Schone’s Syndrome

VIII. Anomalous coronary arteries 2, 5, 6

2, 5 IX. Marfan’s syndrome

2 X. Evaluation of left ventricular function A. Echocardiogram suboptimal for diagnosis

XI. Evaluation of prosthetic valve 2 A. Echocardiogram suboptimal for diagnosis B. Transesophageal echocardiogram suboptimal for diagnosis

XII. Arrhythmogenic right ventricular dysplasia 2, 7, 8 A. Tachycardia (>100 beats/min) B. Supraventricular arrhythmia 1. Atrial fibrillation 2. Paroxysmal Atrial Tachycardia (PAT) 3. Supraventricular Tachycardia (SVT) C. Right heart failure D. Asymptomatic cardiomegaly

XIII. Myocarditis 2, 4, 9, A. Documentation of episode of elevated cardiac enzymes B. No evidence of significant coronary artery disease on recent angiogram or CCTA

XIV. Pericardial disease 2, 4, 10 A. Differentiate constrictive cardiomyopathy from constrictive pericarditis B. Tumor of the pericardium (known or suspected)

CareCore National Criteria for Imaging Version 2.2009

C. Paracardiac masses

XV. Suspicion of intracardiac mass 2, 4, 11

XVI. Venous mapping 2 A. Atrial fibrillation B. Radiofrequency ablation planned

XVII. Cardiomyopathy 2, 12-15 A. Sarcoidosis 1. Known diagnosis of sarcoidosis 2. Documented arrhythmia a. Complete right bundle branch block b. AV block B. Hypertrophic cardiomyopathy C. Amyloid D. Cardiotoxic drugs and failed MUGA scan E. Hemachromatosis F. Hemosiderosis G. Restrictive cardiomyopathy

XVIII. Myocardial viability 16 A. Documented myocardial ischemia B. Revascularization planned

XIX. Complications of myocardial infarction 16 A. Possible cardiac aneurysm 1. Echocardiogram not diagnostic B. Suspected mural thrombus of motion or clot 1. Echocardiogram not diagnostic 2. History or arterial embolization

XX. Aortic dissection 2 A. Unequal blood pressure in the arms B. Rapid onset of "ripping, tearing, searing" severe chest or upper back or abdominal pain C. Pain with abnormal appearance of aorta on prior imaging 1. Chest 2. Back 3. Abdominal D. Syncope E. Shortness of breath F. Prior aortic aneurysm repair G. Chest pain with evidence of a stroke H. Loss of pulses

CareCore National Criteria for Imaging Version 2.2009

XXI. Valvular heart disase A. Echocardiogram is non diagnostic or suboptimal

References:

1.Ho, VB, Yucel EK, Khan A, et al Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Suspected congenital heart disease in the adult, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/SuspectedCongenital HeartDiseaseintheAdultUpdateinProgressDoc18.aspx January 1, 2008. 2. Hendel RC, Patel MR, Kramer CM et al, ACCF/ACR/SCT/SCCT/SCMR/ASNC/ NASCI/ SCAI/ SIR 2006 Appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging, accessed at , http://www.acc.org/qualityandscience/clinical/pdfs/CCT.CMR.pdf January 1, 2008. 3. Hirsch R, Kilner PF, Connelly MS et al, Diagnosis in adolescents and adults with congenital heart disease. Prospective assessment of individual and combined roles of magnetic resonance imaging and transesophageal echocardiography, Circulation, 1994; 90:2937-2951. 4. Pennell, DJ, Sechtem UP, Higgins CB, et al, Clinical indications for cardiovascular magnetic resonance (CMR): Consensus panel report, European Heart Journal, 2004; 25:1940-1965. 5. Crean A, Cardiovascular MR and CT in congenital heart disease, Heart , 2007;93:1637-1647. 6 Post JC, vanRossum AC, Bronzwaer JGF, et al, Magnetic resonance angiography of anomalous coronary arteries, Circulation, 1995; 92:3163-3171. 7. Marcus, FI, Fontaine GH, Guiraudon G, et al, Right ventricular dysplasia: a report of 24 adult cases, Circulation, 1982, 65:384-398. 8..Tandri H, Castillo E, Ferrari VA, et al, Magnetic resonance imaging of Arrhythmogenic right ventricular dysplasia, Journal of the American College of Cardiology, 2006; 48(11):2277-2284 9. Mahrholdt H, Goedecke C, Wagner A et al, Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology, Circulation, 2004; 109:1250-1258. 10.Maisch B, Seferovic PM, Ristic AD et al, Guidelines on the diagnosis and management of pericardial diseases. The task force on the diagnosis and management of pericardial diseases of the European Society of Cardiology, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=4960&nbr=003524&string=cardiac+AND+mass January 1, 2008. 11.Freedberg RS, Kronzon I, Rumancik WM, et al, The contribution of magnetic resonance imaging to the evaluation of intracardiac tumors diagnosed by echocardiography, Circulation, 1988; 77(1):96-103. 12. Doughan AR and Williams BR, Cardiac sarcoidosis, Heart, 2006; 92:282-288. 13 Vignaux O, Cardiac sarcoidosis: spectrum of MRI features, AJR, 2005; 184:249-254 14 Vignaux O, Robin D, Duboc D et al, Detection of myocardial involvement in patients with sarcoidosis applying T2 weighted contrast- enhanced, and cine magnetic resonance imaging: initial results of a prospective study, J Computer Assisted Tomography, 2002; 26:762-767. 15.Jagia P, Gulati Gs and Sharma S, Cardiac magnetic resonance in the assessment of cardiomyopathy, Indian j Radiol Imaging, 2007; 17(2):109-119. 16. Vopgel-Claussen J, Rochitte CE, QWuKC, et al, Delayed enhancement MR imaging: utility in myocardial assessment, RadioGraphics, 2006; 26:795-810.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

75558 MRI of the Heart for Morphology and Function with Flow Velocity without Gadolinium

II. Atrial Septal Defect 1-5 (ASD) A. Asymptomatic 1. Systolic ejection murmur with diastolic rumble 2. Echocardiogram inadequate visualization for surgical repair B. Symptomatic 1. Dyspnea or congestive heart failure 2. CVA with unknown etiology (paradoxical embolus) C. Documented diagnosis by other imaging and planned surgical repair

III. Ventricular Septal Defect 1-5 (VSD) A. Documented diagnosis by other imaging and planned surgical repair

IV. Tetralogy of Fallot 1-5 A. Prior imaging 1. Chest X-ray suggestive of Tetralogy of Fallot 2. Echocardiogram suboptimal for diagnosis B. Documented diagnosis by other imaging and planned surgical repair

V. Ebstein’s anomaly 1-5 A. Documented diagnosis by other imaging and planned surgical repair B. Prior imaging inadequate for diagnosis

VI. Other congenital heart disease 1-5 A. Truncus arteriosus B. Transposition of the Great Vessels C. Single left ventricle D. Total Anomalous pulmonary venous return E. Endocardial cushion defect F. Vascular rings and other congenital anomalies of the Great Vessels Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

G. Left sided aortic arch with aberrant right subclavian artery H. Anomalous left pulmonary artery I. Double aortic arch J. Ebstein’s anomaly K. Eisenmenger’s syndrome

VII. Syndromes with congenital heart disease 1-5 (established diagnosis) A. Holt-Oram syndrome B. Turner’s syndrome C. William syndrome D. Trisomy 21 (Down’ syndrome) E. Schone’s Syndrome

VIII. Anomalous coronary arteries 2, 5, 6

2, 5 IX. Marfan’s syndrome

2 X. Evaluation of left ventricular function A. Echocardiogram suboptimal for diagnosis

XI. Evaluation of prosthetic valve 2 A. Echocardiogram suboptimal for diagnosis B. Transesophageal echocardiogram suboptimal for diagnosis

XIII. Myocarditis 2, 4, 9 A. Documentation of episode of elevated cardiac enzymes B. No evidence of significant coronary artery disease on recent angiogram or CCTA

XIV. Pericardial disease 2, 4, 10 A. Differentiate constrictive cardiomyopathy from constrictive pericarditis B. Tumor of the pericardium (known or suspected) C. Paracardiac masses

CareCore National Criteria for Imaging Version 2.2009

XV. Suspicion of intracardiac mass 2, 4, 11 A. Echocardiogram not diagnostic

XVI. Venous mapping 2 A. Atrial fibrillation B. Radiofrequency ablation planned

XVII. Complications of myocardial infarction A. Possible cardiac aneurysm 1. Echocardiogram not diagnostic B. Suspected mural thrombus or clot [One] 1. Echocardiogram not diagnostic 2. History or arterial embolization

XVIII. Aortic dissection 2 A. Unequal blood pressure in the arms B. Rapid onset of "ripping, tearing, searing" severe chest or upper back or abdominal pain C. Pain with abnormal appearance of aorta on prior imaging 1. Chest 2. Back 3. Abdominal D. Syncope E. Shortness of breath F. Prior aortic aneurysm repairs G. Chest pain with evidence of a stroke H. Loss of pulses

References:

1. Ho, VB, Yucel EK, Khan A, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Suspected congenital heart disease in the adult, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/SuspectedCongenital HeartDiseaseintheAdultUpdateinProgressDoc18.aspx January 1, 2008. 2. Hendel RC, Patel MR, Kramer CM, et al, ACCF/ACR/SCT/SCCT/SCMR/ASNC/ NASCI/ SCAI/ SIR 2006 Appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging, accessed at http://www.acc.org/qualityandscience/clinical/pdfs/CCT.CMR.pdf January 1, 2008. 3. Hirsch R, Kilner PF, Connelly MS, et al, Diagnosis in adolescents and adults with congenital heart disease. Prospective assessment of individual and combined roles of magnetic resonance imaging and transesophageal echocardiography, Circulation, 1994; 90:2937-2951. 4. Pennell, DJ, Sechtem UP, Higgins CB, et al, Clinical indications for cardiovascular magnetic resonance (CMR): Consensus panel report, European Heart Journal, 2004; 25:1940-1965. 5. Crean A, Cardiovascular MR and CT in congenital heart disease, Heart, 2007; 93:1637-1647. 6. Post JC, vanRossum AC, Bronzwaer JGF, et al, Magnetic resonance angiography of anomalous coronary arteries, Circulation, 1995; 92:3163-3171. 7. Marcus, FI, Fontaine GH, Guiraudon G, et al, Right ventricular dysplasia: a report of 24 adult cases, Circulation, 1982; 65:384-398. 8. Tandri H, Castillo E, Ferrari VA, et al, Magnetic resonance imaging of Arrhythmogenic right ventricular dysplasia, JACC, 2006; 48(11):2277- 2284. 9. Mahrholdt H, Goedecke C, Wagner A, et al, Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology, Circulation, 2004; 109:1250-1258. Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

10. Maisch B, Seferovic PM, Ristic AD, et al, Guidelines on the diagnosis and management of pericardial diseases. The task force on the diagnosis and management of pericardial diseases of the European Society of Cardiology, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=4960&nbr=003524&string=cardiac+AND+mass January 1, 2008. 11. Freedberg RS, Kronzon I, Rumancik WM, et al, The contribution of magnetic resonance imaging to the evaluation of intracardiac tumors diagnosed by echocardiography, Circulation, 1988; 77(1):96-103.

CareCore National Criteria for Imaging Version 2.2009

75559 MRI of the Heart for Morphology and Function with Stress without Gadolinium

1 I. Chest pain A. Exertional substernal chest pain or discomfort relieved by rest 1. Men age 30-39 2. Women age 30-59 B. Atypical chest pain 1. Men 30 years of age or older 2. Women 50 years of age or older C. Other types of chest pain 1. Men 40 years or older 2. Women 60 years or older D. Unable to exercise E. Uninterpretable EKG [One] 1. Wolfe-Parkinson-White Syndrome 2. Complete left bundle branch block 3. Ventricular paced rhythm 4. 1mm ST depression with horizontal or downsloping ST segments

II. Prior indeterminate cardiac catheterization 1

Reference:

1.Hendel RC, Patel MR, Kramer CM et al, ACCF/ACR/SCT/SCCT/SCMR/ASNC/ NASCI/ SCAI/ SIR 2006 Appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging, accessed at , http://www.acc.org/qualityandscience/clinical/pdfs/CCT.CMR.pdf January 1, 2008.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

75560 MRI of the Heart for Morphology and Function with Flow Velocity and Stress without Gadolinium

II. Prior indeterminate cardiac catheterization 1

Reference:

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

75561 MRI of the Heart for Morphology and Function without and with Gadolinium

III. Ventricular Septal Defect 1-5 (VSD) A. Documented diagnosis by other imaging and planned surgical repair

IV. Tetralogy of Fallot 1-5 A. Prior imaging 3. Chest x-ray suggestive of Tetralogy of Fallot 4. Echocardiogram suboptimal for diagnosis B. Documented diagnosis by other imaging and planned surgical repair

V. Ebstein’s anomaly 1-5 A. Documented diagnosis by other imaging and planned surgical repair B. Prior imaging inadequate for diagnosis

CareCore National Criteria for Imaging Version 2.2009

G. Left sided aortic arch with aberrant right subclavian artery H. Anomalous left pulmonary artery I. Double aortic arch J. Ebstein’s anomaly K. Eisenmenger’s syndrome

VIII. Anomalous coronary arteries2, 5, 6

2, 5 IX. Marfan’s syndrome

2 X. Evaluation of left ventricular function A. Echocardiogram suboptimal for diagnosis

XI. Evaluation of prosthetic valve 2 A. Echocardiogram suboptimal for diagnosis B. Transesophageal echocardiogram suboptimal for diagnosis

XIII. Myocarditis 2, 4, 9, A. Documentation of episode of elevated cardiac enzymes B. No evidence of significant coronary artery disease on recent angiogram or CCTA

XIV. Pericardial disease 2, 4, 10 A. Differentiate constrictive cardiomyopathy from constrictive pericarditis B. Tumor of the pericardium (known or suspected)

CareCore National Criteria for Imaging Version 2.2009

C. Paracardiac masses

XV. Suspicion of intracardiac mass 2, 4, 11

XVI. Venous mapping 2 A. Atrial fibrillation B. Radiofrequency ablation planned

XVIII. Myocardial viability16 A. Documented myocardial ischemia B. Revascularization planned

XIX. Complications of myocardial infarction16 A. Possible cardiac aneurysm 1. Echocardiogram not diagnostic B. Suspected mural thrombus of motion or clot 1. Echocardiogram not diagnostic 2. History or arterial embolization

XX. Aortic dissection2 A. Unequal blood pressure in the arms B. Rapid onset of "ripping, tearing, searing" severe chest or upper back or abdominal pain C. Pain with abnormal appearance of aorta on prior imaging 1. Chest 2. Back 3. Abdominal D. Syncope E. Shortness of breath F. Prior aortic aneurysm repair G. Chest pain with evidence of a stroke H. Loss of pulses Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

XXI. Valvular heart disase A. Echocardiogram is non diagnostic or suboptimal

References:

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

75562 MRI of the Heart for Morphology and Function and Flow Velocity without and with Gadolinium

II. Atrial Septal Defect 1-5(ASD) A. Asymptomatic 1. Systolic ejection murmur with diastolic rumble 2. Echocardiogram inadequate visualization for surgical repair B. Symptomatic 1. Dyspnea or Congestive Heart Failure 2. CVA with unknown etiology (paradoxical embolus) C. Documented diagnosis by other imaging and planned surgical repair

III. Ventricular Septal Defect1-5 (VSD) A. Documented diagnosis by other imaging and planned surgical repair

V. Ebstein’s anomaly 1-5 A. Documented diagnosis by other imaging and planned surgical repair B. Prior imaging inadequate for diagnosis

VI. Other congenital heart disease 1-5 A. Truncus arteriosus B. Transposition of the Great Vessels C. Single left ventricle D. Total anomalous pulmonary venous return E. Endocardial cushion defect

CareCore National Criteria for Imaging Version 2.2009

F. Vascular rings and other congenital anomalies of the Great Vessels G. Left sided aortic arch with aberrant right subclavian artery H. Anomalous left pulmonary artery I. Double aortic arch J. Ebstein’s anomaly K. Eisenmenger’s syndrome

VII. Syndrome with congenital heart disease 1-5 (established diagnosis) A. Holt-Oram syndrome B. Anomalous pulmonary venous return C. Marfan’s syndrome D. Turner’s syndrome E. William syndrome F. Trisomy 21 (Down’ syndrome) G. Schone’s Syndrome

VIII. Anomalous coronary arteries 2,5,6

2,5 IX. Marfan’s syndrome

2 X. Evaluation of left ventricular function A. Echocardiogram suboptimal for diagnosis

XI. Evaluation of prosthetic valve 2 A. Echocardiogram suboptimal for diagnosis B. Transesophageal echocardiogram suboptimal for diagnosis

XII. Arrhythmogenic right ventricular dysplasia 2,7,8 A. Tachycardia (>100 beats/min) B. Supraventricular arrhythmia 1. Atrial fibrillation 2. Paroxysmal Atrial Tachycardia (PAT) 3. Supraventricular Tachycardia (SVT) C. Right heart failure D. Asymptomatic cardiomegaly

XIII. Myocarditis2,4,9 A. Documentation of episode of elevated cardiac enzymes B. No evidence of significant coronary artery disease on recent angiogram or CCTA

XIV. Pericardial Disease 2,4,10 A. Differentiate constrictive cardiomyopathy from constrictive pericarditis B. Tumor of the pericardium (known or suspected) C. Paracardiac masses

CareCore National Criteria for Imaging Version 2.2009

XV. Suspicion of intracardiac mass 2,4,11

XVI. Venous mapping 2 A. Atrial fibrillation B. Radiofrequency ablation planned

XVII. Cardiomyopathy 2,12-15 A. Sarcoidosis 1. Known diagnosis of sarcoidosis 2. Documented arrhythmia a. Complete right bundle branch block b. AV block B. Hypertrophic cardiomyopathy C. Amyloid D. Cardiotoxic drugs and failed MUGA scan E. Hemachromatosis F. Hemosiderosis G. Restrictive cardiomyopathy

XVIII. Myocardial viability 16 A. Documented myocardial ischemia B. Revascularization planned

XIX. Complications of myocardial infarction 16 A. Possible cardiac aneurysm 1. Echocardiogram not diagnostic B. Suspected mural thrombus or clot 1. Echocardiogram not diagnostic 2. History or arterial embolization

2 XX. Aortic dissection A. Unequal blood pressure in the arms B. Rapid onset of "ripping, tearing, searing" severe chest or upper back or abdominal pain C. Pain with abnormal appearance of aorta on prior imaging 1. Chest 2. Back 3. Abdominal D. Syncope E. Shortness of breath F. Prior aortic aneurysm repairs G. Chest pain with evidence of a stroke H. Loss of pulses

CareCore National Criteria for Imaging Version 2.2009

XXI. Valvular heart disase A. Echocardiogram is non diagnostic or suboptimal

References:

1.Ho, VB, Yucel EK, Khan A, et al Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria- Suspected congenital heart disease in the adult, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/SuspectedCongenital HeartDiseaseintheAdultUpdateinProgressDoc18.aspx January 1, 2008. 2. Hendel RC, Patel MR, Kramer CM et al, ACCF/ACR/SCT/SCCT/SCMR/ASNC/ NASCI/ SCAI/ SIR 2006 Appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging, accessed at , http://www.acc.org/qualityandscience/clinical/pdfs/CCT.CMR.pdf January 1, 2008. 3. Hirsch R, Kilner PF, Connelly MS et al, Diagnosis in adolescents and adults with congenital heart disease. Prospective assessment of individual and combined roles of magnetic resonance imaging and transesophageal echocardiography, Circulation,1994; 90:2937-2951. 4. Pennell, DJ, Sechtem UP, Higgins CB, et al, Clinical indications for cardiovascular magnetic resonance (CMR): Consensus panel report, European Heart Journal, 2004; 25:1940-1965. 5. Crean A, Cardiovascular MR and CT in congenital heart disease, Heart, 2007;93:1637-1647. 6 Post JC, vanRossum AC, Bronzwaer JGF, et al, Magnetic resonance angiography of anomalous coronary arteries, Circulation, 1995; 92:3163-3171. 7. Marcus, FI, Fontaine GH, Guiraudon G, et al , Right ventricular dysplasia: a report of 24 adult cases, Circulation , 1982, 65:384-398. 8..Tandri H, Castillo E, Ferrari VA, et al, Magnetic resonance imaging of Arrhythmogenic right ventricular dysplasia, Journal of the American College of Cardiology, 2006; 48(11):2277-2284 9. Mahrholdt H, Goedecke C, Wagner A et al, Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology, Circulation, 2004; 109:1250-1258. 10.Maisch B, Seferovic PM, Ristic AD et al, Guidelines on the diagnosis and management of pericardial diseases. The task force on the diagnosis and management of pericardial diseases of the European Society of Cardiology, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=4960&nbr=003524&string=cardiac+AND+mass January 1, 2008. 11.Freedberg RS, Kronzon I, Rumancik WM, et al, The contribution of magnetic resonance imaging to the evaluation of intracardiac tumors diagnosed by echocardiography, Circulation, 1988; 77(1):96-103. 12. Doughan AR and Williams BR, Cardiac sarcoidosis, Heart, 2006; 92:282-288. 13 Vignaux O, Cardiac sarcoidosis: spectrum of MRI features, AJR, 2005; 184:249-254 14 Vignaux O, Robin D, Duboc D et al, Detection of myocardial involvement in patients with sarcoidosis applying T2 weighted contrast- enhanced, and cine magnetic resonance imaging: initial results of a prospective study, J Computer Assisted Tomography, 2002; 26:762-767. 15.Jagia P, Gulati Gs and Sharma S, Cardiac magnetic resonance in the assessment of cardiomyopathy, Indian j Radiol Imaging, 2007; 17(2):109-119. 16. Vopgel-Claussen J, Rochitte CE, QWuKC, et al, Delayed enhancement MR imaging: utility in myocardial assessment, RadioGraphics, 2006; 26:795-810.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

75563 MRI of the Heart for Morphology and Function with Stress without and with Gadolinium

I. Determination of myocardial viability1[Both] A. Documented myocardial ischemia B. Revascularization planned

2 II. Chest pain and determination of myocardial viability A. Exertional substernal chest pain or discomfort relieved by rest 1. Men age 30-39 2. Women age 30-59 B. Atypical chest pain 1. Men 30 years of age or older 2. Women 50 years of age or older C. Other types of chest pain 1. Men 40 years or older 2. Women 60 years or older D. Unable to exercise E. Uninterpretable EKG [One] 1. Wolfe-Parkinson-White Syndrome 2. Complete left bundle branch block 3. Ventricular paced rhythm 4. >1mm ST depression which is horizontal or downsloping

III. Prior indeterminate cardiac catheterization and determination of myocardial viability 2

References:

1.. Vopgel-Claussen J, Rochitte CE, QWuKC, et al, Delayed enhancement MR imaging: utility in myocardial assessment, RadioGraphics, 2006; 26:795-810. 2.Hendel RC, Patel MR, Kramer CM et al, ACCF/ACR/SCT/SCCT/SCMR/ASNC/ NASCI/ SCAI/ SIR 2006 Appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging, accessed at , http://www.acc.org/qualityandscience/clinical/pdfs/CCT.CMR.pdf January 1, 2008

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

75564 MRI of the Heart for Morphology and Function with Stress with Flow Velocity without and with Gadolinium

I. Determination of myocardial viability1

III. Prior indeterminate cardiac catheterization and determination of myocardial viability 2

References:

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

75635 CTA of the Abdominal Aorta and Bilateral Ileofemoral Lower Extremity Runoff

I. Peripheral arterial vascular disease 1 A. Intermittent claudication B. Fatigue C. Erectile dysfunction D. Diminished femoral pulses E. Non healing ulcer F. Gangrene G. Absent or weak peripheral pulses H. Rest ABI <0.9 in symptomatic member I. Exercise ABI <0.90 in symptomatic member with rest ABI >0.90 J. Toe brachial index <0.90 or pulse volume recording evidence of peripheral vascular disease if the ABI >1.30

II. Aneurysm A. Known aortic aneurysm documented on prior CT, CTA, MRI, MRA or ultrasound and evidence of PVD 1. Intermittent claudication 2. Fatigue 3. Erectile dysfunction 4. Diminished femoral pulses 5. Non healing ulcer 6. Gangrene 7. Absent or weak peripheral pulses 8. Rest ABI < 0.9 in symptomatic member 9. Exercise ABI <0.90 in symptomatic member with rest ABI >0.90 10. Toe brachial index <0.90 or pulse volume recording evidence of peripheral vascular disease if the ABI >1.30 B. Pulsatile or expansile mass on abdominal, vaginal, or rectal exam and negative US C. Aneurysm detected US exam and evidence of PVD 1. Intermittent claudication 2. Fatigue 3. Erectile dysfunction 4. Diminished femoral pulses 5. Non healing ulcer 6. Gangrene 7. Absent or weak peripheral pulses 8. Rest ABI < 0.9 in symptomatic member 9. Exercise ABI <0.90 in symptomatic member with rest ABI >0.90 10. Toe brachial index <0.90 or pulse volume recording evidence of peripheral vascular disease if the ABI >1.30 Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

III. Prior Aneurysm Repair A. Periodic follow-up of known AAA will be allowed once every six months 1. Inadequate ultrasound 2. No surgical repair B. New onset of pain C. Postoperative evaluation following repair including endovascular repair (stent graft) 1. 1 month after repair 2. 3 months after repair 3. 6 months after repair 4. Annually after repair 5. Suspicion of endoleak

Reference:

Reviewed: 3/18/2009 Posted: 8/15/2009

CareCore National Criteria for Imaging Version 2.2009

76376 3D Rendering of Tomographic Images Not Requiring an Independent Work Station 76377 3D Rendering of Tomographic Images Requiring an Independent Work Station

The rapid evolution of CT, MRI and ultrasound technology in the last decade permits the acquisition of data sets that can be manipulated by computer software into multiplanar images without exposing patients to additional radiation (CT), or time (MRI). Multiplanar 2D images can be created from a multidetector CT data set almost instantly. These codes are not to be used for 2D multiplanar images created from the original data set for CT, MRI or ultrasound.

These codes refer to 3D images only. In some cases (CTA and MRA and Breast MRI) the 3D images are considered to be included in the primary imaging code since these studies should not be interpreted without them. In other circumstances, the 3D images bring additional value to a study and may significantly impact on image interpretation and clinical management. It is often difficult to predict this postoperatively. Some of the common indications are:

I. Bone Tumor

II. Complex facial trauma

III. Complex fracture A. Comminuted fractures of the humerus B. Comminuted fractures of the femur C. Comminuted fractures of the fibula D. Comminuted fractures of the tibia E. Fractures of the pelvis

IV. Congenital anomalies of the ear

V. Craniosynostosis

VI. Developmental dysplasia of the hip

VII. Dislocation of sternoclavicular joint

VIII. Eagles’s syndrome

CareCore National Criteria for Imaging Version 2.2009

IX. Evaluation of the ossicles of the ear

X. Fracture of the acetabulum

XI. Pectus deformity

XII. Pre-operative planning for congenital anomaly repair

XIII. Pre-operative planning of disc surgery

XIV. Pre-operative planning of joint prosthesis

XV. Pre-operative planning of scoliosis surgery

XVI. Suspicion of fracture with negative x-ray A. Pelvis B. Scapula

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

76380 CT Limited or Localized Follow-up Study

I. Prior positive CT or other imaging study that is being followed either at intervals to assess therapy or to clarify a finding. This is commonly used for sinus imaging and must meet the criteria for 70486.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

76801 Ultrasound First Trimester (Up to 14 weeks)

I. Evaluation of gestational age 1, 2

II. Evaluation of first trimester bleeding1,2

III. Confirmation of fetal cardiac activity 1,2

IV. Date gestation prior to elective pregnancy termination1,2

V. Evaluation of first trimester abdominal or pelvic pain1,2

VI. Evaluation of suspected ectopic pregnancy2

VII. Evaluated for suspected hydatidiform mole2

VIII. Diagnosis and documentation of multiple geastations2

References:

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

76802 Ultrasound First Trimester, Each Additional Gestation (Up to 14 weeks)

I. Evaluation of gestational age 1,2

II. Evaluation of first trimester bleeding 1,2

III. Confirmation of fetal cardiac activity 1,2

IV. Date gestation prior to elective pregnancy termination 1,2

V. Evaluation of first trimester abdominal or pelvic pain 1,2

VI. Evaluation of suspected ectopic pregnancy2

VII. Evaluated for suspected hydatidiform mole2

VIII. Diagnosis and documentation of multiple geastations2

References:

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

76805 Ultrasound After First Trimester

I. Routine anatomic screening exam performed from 17 to 23 weeks (permitted once per pregnancy)1 A. Follow up examinations directed at one specific question, (e.g. fetal growth, heart rate, placental position) should be coded 76815 B. Follow up examinations following a finding on 76805 should be coded 76816 C. Follow up examinations regarding fetal growth should be coded 76816

References:

1.ACOG Committee on Practice Bulletins-obstetrics, ACOG Practice Bulletin, Clinical management guidelines for obstetrician- gynecologists, Ultrasonography in pregnancy, Number 58, December 2004, Obstetrics and Gynecology, 2004; 104(6):1449-1466

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

76810 Ultrasound After First Trimester, Each Additional Gestation

I. Routine anatomic screening exam1,2 performed from 17 to 23 weeks (permitted once per pregnancy per additional fetus) A. Follow up examinations directed at one specific question, (e.g. Fetal growth, heart rate, placental position) should be coded 76815 B. Follow up examinations following a finding on 76805 should be coded 76816 C. Follow up examinations regarding fetal growth should be coded 76816

References:

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

76811 High Risk Fetal Anatomy Ultrasound Single Gestation

I. Suspected congenital anomaly 1, 2 A. Abnormal triple or quadruple screen B. Abnormal AFP C. Maternal Age at delivery >35 yrs D. Exposure to teratogens

1. Alcohol 2. Primidone 3. Dilantin (hydantoin) 4. Coumadin 5. Amphetamines 6. Progesterone 7. Lithium 8. Cyclophosphamide 9. Azathioprine 10. Quinine 11. Methotrexate 12. Cytarabine 13. Carbamazepine 14. Thalidomide 15. Oral contraceptives 16. Daunorubicin 17. Chlordiazepoxide 18. Trifluoperazine 19. Paramethadione 20. Dextroamphetamine 21. Codeine 22. Trimethadione 23. Penicillamine 24. Diazepam (valium) 25. Cortisone 26. Valproic Acid

II. Maternal disease  A. Diabetes mellitus B. Connective tissue disorder C. Renal disease D. Hypertension E. Isoimmunization F. Preeclampsia or eclampsia 1. Hypertension 2. Edema 3. Proteinuria G. Congenital heart disease H. Malnutrition I. Maternal exposure to an infectious agent: 1. Parvo virus 2. CMV 3. Rubella 4. Toxoplasmosis 5. HIV

CareCore National Criteria for Imaging Version 2.2009

III. Past obstetrical history 1, 2 A. Prior pregnancy with a congenital anomaly B. Prior pregnancy with placental abnormality C. Microsomia 1. Baby weighing <2500 grams at term or 2. Less than the 10th percentile of expected weight D. Macrosomia E. Baby weighing >4000 grams at term or 1. Greater than the 90th percentile of expected weight 2. Placenta Previa F. Polyhydramnios G. Oligohydramnios

IV. Congenital anomaly suspected on 76805

V. Multiple gestations 3-5

VI. InVitro Fertilization (IVF)

References:

1. AIUM Practice guideline for the performance of an Antepartum obstetric ultrasound examination, J Ultrasound Med, 2003; 22:116-1125. 2. ACOG Committee on Practice Bulletins-obstetrics, ACOG Practice Bulletin, Clinical management guidelines for obstetrician-gynecologists, Ultrasonography in pregnancy, Number 58, December 2004, Obstetrics and Gynecology, 2004; 104(6):1449-1466. 3. Schinzel AAGL, Smith DW, and Miller JR, Monozygotic twinning and structural defects, Journal of Pediatrics, 1979; 95:921-930. 4. Filly RA, Goldstein RB, and Callen PW, Monochorionic twinning: sonographic assessment, AJR, 1990; 154:459-469. 5. Beasley E, Megerian G, Gerson A, et al, Monoamniotic twins: case series and proposal for antenatal management, Obstetrics and Gynecology, 1999; 93:130-134.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

76812 Ultrasound Detailed Fetal, Each Additional Gestation

I. Suspected congenital anomaly 1,2 A. Abnormal triple or quadruple screen B. Abnormal AFP C. Abnormal nuchal translucency 1. > 2.0mm at 11 weeks 2. >2.8mm at 14 weeks D. Maternal age at delivery >35 years E. Exposure to teratogens F. InVitro Fertilization (IVF)

1. Alcohol 2. Primidone 3. Dilantin (hydantoin) 4. Coumadin 5. Amphetamines 6. Progesterone 7. Lithium 8. Cyclophosphamide 9. Azathioprine 10. Quinine 11. Methotrexate 12. Cytarabine 13. Carbamazepine 14. Thalidomide 15. Oral contraceptives 16. Daunorubici 17. Chlordiazepoxide 18. Trifluoperazine 19. Paramethadione 20. Dextroamphetamine 21. Codeine 22. Trimethadione 23. Penicillamine 24. Diazepam (valium) 25. Cortisone 26. Valproic Acid

II. Maternal disease 1,2 A. Diabetes mellitus B. Connective tissue disorder C. Renal disease D. Hypertension E. Isoimmunization F. Pre-eclampsia or eclampsia 1. Hypertension 2. Edema 3. Proteinuria G. Congenital heart disease H. Malnutrition I. Maternal exposure to an infectious agent [One] 1. Parvo virus

CareCore National Criteria for Imaging Version 2.2009

2. CMV 3. Rubella 4. Toxoplasmosis 5. HIV

III. Past obstetrical history 1,2 A. Prior pregnancy with a congenital anomaly B. Prior pregnancy with placental abnormality C. Microsomia 1. Baby weighing < 2500 grams at term or 2. Less than the 10th percentile of expected weight D. Macrosomia E. Baby weighing >4000 grams at term or 1. Greater than the 90th percentile of expected weight 2. Placenta previa F. Polyhydramnios G. Oligohydramnios

IV. Congenital anomaly suspected on 76805

V. Multiple gestations 3-5

VI. InVitro Fertilization (IVF)

References:

1. AIUM Practice guideline for the performance of an Antepartum obstetric ultrasound examination, J Ultrasound Med, 2003; 22:1116-1125. 2. ACOG Committee on Practice Bulletins-obstetrics, ACOG Practice Bulletin, Clinical management guidelines for obstetrician-gynecologists, Ultrasonography in pregnancy, Number 98, October 2008, Obstetrics and Gynecology, 2008;112(4):951-965. 3. Schinzel AAGL, Smith DW, and Miller JR, Monozygotic twinning and structural defects, Journal of Pediatrics, 1979; 95:921-930. 4. Filly RA, Goldstein RB, and Callen PW, Monochorionic twinning: sonographic assessment, AJR, 1990; 154:459-469. 5. Beasley E, Megerian G, Gerson A, et al, Monoamniotic twins: case series and proposal for antenatal management, Obstetrics and Gynecology, 1999; 93:130-134.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

76813 Ultrasound, Pregnant Uterus, Real Time with Image Documentation, Single or First Gestation 76814 Ultrasound, Pregnant Uterus, Real Time with Image Documentation, Each Additional Gestation

I. 76813 - Ultrasound, pregnant uterus first trimester nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation 1 A. Evaluation of nuchal translucency at gestational age between 10-14 weeks; 76813 for a single fetus and 76814 for each additional fetus B. This may be certified once per pregnancy

II. 76814 - Ultrasound, pregnant uterus first trimester nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation1 A. Evaluation of nuchal translucency at gestational age between 10-14 weeks; 76813 for a single fetus and 76814 for each additional fetus B. This may be certified once per pregnancy

Reference:

1. ACOG Committee on Practice Bulletins-Obstetrics, ACOG Committee on Genetics and the Society for Maternal-Fetal Medicine Publications Committee, ACOG Practice Bulletin, Clinical management guidelines for obstetrician-gynecologists, Number 77, January, 2007, Obstetrics and Gynecology, 2007; 109(1):217-226.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

76815 Limited OB Ultrasound One or More Gestations (After 14 weeks)

I. Determination of fetal presentation or size in third trimester 1,2

II. Determination of placental location 1,2 A. Vaginal bleeding B. Low lying placenta on prior imaging

III. Determination of amniotic fluid volume1,2

IV. Detection of fetal heart activity if not determined by Doppler

V. Abdominal and pelvic pain

VI. Vaginal bleeding

VII. Evaluation of cervical insufficiency

References:

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

76816 Follow-up OB Ultrasound (One for Each Gestation)

I. Follow up of previously detected fetal abnormality 1,2

II. Evaluation of fetal growth by comparison with prior imaging 1,2

III. Monitoring of fetal well being in cases of maternal disease 1,2 A. Diabetes mellitus B. Connective tissue disorder C. Renal disease D. Hypertension E. Isoimmunization F. Pre-eclampsia G. Eclampsia H. Congenital heart disease I. Malnutrition J. Thrombophilia K. Hyperthyroidism L. Hypothyroidism M. Maternal exposure to an infectious agent [One] 1. Parvo virus 2. CMV 3. Rubella 4. Toxoplasmosis 5. HIV

IV. Evaluation after amniocentesis or other intrauterine intervention 1,2

References:

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

76817 OB Ultrasound Transvaginal

This code is not to be used for the evaluation of nuchal translucency. I. Risk of pre-term labor1-4 (weekly up to 26 weeks) A. Vaginal bleeding B. Uterine contractions C. Other risks of pre-term labor 1. Previous pre-term delivery 2. Maternal age <18 or >40 3. Multiple gestations 4. Maternal history of spontaneous second trimester abortion 5. Maternal complications a. Uterine fibroids or anomalies b. Known cervical abnormality c. Cervical Incompetence d. Cerclage in place e. Vaginal infection 6. IUGR 7. Retained IUD

II. Evaluation of fetal anatomy not adequately seen on transabdominal scan

III. Evaluation of placenta previa 5, 6

References:

1. ACOG Committee on Practice Bulletins-obstetrics, ACOG Practice Bulletin, Management of preterm labor, Bulletin Number 43, May 2003, Obstetrics and Gynecology, 2003; 101:1039-1047 2. Jeffries J, Atwood L, Bates L, et al, Institute for Clinical Systems Improvement(ICISI), Health Care Guideline: management of Labor, Second edition, March, 2007, accessed at http://www.icsi.org/labor/labor__management_of__full_version__2.html December 2, 2007 3. Fleischer AC, Andreotti RF, Bohm-Velez M et al, Expert panel on women’s imaging, American College of Radiology Appropriateness Criteria, Premature cervical dilatation, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonWomensImaging/PrematureCervicalDilatation Doc8.aspx December 2, 2007. 4. Iams, JD, Prediction and early detection of preterm labor, Obstetrics and Gynecology, 2003; 101(2):402-412. 5.Thurmond A, Fleischer AC, Andreotti RF, et al, Expert panel on women’s imaging, American College of Radiology Appropriateness Criteria, Second and third trimester bleeding, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonWomensImaging/SecondandThirdTrimesterBl eedingDoc9.aspx December 2, 2007. 6. Guidelines and Audit Committee of the Royal College of Obstetricians and Gynaecologists, Guideline NO. 27, Placenta previa and placenta previa accrete: Diagnosis and Management, accessed at http://www.rcog.org.uk/resources/Public/pdf/placenta_previa_accreta.pdf December 2, 2007.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

76818 Biophysical Profile with Non-Stress Testing 76819 Biophysical Profile without Non-Stress Testing

I. Fetal growth problem documented on prior ultrasound 1-7 A. Fetal problems 1. Multiple gestations 2. IUGR Fetal weight in <10th percentile of expected weight 3. Oligohydramnios (amniotic fluid index or volume <10) 4. Polyhydramnios 5. Malpresentation of fetus 6. Known fetal anomaly 7. Known partial or complete placenta previa 8. Post dates (gestation >41 weeks) 9. Non-stress test non reactive 10. Decreased fetal movement 11. Elevated AFP (This value must be related to age of gestation. An abnormal AFP at 10 weeks cannot be used; it must be an abnormal AFP for the gestational age.) 12. Low PAPP-A B. Maternal disease 1. Diabetes 2. Connective tissue disorder 3. Isoimmunization (fetal hemolytic anemia) 4. Renal disease 5. Hypertension 6. Malnutrition 7. Pre-eclampsia/eclampsia 8. Congenital heart disease 9. Thyroid disease 10. Hemoglobinopathy 11. Antiphospholipid antibody

II. Maternal exposure to infectious agent: A. Parvo virus B. CMV C. Rubella D. Toxoplasmosis E. HIV

III. Previous unexplained fetal demise

CareCore National Criteria for Imaging Version 2.2009

References: 1. ACOG Committee on Practice Bulletins-obstetrics, ACOG Practice Bulletin, Clinical management guidelines for obstetrician-gynecologists, Ultrasonography in pregnancy, Number 58, December 2004, Obstetrics and Gynecology, 2004; 104(6):1449-1466. 2. ACOG Committee on Practice Bulletins-obstetrics, ACOG Practice Bulletin, Clinical management guidelines for obstetrician-gynecologists, Number 60, March 2005, Gestational diabetes mellitus, Obstetrics and Gynecology 2005; 105(3): 675-685. 3. ACOG Committee on Practice Bulletins-obstetrics, ACOG Practice Bulletin, Clinical management guidelines for obstetrician-gynecologists, Number 30, September 2001, Gestational Diabetes Obstetrics and Gynecology, 2001; 98(3):525-538. 4. ACOG Committee on Practice Bulletins-obstetrics, ACOG Practice Bulletin, Clinical management guidelines for obstetrician-gynecologists, Number 29, July 2001, Chronic hypertension in pregnancy, Obstetrics and Gynecology, 2001;98(1):177-185. 5. ACOG Committee on Practice Bulletins-obstetrics, ACOG Practice Bulletin, Clinical management guidelines for obstetrician-gynecologists, Number 37, August 2002, Thyroid disease in pregnancy, Obstetrics and Gynecology, 2002, Obstetrics and Gynecology, 2002;100(2):387-396. 6. ACOG Committee on Practice Bulletins-obstetrics, ACOG Practice Bulletin, Clinical management guidelines for obstetrician-gynecologists, Number 64, July 2005, Hemoglobinopathies in pregnancy, Obstetrics and Gynecology, 2005; 106(1):203-211. 7. ACOG Committee on Practice Bulletins-obstetrics, ACOG Practice Bulletin, Clinical management guidelines for obstetrician-gynecologists, Antiphospholipid Syndrome Number 68, November 2005; Obstetrics and Gynecology, 2005; 106(5 Part 1):1113-1121

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

76820 Doppler Velocimetry Umbilical Arteries 76821 Doppler Velocimetry Middle Cerebral Arteries

I. IUGR (fetus below 10th percentile in weight for true gestational age) 1-9

II. Risk of placental insufficiency A. Recreational drug abuse B. Alcohol C. Diabetes D. History of previous pregnancy with IUGR E. Anti-phospholipid antibodies F. Hyperthyroidism which is poorly controlled G. Hemoglobinopathies such as S-thalassemia, sickle cell anemia, SC H. Hypertension I. SLE J. Chronic renal insufficiency

III. Discordant twin pregnancy (variation greater than 20%)

IV. Oligohydramnios

V. Red blood cell (erythrocyte) alloimmunization (isoimmunization)

References:

1. Zelop C, Fleischer AC, Andreotti RF, et al, Expert panel on women’s imaging, American College of Radiology Appropriateness Criteria, Growth disturbances: risk of intrauterine growth restriction, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8591&nbr=004778&string=Umbilical+AND+artery December 2, 2007. 2. ACOG Committee on Practice Bulletins-obstetrics, ACOG Practice Bulletin Number 12, Intrauterine growth restriction, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=3962&nbr=003100&string=Umbilical+AND+artery December 2, 2007. 3. Spinillo A, Montannari S, Bergante C et al, Prognostic value of umbilical artery Doppler studies in unselected preterm deliveries, Obstetrics & Gynecology, 2005; 105(3): 613-620. 4.ACOG Committee on Practice Bulletins-obstetrics, ACOG Practice Bulletin, Clinical management guidelines for obstetrician-gynecologists, Number 30, September 2001, Gestational Diabetes Obstetrics and Gynecology, 2001; 98(3):525-538. 5. Branch DW, and Khamashta MA, Antiphospholipid syndrome: obstetric diagnosis, management and controversies, Obstetrics & Gynecology, 2003; 101(6):1333-1344. 6.ACOG Committee on Practice Bulletins-obstetrics, ACOG Practice Bulletin, Clinical management guidelines for obstetrician-gynecologists, Antiphospholipid Syndrome Number 68, November 2005; Obstetrics and Gynecology, 2005; 106(5 Part 1):1113-1121.

CareCore National Criteria for Imaging Version 2.2009

7.ACOG Committee on Practice Bulletins-obstetrics, ACOG Practice Bulletin, Clinical management guidelines for obstetrician-gynecologists, Number 37, August 2002, Thyroid disease in pregnancy, Obstetrics and Gynecology, 2002, Obstetrics and Gynecology, 2002;100(2):387-396. 8. ACOG Committee on Practice Bulletins-obstetrics, ACOG Practice Bulletin, Clinical management guidelines for obstetrician-gynecologists, Number 29, July 2001, Chronic hypertension in pregnancy, Obstetrics and Gynecology, 2001;98(1):177-185. 9.ACOG Committee on Practice Bulletins-obstetrics, ACOG Practice Bulletin, Clinical management guidelines for obstetrician-gynecologists, Number 64, July 2005, Hemoglobinopathies in pregnancy, Obstetrics and Gynecology, 2005; 106(1):203-211.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

76825 Fetal Echocardiography 76826 Fetal Echocardiography Follow-up or Repeat 76827 Fetal Doppler Echocardiography 76828 Fetal Doppler Echocardiography Follow-up or Repeat

I. Maternal factors 1-4 A. Maternal congenital heart disease B. Excessive alcohol intake C. Family history of first degree relative with congenital heart disease D. Exposure to drugs known to increase the risk of congenital heart disease 1. Lithium 2. Folate antagonists 3. Anticonvulsants 4. Excessive alcohol intake E. Maternal seizure disorder, even if they are not presently taking anticonvulsants F. Exposure to prostaglandin synthetase inhibitors G. Maternal medical illness such as 1. Diabetes 2. Rubella infection 3. Systemic lupus erythematosis 4. Phenylketonuria 5. Anti Ro/SSA 6. Anti La/SSB antibodies

II. Fetal factors 2, 3 A. Suspected cardiac anomaly during basic sonogram B. Extracardiac anomaly C. Aneuploidy or thickened nuchal fold D. Nonimmune hydrops E. Suspected or documented fetal arrhythmia F. Abnormal fetal situs G. Increased nuchal translucency at 11-14 weeks of gestation H. Chromosomal abnormality I. Twin-twin transfusion syndrome J. Following an abnormal or incomplete cardiac evaluation on an anatomic scan, four-chamber study K. Two vessel umbilical cord

References:

CareCore National Criteria for Imaging Version 2.2009

1.Hamar, BD, Dziura J, Friedman A, et al, Trends in fetal echocardiography and implications for clinical practice 1985 to 2003, J Ultrasound Med, 2006; 25:197-202. 2. Small M and Copel JA, Indications for fetal echocardiography, Pediatr Cardiolo, 2004; 25:210-222. 3.Cooper MJ, Enderlein MA, Dyson DC, et al, Fetal echocardiography: retrospective review of clinical experience and an evaluation of indications, Obstetrics & Gynecology, 1995; 86(4 Part 1):577-582. 4. Akkerman D, Johnston T, Klingberg K et al, Institiute for Clinical Systems Improvement, Health Care Guideline: Routine prenatal care, eleventh edition, August, 2007, accessed at http://www.icsi.org/prenatal_care_4/prenatal_care__routine__full_version__2.html December 2, 2007

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

77011 CT for Stereotactic Localization

I. Approve This CPT code refers to a guidance procedure for a biopsy or other intervention, and should be certified upon request.

Formerly 76355

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

77012 CT Guidance for Needle Placement

I. Approve on request

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

77013 CT Guidance Procedures for Ablation

I. Approve on request

Formerly 76394

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

77014 CT Guidance for Radiation Therapy

I. Approve on request

Formerly 76370

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

77021 MR Guidance Procedures

I. MRI demonstrating abnormality A. Recent MRI (within the past 4 weeks) demonstrating an abnormality which requires biopsy 1. Non palpable mass a. Targeted ultrasound after MRI which does not demonstrate a concordant site to biopsy

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

77058 MRI of the Breast Unilateral 77059 MRI of the Breast Bilateral 1-6

I. When necessary to confirm rupture of silicon breast implants in asymptomatic patients whose screening ultrasound shows rupture

II. Asymptomatic member 3 years after the placement of silicon implants and every 2 years thereafter

III. To detect silicon implant rupture in symptomatic patients whose ultrasound shows no rupture

IV. To detect local tumor recurrence in breast cancer patients who have undergone mastectomy and breast reconstruction with an implant

V. Patient with new diagnosis of breast cancer

VI. To detect local tumor recurrence in patients with a personal history of breast cancer and scarring from prior biopsies, radiation or surgery that results in uninterpretable mammography and ultrasound

VII. To detect the extent of residual cancer in the recently postoperative breast with positive pathological margins after incomplete lumpectomy when the patient still desires breast conservation and local re-excision is planned

VIII. To detect and stage patients with new diagnosis of Invasive Lobular Carcinoma (ILC) for tailored therapy, especially when breast conservation is being considered

IX. To localize the site of primary occult breast cancer in patients with adenocarcinoma suggestive of breast cancer discovered as axillary node metastasis or distant metastasis without focal findings on physical examination or on mammography/ultrasonography

X. To evaluate patients with high genetic risk of breast cancer A. Patient is a confirmed carrier of BRCA1 or BRCA2 gene mutations

CareCore National Criteria for Imaging Version 2.2009

B. Patient has a relative who is a confirmed carrier of the BRCA1 or BRCA2 gene mutation C. Male relative with breast cancer D. Gail model lifetime risk of 20% or more E. One or more relatives with either 2 breast cancers or both breast and ovarian cancer F. Family history of breast or ovarian cancer and Ashkenazi Jewish background G. Personal or first degree relative with history of Li-Fraumeni syndrome H. Personal or first degree relative with history of Cowden’s syndrome I. Personal or first degree relative with history of Bannayan-Riley- Ruvalcaba syndrome

XI. To evaluate patients with a high risk of breast cancer based on a diagnosis of Lobular Carcinoma In situ (LCIS) 9,10

XII. History of radiation therapy to the chest between the ages of 10-30

XIII. Indeterminate breast imaging A. Patients with indeterminate mammograms and sonograms if there is new onset of [One] 1. Nipple retraction 2. Unilateral drainage from the nipple that is bloody or clear B. All other requests for breast MRI based on indeterminate mammography and/or ultrasound that do not meet the above criteria must be sent for physician review. All imaging reports should be requested and available for the medical director to review. Only a physician may approve a breast MRI on the basis of abnormal mammography and or ultrasound.

XIV. Breast MRI for ANY of the following indications is not covered because there is insufficient scientific evidence to support its use: A. To confirm implant rupture in symptomatic patients whose ultrasonography shows rupture especially with implants >10 years old (ultrasound sufficient to proceed with removal) B. To screen for breast cancer in non high genetic risk women C. To evaluate breasts before biopsy in an effort to reduce the number of surgical biopsies for benign lesions D. To differentiate benign from malignant breast disease, especially clustered microcalcifications E. To differentiate cysts from solid lesions (ultrasound indicated)

References: 1. Berb, WA, Caskey CI, Hamper UM, et al, Single-and double-lumen silicone breast implant integrity: Prospective evaluation of MR and US criteria, Radiology, 1995; 197:45-52. 2. Harris DM, Ganott MA, Shestak KC, et al, Silicone implant rupture: detection with US, Radiology, 1993; 187:761-768. 3. Important Information for women about breast reconstruction with INAMED silicone-filled breast implants, accessed at http://www.fda.gov/cdrh/pdf2/P020056e.pdf November 5, 2007. 4. Rankin SC, MRI of the breast, BJR, 2000; 73:806-818. 5 Lehman CD, Gatsonis C, Kuhl CK, et al, MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer, New Eng J Med 2007; 356(13):1295-1303. 6. Saslow D, Boetes C, Burke W, et al, American cancer society guidelines for breast screening with MRI as an adjunct to mammography, CA, A Ca J Clin, 2007; 57(2):75-89. Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

77084 MRI Bone Marrow Blood Supply

I. Marrow reconversion A. Severe anemias, especially thalassemia B. X-ray findings of: 1. Expansion of medullary flat bones 2. Bilateral paraspinal masses (particularly in the thorax) 3. Pleural-based masses

II. Marrow infiltration or replacement A. Leukemia B. Lymphoma C. Metastasis D. Primary bone tumors E. Plasmacytoma F. Multiple myeloma

III. Myeloid depletion A. Untreated aplastic anemia

IV. Bone marrow ischemia A. Trauma B. Sickle cell anemia C. Endogenous (Cushing's syndrome) and exogenous corticosteroid excess D. Dysbaric osteonecrosis (generally called “the bends”) E. Alcoholism F. Gaucher's disease

V. Marrow response after radiation therapy

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78000 Thyroid Uptake Single Determination 78001 Thyroid Uptake Multiple Determinations 78003 Thyroid Uptake with Stimulation or Suppression 78006 Thyroid Imaging with Uptake Single Determination 78007 Thyroid Imaging with Uptake Multiple Determinations 78010 Thyroid Imaging Only 78011 Thyroid Imaging with Vascular Flow 78015 Thyroid Carcinoma Metastases Imaging Limited Area 78016 Thyroid Carcinoma Metastases Imaging with Additional Studies 78018 Thyroid Carcinoma Metastases Imaging Whole Body 78020 Thyroid Carcinoma Metastases Uptake (Add-on Code)

I. Hyperthyroidism 1, 2,3 CPT 78000-78010 A. Must have TSH < 0.40mIU/L B. Elevated T3 and/or T4 C. Subclinical hyperthyroidism 1. TSH < 0.40mIU/L

II. Thyroid nodule CPT 78006-78011 4-6 A. US guided FNA contraindicated B. US guided FNA (after at least 2 attempts) reported as showing results that are “equivocal”, “indeterminate”, “suspicious”, “follicular lesion”, or “follicular neoplasm” C. TSH decreased <.40mIU/L

III. Substernal goiters CPT 78010 8-12 A. CT or MRI nondiagnostic or not feasible B. Clinical findings 1. Exertional dyspnea 2. Wheezing 3. Cough 4. Dysphagia

IV. Congenital hypothyroidism 14 CPT 78006-78007 A. Infant recently diagnosed B. Repeat assessment, child of 3 years of age

CareCore National Criteria for Imaging Version 2.2009

V. Assessment of thyroid remnant after thyroidectomy, prior to ablation 2, 15 CPT 78006, 78007

VI. Thyroiditis (Hashimotos’s, viral, drug induced)16 A. Pain or tenderness of the thyroid gland 1. No history or trauma with acute onset of pain 2. TSH <0.40mIU/L

VII. Calculate ablative dose 13 CPT 780018 and 78020 A. Known diagnosis of thyroid cancer and evidence of residual thyroid tissue after thyroidectomy [One] 1. Any level of thyroglobulin 2. US positive for mass with FNA demonstrating thyroid cancer 3. Positive scan for thyroid metastases 78018 VIII. Suspected recurrent or metastatic thyroid cancer CPT 78015-78018 2, 5,6,15 A. Established diagnosis of follicular or papillary carcinoma of the thyroid after thyroid ablation by surgery or other means 1. Baseline 4 - 12 weeks after ablation (may be repeated at any frequency if additional ablations are required.) 2. Annual exams until negative scan 3. Thyroglobulin levels increasing without thyrogen stimulation 4. Thyroglobulin levels >2 after thyrogen stimulation 5. Thyroglobulin levels after thyrogen stimulation are higher than previous levels after stimulation 6. Anti-thyroglobulin antibody present (scan may be certified every 12 months) 7. New neck mass B. Hürthle cell cancer

References:

1. American Association of Clinical Endocrinologists Thyroid Task Force, Medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism and hypothyroidism, Endocrine Practice, 2002; 8:457-469. 2. American Thyroid Association Guidelines Task force, Management guidelines for patients with thyroid nodules and differentiated thyroid cancer, Thyroid, 2006; 16:1-33. 3. Surks MI, Ortiz E, Daniels GFH, et al, Sublinical thyroid disease:scientific review and guidelines for diagnosis and management, JAMA, 2004, 14:291:228-238. 4. American Association of Clinical Endocrinologists and Association Medical Endocrinologist Task Force on Thyroid Nodules, Medicalguidelines for clinical practice for the diagnosis and management of thyroid nodules, Endocrine Practice, 2006; 12:63-102. 5. American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Thyroid Carcinoma Task Force,AACE/AAES medical surgical guidelines for clinical practice: management of thyroid carcinoma, Endocrine Practice, 2001; 7:203-220. 6. National Comprehensive Cancer Center; accessed at http://www.nccn.org/professionals/physician_gls/PDF/thyroid.pdf November 20, 2008.

CareCore National Criteria for Imaging Version 2.2009

7. Society of Nuclear Medicine Procedure Guideline for Thyroid Scintigraphy version 2.0, approved February 7, 1999, David V. Becker, et al, accessed at http://interactive.snm.org/docs/pg_ch05_0403.pdf November 20, 2008. 8Mazzaferi EL and Kloos RT, Current approaches to primary therapy for papillary and follicular thyroid cancer, JCEM, 2001; 86:1447-1463. 9. Mazzaferi EL and Kloos RT, Is diagnostic Iodine-131 scanning with recombinant human TSH useful in the follow-up of differentiated thyroid cancer after total thyroid ablation? JCEM, 2002; 87:1490-1498. 10. Mazzaferi EL, et al, A consensus report of the role of serum thyroglobulin as a monitoring method for low risk patients with papillary thyroid carcinoma. JCEM, 2003; 88:1433-1441. 11. Cailleux AF, et al, Is diagnostic iodine-131 scanning useful after total thyroid ablation for differentiated thyroid cancer? JCEM, 2000; 85:175-178. 12. Lacey NA, et al, Role of radionuclide imaging in hyperthyroid patients with no suspicion of nodules. British Journal of Radiology, 2001; 74:486-489. 13. American Academy of Pediatrics Section on Endocrinology and Committee on Genetics, American Thyroid Association and Lawson Wilkins Pediatric Endocrine Society, Update on newborn screening and therapy for congenital hypothyroidism, Pediatrics,2006, 117: 2290-2302. 14. Society of Nuclear Medicine Procedure Guideline for Scintigraphy for Differentiated Papillary and Follicular Thyroid Cancer, 9/5/06 Edward B. Silberstein, et al, accessed at http://interactive.snm.org/docs/Thyroid%20Uptake%20Measure%20v3%200.pdf November 20, 2008. 15. Haugen BR, et al., A comparison of recombinant human thyrotropin and thyroid hormone withdrawal for the detection of thyroid remnant or cancer, JCEM, 1999; 84:3877-3885. 16.Bindra A, and Braunstein GD, Thyroiditis, Am Fam Physician, 2006; 73:1769-1776.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78070 Parathyroid Imaging

I. Enlarged parathyroid gland or suspected parathyroid adenoma 1-4 A. Preoperative study for known parathyroid adenoma B. Parathyroid hormone >55pg/mL C. Serum calcium >10.2mg/dL

References:

1. Kukora JS, Zeiger MA, Clark OH, et al, American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons position statement of the diagnosis and management of primary hyperparathyroidism, Endocrine Practice, 2005; 11(1):49-54. 2. GAo P, Scheibel S, D’Amour P, et al., Development of a novel immunoradiometric assay exclusively for biologically active whole parathyroid hormone 1-84: implication for improvement of accurate assessment of parathyroid function, J bone and Mineral Research, 2001; 16(4):605- 614. 3. Bioelezikian JP and Silverberg SJ, Asymptomatic primary hyperparathyroidism, New Eng J Med, 2004; 350:1746-1751. 4. Bilezikian Jp, Potts JT Jr, Fuleihan GEH, et al., Summary statement from a workshop on asymptomatic primary hyperparathyroidism: a perspective for the 21st Century, J Clin Endocrinol Metab, 2002; 87:553-561.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78075 Adrenal Nuclear Imaging Cortex and/or Medulla

I. Adrenal mass by CT or MRI 1-15 A. Distinguish adenomas from hyperplasia 1. Elevated cortisol (Cushing’s syndrome) a. Serum >23 µg/dL b. Hypertension c. 24 hour urinary cortisol >100 µg/24 hours 2. Elevated aldosterone (Conn’s syndrome) a. Blood >15 ng/dL b. Urine >85 µg/24hours c. Decreased serum potassium <3.7 mEq/L d. Decreased serum rennin <1.9 ng/mL/hour e. Hypertension 3. Elevated androgens a. Acne b. Hirsutism B. Evaluation of pheochrocytoma 1. Hypertension 2. Abnormal laboratory tests a. Urinary VMA >7 mg/24 hours b. 24 hour metanephrine-free epinephrine and norepinephrine >100 µg c. 24 hour total metanephrine >1.3mg C. Evaluation of neuroblastoma 1. Urinary VMA > 7 mg/24 hours 2. 24 hour urinary VMA and homovanillic acid D. Evaluation of ganglioneuroma E. Evaluation of ganglioneuroblastoma F. Evaluation of paraganglioneuroma G. May have history of MEN (Multiple Endocrine Neoplasms) type IIA (Sipple syndrome) 1. Medullary carcinoma of thyroid 2. Pheochrocytoma a. Hypertension b. Abnormal laboratory tests i. Urinary VMA >7 mg/ 24 hours ii. 24 hour metanephrine-free epinephrine and norepinephrine >100 µg iii. 24 hour total metanephrine >1.3mg H. History of neurofibromatosis I. History of von Hippel-Lindau disease 1. Pheochromocytoma [a and b] a. Hypertension b. Abnormal laboratory tests

CareCore National Criteria for Imaging Version 2.2009

i. Urinary VMA >7 mg/24 hours ii. 24 hour metanephrine-free epinephrine and norepinephrine >100 µg iii. 24 hr total metanephrine > 1.3mg

II. Primary Aldosteronism (Conn’s syndrome) 3, 16 A. Elevated aldosterone 1. Blood >15 ng/dL 2. Urine >85 µg/24 hours B. Hypertension

III. Cushing’s syndrome 3, 17 A. Hypertension B. Elevated serum or urine cortisol levels 1. Serum >23 µg/dL 2. 24 hour urinary cortisol >100 µg/24 hours 3. Overnight dexamethasone suppression test positive

IV. Pheochromocytoma 3-10 A. Hypertension B. Abnormal laboratory tests 1. Urinary VMA > 7 mg/24 hours 2. 24 hour metanephrine-free epinephrine and norepinephrine >100 µg 3. 24 hour total metanephrine >1.3mg

V. Hyperandrogenism 18-21 A. Virilization in women (Hirsutism, acne, hair loss, polycystic ovary syndrome) 1. Total testosterone >80/ng/dL 2. Free testosterone >2.4 ng/dL

References: 1.Moreira SG Jr, Pow-Sang JM, Evaluation and management of adrenal masses, Cancer Control, 2002; 9(4):326-334. 2. Shulkin BL and Shapiro B, Current concepts on the diagnostic use of MIBG in children, Journal of Nuclear Medicine, 1998; 39:679-688. 3.Torre JJ, Bloomgarden ZT, Dickey RA, et al, AACE Hypertension Task Force, American Association of Clinical Endocrinologists Medical guidelines for clinical practice for the diagnosis and treatment of hypertension, Endocrine Practice, 2006; 12(2):193-222. 4. Schwarz G, Canzanello V, Woolley A, et al, Institute for Clinical Systems Improvement(ICISI), Hypertension diagnosis and treatment, 2006; accessed at http://www.icsi.org/hypertension_4/hypertension_diagnosis_and_treatment_4.html December 1, 2007. 5. Sisson JC, et al, Scintigraphic Localization of Pheochromocytoma, N Engl J Med, 1981; 305:12-17. 6. Chrisoulidou A, et al, The diagnosis and management of malignant pheochromocytoma and paraganglioma, Endocrine-Related Cancer, 2007; 14:569-585. 7. Lenders JWM, et al, Biochemical diagnosis of pheochromocytoma. Which test is best? JAMA, 2002; 287:1427-1434. 8. Ilias I and Pacak K, Anatomical and functional imaging of metastatic pheochromocytoma. Annals New York Academy of Science, 2004; 1018:495-504. 9. Reisch N, et al, Pheochromocytoma: presentation, diagnosis and treatment. Journal of Hypertension, 2006; 24: 2331-2339. 10. Manger W, An overview of pheochromocytoma; history, current concepts. vagaries, and diagnostic challenges, Annals New York Academy of Science, 2006, 1073:1-2011. 11. Andrich MP, et al, The role of 131 iodine-metaiodobenzylguanidine scanning in the correlative imaging of patients with neuroblastoma, Pediatrics, 1996; 97:246–250. 12. Weinstein JL, et al, Advances in the diagnosis and treatment of neuroblastoma, The Oncologist, 2003; 8:278–292.

CareCore National Criteria for Imaging Version 2.2009

13. Brodeur GM, et al, Revisions of the international criteria for neuroblastoma diagnosis, staging, and response to treatment. Journal of Clinical Oncology, 1993; 11:1466-1477. 14. Neumann H, et al, Pheochromocytoma, multiple endocrine neoplasia Type 2, and von Hippel-Lindau Disease. N Engl J Med, 1993; 329:1531-1538. 15. Sawka AM, et al, A comparison of biochemical tests for pheochromocytoma: measurement of fractionated plasma metanephrines compared with the combination of 24-hour urinary metanephrines and catecholamines. The Journal of Clinical Endocrinology & Metabolism, 2003; 88:553-558. 16. Ganguly A, Primary aldosteronism, N Engl J Med, 1998; 339:1828-1834. 17. Orth DN, Cushing’s syndrome. N Engl J Med, 1995, 332:791-803 18. Derksen J, et al, Identification of virilizing adrenal tumors in hirsute women, N Engl J Med, 1994; 331: 968-973. 19. Azziz, R, et al, Androgen excess in women: experience with Over 1000 consecutive patients. The Journal of Clinical Endocrinology & Metabolism, 2004; 89:453-462. 20. Rosenfield RL, Hirsutism, N Engl J Med, 2005; 353:2578-2588. 21. Goodman NF, Bledsoe MB, Cobin RH, et al, Hyperandrogenic disorders task force, American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of hyperandrogenic disorders, Endocrine Practice, 2001; 7(2):120-134, accessed at http://www.aace.com/pub/pdf/guidelines/hyperandrogenism2001.pdf December 1, 2007.

CareCore National Criteria for Imaging Version 2.2009

78102 Bone Marrow Imaging Limited Areas 78103 Bone Marrow Imaging Multiple Areas 78104 Bone Marrow Imaging Whole Body

These studies are rarely performed. Marrow imaging is best done with MRI; these should be performed only if MRI is not feasible.

I. Determine extent of marrow in myeloproliferative disorders

II. Detection of ischemic or infarcted regions in sickle cell disease

III. Dysbaric osteonecrosis (generally called “the bends”)

IV. Avascular necrosis

V. Detection of asymmetric marrow distribution in tumors such as A. Myeloma B. Hodgkin's disease C. Metastatic disease

VI. Staging of polycythemia rubra vera, myelofibrosis and aplastic anemia

VII. Suspected osteomyelitis A. Pain B. X-ray non-diagnostic C. Clinical findings 1. ESR >20 mm/hr 2. Fever >100.4 3. Leukocytosis, WBC >12,000/cu.mm 4. C - reactive protein >10mg/L 5. Blood culture positive D. History of infection elsewhere E. History of diabetes, dialysis or peripheral vascular disease F. History of penetrating injury or surgery G. Sinus tract, poor wound or fracture healing H. Pre-operative evaluation of osteomyelitis [MRI preferred]

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78185 Spleen Imaging Only with or without Vascular Flow

This is rarely used. For most indications CT is the preferred imaging modality to evaluate the spleen. I. If CT is not available 78185 can be used A. Suspected splenic trauma B. Spleen size C. LUQ mass D. Suspected splenic 1. Metastases 2. Cysts 3. Abscess 4. Infarct

II. Localization of spleen for radiation ports (if no radiation treatment planning CT is available)

III. Asplenia 1

IV. Suspected functional accessory spleen 1

V. Evaluation of splenic function 1

VI. Non-specific symptoms in LUQ (if neither ultrasound nor CT is available)

References:

1. Royal HD, Brown ML, Drum DE, Society of Nuclear Medicine Procedure guideline for hepatic and splenic imaging 3.0, version 3.0, approved July 20, 2003 accessed at http://interactive.snm.org/docs/pg_ch10_0403.pdf July 8, 2008.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78195 Lymph System Imaging (Lymphoscintigraphy)

I. Sentinel node mapping 1-3 A. Must have tissue diagnosis of: 1. Breast cancer 2. Melanoma 3. Merkel cell carcinoma 4. Head and neck cancer

II. Lymphedema of the lower extremity 4 A. Must have negative venous Doppler including evaluation for valvular insufficiency B. History of Milroy’s disease C. Previous pelvic lymph node biopsy, dissection

References:

1. Lyman GH, Giuliano AE, Somerfield MR et al, American Society of Clinical Oncology Guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer, J Clini Oncol, 2005; 23:7703-7720. 2. Scottish Intercollegiate Guidelines Network, Cutaneous melanoma, a national clinical guideline, accessed at http://www.sign.ac.uk/pdf/sign72.pdf July 6, 2008. 3. Alazraki N, Glass EC, Castronovo F, et al, Society of Nuclear Medicine Procedure Guideline for lymphoscintigraphy ad use of intraopertive gamma probe for sentinel lymph node localization in melanoma of intermediate thickness, version 1.0, approved July 15, 2002, accessed at http://interactive.snm.org/docs/pg_ch24_0403.pdf July 6, 2008. 4. McNeill GC, Witte MH, Witte CL, et al, Whole-body lymphangioscintigraphy: preferred method for initial assessment of the peripheral lymphatic system, Rad, 1989; 172:495-502.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78201 Liver Imaging Static 78202 Liver Imaging with Vascular Flow 78205 Liver Imaging SPECT 78206 Liver Imaging SPECT with Vascular Flow 78215 Liver and Spleen Imaging Static 78216 Liver and Spleen Imaging with Vascular Flow

These studies are rarely indicated, CT, US and MRI are generally preferred.

I. Evaluation, if US, CT and MRI are not available or are inconclusive of liver and spleen 1 A. Masses 1. Primary tumors 2. Metastases 3. Abscess B. Size, shape, and position C. Trauma

II. Differentiating hepatic hemangiomas and Focal Nodular Hyperplasia (FNH) from other hepatic masses 2

III. Diffuse hepatic disease such as cirrhosis, hepatitis 2

IV. Elevated liver function tests

V. Evaluation of hepatic artery catheters for chemotherapy infusion 2

References: 1. Foley WD, Bree RL, Gay SB, et al, Expert Panel on Gastrointestinal Imaging, American College of Radiology Appropriateness Criteria- liver lesion characterization, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonGastrointestinalImaging/liverLesionCharacteri zationDoc9.aspx July 8, 2008. 2. Royal HD, Brown ML, Drum DE, Society of Nuclear Medicine Procedure guideline for hepatic and splenic imaging 3.0, version 3.0, approved July 20, 2003 accessed at http://interactive.snm.org/docs/pg_ch10_0403.pdf July 8, 2008.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78220 Liver Function with Hepatobiliary Agents 78223 Bile Duct Imaging with or without CCK (HIDA Scan)

I. Acute cholecystitis 1, 2 A. US non-diagnostic for cystic duct obstruction or not available B. Clinical findings 1. RUQ Pain 2. RUQ Tenderness

II. Chronic cholecystitis A. Evidence of gallstones on prior ultrasound B. Recurrent right upper quadrant pain

III. Chronic acalculous cholecystitis (Biliary dyskinesia or determination of gallbladder ejection fraction) A. Recurrent right upper quadrant abdominal pain B. Biliary colic C. No evidence of gallstones on ultrasound

IV. Dysfunction of sphincter oddi

V. Suspected bile leak after trauma or surgery

VI. Evaluation of liver function A. Pre-operative assessment of post-operative remnant B. Monitoring of liver regeneration

References: 1. Bree RL, Foley WD, Gay SB, et al, Expert Panel on Gastrointestinal Imaging, American College of Radiology Appropriateness Criteria- right upper quadrant pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonGastrointestinalImaging/RightUpperQuadrant PainDoc13.aspx July 8, 2008. 2. WEissmann GS, Frank MS, Bernstein LH, et al, Rapid and accurate diagnosis of acute cholecystitis with 99mTc-HIDA cholescintigraphy, AJR, 1979; 132:523-528.

CareCore National Criteria for Imaging Version 2.2009

78230 Salivary Gland Nuclear Imaging 78231 Salivary Gland Nuclear Imaging with Serial Imaging 78232 Salivary Gland Function Study

I. Evaluation of parotid masses to allow pre-operative diagnosis of Warthin’s tumor

II. Evaluation of salivary gland function in patients with dry mouth A. Xerostomia B. Sjögren’s syndrome C. Sialadenitis D. After head and neck irradiation

III. Evaluation of children with cerebral palsy

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78258 Esophageal Motility Study

I. Dysphagia A. Chest Pain B. Difficulty swallowing solids initially and then liquids

II. Gastroesophageal reflux

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78261 Gastric Mucosa Imaging

I. Evaluation of 1-5 A. Meckel’s diverticulum 1. Must have lower GI bleeding, usually bright red blood per rectum B. Barrett’s Esophagus

1. Must have clinical history of dyspepsia, esophagitis

II. Evaluation of pulmonary or mediastinal masses suspected of containing gastric mucosa 5, 6

References: 1. Ramsook C, and Endom EE, Approach to lower gastrointestinal bleeding in children, edited by Klish WJ and Teach SJ, Up to Date, accessed at http://www.uptodate.com/online/content/topic.do?topicKey=pedigast/8638&selectedTitle=1~27&source=search_result July 28, 2008. 2. Rossi P, Gourtsoyiannis N, Bezzi M, et al, Meckel’s diverticulum: imaging diagnosis, AJR, 1996; 166:567-573. 3. Elsayes KM, Menias CO, Harvin HJ, et al, Imaging manifestations of Meckel’s diverticulum, AJR, 2007; 189:81-88. 4. Berquist TH, Nolan NG, Stephens DH, et al, Specificity of 99mTc-pertechnetate in scintigraphic diagnosis of Meckel’s diverticulum: review of 100 cases, J Nucl Med, 1976; 17:465-469. 5. Kumar R, Tripathi M, Chandrashekar N, et al, Diagnosis of ectopic gastric musosa using 99Tcm-pertechnetate: spectrum of scintigraphic findings, BJR,2005; 78:714-720. 6. Berquist TH, Nolan NG, Stephens DH, et al, Radioisotope scintigraphy in diagnosis of Barrett’s esophagus, AJR, 1975; 123:401-411.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78262 Gastroesophageal Reflux Study

I. Confirmation of GE reflux A. Pediatric 1. Symptomatic a. Vomiting b. Belching c. Failure to thrive d. Refusal of food e. Chest pain 2. Asymptomatic a. Family history of Barrett’s esophagus or esophageal carcinoma B. Adult 1. Chronic heartburn 2. Dysphagia 3. Family history of Barrett’s esophagus or esophageal carcinoma

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78264 Gastric Emptying Study

I. Delayed gastric emptying in patients (gastroparesis) 1-5 A. Symptoms 1. Nausea 2. Vomiting of old food ingested several hours earlier 3. Bloating 4. Early satiety 5. Post prandial fullness, nausea, vomiting or recurrent aspiration 6. Unexplained poor glucose control in diabetes 7. Gastroesophageal reflux refractory to medical management

II. Pediatric patients with gastroesophageal reflux or rumination syndrome and suspicion of delayed gastric emptying

III. Rapid gastric emptying (Dumping syndrome) 3, 6 A. Must have two or more of the following symptoms: 1. Crampy abdominal discomfort 2. Nausea 3. Diarrhea 4. Belching 5. Tachycardia 6. Palpitations 7. Diaphoresis 8. Lightheadedness

References: 1. Donohoe KJ, Maurer AH, Ziessman HA, et al, Society of Nuclear Medicine Procedure Guideline for Gastric Emptying and Motility, Version 2.0, approved June 6, 2004, accessed at http://interactive.snm.org/docs/pg_ch08_0403.pdf July 28, 2008. 2. Parkman HP, Hasler WL, and Fisher R, American Gastroenterological Association Medical Position Statement: diagnosis and treatment of gastroparesis, Gastroenterology, 2004; 127:1589-1591. 3. Abell TL, Camilleri M, Donohoe D, et al, Consensus recommendations for gastric emptying scintigraphy: A joint report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine, Am J Gastroenterol, 2008; 103:753-763. 4. Sarnelli G, Caenepeel P, Geypens B, et al, Symptoms associated with impaired gastric emptying of solids and liquids in functional dyspepsia, Am J Gastroenterol, 2003; 98:783-788 5. Parkman HP, Hasler WL, and Fisher R, American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis, Gastroenterology, 2004; 127:1592-1622. 6. Lawal A, Barboi A, Krasnow A, et al, Rapid gastric emptying is more common than gastroparesis in patients with autonomic dysfunction, Am J Gastroenterol, 2007; 102:618-623. 7. Chial HJ et al. Rumination Syndrome in Children and Adolescents: Diagnosis, Treatment, and Prognosis, Pediatrics 2003;111:158-62 8. Altailji et al. Utility of gastroesophageal reflux study to assess for abnormal gastric emptying in comparison to the dedicated standardized gastric emptying study, J Nuclear Med. 2007;48(suppl. 2)289 P

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78278 GI Bleeding Scintigraphy

I. Evaluation of lower GI bleeding 1-3 A. Hematest positive stool B. Indeterminate colonoscopy of lower GI bleeding C. Active GI bleeding

References:

1. American Gastroenterological Association Medical Position Statement: Evaluation and management of occult and obscure gastrointestinal bleeding, Gastroenterology, 2000; 118:197-200. 2. Raju GS, Gerson L, Das A, et al, American Gastroenterological Association (AGA) Institute medical position statement on obscure gastrointestinal bleeding, Gastroenterology, 2007; 133:1694-1696. 3. AGA Technical review on the evaluation and management of occult and obscure gastrointestinal bleeding, Gastroenterology, 2000; 118:201-221.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78282 Gastrointestinal Protein Loss

I. Findings A. Decreased plasma albumin or globulins B. Peripheral edema or anasarca C. No active GI bleeding

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78290 Intestinal Imaging

I. Evaluation for ectopic gastric mucosa 1, 2 A. Active GI bleeding B. Unexplained anemia with guaic positive stools

References:

1. Morton KA, Clark PB, et al, Diagnostic Nuclear Medicine, Amursys, 2007, (8):122-125. 2. Thrall JH, Zeissman HA, Nuclear Medicine, The Requisites, Mosby, 2001, 288-289.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78291 Peritoneal - Venous Shunt Patency

I. Approve for evaluation of shunt patency and function in a patient with ascites (Leveen shunt, Denver shunt)

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78300 Nuclear Bone Scan Limited 78305 Nuclear Bone Scan Multiple Areas 78306 Nuclear Bone Scan Whole Body 78320 Nuclear Bone Scan SPECT

A SPECT scan may be approved for any of the indications listed below. It includes a whole body bone scan. Indication XI is specific for SPECT. The need for SPECT may not be obvious until the time of the scan and a change of code may be requested for clarification of findings on the whole body scan. A repeat scan should not be necessary in order to perform a SPECT study.

I. Tumor 1-8 A. Metastases 1. Breast cancer a. Initial evaluation of patient with new diagnosis of breast cancer stage II or higher b. Prior evidence of bone metastases c. Elevated alkaline phosphatase 2. Prostate cancer a. Initial diagnosis b. Surveillance i. Rising PSA on 2 consecutive tests ii. Elevated alkaline phosphatase iii. Bone pain iv. Known prior bone metastases 3. Bone pain or elevated alkaline phosphatase with known malignancy 4. Initial staging of renal cell carcinoma 5. Initial staging of small cell lung cancer (SCLC) a. PET scan not done or planned B. Primary bone tumor 1. Abnormality discovered on x-ray, CT or MRI 2. Known primary bone malignancy evaluation for extent and metastases

II. Suspected fracture 2, 9 (for stress fractures may request three phase scan [78315]) A. Pain at site 1. Decreased with rest 2. Worsened with activity B. Two negative x-rays at least 10 days apart for all suspected fractures except hip fracture

III. Suspected avascular necrosis (osteonecrosis, osteochondritis dissecans, OCD) 2 [MRI is the preferred imaging test] A. Chronic bone pain and one risk factor Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

1. Excessive alcohol use and smoking 2. HIV infection 3. SLE 4. History of steroid use 5. Sickle cell disease 6. Renal transplant 7. Trauma a. Fracture b. Dislocation 8. Biphosphonate use 9. Coagulopathy B. Knee pain at joint and x-ray non-diagnostic 1. Knee pain 2. Swelling, tenderness or stiffness 3. Pain with passive movement C. Talus pain at joint and x-ray non-diagnostic 1. Pain with passive movement 2. Chronic pain after sprain or sprains D. Hip pain, x-ray non-diagnostic 1. Pain in groin or buttocks 2. Worse with ambulation 3. Present at night 4. Pain with internal rotation of leg 5. Limited Range of Motion (ROM)

IV. Osteomyelitis 2, 10, 11 [MRI or Three phase bone scan (78315) preferred if not a follow-up study] A. Suspected osteomyelitis 1. Pain 2. Clinical findings a. ESR >20 mm/hr b. Fever >100.4 c. Leukocytosis, WBC >12,000/cu.mm d. C-reactive protein >10 mg/ml e. Blood culture positive f. X-ray suggestive of osteomyelitis 3. History of infection elsewhere 4. History of diabetes, dialysis or peripheral vascular disease 5. History of penetrating injury or surgery 6. Sinus tract, poor wound or fracture healing

V. Loosening of prosthesis X-ray nondiagnostic 12 A. Pain at site, worsened with weight bearing B. Limp or antalgic gait

CareCore National Criteria for Imaging Version 2.2009

VI. Complex regional pain syndrome or reflex sympathetic dystrophy2, 13 A. Local pain and tenderness B. Flushing or diminished blood flow C. Skin changes

VII. Myositis ossificans14, 15 [Three phase bone scan (78315) may be requested] A. Heterotopic calcification seen on x-ray 1. Recent trauma or surgery 2. Pain swelling and erythema at site

VIII. Suspected frostbite16 [Three phase bone scan (78315) may be requested]

IX. Suspected child abuse 17 A. For most children, plain x-rays are suggested as the initial examination B. If false negative x-ray exam is suspected scintigraphy may be certified

X. Paget's disease A. Deformity of skull, jaw or clavicle B. Aching pain, worse at night, especially in pelvis C. Elevated alkaline phosphatase

XI. Indications for Single Photon Emission CT (SPECT) [78320]18-22 A. Clarification of equivocal findings on planar bone scan B. Spondylolysis with CT or MRI non-diagnostic or not feasible C. Avascular necrosis of hip D. Temporomandibular joint disease E. Pediatric or adolescent back pain

References:

1. El-Koury GY, Bennett DL, Kalika MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Metastatic bone disease, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/MetastaticboneDisea seDoc14.aspx July 6, 2008. 2. Donohoe KJ, Brown ML, Collier D, et al, Society of Nuclear Medicine procedure guideline for bone scintigraphy, version 3.0, approved June 20, 2003 accessed at http://interactive.snm.org/docs/pg_ch34_0403.pdf July 6, 2008. 3. Curry NS, Francis IR, Baumgarten DA, et al, Expert Panel on Urologic Imaging, American College of Radiology Appropriateness Criteria Renal cell carcinoma staging, accessed at, American College of Radiology Appropriateness Criteria, July 6, 2008. 4. Kawashima A, Francis IR, Baumgarten DA, et al, Expert Panel on Urologic Imaging, American College of Radiology Appropriateness Criteria Post-treatment follow up of prostate cancer, accessed http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonThoracicImaging/StagingofBronchogenicCarci nomaDoc11.aspx July 6, 2008.

CareCore National Criteria for Imaging Version 2.2009

5. Rozenshtein A, Davis SD, Komaki RU, et al, Expert Panels on Thoracic Imaging and Radiation Oncology-Lung Work Group, American College of Radiology Appropriateness Criteria Staging bronchogenic carcinoma, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonThoracicImaging/StagingofBronchogenicCarci nomaDoc11.aspx July 6, 2008. 6. Shen KR, Meyers BF, Larner JM, et al, Special treatment issues in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition) accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=11419&nbr=005938&string=bone+AND+metastases July 6, 2008. 7. Israel GM, Frances IR, Roach M III, et al, Expert Panels on Urologic Imaging and Radiation Oncology-Prostate, American College of Radilogy Appropriateness Criteria, Pretreatment staging of prostate cancer, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonUrologicImaging/PretreatmentStagingProstat eCancerDoc12.aspx July 6, 2008. 8. Morrison WB, Kalinka MK, Daffner RH, et al, Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria: Bone tumors, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/BoneTumorsDoc4.as px July 6, 2008. 9. Manaster BJ, Grossman JW, Dalinka MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria: Stress/insufficiency fracture including sacrum, excluding other vertebrae, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/StressInsufficiencyfr acturesIncludingSacrumExcludingOtherVertebraeDoc20.aspx July 6, 2008. 10. Tuson CE, Hoffman EB, and Mann MD, Isotope bone scanning for acute osteomyelitis and septic arthritis in children, J Bone Joint Surg, 1994; 76-B:306-310. 11. Lazzarini L, Mader JT and Calhoun JH, Osteomyelitis in long bones, J Bone Joint Surg, 2004; 86:2305-2318. 12. Weissman BN, Dalinka MK, Daffner RH, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Imaging after total knee arthroplasty, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ImagingafterTotalKn eeArthroplastyDoc13.aspx July 6, 2008. 13. El-Koury GY, Bennett DL, Kalinka MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Chronic foot pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ChronicFootPainDoc 7.aspx July 6, 2008. 14. Drane WE, Myositis ossificans and the three phase bone scan, AJR, 1984; 142:179-180. 15. Krabsdirf NH and NEus HN, Extraskeletal osseous and cartilaginous tumors of the extremities, RadioGraphics, 1993; 13:853-884. 16. Mehta RC and Wilson MA, Frostbite injury: prediction of tissue viability with triple-phase bone scanning, Rad, 1989; 170:511-514. 17. Kellogg ND, and the Committee on Child Abuse and Neglect, Evaluation of suspected child physical abuse, Pediatrics, 2007; 119:1232- 1241. 18. Bellah RD, Summerville DA, Treves ST, et al, Low-back pain in adolescent athletes: detection of stress injury to the pars interarticularis with SPECT, Rad, 1991; 180:509-512. 19. Crook GJR and Fogelman I, Bone single photon emission computed tomography, Imaging, 2001; 13:149-154. 20. Afshani E and Kuhn JP, Common causes of low back pain in children, RadioGraphics, 1991; 11:269-291. 21.Bradleyu WG Jr, Seidenwurm DJ, Brunbert JA, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria-Low back pain, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/LowBackPainDoc7.aspx July 6, 2008. 22.Ryu JS, Kim JS, Moon DH, et al, Bone SPECT is more sensitive than MRI in the detection of early osteonecrosis of the femoral head after renal transplantation, J Nucl Med, 2002; 43:1006-1011.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78315 Bone Scan Three Phase

I. Suspected frostbite 1

II. Suspected stress fracture 2, 3] A. Insidious or gradual onset of activity related pain B. Pain on palpation or Range of Motion (ROM) C. Initial radiographs (x-rays) normal

III. Osteomyelitis2, 4, 5 A. MRI contraindicated B. Suspected osteomyelitis 1. Pain 2. Clinical findings a. ESR >20 mm/hr b. Fever >100.4 c. Leukocytosis, WBC >12,000/cu.mm d. C-reactive protein >10 mg/L e. Blood culture positive f. X-ray suggestive of osteomyelitis 3. History of infection elsewhere 4. History of diabetes, dialysis or peripheral vascular disease 5. History of penetrating injury or surgery 6. Sinus tract, poor wound or fracture healing

IV. Loosening of prosthesis x-ray non-diagnostic 6 A. Pain at site, worsened with weight bearing B. Limp or antalgic gait

V. Myositis ossificans 7, 8 A. Heterotopic calcification seen on x-ray 1. Recent trauma or surgery 2. Pain swelling and erythema at site

References: 1. Mehta RC and Wilson MA, Frostbite injury: prediction of tissue viability with triple-phase bone scanning, Rad, 1989; 170:511-514. 2. Donohoe KJ, Brown ML, Collier D, et al, Society of Nuclear Medicine procedure guideline for bone scintigraphy, version 3.0, approved June 20, 2003 accessed at http://interactive.snm.org/docs/pg_ch34_0403.pdf July 6, 2008. 3 Manaster BJ, Grossman JW, Dalinka MK, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria: Stress/insufficiency fracture including sacrum, excluding other vertebrae, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/StressInsufficiencyfr acturesIncludingSacrumExcludingOtherVertebraeDoc20.aspx July 6, 2008. Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

4. Tuson CE, Hoffman EB, and Mann MD, Isotope bone scanning for acute osteomyelitis and septic arthritis in children, J Bone Joint Surg, 1994; 76-B:306-310. 5. Lazzarini L, Mader JT, and Calhoun JH, Osteomyelitis in long bones, J Bone Joint Surg, 2004; 86:2305-2318. 6. Weissman BN, Dalinka MK, Daffner RH, et al, Expert Panel on Musculoskeletal Imaging, American College of Radiology Appropriateness Criteria, Imaging after total knee arthroplasty, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ImagingafterTotalKn eeArthroplastyDoc13.aspx July 6, 2008. 7. Drane WE, Myositis ossificans and the three phase bone scan, AJR, 1984; 142:179-180. 8. Krabsdirf NH and NEus HN, Extraskeletal osseous and cartilaginous tumors of the extremities, RadioGraphics, 1993; 13:853-884.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78414 Central C-V Hemodynamics (Non-imaging) Single or Multiple

As stated in the definition this is not an imaging study, and is rarely performed. If requested for a patient with congestive heart failure (CHF) it may be certified after the requester is informed that this is NOT an imaging exam or MUGA examination. It should not be certified with any other 784xx code.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78428 Cardiac Shunt Detection

I. Calculation of left and right ventricular ejection fractions

II. Assessment of wall motion

III. Quantitation of right to left shunts

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78445 Non-cardiac Vascular Flow Imaging

This is an obsolete examination that has been largely superseded by vascular ultrasound, MRA and CTA. It is of occasional value when these newer examinations are not feasible.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78456 Acute Venous Thrombosis Imaging 78457 Venous Thrombosis Imaging Unilateral 78458 Venous Thrombosis Imaging Bilateral

These are obsolete examinations that have been largely superseded by vascular ultrasound, MRA and CTA. They may be of occasional value when these newer examinations are not feasible.

CareCore National Criteria for Imaging Version 2.2009

78459 Myocardial PET, Metabolic

I. Evaluation for “hibernating myocardium” or myocardial viability A. Evidence of ischemia 1. By stress imaging (nuclear or echo) 2. By angiography B. Revascularization procedure contemplated

II. Clinical suspicion of cardiac sarcoid A. Known diagnosis of sarcoidosis B. Documented arrhythmia 1. Complete right bundle branch block 2. AV block C. Abnormal wall motion of left ventricle on echocardiogram

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78460 Myocardial Perfusion Imaging Planar Rest or Stress 78461 Myocardial Perfusion Imaging Planar Rest and/or Stress

These are obsolete examinations that have been largely superseded by SPECT.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78464 Myocardial Perfusion with SPECT - Single Study 78465 Myocardial Perfusion with SPECT - Multiple Studies 78478 Myocardial Perfusion - Wall Motion 78480 Myocardial Perfusion - Ejection Fraction

I. Assessment of an asymptomatic member prior to non-cardiac surgery 1

Members scheduled for non-cardiac surgery may require a nuclear stress test within four weeks of surgery to assess cardiac risk in an effort to reduce peri-operative complications. The acceptable risk depends on whether the surgery is deemed "High", "Intermediate", or "Low" risk surgery and whether or not the member has pre-existing coronary artery disease.

The American College of Cardiology defines surgical risk as follows:

• High Risk Surgery- 1. Emergent operations, especially in the elderly 2. Aortic and other major vascular surgeries 3. Peripheral vascular surgeries 4. Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss.

• Intermediate Risk Surgery- 1. Carotid endarterectomy 2. Head and neck surgery 3. Intraperitoneal and intrathoracic surgery 4. Orthopedic surgery 5. Prostate surgery

• Low Risk Surgery- 1. Endoscopy 2. Superficial procedures 3. Cataract surgery 4. Breast surgery

A. Intermediate risk surgery 1. Framingham risk† percentage is >10% 2. Diabetes 3. Renal insufficiency with creatinine of 2 mg/dl or more 4. History of CVA 5. History of compensated or prior heart failure Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

6. Significant arrhythmia a. Atrial fibrillation b. Symptomatic bradycardia c. Third degree AV (Atrioventricular) heart block d. Mobitz II AV (Atrioventricular) heart block 7. Severe valvular disease aortic stenosis a. Mitral stenosis B. High risk surgery

II. Assessment of a member discharged within the last eight weeks after hospitalization or ER visit for a cardiac condition 2, 3 A. Discharged, without a positive or symptom-limited stress test 1. Atrial fibrillation- if the member has not had an imaging stress test within two years prior to the hospital discharge a. Framingham risk† percentage of >10% b. Diabetes

If the Framingham risk† is <10% and there are no contraindications to a routine exercise stress test, then a nuclear study is not supported by adequate peer-reviewed literature as a routine stress test can be performed as the initial test modality. Contraindications to a routine exercise stress test include diabetes, inability to exercise, digoxin use, inability to raise heart rate due to electrical system disease or medication that cannot be stopped or an uninterpretable electrocardiogram. The American College of Cardiology defines an uninterpretable electrocardiogram as a ventricular paced rhythm, left bundle branch block, Wolfe-Parkinson-White Syndrome or >1mm ST depression at baseline.

B. Myocardial ischemia (including myocardial infarction, unstable angina, or chest pain syndrome ††) 1. Percutaneous intervention was performed during the hospitalization and lesions of the coronary anatomy of >50% were present but not fixed 2. None of the following prior to discharge a. Heart catheterization b. Coronary CT angiography c. Symptom limited stress test prior to discharge C. Congestive heart failure 1. New diagnosis and NONE of the following a. Cardiac catheterization b. Coronary CT Angiogram (CCTA) c. Imaging (nuclear or echo) stress test during or since hospitalization 2. Recurrent congestive heart failure and and NONE of the following: a. Cardiac Catheterization within the last 3 years b. Coronary CT Angiogram (CCTA) within the last 3 years c. Imaging (nuclear or echo) stress test within the last 2 years 3. Recurrent congestive heart failure and 40% or greater stenosis in any coronary artery documented by catheterization or Coronary CT Angiogram (CCTA) and NONE of the following: Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

a. Cardiac Catheterization within the last 3 years b. Coronary CT Angiogram (CCTA) within the last 3 years c. Imaging (nuclear or echo) stress test within the last year 4. Recurrent congestive heart failure and maximum coronary artery stenosis of less than 40% in any vessel and NONE of the following: a. Cardiac catheterization within the last 3 years b. Coronary CT Angiogram (CCTA) within the last 3 years c. No imaging (nuclear or echo) stress test within the last 2 years D. Syncope or near syncope 1. Imaging (nuclear or echo) stress test more than 1 year ago or never 2. Cardiac Catheterization test more than 1 year ago or never 3. Coronary CT Angiogram (CCTA) test more than 1 year ago or never

III. Assessment of a member with known coronary artery disease 2 A. Asymptomatic or stable 1. No CHF certify every two years 2. CHF yearly 3. Percutaneous Intervention (PCI) a. Two years after the procedure 4. Coronary artery bypass graft a. 5 years after surgery b. Every 2 years after the first post operative study 5. Known coronary artery stenosis of greater than 50% a. Cardiac catheterization or coronary artery CT angiogram more than 1 year ago B. New or changed chest pain or chest pain syndrome ††

IV. The assessment of a symptomatic or asymptomatic member without documented coronary artery disease 2 A. Framingham risk† percentage >10% 1. Symptomatic a. Previous nuclear stress test normal b. Worsening or recurrent symptoms 2. Asymptomatic every 2 years B. Diabetes 1. Symptomatic (chest pain or shortness of breath) a. Nuclear stress test normal >1 year ago b. New or worsening symptoms with nuclear stress test <1 year ago 2. Asymptomatic every 2 years C. Uninterpretable electrocardiogram and another finding [1 and 2] 1. Defined as a. Ventricular paced rhythm b. Left bundle branch block c. Wolfe-Parkinson-White syndrome d. >1mm ST depression at baseline 2. Other findings Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

a. Atrial fibrillation b. Chest pain c. Dyspnea on exertion d. Syncope D. Digoxin or similar medications and another indication in VI E. Abnormal routine exercise stress test 1. The definition of an abnormal routine exercise test is 1 mm or greater ST depression which is horizontal or downsloping a. Heart catheterization not planned b. Coronary artery CT angiogram not planned 2. Chest pain during the exercise stress test 3. PVCs during the exercise stress test 4. Drop in systolic blood pressure of > 10 mmHg F. Inability to attain an adequate heart rate due to electrical system disease or medications that cannot be withdrawn G. Inability to exercise due to medical illness H. Ventricular tachycardia I. Ejection fraction <50% 1. Symptomatic every year 2. Asymptomatic every 2 years

† An online Framingham risk calculator can be accessed at the follow link: http://www.intmed.mcw.edu/clincalc/heartrisk.html.

†† Chest pain syndrome includes chest pain, chest tightness, chest burning, dyspnea, shoulder pain, and jaw pain

References:

1. Fleisher LA, Beckman JA, Brown KA, et al, ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for non cardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, J Am Coll cardiol, 2007; 50:159-241. 2. Brindis RG, Douglas PS, Hendel RC, et al, ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology. J Am Coll Cardiol 2005; 46:1587- 1605. 3. Strickberger SA, Benson DW, Biaggioni I, et al, FAHA AHA/ACCF Scientific statement on the evaluation of syncope from the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation In Collaboration With the Heart Rhythm Society, J Am Coll Cardiol, 2006; 47:473-484, doi:10.1016/j.jacc.2005.12.019.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78464 Myocardial Perfusion with SPECT - Single Study 78465 Myocardial Perfusion with SPECT - Multiple Studies 78478 Myocardial Perfusion - Wall Motion 78480 Myocardial Perfusion - Ejection Fraction

Medicare Connecticut1, New York1

This is NOT a screening test for asymptomatic patients.

SPECT is not medically necessary if the PET Myocardial Perfusion Imaging is equivocal or inconclusive.

I. Chest pain or chest pain syndrome† A Uninterpretable EKG 1. Complete left bundle branch block 2. Ventricular paced rhythm 3. Wolf Parkinson White syndrome 4. ST changes with > 1 mm ST depression B. Left ventricular hypertrophy C. Digoxin or similar medication D. Diabetes* E. Angina 1. Substernal chest pain or discomfort provoked by exertion or emotional stress and relieved by rest and/or nitroglycerin**

II. Known coronary artery Disease A. Asymptomatic or stable 1. Prior positive MPI, or PET myocardial perfusion imaging or prior cardiac catheterization demonstrating coronary artery disease 2. No revascularization ( CABG or PCI including angioplasty and/or stent) procedure within the past 2 years B. Symptomatic 1. Chest pain or chest pain syndrome a. Chest Pain b. Chest burning c. Jaw pain d. Chest tightness e. Dyspnea

CareCore National Criteria for Imaging Version 2.2009

f. Shoulder pain C. Documented myocardial infarction in the past

III. No known coronary artery disease A. No chest pain syndrome 1. New onset of congestive heart failure 2. New onset of decreased LV ejection fraction less than 50% 3. Diabetes * and asymptomatic every 2 years B. Abnormal Exercise or treadmill stress test *** 1. > 1mm ST depression which is horizontal or downsloping 2. PVCs induced during stress 3. Drop of >10mm Hg in systolic blood pressure during the stress test 4. Chest pain during the stress test

IV. Assessment prior to non-cardiac surgery A. High risk surgery†† 1. Emergency procedures 2. Aortic or other major vascular procedures 3. Peripheral vascular Surgery 4. Anticipated prolonged surgical procedures with large fluid shits and/or blood loss such as but not limited to liver transplant, hepatic resection, radical prostatectomy 5. Asymptomatic a. No evidence of prior imaging stress test or catheterization in the past year B. Intermediate risk surgery including carotid endarterectomy, head and neck surgery, orthopedic surgery, abdominal surgery, chest surgery 1. Diabetes 2. Renal insufficiency with creatinine of 2mg/dl or more 3. History of prior stroke or CVA 4. History of compensated heart failure 5. Arrhythmia a. Atrial fibrillation b. Symptomatic bradycardia c. Third degree AV heart block d. Mobitz type II AV block 6. Severe valvular disease 7. Poor functional exercise capacity secondary to function limiting comorbidities

V. Congenital anomalies of the coronary arteries

VI. Cardiomyopathy A. Cardiac catheterization is not planned B. Ejection fraction <50%

†Chest pain syndrome includes chest pain, chest tightness, chest burning, dyspnea,

CareCore National Criteria for Imaging Version 2.2009

shoulder pain, and jaw pain.

†† High risk surgery includes: Emergent operations especially in the elderly Aortic and other major vascular surgery Peripheral vascular surgery Anticipated prolonged surgical procedures associated with large fluid shits and/or blood loss

The following assessment is used to determine the pre-test probability of coronary artery disease based on a description of the character of the chest pain, member age and sex. This assessment will define the chest pain as typical angina, atypical angina, and nonanginal chest pain. To characterize the chest pain the following questions are to be asked and scored:

1) Substernal Chest Pain=1 2) Arm Pain=0 3) Jaw Pain=0 4) Relieved by Nitroglycerin or Rest=1 5) Shortness of Breath=0 6) Nocturnal= 0 7) Pain or Discomfort with Inspiration= 0 8) Discomfort at Rest = 0 9) Exercise Induced or emotionally Induced=1

A score of 3 qualifies as typical angina; a score of 2 qualifies as atypical angina, and 0-1 qualifies as non-anginal. This description then is applied to the age/sex criteria as follows:

CareCore National Criteria for Imaging Version 2.2009

CHART 1 Determination of Pretest Probability for Coronary Disease Based on Chest Pain 2 The following assessment is used to determine pre-test probability of coronary artery disease based on description of the character of chest pain, member age and sex. This assessment will define the chest pain as typical angina, atypical angina, and nonanginal chest pain. This description then is applied to the age/sex criteria as follows

Typical Angina (definite): 1) Substernal chest pain or discomfort is 2) provoked by exertion or emotional stress and 3) relieved by rest and/or nitroglycerin.

Atypical angina (probable): Chest pain or discomfort that lacks one of the characteristics of definite or typical angina.

Non-anginal chest pain: Chest pain or discomfort that meets one or none of the typical angina characteristics.

References:

1. LCD for Cardiovascular Nuclear Medicine (L26859) accessed at http://www.ngsmedicare.com/NGSMedicare/lcd/L26859_active_lcd.htm , June 8, 2009 2. Hendel RC, Kramer CM, Patel MR, et al, ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging, accessed at http://www.acc.org/qualityandscience/clinical/pdfs/CCT.CMR.pdf February 18, 2008.

Notes:

*Diabetes added as an indication to the basic LCD

** Definition of Angina from Hendel RC, Kramer CM, Patel MR, et al, ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging, accessed at http://www.acc.org/qualityandscience/clinical/pdfs/CCT.CMR.pdf February 18, 2008

*** Abnormal exercise stress test added as an indication to basic LCD

CareCore National Criteria for Imaging Version 2.2009

78466 Infarct Avid Myocardial Imaging 78468 Infarct Avid Myocardial Imaging with Ejection Fraction by First Pass Technique 78469 Infarct Avid Myocardial Imaging Tomographic SPECT

These are obsolete examinations that have been largely superseded by other imaging modalities and CPT codes.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78472 Gated Cardiac Radionuclide Angiography

A first pass or multi-gated acquisition (MUGA) scan uses a radioisotope circulating in the blood to assess ventricular function. Similar data is collected during myocardial perfusion examinations (represented by CPT codes 78478 and 78480) and can also be derived from echography and certain CT and MR examinations. I. Evaluation of left ventricular function A. New or worsening CHF B. Re-evaluation of Left Ventricular Ejection Fraction (LVEF) of <45% C. Evaluation of LVEF prior to, during and after potentially cardiotoxic chemotherapy 1. Adriamycin 2. Idarubicin 3. Mitoxantrone 4. Daunorubicin 5. Hercerptin 6. Mitoxantrone 7. Doxorubicin 8. Epirubicin 9. 5FU (5flourouriacil) 10. Paclitaxel 11. Cytoxin 12. Mitomycin C 13. Trastuzamab

II. Evaluation of an intracardiac shunt, ventricular or atrial septal defects

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78473 Gated Multiple Cardiac Radionuclide Angiography

A first pass or multi-gated acquisition (MUGA) uses a radioisotope circulating in the blood to assess ventricular function. Similar data is collected during myocardial perfusion examinations (represented by CPT codes 78478 and 78480) and can also be derived from echography and certain CT and MR examinations.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78481 Planar First Pass Cardiac Radionuclide Angiography

A first pass or multi-gated acquisition (MUGA) scan uses a radioisotope circulating in the blood to assess ventricular function. Similar data is collected during myocardial perfusion examinations (represented by CPT codes 78478 and 78480) and can also be derived from echography and certain CT and MR examinations. I. Evaluation of left ventricular function A. New or worsening CHF B. Re-evaluation of Left Ventricular Ejection Fractino (LVEF) of <45% C. Evaluation of LVEF prior to, during and after potentially cardiotoxic chemotherapy 1. Adriamycin 2. Idarubicin 3. Mitoxantrone 4. Daunorubicin 5. Hercerptin 6. Mitoxantrone 7. Doxorubicin 8. Epirubicin 9. 5FU (5flourouriacil) 10. Paclitaxel 11. Cytoxin 12. Mitomycin C 13. Trastuzamab

II. Evaluation of an intracardiac shunt A. Ventricular or atrial septal defect proven by echography or other imaging

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78483 Planar First Pass Multiple Cardiac Radionuclide Angiography

A first pass or multi-gated acquisition (MUGA) scan uses a radioisotope circulating in the blood to assess ventricular function. Similar data is collected during myocardial perfusion examinations (represented by CPT codes 78478 and 78480) and can also be derived from echography and certain CT and MR examinations. I. Evaluation of left ventricular function A. New or worsening CHF B. Re-evaluation of LVEF of less than 45% C. Evaluation of LVEF prior to, during and after potentially cardiotoxic chemotherapy 1. Adriamycin 2. Idarubicin 3. Mitoxantrone 4. Daunorubicin 5. Hercerptin 6. Mitoxantrone 7. Doxorubicin 8. Epirubicin 9. 5FU (5flourouriacil) 10. Paclitaxel 11. Cytoxin 12. Mitomycin C 13. Trastuzamab

II. Evaluation of an intracardiac shunt A. Ventricular or atrial septal defect proven by echography or other imaging

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78491 PET Myocardial Perfusion Imaging Rest or Stress 78492 PET Myocardial Perfusion Imaging Rest and Stress

ALL PET SCANS REQUIRE WRITTEN HISTORIES.

This is NOT a screening test for asymptomatic patients. Myocardial perfusion imaging (PET) may be certified for patients who meet the criteria below after stress imaging that is non-diagnostic or inconsistent with the clinical state (equivocal) and who are being considered for catheterization. A copy of the stress imaging report must be submitted prior to authorization of the PET scan.

May be used in place of SPECT imaging only for patients who are severely obese (BMI of 40 or more) or have silicone breast implants and who meet the following criteria:

I. Asymptomatic, prior to non-cardiac surgery A. With known coronary artery disease 1. For intermediate or high risk non-cardiac surgery documented within the last year by: a. Nuclear stress test b. Echo stress test c. CCTA d. Cardiac catheterization B. No prior history of coronary artery disease- 1. For intermediate risk surgery, a nuclear stress test is medically necessary if a. Framingham risk† percentage is >10% b. If a member has diabetes 2. For high risk surgery, a nuclear stress test is medically necessary

The ACC defines the following: • High risk surgery: 1. Emergent operations, especially in the elderly 2. Aortic and other major vascular surgeries 3. Peripheral vascular surgeries 4. Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss

• Intermediate risk surgery: 1. Carotid endarterectomy 2. Head and neck surgery 3. Intraperitoneal and intrathoracic surgery 4. Orthopedic surgery Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

5. Prostate surgery

• Low risk surgery (Note: asymptomatic members planning low risk surgery do not require MPI): 1. Endoscopic surgeries 2. Superficial procedures 3. Cataract surgery 4. Breast surgery

II. Discharged within the last eight weeks after hospitalization for a cardiac condition A. Discharged, without positive or symptom-limited stress test, for 1. Atrial fibrillation- if the member has not had an imaging stress test within two years prior to the hospital discharge, and has: a. Framingham risk† percentage of >10% or b. Diabetes B. Myocardial ischemia (including myocardial infarction, unstable angina, or chest pain syndrome ††) 1. And none of the following: a. Heart catheterization b. CCTA c. Symptom limited stress test prior to discharge 2. Percutaneous intervention was performed during the hospitalization and lesions of the coronary anatomy of >50% were present but not fixed, a myocardial PET scan can be certified if the member has a BMI of 40 or more or has silicone breast implants C. Congestive heart failure 1. New diagnosis and NONE of the following: a. Cardiac catheterization b. Coronary CT Angiogram (CCTA) c. Imaging (nuclear or echo) stress during or since hospitalization 2. Recurrent congestive heart failure and no known coronary artery disease and NONE of the following: a. Cardiac catheterization within the last three years b. Coronary CT Angiogram (CCTA) within the last three years c. Imaging (nuclear or echo) stress test during or since hospitalization 3. Recurrent congestive heart failure and 40% or greater stenosis in any coronary artery documented by catheterization or Coronary CT Angiogram (CCTA) and NONE of the following: a. Cardiac Catheterization within the last 3 years b. Coronary CT Angiogram (CCTA) within the last 3 years c. Imaging (nuclear or echo) stress test within the last year 4. Recurrent congestive heart failure and either no known coronary artery disease or maximum coronary artery stenosis of less than 40% in any vessel and NONE of the following: a. Cardiac catheterization within the last 3 years b. Coronary CT Angiogram (CCTA) within the last 3 years Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

c. No imaging (nuclear or echo) stress test within the last 2 years D. Syncope or near syncope 1. Imaging (nuclear or echo) stress test more than 1 year ago or never 2. Cardiac Catheterization test more than 1 year ago or never 3. Coronary CT Angiogram (CCTA) test more than 1 year ago or never

In the absence of known coronary artery disease, a routine exercise stress test is the first-line test provided; there are no contraindications to a routine exercise stress test as described in section IIA above.

† If the Framingham risk is <10% and there are no contraindications to a routine exercise stress test then the routine stress test should be performed prior to a myocardial PET scan. Contraindications to a routine exercise stress test include diabetes, inability to exercise, digoxin use, inability to raise heart rate due to electrical system disease or medication that cannot be stopped or an uninterpretable electrocardiogram. The ACC defines an uninterpretable electrocardiogram as a ventricular paced rhythm, left bundle branch block, Wolfe-Parkinson-White syndrome or >1mm ST depression at baseline. If the routine exercise stress test is positive, the member needs a nuclear stress test. If the member has a BMI of more than 40 or silicone breast implants, a myocardial PET scan can be certified instead of the standard nuclear myocardial perfusion stress test.

III. Known cardiac disease A. Asymptomatic or stable 1. No CHF, certify every two years 2. CHF yearly 3. Percutaneous Intervention (PCI) a. Two years after the procedure 4. Coronary artery bypass graft a. 5 years after surgery b. Every 2 years after the first post operative study 5. Known coronary artery stenosis of greater than 50% a. Cardiac catheterization or coronary artery CT angiogram more than 1 year ago B. New or changed chest pain or chest pain syndrome††

IV. The assessment of a symptomatic or asymptomatic member without documented coronary artery disease

A routine exercise stress test is the first-line test with the indications listed below unless the member meets one of the following criteria and then a myocardial PET scan can be certified if the member has a BMI of 40 or greater or has silicone breast implants A. Framingham risk† percentage >10% 1. Symptomatic a. Previous nuclear stress test normal b. Worsening or recurrent symptoms

CareCore National Criteria for Imaging Version 2.2009

2. Asymptomatic every 2 years B. Diabetes 1. Symptomatic (chest pain or shortness of breath) a. Nuclear stress test normal > 1 year ago b. New or worsening symptoms with nuclear stress test < 1 year ago 2. Asymptomatic every 2 years C. Uninterpretable electrocardiogram and another finding [1 and 2] 1. Defined as [One] a. Ventricular paced rhythm b. Left bundle branch block c. Wolfe-Parkinson-White syndrome d. >1mm ST depression at baseline 2. Other findings [One] a. Atrial fibrillation b. Chest pain c. Dyspnea on exertion d. Syncope D. Digoxin use and any other similar medication E. Abnormal routine exercise stress test 1. >1 mm or greater ST depression with horizontal or down-sloping ST segments 2. During routine stress test the member developed [ONE] a. Chest pain but had no electrocardiogram changes b. Ventricular tachycardia, multifocal premature ventricular contractions, triplets, c. Supraventricular tachycardia d. Heart block induced during the routine stress test e. Drop in systolic blood pressure of >10 mmHg. F. Inability to attain an adequate heart rate due to electrical system disease or medications that cannot be withdrawn, or G. Member unable to exercise due to medical illness H. Ventricular tachycardia

† An online Framingham risk calculator can be accessed at the follow link: http://www.intmed.mcw.edu/clincalc/heartrisk.html.

†† Chest pain syndrome includes chest pain, chest tightness, chest burning, dyspnea, shoulder pain, and jaw pain.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78491 PET Myocardial Perfusion Imaging Rest or Stress 78492 PET Myocardial Perfusion Imaging Rest and Stress

Medicare Connecticut1, New York1

This is NOT a screening test for asymptomatic patients.

May be used in place of SPECTimaging but not in addition to for Medicare members. May be used if SPECT imaging is equivocal or inconclusive. However, SPECT is not medically necessary if the PET Myocardial Perfusion Imaging is equivocal or inconclusive.

I. Chest pain or chest pain syndrome † A. Uninterpretable EKG 1. Complete left bundle branch block 2. Ventricular paced rhythm 3. Wolf Parkinson White syndrome 4. ST changes with >1 mm ST depression which is horizontal or downsloping B. Left ventricular hypertrophy C. Digoxin or similar medication D. Diabetes * E. Angina 1. Substernal chest pain or discomfort provoked by exertion or emotional stress and relieved by rest and/or nitroglycerin **

II. Known coronary artery disease A. Asymptomatic or stable 1. Prior positive MPI, or PET myocardial perfusion imaging or prior cardiac catheterization demonstrating coronary artery disease 2. No revascularization ( CABG or PCI including angioplasty and/or stent) procedure within the past 2 years B. Symptomatic 1. Chest pain or chest pain syndrome a. Chest pain b. Chest burning c. Jaw pain d. Chest tightness e. Dyspnea f. Shoulder pain

CareCore National Criteria for Imaging Version 2.2009

III. No known coronary artery disease A. No chest pain syndrome 1. New onset of congestive heart failure 2. New onset of decreased LV ejection fraction less than 50% 3. Diabetes and asymptomatic every 2 years B. Abnormal Exercise or treadmill stress test *** 1. >1mm ST depression which is horizontal or downsloping 2. PVCs induced during stress 3. Drop of >10mm Hg in systolic blood pressure during the stress test 4. Chest pain during the stress test

IV. Assessment prior to non-cardiac surgery A. High risk surgery†† 1. Emergency procedures 2. Aortic or other major vascular procedures 3. Peripheral vascular surgery 4. Anticipated prolonged surgical procedures with large fluid shits and/or blood loss such as but not limited to liver transplant, hepatic resection, radical prostatectomy 5. Asymptomatic a. No evidence of prior imaging stress test or catheterization in the past year B. Intermediate risk surgery including carotid endarterectomy, head and neck surgery, orthopedic surgery, abdominal surgery, chest surgery 1. Diabetes 2. Renal insufficiency with creatinine of 2mg/dl or more 3. History of prior stroke or CVA 4. History of compensated heart failure 5. Arrhythmia a. Atrial fibrillation b. Symptomatic bradycardia c. Third degree AV heart block d. Mobitz type II AV block 6. Severe valvular disease

V. Congenital anomalies of the coronary arteries

VI. Cardiomyopathy A. Cardiac catheterization is not planned B. Ejection fraction <50%

VII. Documented myocardial infarction in the past

†Chest pain syndrome includes chest pain, chest tightness, chest burning, dyspnea, shoulder pain, and jaw pain. †† High risk surgery includes:

CareCore National Criteria for Imaging Version 2.2009

Emergent operations especially in the elderly Aortic and other major vascular surgery Peripheral vascular surgery Anticipated prolonged surgical procedures associated with large fluid shits and/or blood loss

The following assessment is used to determine the pre-test probability of coronary artery disease based on a description of the character of the chest pain, member age and sex. This assessment will define the chest pain as typical angina, atypical angina, and nonanginal chest pain. To characterize the chest pain the following questions are to be asked and scored:

A score of 3 qualifies as typical angina; a score of 2 qualifies as atypical angina, and 0-1 qualifies as non-anginal. This description then is applied to the age/sex criteria as follows:

CareCore National Criteria for Imaging Version 2.2009

CHART 1 Determination of Pretest Probability for Coronary Disease Based on Chest Pain2 The following assessment is used to determine pre-test probability of coronary artery disease based on description of the character of chest pain, member age and sex. This assessment will define the chest pain as typical angina, atypical angina, and nonanginal chest pain. This description then is applied to the age/sex criteria as follows

Typical Angina (definite): 1) Substernal chest pain or discomfort is 2) provoked by exertion or emotional stress and 3) relieved by rest and/or nitroglycerin.

Atypical angina (probable): Chest pain or discomfort that lacks one of the characteristics of definite or typical angina.

Non-anginal chest pain: Chest pain or discomfort that meets one or none of the typical angina characteristics.

References:

1. LCD for Cardiovascular Nuclear Medicine (L26859) accessed at http://www.ngsmedicare.com/NGSMedicare/lcd/L26859_active_lcd.htm June 8, 2009 2. Hendel RC, Kramer CM, Patel MR, et al, ACC/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2005 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions and Society of Interventional Radiology, J Am Coll Cardiol, 2006; 48:1475- 1497.

Notes:

*Diabetes added as an indication to the basic LCD

*** Abnormal exercise stress test added as an indication to basic LCD

CareCore National Criteria for Imaging Version 2.2009

78494 SPECT Equilibrium Cardiac Radionuclide Angiography

II. Evaluation of an intracardiac shunt A. Ventricular or atrial septal defect proven by echography or other imaging

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78496 SPECT Equilibrium Multiple Cardiac Radionuclide Angiography

A first pass or multi-gated acquisition (MUGA) scan uses a radioisotope circulating in the blood to assess ventricular function. Similar data is collected during myocardial perfusion examinations (represented by CPT codes 78478 and 78480) and can also be derived from echography and certain CT and MR examinations. I. Evaluation of left ventricular function A. New or worsening CHF B. Re-evaluation of LVEF of less than 45% C. Evaluation of LVEF prior to, during and after potentially cardiotoxic chemotherapy 1. Adriamycin 2. Idarubicin 3. Mitoxantrone 4. Daunorubicin 5. Hercerptin 6. Mitoxantrone 7. Doxorubicin 8. Epirubicin 9. 5FU (5flourouriacil) 10. Paclitaxel 11. Cytoxin 12. Mitomycin C 13. Trastuzamab

II. Evaluation of an intracardiac shunt A. Ventricular or atrial septal defect proven by echography or other imaging

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78580 Pulmonary Perfusion Imaging Particulate

This series of studies represent the range of options for ventilation and perfusion lung scanning. Since there are codes that cover perfusion-only exams, ventilation-only exams and combined ventilation and perfusion exams, only one of these codes can be requested for a single date of service. Perfusion only and ventilation only lung scans are occasionally useful, but have been largely replaced by other modalities.

I. For follow-up of an equivocal recent ventilation-perfusion lung scan to evaluate for interval change 1-5

II. For suspected Pulmonary Embolism (PE), in general only ventilation- perfusion (also called VQ studies), CPT 78584, 78585, 78588 should be certified 1-5

References:

1. Bettman MA, Lyders EM, Yucel EK, et al, Expert Panel on Cardiac Imaging, American College of Radiology Appropriateness Criteria, Acute chest pain-suspected pulmonary embolism, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainSusp ectedpulmonaryembolismUpdateinProgressDoc4.aspx July 6, 2008. 2. Fesmikre FM, Kline JA, and Wolf SJ l, Members of the Clinical Policies Subcommittee on Suspected Pulmonary Embolism, Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected pulmonary embolism, Ann Emerg Med, 2003; 41:257-270. 3. Parker JA, Coleman RE, Hilson AJW, et al, Society of Nuclear Medicine Procedure guideline for lung scintigraphy, version 3.0, approved February 7, 2004, accessed at http://interactive.snm.org/docs/Lung%20Scintigraphy_v3.0.pdf July 6, 2008. 4. Stanford W, Yucel KE, Bettman MA, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria, Acute chest pain- no ecg or enzyme evidence of myocardial ischemia/infarction, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainNoEC GorEnzymeEvidenceofMyocardialIschemiaInfarctionDoc1.aspx July 6, 2008. 5. Campbell IA, Fennerty A, and Miller AC, British Thoracic Society guidelines for the management of suspected acute pulmonary embolism, Thorax, 2003; 58:470-484.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78584 Pulmonary Perfusion Imaging, Particulate, with Ventilation Single Breath

There are a series of CPT codes covering lung scanning. Any code that deals only with ventilation or perfusion are rarely used. Those codes that cover both ventilation and perfusion should be reviewed using the criteria below. In general, only ventilation-perfusion, also called VQ, (CPT 78584, 78585, 78588) studies should be requested.

I. Suspected Pulmonary Embolus (PE) [CT with contrast or CT pulmonary arteriography are also appropriate and are preferred] 1-5 A. For evaluation of suspected pulmonary embolism 1. Clinical findings a. Sudden onset of dyspnea b. Pleuritic chest pain c. Cough d. Hemoptysis e. Tachypnea f. Hypoxia g. Known DVT by sonography or by abdominal, pelvic or extremity CT or MRI h. New onset of atrial fibrillation

References: 1. Bettman MA, Lyders EM, Yucel EK, et al, Expert Panel on Cardiac Imaging, American College of Radiology Appropriateness Criteria, Acute chest pain-suspected pulmonary embolism, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainSusp ectedpulmonaryembolismUpdateinProgressDoc4.aspx July 6, 2008. 2. Fesmikre FM, Kline JA, and Wolf SJ l, Members of the Clinical Policies Subcommittee on Suspected Pulmonary Embolism, Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected pulmonary embolism, Ann Emerg Med, 2003; 41:257-270. 3. Parker JA, Coleman RE, Hilson AJW, et al, Society of Nuclear Medicine Procedure guideline for lung scintigraphy, version 3.0, approved February 7, 2004, accessed at http://interactive.snm.org/docs/Lung%20Scintigraphy_v3.0.pdf July 6, 2008. 4. Stanford W, Yucel KE, Bettman MA, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria, Acute chest pain- no ecg or enzyme evidence of myocardial ischemia/infarction, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainNoEC GorEnzymeEvidenceofMyocardialIschemiaInfarctionDoc1.aspx July 6, 2008. 5. Campbell IA, Fennerty A, and Miller AC, British Thoracic Society guidelines for the management of suspected acute pulmonary embolism, Thorax, 2003; 58:470-484.

CareCore National Criteria for Imaging Version 2.2009

78585 Pulmonary Perfusion Imaging, Particulate, with Ventilation, without or with Single Breath

References:

1. Bettman MA, Lyders EM, Yucel EK et al, Expert Panel on Cardiac Imaging, American College of Radiology Appropriateness Criteria, Acute chest pain-suspected pulmonary embolism, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainSusp ectedpulmonaryembolismUpdateinProgressDoc4.aspx July 6, 2008. 2. Fesmikre FM, Kline JA, and Wolf SJ l, Members of the Clinical Policies Subcommittee on Suspected Pulmonary Embolism, Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected pulmonary embolism, Ann Emerg Med, 2003; 41:257-270. 3. Parker JA, Coleman RE, Hilson AJW, et al, Society of Nuclear Medicine Procedure guideline for lung scintigraphy, version 3.0, approved February 7, 2004, accessed at http://interactive.snm.org/docs/Lung%20Scintigraphy_v3.0.pdf July 6, 2008. 4. Stanford W, Yucel KE, Bettman MA, et al, Expert Panel on Cardiovascular Imaging, American College of Radiology Appropriateness Criteria, Acute chest pain- no ecg or enzyme evidence of myocardial ischemia/infarction, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainNoEC GorEnzymeEvidenceofMyocardialIschemiaInfarctionDoc1.aspx July 6, 2008. 5. Campbell IA, Fennerty A, and Miller AC, British Thoracic Society guidelines for the management of suspected acute pulmonary embolism, Thorax, 2003; 58:470-484.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78586 Pulmonary Ventilation Imaging, Aerosol, Single Projection

I. For suspected Pulmonary Embolism (PE), in general only ventilation- perfusion (also called VQ studies), CPT 78584, 78585, 78588 should be certified. 1-5

References:

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78587 Pulmonary Ventilation Imaging, Aerosol, Multiple Projections

I. For suspected Pulmonary Embolism (PE), in general only ventilation- perfusion (also called VQ studies), CPT 78584, 78585, 78588 should be certified. 1-5

References:

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78588 Pulmonary Perfusion Imaging, Particulate, with Ventilation, Aerosol, Single or Multiple Projections

References:

CareCore National Criteria for Imaging Version 2.2009

78591 Pulmonary Ventilation Imaging, Gaseous, Single Breath, Single Projection

I. For suspected Pulmonary Embolism (PE), in general only ventilation- perfusion (also called VQ studies), CPT 78584, 78585, 78588 should be certified. 1-5

References:

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78593 Pulmonary Ventilation Imaging, Gaseous, with or without Single Breath, Single Projection

I. For suspected Pulmonary Embolism (PE), in general only ventilation- perfusion (also called VQ studies), CPT 78584, 78585, 78588 should be certified. 1-5

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78594 Pulmonary Ventilation Imaging, Gaseous, with or without Single Breath, Multiple Projections

I. For suspected Pulmonary Embolism (PE), in general only ventilation- perfusion (also called VQ studies), CPT 78584, 78585, 78588 should be certified. 1-5

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78596 Pulmonary Quantitative Differential Function Study

Also known as pulmonary split crystal function study.

I. Pre-operative assessment for planned segmental, lobar or lung removal 1, 2

References:

1. Morton KA, Clark PB, et al, Diagnostic Nuclear Medicine, Amursys, 2007; (4)2-15. 2. Thrall JH, Zeissman HA, Nuclear Medicine, The Requisites, Mosby, 2001, 145-165

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78600 Brain Scintigraphy Static Limited 78601 Brain Scintigraphy Limited with Vascular Flow 78605 Brain Scintigraphy Complete Static 78606 Brain Scintigraphy Complete with Vascular Flow

These are obsolete studies and are rarely ordered.

I. 78600-78606 1 a. Establish brain death

Reference:

1. New York State Department of Health, Guidelines for Determining Brain Death, December 2005, pg. 7-8.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78607 Brain Imaging SPECT

I. Dementia, memory loss 1

II. Seizure disorder 2

III. Immunocompromised patients with mass lesion detected on CT or MR for differentiation of lymphoma and infection 3

References: 1. Guedj E, Brain SPECT perfusion of frontotemporal dementia associated with motor neuron disease, Neurology, 2007; 69 (5):488-490. 2. Thrall JH, Zeissman HA, Nuclear Medicine, The Requisites, Mosby, 2001, 313-314. 3. Thrall JH, Zeissman HA, Nuclear Medicine, The Requisites, Mosby, 2001, 314-316.

CareCore National Criteria for Imaging Version 2.2009

78608 PET Brain Metabolic

I. Primary brain tumor1 A. Pre-operative study tumor resection with margins not defined on MRI or CT B. Post treatment determination of viable tumor versus radiation necrosis

II. Movement disorder 2, 3 A. Suspected Huntington's chorea [(1 or 2 or 3) + (4 and 5)] 1. Irregular lurching gait 2. Speech disturbance 3. Positive family history 4. MRI is non diagnostic 5. Genetic testing unavailable B. Progressive ataxia of undetermined etiology

III. Seizure 4 A. Reserved for patients in whom seizures are not responsive to adequate dosage of medication, in whom surgery is planned, and in whom MRI has failed to define the “seizure focus.”

References: 1. Matchar DB, Kulasingam SL, Havrilesky L, et al, Positron Emission testing for six cancers (brain, cervical, small cell lung, ovarian, pancreatic and testicular),, prepared for the Agency for Health Care Research and Quality, accessed at http://www.cms.hhs.gov/determinationprocess/downloads/id21TA.pdf November 25, 2008. 2. Dormont D, Seidenwurm DJ, Davis PC, et al. Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria Dementia and movement disorders, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/NeurodegenerativeDisord ersUpdateinProgressDoc9.aspx November 25, 2008. 3. Bartenstein, Central motor processing in Huntington’s disease. A PET study, Brain. Journal of Neurology, 1997; 120(9):1553-1567. 4. Karis JP, Seidenwurm DJ, Davis PC, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria, Epilepsy, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/EpilepsyDoc3.aspx November 25, 2008.

CareCore National Criteria for Imaging Version 2.2009

78608 PET Brain Metabolic –

Medicare

I. Dementia 1, 2 NOTE: Currently only Medicare has adopted the following criteria. A. Clinical manifestations 1. Progressive cognitive decline (suspected Alzheimer's) with Mini Mental State score of 24 or less on two exams at least 6 months apart 2. Other symptoms a. Aphasia language disturbance b. Apraxia impaired ability to carry out motor activities despite intact motor function c. Agnosia failure to identify objects despite intact sensory function d. Memory loss e. Confusion f. Disorientation g. Behavioral disturbance h. Deterioration in intellectual function B. No observed medical conditions to explain dementia 1. Lab blood and urine results non-diagnostic for etiology of mental status change [Any two must be normal] a. Thyroid-function tests b. Vitamin B12 level c. Blood urea nitrogen (BUN) d. Serum electrolyte e. Blood glucose levels, and f. Liver-function C. Prior non-contributory SPECT, non-contrast MRI or CT D. Planned medical intervention if AD is diagnosed

References:

1. Centers for Medicare and Medicaid Services, NCD for PET (FDG) for dementia and neurodegenerative diseases (220.6.13) accessed at http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6.13&ncd_version=2&basket=ncd%3A220%2E6%2E13%3A2%3APET+%28FDG%29+ for+Dementia+and+Neurodegenerative+Diseases 2. Norman L. Foster, et al, FDG-PET improves accuracy in distinguishing frontotemporal dementia and Alzheimer's disease, Brain 2007; 130(10):2616-2635.

CareCore National Criteria for Imaging Version 2.2009

78609 PET Brain Perfusion

This procedure is considered to be investigational and/or experimental

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78609 PET Brain Perfusion

Medicare

I. Tumor perfusion 1,2 A. Must be a participant in an approved clinical trial B. Must have a brain tumor documented by CT or MRI not responding to standard therapy

References: 1. Centers for Medicare and Medicaid services NCD for pet (fdg) Brain, cervical, ovarian, pancreatic , small cell lung and testicular cancers (220.6.14) accessed at http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6.14&ncd_version=1&basket=ncd%3A220%2E6%2E14%3A1%3APET+%28FDG%29+ for+Brain%7C%7C+Cervical%7C%7C+Ovarian%7C%7C+Pancreatic%7C%7C+Small+Cell+Lung%7C%7C+and+Testicular+Cancers November 25, 2008. 2. Centers for Medicare and Medicaid Services, NCD for PET scans (220.6), accessed at http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6&ncd_version=3&basket=ncd%3A220%2E6%3A3%3APET+Scans November 25, 2008.

Reviewed: 1/21/2009 Posted: 4/1/2009

CareCore National Criteria for Imaging Version 2.2009

78610 Brain Imaging Vascular Flow

I. Cerebral Ischemia 1

II. Establish brain death

Reference:

1. Thrall JH, Zeissman HA, Nuclear Medicine, The Requisites, Mosby, 2001, 312-313.

Reviewed: 1/21/2009 Posted: 4/1/2009

CareCore National Criteria for Imaging Version 2.2009

78630 Cisternogram

I. Evaluation of normal pressure hydrocephalus vs. obstructive hydrocephalus 1 A. Suspected obstructive hydrocephalus 1. Clinical findings a. Headache b. Papilledema c. Diplopia d. Mental status changes e. Gait disturbance or ataxia f. Seizure 2. History a. AVM b. Aneurysm c. Intraventricular or SAH (Subarachnoid Hemorrhage) d. Meningitis e. Hydrocephalus on prior imaging B. Normal pressure hydrocephalus 1. Apraxic gait 2. Dementia 3. Urinary incontinence 4. Hyrdrocephalus on prior imaging

II. Known hydrocephalus with worsening symptoms

References:

1. Dormont D, Seidenwurm DJ, Davis PC, et al, Expert Panel on Neurologic Imaging, American College of Radiology Appropriateness Criteria, Dementia and movement disorders, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/Neurodege nerativeDisordersUpdateinProgressDoc9.aspx , August 11, 2009.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78635 Cerebrospinal Ventriculography

I. Cerebrospinal ventriculography A. Evaluation of internal shunt B. Evaluation of porencephalic cyst C. Evaluation of posterior fossa cyst

CareCore National Criteria for Imaging Version 2.2009

78645 Shunt Evaluation

I. Shunt evaluation A. Patient with ventricular-peritoneal, ventricular-pleural or ventricular venous shunt that is suspected of malfunctioning

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78647 CSF Flow SPECT

I. Shunt evaluation A. Patient with ventricular-peritoneal or ventricular-pleural or ventricular venous shunt that is suspected of malfunctioning

CareCore National Criteria for Imaging Version 2.2009

78650 CSF Leakage Detection

I. CSF rhinorrhea

II. CSF otorrhea

III. Post lumbar puncture headache

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78660 Radiopharmaceutical Dacrocystography

I. Excessive tearing and clinical suspicion of obstruction of nasolacrimal duct

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78700 Kidney Imaging (Nuclear) Static

I. Renal transplant follow-up per protocol

II. Kidney salvage versus nephrectomy

III. Recurrent flank pain with normal IVP A. CT and US non-diagnostic

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78701 Kidney Imaging (Nuclear) with Vascular Flow

I. Renal transplant follow-up per protocol

II. Kidney salvage versus nephrectomy

III. Recurrent flank pain with normal IVP A. CT and US non-diagnostic

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78707 Kidney Flow and Function, Single Study without Pharmacologic Intervention

I. Renovascular hypertension, suspected renal artery stenosis [A + (B or C or D or E or F or G or H or I)] A. Severe hypertension (diastolic blood pressure greater than 110 mm Hg) with either: 1. Progressive renal insufficiency 2. Refractoriness to aggressive medical therapy B. Grade III or grade IV retinopathy C. Hypertension in a patient with 1. Diffuse atherosclerosis 2. Incidentally detected asymmetry of kidney size D. Hypertension with an acute elevation in plasma creatinine concentration unexplained or after therapy with an ACE inhibitor E. Acute worsening of previously stable hypertension F. Abdominal bruit G. Recurring acute pulmonary edema H. Hypokalemia with normal or elevated plasma renin levels in the absence of diuretic therapy I. An acute deterioration in renal function following therapy with an ACE inhibitor or an ARB should suggest the possibility of bilateral renal artery stenosis

II. Kidney salvage versus nephrectomy

III. Recurrent flank pain with normal IVP A. CT and US non-diagnostic

IV. Suspected obstructive uropathy [Diuretic enhanced studies included here] A. Prior imaging (IVP or sonography) suggesting obstruction

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78708 Kidney Imaging with Vascular Flow and Function with Pharmacological Intervention Single

I. Renovascular hypertension, suspected renal artery stenosis A. Severe hypertension (diastolic blood pressure greater than 110 mm Hg) with either 1. Progressive renal insufficiency 2. Refractoriness to aggressive medical therapy B. Grade III or grade IV retinopathy C. Hypertension in a patient with 1. Diffuse atherosclerosis 2. Incidentally detected asymmetry of kidney size (by imaging) D. Hypertension with an acute elevation in plasma creatinine concentration unexplained or after therapy with an ACE inhibitor E. Acute worsening of previously stable hypertension F. Abdominal bruit G. Recurring acute pulmonary edema H. Hypokalemia (< 3.5 mmol/L) with normal or elevated plasma renin (>1 ng/ml/Hr) levels in the absence of diuretic therapy

II. Suspected obstructive uropathy [Diuretic enhanced studies included here] A. Prior imaging (IVP or sonography) suggesting obstruction

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78709 Kidney Imaging with Vascular Flow and Function with and without Pharmacological Intervention, Multiple

I. Renovascular hypertension, suspected renal artery stenosis A. Severe hypertension (diastolic blood pressure greater than 110 mm Hg) with either: 1. Progressive renal insufficiency 2. Refractoriness to aggressive medical therapy B. Grade III or grade IV retinopathy C. Hypertension in a patient with 1. Diffuse atherosclerosis 2. Incidentally detected asymmetry of kidney size (by imaging) D. Hypertension with an acute elevation in plasma creatinine concentration unexplained after therapy with an ACE inhibitor E. Acute worsening of previously stable hypertension F. Abdominal bruit G. Recurring acute pulmonary edema H. Hypokalemia (< 3.5) with normal or elevated plasma renin levels in the absence of diuretic therapy

II. Suspected obstructive uropathy [Diuretic enhanced studies included here] A. Prior imaging (IVP or sonography) suggesting obstruction

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78710 Kidney Imaging with SPECT

I. Renal transplant follow-up per protocol

II. Kidney salvage versus nephrectomy

III. Recurrent flank pain with normal IVP

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78725 Nuclear Non-imaging Renal Function

This is a test performed using a radioisotope and a counter. It does not involve imaging, but may be ordered in error by someone actually seeking a renal scan with function.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78730 Urinary Bladder Residual Study

I. Suspicion of urinary retention A. Must have non diagnostic ultrasound of the bladder for post void residual urine B. Urgency C. Frequency D. Hesitancy E. Recurrent urinary tract infections

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78740 Ureteral Reflux Study (Radiopharmaceutical Voiding Cystogram)

This study is almost exclusively performed in children.

I. Suspected vesicoureteral reflux A. Clinical evidence of recurrent urinary tract infections B. Known reflux C. Prenatal diagnosis of hydronephrosis

II. Antenatal renal pelvis measuring 5 mm (hydronephrosis) or more

III. Clinical evidence of recurrent urinary tract infections

IV. Known reflux

V. Sibling with proven ureteral reflux

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78761 Testicular Scan – Vascular Flow and Delayed Images

I. Testicular scan - vascular flow A. Suspected testicular torsion; to differentiate inflammation from ischemia in a painful testis B. Non-diagnostic evaluation by color Doppler ultrasound, or US not available

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78800 Radiopharmaceutical Localization of Tumor Limited Area 78801 Radiopharmaceutical Localization of Tumor Multiple Areas 78802 Radiopharmaceutical Localization of Tumor Whole Body Single Day Study 78803 Radiopharmaceutical Localization of Tumor SPECT 78804 Radiopharmaceutical Localization of Tumor Whole Body Two or More Days

I. Octreoscan 1 A. Neuroendocrine tumors of stomach, small bowel or pancreas B. Medullary thyroid carcinoma (patient must have an established diagnosis) C. Carcinoid tumors 1. Elevated 5HIAA D. Other neuroendocrine tumors-Elevated blood levels 1. Gastrin (Gastrinoma) 2. Somatostatin (Vipoma) 3. Vasoactive Intestinal Polypeptide (VIP) 4. Glucagon > 200pg/ml 5. Pancreatic polypeptide 6. Multiple Endocrine Neoplasia type-1 (MEN-1) 7. Multiple Endocrine Neoplasia type-2 (MEN-2)

II. Prostascint scan 2, 3 Before prostascint scan may be certified the patient must have the following non-diagnostic or negative imaging studies (chest x-ray, bone scan, and CT or MRI scan abdomen and pelvis) A. New diagnosis of biopsy proven prostate carcinoma 1. Gleason score of 7 or more 2. PSA >10 B. Patients with a history of prostate carcinoma treated with a radical prostatectomy 1. The patient must have a rising PSA. A rising PSA means any increase in the PSA level on two or more consecutive tests after the first or reference test. The levels can be <10. C. Patients with a history of prostate carcinoma treated with radiation or seed implantation, etc., but without prostatectomy, must have a rising PSA. Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

III. Gallium scan A. Lymphoma and Hodgkin’s disease 1. No PET scan within 2 months B. Sarcoid C. Suspected inflammatory reaction

IV. Zevalin chemotherapy 4

References:

1. Clark OH, Ajani J, Benson AB, et al, NCCN Neuroendocrine Tumors Panel Members, NCCN Practice Guidelines in Oncologn-v1.2008, Neuroendocrine Tumors, accessed at http://www.nccn.org/professionals/physician_gls/PDF/neuroendocrine.pdf June 30, 2008. 2. Mohler J, Bahnson RR, Boston B, et al, NCCN Prostate Cancer Panel Members, NCCN Practice Guidelines in Oncologn-v1.2008, Prostate Cancer, accessed at http://www.nccn.org/professionals/physician_gls/PDF/neuroendocrine.pdf June 30, 2008. 3. Kahn, et al, Prostascint in the evaluation of patients with residual or recurrent prostate cancer after radical prostatectomy, Journal of Urology, 1998; 159(6)2041-2046. 4. Conti PS, White C, Pieslor P, et al, the role of imaging with 111In-Ibritumopmab Tiuxetan in the Ibritumomab Tiuxetan (Zevalin) regimen: results from a Zevalin imaging registry, J Nucl Med, 2005; 46:1812-1818.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78805 Radiopharmaceutical Imaging of Inflammatory Process Limited Area 78806 Radiopharmaceutical Imaging of Inflammatory Process Whole Body 78807 Radiopharmaceutical Imaging of Inflammatory Process SPECT

I. Suspected osteomyelitis A. Pain B. X-ray non-diagnostic C. Clinical findings 1. ESR >20 mm/hr 2. Fever >100.4 3. Leukocytosis, WBC >12,000/cu.mm 4. C - reactive protein >10mg/L 5. Blood culture positive D. History of infection elsewhere E. History of diabetes, dialysis or peripheral vascular disease F. History of penetrating injury or surgery G. Sinus tract, poor wound or fracture healing H. Pre-operative evaluation of osteomyelitis [MRI preferred]

II. Cellulitis A. Local pain B. Erythema C. Swelling D. Heat

III. Peritonitis

IV. Inflammatory granulomatous process A. Tuberculosis B. Sarcoidosis

V. Pulmonary infection and inflammatory disease

VI. Pneumonia A. Lung abscess

CareCore National Criteria for Imaging Version 2.2009

B. Tuberculosis C. Sarcoidosis D. Pneumocystis carinii E. Adult Respiratory Distress Syndrome (ARDS) F. Cytomegalovirus (CMV) G. Lymphadenitis H. Actinomyces I. Nocardia J. Aspergillus K. Cryptococcosis

VII. Drug induced pulmonary reactions or toxicity A. Cytoxan B. Busulfan C. Bleomycin D. Amiodarone E. Nitrofurantoin

VIII. Urinary tract infections A. Pyelonephritis B. Diffuse interstitial nephritis

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78811 PET Limited Area 78812 PET Skull Base to Mid-thigh 78813 PET Whole Body 78814 PET/CT Limited Area 78815 PET/CT Skull Base to Mid-thigh 78816 PET/CT Whole Body

General Statements 1 A. PET may be approved in a patient with known diagnosis of malignancy to determine optimal anatomic site for biopsy or other invasive diagnostic procedure. B. Staging and restaging for the tumors and indications listed below when indicated 1. May be used if standard diagnostic imaging work up (US, CT, MRI) is inconclusive 2. May replace conventional imaging when conventional imaging will be inadequate for accurate staging and clinical management will depend upon the stage of disease. 3. Routine monitoring of tumor response during treatment (when no change in therapy is planned) is not covered except for breast cancer. Restaging should be performed only after a course of therapy is completed. 4. Restaging after completion of therapy to detect residual disease, recurrence, and extent of recurrence when indicated below C. Requests for suspected recurrence should include changes in the clinical status of the patient leading to the suspicion. 1. New symptoms 2. Elevated tumor markers or other laboratory changes D. If you receive a request for PET/CT and CT for the same date of service and the requesting provider provides you with the name and number of a treatment protocol and the requested studies meet criteria you may approve all the requested studies.

I. Breast carcinoma2-8 A. Must have tissue diagnosis of breast cancer B. Initial staging 1. Not to be used if the only type of breast cancer is DCIS 2. C. Evaluating response to treatment D. Suspected recurrence 1. New palpable lesion in axilla or adjacent area 2. Rising tumor markers 3. Changes on other imaging E. PET is not to be used to:

CareCore National Criteria for Imaging Version 2.2009

1. Establish the diagnosis of breast cancer or to detect the primary lesion. 2. Clarify a finding on mammography, physical examination, MRI or ultrasound. 3. Evaluate axillary nodes

II. Thyroid carcinoma 9-12 A. Must have tissue diagnosis of thyroid cancer (follicular, papillary, Hürthle cell and anaplastic thyroid cancer) and have been treated by thyroidectomy and/or radioiodine ablation. [1 or 2] 1. Indicated for staging and restaging in patients with [a and (b or c)] a. Negative I131 and/ or thallium 201 scans (whole body) b. Thyroglobulin level detectable on hormone replacement therapy c. Thyroglobulin >2 micro grams/liter after thyrogen stimulation 2. Medullary thyroid cancer a. Elevated or rising calcitonin

III. Head and neck cancers 5,13-16 A. Evaluation of patient with metastatic cervical lymph node(s) to establish primary site B. Initial staging of patient with pathologically documented primary head and neck cancer C. Restaging after completion of treatment 1. Radiation therapy - no sooner than 2 months after completion of treatment (If done too soon, may give false positive result.) 2. Surgery - no sooner than 6 weeks after surgery. 3. Evaluation for possible recurrence based on physical examination or conventional imaging D. Monitoring for recurrence 1. Stable clinical situation a. 4-6 months after therapy b. 1 year after therapy c. Annually thereafter if requested 2. Altered clinical situation

IV. Solitary pulmonary nodule by CXR: 5,17,18 Performed for changes or equivocal findings on CXR. Multiple nodules are not covered by these criteria unless one is significantly larger than the others or is new since a prior chest x-ray. Such a lesion should be treated as a solitary nodule.

A. Size greater than 8mm but less than 4cm (40mm) AND CT nondiagnostic for malignancy

V. Lung carcinoma 5, 19-28 A. Initial staging of non small cell lung cancer (after tissue diagnosis is established) B. Restaging after chemotherapy or radiation therapy is completed 1. No sooner than 12 weeks after completion of radiation therapy unless there is a change in clinical or imaging findings suggestive of recurrence or progression. C. PET is not to be used for surveillance imaging of non small cell lung cancer or small cell lung cancer or neuroendocrine tumors of the lung unless there is documented evidence of rising tumor markers or new symptoms

CareCore National Criteria for Imaging Version 2.2009

D. Initial staging of small cell lung cancer E. Initial staging of pathologically documented neuroendocrine tumors of the lung F. Monitoring response to therapy when a change in therapy is considered

VI. Colorectal carcinoma29-38 A. Initial staging (after tissue diagnosis is established) B. Evaluation of radiofrequency ablation (or similar procedure) of metastases 1. After procedure to evaluate effect and confirm adequate margins 2. May be repeated after each procedure C. Restaging after completion of therapy D. Rising CEA on 2 consecutive tests or any significant increase > 2.5 E. Rising liver function tests F. New findings on chest x-ray G. Not to be performed in asymptomatic individual with no evidence of disease on the basis of signs, symptoms and laboratory data H. New findings on standard imaging

VII. Lymphoma/Hodgkin’s Disease 39-50 A. Initial staging (after tissue diagnosis is established). B. Assessment during chemotherapy (not more frequently than after 2 cycles) C. Restaging (establish new baseline) after therapy is completed. D. Surveillance PET is not permitted for Hodgkin’s lymphoma in asymptomatic individual E. PET may be used for suspicion of progression for Follicular lymphoma F. Large B-Cell Lymphoma 1. Repeat PET at completion of chemotherapy and prior to radiation therapy if planned 2. Repeat PET at completion of radiation therapy but no sooner than 8 weeks after completion of radiation G. New symptoms or findings: 1. Night sweats 2. Weight loss 3. ESR >30 mm/hr 4. Fever >100.4 (unknown etiology) >one week 5. Suspected metastasis by CXR, MRI, CT

VIII. Esophageal carcinoma51-57 A. Initial staging of known esophageal cancer B. Reevaluation of patients after completion of chemotherapy or radiation therapy C. Reevaluation for suspected recurrence 1. Changed findings on endoscopy or imaging 2. Inability to perform endoscopy 3. Lymphadenopathy

IX. Cervical carcinoma 58-65

CareCore National Criteria for Imaging Version 2.2009

A. Initial staging of known cervical cancer if there is no evidence of extra-pelvic metastases on conventional imaging B. Evaluate for recurrence

X. Ovarian carcinoma 28,66-71 A. Not for initial staging and does not replace second look surgery after completion of initial treatment. B. Evaluation of recurrence 1. Elevated tumor markers CA-125 2. Change in physical examination or clinical condition C. Not for routine surveillance imaging in an asymptomatic individual with no clinical or laboratory evidence of disease

XI. Pancreatic carcinoma 28, 72-76 A. Initial staging of an established diagnosis of pancreatic cancer B. Evaluation for possible recurrence 1. Elevated tumor markers CA 19-9 2. Change on conventional imaging suggestive of recurrence or progression

XII. Gastric carcinoma 77,78 A. Must have established tissue diagnosis of gastric cancer B. Initial staging prior to surgery C. Restaging after completion of treatment

XIII. Testicular carcinoma 28, 79, 80(seminoma or non-seminomatous germ cell tumor) A. Initial staging of pathologically proven testicular cancer B. A single post therapy PET exam may be approved 6 or more weeks after therapy is completed 1. If first post therapy PET scan is negative and the markers remain negative, then no further PET scans are indicated unless the markers turn positive C. Subsequent follow up PET studies may be approved if there is an abnormal lab value: 1. Elevated tumor markers a. Beta HCG- b. Alpha Fetoprotein 2. Residual mass on CT D. If the second post therapy PET scan is negative and the tumor markers remain elevated or rise, another post therapy follow up PET in 1-3 months is indicated. 1. If the third PET scan is negative, continued surveillance without PET is appropriate.

XIV. GIST (Gastrointestinal Stromal Tumor) 81-85 A. Must have established tissue diagnosis B. Initial staging C. Response to chemotherapy (initial evaluation may be as soon as 2-4 weeks after initiation of therapy

CareCore National Criteria for Imaging Version 2.2009

D. Unresectable or metatstatic disease 1. Baseline before chemotherapy 2. 3 months after start of chemotherapyon for recurrence

XV. Soft tissue sarcoma85-89 A. Must have an established tissue diagnosis of intermediate or high grade sarcoma B. Initial staging C. Restaging after completion of therapy

XVI. Endometrial carcinoma 90 A. Must have an established tissue diagnosis B. Patient must be status post surgery C. Must have elevated tumor markers 1. CA 125 or CEA or CA 19-9

XVII. Multiple myeloma 91-94 A. Must have an established diagnosis of myeloma B. This may be used for Initial staging C. Restaging after completion of therapy D. Surveillance after completion of therapy every 6-12 months

XVIII. Melanoma 95-98 A. Must have an established diagnosis of stage greater than I B. Initial staging C. Restaging after completion of therapy D. Suspicion of recurrence in stage IIB or higher

XIX. Thymoma 99 A. Established tissue diagnosis of thymoma B. Initial staging C. Restaging after completion of therapy (one time only) D. Not allowed for surveillance

XX. Ewing’s Sarcoma and Osteogenic Sarcoma 100 A. Must have an established diagnosis B. Initial staging C. Restaging after completion of therapy

XXI. Initial staging of an occult cancer 68 A. Must have either 1. An established diagnosis of malignancy of unknown primary site or 2. Indeterminate histology on biopsy B. Primary site cannot be determined by 1. Endoscopy

CareCore National Criteria for Imaging Version 2.2009

2. Prior CT 3. Prior MRI C. May not be used for restaging carcinoma of unknown primary

References:

1. Juweid ME and Cheson BD, Positron-emission tomography and assessment of cancer therapy, N Engl J Med, 2006; 354:496-507. 2. Eubank WB, Detection of locoregional and distant recurrences in breast cancer patients by using FDG PET, RadioGraphics, 2002; 22(1):5- 17. 3. Rosen EL, Eubank WB, Mankoff DA, FEGPT, PET/CT, and breast cancer imaging, RadioGraphics, 2007; 27:S15-S229. 4. Eubanks WB, Mankoff DA, Vesselle HJ, et al, Detection of locoregional and distant recurrences in breast cancer patients by using FDG PET, RadioGraphics, 2002; 22:5-17. 5. Centers for Medicare and Medicaid Services, NCD for PET scans (220.6) accessed at , http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6&ncd_version=2 December 10, 2007. 6. Isasi CR, Moadel RM, and Blaufox MD, A meta-analysis of FEG-PET for the evaluation of breast cancer recurrence and metastases, Breast Cancer Research and Treatment, 2005; 90:105-112. 7. Radan L, Ben-Haim S, Bar-Shalom R, et al, The role of FDG-PET/CT in suspected recurrence of breast cancer, Cancer, 2006; 107(11):2545-2551. 8.Eubank WB, Mankoff D, Bhattacharya M, et al, Impact of FEGPET on defining the extent of disease and on the treatment of patients with recurrent or metastatic breast cancer, AJR, 2004; 183:479-486. 9. Centers for Medicare and Medicaid Services, NCD for PET (FDG) for thyroid cancer (220.6.11) accessed at http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6.11&ncd_version=1&basket=ncd%3A220%2E6%2E11%3A1%3APET+%28FDG%29+ for+Thyroid+Cancer December 10, 2007. 10. Cooper DS, Doherty GM, Haugen BR, et al, Management Guidelines for patients with thyroid nodules and differentiated thyroid cancer, Thyroid, 2006; 16(2):109-142. 11. Sherman SI, Angelos P, Ball DW, et al, NCCN Thyroid Carcinoma Panel Members, NCCN practice guidelines in Oncology v2.2007, Thyroid carcinoma, accessed at http://www.nccn.org/professionals/physician_gls/PDF/thyroid.pdf December 10, 2007. 12. Perros P, Clarke SEM, Franklyn J, Thyroid cancer guidelines update group, Guidelines for the management of thyroid cancer, second edition, British Thyroid Association Royal College of Physicians, 2007, accessed at http://www.british-thyroid- association.org/Thyroid_cancer_guidelines_2007.pdf December 10, 2007. 13. Centers for Medicare and Medicaid Services, NCD for PET (FDG) for head and neck cancers (220.6.7) accessed at http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6.7&ncd_version=1&basket=ncd%3A220%2E6%2E7%3A1%3APET+%28FDG%29+for +Head+and+Neck+Cancers December 10, 2007. 14. Scottish Intercollegiate Guidelines Network, Diagnosis and Management of Head and Neck Cancer Quick Reference Guide, 2006 accessed at http://www.sign.ac.uk/pdf/qrg90.pdf December 10, 2007. 15. Forastiere AA, Ang KK, Brizel D, et al, NCCN Head and Neck Cancers Panel Members, NCCN practice guidelines in Oncology v2.2007, Head and Neck Cancers, accessed at http://www.nccn.org/professionals/physician_gls/PDF/head-and-neck.pdf December 10, 2007. 16. Fukui MB, Blodgett TM, Snyderman CH, et al, Combined PET-CT in the head and neck, Part 2. Diagnostic uses and pitfalls of oncologic imaging, RadioGraphics, 2006; 25:913-930. 17. Kahn A, Davis SD, Goodman PC, et al, Expert Panel on Thoracic Imaging, American College of Radiology Appropriateness Criteria: solitary pulmonary nodule, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonThoracicImaging/solitarypulmonarynoduleDoc 10.aspx December 10, 2007. 18. Tan BB, Flaherty KR, Kazerooni EA,et al, The solitary pulmonary nodule, Chest, 2003; 123(1Suppl):89S-96S. 19. Pfister DG, Johnson DH, Azzoli CG, et al, American society of clinical oncology treatment of unresectable non-small-cell lung cancer guideline: Update 2003, Journal of Clinical Oncology, 2004; 22(2):330-353. 20.Thomas WW, Komaki RU, Gewanter RM, et al Expert Panel on Radiation Oncology-Lung, American College of Radiology Appropriateness Criteria Follow- up of non-small-cell lung cancer, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonRadiationOncologylungWorkGroup/FollowUp ofNonSmallCelllungcancerDoc1.aspx December 11, 2007. 21.Rozenshtein A, Davis SD, Komaki RS, et al, Expert Panels on Thoracic Imaging and Radiation Oncology-Lung Work Group, American College of Radiology Appropriateness Criteria, Staging of bronchogenic carcinoma, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonThoracicImaging/StagingofBronchogenicCarci nomaDoc11.aspx December 11, 2007. 22. Centers for Medicare and Medicaid Services, NCD for PET (FDG) for Lung Cancer 220.6.2) accessed at , http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6.2&ncd_version=1&basket=ncd%3A220%2E6%2E2%3A1%3APET+%28FDG%29+for +Lung+Cancer December 11, 2007.

CareCore National Criteria for Imaging Version 2.2009

23. Rivera MP and Mehta AC, Initial diagnosis of lung cancer: ACCP evidence-based clinical practice guidelines, Chest, 2007; 132:131-148. 24. Silvestri GA, Gould MK, Margolis ML, et al, Noninvasive staging of non-small cell lung cancer: ACCP evidenced-based clinical practice guidelines (2nd edition), Chest, 2007; 132:178-201. 25 Rubins J, Unger M and Colice GL, follow-up and surveillance of the lung cancer patient following curative intent therapy, ACC, Evidence- based clinical practice guideline (2nd edition), Chest, 2007; 132:355-367. 26. Ettinger DS, Akerley W, Bepler G, et al, NCCN Non-small Cell Lung Cancer Panel Members, NCCN Practice Guidelines in Oncology v1.2008, accessed at http://www.nccn.org/professionals/physician_gls/PDF/nscl.pdf December 11, 2007. 27. Kalemkerian GP, Akerley W, Downey RJ, et al, NCCN Small Cell Lung Cancer Panel Members, NCCN Practice Guidelines in Oncology v1.2008, accessed at http://www.nccn.org/professionals/physician_gls/PDF/sclc.pdf December 11, 2007. 28. Centers for Medicare and Medicaid Services, NCD for PET (FDG) Brain, Cervical, Ovarian, Pancreatic, Small Cell Lung and Testicular Cancers (220.6.24) accessed at http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6.14&ncd_version=1&basket=ncd%3A220%2E6%2E14%3A1%3APET+%28FDG%29+ for+Brain%7C%7C+Cervical%7C%7C+Ovarian%7C%7C+Pancreatic%7C%7C+Small+Cell+Lung%7C%7C+and+Testicular+Cancers December 13, 2007. 29. Foley WD, Bree RL, Gay SB, et al, Expert Panel on Gastrointestinal Imaging, American College of Radiology Appropriateness Criteria, Liver Lesion Characterization, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=9594&nbr=005115&string=colon+AND+cancer+AND+PET December 11, 2007. 30. Engst PF, Arnoletti JP, Benson AIB, et al, NCCN Colon Cancer Panel Members, NCCN Practice Guidelines in Oncology v1.2008, accessed at http://www.nccn.org/professionals/physician_gls/PDF/colon.pdf December 11 2007. 31. Engst PF, Arnoletti JP, Benson AIB, et al, NCCN rectal cancer panel members, NCCN Practice Guidelines in Oncology v1.2008, accessed at http://www.nccn.org/professionals/physician_gls/PDF/rectal.pdf December 11, 2007. 32. Engst PF, Arnoletti JP, Benson AIB, et al, NCCN Anal Cancer Panel Members, NCCN Practice Guidelines in Oncology v1.2008, accessed at http://www.nccn.org/professionals/physician_gls/PDF/anal.pdf December 11, 2007. 33. Centers for Medicare and Medicaid Services, NCD for PET (FDG) for colorectal cancer 220.6.2.4) accessed at , Centers for Medicare and Medicaid Services NCD for PET (FDG) for lung cancer 220.6.2 accessed at , http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6.2&ncd_version=1&basket=ncd%3A220%2E6%2E2%3A1%3APET+%28FDG%29+for +Lung+Cancer December 11, 2007. 34. Israel O, Mor M, Guralnik L, et al, Is 18F-FDG PET/CT useful for imaging and management of patients with suspected occult recurrence of cancer, J Nucl Med, 2004; 45:2045-2051. 35. Kinkel D, Lu Y, Both M, et al, Detection of hepatic metastases from cancers of the gastrointestinal tract by using noninvasive imaging methods (US, CT, MR imaging, PET): a meta-analysis, Radiology, 2002; 224:748-756. 36.Even-Sapir E, Parag Y, Lerman H, et al, Detection of recurrence in patients with rectal cancer: PET/CT after abdominoperineal or anterior resection, Radiology, 2004; 232:815-822. 37. Bipat S, van Leeuwen MS, Comans EFI, et al, Colorectal liver metastases: CT, MR imaging, and PET for diagnosis-meta-analysis, Radiology, 2005; 237:123-131. 38. Blodgett TM, Meltzer CC, Townsend DW, PET/CT: form and function, Radiology, 2007; 242:360-385. 39. Wolkov HB, Elman AJ, Hoppe RT, et al, American College of Radiology Appropriateness Criteria, Staging Evaluation for Patients with Hodgkin’s Disease, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=8307&nbr=004639&string=lymphoma December 12, 2007. 40.Ka-Min Ng A, Constine LS, Deming RL, et al, Expert panel on radiation oncology-Hodgkin’s disease, American College of Radiology Appropriateness Criteria, Follow up of Hodgkin’s disease, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonRadiationOncologyHodgkinsWorkGroup/Follo wUpofHodgkinsDiseaseDoc2.aspx December 12, 2007. 41. Centers for Medicare and Medicaid Services, NCD for PET (FDG) for lymphoma ( 220.6.5) accessed at http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6.5&ncd_version=1&basket=ncd%3A220%2E6%2E5%3A1%3APET+%28FDG%29+for +Lymphoma December 12, 2007. 42. Hoppe RT, Advani RH, Ambinder RF, et al, NCCN Hodgkin Disease/Lymphoma Panel Members, NCCN practice guidelines in oncology v.2.2099, accessed at http://www.nccn.org/professionals/physician_gls/PDF/hodgkins.pdf November 17, 2008. 43. Zelenetz AD, Advani RH, Bocjek RG, NCCN Non-Hodgkin’s Lymphomas Panel Members, NCCN practice guidelines in oncology v.3.2008, accessed at http://www.nccn.org/professionals/physician_gls/PDF/nhl.pdf November 17, 2008 44. Raanani P, Shasha Y, Perry C, et al, Is CT scan still necessary for staging in Hodgkin and Non-Hodgkin lymphoma patients in the PET/CT era, Annals of Oncology, 2006; 17:117-122. 45. Mikhaeel NG, Hutchings M, Fields PA, et al, FEG-PET after two to three cycles of chemotherapy predicts progression-free and overall survival in high-grade Non-Hodgkin’s lymphoma, Annals of Oncology, 2005; 16:1514-1523. 46. Jhanwar YS and Straus DJ, The role of PET in lymphoma, J Nucl Med, 2006; 47:1326-134. 47.Barosi G, Carella A, Lazzarino M, et al, Management of nodal diffuse large B-cell lymphomas: practice guidelines from the Italian Society of Experimental Hematology and the Italian Group for Bone Marrow Transplantation, Hematologica, 2006; 91:96-103. 48.Seam P, Juweid ME, and Cheson BD, The role of FDG-PET scans in patients with lymphoma, Blood, 2007; published on line at http://bloodjournal.hematologylibrary.org/cgi/reprint/110/10/3507 accessed December 13, 2007. 49. Juweid MD, Utility of Positron Emission Tomography (PET) scanning in managing patients with Hodgkin lymphoma, Hematology, Jan 2006; 259-264 accessed at http://asheducationbook.hematologylibrary.org/cgi/reprint/2006/1/259 December 13, 2007. Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

50. Schaefer NG, Hany TF, Taverna C, et al, Non-Hodgkin lymphoma and Hodgkin disease: coregistered FDG PET and CT at staging and restaging-do we need contrast-enhanced CT, Radiology, 2004; 232:823-829. 51. Ajani J, Bekaii-Saab T, D’Amico TA, et al, NCCM Esophageal Cancer Panel Members, NCCN Practice Guidelines in Oncology v.1.2009, accessed at http://www.nccn.org/professionals/physician_gls/PDF/esophageal.pdf November 17, 2008. 52. Himeno S, Yasuda S, Shimada H, et al, Evaluation of esophageal cancer by positron emission tomography, Jpn J Clin Oncol, 2002; 32(9):340-346. 53.Downey RJ, Akjurst T, Ilson D, et al, Whole body 18 FDG-PET and the response of esophageal cancer to induction therapy: results of a prospective trial, J Clin Oncol 21:428-432. 54.Skehan SJ, ,Brown AL, , Thompson M, et al, Imaging features of primary and recurrent esophageal cancer at FDG PET RadioGraphics 2000; 20:713-723. 55. Flamen P, Lerut A, Van Cutsem E, et al, Utility of positron emission tomography for the staging of patients with potentially operable esophageal carcinoma, 18:3202-3210. 56. van Westreen HL, Westerterp M, Bossuyt PMM, et al, Systematic review of the staging performance of 18F-Fluorodeoxyglucose positron emission tomography in esophageal cancer, J Clin Oncol, 2004; 22(8):3805-3812. 57.Swisher SG, Maish M, Erasmus JJ, et al, Utility of PET,CT and EUS to identify pathologic responders in esophageal cancer, Ann Thorac Surg, 2004; 78:1152-1160. 58. Matchar DB, Kulasingam SL, Havrilesky L et al, Positron emission testing for six cancers (brain, cervical, small cell lung, ovarian, pancreatic and testicular), Technology Assessment, Agency for Healthcare Research and Quality, 2004, accessed at http://www.cms.hhs.gov/mcd/search1.asp from 2=search1.asp& December 13, 2007. 59. Pandit-Tasker N, Oncologic imaging in gynecologic malignancies, J Nucl Med, 2005; 46:1842-1850. 60. Moore DH, Cervical Cancer, Obstetrics and Gynecology, 2006; 107:1152-1161. 61. Follen M, Levenback CF, Iiyer RB, et al, Imaging in cervical cancer, Cancer, 2003; 98(9 Suppl):2028-2038. 62. Havrilesky LF, Wong TZ, Secird AA, et al, The role of PET scanning in the detection of recurrent cervical cancer, Gynecol Oncol, 2003; 90(1):186-190. 63. Grigsby PW, Siegel BA, Dehdashti F, et al, Post therapy surveillance monitoring of cervical cancer by FDG-PET, Int J Radiat Oncol Biol Phys, 2003; 55(4):907-913. 64. Grigsby PW, Siegel BA, and Dehdashti F, Lymph node staging by positron emission tomography in patients with carcinoma of the cervix, J Clin Oncol, 2001; 19(17):3745-3749. 65. Narayan K, Hicks RJ, Jobling T, et al, A comparison of MRI and PET scanning in surgically staged loco-regionally advanced cervical cancer: potential impact on treatment, In J Gynecol Cancer, 2001; 11:263-271. 66.Yoshida Y, Kurokawa TG, Kawahara K, et al, Incremental benefits of FDG positron emission tomography over CT alone for the preoperative staging of ovarian cancer, AJR, 2004; 182:227-277. 67. Sironi S, Messa C, Mangili G, et al, Integrated FDG PET/CT in patients with persistent ovarian cancer: correlation with histologic findings, Radiology, 2004; 233:433-440 . 68. Israel O and Kuten A, Early detection of cancer recurrence: 18F-FDG PET/CT can make a difference in diagnosis and patient care, J Nucl Med, 2007; 48:28S-35S. 69. Rose PG, FaulhaberP, Miraldi F, et al, Positive emission tomography for evaluating a complete clinical response in patients with ovarian or peritoneal carcinoma: correlation with second-look laparotomy, Gynecol Oncol, 2001; 82(1):17-21. 70. Nakamoto Y, Saga T, Ishimori T, et al, Clinical value of positron emission tomography with FDG for recurrent ovarian cancer, AJR 2001; 176(6):1449-1454. 71. Torizuka T, Nnobezawa S, Kanno T, et al, Ovarian cancer recurrence: role of whole-body positron emission tomography using 2-[fluorine- 18]-fluoro-2-deoxy-d-glucose, Eur J Nucl Med Mol Imaging, 2002; 29(6):797-803. 72.Sperti C, Pasquali C, Chierichetti F, et al, 18-fluorodeoxyglucose positron emission tomography in predicting survival of patients with pancreatic carcinoma, J Gastrointest Surg, 2003; 7:953-960. 73.Diederichs CG, Staib L, Vogel J, et al, Values and limitations of 18F-fluorodeoxyglucose-positron-emission tomography with preoperative evaluation of patients with pancreatic masses, Pancreas, 2000; 20(2):109-116. 74. Hillner BE, Liu D, Coleman RE, et al, The national oncologic PET registry (NOPR): design and analysis plan, J Nucl Med 2007; 48:1901- 1908. 75. Nakamoto Y, Higashi T, Sakahara H, et al, Delayed 18F-Fluoro-2-Deoxy-D-Glucose positron emission tomography scan for differentiation between malignant and benign lesions in the pancreas, Cancer, 2000; 89:2547-2554. 76. Jadvar H and Fischman AJ, Evaluation of pancreatic carcinoma with FDG PET, Abdom Imaging, 2001; 26:254-259. 77. Ajani F, Bekaii-Saab T, D’Amico TA, et al, NCCN Gastric Cancer Panel Members, NCCN Practice Guidelines in Oncology v2.2007, Gastric Cancer accessed at http://www.nccn.org/professionals/physician_gls/PDF/gastric.pdf December 24, 2007. 78. Lim JS, Yun MJ, Kim M, et al, CT and PET in stomach cancer: preoperative staging and monitoring of response to therapy, RadioGraphics, 2006; 26:143-156. 79. Motzer RJ, Bolger GB, Boston B, et al, NCCN Testicular Cancer Panel Members, NCCN Practice Guidelines in Oncology v1.2009, Testicular Cancer, accessed at http://www.nccn.org/professionals/physician_gls/PDF/testicular.pdf November 18, 2008 80. Sonpavde G, Hutson TE, and Roth BJ, Management of Recurrent Testicular Germ Cell Tumors, The Oncologist, 2007; 12:51-61 accessed at http://theoncologist.alphamedpress.org/cgi/reprint/12/1/51 December 23, 2007.

CareCore National Criteria for Imaging Version 2.2009

81. Demetri GD, Benjamin RS, Blanke CD, et al, NCCN task force report: optimal management of patients with Gastrointestinal Stromal Tumor (GIST)- update of the NCCN clinical practice guidelines,SupplementS1-S32. JNCCN, 2007; 5(2): accessed at http://www.nccn.org/JNCCN/PDF/GIST2007.pdf December 24, 2007. 82. Holdsworth CH, Badawi RD, Manola JB, et al, CT and PET: Early Prognostic Indicators of Response to Imatinib Mesylate in Patients with Gastrointestinal Stromal Tumor, AJR, 2007; 189:W324-330, accessed at http://www.ajronline.org/cgi/reprint/189/6/W324 December 24. 2007. 83. Blay J-Y, Bonvalot S, Casali H, et al, Consensus meeting for the management of gastrointestinal stromal Tumor, report of the GIST consensus conference of 20-21 March 21004, under the auspices of ESMO, Annals of Oncology, 2005; 16:566-578. 84. Choi H, Charnsangavej C, deCastro Faria S, et al, CT evaluation of the response of gastrointestinal stromal tumors after imatinib mesylate treatment: a quantitative analysis correlated with FDF PET findings, AJR, 2004; 183:1619-1628. 85. Demetri GD, Baker LH, Benjamin RS, et al, NCCN Soft Tissue Sarcoma Panel Members, NCCN Practice Guidelines in Oncology v.2.2008, Soft tissue sarcoma, accessed at http://www.nccn.org/professionals/physician_gls/PDF/sarcoma.pdf November 18, 2008 86. CMS Manual System Pub 100-04 Medicare Claims Processing Transmittal 956, Subject: Payment for Positron Emission Tomography scans May 19, 2006; accessed at http://www.cms.hhs.gov/Transmittals/Downloads/R956CP.pdf December 24, 2007 87. Tateishi U, Yamaguchi U, Seki K, et al, Bone and soft-tissue sarcoma: preoperative staging with Gluorine 18 Fluorodeoxyglucose PET/CT and conventional imaging, Radiology, 2007; 245:839-847. 88. Bastinaannet 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. 89. Centers for Medicare and Medicaid Services, NCD for PET(FDG) for soft tissue sarcoma (220.6.12), accessed at http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6.12&ncd_version=1&basket=ncd%3A220%2E6%2E12%3A1%3APET+%28FDG%29+fo r+Soft+Tissue+Sarcoma December 24, 2007. 90.Belhocine T, De Barsy C, Hustinx R, et al, Usefulness of 18F-FDG PET in the post-therapy surveillance of endometrial carcinoma, Eur J Nucl Med, 2002; 29:1132-1139. 91. D’Sa S, Abildgaard N, Tighe J, et al, Guidelines for the use of imaging in the management of myeloma, accessed at http://www.bcshguidelines.com/pdf/myeloma_management_guidelines.pdf December 24, 2007. 92. Anderson DC, Alsina M, Bensinger W, et al, NCCN Multiple Myeloma Panel Members, NCCN Practice Guidelines in Oncology, v.2.2009, Multiple Myeloma, accessed at http://www.nccn.org/professionals/physician_gls/PDF/myeloma.pdf November 18, 2008 93.Bredella MA, Stenbachj L, Caputo G, et al, Value of FEG PET in the assessment of patients with multiple myeloma, AJR, 2005: 184:1199- 1204. 94. Nanni C, Zamagni E, Farsad M, et al, Role of 18F-FDG PET/CT in the assessment of bone involvement in newly diagnosed multiple myeloma: preliminary results, Eur J Nucl Med Mol Imaging, 2006; 33:525-531. 95. Coit DG, Andtbacka R, Bichakjian CK, et al, NCCN Melanoma Panel Members, Practice Guidelines in Oncology v.2.2009 Melanoma, accessed at http://www.nccn.org/professionals/physician_gls/PDF/melanoma.pdf November 18, 2008.. 96. Strobel K, Dummer R, Husarik DB, et al, High-risk melanoma: accuracy of FDG PET/CT with added CT morphologic information for detection of metastases, Radiology, 2007; 244:566-574. 97. Centers for Medicare and Medicaid Services, NCD for PET(FDG) for Melanoma (220.6/6), accessed at http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6.6&ncd_version=1&basket=ncd%3A220%2E6%2E6%3A1%3APET+%28FDG%29+for+ Melanoma December 24, 2007. 98.Swetter SM, Carroll LA, Johnson DL, et al, Positron emission tomography is superior to computed tomography for metastatic detection in melanoma patients, Annals of Surgical Oncology, 2002; 9(7): 646-653. 99. Ettinger DS, Akerley W, Bepler G, et al, NCCN Non-Small Cell Lung Cancer Panel Members, NCCN practice Guidelines in Oncology v2.2008, Thymic Malignancies, accessed at http://www.nccn.org/professionals/physician_gls/PDF/nscl.pdf December 19, 2007. 100. Biermann JS, Adkins DR, Benjamin RS, et al, NCCN Bone Cancer Panel Members, Practice Guidelines in Oncology v.1.2009, Bone Cancer accessed at http://www.nccn.org/professionals/physician_gls/PDF/bone.pdf , November 18, 2008.

Reviewed: 1/21/09 Posted: 4/1/09

CareCore National Criteria for Imaging Version 2.2009

78811 PET Limited Area 78812 PET Skull Base to Mid-thigh 78813 PET Whole Body 78814 PET/CT Limited Area 78815 PET/CT Skull Base to Mid-thigh 78816 PET/CT Whole Body

Medicare

General Statements

1. PET or PET/CT cannot be certified for initial staging for beneficiaries with a diagnosis of prostate cancer. However, it may be certified for restaging or response to therapy if the beneficiary is enrolled in a prospective clinical study that meets the requirements of CMS and is registered with the NOPR.

2. PET or PET/CT cannot be certified for the initial diagnosis of male or female breast cancer

3. PET or PET/CT cannot be certified for evaluation of axillary nodes in beneficiaries with a diagnosis of breast cancer

4. PET or PET/CT cannot be certified for the evaluation of regional lymph nodes in beneficiaries with a diagnosis of melanoma

5. PET or PET/CT cannot be certified for initial diagnosis or initial staging of cervical cancer unless there is documentation that standard imaging is negative for extrapelvic metastases unless the beneficiary is enrolled and registered with the NOPR.

6. PET or PET/CT may be certified for subsequent treatment of women with known diagnosis of cervical cancer.

7. PET or PET/CT may be certified one time only for all other biopsy proven solid tumors. For some cancers, additional scans may be certified as indicated below.

8. PET or PET/CT may be certified one time only for beneficiaries with a very strong suspicion of a solid tumor based on standard imaging (must have results of these tests).

9. PET and PET/CT may be certified for subsequent treatment for beneficiaries who have documented diagnosis of tumors of the breast, esophagus, colon or rectum, head and neck (non

CareCore National Criteria for Imaging Version 2.2009

thyroid) cancer, lymphoma, melanoma, non small cell lung cancer and thyroid cancer as indicated below.

10. PET and PET/CT may be certified for subsequent treatment in women with known diagnosis of ovarian cancer.

11. PET or PET/CT may be certified for initial and subsequent evaluation of members with documented diagnosis of myeloma.

12. For all solid tumors subsequent PET or PET/CT scans may be certified if the beneficiary and rendering site are enrolled and registered with the NOPR.

13. PET and PET/CT may not be certified for beneficiaries who have an established diagnosis of a solid tumor but who are asymptomatic with no signs or symptoms of disease and are not currently in treatment.

14. PET and PET/CT may be approved in a beneficiary with known diagnosis of malignancy to determine the optimal anatomic site for biopsy or other invasive diagnostic procedure.

I. Breast carcinoma 1-6 A. Must have tissue diagnosis of breast cancer B. Staging of patients with distant metastases suggested on standard imaging C. Restaging of women with known metastasis D. Evaluating response to treatment with locally advanced and metastatic disease when a change in therapy is contemplated E. Suspected recurrence 1. New palpable lesion in axilla or adjacent area 2. Rising tumor markers 3. Changes on other imaging F. PET is not to be used to: 1. Establish the diagnosis of breast cancer or to detect the primary lesion 2. Clarify a finding on mammography, physical examination, MRI or ultrasound 3. Evaluate axillary nodes 4. Not indicated for surveillance imaging in asymptomatic women with no signs or symptoms or laboratory findings suggestive of recurrent disease

II. Thyroid carcinoma 1,3,7-10 A. Must have tissue diagnosis of thyroid cancer (follicular, papillary, and medullary Hürthle cell and have been treated by thyroidectomy and/or radioiodine ablation. 1. Indicated for staging and restaging in patients with a. Negative I131 and/ or thallium 201 scans (whole body) b. Thyroglobulin level >10ng/ml c. Thyroglobulin >2 μgrams/liter after thyrogen stimulation B. Not indicated for surveillance of an asymptomatic individual who is currently not in treatment and has no signs, symptoms or laboratory tests suggesting recurrence of disease. Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

III. Head and neck cancers 1,3,11-14 A. Evaluation of patient with metastatic cervical lymph node(s) to establish primary site B. Staging of patient with known primary head and neck cancer C. Restaging after completion of therapy- surgery, chemotherapy, radiation therapy D. Monitor response to therapy only if a change in therapy is anticipated 1. Radiation therapy - no sooner than 1 month after completion of treatment (If done too soon may give false positive result) 2. Surgery - no sooner than 6 weeks after surgery 3. Chemotherapy - no sooner than 1-2 weeks after completion of first cycle E. Symptomatic member with new signs or symptoms of disease F. Not indicated for surveillance of an asymptomatic individual who is currently not in treatment and has no signs, symptoms or laboratory tests suggesting recurrence of disease.

IV. Non small cell lung cancer (NSCLC)1,3,15-24 A. CT demonstrates a lung mass or pulmonary nodule < to 4cm B. Initial staging of non small cell lung cancer that is pathologically confirmed C. Restaging after completion of treatment-surgery, chemotherapy, radiation therapy 1. No sooner than 12 weeks after completion of radiation therapy unless there is a change in clinical or imaging findings suggestive of recurrence or progression. D. Monitoring response to therapy only when a change in therapy is anticipated E. Not indicated for surveillance of an asymptomatic individual who is currently not in treatment and has no signs, symptoms or laboratory tests suggesting recurrence of disease.

V. Small cell lung cancer 1,25 A. CT demonstrates a lung mass or solitary pulmonary nodule less than or equal to 4cm B. Initial staging of small cell lung cancer that is pathologically confirmed C Restaging after completion of treatment-surgery, chemotherapy or radiation therapy may be certified if the beneficiary and rendering site are enrolled S and registered with the NOPR. D. Monitoring response to therapy may be certified if the beneficiary and rendering site are enrolled in and registered with the NOPR. E. Not indicated for surveillance of an asymptomatic individual who is currently not in treatment and has no signs, symptoms or laboratory tests suggesting recurrence of disease.

VI. Colorectal carcinoma 1,3,26-34 A. Initial staging (after tissue diagnosis is established) B. Evaluation of radiofrequency ablation (or similar procedure) of metastases 1. After procedure to evaluate effect and confirm adequate margins 2. May be repeated after each procedure C. Evaluation of response to chemotherapy of hepatic metastases with the intent of changing therapy based on the result of the PET scan. If there is no consideration of a change in therapy, a PET or PET/CT scan is not indicated. 1. No sooner than 4-5 weeks of treatment (about 1 complete cycle) 2. If there is a good response to therapy there is no need to repeat until the termination of the course of therapy, unless there is a change in clinical status i.e. increasing CEA. D. Rising CEA (>2.5 in nonsmoker and >5.0 in a smoker) Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

E. Restaging after completion of therapy F. Not indicated for surveillance of an asymptomatic individual who is currently not in treatment and has no signs, symptoms or laboratory tests suggesting recurrence of disease.

VII. Lymphoma/Hodgkin’s Disease 1,3,35-46 A. Initial staging (usually after tissue diagnosis is established) B. Restaging after completion of therapy C. Monitor response to therapy if a change in treatment is anticipated D. New symptoms or findings: 1. Night sweats 2. Weight loss 3. ESR >30 mm/hr 4. Fever >100.4 (unknown etiology) >one week 5. Suspected metastasis by CXR, MRI, CT E. PET is not indicated for surveillance imaging during remission in an asymptomatic beneficiary with no signs or symptoms of disease

VIII. Esophageal carcinoma 1,3,47-53 A. Initial staging of known esophageal cancer (must have tissue diagnosis) B. Restaging of patients treated with either surgery, chemotherapy or radiation therapy C. Reevaluation for suspected recurrence in a symptomatic individual with new signs or symptoms of disease 1. Changed findings on endoscopy or imaging 2. Inability to perform endoscopy 3. Lymphadenopathy D. Monitoring response to treatment if a change in therapy is anticipated E. PET is not indicated for surveillance imaging during remission in an asymptomatic beneficiary with no signs or symptoms of disease

IX. Cervical carcinoma 1,25 A. Initial staging 1. No evidence of extra-pelvic metastases on conventional imaging 2. If there is evidence of extra-pelvic metastases may be certified if the beneficiary and rendering site are enrolled in and registered with the NOPR. B. Monitor response to therapy if a change in therapy is anticipated C. Evaluate for recurrence in an individual with new signs and symptoms D. PET is not indicated for surveillance imaging during remission in an asymptomatic beneficiary with no signs or symptoms of disease

X. Ovarian carcinoma 1,53-58 A. Initial staging with a tissue diagnosis B. Evaluation of recurrence in a symptomatic member with signs and/or symptoms of of disease 1. Elevated tumor markers a. > 35U/mL Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

2. Change in physical examination or clinical condition C. Monitoring response to treatment if a change in therapy is anticipated D. PET is not indicated for surveillance imaging during remission in an asymptomatic beneficiary with no signs or symptoms of disease

XI. Pancreatic carcinoma 1 A. Must have a tissue diagnosis B. Initial staging C. Monitoring response to treatment if a change in therapy is anticipated and if the beneficiary and rendering site are enrolled in and registered with the NOPR. D. Restaging after completion of treatment-surgery, chemotherapy or radiation therapy may be certified if the beneficiary and rendering site are enrolled in S and registered with the NOPR. E. Suspected recurrence in a symptomatic member with new signs or symptoms 1. Beneficiary and rendering site are enrolled in and registered with the NOPR. 2. Rising tumor markers a. Ca 19-9 >120U/mL b. Ca 27.29 >100U/mL c. Ca 125 >35U/mL 3. New or increasing jaundice or bilirubin levels a. Direct bilirubin >0.3mg/mL b. Indirect bilirubin >1.9mg/mL 4. Other abnormal liver function tests a. AST >34 IU/L b. ALP or alkaline phosphatase >147IU/L 5. New onset of weight loss 6. Ascites F. PET is not indicated for surveillance imaging during remission in an asymptomatic beneficiary with no signs or symptoms of disease

XII. Testicular carcinoma (seminoma or non-seminomatous germ cell tumor) 1,25 A. Must have tissue diagnosis B. Initial staging C. Monitoring response to treatment if change in therapy is anticipated and if the beneficiary and rendering site are enrolled in and registered with the NOPR. D. Restaging after completion of therapy-surgery, radiation or chemotherapy and if the beneficiary and rendering site are enrolled in and registered with the NOPR. E. Suspected recurrence in a symptomatic member with new signs or symptoms and if the beneficiary and rendering site are enrolled in and registered with the NOPR. F. PET is not indicated for surveillance imaging during remission in an asymptomatic beneficiary with no signs or symptoms of disease

XIII. Soft tissue sarcoma 1 A. Must have an established tissue diagnosis Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

B. Initial staging C. Monitoring response to treatment if change in therapy is anticipated and if the beneficiary and rendering site are enrolled in and registered with the NOPR. D. Restaging after completion of therapy-surgery, radiation or chemotherapy and if the beneficiary and rendering site are enrolled and registered with the NOPR. E. Suspected recurrence in a symptomatic member with new signs or symptoms and if the beneficiary and rendering site are enrolled in and registered with the NOPR. F. PET is not indicated for surveillance imaging during remission in an asymptomatic beneficiary with no signs or symptoms of disease

XIV. Melanoma 1 A. Must have tissue diagnosis B. Initial staging other than regional lymph nodes C. In known disease, detection of distal metastases D. NOT PERMITTED FOR EVALUATION OF REGIONAL NODES E. Monitoring response to therapy when a change is anticipated F. Restaging after completion of therapy G. Symptomatic individual with new signs or symptoms of disease H. PET is not indicated for surveillance imaging during remission in an asymptomatic beneficiary with no signs or symptoms of disease

XV. Prostate 1 A. May not be used for initial staging B. Monitoring response to treatment if change in therapy is anticipated and if the beneficiary and rendering site are enrolled in and registered with the NOPR. C. Restaging after completion of therapy-surgery, radiation or chemotherapy if the beneficiary and rendering site are enrolled in and registered with the NOPR. D. Suspected recurrence in a symptomatic member with new signs or symptoms and if the beneficiary and rendering site are enrolled in and registered with the NOPR. E. PET is not indicated for surveillance imaging during remission in an asymptomatic beneficiary with no signs or symptoms of disease

XVI. Myeloma 1,59-62 A. Established diagnosis B. Initial staging C. Restaging after completion of initial therapy D. Suspected recurrence in symptomatic individual with new signs and symptoms of disease E. PET is not indicated for surveillance imaging during remission in an asymptomatic beneficiary with no signs or symptoms of disease

XVII. All other solid tumors 1 A. Initial staging with a pathologic diagnosis ONE TIME ONLY B. Monitoring response to treatment if a change in therapy is anticipated and if the beneficiary and rendering site are enrolled in and registered with the NOPR.

CareCore National Criteria for Imaging Version 2.2009

C. Restaging after completion of therapy- surgery, radiation, chemotherapy if the beneficiary and rendering site are enrolled and registered with the NOPR. D. Suspected recurrence in a symptomatic member with new signs or symptoms and if the beneficiary and rendering site are enrolled and registered with the NOPR. E. PET is not indicated for surveillance imaging during remission in an asymptomatic beneficiary with no signs or symptoms of disease

1 XVIII. Other cancers A. Initial staging only if the beneficiary and rendering site are enrolled in and registered with the NOPR. B. Monitoring response to treatment if change in therapy is anticipated and if the beneficiary and rendering site are enrolled in and registered with the NOPR. C. Restaging after completion of therapy-surgery, radiation or chemotherapy if the beneficiary and rendering site are enrolled in and registered with the NOPR. D. Suspected recurrence in a symptomatic member with new signs or symptoms if the beneficiary and rendering site are enrolled and registered with the NOPR. E. PET is not indicated for surveillance imaging during remission in an asymptomatic beneficiary with no signs or symptoms of disease

References:

1. Decision Memo for Positron Emission Tomography (FDG) for Solid tumors (CAG-00181R), Centers for Medicare and Medicaid Services accessed at https://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=218 April 5, 2009. 2. Centers for Medicare and Medicaid Services, NCD for PET (FDG) for Breast Cancer (220.6.10), accessed at http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6.10&ncd_version=1&basket=ncd%3A220%2E6%2E10%3A1%3APET+%28FDG%29+ for+Breast+Cancer October 30, 2008. 3. Centers for Medicare and Medicaid Services, NCD for PET scans(220.6) accessed at , http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6&ncd_version=2 December 10, 2007 4. Isasi CR, Moadel RM, and Blaufox MD, A meta-analysis of FEG-PET for the evaluation of breast cancer recurrence and metastases, Breast Cancer Research and Treatment, 2005; 90:105-112. 5. Radan L, Ben-Haim S, Bar-Shalom R et al, The role of FDG-PET/CT in suspected recurrence of breast cancer, Cancer, 2006; 107(11):2545-2551. 6.Eubank WB, Mankoff D, Bhattacharya M, et al, Impact of FEGPET on defining the extent of disease and on the treatment of patients with recurrent or metastatic breast cancer, AJR, 2004; 183:479-486. 7. Centers for Medicare and Medicaid Services, NCD for PET (FDG) for thyroid cancer (220.6.11) accessed at http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6.11&ncd_version=1&basket=ncd%3A220%2E6%2E11%3A1%3APET+%28FDG%29+ for+Thyroid+Cancer December 10, 2007. 8. Cooper DS, Doherty GM, Haugen BR, et al, Management Guidelines for patients with thyroid nodules and differentiated thyroid cancer, Thyroid, 2006; 16(2):109-142. 9. Sherman SI, Angelos P, Ball DW et al, NCCN Thyroid Carcinoma Panel Members, NCCN practice guidelines in Oncology v2.2007, Thyroid carcinoma, accessed at http://www.nccn.org/professionals/physician_gls/PDF/thyroid.pdf December 10, 2007. 10. Perros P, Clarke SEM, Franklyn J, Thyroid cancer guidelines update group, Guidelines for the management of thyroid cancer, second edition, British Thyroid Association Royal College of Physicians, 2007, accessed at http://www.british-thyroid- association.org/Thyroid_cancer_guidelines_2007.pdf December 10, 2007. 11. Centers for Medicare and Medicaid Services, NCD for PET (FDG) for head and neck cancers (220.6.7) accessed at http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6.7&ncd_version=1&basket=ncd%3A220%2E6%2E7%3A1%3APET+%28FDG%29+for +Head+and+Neck+Cancers December 10, 2007. 12. Scottish Intercollegiate Guidelines Network, Diagnosis and management of head and neck cancer Quick reference guide,2006 accessed at http://www.sign.ac.uk/pdf/qrg90.pdf December 10, 2007. 13. Forastiere AA, Ang KK, Brizel D, et al, NCCN Head and Neck Cancers Panel Members, NCCN practice guidelines in Oncology v2.2007, Head and neck cancers, accessed at http://www.nccn.org/professionals/physician_gls/PDF/head-and-neck.pdf December 10, 2007.

CareCore National Criteria for Imaging Version 2.2009

14. Fukui MB, Blodgett TM, Snyderman, CH, et al, Combined PET-CT in the head and neck, Part 2. Diagnostic uses and pitfalls of oncologic imaging, RadioGraphics, 2006; 25:913-930. 15. Kahn A, Davis SD, Goodman PC, et al, Expert Panel on Thoracic Imaging, American College of Radiology Appropriateness Criteria: solitary pulmonary nodule, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonThoracicImaging/solitarypulmonarynoduleDoc 10.aspx December 10, 2007. 16. Tan BB, Flaherty KR, Kazerooni EA et al, The solitary pulmonary nodule, Chest, 2003; 123(1Suppl):89S-96S. 17. Pfister DG, Johnson DH, Azzoli CG, et al, American society of clinical oncology treatment of unresectable non-small-cell lung cancer guideline: Update 2003, Journal of Clinical Oncology, 2004; 22(2):330-353. 18.Thomas WW, Komaki RU, Gewanter RM, et al Expert Panel on Radiation Oncology-Lung, American College of Radiology Appropriateness Criteria Follow- up of non-small-cell lung cancer, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonRadiationOncologylungWorkGroup/FollowUp ofNonSmallCelllungcancerDoc1.aspx December 11, 2007. 19.Rozenshtein A, Davis SD, Komaki RS et al, Expert Panels on thoracic Imaging and Radiation Oncology-Lung Work Group, American College of Radiology Appropriateness Criteria, Staging of bronchogenic carcinoma, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonThoracicImaging/StagingofBronchogenicCarci nomaDoc11.aspx December 11, 2007. 20. Centers for Medicare and Medicaid Services, NCD for PET (FDG) for lung cancer 220.6.2) accessed at , http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6.2&ncd_version=1&basket=ncd%3A220%2E6%2E2%3A1%3APET+%28FDG%29+for +Lung+Cancer December 11, 2007. 21. Rivera MP, and Mehta AC, Initial diagnosis of lung cancer: ACCP evidence-based clinical practice guidelines, Chest, 2007; 132:131-148. 22. Silvestri GA, Gould MK, Margolis ML et al, Noninvasive staging of non-small cell lung cancer: ACCP evidenced-based clinical practice guidelines (2nd edition) Chest, 2007; 132:178-201. 23 Rubins J, Unger M and Colice GL, follow-up and surveillance of the lung cancer patient following curative intent therapy, ACC{ Evidence- based clinical practice guideline (2nd edition), Chest, 2007; 132:355-367. 24. Ettinger DS, Akerley W, Bepler G et al, NCCN Non-small cell lung cancer panel members, NCCN Practice Guidelines in Oncology v.2.2009, accessed at http://www.nccn.org/professionals/physician_gls/PDF/nscl.pdf , April 13, 2009 . 25. AHRQ Technology Assessment Program, Positron Emission Tomography for nine cancers (bladder, brain, cervical, kidney, small cell lung, testicular), accessed at http://www.cms.hhs.gov/determinationprocess/downloads/id54TA.pdf , April 13, 2009. 26. Foley WD, Bree RL Gay SB, et al, Expert Panel on Gastrointestinal Imaging, American College of Radiology Appropriateness Criteria, Liver lesion characterization, accessed at http://www.guideline.gov/summary/summary.aspx?doc_id=9594&nbr=005115&string=colon+AND+cancer+AND+PET December 11, 2007. 27 . Engst PF, Arnoletti JP, Benson AIB, et al, NCCN colon cancer panel members, NCCN Practice Guidelines in Oncology v.2.2009 accessed http://www.nccn.org/professionals/physician_gls/PDF/colon.pdf , April 13, 2009. 28. EngstPF, Arnoletti JP, Benson AIB, et al, NCCN rectal cancer panel members, NCCN Practice Guidelines in Oncology v.2.2009, accessed at http://www.nccn.org/professionals/physician_gls/PDF/rectal.pdf , April 13, 2009. 29. Engst PF, Arnoletti JP, Benson AIB, et al, NCCN anal cancer panel members, NCCN Practice Guidelines in Oncology v.2.2009, accessed at http://www.nccn.org/professionals/physician_gls/PDF/anal.pdf , April 13, 2009. 30. Centers for Medicare and Medicaid Services, NCD for PET (FDG) for colorectal cancer 220.6.2.4) accessed at Centers for Medicare and Medicaid Services, accessed at http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6.4&ncd_version=1&basket=ncd%3A220%2E6%2E4%3A1%3APET+%28FDG%29+for +Colorectal+Cancer December 11, 2007. 31. Israel O, Mor M, Guralnik L, et al, Is 18F-FDG PET/CT useful for imaging and management of patients with suspected occult recurrence of cancer, J Nucl Med, 2004; 45:2045-2051. 32. Kinkel D, Lu Y, Both M, et al, Detection of hepatic metastases from cancers of the gastrointestinal tract by using noninvasive imaging methods (US, CT, MR imaging, PET): a meta-analysis, Radiology, 2002; 224:748-756. 33.Even-Sapir E, Parag Y, Lerman H et al, Detection of recurrence in patients with rectal cancer: PET/CT after abdominoperineal or anterior resection, Radiology, 2004; 232:815-822. 34.Bipat S, van Leeuwen MS, Comans EFI, et al, Colorectal liver metastases: CT, MR imaging, and PET for diagnosis-meta-analysis, Radiology, 2005; 237:123-131. 35. Wolkov HB, Elman AJ, Hoppe RT, et al, American College of Radiology Appropriateness Criteria, Staging evaluation for patients with Hodgkin’s disease, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonRadiationOncologyHodgkinsWorkGroup/Stagi ngEvaluationHodgkinsDiseaseDoc7.aspx April 13, 2009. 36.Ka-Min Ng A, Constine LS, Deming RL, et al, Expert panel on radiation oncology-Hodgkin’s disease, American College of Radiology Appropriateness Criteria, Follow up of Hodgkin’s disease, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonRadiationOncologyHodgkinsWor Group/FollowUpofHodgkinsDiseaseDoc2.aspx December 12, 2007. 37. Centers for Medicare and Medicaid Services, NCD for PET (FDG) for lymphoma ( 220.6.5) accessed at http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6.5&ncd_version=1&basket=ncd%3A220%2E6%2E5%3A1%3APET+%28FDG%29+for +Lymphoma December 12, 2007. Copyright © 2009 CareCore National. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.carecorenational.com

CareCore National Criteria for Imaging Version 2.2009

38. Hoppe RT, Advani RH, Ambinder RF, et al, NCCN Hodgkin disease/lymphoma panel members, NCCN practice guidelines in oncology v.2.2009, accessed at http://www.nccn.org/professionals/physician_gls/PDF/hodgkins.pdf April 13, 2009. 39. Zelenetz ADAbramson JS, Advani RH et al, NCCN non-Hodgkin’s lymphomas panel members, NCCN practice guidelines in oncology v.1.2009, http://www.nccn.org/professionals/physician_gls/PDF/nhl.pdf April 13, 2009. 40. Raanani P, Shasha Y, Perry C, et al, Is CT scan still necessary for staging in Hodgkin and non-Hodgkin lymphoma patients in the PET/CT era, Annals of Oncology, 2006; 17:117-122. 41. Mikhaeel NG, Hutchings M, Fields PA, et al, FEG-PET after two to three cycles of chemotherapy predicts progression-free and overall survival in high-grade non-Hodgkin lymphoma, Annals of Oncology, 2005; 16:1514-1523. 42. Jhanwar YS, and Straus DJ, The role of PET in lymphoma, J Nucl Med, 2006; 47:1326-134. 43.Barosi G, Carella A, Lazzarino M, et al, Management of nodal diffuse large B-cell lymphomas: practice guidelines from the Italian Society of Experimental Hematology and the Italian Group for Bone Marrow Transplantation, Hematologica, 2006; 91:96-103. 44.Seam P, Juweid ME, and Cheson BD, The role of FDG-PET scans in patients with lymphoma, Blood, 2007; published on line at http://bloodjournal.hematologylibrary.org/cgi/reprint/110/10/3507 accessed December 13, 2007. 45. Juweid MD, Utility of positron emission tomography (PET) scanning in managing patients with Hodgkin lymphoma, Hematology, Jan 2006; 259-264 accessed at http://asheducationbook.hematologylibrary.org/cgi/reprint/2006/1/259 December 13, 2007. 46. Schaefer NG, Hany TF, Taverna C et al, Non-Hodgkin lymphoma and Hodgkin disease: coregistered FDGPET and CT at staging and restaging-do we need contrast-enhanced CT, Radiology, 2004; 232:823-829. 47. Ajani J, Barthel JS, Bekaii-Saab T et al, NCCM Esophageal Cancer Panel Members, NCCN practice guidelines in oncology v.1.2009, accessed at http://www.nccn.org/professionals/physician_gls/PDF/esophageal.pdf April 13, 2009. 48. Himeno S, Yasuda S, Shimada H, et al, Evaluation of esophageal cancer by positron emission tomography, Jpn J Clin Oncol, 2002; 32(9):340-346. 49.Downey RJ, Akjurst T, Ilson D, et al, Whole body 18 FDG-PET and the response of esophageal cancer to induction therapy: results of a prospective trial, J Clin Oncol 21:428-432. 50.Centers for Medicare and Medicaid Services, NCD for PET (FDG) for esophageal cancer (200.6.3) accessed at http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6.3&ncd_version=1&basket=ncd%3A220%2E6%2E3%3A1%3APET+%28FDG%29+for+ Esophageal+Cancer October 30, 2008. 51. Flamen P, Lerut A, Van Cutsem E et al, Utility of positron emission tomography for the staging of patients with potentially operable esophageal carcinoma, 18:3202-3210. 52. van Westreen HL, Westerterp M, Bossuyt PMM, et al, Systematic review of the staging performance of 18F- Fluorodeoxyglucose positron emission tomography in esophageal cancer, J Clin Oncol, 2004; 22(8):3805-3812. 53.Swisher SG, Maish M, Erasmus JJ et al, Utility of PET,CT and EUS to identify pathologic responders in esophageal cancer, Ann Thorac Surg,2004; 78:1152-1160. 54.Yoshida Y, Kurokawa TG, Kawahara K et al, Incremental benefits of FDG positron emission tomography over CT alone for the preoperative staging of ovarian cancer, AJR, 2004; 182:227-277. 55. Sironi S, Messa C, Mangili G et al, Integrated FDG PET/CT in patients with persistent ovarian cancer: correlation with histologic findings, Radiology, 2004; 233:433-440 . 56. Rose PG, FaulhaberP,, Miraldi F, et al, Positive emission tomography for evaluating a complete clinical response in patients with ovarian or peritoneal carcinoma: correlation with second-look laparotomy, Gynecol Oncol, 2001; ;82(1):17-21. 57. Nakamoto Y, Saga T, Ishimori T, et al, Clinical value of positron emission tomography with fdg for recurrent ovarian cancer, AJR 2001; 176(6):1449-1454. 58. Torizuka T, Nnobezawa S, Kanno T, et al, Ovarian cancer recurrence: role of whole-body positron emission tomography using 2-[fluorine- 18]-fluoro-2-deoxy-d-glucose, Eur J Nucl Med Mol Imaging, 2002; 29(6):797-803. 59. Coit DG, Andtbacka R, Bichakjian CK et al, NCCN Melanoma Panel Members, Practice Guidelines in Oncology v.2.2009, Melanoma, accessed at http://www.nccn.org/professionals/physician_gls/PDF/melanoma.pdf April 13, 2009. 60. STrobel K, Dummer R, Husarik DB, et al, High-risk melanoma: accuracy of FDG PET/CT with added CT morphologic information for detection of metastases, Radiology, 2007; 244:566-574. 61. Centers for Medicare and Medicaid Services, NCD for PET(FDG) for Melanoma (220.6/6), accessed at http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.6.6&ncd_version=1&basket=ncd%3A220%2E6%2E6%3A1%3APET+%28FDG%29+for+ Melanoma December 24, 2007. 62.Swetter SM, Carroll LA, Jophnson DL, et al, Positron emission tomography is superior to computed tomography for metastatic detection in melanoma patients, Annals of Surgical Oncology,

Reviewed: 6/9/2009 Posted: 6/10/2009