Cigna Medical Coverage Policies – Radiology Abdomen Imaging Effective February 17, 2020

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

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

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

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

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

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

CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in the CPT® book. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Imaging Abdomen © AB AB AB AB AB AB AB AB AB AB AB Hypertension and Portal Ascites (HCC); AB AB AB Ulcerative Colitis AB AB AB AB AB AB AB AB AB AB AB AB Surgery AB AB AB AB AB AB AB Guidelines Imaging for Abdomen Abbreviations 2019 ------

19: Inflammatory Bowel Disease Rule Out Crohn’s Disease or Disease Crohn’s Out Rule Disease Bowel Inflammatory 19: 18: GI Bleeding Bowel and Irritable Constipation, Diarrhea, 17: and Gastroparesis Obstruction Bowel 16: Lesions Cortical Adrenal 15: Zollinger 14: Abdominal 13: Hernias 12: Disease Gaucher 11: and Hemochromatosis 10: 9: Bariatric Surgery Lymphadenopathy Abdominal 8: Post 7: Mes 6: Gastroenteritis 5: Stone or Known Renal/Ureteral Out Rule Pain, Flank 4: Abdom3: Pain Abdominal 2: Guidelines General 1: 33: Polycystic33: KidneyDisease Hypertension Renovascular 32: Failure Renal 31: Indetermin 30: Spleen 29: Pancreatitis 28: Lesion Pancreatic 27: Chemistries Liver Abnormal 26: Liver Lesion25: Characterization Polyps Gallbladder 24: (MRCP) Cholangiopancreatography MR 23: Carcinoma Hepatocellular for Screening and Liver Cirrhosis 22: (CTC) CTColonography 21: Disease Celiac 20: (Sprue) healthcare eviCore Blunt Abdominal Trauma Abdominal Blunt –

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Abdomen Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Imaging Abdomen © AbbreviationsAbdomen for Imaging Guidelines HU HCPCS HCC GI GGT GFR FNH ERCP DVT CTC CTA CT CNS CAG BUN BEIR AUA AST ASGE ALT AGA AFP ACTH ACR ACG ACE AASLD AAA 2019

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Abdomen Imaging Abdomen Imaging Guidelines V1.0

AB-1: General Guidelines AB-1.1: Overview 7 AB-1.2: CT Imaging 7 AB-1.3: MR Imaging 8 AB-1.4: MR Enterography and Enteroclysis Coding Notes 8 AB-1.5: Ultrasound 8 AB-1.6: Abdominal Ultrasound 9 AB-1.7: Retroperitoneal Ultrasound 10 AB-1.8: This section intentionally left blank 10 AB-1.9: Contrast-Enhanced Ultrasound 10 AB-1.10: Special Considerations 10

______©2019 eviCore healthcare. All Rights Reserved. Page 6 of 144 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______ AB       AB Imaging Abdomen © 2019

    contrast (CPT imaging CT abdomenpelvis). or Clinical concerns Pelvic imaging begins at the iliac crest and extends to the pubis. crest. Abdominal imaging begins at the diaphragm and extends to the umbilicus or iliac      Conservative treatment abdominalfor pain can include (list is not exhaustive): or need for MRCP. mesenteric/colonic ischemia, diarrhea/constipation, irritable bowel syndrome (IBS), GI Specialist evaluations can be helpful, particularly in determining substitutea face for- (telephone call, electronic mail or messaging) by anestablished individual can imaging modalities such as plain X and physical examination, appropriate laboratory studies, and non- imaging can be considered. The clinical evaluation may include a relevant history A current clinical evaluation (within 60 days) is generally CTImaging -1.2: Overview -1.1:

eviCore healthcare eviCore of the abdomen. the of considered when CT Abdomen and Pelvis, usually with contrast (CPT  Shellfish allergy:  Exceptions are noted in these guidelines, and include: Oral contrast has no relation to the IV contrast administered. Pro modification Diet Plain abdominal radiography Non Anti  only refers to IV contrast. There is no coding for oral contrast.

very elderly. documented allergy to contrast. It can also be considered reactionIVcontrast to anymore thanthat of other allergens. these allergic reactions. Allergies to shellfish do not increase the risk of NOT true. Shellfish allergy is dueto tropomyosins. Iodine plays no role in that this implies an allergy to CT iodinated contrast media. However, this is It is commonly assumed that an allergy to shellfish infers iodine allergy, and without contrast 74170) with suspicion of CT Abdomen with contrast (CPT CT Abdomen without contrast (CPT - - - secretory or Pylori H. steroidalopiate or or anti

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to signs or symptoms are generalized, or involve alower quadrant

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a solid organ lesion (liver, kidney, pancreas, spleen).

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body structures. Ultrasound, also called sonography, uses high frequency sounds   MRI Enterography or Enteroclysis is reported in one of two ways: 74181) requestsfor for MR Elastography liver (See MR Elastography (   individuals MRI    Ultrasound -1.5: and Notes Enteroclysis Enterography Coding MR -1.4: Imaging MR -1.3:

eviCore healthcare eviCore  ingested neutral bowel contrast material to allowvisualization of the small bowel. without contrast (CPT MRI Abdomen without and with contrast (CPT MRI Abdomen without and with contrast (CPT the amniotic fluid with unknown long term effects on the fetus. during pregnancy radiat For pregnant women ultrasound or MRI without contrast should be used to avoid indicated, MRI Abdomen without and with contrast (CPT MRI  Triple    Enteroclysis CT CT Enterography (CPT performed.

maybe preferred a moretargeted as which precontrast imaging is needed CT a embolic or ablative therapies. Thus, for the evaluation of liver lesions EITHER not needed, except in those individuals previously treated with locoregional It should be noted that, in general, a precontrast or noncontrast CT is usually    contrast (CPT phases3 o Report by assigning: CPT small bowel than CT lumen. CT E CT imaging is performed either with or without intravenous contrast. or jejunum. Bowel contrast material is infused through the tube and CT tu A

A ion exposure. The use of gadolinium contrast agents is contraindicated - bdomen with contrast only is essentially never performed. phase CT 3) W 3) 2) P 2) 1) E

be is placed through the nose or mouth and advanced into the duodenum alle

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eviCore healthcare eviCore    Further, CPT document the reason. a particularIf structure or organ cannot be visualized, the report should abdominal aorta, and inferior vena cava. Liver, gallbladder, common bile duct, pancreas, spleen, kidneys, upper reimbursable. identification during astandard ultrasound procedure, is not separate T The use of a hand- a Pictureinor Archi All ultrasound studies require permanently recorded images either stored on film ultrasound is considered investigational. routineThe 3Drendering, use and4D of (post permit analysis bi of billable. This exclusionincludes devices output is considered part of the physical examination and is not separately color flowDoppler imaging

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further  of the abdomen, or a follow required elements and can refer to a specific study of a single organ, alimited area   Persistent unexplained nausea and vomiting: Limited retroperitoneal ultrasound (CPT   required elements: Complete retroperitoneal ultrasound (CPT : Special Considerations Special : -1.10 -1.8: Ultrasound Retroperitoneal -1.7: -1.9: Contrast

eviCore healthcare eviCore Further, CPT Imaging Guidelines. Se persistent, unexplained nausea and vomiting and a negative GI evaluation. One non-   bladder. For urinary tract indications, a complete study can consist of kidneys and vena cava. Kidneys, lymph nodes, abdominal aorta, common iliac artery origins, inferior

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Trillaud H, Bruel J Bruel H, Trillaud - - Medizin Liver with MRI and CEUS using Lesions Liver Focal of Characterization al. B, et Pregler F, L, Wassermann Beyer Ultrasound of Journal European Liver the in (CEUS) Ultrasound Enhanced Contrast for Recommendations Practice Clinical Good and al. Guidelines et B, Choi C, Dietrich M, Claudon . . doi:10.1159/000447670 in Medicine and Biology (EFSUMB) Guidelines. Ultrasound for Societies of Federation European onthe Comments Agents: Contrast Ultrasound with Assessment Lesion Liver Focal of Limitations and Advantages al. et B, Braden C, Tana L, Chiorean Radiology Features. Imaging Ancillary and Agents, Hepatobiliary Agents, Extracellular II. Part Carcinoma: Berzigotti A, Ashkenazi E, Reverter - al.et Non E, E, Reverter A, Ashkenazi Berzigotti - 2009;49(6):2087 Hepatology. update. An cirrhosis: dueto ascites with patients adult of Management BA. Runyon Choi J Choi 29- 2011;31(3):1 Markers. Disease Hypertension. Portal and Cirrhosis Liver 2014. Published Radiology. of College American Radiation. Ionizing with and Women Adolescents Pregnant Potentially or Pregnant Imaging for Guideline Practice ACR 2014. Published Radiology of College American (MRI) Imaging Resonance Magnetic Fetal Of Performance Optimal Gastroenterology multicenter International sonography: enhanced al. et LP, Browne RM, Benator EN, Faerber Hepatology Diseases. Liver of Study the for Association American the by Guidance Practice 2018 Carcinoma: Hepatocellular of Management and Staging, Diagnosis, al. et CB, Sirlin LM, Kulik JA, Marrero . . doi:10.1016/j.jemermed.2009.10.014 - 701 5(2010): no. 39, Medicine Emergency of Journal The Exposed." Myth A Medical Allergies: Seafood and Iodine, Radiocontrast, of Relationship "The Witting. Michael and Esteban, Schabelman, 3 no. 6, Cardiology of Journal World Survey." Kingdom United Media: Contrast Iodinated to Relation and Allergy "Shellfish Mudassar. Baig, doi:10.1148/rg.2015150033 - 1738 6(2015): no. 35, RadioGraphics Know." to Needs Radiologist the What Media: Contrast of Use "Safe Langer. M. Jessica and Moriarity, K. Andrew R., Katrina Beckett,

healthcare eviCore - Y, J Lee - 2017;38(06):619 . Ultrasound of Journal European - 2014;273(1):30 . - 2018;68(2):723 .

- Guidelines Ultraschall in der der in Ultraschall Center. Radiologic aSingle of Experience Media: Contrast Specific - M, Sirlin CB. CT and MR Imaging Diagnosis and Staging of Hepatocellular Hepatocellular of Staging and Diagnosis Imaging MR and CT CB. Sirlin M, 2107.(revised 2012). 2107.(revised . . doi:10.3748/wjg.15.3748 2009;15(30):3748. . - M, Valette P Valette M, . All All .

Rights Reserved. Rights 50. doi:10.1148/radiol.14132362 50. . 750. doi:10.1002/hep.29913. 750. - J, et al. Characterization of focal liver lesions with SonoVue with lesions liver focal of Characterization al. et J, - 2012;34(01):11 .

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Abdomen Imaging Abdomen Imaging Guidelines V1.0

AB-2: Abdominal Pain AB-2.1: General Information 13 AB-2.2: Abdominal Pain 14 AB-2.3: Right Upper Quadrant Pain including Suspected Gallbladder Disease 16 AB-2.4: Left Upper Quadrant (LUQ) Pain 16 AB-2.5: Epigastric Pain and Dyspepsia 18 AB-2.6: Chronic Abdominal Pain 18 AB-2.7: Non-operative Treatment of Acute Appendicitis 19

______©2019 eviCore healthcare. All Rights Reserved. Page 12 of 144 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______ Women Pregnant  Red Flag Signsand Symptoms quadrant The AB Imaging Abdomen  © of Location/type pain 2019

abdominal Location  first. If ultrasound is equivocal or red flags are present, proceed to: ( umbilicus) A  pathway. A red flag situation is described as the following: In “red flag” situations, the imaging indications may vary the from usual imaging “ ultrasound is not required. Please proceed to the imaging indications under the Please note, that when any one red flag is present with abdominal pain, the initial 2.1: General -2.1: General

Advanced Im tables bdominalultrasound

Pain eviCore healthcare eviCore (CPT MRI   Persistent abdominal pain and at least ONE      

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Advanced 8924  Pelvis should goto M RequestsCT for and technique. radiation protection with careful attention to be safely performed thefor mother, it can considered life saving imaging may be individual In carefully selected  red flag: one accompanied with any ultrasound or if pain is *If equivocal  red flag one accompanied with: any ultrasound or if pain is *If equivocal CT CT  flag, pain or any onered equivocal with acute ultrasoundIf is D

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Page 16of144

and contrast Abdomen Comments

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procedures. potential etiologies, which might be better evaluated with different imaging LUQ pain is more difficult to categorize with regards to imaging as there are many      

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ACR Appropriateness Criteria Appropriateness ACR Gastroenterology of Journal American dyspepsia. of management the for Gastroenterology.Guidelines of College American the of Committee Parameters Practice the and N, Vakil NJ, Talley of the abdomen and/or retroperitoneum, amended 2014(Revised 2017). 2017). 2014(Revised amended retroperitoneum, and/or abdomen the of Rosen MP, Ding A, Blake MA, et al. ACR appropriateness Criteria appropriateness ACR al. et MA, A, Blake Ding MP, Rosen - meta A adults? Hui J, Sheth S, Kim DU, et DU, Kim S, Sheth Hui J, Moayy 2008 . Physician Fam Am Adults. in Pain Abdominal Acute of Evaluation M. Knudsen and S Cartwright College of Radiology of College Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for diagnosis for CT or US al. et CJ, Kellenberger R, Moineddin AS, Doria Radiology of College American the of Journal appendicitis. suspected Appropriateness Criteria Appropriateness ACR Imaging. Gastrointestinal on Panel Expert al. et MP, Rosen MP, Smith GM, Yarmish Medical Journal). Medical British by (Content - 2014;57(3):284 . & Rectum Colon the of Diseases Diverticulitis. Sigmoid of Treatment the for Parameters Practice al. S, et Lee SR, Steele D, Feingold Patients infection. pylori H. and Disease Ulcer Peptic of Treatment and A.Diagnosis Gitu and J Fashier Dyspepsia. Ringel . doi:10.1038/ajg.2017.190 Gastroenterology of Journal American The Dyspepsia. of Management Guideline: Clinical CAG and ACG 2017: July Education: Medical Continuing Osteopathic Family Physician; Jan/Feb, 2019.11(1). Jan/Feb, Physician; Family Osteopathic Provider. Care Primary the for Tips Pain: Abdominal Chronic M. Channell, King M, Chery, G, Charles, - 236 (4): 15:91 Feb 2015 Physician Fam - 2015;38(2):49 Australian adults. in pain abdominal chronic for Imaging tests: Diagnostic R. Mendelson . . doi:10.1097/ta.0000000000002137 - 2019;86(4):722 Surgery. Care and Acute Trauma of Journal appendicitis. uncomplicated acute of treatment antibiotic conservative of Methods GJ. Moran DA, Deugarte DJ, Saltzman DA, Talan . doi:10.4240/wjgs.v4.i4.83 2012;4(4):83. Surgery. Gastrointestinal of Journal World needed. it really Is appendicitis: acute of treatment conservative following appendectomy routine Interval GH. Sakorafas

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Radiology of College American abscess. abdominal suspected or fever and pain abdominal (nonlocalized) Appropriateness Criteria Appropriateness ACR Imaging. Gastrointestinal on Panel Expert al. et MP, Rosen , TA Rose Small WC, abdominal pain and fever or suspected abdominal abscess. ACR Appropriateness Criteria Appropriateness ACR abscess. abdominal suspected or fever and pain abdominal Beyond 60 days postoperatively, See bowel obstruction, abscess or anastomotic leak). 72193) suspectedfor postoperative/post procedure complications (For example: CT Abdomen and/or Pelviswith contrast (CPT Yaghmai V, Rosen MP, Lalani T, et al. ACR Appropriateness Criteria Appropriateness ACR al. et T, Lalani MP, V, Rosen Yaghmai 2013). (Revised 2010. -7.1: Post

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AB-8: Abdominal Lymphadenopathy AB-8.1: Abdominal Lymphadenopathy 35 AB-8.2: Inguinal Lymphadenopathy 35 AB-8.3: Sclerosing Mesenteritis and Mesenteric Panniculitis 36

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  Generalized inguinal lymphadenopathy should prompt:    Localized inguinal lymphadenopathy should prompt: Guidelines Other Types and of Cancer Primary Site, Unknown Prior history of malignancy See Lymphoma Hodgkin biopsy is inconclusive, PET/CT (CPT followa If    malignancy: Clinical or laboratory findings suggesting benign etiology, andno history of    Clinical or lab findings suggesting alymphoproliferative disorder:   History malignancyof High High 8.2: Inguinal Lymphadenopathy Inguinal -8.2: Lymphadenopathy Abdominal -8.1:

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sequential radiologic imaging to assess treatment response is not recommended. management decisions are guided by the severity andtype of symptoms. Thus, ad In authors. scans with the aim of detecting a future malignancy”1. This is supported by other abdomino- subjec subsequent malignancy is inconclusive andthus “it does not seem justified to However, studies have reported that the data on potentially developing a response in those undergoing active treatment. asymptomatic individuals. In addition, requests may be made to assess the clinical mesenteritis, and this has resulted in requested for sequential imaging in stable or There is an increased prevalence of malignancy in individuals with sclerosing though this is controversial. possibly may represent aparaneoplastic syndrome secondary to a malignancy, (previous abdominal surgery), anautoimmune process, ischemia, infection, and retroperitoneal organs. The etiology is uncertain, but may besecondary to trauma the gut (causing obstruction), t The chronic inflammation may result in fibrosis with amass effect and can involve stages of one disease with progression. mesenteritis, mesenteric panniculitis, and mesenteric lipodystrophy), or may be Sclerosing mesenteritis may represent a spectrum of diseases (retractile       the mesentery, with radiologic findings including understood entities that are characterized by anidiopathic inflammatory condition of Scl Mesenteric Panniculitis P  to monitorthe for developmentof malignancy: R  F -8.3: Sclerosing andMesenteritis Panniculitis Mesenteric or new or worsening clinical symptoms, or if not previously performed: ET imaging is not indicated thefor evaluation of Sclerosing Mesenteritis or

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. doi:10.1016/j.soard.2018.01.009 Diseases Related and Obesity for Surgery cases. 1200 acohort of results patients; bariatric of management on the investigations preoperative of impact The R. Peterli B, C, Wölnerhanssen Beglinger M, Kraljević I, Lazaridis R, Schneider Endoscopy Gastrointestinal Varghese JC Varghese Complications. RadiologyComplications. MS Levine Radiology - Gaetke See evaluation with CT imaging. have intermittent and relatively mild abdominal symptoms which require immediate Note: flags”. recommendations for imaging in the post bariatric surgery can become quickly life- inducedand anultrasound Though and biliopancreatic diversionprocedures. Bariatric procedures include gastric banding, gastric bypass, sleeve gastrectomy, –  Post-  Pre 9.1: Bariatric Surgery Bariatric -9.1:

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. . doi:10.1016/j.annemergmed.2011.01.013 Abdominal Issues Diercks 942. JO, Jansen Guideline. Washington JAMA Nishijima 693. Soto ACR   74177): CT Abdomen and/or Pelviswith contrast (CPT approvedthe forevaluation of bluntabdominal Abdominal and/or 10.1: Blunt Abdominal Trauma Abdominal Blunt -10.1:

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and stem cell transplant individual (e.g., sickle cell disease, thalassemia, oncology individual For the evaluation of suspected hepatic iron overload in chronic transfusional states    MRI Abdomen without contrast (CPT accumulation in the spleen, liver, kidneys, lung, brain, and bone marrow Gaucher diseasei Imaging   contrast (CPT MRI S 11.2: Hereditary (Primary) Hemochromatosis (HH) and Other Iron Iron Other and (HH) Hemochromatosis (Primary) Hereditary -11.2: -11.1 ee

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Appropriateness Criteria Appropriateness ACR Imaging. on Urologic Panel Expert al., et B, Friedman JR, S, Leyendecker Hartman . doi:10.2214/ajr.13.12071 2014;202(6). Roentgenology. of Journal American Hernias. Abdominal Adult MM. Maher OJ, Oconnor KP, Murphy Physician ement. Manag and Diagnosis hernias: Inguinal KA. LeBlanc LL, LeBlanc KE, LeBlanc 017- - 2018;22(1):1 Hernia. management. hernia groin for guidelines International Yaghmai V, Yee J, Cash B, B, V, Yee Cash J, Yaghmai palpable abdominal mass. American College of Radiology. Published 2014. Published Radiology. of College American mass. abdominal palpable Reston (VA): (VA): Reston See -12.4: Indeterminate Groin Pain

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has been performed contrast (CPT indeterminate, CT Abdomen with andwithout If initial CT Abdomen without contrast is contrast indicated is after initial AbdomenCT without and/or suppression testing: A CT primary aldosteronism is confirmed onbiochemical If adrenal vein sampling (AVS) planned is once contrastCT contraindicated. is indicated or MRI Abdomen (contrast as requested), if s with bilateral adrenal masses, with each - ONC

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Chemical      Signs andsymptoms of pheochromocytoma: Biopsy is often considered if pheochromocytoma is excluded. hormone- Resection or biopsy is often considered r mass fo hormone secreting. Routine screening for endocrine function is recommended since 5% carcinoma is as high as 5%. Metastases with history of malignancy are 25- The majority of “incidentalomas” are benign adenomas. The risk of primary adrenal adrenomyeloneuropathy. necessary testing if has confirmed adrenal insufficiency or (CPT CT .3:-15 Insufficiency Adrenal :-15.2

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- 756 2008,49: RSNA, Characterization. Imaging for Algorithms and Techniques, Principles, Lesions: Adrenal Incidental al. et PF, Hahn MA, Blake GW, Boland - 414 39: 2015, JCAT, Sampling. Vein Adrenal with Tomography Computed Multidetector Distinguish in Tomography Computed Multidetector of Performance Diagnostic al. et M, P, Lessne, Siva Raman, - 31;361(9372):1881 May 2003 Lancet. insufficiency. Adrenal B. Allolio Arlt W, - 5):351 Sep;46(Pt 2009 AnnClinBiochem. adults. in sufficiency adrenalin of investigation and diagnosis The J. Lindsay S, Cunningham I, Wallace - 1043 202: 2014, AJR, CT. Washout and MRI Seo - 2008Sept;93(9):3266 Metabolism, and Endocrinology Clinical of Journal Guideline. Practice Clinical Society Endocrine An Aldosteronism: Primary with of and Treatment Diagnosis, Detection, Case al. et C, Fardella Carey RM, JW, Funder Reontgenology of Journal malignancy. known no with in individuals masses adrenal consecutive 1,049 in disease Differentiation of Adrenal Pheochromocytoma from Adrenal Adenoma. Am J Roentgenol. J Am Adenoma. Adrenal from Pheochromocytoma Adrenal of Differentiation T A, Flood Arrashad N, Scheida Chaudry JH, Song 206(6) Reontgenol Am J masses. adrenal indeterminate - 1319 29: 2009, Radiographics, Practice. Interpretative and Optimization Protocol - ence Evid CT: Multidetector with Imaging Adrenal EK. Fishman, KM, Horton PT, Johnson Follow necessary? imaging further is cancer: without individuals in Chaudry JH, Song 1044. 1044. - 2014;99(6):1915 Guideline. Practice Clinical Society Q Duh JWM, Lenders . doi:10.4158/ep.15.5.450 Criteria Bishoff DD, EM, Casalino Remer - Feb;90(2):871 & Endocrinology Clinical of Journal Experience. Clinic Cleveland nonadenomas: from adenomas/hyperplasias adrenal differentiate to Units) (Hounsfield value attenuation tomography EM, Remer AG, Ioachimescu AH, Hamrahian JACR J JACR Committee. Findings Incidental ACR the of paper Mayo Incidentalomas: Executive Summary of Recommendations. Recommendations. of Summary Executive Incidentalomas: Adrenal of Management the for Guidelines Medical Surgeons Endocrine of Association American & Endocrinology Clinical of Journal The Guideline. Practice Clinical Society Endocrine An Treatment: and Diagnosis, Detection, Case Aldosteronism: Primary of Management The al. et F, Mantero Carey RM, JW, Funder Q Duh G, Thompson M, Zeiger

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- May;190:1163 2008 , Rights Reserved. Rights - 2016;101(5):1889 . Metabolism - - Smith WW. The incidental adrenal mass on mass adrenal incidental The Smith WW. Smith WW. The incidental indeterminate adrenal mass on CT (> 10 H) 10H) (> onCT mass adrenal indeterminate incidental The Smith WW. - Y, et al. American Association of Clinical Endocrinologists and and Endocrinologists Clinical of Association American Y, al. et A. Comparison of Quantitative MRI and CT Washout Analysis for for Analysis andCT MRI Washout Quantitative of A. Comparison

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– O46 19: Dis, Colorectal prolapse. compartment floor pelvic posterior for defaecography conventional and contrast rectal with defaecography - 2015;110(3):444 Journal American The IBS. With Adults in Disease Bowel Inflammatory Exclude to Lactoferrin Fecal and Calprotectin Fecal Rate, Sedimentation Erythrocyte Protein, van Iersel JJ Iersel van Gastroenterology onConstipation. Review Technical Association Gastroenterological American 3: Exam A. Bharucha Gastroenterology diarrhea. chronic of and management evaluation the for Guidelines statement: position medical Association Gastroenterological American - V):v1 2003;52(Suppl Gut diarrhea. chronic of investigation the for Guidelines al. et J, Green A, Forbes PD, Thomas 622. Gastroenterology of Journal American The Adults. in Infections Diarrheal Acute of Prevention and Treatment, Diagnosis, Guideline: Clinical ACG BA. Connor HL, Dupont MS, Riddle prolapse. vault in vaginal imaging reso magnetic dynamic and examination Clinical L. Berger K, Singh WMN, Reid E, Cortes Gastroentero constipation. on Guidelines statement: position medical AGA Association. Gastroenterological American Disorders. Disorders. A Wald - A Meta Chey WD. A, Goel J, Kurlander C, Powell SB, Menees . . doi:10.1038/ajg.2008.122 2008;104(S1). Gastroenterology. of Journal American - An Evidence doi:10.7326/aitc201706060 2017;166(11). . Medicine Internal of Annals Syndrome. Bowel Irritable A. Malhotra S, Sultan

Am Fam Am Fam Syndrome? Bowel Irritable it Is habits: bowel altered and pain abdominal with individual the Diagnosing L. Bankston A, KB, Wetherington Holten - Evidence syndrome: radiolo of Role S, al. et McWiliams SE, McSweeney OJ, O’Connor Gastroenterology of Journal American The Constipation. Idiopathic Chronic and Syndrome Bowel Irritable of Management the on Monograph Gastroenterology of College American al. et BE, Lacy P, Moayyedi AC, Ford - Evidence Syndrome: Bowel in Irritable Imaging Radiologic of Role S, al. et Mcwilliams SE, Mcsweeney OJ, O’Connor

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, Bharucha AE, Cosman BC, Cosman AE, Bharucha Am. J. Gastroenterol J. Am. , Based Position Statement on the Management of Irritable Bowel Irritable of Management the on Statement Position Based Jonkers

Guidelines . . doi:10.1038/ajg.2015 454. . 2013;144(1). 2013;144(1). . . 2014;109(S1). doi:10.1 2014;109(S1). . based review. Radiology review. based v5. v5. based Review. Radiology Review. based F . All All . , Verheijen PMm et al. et PMm Verheijen ,

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; - 119:1761 ObstetGyneco

et.al. Clinical Guideline: Management of Benign Anorectal Anorectal Benign of Management Guideline: Clinical et.al. 1778.

. 038/ajg.2014.187 - 485 2012;262(2): ,

(2017), Comparison of dynamic magnetic resonance resonance magnetic dynamic of Comparison (2017), - 2012;262(2):485 . O53. O53. - 103:41 l 2004;

Physician, - 1999;116(6):1461 . 8924

Analysis of the Utility of C of Utility the of Analysis 46. 46. - 67(10):2157 2003; 494. 494. doi: 494. gic imaging in irritable bowel bowel in irritable imaging gic

of Gastroenterology of . . 10.1148/radiol.11110423 1463.

Syndrome. The The Syndrome. - 11(5):602 2016;1 .

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ForTIPS placement, brisk active b    lower endoscopies are negative: If small bowel bleeding is suspected as the source of bleeding, and if upper and Gastrointestinal Meckel’s diverticulum M        A CTA Colonoscopy for lower GI bleeding as initial evaluation Endoscopy upperfor GI bleeding as initial evaluation   Anemia Deficient Iron Suspected Bleeding Bowel Small .2: -18 .1:-18 GI Bleeding bdomenand

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A bdomen stricture is stricture VCE is not required prior to advanced imaging small if bowel obstruction or nterography eding and severe abdominal pain Providers occasionally request aCT or MR E

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Hemorrhage in Cirrhosis. Cirrhosis. in Hemorrhage Garcia - 107:345 Bleeding. Ulcer with Individuals of Management D. Jensen L, Laine Physician, Short of occult and obscure gastrointestinal bleeding. gastrointestinal obscure and occult of management and Evaluation Statement: Position Medical Association Gastroenterological American Loss Blood Gastrointestinal of Evidence Clinical without Anemia Deficiency Iron Investigating S. Ghosh Gastroenterol, position statement on obscure gastrointestinal bleeding. gastrointestinal obscure on statement position medical Institute (AGA) Association Gastroenterological American al. et A, Das L, Gerson GS, Raju - 2017;152(3):497 Gastroenterology. Endoscopy. Capsule Video of Use the for Guidelines Practice Clinical al. et D, Armstrong L, Hookey RA, Enns bleeding. gastrointestinal obscure and occult of t managemen and evaluation the on review Technical AGA al. et MP, Askin C, Prakash GR, Zuckerman l, Gerson Gastrointestinal Strate Fam Wilk with Techniques Conference of AN, Barkun Of CJ, Laing Gastroenterological American ACR

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of Journal Canadian . Physician M Appropriateness

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Tsao G, et al. Prevention and Management of Gastroesophageal Varices and Variceal Variceal and Varices Gastroesophageal of Management and Prevention al. et G, Tsao T, capsule endoscopy is negative , E CT (if 74177) CT (unless contraindicated). Small bowelvi indicated. Upper endoscopy and colonoscopy should be performed, unless contra - given the lack of motion artifact and its superior spatial resolution. capsule findings. Domagalski and . . 360

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Gralnek Kh 2013

. Bardou al. Radiographics Group. Abdomenand an N,

Obscure . Guidelines - 2015;110:1265 ACG

2012 CT Bleeding. 15; Jan

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Upper nterography is contraindicated) can be performed, if small bowel video T,

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Bleeding. International

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- 2015;110(3):444 American The IBS. With Adults in Disease Bowel Inflammatory Exclude to Lactoferrin Fecal and Calprotectin Fecal Rate, Sedimentation Erythrocyte Protein, - 2016;59(12):1117 - A Meta Chey WD. A, Goel J, Kurlander C, Powell SB, Menees Capsule Video of Use the for Guidelines Practice Clinical al. et D, Armstrong L, Hookey RA, Enns study. A multicenter Greek diarrhea: without or with pain abdominal chronic with in patients endoscopy capsule wireless of impact clinical and yield Diagnostic al. et A, Beltsis K, Fasoulas P, Katsinelos Abscess, Fistula Anorectal of Management the for Guideline Practice Clinical al. et AM, Morris EK, Johnson JD, Vogel . doi:10.3748/wjg.v13.i23.3153 2007;13(23):3153. Gastroenterology. of Journal World disease. anorectal in imaging resonance magnetic of Utility L. Berman - 2009;7(10):1037 Hepatology. Felt M, Ziech Hepatology Cholangitis. Sclerosing Primary of Management and Diagnosis al. et A, Kalloo J, Fevery R, Chapman Hepatology cholangitis. sclerosing primary with individuals in Surveillance Cancer al. et N. Razumilava, - 2015;110:646 Gastroenterol. J Amer ng Cholangitis. Sclerosi Primary Guideline: Clinical ACG al. et KD Linder Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria Appropriateness ACR Imaging. on Gastrointestinal Panel Expert Opinion in Gastroenterology. Opinion Lin MF Radiology Small Endoscopy, Capsule Enterography, CT among Hei JA, Leighton AK, Hara . doi:10.1038/ajg.2018.27 517. - 2018;113(4):481 Gastroenterology. of Journal American Adults. in Disease Crohnʼs of Management Guideline: Clinical ACG BE. Sands LB, Gerson MD, Regueiro KL, Isaacs EV, Loftus GR, Lichtenstein endoscopy, especially there if is suspected inflammatory bowel disease. prior to endoscopy if requested by the physician who will beperforming the CT College of Radiology (ACR) Radiology of College erences .5: .5: -19 there stage

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- 2010;30(7):1955 RadioGraphics. Findings. of and Interpretation Al KM, Elsayes Resonance Imaging. 2017;46(4):10 Imaging. Resonance Magnetic of Journal features. genetic and serologic, pathologic, endoscopic, with Correlation disease: celiac adult nonresponsive in enterography MR al. ES, et Nik APH, Taheri AR, Radmard - (2):252 2015;33 Diseases. Digestive Disease. in Celiac Bowel Imaging Small JHTV. CJ, Waesberghe Mulder SJV, Weyenberg The American Journal of Gastroenterology of Journal American The Disease. Celiac of Management - Rubio  Diagnosis is made by blood testing intestinal adenocarcinoma. Complications of celiac disease include ulcerative jejunitis, lymphoma, and small from eating gluten (found in wheat, barley, and rye). Celiac is an autoimmune disease in which the villi the of small intestine are damaged   74176 or CPT CT anti Endoscopy and biopsy of the small bowel is performed to confirm the diagnosis if the -20

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Disease .1: Celiac tTG and EMA tests are positive. bdomenand Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA. ACG Clinical Guidelines: Diagnosis and and Diagnosis Guidelines: Clinical ACG JA. Murray AH, Calderwood CP, Kelly ID, A, Hill Tapia - s s tissue transglutaminase antibody (anti . .

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Hawary MM, Jagdish J, Ganesh HS, Platt JF. CT Enterography: Principles, Trends, Trends, Principles, Enterography: CT JF. Platt HS, Ganesh J, Jagdish MM, Hawary is experiencing new or continued weight loss, diarrhea, abdominal ® 74177) is appropriate for: P . All All . elvis

, or other symptoms suggesting complications of celiac . . doi:10.1159/000369516 259. Rights Reserved. Rights with contrast (CPT

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AB-21: CT Colonography (CTC) AB-21.1: CTC 79

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eviCore healthcare eviCore organs There is a clearly stated indication for IV contrast to evaluate extra- surgery can beperformed, if desired. There is a known obstructing colorectal malignancy so that staging prior to     abnormality Failed conventional colonoscopy (e.g. due to a known colonic lesion, structural should bescreened via colonoscopy, not CTC). with CRC or anadvanced adenoma, or a first degree relative <60, the individual CTC beginning at age 40. (If there are 2 or more first degree relatives at any age colorectal cancer or an advanced adenoma can be screened every5 years with Individual there is no history of a previously negative colonoscopy or CTC O E *T P OR (HNPCC), cancer I C OR FIT adenomas, or inflammatory bowel disease involving the colon) (average risk is defined as no previously diagnosed colorectal cancer, colonic include: Conventional colonoscopy is medically contraindicated. Contraindications may E ndividual

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AB-22: Cirrhosis and Liver Screening for Hepatocellular Carcinoma (HCC); Ascites and Portal Hypertension AB-22.1: Chronic Liver Disease, Cirrhosis and Screening for HCC 82 AB-22.2: Ascites 83 AB-22.3: Portal Hypertension 83 AB-22.4: Monitoring After Fontan Procedure 84

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M - 2018;11(1):1 Disease. Liver Clinical - Fontan N. Ovchinsky T, Diamond Radiology and Interventional Vascular of Journal Shunts. Portosystemic Intrahepatic Transjugular for Guidelines Improvement Quality al. et M, Midia ZJ, Haskal SR, Dariushnia - 2017;70(25):3173 Cardiology. of College American - MJ, al. et Fontan EA, Landzberg Bradley CJ, Daniels Hepatology Diseases. Liver of Study the for Association American the by Guidance Practice 2018 Carcinoma: Hepatocellular of Management and Staging, Diagnosis, al. et CB, Sirlin LM, Kulik JA, Marrero . doi:10.1016/j.jvir.2015.09.018 doi:10.1055/s - 2018;40(13):1057 Journal. Heart European cohort. screening multimodality aprospective from results disease: Contraindications, and Patient andPatient Work Contraindications, Indications, Shunt: Portosystemic Intrahepatic Transjugular A. Copelan M, Sands B, Kapoor . doi:10.1002/hep.23392 Hepatology 2009. update hypertension portal of management the in (TIPS) shunt portosystemic intrahepatic transjugular of role the guidelines practice AASLD ZJ. Haskal TD, Boyer 1437 Radiol. Coll Am J JACR Committee. Findings Incidental ACR the of paper white a CT: on lesions liver incidental of Management al. et KJ, Mortele PJ, Pickhardt RM, Gore Hepatology - Non SK. Sarin R, Khanna . NCCN.org to online go Guidelines™, NCCN the of version complete and recent most the view To NCCN. the of permission written express the without purpose any for form any in reproduced be not may herein illustrations and Guidelines™ NCCN The reserved. – V 2.2018 cancers, Hepatobiliary for Guidelines™) (NCCN in Oncology Guidelines Practice Clinical NCCN the from permission with Referenced https://www.nccn.org/professionals/physician_gls/pdf/hepatobiliary.pdf Guidelines Version 2.2018 2.2018 Version Guidelines (NCCN) Network Cancer Comprehensive National al. et D Abbot MI, D’Angelica AB, Benson Hepatology carcinoma. hepatocellular of treatment the for guidelines AASLD al. et RS, Finn LM, Kulik JK, Heimbach

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AB-23: MR Cholangiopancreatography (MRCP) AB-23: MR Cholangiopancreatography (MRCP) - General 88 AB-23.1: MRCP 88

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when Kaltenthaler of College for Faerber F  difficult. ERCP is indicated but is not available, is contraindicated, or is expected to be be opened by ERCP. Evaluation of pancreaticobiliary anatomy proximal to a biliary obstruction that cannot Failed ERCP in an ERCP Failed Altered biliary anatomy that precludes ERCP (e.g. post Guidelines Evaluation Preoperative planning  Rule out pathology in the biliary system or pancreatic duct. -23 -23: or 3D requests:

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. . doi:10.1016/j.gie.2012.09.029 treatment MA, Anderson - 2018;24(26):2844 management RS, Mccain Medical - Andrén Radiology. Wiles  For confirmed gallbladder malignancy:  Findings on ultrasound or EUS suspicious for malignancy:  Alternative Imaging:  Gallbladder polyp ≥10 mm:   No increased risk gallbladderfor malignancy:   Increasedrisk gallbladder for malignancy:     Individuals at i :24.1 Gallbladder Polyps

eviCore healthcare eviCore Oncology Imaging Guidelines CT Abdomen with or without and with contrast (CPT gallbladder polyps. MRI) should be used ahead of conventional ultrasound in the investigation of of gallbladder polyps. There is insufficient data that advanced imaging (CT or Endoscopic ultrasound (EUS) may provide additional information in the diagnosis risk gallbladder of Surgery recommended. If surgery not performed, follow guidelines for increased  Polyp 6-  Polyp <6 mm  Polyp 6-  Polyp <6 mm Sessile polyp or gallbladder wall thickening >4 mm Indian ethnicity Primary Sclerosing Cholangitis Age >50

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 Incidental Liver Lesion discovered on CT:    Incidental Liver Lesion discovered on US:     Low Abdomen without and with contrast (CPT and with contrast (CPT Note: Advanced imaging approvals in this section refers to MRI Abdomen without -25

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individuals defined as: Suspiciousimaging features noted byradiologist st sclerosing cholangitis*, choledchal cysts, hemochromatosis, or anabolic HCC High specific guidelines in the Oncology Imaging Guidelines). See malignancy, please refer- to ONC (NOTE: For additional considerations in individuals with aknown metastasize to the liver High No further advanced imaging - high -

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eviCore healthcare eviCore atypical or inconclusive. If documented that a percutaneous liver biopsy is to beconsidered if imaging is  cysts: Hepatic  Focal Nodular Hyperplasia (FNH): protocol): Hepatic Hemangioma (if not completely characterized oninitial CT without aliver    considered MRA Abdomen (CPT Oncology Imaging Guidelines For suspected liver metastases, See- ONC gas, chest wall deformity, etc.) specifically noted technical limitations of US such as obscuration by intestinal **If there is a technical limitation to US (e.g. marked heterogeneity, or other Fatty liver onUS with a focal liver lesion.   Suspectedhepatic adenoma: have been categorized, regardless of size, see below Most lesions ≥1cm can be categorized by MRI or histology. For lesions which

 calcifications, irregular walls, as well as the presence of daughter cysts): For complicated cysts (US shows internal septations, fenestrations, can be done if the lesion is not adequately visualized onUS. FNHwho are continuing to use oral contraceptives. Follow Additional follow in differentiating FNH from other lesions seen onMRI or CT. to confirm a diagnosis of FNH. The use of Eovist contrast is often diagnost   demonstrates classic features of hemangioma with the following exception: establish any growth patterns and assess for malignant transformation. can be CT or MRI Abdomen every 6months for 2years, and then annually, MRI is considered the best technique characterization.for Follow Asymptomatic, simple cysts donot require additional follow Additional follow MRI Abdomen (CPT Multiphase CT Abdomen (CPT

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No central scar No rim enhancement Vessels can course through the region Abs Area with sharply demarcated borders Delayed post rapidly out Washes May have anecrotic central region (hyperintense) due to hepatic arterial supply. During the early arterial phase: HCC appears brighter than surrounding liver contrast bolus. Dynamic imaging via MRI andCT follows tumor density with time after IV during imaging. artery and70% from the portal vein, and this discrepancy can be exploited hepatic artery, whereas the liver parenchyma recei HCC’s are hypervascular and receive 100% of their blood supply from the lipid lesional MRI specifics: Hyperintense signal on T1 and - T2 No central scar Fills in from the periphery (nodular centripedal fill Peripheral nodularenhancement Hyperechoic Triple the etiology of alesion non A No rim enhancement Central hemorrhage Washout non A Fat Irregular enhancement    MRI specifics: Central Washout. No delayed rim enhancement Homogenous enhancement phases)

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Isolated elevated bilirubin (no other LFTs elevated).     where it was drawn andother LFTs are normal: Forelevated A      The .1: .1: -26 Elevated alkaline phosphatase level, and other LFTs are normal

eviCore healthcare eviCore    Etiology of elevated ALKP should be determined prior to imaging.  >15X normal:  2 to 15X normal:   <      “R” Ratio I M C H

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2X normal holestatic epatocellular ixed pattern   checked prior to If no dilated biliary ducts: anti  ALKP RUQ ultrasound (CPT is necessary.confirmatory test hepatic etiology, prior to imaging. If ALKP is elevated If isolated ALKP elevation, GGT should be obtained confirmationfor of Abdominal US with Doppler (CPT US Abdominal (CPT US Abdominal applicable.if elevated LFTs (such as statins, niacin, sulfa, rifampin, tetracycline, estrogen) Repeat lab after 3weeks and discontinuation of medications associated with individual lab report Use ULN ALTfor as noted below, and ULN for alkphos based on the For cholestatic, use ALKPH elevation guidelines For hepatocellular, use AST or ALT elevation guidelines  ALKPH) (ULN))/(ALKPH/ULN of normal limit R=(ALT/Upper hepatocellular in origin of multiple elevated liver chemistries is predominately cholestatic or “R” Ratio: The so-

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- 2016;33(04):253 Radiology. in Interventional Seminars Jaundice. with Patients to Approach Systematic A B. Gondal A, Aronsohn College American - 14 105: 2010, Gastroenterology. of Journal American disease. liver alcoholic guidelines: practice ACG AJ. McCullough S, Dasarathy RS, O’Shea 112:18 2017; Gastroenterol et Paul, Kwo,   with BMI >35): diagnostic or technically limited US (e.g., large amounts of intestinal gas, obesity suspected tumor),USor findingssuggesting mechanical biliaryobstruction, non- suspected stricture from a recent invasive procedure, previous biliary surgery, laboratoryvalues (e.g., known choledocholithiasis, acute and chronic pancreatitis, Clinical jaundice, suspected mechanical obstruction based on clinical condition or   Clinical jaundice, no known predisposing condition Lesion Characterization needs further characterization, refer to liver lesion imaging as per MRCP results, as appropriate to the finding (for example, if a lesion is identified that Requests for additional advanced imaging (CT,MRI, etc.) are based onthe US or to the specific oncology guidelines, when appropriate. For individuals with elevated LFTs and history of underlying malignancy, please refer those with IBD,S For individuals with elevated LFTs and suspicion of sclerosing cholan asgitis, such  - 2017;95(3):164 Physician, Fam Am Adults. in Jaundice of Evaluation et.al, MV, Fargo, - 2009;51(2):237 Hepatology. of Journal diseases. liver cholestatic of Management Guidelines: Practice Clinical EASL

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     Pancreatic Cyst seen on Imaging     This guideline applies to the following pancreatic cystic lesions:   Note:  CystPancreatic  .1: Pancreatic Cystic.1:-27 Pancreatic

risk

eviCore healthcare eviCore If any of the following are present cystadeno Radiographic diagnosis of a non- US or CT Abdomen has been performed. the lesion, without reference to the timeframe for proceeding with surveillance. MRI/MRCP can be approved to better characterize Indeterminate cysts may benefit from asecond imaging modality or EUS prior to unableare to undergo MRI CT evaluation. MRI Solid Se Mucinous cystic neoplasms (MCN Intraductal which palliative treatment might be available. cystsymptomatic (such as the development of jaundice secondary to cyst), in candidate. However, follow Surveillance should be discontinued if a surveillance of incidentally found pancreatic cysts, irrespective size of . Individuals  and depending on findings, surgical consultation:     present,then thenext follow If high risk features (See below High Risk Considerations and Features) are not then f cytologywith high- If EUS does not reveal findings of main duct involvement, patulous ampulla,  

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   High cystadenomas, do not require further evaluation. initial imaging and clinical history, or are determined to be serous Individuals If increase in cyst size, EUS + FNA If remains stable, consider lengthening of surveillance interval. years. If stable for 3years, increase interval to MRI alternating with EUS yearly 4 for MRI alternating with EUS every 6 If If stable after 3 years, change to MRI everyyear for 4 years evaluation If the cyst is determined to be a serous cystadenoma, then no further MRI every 6 every MRI and if remains stable, resume original surveillance schedule. If increase in cyst size, repeat MRI in 6 months. If stable, repeat MRI in 1year surveillance. If stable after the additional 4 years, consider lengthening of interval for If stable for 3years, then change to MRI every 2years 4 for years yearly MRI If stable, repeat again in 1year and if stable return to MRI every 2years. If increase in cyst size, then MRI or EUS in 6 months. If stable after 4 years consider lengthening of interval imaging MRI every 2years for 4 years

≥ <1cm remains 3cm 3cm -<3cm -<3cm -<2cm   Additional features which may prompt early evaluation are EUS. increased risk of malignancy and R Individuals Surveillance for a presumed IPMN or MCN - apid increase in cyst size (>3mm/year) during surveillance may have an

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- 2017;5(2):153 Journal. Gastroenterology European United (HaPanEU). pancreatitis chronic of therapy and diagnosis the for guidelines based Dominguez JM, Löhr - 2014;43(8):1143 Pancreas. Pancreatitis. in Chronic Guidelines Practice Association Pancreatic American al. et D, Yadav LS, Lee DL, Conwell doi:10.2214/ajr.10.4339. 2011;197(3). Roentgenology. of Journal American Pancreatitis. Acute of Complications the of Imaging MM. Maher JM, Buckley OJ, Oconnor doi:10.1097/md.0000000000000960. 2015;94(24). K Xie MH, Pan G, Wan doi:10.3748/wjg.v20.i45.16891. 2014;20(45):16891. Gastroenterology. of Journal World treatment. and diagnosis Etiopathogenesis, pancreatitis: recurrent Acute PA. Testoni doi:10.1053/j.gastro.2013.02.008. 3;144(6). 201 Gastroenterology. Pancreatitis. Chronic of Management CE. Forsmark 2016; Surgery. of Journal Canadian pancreatitis. acute of management guideline: practice Clinical al. et M, Bawazeer J, Hsu JA, Greenberg ACR Appropriateness Criteria: Acute Pancreatitis. Rev. 2019. 2019. Rev. Pancreatitis. Acute Criteria: Appropriateness ACR doi:10.1148/rg.2019194003. Pancreatitis: A Pictorial Essay Pictorial A Pancreatitis: Acute for Classification Atlanta Revised FV. Coakley AM, Shaaban G, Bakis KK, Jensen BR, Foster doi:10.3998/panc.2016.31. Base. Knowledge Pancreas Exocrine Pancreapedia: The Pancreatitis. Acute of Severity and Etiology of Assessment Imaging doi:10.3748/wjg.v22.i7.2304. - 2016;22(7):2304 Gastroenterology. of Journal World dilemma. diagnostic A pancreatitis: Chronic KC. Conlon DB, O’Connor O, Lawal HMN, Chonchubhair SN, Duggan - 2012;10(10):1088 Hepatology. and Gastroenterology Clinical Diagnosis. the Making Pancreatitis: Chronic BU. DL, Wu Conwell

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88. Radiology scans. phase venous portal and arterial for need injury: splenic blunt Bosc - 2013;94(4):410 Apr . Imaging DiagnInterv trauma. multiple have may who patient a in scan CT body whole a performing when injection contrast without acquisition abdominopelvic of value the of Evaluation al. A, et Gervaise J, P, Wassel Naulet J VascIntervRadiol J trauma. - Boyd K, Shanmuganathan KL, Killeen Med Ultrasound J spleen. the of Sonography U. Teichgräber L, Klühs T, Benter British Journal of Radiology of Journal British findings. imaging O’Regan KM, Krajewski SS, Saboo Thut, Daniel, et. al. A diagnostic approach to splenic lesions. Appl. Radiology 2017; 46 (2): 7- (2): 46 2017; Radiology Appl. lesions. splenic to approach diagnostic A al. et. Daniel, Thut, - 833 Pages 11, Issue 10, Vol. Radiology, of College American the of 3.Journal Part MRI, and CT Pelvic and Abdominal on Findings Incidental Managing al. et. Matthew, Heller, the left upper quadrant. See trauma with

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Abdomen Imaging Abdomen Imaging Guidelines V1.0

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Abdomen Imaging

AB-40: Liver Elastography  Vibration-Controlled Transient Elastography (VCTE) (e.g. Fibroscan, CPT® 91200) may be considered appropriate to assess for advanced fibrosis and cirrhosis in the following conditions:  Hepatitis C  Hepatitis B  Chronic alcoholic liver disease  All other chronic liver diseases  If requested, Magnetic Resonance Elastography Liver (MRE, CPT® 76391) can be approved for:  Non-alcoholic fatty liver disease (NAFLD) in high risk (for cirrhosis) populations:  Advanced age (≥65 years)  Obesity (BMI ≥30)  Diabetes  ALT >2X upper limit of normal  For NAFLD in low risk populations (e.g. signs of fatty liver found on imaging only, without the above-noted risk factors) MRE would be considered investigational.  The use of VCTE and MRE are considered experimental and investigational for all other indications with regards to liver disease  The use of other ultrasound elastographic techniques (CPT® 76981, CPT® 76982, and CPT® 76983), including but not limited to acoustic radiation force impulse imaging or real-time tissue elastography for any indication is considered experimental or investigational at this time

Background and Supporting Information For the assessment of cirrhosis in individuals with hepatitis C, the AGA noted that MRE has little to no increase in identifying cirrhosis, but had poorer specificity and thus higher false-positive rates than VCTE. In view of this, the AGA concluded that MRE has a poorer diagnostic performance in this setting, compared to VCTE. In their recommendations for the assessment of fibrosis in chronic liver disease, VCTE was recommended over MRE with the exception of NAFLD in high risk populations, in which MRE resulted in a lower rate of false positives compared to VCTE. In low risk populations with NAFLD, both MRE and VCTE performed poorly, and their role is as yet, undefined.

References 1. American Gastroenterologic Association Institute guideline on the role of elastography in the evaluation of liver fibrosis. Gastroenterology. 2017:152:1536-1543. 2. Conti CB, Cavalcoli F, Fraquelli M, Conte D, Massironi S. Ultrasound elastographic techniques in focal liver lesions. World Journal of Gastroenterology. 2016;22(9):2647. doi:10.3748/wjg.v22.i9.2647. 3. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. Clinical Liver Disease. 2018;11(4):81-81. doi:10.1002/cld.722. Abdomen Imaging

AB-41:Hiccups  Hiccups <48 hours without any localizing or specific symptoms:  No advanced imaging  Hiccups ≥48 hours:  History and physical examination, laboratory and CMP and baseline chest x-ray  Abnormal or negative chest x-ray with symptoms referable to the chest:  CT Chest with contrast (CPT® 71260)  Lab or history/physician findings suggest a gastrointestinal etiology:  CT Abdomen with contrast (CPT® 74160)

References 1. British Journal of General Practice. Hiccups. A Common Problem with Some Unusual Causes and Cures: 2016;66(652):584-586. 2. Steger M, Schneemann M, Fox M. Systemic review: the pathogenesis and pharmacological treatment of hiccups. Alimentary Pharmacology & Therapeutics. 2015;42(9):1037-1050. doi:10.1111/apt.13374.

Abdomen Imaging

AB-42: Retroperitoneal Fibrosis  Individuals diagnosed with retroperitoneal fibrosis:  ONE of the following every 3 months until stability demonstrated:  CT Abdomen and Pelvis with contrast (CPT® 74177)  MRI Abdomen and Pelvis without contrast (CPT® 74181 and CPT® 72192)  MRI Abdomen and Pelvis with and without contrast (CPT® 74183 and CPT® 72195)  Retroperitoneal or Abdominal ultrasound (CPT® 76770 or CPT® 76700) can be approved if requested.  After stability established repeat imaging can be approved every 6 months.  Requests for non-contrasted studies in individuals with renal insufficiency is appropriate. Gadolinium may induce nephrogenic systemic fibrosis in individuals with moderate or severe renal insufficiency, especially if the GFR is <30 ml/min.  Additional imaging:  CT Chest (CPT® 74160) can also be performed upon initial diagnosis if requested, to further evaluate for the possibility of malignancy as an underlying etiology.  PET/CT (CPT® 78815)  Can be considered initially, after diagnosis, to establish avidity patterns to assess for the likelihood of malignancy and for stratification for the likelihood of response to steroids.  Follow-up can be considered if there is documentation of an anticipated therapeutic change based on the results (such as a change in immunosuppression therapy or stent removal).  Methysergide-induced retroperitoneal fibrosis:  Methysergide for migraine treatment is generally no longer available but is rarely being used at some centers. It has a known complication of retroperitoneal fibrosis.  Individuals can be screened at baseline and then every 6 months with ONE of the following:  CT Abdomen and Pelvis with contrast (CPT® 74177)  CT Abdomen and Pelvis without contrast (CPT® 74176)  MRI Abdomen and Pelvis without and with contrast (CPT® 74183 and CPT® 72197) ® ®  MRI Abdomen and Pelvis without contrast (CPT 74181 and CPT 72195)  Retroperitoneal ultrasound (CPT® 76770 or CPT 76775)

Background and Supporting Information Retroperitoneal fibrosis is a rare disease, and may be idiopathic (IgG4 or non-IgG-4 related) or secondary. Secondary causes include malignancy, infections, previous radiation therapy, previous abdominal surgery, drugs such as methysergide, and biologic agents.

Abdomen Imaging

References 1. Retroperitoneal Fibrosis Clinical Presentation: History and Physical Examination. Retroperitoneal Fibrosis Clinical Presentation: History and Physical Examination. https://emedicine.medscape.com/article/458501-clinical. Published May 30, 2019. 2. Vaglio A, Maritati F. Idiopathic Retroperitoneal Fibrosis. Journal of the American Society of Nephrology. 2016;27(7):1880-1889. doi:10.1681/asn.2015101110. 3. Runowska M, Majewski D, Puszczewicz M. Retroperitoneal fibrosis – the state-of-the-art. Reumatologia/Rheumatology. 2016;5:256-263. doi:10.5114/reum.2016.63667. 4. Urban M, Palmisano A, Nicastro M, Corradi D, Buzio C, Vaglio A. Idiopathic and secondary forms of retroperitoneal fibrosis: A diagnostic approach. La Revue de Médecine Interne. 2015;36(1):15-21. doi:10.1016/j.revmed.2014.10.008. 5. EMA restricts methysergide use, concern over fibrosis. Reactions Weekly. 2014;1491(1):2-2. doi:10.1007/s40278-014-9172-x. 6. Fendler WP, Eiber M, Stief CG, Herrmann K. A PET for All Seasons: 18 F-Fluorodeoxyglucose to Characterize Inflammation and Malignancy in Retroperitoneal Fibrosis? European Urology. 2017;71(6):934-935. doi:10.1016/j.eururo.2017.01.019. 7. Gu L, Wang Y, Zhang X. Re: Archie Fernando, James Pattison, Catherine Horsfield, David D’Cruz, Gary Cook, Tim O’Brien. [18F]-Fluorodeoxyglucose Positron Emission Tomography in the Diagnosis, Treatment Stratification, and Monitoring of Patients with Retroperitoneal Fibrosis: A Prospective Clinical Study. Eur Urol 2017;71:926–33. European Urology. 2017;72(2). doi:10.1016/j.eururo.2017.02.029.

Abdomen Imaging