Clinical Appropriateness Guidelines: Advanced Imaging Imaging Program Guidelines EffectiveDate: October 29, 2018 Proprietary Guideline Last Revised Last Reviewed Administrative 07-26-2016 07-26-2016 Head and Neck 11-01-2016 08-15-2017 Chest 03-01-2018 03-01-2018 Cardiac 11-14-2017 11-14-2017 Abdomen and Pelvis 03-01-2018 03-01-2018 Spine 07-26-2016 02-14-2017 Extremity 07-26-2016 09-22-2017 PET or PET/CT 09-07-2017 09-07-2017 MRI Bone Marrow Blood Supply 08-27-2015 07-26-2016 Magnetic Resonance Spectroscopy (MRS) 06-19-2012 07-26-2016 Quantitative CT (QCT) Bone Mineral Densitometry 11-01-2016 11-01-2016 ARCHIVED 8600 W Bryn Mawr Avenue South Tower – Suite 800 Chicago, IL 60631 P. 773.864.4600 Copyright © 2018. AIM Specialty Health. All Rights Reserved www.aimspecialtyhealth.com Table of Contents Description and Application of the Guidelines ........................................................................4 Administrative Guidelines ........................................................................................................5 Ordering of Multiple Studies ...................................................................................................................................5 Pre-test Requirements ...........................................................................................................................................6 Head & Neck Imaging ...............................................................................................................7 CT of the Head .......................................................................................................................................................7 CTA/MRA of the Head: Cerebrovascular ..............................................................................................................17 MRI of the Head ...................................................................................................................................................21 Functional MRI (fMRI) Brain .................................................................................................................................30 PET Brain Imaging ...............................................................................................................................................31 CT of the Orbit, Sella Turcica, Posterior Fossa, Temporal Bone, including Mastoids ..........................................32 MRI of the Orbit, Face & Neck (Soft Tissues) ......................................................................................................35 CT of the Paranasal Sinus & Maxillofacial Area ...................................................................................................38 MRI Temporomandibular Joint (TMJ) ...................................................................................................................41 CT of the Neck (Soft Tissue) ................................................................................................................................42 CTA/MRA of the Neck ..........................................................................................................................................45 Chest Imaging .........................................................................................................................47 CT of the Chest ....................................................................................................................................................47 CTA of the Chest (Non-Coronary) ........................................................................................................................58 MRI of the Chest ..................................................................................................................................................62 MRA of the Chest .................................................................................................................................................66 MRI of the Breast .................................................................................................................................................69 Cardiac Imaging ......................................................................................................................72 Myocardial Perfusion Imaging ..............................................................................................................................72 Cardiac Blood Pool Imaging .................................................................................................................................78 Infarct Imaging .....................................................................................................................................................81 Stress Echocardiography (SE) .............................................................................................................................82 Transesophageal Echocardiography (TEE) .........................................................................................................89 Resting Transthoracic Echocardiography (TTE) ..................................................................................................91 CT Cardiac (Structure) .........................................................................................................................................99 Coronary CT Angiography (CCTA) and CT Derived Fractional Flow Reserve (FFR-CT) ..................................102 Cardiac CT - QuantitativeARCHIVED Evaluation of Coronary Calcification .........................................................................107 MRI - Cardiac .....................................................................................................................................................108 PET Myocardial Imaging ....................................................................................................................................111 Cardiac Bibliography ..........................................................................................................................................118 Table of Contents | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 2 Abdominal & Pelvic Imaging ................................................................................................123 CT of the Abdomen ............................................................................................................................................123 MRI of the Abdomen ..........................................................................................................................................132 MRCP of the Abdomen .......................................................................................................................................137 CTA/MRA of the Abdomen .................................................................................................................................139 CTA Abdominal Aorta and Bilateral Illiofemoral Lower Extremity Run-off ..........................................................143 CT of the Pelvis ..................................................................................................................................................145 MRI of the Pelvis ................................................................................................................................................152 Fetal MRI ............................................................................................................................................................158 CTA/MRA of the Pelvis .......................................................................................................................................160 CT of the Abdomen & Pelvis Combination .........................................................................................................162 CTA of the Abdomen & Pelvis Combination .......................................................................................................168 CT Colonography (Virtual Colonscopy) ..............................................................................................................171 Spine Imaging .......................................................................................................................173 CT of the Cervical Spine ....................................................................................................................................173 MRI of the Cervical Spine ..................................................................................................................................177 CT of the Thoracic Spine ....................................................................................................................................181 MRI of the Thoracic Spine ..................................................................................................................................184 CT of the Lumbar Spine .....................................................................................................................................187 MRI of the Lumbar Spine ...................................................................................................................................190 MRA of the Spinal Canal ....................................................................................................................................193 Spine Biblography ..............................................................................................................................................194