ADVANCED IMAGING CLINICAL APPROPRIATENESS GUIDELINES. Appropriate Use Criteria: Imaging of the Abdomen and Pelvis

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1 CLINICAL APPROPRIATENESS GUIDELINES ADVANCED IMAGING Apprpriate Use Criteria: Imaging f the Abdmen and Pelvis EFFECTIVE JANUARY 1, 2019 Prprietary 8600 West Bryn Mawr Avenue Suth Twer Suite 800 Chicag, IL Apprpriate.Safe.Affrdable AIM Specialty Health

2 Table f Cntents Descriptin and Applicatin f the Guidelines... 5 Administrative Guidelines... 6 Ordering f Multiple Studies... 6 Simultaneus Ordering f Multiple Studies... 6 Repeated Imaging... 6 Pre-Test Requirements... 7 Histry... 7 Imaging f the Abdmen and Pelvis... 8 General Infrmatin/Overview... 8 Scpe... 8 Technlgy Cnsideratins... 8 Definitins... 9 Clinical Indicatins General Abdminal and Pelvic Indicatins Cngenital and develpmental cnditins Infectius and inflammatry cnditins nt therwise referenced Trauma Tumr r neplasm nt therwise referenced Female Reprductive System and Obstetrics Adenmysis Adnexal mass Endmetrisis Obstetric indicatins Uterine artery emblizatin prcedures Gastrintestinal Cnditins Appendicitis Bwel bstructin Cnstipatin (Pediatric nly) Diverticulitis Enteritis and clitis Freign bdy (Pediatric nly) Gastrintestinal bleeding (Pediatric nly) Hench-Schnlein purpura (Pediatric nly) Inflammatry bwel disease Intussusceptin (Pediatric nly) Ischemic bwel Hepatbiliary Cnditins Ascites Biliary tract dilatatin r bstructin Chlecystitis Cpyright AIM Specialty Health. All Rights Reserved. 2

3 Chledchlithiasis Diffuse liver disease Fcal liver lesin Hepatmegaly Jaundice Primary sclersing chlangitis Osseus Cnditins Avascular necrsis Axial spndylarthrpathy Develpmental hip dysplasia (Pediatric nly) Osseus tumr Osteid stema Ostemyelitis Pelvic fracture Sacriliitis Septic arthritis Pancreatic Indicatins Pancreatic mass Pancreatic pseudcyst Pancreatitis Renal & Urinary Tract Indicatins Bladder r urethral diverticula Hematuria Hydrnephrsis Nephrcalcinsis Plycystic kidney disease Pyelnephritis Renal mass Urinary tract calculi Miscellaneus Cnditins Adrenal hemrrhage Adrenal mass Hemperitneum Hernia Lymphadenpathy Pelvic flr disrders assciated with urinary r bwel incntinence Prstate cancer Retrperitneal cnditins Splenic hematma Splenmegaly Sprts hernia (athletic pubalgia) Undescended testicle (cryptrchidism) Cpyright AIM Specialty Health. All Rights Reserved. 3

4 Nnspecific Signs and Symptms Abdminal pain Aztemia Lwer extremity edema Fever f unknwn rigin Pelvic pain Weight lss Exclusins Cystic liver disease Failure t thrive Gastrenteritis Hirschsprung s disease (cngenital aganglinsis) Hypspadias Irritable bwel syndrme Jejunal r ileal stensis Meckel s diverticulum r diverticulitis Midgut vlvulus Nenatal jaundice: biliary atresia and nenatal hepatitis Pirifrmis syndrme Psterir urethral valve Pylric stensis Small left cln syndrme Urinary tract infectin Vesicureteral reflux References Cdes Histry Cpyright AIM Specialty Health. All Rights Reserved. 4

5 Descriptin and Applicatin f the Guidelines The AIM Clinical Apprpriateness Guidelines (hereinafter the AIM Clinical Apprpriateness Guidelines r the Guidelines ) are designed t assist prviders in making the mst apprpriate treatment decisin fr a specific clinical cnditin fr an individual. As used by AIM, the Guidelines establish bjective and evidence-based criteria fr medical necessity determinatins where pssible. In the prcess, multiple functins are accmplished: T establish criteria fr when services are medically necessary T assist the practitiner as an educatinal tl T encurage standardizatin f medical practice patterns T curtail the perfrmance f inapprpriate and/r duplicate services T advcate fr patient safety cncerns T enhance the quality f health care T prmte the mst efficient and cst-effective use f services The AIM guideline develpment prcess cmplies with applicable accreditatin standards, including the requirement that the Guidelines be develped with invlvement frm apprpriate prviders with current clinical expertise relevant t the Guidelines under review and be based n the mst up-t-date clinical principles and best practices. Relevant citatins are included in the References sectin attached t each Guideline. AIM reviews all f its Guidelines at least annually. AIM makes its Guidelines publicly available n its website twenty-fur hurs a day, seven days a week. Cpies f the AIM Clinical Apprpriateness Guidelines are als available upn ral r written request. Althugh the Guidelines are publicly-available, AIM cnsiders the Guidelines t be imprtant, prprietary infrmatin f AIM, which cannt be sld, assigned, leased, licensed, reprduced r distributed withut the written cnsent f AIM. AIM applies bjective and evidence-based criteria, and takes individual circumstances and the lcal delivery system int accunt when determining the medical apprpriateness f health care services. The AIM Guidelines are just guidelines fr the prvisin f specialty health services. These criteria are designed t guide bth prviders and reviewers t the mst apprpriate services based n a patient s unique circumstances. In all cases, clinical judgment cnsistent with the standards f gd medical practice shuld be used when applying the Guidelines. Guideline determinatins are made based n the infrmatin prvided at the time f the request. It is expected that medical necessity decisins may change as new infrmatin is prvided r based n unique aspects f the patient s cnditin. The treating clinician has final authrity and respnsibility fr treatment decisins regarding the care f the patient and fr justifying and demnstrating the existence f medical necessity fr the requested service. The Guidelines are nt a substitute fr the experience and judgment f a physician r ther health care prfessinals. Any clinician seeking t apply r cnsult the Guidelines is expected t use independent medical judgment in the cntext f individual clinical circumstances t determine any patient s care r treatment. The Guidelines d nt address cverage, benefit r ther plan specific issues. If requested by a health plan, AIM will review requests based n health plan medical plicy/guidelines in lieu f the AIM Guidelines. The Guidelines may als be used by the health plan r by AIM fr purpses f prvider educatin, r t review the medical necessity f services by any prvider wh has been ntified f the need fr medical necessity review, due t billing practices r claims that are nt cnsistent with ther prviders in terms f frequency r sme ther manner. Cpyright AIM Specialty Health. All Rights Reserved. 5

6 Administrative Guidelines Ordering f Multiple Studies Requests fr multiple imaging studies t evaluate a suspected r identified cnditin and requests fr repeated imaging f the same anatmic area are subject t additinal review t avid unnecessary r inapprpriate imaging. Simultaneus Ordering f Multiple Studies In many situatins, rdering multiple imaging studies at the same time is nt clinically apprpriate because: Current literature and/r standards f medical practice supprt that ne f the requested imaging studies is mre apprpriate in the clinical situatin presented; r One f the imaging studies requested is mre likely t imprve patient utcmes based n current literature and/r standards f medical practice; r Apprpriateness f additinal imaging is dependent n the results f the lead study. When multiple imaging studies are rdered, the request will ften require a peer-t-peer cnversatin t understand the individual circumstances that supprt the medically necessity f perfrming all imaging studies simultaneusly. Examples f multiple imaging studies that may require a peer-t-peer cnversatin include: CT brain and CT sinus fr headache MRI brain and MRA brain fr headache MRI cervical spine and MRI shulder fr pain indicatins MRI lumbar spine and MRI hip fr pain indicatins MRI r CT f multiple spine levels fr pain r radicular indicatins MRI ft and MRI ankle fr pain indicatins Bilateral exams, particularly cmparisn studies There are certain clinical scenaris where simultaneus rdering f multiple imaging studies is cnsistent with current literature and/r standards f medical practice. These include: Onclgic imaging Cnsideratins include the type f malignancy and the pint alng the care cntinuum at which imaging is requested Cnditins which span multiple anatmic regins Examples include certain gastrintestinal indicatins r cngenital spinal anmalies Repeated Imaging In general, repeated imaging f the same anatmic area shuld be limited t evaluatin fllwing an interventin, r when there is a change in clinical status such that imaging is required t determine next steps in management. At times, repeated imaging dne with different techniques r cntrast regimens may be necessary t clarify a finding seen n the riginal study. Repeated imaging f the same anatmic area (with same r similar technlgy) may be subject t additinal review in the fllwing scenaris: Repeated imaging at the same facility due t mtin artifact r ther technical issues Repeated imaging requested at a different facility due t prvider preference r quality cncerns Repeated imaging f the same anatmic area (MRI r CT) based n persistent symptms with n clinical change, treatment, r interventin since the previus study Cpyright AIM Specialty Health. All Rights Reserved. 6

7 Repeated imaging f the same anatmical area by different prviders fr the same member ver a shrt perid f time Pre-Test Requirements Critical t any finding f clinical apprpriateness under the guidelines fr specific imaging exams is a determinatin that the fllwing are true with respect t the imaging request: A clinical evaluatin has been perfrmed prir t the imaging request (which shuld include a cmplete histry and physical exam and review f results frm relevant labratry studies, prir imaging and supplementary testing) t identify suspected r established diseases r cnditins. Fr suspected diseases r cnditins: Based n the clinical evaluatin, there is a reasnable likelihd f disease prir t imaging; and Current literature and standards f medical practice supprt that the requested imaging study is the mst apprpriate methd f narrwing the differential diagnsis generated thrugh the clinical evaluatin and can be reasnably expected t lead t a change in management f the patient; and The imaging requested is reasnably expected t imprve patient utcmes based n current literature and standards f medical practice. Fr established diseases r cnditins: Advanced imaging is needed t determine whether the extent r nature f the disease r cnditin has changed; and Current literature and standards f medical practice supprt that the requested imaging study is the mst apprpriate methd f determining this and can be reasnably expected t lead t a change in management f the patient; and The imaging requested is reasnably expected t imprve patient utcmes based n current literature and standards f medical practice. If these elements are nt established with respect t a given request, the determinatin f apprpriateness will mst likely require a peer-t-peer cnversatin t understand the individual and unique facts that wuld supersede the pre-test requirements set frth abve. During the peert-peer cnversatin, factrs such as patient acuity and setting f service may als be taken int accunt. Histry Status Date Actin Reviewed and revised 07/26/2016 Independent Multispecialty Physician Panel review and revisin Created 03/30/2005 Original effective date Cpyright AIM Specialty Health. All Rights Reserved. 7

8 Imaging f the Abdmen and Pelvis General Infrmatin/Overview Scpe These guidelines address advanced imaging f the abdmen and pelvis in bth adult and pediatric ppulatins. Fr interpretatin f the Guidelines, and where nt therwise nted, adult refers t persns age 19 and lder, and pediatric refers t persns age 18 and yunger. Where separate indicatins exist, they are specified as Adult r Pediatric. Where nt specified, indicatins and prerequisite infrmatin apply t persns f all ages. See the Cding sectin fr a list f mdalities included in these guidelines. Technlgy Cnsideratins Ultrasund is the initial imaging mdality f chice fr many cnditins f the abdmen and pelvis, including hepatbiliary, urinary tract, and gyneclgic cnditins. While ultrasund is peratr dependent and image quality may be impacted by besity and bwel gas, accuracy, availability and absence f inizing radiatin make it an ideal chice fr initial evaluatin f several intra-abdminal cnditins, especially in the right upper quadrant and in the pelvis and especially in pediatric patients and pregnant wmen. Cmputed tmgraphy (CT) is ften utilized fr imaging the abdmen and pelvis. It prvides excellent 3- dimensinal reslutin and can be perfrmed relatively quickly, reducing the ptential fr mtin artifact. A majr drawback f CT is the dse f inizing radiatin required fr image acquisitin, which is f particular cncern in yunger patients and thse wh require multiple scans ver time. CT may be perfrmed with r withut cntrast; cntrast prvides additinal detail t delineate vascular and gastrintestinal structures and is recmmended in certain settings, such as infectin, tumr, hemrrhage and visceral lesins. Hwever, cntrast increases scan acquisitin time, and cnfers risk in cases f impaired renal functin, pregnancy, metfrmin use, radiactive idine treatment fr thyrid disease, r previus reactins t cntrast agents. Nncntrast CT may ften suffice in sme situatins, and is preferred when evaluating fr intra-abdminal hemrrhage and/r calcificatin. Magnetic resnance imaging (MRI) requires a lnger time fr image acquisitin and is mre prne t mtin artifact than CT. Hwever, MRI des nt expse patients t inizing radiatin and has better cntrast reslutin than CT. MRI may be a useful substitute in cases where cntrast CT is cntraindicated. It is ften preferred in pediatric patients due t the absence f radiatin; hwever, sedatin may be required in yunger patients in rder t btain adequate images. MRI may be perfrmed with r withut cntrast. Use f cntrast is recmmended fr imaging f vascular structures r slid rgans. The mst cmmnly used agent fr cntrast MRI is gadlinium, but irn xide and irn platinum cntrast agents are als available. Administratin f gadlinium has been assciated with a rare but serius cnditin knwn as nephrgenic systemic fibrsis, and shuld be avided in persns with advanced renal disease. Gadlinium cntrast has als recently been shwn t accumulate within the brain parenchyma, a finding f uncertain clinical significance.there are a number f alternative cntrast agents which have been develped fr specialized use including gadxetic acid (hepatbiliary imaging), gadfsveset (a bld pl agent), and gadbutrl (an extracellular fluid agent). The use f cntrast is at the discretin f the rdering prvider and/r the radilgist perfrming the imaging study, and shuld be tailred t the individual circumstances f each case. Magnetic resnance chlangipancreatgraphy (MRCP) is a nninvasive alternative t endscpic retrgrade chlangipancreatgraphy (ERCP). MRCP avids the risks assciated with anesthesia and des nt expse patients t inizing radiatin. It is able t detect extraductal abnrmalities and can Cpyright AIM Specialty Health. All Rights Reserved. 8

9 prvide better visualizatin f structures prximal t a ductal bstructin. Hwever, it is prne t mtin artifact, may be less able t detect subtle abnrmalities, and unlike ERCP has n therapeutic capabilities. Dynamic pelvic MRI yields a 3-dimensinal image used t evaluate the pelvic flr and rectal functin by imaging pelvic muscles at rest and while cntracted. Magnetic resnance defecgraphy is a frm f dynamic MRI used fr evaluatin f pelvic rgan and muscle functin thrugh imaging stages f defecatin. Dynamic pelvic MRI may be indicated in cases f pelvic rgan prlapse, pelvic pain, and fecal and urinary incntinence. Multiparametric MRI uses multiple pulse sequences t image tissue. Its primary use in clinical medicine is fr diagnsis and fllw up f prstate cancer. CT entergraphy and MR entergraphy are nninvasive, crss-sectinal imaging mdalities prtclled t ptimize visualizatin f the small intestine. CT entergraphy prvides images f the entire small intestine withut interference frm verlapping lps, and detects bth extraluminal and luminal disease. MR entergraphy als prvides high-cntrast reslutin; it can detect abscesses and fistulas, and can distinguish fibrtic frm inflammatry structures. In general, CT entergraphy is preferred fr extraluminal pathlgy, whereas MR entergraphy is preferred fr rgan-specific and disease-specific (such as Crhn s disease) evaluatin. Imaging f the urinary tract ften begins with kidney, ureter, and bladder (KUB) radigraphy. This type f radigraph is particularly useful in acute care settings fr evaluatin f diffuse pain, r pain suggestive f renal r urinary tract disease. Ultrasund is als useful fr initial evaluatin and avids the risks assciated with radiatin expsure. Bth ultrasund and KUB radigraphy may be used fr fllw-up f nephrlithiasis in select patients. CT abdmen/pelvis stne prtcl (CT KUB), a nncntrast CT scan that images the kidney, ureters, and bladder, is cmmnly used fr visualizing the urinary tract. Indicatins fr CT KUB include urlithiasis/nephrlithiasis, renal parenchymal calcificatins, and exclusin f hemrrhagic changes. Lwdse CT can als be used t scan fr urinary tract stnes with a lwered effective radiatin dse. Cmpared t standard CT, lw-dse CT still has excellent sensitivity, but image reslutin can suffer, especially in the case f urinary tract stnes under 3 mm in size. CT urgraphy (CTU, als referred t as CT IVP r CT IVU) is a mre cmplex variant f CT that is used t evaluate the urinary tract. While CT KUB is simply a nncntrast CT scan, CT urgram includes an initial nncntrast CT scan fllwed by cntrast-enhanced nephrgraphic phase and excretry phase imaging. CT urgram cmbines cnventinal CT with thin-sectin axial CT images taken during the excretry phase. Histrically, CT was cmbined with excretry urgraphy (EU) fr CT urgram, but this methd is n lnger standard. CT urgram can be used t evaluate varius tumr types, papillary necrsis, and renal inflammatry disease, amng ther cnditins. Definitins Phases f the care cntinuum are bradly defined as fllws: Screening testing in the absence f signs r symptms f disease Diagnsis testing based n a reasnable suspicin f a particular cnditin r disrder, usually due t the presence f signs r symptms Management testing t direct therapy f an established cnditin, which may include preperative r pstperative imaging, r imaging perfrmed t evaluate the respnse t nnsurgical interventin Surveillance peridic assessment fllwing cmpletin f therapy, r fr mnitring knwn disease that is stable r asymptmatic Statistical terminlgy 1 Cpyright AIM Specialty Health. All Rights Reserved. 9

10 Cnfidence interval (CI) range f values which is likely t cntain the cited statistic. Fr example, 92% sensitivity (95% CI, 89%-95%) means that, while the sensitivity was calculated at 92% n the current study, there is a 95% chance that, if a study were t be repeated, the sensitivity n the repeat study wuld be in the range f 89%-95%. Diagnstic accuracy ability f a test t discriminate between the target cnditin and health. Diagnstic accuracy is quantified using sensitivity and specificity, predictive values, and likelihd ratis. Hazard rati dds that an individual in the grup with the higher hazard reaches the utcme first. Hazard rati is analgus t dds rati and is reprted mst cmmnly in time-t-event analysis r survival analysis. A hazard rati f 1 means that the hazard rates f the 2 grups are equivalent. A hazard rati f greater than 1 r less than 1 means that there are differences in the hazard rates between the 2 grups. Likelihd rati rati f an expected test result (psitive r negative) in patients with the disease t an expected test result (psitive r negative) in patients withut the disease. Psitive likelihd ratis, especially thse greater than 10, help rule in a disease (i.e., they substantially raise the pst-test prbability f the disease, and hence make it very likely and the test very useful in identifying the disease). Negative likelihd ratis, especially thse less than 0.1, help rule ut a disease (i.e., they substantially decrease the pst-test prbability f disease, and hence make it very unlikely and the test very useful in excluding the disease). Odds rati dds that an utcme will ccur given a particular expsure, cmpared t the dds f the utcme ccurring in the absence f that expsure. An dds rati f 1 means that the expsure des nt affect the dds f the utcme. An dds rati greater than 1 means that the expsure is assciated with higher dds f the utcme. An dds rati less than 1 means that the expsure is assciated with lwer dds f the utcme. Predictive value likelihd that a given test result crrelates with the presence r absence f disease. Psitive predictive value is defined as the number f true psitives divided by the number f test psitives. Negative predictive value is defined as the number f true negatives divided by the number f test negative patients. Predictive value is dependent n the prevalence f the cnditin. Pretest prbability prbability that a given patient has a disease prir t testing. May be divided int very lw (less than 5%), lw (less than 20%), mderate (20%-75%), and high (greater than 75%) althugh these numbers may vary by cnditin. Relative risk prbability f an utcme when an expsure is present relative t the prbability f the utcme ccurring when the expsure is absent. Relative risk is analgus t dds rati; hwever, relative risk is calculated by using percentages instead f dds. A relative risk f 1 means that there is n difference in risk between the 2 grups. A relative risk f greater than 1 means that the utcme is mre likely t happen in the expsed grup cmpared t the cntrl grup. A relative risk less than 1 means that the utcme is less likely t happen in the expsed grup cmpared t the cntrl grup. Sensitivity cnditinal prbability that the test is psitive, given that the patient has the disease. Defined as the true psitive rate (number f true psitives divided by the number f patients with disease). Excellent r high sensitivity is usually greater than 90%. Specificity cnditinal prbability that the test is negative, given that the patient des nt have the disease. Defined as the true negative rate (number f true negatives divided by the number f patients withut the disease). Excellent r high specificity is usually greater than 90%. Cpyright AIM Specialty Health. All Rights Reserved. 10

11 Clinical Indicatins The fllwing sectin includes indicatins fr which advanced imaging f the abdmen and pelvis is cnsidered medically necessary, alng with prerequisite infrmatin and supprting evidence where available. Indicatins, diagnses, r imaging mdalities nt specifically addressed are cnsidered nt medically necessary. It is recgnized that imaging ften detects abnrmalities unrelated t the cnditin being evaluated. Such findings must be cnsidered within the cntext f the clinical situatin when determining whether additinal imaging is required. General Abdminal and Pelvic Indicatins Cngenital and develpmental cnditins Advanced imaging is cnsidered medically necessary fr diagnsis and management when the results f imaging will impact treatment. ADULT - CT r MRI abdmen and/r pelvis PEDIATRIC - Ultrasund required fr initial evaluatin f hepatbiliary and geniturinary anmalies - Ultrasund recmmended fr initial evaluatin f pancreatic anmalies - CT r MRI abdmen and/r pelvis when additinal imaging is needed t guide treatment - MRI preferred fr evaluatin f uterine anmalies - MRCP preferred fr evaluatin f biliary and pancreatic duct anmalies Nte: The fllwing cnditins d nt require advanced imaging: Accessry spleen Biliary atresia Hirschsprung s disease Jejunal r ileal stensis Meckel s diverticulum Pylric stensis Small left cln Infectius and inflammatry cnditins nt therwise referenced Advanced imaging is cnsidered medically necessary when the results f imaging will impact management. - CT r MRI abdmen and/r pelvis Cpyright AIM Specialty Health. All Rights Reserved. 11

12 Trauma Advanced imaging is cnsidered medically necessary when the results f imaging will impact management. - CT abdmen and/r pelvis - MRI when CT cntraindicated Tumr r neplasm nt therwise referenced Fr management f dcumented malignancy, see Onclgic Imaging guidelines. Advanced imaging is cnsidered medically necessary in EITHER f the fllwing scenaris: Evaluatin f palpable abdminal r pelvic masses f indeterminate rigin Characterizatin f indeterminate lesins arising in the slid abdminal viscera and surrunding anatmic structures ADULT - Ultrasund required fr initial evaluatin f a palpable pelvic mass in wmen - CT abdmen and/r pelvis fr all ther scenaris, r fllwing nndiagnstic pelvic ultrasund - MRI abdmen fr further characterizatin f abdminal mass seen n prir imaging, including CT scan PEDIATRIC - Ultrasund required fr initial evaluatin f a palpable pelvic mass - Ultrasund recmmended fr initial evaluatin f an abdminal mass - CT r MRI abdmen and/r pelvis fr initial evaluatin f a palpable abdminal mass, r fllwing nndiagnstic ultrasund Female Reprductive System and Obstetrics Adenmysis Advanced imaging is cnsidered medically necessary fllwing pelvic ultrasund, when further imaging is required t direct management. - MRI pelvis Ratinale There is wide clinical agreement and supprt frm multiple clinical guidelines fr ultrasund as the initial imaging mdality fr evaluatin f structural pathlgy within the reprductive rgans f the female pelvis 2-5 with advanced imaging reserved in select cases as an add-n test t further characterize abnrmalities n ultrasund r when ultrasund is nndiagnstic. MRI is the advanced imaging mdality f chice due t its superir sft tissue cntrast. 4,6 Adnexal mass Advanced imaging is cnsidered medically necessary fllwing pelvic ultrasund when further imaging is required t direct management. Cpyright AIM Specialty Health. All Rights Reserved. 12

13 - MRI pelvis Ratinale There is wide clinical agreement and supprt frm multiple clinical guidelines fr ultrasund as the initial imaging mdality fr evaluatin f structural pathlgy within the reprductive rgans f the female pelvis 2-5 with advanced imaging reserved in select cases as an add-n test t further characterize abnrmalities n ultrasund r when ultrasund is nndiagnstic. MRI is the advanced imaging mdality f chice due t its superir sft tissue cntrast. 4,6 Endmetrisis Advanced imaging is cnsidered medically necessary fllwing pelvic ultrasund, when further imaging is required t direct management. - MRI pelvis Ratinale There is wide clinical agreement and supprt frm multiple clinical guidelines fr ultrasund as the initial imaging mdality fr evaluatin f structural pathlgy within the reprductive rgans f the female pelvis 2-5 with advanced imaging reserved in select cases as an add-n test t further characterize abnrmalities n ultrasund r when ultrasund is nndiagnstic. MRI is the advanced imaging mdality f chice due t its superir sft tissue cntrast. 4,6 A review f 49 studies invlving 4807 wmen was perfrmed t determine whether imaging tests culd be used as a replacement fr diagnstic surgery r as a triage test t assist in decisin making regarding diagnstic surgery. The evaluated mdalities included ultrasund, MRI, and CT. While nne f the imaging mdalities met criteria t replace surgery in making the diagnsis f endmetrisis, transvaginal ultrasund did apprach the criteria fr a triage test fr pelvic endmetrisis in general. Transvaginal ultrasund met the criteria fr a triage test fr endmetrima, as well as fr deeply infiltrating endmetrisis invlving the utersacral ligaments, rectvaginal septum, vaginal wall, puch f Duglas, and rectsigmid. 7 Obstetric indicatins Advanced imaging is cnsidered medically necessary fr diagnsis and management f ANY f the fllwing: Fetal anmalies Assessment prir t fetal interventin Placental cmplicatins Cmplicatins related t mnchrinic twins Pelvimetry Other bstetrical cmplicatins - Ultrasund is required fr initial evaluatin f fetal and placental cnditins - Fetal MRI fr indicatins invlving the fetus r placenta, fllwing nndiagnstic ultrasund - MRI pelvis fr pelvimetry r ther bstetrical cmplicatins Uterine artery emblizatin prcedures Advanced imaging is cnsidered medically necessary fr evaluatin related t a uterine artery emblizatin prcedure when the results f imaging will impact management. - MRI pelvis Cpyright AIM Specialty Health. All Rights Reserved. 13

14 Gastrintestinal Cnditins Appendicitis Advanced imaging is cnsidered medically necessary in EITHER f the fllwing scenaris: Diagnsis f suspected appendicitis Periperative management - Nnpregnant adults CT abdmen and pelvis - Pregnant wmen Ultrasund required fr initial evaluatin MRI abdmen and pelvis when ultrasund is nndiagnstic CT abdmen and pelvis when ultrasund is nndiagnstic and MRI is cntraindicated r unavailable - Pediatric patients Ratinale Ultrasund recmmended fr initial evaluatin CT r MRI abdmen and/r pelvis when ultrasund is unavailable r is expected t be limited due t bdy habitus The incidence f acute appendicitis is estimated at 3.4 millin cases per year in the U.S. Typical signs and symptms, including right lwer quadrant pain, fever, anrexia, nausea, and vmiting, shuld lead t surgical cnsultatin. When the diagnsis cannt be made n clinical exam alne, imaging mdalities including ultrasund, CT, and MRI may be indicated. Alternative mdalities may be cnsidered in pediatric patients and pregnant wmen due t lng-term cncerns related t inizing radiatin. 8 A meta-analysis f 29 studies evaluating the relative accuracies f ultrasund, CT, and MRI fr clinically suspected acute appendicitis in children indicated high diagnstic accuracy fr all 3 mdalities and n statistically significant difference between them. 9 A systematic review and meta-analysis fund that, with an experienced sngrapher, pint f care ultrasund is apprpriate as the initial imaging test in the evaluatin f suspected acute appendicitis in patients f any age. 10 In a prspective chrt study f patients age 4 t 30 years t determine predictrs fr nndiagnstic ultrasund in clinically suspected acute appendicitis, bdy mass index greater than 85th percentile (dds rati 4.9 [95% CI, ]) and lder age (dds rati 1.1 [95% CI, ]) were fund t be statistically significant predictrs f nndiagnstic ultrasund. Thus, in yunger patients and thse nt classified as verweight, ultrasund is an apprpriate initial study, while ther mdalities shuld be cnsidered in lder and verweight patients. 11 In pediatric patients with a nndiagnstic ultrasund and clinically suspected appendicitis, MRI was fund t have a sensitivity f 90% and specificity f 97.1%, while CT had a sensitivity f 88% and specificity f 98.6%, indicating cmparable diagnstic utility f CT and MRI as secndary imaging mdalities fllwing ultrasund. 12 The American Cllege f Radilgy indicates that ultrasund is the preferred initial imaging mdality in pediatric patients due t lack f inizing radiatin and an accuracy appraching that f CT. In pregnant wmen, ultrasund is als preferred fr initial imaging evaluatin, with MRI used as a secndary test when ultrasund is nndiagnstic. 13 Bwel bstructin Advanced imaging is cnsidered medically necessary fr diagnsis and management when the results f imaging will impact treatment. - Radigraphs required fr initial evaluatin in pediatric patients - CT abdmen and/r pelvis when additinal imaging is needed t guide treatment Cpyright AIM Specialty Health. All Rights Reserved. 14

15 - MRI abdmen and pelvis in pediatric patients nly Ratinale Abdminal radigraphy has mderate accuracy (apprximately 83%) fr the diagnsis f small bwel bstructin and is a useful initial test, especially in radiatin-sensitive patients. 14 CT abdmen and pelvis is a mre accurate exam that is less reader-dependent and can prvide incremental infrmatin ver radigraphs in differentiating grade, severity, and etilgy f small bwel bstructins that may lead t changes in management. 15 In children and yunger patients with knwn r suspected small bwel bstructins r repetitive episdes f bstructin, MRI is indicated as the first-line imaging mdality. 16,17 Cnstipatin (Pediatric nly) Advanced imaging is cnsidered medically necessary fr evaluatin f symptms persisting 2 r mre weeks when ANY f the fllwing are present: Failure f medical management Failure t thrive Fever Vmiting Fllwing barium enema r anal manmetry when there is suspicin fr ANY f the fllwing: Anal stensis Impactin in patients yunger than 1 year f age Tight empty rectum - Radigraphs required fr initial evaluatin - CT r MRI abdmen and/r pelvis Ratinale Cnstipatin is a cmmn prblem in children and largely a clinical diagnsis. While a cmmnly perfrmed practice, there is cnflicting evidence that abdminal radigraphy substantially aids the diagnsis f cnstipatin with at best small likelihd ratis (1-1.2) based n well designed studies. 18 Cnstipatin can have bth functinal and rganic causes. When cnstipatin is assciated with red flag features such as failure t thrive, unexplained weight lss, r vmiting, referral t a pediatric gastrenterlgist shuld be cnsidered and additinal testing with clnscpy and/r advanced imaging may be apprpriate. 19,20 Diverticulitis Advanced imaging is cnsidered medically necessary fr diagnsis and management when the results f imaging will impact management. - CT abdmen and/r pelvis Ratinale CT abdmen and pelvis with intravenus cntrast shuld be used t assess fr diverticulitis based n recmmendatins frm multiple high quality clinical guidelines. There is a lack f clinical data t supprt the use f MRI as a first-line mdality in the diagnsis f diverticulitis. 21 Enteritis and clitis Includes neutrpenic clitis and radiatin enteritis, and excludes inflammatry bwel disease. Advanced imaging is cnsidered medically necessary fr diagnsis and management when the results f imaging will impact management. Cpyright AIM Specialty Health. All Rights Reserved. 15

16 - CT abdmen and/r pelvis Freign bdy (Pediatric nly) Advanced imaging is cnsidered medically necessary fllwing nndiagnstic radigraph and high clinical suspicin f ingested freign bdy. - CT abdmen and/r pelvis - MRI when CT cntraindicated Gastrintestinal bleeding (Pediatric nly) Advanced imaging is cnsidered medically necessary fllwing nndiagnstic endscpy, clnscpy, r upper/lwer gastrintestinal series when the results f imaging are essential t establish a diagnsis and/r direct management. - CT abdmen and/r pelvis - MRI when CT cntraindicated Hench-Schnlein purpura (Pediatric nly) Advanced imaging is cnsidered medically necessary fr diagnsis and management when the results f imaging will impact management. - CT abdmen and/r pelvis Inflammatry bwel disease Advanced imaging is cnsidered medically necessary in EITHER f the fllwing scenaris: Diagnsis f suspected Crhn s disease fllwing nndiagnstic upper and lwer endscpy Management f new r wrsening symptms t cnfirm exacerbatin r evaluate fr cmplicatins, including stricture, abscess, r fistula - CT r MRI abdmen and/r pelvis Ratinale MRI, CT, and ultrasund may be indicated as an adjunct t endscpy fr diagnsis f clnic inflammatry bwel disease, which remains the gld standard fr diagnsis. MRI and CT have higher sensitivity fr examining lcatins difficult t access by ultrasund. 22 Small bwel fllw thrugh and enterclysis have high accuracy fr mucsal abnrmality and are widely available. They are less able t detect extramural cmplicatins and are cntraindicated in high-grade bstructin and perfratin. Radiatin expsure is a majr limitatin. Ultrasund, CT, and MRI have a high and cmparable diagnstic accuracy at the initial presentatin f terminal ileal Crhn s disease. Small bwel fllw thrugh and enterclysis have an acceptable accuracy fr mucsal disease but are less accurate fr mural disease and extramural cmplicatins. 22 Intussusceptin (Pediatric nly) Advanced imaging is cnsidered medically necessary in EITHER f the fllwing scenaris: Cpyright AIM Specialty Health. All Rights Reserved. 16

17 Fllwing nndiagnstic ultrasund Fllwing intussusceptin reductin - CT abdmen and/r pelvis - MRI when CT cntraindicated Ischemic bwel Advanced imaging is cnsidered medically necessary fr diagnsis and management when the results f imaging will impact treatment. - CT abdmen and/r pelvis - MRI when CT cntraindicated Nte: Radigraphs are preferred fr necrtizing enterclitis. Ratinale CT with intravenus and ral cntrast is indicated fr suspected clnic ischemia t assess the distributin and phase f clitis. The diagnsis f cln ischemia can be suggested based n CT findings, such as bwel wall thickening, edema, r thumbprinting. 23 Hepatbiliary Cnditins Ascites Advanced imaging is cnsidered medically necessary fr diagnsis and surveillance fllwing nndiagnstic ultrasund. - CT abdmen and pelvis - MRI fr pediatric patients nly Biliary tract dilatatin r bstructin Advanced imaging is cnsidered medically necessary in patients with unexplained biliary tract dilatin, bichemical evidence f biliary bstructin, and/r unexplained right upper quadrant pain when the results f imaging are essential t establish a diagnsis and/r direct management. - MRCP Chlecystitis Advanced imaging is cnsidered medically necessary in the fllwing scenari: Suspected cmplicatins f acute chlecystitis including perfratin, abscess, gangrenus r hemrrhagic chlecystitis, gallstne ileus, and Mirizzi s syndrme - Ultrasund required fr initial evaluatin in pediatric patients - CT abdmen Cpyright AIM Specialty Health. All Rights Reserved. 17

18 - MRI abdmen fr pediatric patients nly when ultrasund is nndiagnstic Imaging f the Abdmen and Pelvis Nte: Advanced imaging nt recmmended fr evaluatin f acute uncmplicated chlecystitis. Ratinale Right upper quadrant ultrasund is indicated in patients with jaundice t evaluate fr cmmn bile duct dilatin, presence f stnes, and t direct any additinal testing. If a patient has jaundice with a suspected mechanical cause, right upper quadrant pain, r a histry f stnes, MRI abdmen with and withut intravenus cntrast and MRCP is secnd line. 27 One study fund that patients wh receive initial CT fr suspected chlecystitis are 11 times mre likely t underg a secnd examinatin than patients wh receive initial ultrasund. 28 CT can accurately visualize gallbladder distentin and wall thickening and identify cmplicatins f acute chlecystitis such as gallbladder wall emphysema, abscess frmatin, and perfratin. 29 Chledchlithiasis Advanced imaging is cnsidered medically necessary when the diagnsis is suspected fllwing chlecystectmy. - MRCP Ratinale Endscpic ultrasund (EUS) is the gld standard, but MRCP has cmparable diagnstic accuracy and is nninvasive. Fr intermediate pretest prbability fr chledchlithiasis (10%-50%), the summary sensitivity f EUS is 0.95 cmpared with 0.93 fr MRCP, while summary specificity is 0.97 fr EUS cmpared with 0.96 fr MRCP. 24,25 Diagnstic ERCP has largely been replaced by EUS r MRCP, as the risk f pst-ercp pancreatitis is greater in a patient with nrmal caliber bile duct and nrmal bilirubin (dds rati 3.4 fr pst-ercp pancreatitis). 26 Diffuse liver disease Includes chrnic hepatitis, cirrhsis, glycgen strage diseases, hemchrmatsis, and Wilsn s disease Advanced imaging is cnsidered medically necessary in ANY f the fllwing scenaris: Evaluatin f suspected liver disease based n clinical findings r abnrmal liver functin tests when ultrasund is nndiagnstic and further evaluatin is required Suspected hepatcellular carcinma in persns with knwn cirrhsis Evaluatin fr irn verlad in hemchrmatsis when chelatin therapy r phlebtmy is being cnsidered - CT abdmen fr ANY f the fllwing: Suspected liver disease Suspected hepatcellular carcinma Irn verlad in hemchrmatsis when MRI cntraindicated - MRI abdmen fr evaluatin f hemchrmatsis Ratinale There are many ptential causes f diffuse liver damage, including autimmune disease, infectin, hereditary cnditins, and txic r metablic factrs. A cmmn presentatin is asymptmatic transaminase elevatin detected n rutine labratry testing. Advanced liver disease may manifest as jaundice r aberratins in the synthetic functin f the liver. When imaging is required, ultrasund is the initial study f chice fr evaluatin f bth the liver parenchyma and biliary tree. In a study cmparing ultrasngraphy f alchlic liver disease t histlgical crrelatin, ultrasund had a Cpyright AIM Specialty Health. All Rights Reserved. 18

19 sensitivity f 95% and specificity f 94%. 30 Anther study cmparing histlgic findings with ultrasngraphy fr assessment f diffuse parenchymal disease fund a sensitivity and specificity f 89% and 93%, respectively. 31 Limited data is available cmparing accuracy f available crss-sectinal imaging mdalities. A small trial cmparing the ability f ultrasund, CT, and MRI t determine diffuse liver steatsis demnstrated that ppsed-phase MRI had the highest crrelatin with histpathlgy, cmpared t T2-weighted MRI with and withut fat saturatin, CT, and ultrasund fr quantificatin f diffuse liver fat. 32 In a multicenter cllabrative study evaluating the accuracy, sensitivity, and specificity f these imaging mdalities fr detecting liver cirrhsis, CT and MRI were nt statistically better than ultrasund in receiver perating characteristic analysis. 33 Fcal liver lesin ADULT Advanced imaging is cnsidered medically necessary in ANY f the fllwing scenaris: Indeterminate lesins (nt bipsied and nt fully characterized by prir imaging) Initial evaluatin f an indeterminate lesin identified n prir imaging when ANY f the fllwing high-risk features are present: Size > 1 cm in diameter Multiple lesins Knwn malignancy Knwn cirrhsis Chrnic hepatitis Sclersing chlangitis Primary biliary cirrhsis Hemchrmatsis Hemsidersis Oral cntraceptive use Anablic sterid use Fllw up r surveillance at 3 t 6 mnths when any f the abve risk factrs are present, r when the lesin is enhancing, prly defined, r increasing in size Benign lesins (bipsy-prven r fully characterized by imaging) Evaluatin f symptms suggesting a change in size r character Peridic surveillance f knwn hepatic adenma PEDIATRIC - CT r MRI abdmen Advanced imaging is cnsidered medically necessary in EITHER f the fllwing scenaris: Suspected malignancy Diagnsis r management f a benign neplasm - Ultrasund required fr evaluatin f a benign neplasm - CT r MRI abdmen when ultrasund is nndiagnstic r when malignancy is suspected Cpyright AIM Specialty Health. All Rights Reserved. 19

20 Nte: A simple liver cyst with benign characteristics n ultrasund may nt require advanced imaging r surveillance. Ratinale Cmmn benign liver lesins, such as cysts and hemangimas, usually have a characteristic appearance n ultrasund; this ften eliminates the need fr additinal evaluatin. 34 In the setting f classic imaging findings and lw risk fr hepatic malignancy, ultrasngraphy is ften sufficient. 34 Otherwise, further evaluatin with MRI shuld be cnsidered. 35,36 Cavernus hemangimas are cmmn; autpsy studies have shwn that they ccur in up t 7% f the ppulatin. 37,38 Hemangimas appear as a hmgenus hyperechic mass, usually < 3 cm in diameter with acustic enhancement and sharp margins. Simple cysts are als very cmmn in the liver, ccurring in abut 5% f individuals. Cysts typically shw thrugh transmissin with n internal eches and a sharp distant brder with edge shadwing n liver ultrasund. 37 Small hepatic lesins (< 1 cm) are difficult t characterize and bipsy, but have a high prbability f being benign (> 80% even in patients with knwn malignancy), 34,39 thus clse clinical fllw up and mnitring fr prgressin may be the mst apprpriate next step. 40 In an therwise healthy patient, an incidentally discvered fcal liver lesin has an estimated prbability f greater than 95% f being benign. 41 Multiple clinical guidelines recmmend further characterizatin f liver lesins in high-risk patients, as well as thse measuring greater than 1 cm in diameter, but there is n cnsensus n the mst apprpriate fllw-up interval. 42,43 High-risk individuals include thse with a knwn primary malignancy with a prpensity t metastasize t the liver. Other hepatic risk factrs include cirrhsis, chrnic hepatitis, sclersing chlangitis, hemchrmatsis, hemsidersis, ral cntraceptive use, and anablic sterid use. 40 In terms f apprpriate fllw up, the American Assciatin fr the Study f Liver Diseases, as part f the The American Bard f Internal Medicine initiative, recmmends that clinicians nt perfrm CT r MRI rutinely t mnitr benign fcal liver lesins unless there is a majr change in clinical findings r symptms. 39 Hepatmegaly Advanced imaging is cnsidered medically necessary fr clinically suspected r wrsening hepatic enlargement when the results f imaging will impact management. ADULT - Ultrasund shuld be cnsidered fr initial evaluatin - CT abdmen - MRI abdmen nly when CT cntraindicated PEDIATRIC Jaundice - Ultrasund required fr initial evaluatin - CT r MRI abdmen when ultrasund is nndiagnstic Advanced imaging is cnsidered medically necessary fr evaluatin f unexplained icterus and abnrmal liver functin testing fllwing nndiagnstic ultrasund. - CT abdmen - MRI abdmen fr pediatric patients nly Ratinale Right upper quadrant ultrasund is the first-line mdality in patients with jaundice t evaluate fr cmmn bile duct dilatin, presence f stnes, and t direct any additinal testing. If patient has jaundice with a suspected mechanical Cpyright AIM Specialty Health. All Rights Reserved. 20

21 cause, right upper quadrant pain, r a histry f stnes, MRI abdmen with and withut intravenus cntrast and MRCP is secnd line. 27 Primary sclersing chlangitis Advanced imaging is cnsidered medically necessary fr diagnsis and management when the results f imaging will impact treatment decisins. - MRCP Osseus Cnditins Avascular necrsis Advanced imaging is cnsidered medically necessary in EITHER f the fllwing scenaris: Diagnsis fllwing negative r incnclusive radigraphs Preperative planning fr stenecrsis with femral head cllapse - MRI pelvis - CT pelvis when MRI r bne scan nt available r cntraindicated Axial spndylarthrpathy Advanced imaging is cnsidered medically necessary in ANY f the fllwing scenaris: Diagnsis f nnradigraphic spndylarthrpathy (nrspa) when BOTH f the fllwing are present: Radigraphs which are negative r equivcal fr sacriliitis (Grade 0-2) Inflammatry back pain which has been present fr at least 3 mnths. Inflammatry back pain is defined as back pain with at least FOUR (4) f the fllwing features: Patient is yunger than age 40 Insidius (gradual) nset Imprvement with exercise N imprvement with rest Pain at night that imprves n getting up Baseline imaging prir t therapy when the diagnsis is based n radigraphic findings Reevaluatin in patients wh have received at least 3 mnths f tumr necrsis factr inhibitrs withut clinical imprvement - MRI pelvis Ratinale Axial spndylarthritis includes a grup f rare (estimated 0.25% t 1% prevalence) disrders that may be HLA-B27 psitive and that manifest with inflammatry changes arund the enthesis. Spndylarthritis includes ankylsing Cpyright AIM Specialty Health. All Rights Reserved. 21

22 spndylitis, reactive arthritis, psriatic arthritis, arthrpathy assciated with inflammatry bwel disease, and undifferentiated spndylarthritis. The Assessment f SpndylArthritis Internatinal Sciety (ASAS) has develped and validated criteria fr spndylarthritis, as well as fr their subsets: axial spndylarthritis and peripheral spndylarthritis. 44 While sacriliitis is the mst cmmn MRI manifestatin f axial spndylarthrpathy, bne marrw edema can be seen in the vertebrae as well and characteristic patterns have been described. 45 There is cnsensus amng guidelines that radigraphy f the pelvis and/r spine is the preferred imaging mdality fr initial evaluatin f spndylarthritis. Radigraphs f the whle spine are recmmended as the first-line imaging mdality. 46 Plain film x-ray f the sacriliac jints shuld be cnsidered fr suspected axial spndylarthritis, unless the persn is likely t have an immature skeletn. 47 In patients with ankylsing spndylitis (nt nnradigraphic axial spndylarthritis), initial cnventinal radigraphy f the lumbar and cervical spine is recmmended t detect syndesmphytes, which are predictive f develpment f new syndesmphytes. 48 The ASAS criteria fr axial spndylarthritis have a high diagnstic accuracy, sensitivity 82% and specificity 88% based n a systematic review f 9 papers and 5739 patients. 44 Patients that d nt meet the ASAS criteria are a lw pretest prbability grup unlikely t have axial spndylarthrpathy. The ASAS criteria fr axial spndylarthritis include age < 45 years, back pain f at least 3 mnths duratin, sacriliitis n imaging (either definitive changes n radigraphy r evidence frm MRI) and ne characteristic feature, and HLA-B27 psitive; r at least 2 characteristic clinical features, which include arthritis, uveitis, dactylitis, psriasis, Crhn s disease, psitive nnsteridal anti-inflammatry drug respnse, family histry, and psitive HLA-B27. Diagnstic criteria fr ASAS are based n MRI f the sacriliac jints, nt the spine. MRI f the spine has a lw yield in patients with a negative sacriliac jint MRI and shuld nt be rutinely perfrmed. A retrspective study f 1191 patients under age 45 with chrnic lwer back pain fund sacriliitis in apprximately 7% f patients. Less than 2% f patients with a negative sacriliac jint MRI had a psitive spine MRI, and spine MRI changed management in nly 0.16% f cases. 49 MRI can demnstrate edema f the vertebral bdy crners (als knwn as crner inflammatry lesins) and bne marrw edema. A psitive MRI spine is defined as 3 r mre lesins present n 2 r mre slices, but this definitin is used primarily fr research purpses. 49 Cnsensus amng guidelines is that MRI shuld be btained in patients with persistent clinical suspicin when radigraphy is negative r indeterminate. When a diagnsis f axial spndylarthritis cannt be cnfirmed and clinical suspicin remains high, a fllw up MRI shuld be cnsidered. 48 When radigraphs are negative and there is suspicin f spndylarthritis, MRI is mandatry t lk fr early inflammatry lesins. 46 Plain film x-rays, ultrasund, and/r MRI shuld be cnsidered fr ther peripheral and axial symptmatic sites. 47 A negative/indeterminate radigraph des nt satisfy the New Yrk Criteria fr Ankylsing Spndylitis (bilateral grade 2 4 r unilateral grade 3 4 sacriliitis [evidence f ersins, sclersis, jint space widening, narrwing r ankylses]) and des nt therwise explain the back pain. MRI f the sacriliac jints and/r spine may be used t assess and mnitr disease activity in axial spndylarthritis, prviding additinal infrmatin n tp f clinical and bichemical assessments. The decisin n when t repeat MRI depends n the clinical circumstances. In general, shrt tau inversin recvery sequences are sufficient t detect inflammatin and the use f cntrast medium is nt needed. 48 Develpmental hip dysplasia (Pediatric nly) Advanced imaging is cnsidered medically necessary fr preperative planning. - CT pelvis Osseus tumr Advanced imaging is cnsidered medically necessary fr diagnsis and management when the results f imaging will impact treatment decisins. - CT pelvis - MRI pelvis fr pediatric patients nly Nte: MRI r radinuclide bne scintigraphy (bne scan) may be mre apprpriate fr detectin f skeletal metastases and primary bne tumrs. Cpyright AIM Specialty Health. All Rights Reserved. 22