InterQual Care Planning Imaging Criteria 2014 Clinical Revisions

Transcription

1 InterQual Care Planning Imaging Criteria 2014 Clinical s The Clinical s provide details of changes to InterQual Clinical Criteria. They do not provide information on changes made to CareEnhance Review Manager software. For information on Review Manager software changes, see the Review Manager Release Notes and the What's New topic in CareEnhance Review Manager Help. Review and Incorporation of Recent Medical McKesson Health Solutions is committed to keeping the InterQual product suite current and accurate. Criteria are continually reviewed and updated, with new editions of every product released at least annually. McKesson Health Solutions staff of physicians, nurses, and other licensed healthcare professionals, and its extensive array of primary care and specialty consultants, participate in ongoing criteria revision as new medical information emerges. Each release of the criteria reflects a thorough review of new medical literature, society guidelines, and current practice standards and incorporates consultant and user feedback. MHS Customer Hub The MHS Customer Hub ( provides interactive support, answers to commonly asked questions, and links to other resources. Need a user ID and password? Click the link above and then click the "Need a user ID and password?" link. Organization and Features Although some revisions below apply to all criteria subsets, the revisions will only display in new criteria sets or in those that were updated this cycle. Criteria subsets that were not updated this cycle will be updated in the next revision cycle. s Adult vs Pediatric revisions: All clinical revisions pertain to adult clinical changes unless otherwise specified. The pediatric changes will be identified as Pediatric in the Indication. InterQual Care Planning Imaging Clinical s Page 1 of 50

2 Category: Abdomen and Pelvis Subset Monoclonal Antibody Imaging (Oncoscint) Scan Hysterosalpingogram (HSG) Hysterosalpingogram (HSG) Subset Subset Removed subset Monoclonal Antibody Imaging (Oncoscint) Scan Added indication Suspected septate or bicornuate uterus Indication: Infertility Changed Ovulation confirmed by midluteal serum progesterone or endometrial Bx to Ovulation confirmed by midluteal serum progesterone Imaging, Abdomen Subset Indication: Abdominal aortic aneurysm (AAA) Added indication Known AAA Imaging, Abdomen Subset Indication: Abdominal aortic aneurysm (AAA) Changed indication Follow-up post endovascular repair AAA to Follow-up post AAA repair Imaging, Abdomen Subset Indication: Abdominal aortic aneurysm (AAA) Added indication Screening study Imaging, Abdomen Indication: Abdominal aortic aneurysm (AAA) and Suspected AAA leak or rupture Changed recommendations CT, Abdomen and Pelvis (Abdomen) to CTA, Abdomen and Pelvis, Abdominal Aorta, (AAA) and CT, Abdomen and Pelvis, with contrast, (AAA) when CT feasible and CT, Abdomen and Pelvis, without contrast, (AAA) when CT not feasible PET-CT has replaced monoclonal antibody scan in the investigation of suspected recurrent colorectal and ovarian cancer. HSG can further delineate the structural anomaly in the evaluation of a suspected septate or bicornuate uterus. An endometrial biopsy is no longer routinely performed in the evaluation of infertility since is does not consistently reflect progesterone secretion amount or duration. Imaging may be appropriate in the evaluation of patients with a AAA. This pathway now contains criteria to address follow-up imaging after open AAA repair, as well as after endovascular aneurysm repair (EVAR). This change was made so the user could more readily find screening criteria. Criteria addressing screening for AAA was previously located under Suspected AAA. CTA and CT with contrast are the preferred imaging studies for evaluating patients with a suspected AAA leak or rupture. CT without contrast would only be done if the patient had a contraindication to contrast. Page 2 of 50

3 Imaging, Abdomen Indication: Abdominal aortic aneurysm (AAA) and Suspected AAA leak or rupture Changed recommendation MRI, Abdomen to MRA, Abdomen and Pelvis, Abdominal Aorta, (AAA) when CT not feasible Imaging, Abdomen Indication: Abdominal aortic aneurysm (AAA) and Suspected AAA leak or rupture Added Further imaging needed for treatment planning if Ultrasound diagnostic for aneurysm and recommendations for CTA, Abdomen and Pelvis, Abdominal Aorta, (AAA), CT, Abdomen and Pelvis, with contrast, (AAA) or MRA, Abdomen and Pelvis, Abdominal Aorta, (AAA) if Ultrasound not diagnostic for aneurysm Imaging, Abdomen Indication: Abdominal aortic aneurysm (AAA) and Suspected AAA Changed recommendations US, Abdominal and US, Retroperitoneal to Duplex scan, Abdominal Aorta, (AAA) Imaging, Abdomen Indication: Abdominal aortic aneurysm (AAA) and Known AAA Added Periodic assessment of AAA and Preoperative planning Imaging, Abdomen Indication: Abdominal aortic aneurysm (AAA) and Known AAA Changed recommendations US, Abdominal and US, Retroperitoneal to Duplex scan, Abdominal Aorta, (AAA) for Periodic assessment of AAA Imaging of the vasculature with MR angiography (MRA) is necessary; MR without angiography (MRI) would not provide the information necessary for preoperative planning. Further imaging is appropriate if an aneurysm is suspected and the ultrasound (US) does not provide enough information for treatment planning or if the US is not confirmatory of a AAA. Duplex scanning, which includes both ultrasound and Doppler analysis, is more accurate for evaluating an aneurysm than abdominal or retroperitoneal ultrasound. These criteria cover imaging of a known AAA for surgical planning, as well as periodic assessment of the AAA to monitor growth. Duplex scanning, which includes both ultrasound and Doppler analysis, is more accurate for evaluating an aneurysm than abdominal or retroperitoneal ultrasound. Page 3 of 50

4 Imaging, Abdomen Indication: Abdominal aortic aneurysm (AAA) and Follow-up post AAA repair Added Post open AAA repair Imaging, Abdomen Indication: Abdominal aortic aneurysm (AAA) and Follow-up post AAA repair Changed "4 weeks post procedure" to "Initial follow-up imaging study" under Post endovascular aneurysm repair (EVAR) Imaging, Abdomen Indication: Abdominal aortic aneurysm (AAA) and Follow-up post AAA repair Changed recommendation CT, Abdomen and Pelvis (Abdomen) to CTA, Abdomen and Pelvis, Abdominal Aorta, (AAA), CT, Abdomen and Pelvis, without contrast, (AAA) AND Duplex scan, Abdominal Aorta, (AAA), and MRA, Abdomen and Pelvis, Abdominal Aorta, (AAA) for Initial follow-up imaging study under Post endovascular aneurysm repair (EVAR) Imaging, Abdomen Indication: Abdominal aortic aneurysm (AAA) and Follow-up post AAA repair Changed recommendation CT, Abdomen and Pelvis (Abdomen) to CTA, Abdomen and Pelvis, Abdominal Aorta, (AAA) if CTA feasible or CT, Abdomen and Pelvis, without contrast, (AAA) AND Duplex scan, Abdominal Aorta, (AAA) and MRA, Abdomen and Pelvis, Abdominal Aorta, (AAA) if CTA not feasible for History of II endoleak under Post endovascular aneurysm repair (EVAR) Surveillance imaging is appropriate not only after endovascular repair but after open resection and repair of AAA. This change was made to clarify that the first study done for surveillance after surgery, although usually done at 4 weeks, may be done at any time, depending on surgeon preference. Any of the listed imaging studies can be used for the initial follow-up post EVAR. CT of the abdomen and pelvis alone would not be sufficient to evaluate the stent. CTA is the preferred imaging study for evaluating patients after EVAR. CT without contrast with a duplex scan to look at the vasculature or MRA could be done if the patient has a contraindication to contrast. Page 4 of 50

5 Imaging, Abdomen Indication: Abdominal aortic aneurysm (AAA) and Follow-up post AAA repair Added recommendation Duplex Scan, Abdominal Aorta, (AAA) when 2 years post EVAR and 1 year since last imaging study for No history of type II endoleak under Post endovascular aneurysm repair (EVAR) Imaging, Abdomen Indication: Abdominal aortic aneurysm (AAA) and Screening study Duplex scanning may be sufficient for monitoring stents if there has not been an endoleak reported on previous surveillance. These changes were made to more specifically identify those patients that are at risk of developing an AAA. Changed Age 50 and First degree relative with AAA to Age 50 and first degree relative with AAA or peripheral vascular aneurysmal disease Changed Age 50 and Known atherosclerotic disease to Age 50 and history of atherosclerotic or connective tissue disease Imaging, Abdomen Indication: Abdominal aortic aneurysm (AAA) and Screening study This change was made to more specifically identify those patients that are at risk of developing an AAA. Added Peripheral vascular aneurysmal disease by history Imaging, Abdomen Indication: Abdominal aortic aneurysm (AAA) and Screening study Added Initial screening and Repeat screening Imaging, Abdomen Subset For Adult and Pediatric Criteria: Indication: Abscess This change was made to clarify that screening for the presence of an AAA should only be done once in the patient s lifetime. These criteria now address pathology that may extend into the pelvic region. Changed indications Suspected intra-abdominal abscess (urgent) and Follow-up of known abdominal abscess after treatment to Suspected intra-abdominal or pelvic abscess (urgent) and Follow-up of known abdominal or pelvic abscess after treatment, respectively Page 5 of 50

6 Imaging, Abdomen For Adult and Pediatric Criteria: Indication: Abdominal or pelvic evaluation with known cancer MRI of the abdomen or pelvis or both may be appropriate for staging cancer. Added recommendations MRI, Abdomen and MRI, Pelvis for Initial staging Imaging, Abdomen For Adult and Pediatric Criteria: Indications: Abscess, Suspected intra-abdominal or pelvic abscess (urgent), and Follow-up of known abdominal or pelvic abscess after treatment A pelvic ultrasound is an appropriate imaging test for evaluating a pelvic abscess. Added recommendation US, Pelvis Imaging, Abdomen Subset Changed Indication Acute abdominal pain, unknown etiology to Acute abdominal or pelvic pain, unknown etiology Imaging, Abdomen Indication: Acute abdominal or pelvic pain, unknown etiology (urgent) These criteria now address pathology that may extend into the pelvic region. The evaluation of acute abdominal or pelvic pain differs between these groups. Added Male, Postmenopausal woman, and Premenopausal woman Imaging, Abdomen Indication: Acute abdominal or pelvic pain, unknown etiology (urgent) Added Pelvic examination nondiagnostic for etiology of pain under Premenopausal woman Imaging, Abdomen Indication: Acute abdominal or pelvic pain, unknown etiology (urgent) Added Ultrasound performed under Premenopausal woman All premenopausal women with acute abdominal or pelvic pain should have a pelvic exam to evaluate gynecologic causes of the pain before considering imaging. Ultrasound should be the initial imaging study done in the evaluation of a premenopausal woman with acute abdominal or pelvic pain. Page 6 of 50

7 Imaging, Abdomen Indication: Acute abdominal or pelvic pain, unknown etiology (urgent) Added Ultrasound diagnostic for etiology of abdominal or pelvic pain under Premenopausal woman Imaging, Abdomen Indication: Acute abdominal or pelvic pain, unknown etiology (urgent) Imaging, Gastrointestinal (GI) Tract Imaging, Gastrointestinal (GI) Tract Imaging, Gastrointestinal (GI) Tract Imaging, Gastrointestinal (GI) Tract Subset Added recommendations MRI, abdomen and MRI, pelvis when Ultrasound not diagnostic for etiology of abdominal or pelvic pain under Premenopausal woman For Adult and Pediatric Criteria: Added indication Known Crohn's disease Changed indication Suspected upper GI obstruction by history and physical examination or KUB to Suspected upper GI obstruction by history or physical examination and KUB Indication: Suspected Crohn's disease Removed Lower GI tract evaluation by colonoscopy normal or nondiagnostic for etiology of symptoms or findings, Lower GI tract evaluation by BE normal or nondiagnostic for etiology of symptoms or findings, and Endoscopy (EGD) nondiagnostic for etiology of symptoms Indication: Suspected Crohn's disease Added Intermittent, cramping abdominal pain, Recurrent or bloody diarrhea, and Weight loss The need for further imaging is determined on whether the ultrasound provides enough information for management of the patient. Although ultrasound is the initial imaging study of choice for evaluating a premenopausal woman with acute abdominal or pelvic pain, MRI may be appropriate if the ultrasound does not provide the necessary information. Imaging may be appropriate for evaluating patients with Crohn's disease who have new or worsening symptoms. A KUB should always be performed when a bowel obstruction is suspected on physical examination. Since Crohn's disease typically involves the small bowel, evaluation of the lower GI tract with barium enema or the upper and lower GI tract with endoscopy is not usually informative. The listed symptoms are highly suspicious for Crohn's disease. Page 7 of 50

8 Imaging, Gastrointestinal (GI) Tract Indication: Suspected Crohn's disease Changed recommendation Capsule Endoscopy, Gastrointestinal Tract to Capsule Endoscopy, Gastrointestinal Tract, OR MR Enterography, Gastrointestinal Tract, OR CT Enterography, Gastrointestinal Tract, OR UGI, Gastrointestinal Tract with small bowel follow-through (SBFT) CT enterography, MR enterography, and an UGI series with small bowel follow-through (SBFT), in addition to capsule endoscopy, have all been shown to be valuable in the evaluation of suspected Crohn s disease. Imaging, Gastrointestinal (GI) Tract Subset Changed indication Suspected small bowel tumor to Suspected small bowel lesion Imaging may be appropriate for evaluating any lesion in the small bowel, not just tumors. Imaging, Gastrointestinal (GI) Tract Indication Suspected small bowel lesion Removed Lower GI tract evaluation by colonoscopy normal or nondiagnostic for etiology of symptoms or findings, Lower GI tract evaluation by BE normal or nondiagnostic for etiology of symptoms or findings, Endoscopy (EGD) nondiagnostic for etiology of symptoms or findings, and UGI with small bowel follow-through (SBFT) nondiagnostic for etiology of symptoms or findings Evaluation of the lower GI tract with barium enema or colonoscopy and the upper GI tract with endoscopy or UGI with small bowel follow-through (SBFT) is not usually informative when symptoms and findings are suspicious for a lesion of the small bowel. Imaging, Gastrointestinal (GI) Tract Indication Suspected small bowel lesion Changed recommendation Capsule Endoscopy, Gastrointestinal Tract to Capsule Endoscopy, Gastrointestinal Tract, OR CT Enterography, Gastrointestinal Tract, OR MR Enterography, Gastrointestinal Tract CT enterography and MR enterography, in addition to capsule endoscopy, have been shown to be valuable in the evaluation of a suspected lesion of the small bowel. Imaging, Gastrointestinal (GI) Tract For Pediatric Criteria Only: Indication: Suspected Crohn's disease The listed symptoms are more suggestive of Crohn s disease. Changed Colicky abdominal pain, Recurrent diarrhea, and ESR > 30 mm/hr to Intermittent, cramping abdominal pain, Recurrent or bloody diarrhea, and Weight loss or growth failure or short stature Page 8 of 50

9 Imaging, Gastrointestinal (GI) Tract For Pediatric Criteria Only: Indication: Suspected Crohn's disease Changed recommendation UGI, Gastrointestinal Tract to UGI, Gastrointestinal Tract with small bowel follow-through (SBFT), OR CT Enterography, Gastrointestinal Tract OR MR Enterography, Gastrointestinal Tract Imaging, Pelvis Subset For Adolescent Criteria Only: Added indications: Adnexal or pelvic mass by physical examination or KUB, Suspected ovarian cyst rupture (urgent), Suspected pelvic inflammatory disease (PID) or tubo-ovarian abscess (TOA), Follow-up of known pelvic inflammatory disease (PID) or tubo-ovarian abscess (TOA) after treatment, Suspected ovarian torsion (urgent), Suspected endometriosis, Suspected ectopic pregnancy (urgent) Imaging, Pelvis Subset For Adult and Adolescent Criteria: Removed indications Suspected pelvic abscess and Follow-up of known pelvic abscess after treatment Imaging, Pelvis Subset Removed indication Acute abdominal or pelvic pain, unknown etiology CT enterography and MR enterography, in addition to UGI series with small bowel follow-through (SBFT), have been shown to be valuable in the evaluation of suspected Crohn s disease in children. Females between the ages of 13 and 18 are susceptible to many of the same conditions that effect women older than age 18. These indications are now addressed in the Imaging, Abdomen subset since a pelvic abscess may require both abdominal and pelvic imaging. This indication is now addressed in the Imaging, Abdomen subset since abdominal pain requires both abdominal and pelvic imaging. Imaging, Pelvis Subset Removed indication Cancer Staging This indication is now addressed in the Imaging, Abdomen subset since cancer staging requires both abdominal and pelvic imaging. Imaging, Pelvis Subset Added indication Follow-up of known pelvic inflammatory disease (PID) or tubo-ovarian abscess (TOA) after treatment Imaging, Pelvis Subset Added indication Suspected ovarian torsion (urgent) Imaging of the pelvis is appropriate for monitoring patients with PID or a TOA. Urgent ultrasound can confirm a diagnosis of ovarian torsion. Page 9 of 50

10 Imaging, Pelvis Subset Added indication Suspected endometriosis Imaging of the pelvis (e.g., ultrasound, MRI) can detect endometriomas and exclude other causes for the patient s symptoms. Imaging, Pelvis Subset Changed indication DUB in premenopausal woman to Abnormal uterine bleeding (AUB) in premenopausal woman Imaging, Pelvis Subset Changed indication Lost IUD to Ultrasoundguided intrauterine device (IUD) removal Imaging, Pelvis Indication: Adnexal or pelvic mass by physical examination or KUB Added Further imaging needed for treatment planning under Ultrasound diagnostic for etiology of mass Imaging, Pelvis Indication: Suspected adenomyosis Removed Ureteral compression by US or IVP Imaging, Pelvis Indication: Suspected adenomyosis Added Other etiologies of bleeding excluded under Abnormal bleeding Imaging, Pelvis Indication: Suspected adenomyosis Changed Hct < 27% unresponsive to iron treatment > 12 weeks and Hb < 9.0 g/dl unresponsive to iron treatment > 12 weeks to Anemia unresponsive to iron treatment > 12 weeks Imaging, Pelvis Indication: Suspected adenomyosis Added Further imaging needed for treatment planning under US is diagnostic for adenomyosis Imaging, Pelvis Indication: Chronic pelvic pain, unknown etiology Added Ultrasound performed and Ultrasound diagnostic for etiology of pelvic pain Page 10 of 50 This change was made to reflect current medical terminology. Imaging is done for ultrasound-guided removal of the IUD, not for identification of the location of the IUD. Although an ultrasound can identify a mass, CT or MRI may be needed to determine characteristics of the mass and to assess the surrounding tissue. Ureteral compression due to adenomyosis is a rare finding. Other causes of the bleeding should be excluded prior to doing an imaging workup of adenomyosis. Because laboratories vary in their range of normal levels, these values have been removed. Although an initial ultrasound may be able to identify adenomyosis, further imaging may be needed to determine the extent of adenomyosis and to guide treatment. Ultrasound is the initial imaging study of choice In the evaluation of chronic pelvic pain.

11 Imaging, Pelvis Indication: Chronic pelvic pain, unknown etiology Added recommendations CT, Pelvis and MRI, Pelvis Imaging, Pelvis Indication: Suspected pelvic inflammatory disease (PID) or tubo-ovarian abscess (TOA) If the ultrasound is nondiagnostic, MRI or CT are appropriate in the evaluation of chronic pain. One of the listed symptoms, as well as one of the listed findings, is sufficient to suspect a PID or TOA. Changed rule from ALL to ONE for Symptoms and Findings Imaging, Pelvis Indications: Suspected PID or tubo-ovarian (TOA) abscess Added Further imaging needed for treatment planning under US is diagnostic for PID or TOA Imaging, Pelvis Indications: Suspected pelvic inflammatory disease (PID) or tubo-ovarian (TOA) abscess Although an ultrasound may be able to diagnose PID or TOA, further imaging may be appropriate to determine the extent of the infection and to guide treatment. MRI can be done to determine the characteristics of the infection and to assess the surrounding tissue. Added recommendation MRI, Pelvis Imaging, Pelvis Indication: Suspected septate or bicornuate uterus Imaging, Pelvis Indication: Fibroids Imaging, Pelvis Indication: Fibroids Added Further imaging needed for treatment planning under Sonohysterogram or ultrasound diagnostic for septate or bicornuate uterus Added Preoperative study of fibroids prior to myomectomy or uterine artery embolization (UAE) Added recommendation Sonohysterogram under Initial assessment of uterine enlargement by physical examination Although an ultrasound may be able to diagnose a septate or bicornuate uterus, further imaging may be appropriate to determine the extent of the anomaly and to guide treatment. Preprocedure or preoperative imaging can be performed to delineate fibroid size and location. Sonohysterogram is appropriate to evaluate the type and extent of the fibroids. Page 11 of 50

12 Imaging, Pelvis Indication: Abnormal uterine bleeding (AUB) in premenopausal woman Any abnormal bleeding pattern, not necessarily only one that lasts 3 cycles, is worrisome and should be evaluated. Changed Abnormal bleeding > 3 cycles to Abnormal bleeding Imaging, Pelvis Indication: Abnormal uterine bleeding (AUB) in premenopausal woman Removed Continued abnormal bleeding after progestin or OCP x3 consecutive cycles Imaging, Pelvis Indication: Abnormal uterine bleeding (AUB) in premenopausal woman In the evaluation of AUB, imaging is usually done prior to medical treatment to exclude structural causes of the bleeding. Sonohysterogram can be done to evaluate the cause of AUB. Added recommendation Sonohysterogram Imaging, Pelvis Indication: Assessment of follicle function with infertility Changed Ovulation confirmed by midluteal serum progesterone or endometrial biopsy to Ovulation confirmed by midluteal serum progesterone Imaging, Pelvis Indication: Ultrasound-guided intrauterine device (IUD) removal An endometrial biopsy is no longer routinely performed in the evaluation of infertility since it does not consistently reflect progesterone secretion amount or duration. Bleeding, as well as pain, are both symptoms that would be a cause for concern and a reason to remove an IUD. Changed Pelvic pain to Pelvic pain or bleeding Ultrasound, Transrectal (TRUS) Subset Removed indication: Suspected rectovaginal endometriosis Criteria for endometriosis are addressed in the Imaging, Pelvis subset. Page 12 of 50

13 Category: Chest and Heart Subset, Non-stress Computed Tomography (CT), Cardiac or Magnetic Resonance Imaging (MRI), Cardiac Computed Tomography (CT), Cardiac or Magnetic Resonance Imaging (MRI), Cardiac Computed Tomography (CT), Cardiac or Magnetic Resonance Imaging (MRI), Cardiac Global Removed subset, Non-stress. The following imaging studies are now listed individually: Angiogram, Coronary +/- Left Heart Catheterization; Cardiac Catheterization, Right Heart with Coronary Angiogram; Computed Tomography (CT), Cardiac or Magnetic Resonance Imaging (MRI), Cardiac; Computed Tomography (CT), Coronaries; Computed Tomography Angiogram (CTA), Coronaries or Magnetic Resonance Angiogram (MRA), Cardiac; ; Multi Gated Acquisition (MUGA) Scan, Resting; and Positron Emission Tomography (PET), Cardiac This change was made so users could more easily find the cardiac imaging criteria that was being reviewed. Subset Added indication Valvular heart disease Cardiac MRI is appropriate for evaluating aortic regurgitation and mitral regurgitation when the echocardiogram is equivocal or inconsistent with the clinical findings and it is necessary to clarify the severity of the disease to plan further treatment. Subset Added indication Preoperative evaluation for transcatheter aortic valve implantation or replacement Indication: Suspected hypertrophic cardiomyopathy Removed Secondary hypertension (HTN) Cardiac CT is recommended as part of the preoperative workup for transcatheter aortic valve implantation or replacement to evaluate valve structure, calcification, aortic root, aortic annulus dimensions, and catheter access approach. Secondary hypertension is not commonly seen in patients with hypertrophic cardiomyopathy. Page 13 of 50

14 Computed Tomography (CT), Cardiac or Magnetic Resonance Imaging (MRI), Cardiac Indication: Hypertrophic cardiomyopathy Changed Presyncope or syncope 2 episodes by history to Presyncope or syncope by history Any episode of presyncope or syncope, not just recurrent episodes, in a patient with suspected hypertrophic cardiomyopathy should be evaluated. Computed Tomography (CT), Cardiac or Magnetic Resonance Imaging (MRI), Cardiac Indication: Suspected hypertrophic cardiomyopathy Changed Family history of sudden cardiac death in a first degree relative with hypertrophic cardiomyopathy to First degree relative with hypertrophic cardiomyopathy under Presyncope or syncope by history It is reasonable to suspect hypertrophic cardiomyopathy in a patient who presents with presyncope or syncope and who also has a first degree relative with hypertrophic cardiomyopathy, even if that relative did not suffer a cardiac event. Computed Tomography (CT), Cardiac or Magnetic Resonance Imaging (MRI), Cardiac Indication: Hypertrophic cardiomyopathy Removed No murmur by physical examination under Presyncope or syncope by history Patients with hypertrophic cardiomyopathy often have a cardiac murmur. Computed Tomography (CT), Cardiac or Magnetic Resonance Imaging (MRI), Cardiac Indication: Suspected hypertrophic cardiomyopathy Removed Further imaging needed for treatment planning when echocardiogram (TTE) is diagnostic for hypertrophic cardiomyopathy This indication covers suspected cardiomyopathy. If the TTE confirms a diagnosis of hypertrophic cardiomyopathy, further imaging is not necessary. Computed Tomography (CT), Cardiac or Magnetic Resonance Imaging (MRI), Cardiac Indication: Suspected hypertrophic cardiomyopathy Changed recommendation MRI, Cardiac to Current evidence does not support this clinical scenario when echocardiogram (TTE) is diagnostic for hypertrophic cardiomyopathy This indication covers suspected cardiomyopathy. If the TTE confirms a diagnosis of hypertrophic cardiomyopathy, further imaging with cardiac MRI is not necessary. Computed Tomography (CT), Cardiac or Magnetic Resonance Imaging (MRI), Cardiac Indication: Suspected arrhythmogenic right ventricular dysplasia (ARVD) Added Cardiac arrest survivor Sudden cardiac death may be the first manifestation of arrhythmogenic right ventricular dysplasia. Page 14 of 50

15 Computed Tomography (CT), Cardiac or Magnetic Resonance Imaging (MRI), Cardiac Indication: Suspected arrhythmogenic right ventricular dysplasia (ARVD) Changed Presyncope or syncope 2 episodes by history to Presyncope or syncope by history Any episode of presyncope or syncope in a patient with suspected arrhythmogenic right ventricular dysplasia should be evaluated, not just recurrent episodes. Computed Tomography (CT), Cardiac or Magnetic Resonance Imaging (MRI), Cardiac Indication: Assessment of myocardial viability Removed Single photon emission computed tomography (SPECT) performed and Single photon emission computed tomography (SPECT) scan nondiagnostic for extent of myocardial viability SPECT is not necessarily the first test used for myocardial viability assessment. Computed Tomography (CT), Cardiac or Magnetic Resonance Imaging (MRI), Cardiac Indication: Assessment of myocardial viability Changed recommendation "MRI, Cardiac, Limited Evidence, additional review required" to "MRI, Cardiac Evidence now supports the use of MRI to assess viability. Computed Tomography (CT), Coronaries Indications: Cardiac risk assessment and Coronary calcium measurement This change was made to include patients classified as having an intermediate risk for coronary artery disease. Changed PROCAM total risk score > 54 or Predicted 10 year risk by SCORE 5% to PROCAM total risk score 45 and 53 or Predicted 10 year risk by SCORE 1 and < 5% under Coronary artery disease (CAD) risk by scoring algorithm Computed Tomography (CT), Coronaries Indications: Cardiac risk assessment and Coronary calcium measurement Changed the rule of TWO or more to a rule of exactly TWO for Diabetes mellitus (DM), Family history of coronary artery disease (CAD) at age < 60, Dyslipidemia, Hypertension (HTN), Cigarette smoking, Woman age > 55 or postmenopausal, Man age > 45, and Cocaine abuse Patients with more than two risk factors for coronary artery disease are considered high risk, not intermediate risk, and are, therefore, not candidates for coronary artery calcium evaluation. Page 15 of 50

16 Computed Tomography Angiogram (CTA), Coronaries or Magnetic Resonance Angiogram (MRA), Cardiac Indication: Suspected cardiac chest pain Changed Intermediate coronary artery disease (CAD) risk to Intermediate pretest probability of coronary artery disease (CAD) When determining coronary artery disease (CAD) risk in patients who present with chest pain, risk models for symptomatic patients should be used to determine the pretest probability of CAD. Computed Tomography Angiogram (CTA), Coronaries or Magnetic Resonance Angiogram (MRA), Cardiac Indication: Suspected cardiac chest pain Changed Exercise tolerance tests (ETT) or nuclear stress test performed and Exercise tolerance test (ETT) or nuclear stress test nondiagnostic for etiology of chest pain to test nondiagnostic for etiology of chest pain This change was made to streamline the criteria. The information on the different types of stress tests used is now included in a note. Subset Combined indications Valve endocarditis, Valvular heart disease, Prosthetic valve, and New murmur by physical examination into new indication Valve disorders or murmur This change was made to streamline the criteria. Subset Removed indication Left ventricular (LV) function assessment echocardiogram is not appropriate for routine assessment of low ejection fractions. Subset Added indication Guidance of percutaneous noncoronary cardiac procedures Transesophageal echocardiogram can be used for catheter guidance or device placement during percutaneous noncoronary cardiac procedures (e.g., radiofrequency ablation, percutaneous valve replacement, closure device placement). Changed Holosystolic or late systolic murmur > Grade I to Holosystolic and Late systolic under Systolic murmur for New murmur by physical examination and no history of valvular heart disease A new late systolic murmur, regardless of grade, warrants imaging with echocardiogram to rule out valvular or structural heart disease. Page 16 of 50

17 Added Midsystolic and symptomatic under Systolic murmur for New murmur by physical examination and no history of valvular heart disease A new midsystolic murmur in a symptomatic patient warrants imaging with echocardiogram to rule out valvular or structural heart disease. Added Early systolic under Systolic murmur for New murmur by physical examination and no history of valvular heart disease A new early systolic murmur warrants imaging with echocardiogram to rule out valvular or structural heart disease. Added Continuous murmur under New murmur by physical examination and no history of valvular heart disease A new continuous murmur warrants imaging with echocardiogram to rule out structural heart disease. Added echocardiogram (TTE) equivocal or inconsistent with clinical findings and Further imaging needed for treatment planning under New murmur by physical examination and no history of valvular heart disease Transesophageal echocardiogram is appropriate for patients with a new murmur by physical examination when the transthoracic echocardiogram is equivocal or inconsistent with the clinical findings and it is necessary to clarify the severity of the disease to plan further treatment. Added recommendation Transesophageal echocardiogram (TEE) under New murmur by physical examination and no history of valvular heart disease Transesophageal echocardiogram is appropriate for patients with a new murmur by physical examination when the transthoracic echocardiogram is equivocal or inconsistent with the clinical findings and it is necessary to clarify the severity of the disease to plan further treatment. Removed Periodic assessment of prosthetic valves and New or changed murmur of valve sounds by physical examination with prosthetic valve under Native valvular heart disease Criteria for prosthetic valves can be found in the Prosthetic valve pathway in the new indication Valve disorders or murmur. Page 17 of 50

18 Added New onset heart failure by physical examination and CXR under Aortic stenosis (AS), Aortic regurgitation (AR), Mitral stenosis (MS), and Mitral regurgitation (MR) for Native valvular heart disease New onset heart failure in a patient with known valvular heart disease can be evaluated with an echocardiogram. Removed echocardiogram (TTE) nondiagnostic for aortic stenosis (AS) under Aortic stenosis (AS) for Native valvular heart disease This pathway is for known valvular disease. Criteria for suspected valvular disease can be found in the New murmur by physical examination and no history of valvular heart disease pathway. Changed New onset syncope by history to New onset presyncope or syncope under Aortic stenosis (AS) for Native valvular heart disease Both presyncope and syncope in a patient with aortic stenosis warrant further evaluation with echocardiogram. Added echocardiography equivocal or inconsistent with clinical findings and Further imaging needed for treatment planning under Aortic stenosis (AS) for Native valvular heart disease Transesophageal echocardiogram is appropriate for patients with symptomatic aortic stenosis (angina, anginal equivalent, syncope, heart failure) when the transthoracic echocardiogram is equivocal or inconsistent with the clinical findings and it is necessary to clarify the severity of the disease to plan further treatment. Added recommendation Transesophageal echocardiogram (TEE) under Aortic stenosis (AS) for Native valvular heart disease Transesophageal echocardiogram is appropriate for evaluating patients with symptomatic aortic stenosis (angina, anginal equivalent, syncope, heart failure) when the transthoracic echocardiogram is equivocal or inconsistent with the clinical findings and it is necessary to clarify the severity of the disease to plan further treatment. Added Valve area > 1.5 cm 2 and Prior transthoracic echocardiogram 3 years under Periodic assessment for Aortic stenosis (AS) for Native valvular heart disease Evidence supports transthoracic echocardiogram every 3 to 5 years for patients with mild, asymptomatic aortic stenosis. Page 18 of 50

19 Added Valve area 1.0 cm 2 and 1.5 cm 2 and Prior transthoracic echocardiogram 1 year under Periodic assessment for Aortic stenosis (AS) for Native valvular heart disease Evidence supports transthoracic echocardiogram every 1 to 2 years for patients with moderate, asymptomatic aortic stenosis. Added Valve area < 1.0 cm 2 and Prior transthoracic echocardiogram 1 year under Periodic assessment for Aortic stenosis (AS) for Native valvular heart disease Evidence supports transthoracic echocardiogram yearly for patients with severe, asymptomatic aortic stenosis. Added Enlarged aortic root by CXR and Cardiogenic shock (urgent) under Aortic regurgitation (AR) for Native valvular heart disease Cardiogenic shock, as well as the presence of an enlarged aortic root on chest x-ray, can indicate acute severe aortic regurgitation or aortic dissection. Echocardiography is indicated to determine the severity of the disease. Added echocardiography equivocal or inconsistent with clinical findings and Further imaging needed for treatment planning under Aortic regurgitation (AR) for Native valvular heart disease Transesophageal echocardiogram may be appropriate for patients with symptomatic aortic regurgitation when the transthoracic echocardiogram is equivocal or inconsistent with the clinical findings and it is necessary to clarify the severity of the disease to plan further treatment. Added recommendation Transesophageal echocardiogram (TEE) under Aortic regurgitation (AR) for Native valvular heart disease Transesophageal echocardiogram is appropriate for patients with symptomatic aortic regurgitation when the transthoracic echocardiogram is equivocal or inconsistent with the clinical findings and it is necessary to clarify the severity of the disease to plan further treatment. Removed echocardiogram (TTE) nondiagnostic for etiology of mitral stenosis (MS) under Mitral stenosis (MS) for Native valvular heart disease This pathway is for known valvular disease. Criteria for suspected valvular disease can be found in the New murmur by physical examination and no history of valvular heart disease pathway Page 19 of 50

20 Added echocardiography equivocal or inconsistent with clinical findings and Further imaging needed for treatment planning under Mitral stenosis (MS) for Native valvular heart disease Transesophageal echocardiogram is appropriate for patients with symptomatic mitral stenosis when the transthoracic echocardiogram is equivocal or inconsistent with the clinical findings and it is necessary to clarify the severity of the disease to plan further treatment. Added recommendation Transesophageal echocardiogram (TEE) under Mitral stenosis (MS) for Native valvular heart disease Transesophageal echocardiogram is appropriate for patients with symptomatic mitral stenosis when the transthoracic echocardiogram is equivocal or inconsistent with the clinical findings and it is necessary to clarify the severity of the disease to plan further treatment. Added Valve area > 1.5 cm 2 and Prior transthoracic echocardiogram 3 years under Periodic assessment for Mitral stenosis (MS) for Native valvular heart disease Evidence supports transthoracic echocardiogram every 3 to 5 years for patients with mild, asymptomatic mitral stenosis. Added Valve area 1.0 cm 2 and 1.5 cm 2 and Prior transthoracic echocardiogram 1 year under Periodic assessment for Mitral stenosis (MS) for Native valvular heart disease Evidence supports transthoracic echocardiogram every 1 to 2 years for patients with moderate, asymptomatic mitral stenosis. Added Valve area < 1.0 cm 2 and Prior transthoracic echocardiogram 1 year under Periodic assessment for Mitral stenosis (MS) for Native valvular heart disease Evidence supports transthoracic echocardiogram yearly for patients with severe, asymptomatic mitral stenosis. Removed echocardiogram (TTE) nondiagnostic for etiology of mitral regurgitation (MR) under Mitral regurgitation (MR) for Native valvular heart disease This pathway is for known valvular disease. Criteria for suspected valvular disease can be found in the New murmur by physical examination and no history of valvular heart disease Page 20 of 50

21 Changed Periodic assessment for severity 3+ or 4+ to Periodic assessment for severity 2+ under Mitral regurgitation (MR) in the Native valvular heart disease pathway Evidence supports transthoracic echocardiogram for surveillance of left ventricular function in asymptomatic patients with moderate to severe mitral regurgitation. Added echocardiography equivocal or inconsistent with clinical findings and Further imaging needed for treatment planning under Mitral regurgitation (MR) for Native valvular heart disease Transesophageal echocardiogram is appropriate for patients with symptomatic mitral regurgitation when the transthoracic echocardiogram is equivocal or inconsistent with the clinical findings and it is necessary to clarify the severity of the disease to plan further treatment. Added recommendation Transesophageal echocardiogram (TEE) under Mitral regurgitation (MR) for Native valvular heart disease Transesophageal echocardiogram is appropriate for patients with symptomatic mitral regurgitation when the transthoracic echocardiogram is equivocal or inconsistent with the clinical findings and it is necessary to clarify the severity of the disease to plan further treatment. Removed Prosthetic valve assessment, Prosthetic valve dysfunction, Mechanical valve, and Biologic valve under Prosthetic valve This change was made to streamline the criteria. The Prosthetic valve pathway covers an echocardiogram for periodic assessment, assessment of prosthetic valve dysfunction, and symptomatic mechanical or biological valves. Added New onset heart failure (HF) by physical examination and CXR under Prosthetic valve New onset heart failure in a patient with a prosthetic valve may be evaluated with echocardiogram. Added echocardiography equivocal or inconsistent with clinical findings and Further imaging needed for treatment planning under Prosthetic valve Transesophageal echocardiogram is appropriate for patients with prosthetic valves who are symptomatic when the transthoracic echocardiogram is equivocal or inconsistent with the clinical findings and it is necessary to clarify the severity of the disease to plan further treatment. Page 21 of 50

22 Added Prior biological valve replacement 3 years under Periodic assessment post valve replacement for Prosthetic valve Evidence supports echocardiogram in asymptomatic patients with mechanical heart valves 3 years after valve replacement with a bioprosthetic valve. Added Temperature > 100.4F (38.0 C) with implantable cardiac device under Suspected native valve endocarditis and Suspected prosthetic valve endocarditis for Valve endocarditis Patients with an implantable cardiac device are at an increased risk for endocarditis and an echocardiogram is warranted for evaluation of a fever. Changed the rule of TWO to a rule of ONE for Findings of inflammation or infection or murmur under Suspected prosthetic valve endocarditis for Valve endocarditis Patients with a prosthetic valve are at an increased risk for endocarditis and an echocardiogram is warranted for any one of the listed symptoms or findings. Added New or changed murmur by physical examination under Known native valve endocarditis by transthoracic echocardiogram (TTE) or transesophageal echocardiogram (TEE) for Valve endocarditis A new or changed murmur in a patient with endocarditis warrants further work-up with transesophageal echocardiogram. Indication: Congenital heart disease Added New onset heart failure (HF) by physical examination and CXR and Worsening heart failure by physical examination despite optimal medical treatment Patients with congenital heart disease who present with symptoms of new onset heart failure or worsening heart failure may be evaluated with an echocardiogram. Indication: Congenital heart disease Changed New atrial fibrillation or flutter to New arrhythmia by electrocardiogram (ECG) Any new arrhythmia, not just atrial fibrillation or atrial flutter, in a patient with congenital heart disease could be evaluated with an echocardiogram. Page 22 of 50

23 Indication: Congenital heart disease Changed Nondiagnostic for etiology of findings to echocardiogram equivocal or inconsistent with clinical findings and Further imaging needed for treatment planning Transesophageal echocardiogram may be appropriate for evaluating patients with symptomatic congenital heart disease when the transthoracic echocardiogram is equivocal or inconsistent with the clinical findings and it is necessary to clarify the severity of the disease to plan further treatment. Indication: Hypertrophic cardiomyopathy Removed Secondary hypertension (HTN) under Suspected hypertrophic cardiomyopathy Secondary hypertension is not commonly seen in patients with hypertrophic cardiomyopathy. Indication: Hypertrophic cardiomyopathy Changed With presyncope or syncope 2 episodes by history to Presyncope or syncope by history under Suspected hypertrophic cardiomyopathy Any episode of presyncope or syncope, not just recurrent episodes, in a patient with suspected hypertrophic cardiomyopathy should be evaluated. Indication: Hypertrophic cardiomyopathy Changed Family history of sudden cardiac death in a first degree relative with hypertrophic cardiomyopathy to First degree relative with hypertrophic cardiomyopathy under Presyncope or syncope by history It is reasonable to suspect hypertrophic cardiomyopathy in a patient who presents with presyncope or syncope and who also has a first degree relative with hypertrophic cardiomyopathy, even if that relative did not suffer a cardiac event. Indication: Hypertrophic cardiomyopathy Added Initial evaluation and Prior transthoracic echocardiogram 5 years under Periodic screening for Suspected hypertrophic cardiomyopathy Evidence supports transthoracic echocardiogram for patients with first degree relatives diagnosed with idiopathic hypertrophic cardiomyopathy, as well as for patients with a positive genetic mutation for the disease. Screening is recommended as part of an initial assessment and then every 5 years. Indication: Hypertrophic cardiomyopathy Added Known hypertrophic cardiomyopathy Echocardiogram is appropriate for symptomatic patients with known hypertrophic cardiomyopathy and for asymptomatic patients as part of a preoperative evaluation or periodic screening. Page 23 of 50

24 Subset Combined indications New onset atrial fibrillation or flutter by electrocardiogram (ECG), Arrhythmia, and New electrocardiogram (ECG) abnormality into new indication Arrhythmia or new electrocardiogram (ECG) abnormality Indication: Arrhythmia or new electrocardiogram (ECG) abnormality Added Duration > 48 hours and cardioversion planned, INR subtherapeutic and Patient not taking anticoagulation medication under New onset atrial fibrillation or flutter by electrocardiogram (ECG) This change was made to streamline the criteria. Transesophageal echocardiogram may be appropriate when cardioversion is planned in patients with new onset atrial fibrillation or flutter to rule out the presence of a left atrial thrombus. Indication: Arrhythmia or new electrocardiogram (ECG) abnormality Added recommendation Transesophageal echocardiogram (TEE) for New onset atrial fibrillation or flutter by electrocardiogram (ECG) Transesophageal echocardiogram may be appropriate when cardioversion is planned in patients with new onset atrial fibrillation or flutter to rule out the presence of a left atrial thrombus. Subset Changed indication Presyncope or syncope with nondiagnostic ambulatory electrocardiography or exercise treadmill test (ETT) to Presyncope or syncope with nondiagnostic electrocardiogram (ECG) An ambulatory electrocardiogram and exercise treadmill test are not necessarily done prior to echocardiography but are often ordered simultaneously in the work-up of presyncope or syncope. Indication: Presyncope or syncope with nondiagnostic electrocardiogram (ECG) Changed Chest pain by history and risk factors for coronary artery disease (CAD) to Chest pain by history and pretest probability of coronary artery disease (CAD) and removed Coronary artery disease (CAD) risk factors Echocardiography may be appropriate when the patient s probability of having coronary artery disease is high, even if they do not have specific risks for CAD. Indication: Presyncope or syncope with nondiagnostic electrocardiogram (ECG) Removed Low coronary artery disease (CAD) risk echocardiogram may be appropriate for evaluating patients with any coronary artery disease (CAD) risk, not just those with low risk. Page 24 of 50

25 Indication: Acute cardiopulmonary dysfunction Changed TTE and right heart catheterization nondiagnostic for etiology of hypotension to echocardiogram (TTE) nondiagnostic for etiology of hypotension for Hypotension unresponsive to intravenous (IV) fluids or vasopressors (urgent) A right heart catheterization is not necessarily done with transesophageal echocardiogram when evaluating acute cardiopulmonary dysfunction. Indication: Acute cardiopulmonary dysfunction Changed TTE and right heart catheterization nondiagnostic for etiology of respiratory failure to echocardiogram (TTE) nondiagnostic for etiology of respiratory failure for Respiratory failure requiring intubation (urgent) A right heart catheterization is not necessarily done with transesophageal echocardiogram when evaluating respiratory failure. Indication: Intraoperative monitoring Removed Abdominal aortic aneurysm (AAA) resection or repair, Thoracic aortic aneurysm resection or repair, Proximal bypass procedure, Coronary artery bypass graft (CABG) with ejection fraction (EF) 40%, Valve surgery, Cardiac tumor excision, and Congenital heart disease surgery This change was made to streamline the criteria. The information on the different types of surgeries are now included in a note., Indications: ALL Changed recommendations Nuclear Test, dobutamine and Nuclear Test, Persantine to Nuclear Test, Pharmacological This change was made to cover all pharmacological agents used for nuclear stress testing (e.g., adenosine, regadenoson), not just dobutamine and Persantine., Indications: ALL Changed recommendations Nuclear Test, thallium or technetium or sestamibi and SPECT, nuclear stress test to Nuclear Test, Exercise This change was made to cover all radioisotopes used for nuclear stress testing, not just thallium, technetium, sestamibi, and SPECT. Page 25 of 50

26 , Subset Indications: Risk factors for coronary artery disease (CAD), Presyncope or syncope by history with nondiagnostic electrocardiogram (ECG), Risk stratification for major noncardiac surgery, Newly discovered left ventricular (LV) dysfunction, New onset heart failure (HF) by physical examination and CXR, Nonsustained ( 30 seconds) ventricular tachycardia (VT) tach by electrocardiogram (ECG), Coronary artery disease (CAD) by prior positive stress test or coronary artery disease (CAD) event, and Assess for myocardial ischemia with culprit vessel Which stress test to use is influenced by the resting ECG. Patients with ST segment depression, Wolff-Parkinson- White syndrome, a left bundle branch block, or a 100% ventricularly paced rhythm for example, require different testing strategies. Added Resting electrocardiogram (ECG) interpretable, Subset Indications: Risk factors for coronary artery disease (CAD), Presyncope or syncope by history with nondiagnostic electrocardiogram (ECG), Risk stratification for major noncardiac surgery, Newly discovered left ventricular (LV) dysfunction, New onset heart failure (HF) by physical examination and CXR, Nonsustained ( 30 seconds) ventricular tachycardia (VT) tach by electrocardiogram (ECG), Coronary artery disease (CAD) by prior positive stress test or coronary artery disease (CAD) event, and Assess for myocardial ischemia with culprit vessel This change was made to not limit stress testing to patients who can exercise. The criteria now include patients that may not have full exercise potential but can exercise to such an extent that the test will accurately reflect their cardiac status., Changed Inability to exercise due to physical limitations to Individual able to achieve the appropriate level of exercise Subset Added indication Suspected cardiac chest pain testing may be appropriate for the evaluation of suspected cardiac chest pain in patients with an intermediate or high pretest probability of coronary artery disease. Subset Added indication Suspected acute myocardial infarction (MI) testing may be appropriate in the evaluation of lowrisk patients with a suspected acute myocardial infarction. Subset Added indication Abnormal Duke treadmill score Patients with an intermediate or high-risk Duke treadmill score should be further evaluated with stress testing. Page 26 of 50