CLINICAL APPROPRIATENESS GUIDELINES ADVANCED IMAGING Appropriate Use Criteria: Imaging of the Extremities ARCHIVED SEPTEMBER 28, 2019 These documents have been archived because they have outdated information. They are for historical information only and should not be consulted for clinical use. Current versions of guidelines are available on the AIM Specialty Health website at http://www.aimspecialtyhealth.com/ EFFECTIVE MARCH 9, 2019 Proprietary Approval and implementation dates for specific health plans may vary. Please consult the applicable health plan for more details. AIM Specialty Health disclaims any responsibility for the completeness or accuracy of the information contained herein. 8600 West Bryn Mawr Avenue Appropriate.Safe.Affordable South Tower – Suite 800 Chicago, IL 60631 © 2017 ©©©© 2019 AIM Specialty Health www.aimspecialtyhealth.com 2057-0319 Imaging of the Extremities Table of Contents Description and Application of the Guidelines .......................................................................................................... 5 General Clinical Guideline ........................................................................................................................................... 6 Clinical Appropriateness Framework .................................................................................................................... 6 Simultaneous Ordering of Multiple Diagnostic or Therapeutic Interventions .................................................... 6 Repeat Diagnostic Intervention .............................................................................................................................. 6 Repeat Therapeutic Intervention ............................................................................................................................ 7 History ...................................................................................................................................................................... 7 Imaging of the Extremities .......................................................................................................................................... 8 General Information/Overview ................................................................................................................................ 8 Scope .................................................................................................................................................................... 8 Technology Considerations ................................................................................................................................... 8 Definitions .............................................................................................................................................................. 8 Clinical Indications .................................................................................................................................................... 10 Congenital and Developmental Conditions ......................................................................................................... 10 Blount disease (Pediatric only) ............................................................................................................................ 10 Congenital anomalies of the lower extremity (Pediatric only) .............................................................................. 10 Congenital anomalies of the upper extremity (Pediatric only) .............................................................................. 11 Coxa vara (Pediatric only) ................................................................................................................................... 11 Developmental dysplasia of the hip (Pediatric only) ............................................................................................ 11 Discoid meniscus (Pediatric only) ........................................................................................................................ 11 Tarsal coalition .................................................................................................................................................... 11 Infection .................................................................................................................................................................. 12 Soft tissue infection ............................................................................................................................................. 12 Osteomyelitis ....................................................................................................................................................... 12 Septic arthritis ...................................................................................................................................................... 13 Inflammatory Conditions....................................................................................................................................... 14 Bursitis................................................................................................................................................................. 14 Capitellar osteochondritis .................................................................................................................................... 14 Epicondylitis ........................................................................................................................................................ 14 Juvenile idiopathic arthritis (Pediatric only) .......................................................................................................... 14 Myositis ............................................................................................................................................................... 15 Plantar fasciitis .................................................................................................................................................... 15 Tenosynovitis – long head of biceps ................................................................................................................... 15 Trauma .................................................................................................................................................................... 16 Fracture ............................................................................................................................................................... 16 Patellar dislocation – transient (Pediatric only) .................................................................................................... 17 Patellar sleeve avulsion (Pediatric only) .............................................................................................................. 17 Trauma complications (Pediatric only) ................................................................................................................ 17 Traumatic injuries – acute/not otherwise specified .............................................................................................. 17 Copyright © 2019. AIM Specialty Health. All Rights Reserved. 2 Imaging of the Extremities Tumor/Neoplasm ................................................................................................................................................... 18 Brachial plexus mass .......................................................................................................................................... 18 Morton’s neuroma ............................................................................................................................................... 18 Osteochondroma or exostosis (Pediatric only) .................................................................................................... 18 Osteoid osteoma (Pediatric only) ........................................................................................................................ 18 Pigmented villonodular synovitis ......................................................................................................................... 18 Posterior knee mass (Adult only) ......................................................................................................................... 19 Soft tissue mass – not otherwise specified .......................................................................................................... 19 Ligament and Tendon Derangement .................................................................................................................... 20 Adhesive capsulitis (Adult only) ........................................................................................................................... 20 Labral tear – hip .................................................................................................................................................. 20 Labral tear – shoulder ......................................................................................................................................... 21 Ligament tear – knee ........................................................................................................................................... 22 Meniscal tear/injury ............................................................................................................................................. 22 Rotator cuff tear (Adult only) ...............................................................................................................................