1. Multiple Sclerosis and Other White- Matter Diseases... CT Head/Brain MRI Head 11 22 Change: Split the paragraph into five bullets 2. Evaluation of Abnormal Findings Detected on Other Imaging Studies Such as a Mass Lesion or Abnormal Intracranial Calcification CT Head/Brain Change: Delete this indication 3. Abnormalities Detected on Other Imaging Studies Which Require Additional Clarification to Direct Treatment CTA Head MRA Head 4. Multiple Sclerosis CTA Head MRA Head CTA Neck MRA Neck 15 27 16 28 52 55 Change: Add this indication Change: Add this indication 5. Cochlear Implant Pre-operative Evaluation CT Orbit 36 Change: Modify the name of this indication to, Cochlear Implant Pre-operative and Postoperative Evaluation Page 1 of 32
6. Abnormalities Noted on Other Imaging Studies CT Orbit 7. Laryngeal Edema: MRI Orbit, Face, Neck 38 40 Change: Modify this indication to read: ABNORMALITIES DETECTED ON OTHER IMAGING STUDIES WHICH REQUIRE ADDITIONAL CLARIFICATION TO DIRECT TREATMENT Such as surveillance of an unexplained mass lesion, without pathologic tissue confirmation Change: Add this indication 8. Abnormalities Detected on Other Diagnostic Exams MRI Orbit, Face, Neck CT Neck (Soft Tissue) 9. Follow-Up of Abnormal or Inconclusive findings CTA Neck MRA Neck 10. Imaging Considerations CT Chest 41 49 52 55 57 Change: Modify this indication so that it is consistent with other imaging indications: ABNORMALITIES DETECTED ON OTHER IMAGING STUDIES WHICH REQUIRE ADDITIONAL CLARIFICATION TO DIRECT TREATMENT Change: Modify this indication so that it reads, ABNORMAL OR INCONCLUSIVE FINDINGS ON CAROTID DOPPLER ULTRASOUND OR OTHER IMAGING STUDIES Change: Add this bullet to the imaging considerations section, CT chest is not appropriate for cardiac and coronary artery imaging. Please review guidelines for cardiac CT and CCTA. Page 2 of 32
11. Common Diagnostic Indications CT Chest Change: Remove the sub-title, Additional Cardiac and Pericardial Indications from the very beginning of the indications section. 12. Fever of unknown origin CT Chest CT Abdomen CT Abdomen / Pelvis Combo 58 126 147 163 Also remove the sub-header with the same name and the three indications that follow, Congenital heart disease, Cardiac aneurysm and pseudoaneurysm, and Intra-cardiac and para-cardiac mass AIM Comment: There is a specific CPT code for Cardiac CT and CCTA Change: Add two informational bullets - Lasting more than three weeks - Following standard work-up to localize the source 13. Unexplained Weight Loss CT Chest 58 Change: Add text,, after initial evaluation for other causes to the end of the title 14. Imaging Considerations CTA chest (Non-Coronary) 15. Developmental Anomalies of the Thoracic Vasculature CTA Chest (Non-Coronary) MRI Chest 62 63 68 Change: Add this bullet to the imaging considerations section, CTA chest is not appropriate for cardiac and coronary artery imaging. Please review guidelines for cardiac CT and CCTA. Change: remove the two sub-bullets, "Patent ductus arteriosus" and "Transposition of the Great Vessels" Page 3 of 32
16. Congenital Heart Disease CTA Chest (Non-Coronary) MRA Chest Change: Remove this indication 17. Cardiac Masses and Tumors CTA Chest (Non-Coronary) MRA Chest Change: Remove this indication 18. Post-Operative or Post- Interventional Vascular Procedure CTA Chest (Non-Coronary) MRA Chest 64 71 Change: add parenthetical statement, (Excluding Coronary Arteries) 19. Evaluation of Cardiac Venous Anatomy CTA Chest (Non-Coronary) MRA Chest Change: Remove this indication 20. Evaluation of Pericardial Conditions MRA chest Change: Remove this indication Page 4 of 32
21. Imaging Considerations MRI Chest 67 Change: Add this bullet to the imaging considerations section, 22. Lesion Characterization MRI Breast 74 Cardiac and coronary artery imaging should not be performed using MRI chest. Please review guidelines for Cardiac MRI. Change: Modify the formatting of this indication so that instead of one large block of text; it is a shorter title with a bullet(s). 23. Invasive Carcinoma and Ductal Carcinoma In Situ (DCIS) MRI Breast 74 Change: Modify the formatting of this indication so that instead of one large block of text; it is a shorter title with a bullet(s). 24. Invasion of Breast Cancer Deep to Fascia MRI Breast 74 Change: Modify the formatting of this indication so that instead of one large block of text; it is a shorter title with a bullet(s). 25. Metastatic Cancer MRI Breast 74 Change: Modify the formatting of this indication so that instead of one large block of text; it is a shorter title with a bullet(s). Page 5 of 32
26. Neoadjuvant Chemotherapy MRI Breast 74 Change: Modify the formatting of this indication so that instead of one large block of text; it is a shorter title with a bullet(s). 27. Recurrence of Breast Cancer MRI Breast 74 Change: Modify the formatting of this indication so that instead of one large block of text; it is a shorter title with a bullet(s). 28. Post-Lumpectomy with Positive Margins MRI Breast 74 Change: Modify the formatting of this indication so that instead of one large block of text; it is a shorter title with a bullet(s). 29. Post-Operative Tissue Reconstruction MRI Breast 74 Change: Modify the formatting of this indication so that instead of one large block of text; it is a shorter title with a bullet(s). 30. Differentiation of Palpable Mass(es) from Surgical Scar Tissue MRI Breast 74 Change: Modify the formatting of this indication so that instead of one large block of text; it is a shorter title with a bullet(s). Page 6 of 32
31. Lifetime Risk ~ 20-25% or Greater MRI Breast 74 Change: Modify the formatting of this indication so that instead of one large block of text; it is a shorter title with a bullet(s). 32. At 6 months Following a Previous Breast MRI MRI Breast 33. Uses of Myocardial Perfusion Imaging MPI Stress Echo 34. Established Coronary Artery Disease ( in patients who have new or worsening symptoms) MPI Stress Echo 74 76 90 79 93 Change: Modify the formatting of this indication so that instead of one large block of text; it is a shorter title with a bullet(s). Add informational bullet BI-RADS category 3 breast MRI is defined as a result recommended for short term follow-up, usually six months Change: in the bullet, MPI is also used for risk stratifications with established coronary artery disease delete "risk stratifications with" and add "management of" Note for Stress Echo, MPI changes to SE Change: Add the text, "not undergone revascularization and have" to the name of this indication 35. Established Coronary Artery Disease in Patients who have Undergone Revascularization MPI Stress Echo 79 93 Change: Add this new indication (note that in the sub-bullets it will show MPI for MPI and Stress Echo for Stress Echo) Page 7 of 32
36. Established Coronary Artery Disease in a Patient who has had Myocardial Infarction (ST Elevation or Non-ST Elevation) or Unstable Angina within the Preceding Ninety (90) Days Provided That: MPI Stress Echo 79 93 Change: Add this indication 37. Patients with new Onset Arrhythmias (Patient can be symptomatic or asymptomatic) MPI Stress Echo 38. Myocardial Viability Evaluation MPI Stress Echo 79 93 80 94 Change: For Stress Echo Only, add a teaching point This guideline applies to patients with suspected or established CAD For both SE and MPI: Modify the first bullet to read, In patients who have sustained (lasting more than 30 seconds) or non-sustained (more than 3 beats but terminating within 30 seconds) ventricular tachycardia Add new bullet and sub-bullet: Patients who have frequent premature ventricular contractions (PVC) defined as more than ten (10) PVCs per hour on ambulatory EKG (Holter) monitoring - It is not clinically indicated to perform stress echocardiography for evaluation of infrequent premature atrial or ventricular depolarizations (note that in the sub-bullets it will show MPI for MPI and stress echocardiography for Stress Echo) Change: Add text, (Left ventricular ejection fraction <55%) to the second bullet For Stress Echo only in the note, change the word form to protocol Page 8 of 32
39. Preoperative Cardiac Evaluation of Patients Undergoing Non-Cardiac Surgery MPI Stress Echo 81 94 Change: Add "including but not limited to" in the first and second set of parenthesis under intermediate risk surgery. Add the new bullet "The patient has not had..." add the word "Or" just after that bullet. Modify the bullet regarding treadmill to begin "patient is unable to..." and move it as a sub-bullet of the clinical risk factors bullet and then change the clinical risk factors to read "at least one of the following applies" then modify the sub-bullets underneath by adding "patient has..." (fix the sentence case) 40. Imaging Considerations Cardiac Blood Pool Imaging 84 For Stress Echo Only in the bullet regarding patients with active cardiac conditions, change the word MPI to Stress Echo at the end of the bullet Change: From the 10th bullet, delete the phrase in parenthesis "treadmill stress test", add "transthoracic echocardiography, transesophageal echocardiography" and "cardiac CT Add new bullet, In interpretation of this document, the term clinically stable is taken to mean that the patient has no new or worsening cardiac symptoms and there are no changes on cardiovascular examination Page 9 of 32
41. Evaluation of left Ventricular Function Cardiac Blood Pool Imaging 85 Change: in the Note, delete the phrase "except in the situations outlined below", Modify the second bullet to add "LVH" modify the 9th bullet by replacing "for dyssynchrony" with "of LV function" adding "with known cardiomyopathy" and "implantable defibrillator (AICD) or ventricular assist device (VAD)". Reword the 10th and 11th bullets completely. modify the 12th bullet by adding "and LV function has not been evaluated by another modality since that testing was performed" and delete the sub-bullet underneath 42. Coronary Artery Disease (CAD) {Applies to Patients with Established Coronary Artery Disease} Cardiac Blood Pool Imaging 86 Change: modify the first bullet to include "acute coronary syndrome (myocardial infarction or unstable angina)" leave the subbullets alone, but delete the rest of the bullets and replace completely with the three new bullets 43. Valvular Heart Disease Stress Echo 95 Change: Rewrite this indication for clarification and ease of use 44. Pulmonary Hypertension Stress Echo 95 Change: add the text "exercise induced" to the second bullet Page 10 of 32
45. In Patients who Have, or are Likely to Have Suboptimal Transthoracic Imaging TEE 46. In Patients Whose Clinical Situation Suggests That TEE May be Preferable to Transthoracic Echocardiography as an Initial Imaging Test TEE 98 99 Change: Add the new sub-bullet: - In patients with a cardiac diagnosis was made by TEE who require re-evaluation the results of which would lead to a change in therapy (e.g. resolution of an intracardiac thrombus following anticoagulation) Change: reword the second bullet as shown below In evaluation of valvular structure and function to assess suitability for and assist in planning of surgical or catheter based valvular intervention 47. In Patients who have Undergone Technically Adequate Transthoracic Echocardiography TEE 48. Imaging Considerations TTE 99 100, add the words "to exclude endocarditis" to the fifth bullet, add a sub-bullet to the sixth bullet - TEE is not required when the decision has been made to anticoagulate the patient and not perform cardioversion Change: reword the bullet replacing the text, "in patients who have no history of atrial fibrillation or atrial flutter with normal EKG and normal TTE" with "when no non-cardiac source has been identified" Change: Add a new bullet to this section under the ordering issues sub-header: In interpretation of this document, the term clinically stable is taken to mean that the patient has no new or worsening cardiac symptoms and there are no changes on cardiovascular examination Page 11 of 32
49. Established Native Valvular Stenosis TTE 101 Change: modify name of indication, removing "aortic stenosis or pulmonic" and adding "native valvular", rewrite second bullet removing "asymptomatic patients with" and adding" clinically stable patients with moderate or" and rewrite third bullet changing asymptomatic to clinically stable, moderate to mild, and 2 to three years 50. Established Native Valvular Regurgitation TTE 51. Established Bicuspid Aortic Valve TTE 52. Established Mitral or Tricuspid Stenosis TTE 101 101 Change: modify name of indication removing "aortic or pulmonic" and adding "native valvular", rewrite second bullet removing "asymptomatic patients with" and adding" clinically stable patients with moderate or" and rewrite third bullet changing "asymptomatic" to "clinically stable", remove "or moderate", remove "and ventricular dilation or dysfunction annually" to "every three (3) years" Change: add "Bicuspid aortic valve and" and "on prior echo" to the second bullet, modify the third bullet to read "Bicuspid aortic valve and normal aortic root on prior echo (echo at three (3) yearly intervals is indicated)" Change: Delete this indication 53. Established Mitral or Tricuspid Regurgitation TTE Change: Delete this indication Page 12 of 32
54. Prosthetic Cardiac Valves (Mechanical or Bioprosthetic) and Patients who have Undergone Valve Repair TTE 101 Change: delete the "and" under the title, move the signs and/or symptoms bullet so that it is the second bullet listed, rewrite the first "annual reevaluation" bullet (adding the sub-bullet as well), rewrite the second annual reevaluation bullet 55. Evaluation of Ventricular Function TTE 56. Evaluation of Patients with Cardiac Arrhythmias TTE 102 103 Change: Add the note add the three new bullets, Initial evaluation for cardiac resynchronization therapy (CRT) device optimization following implantation Echocardiography is indicated for optimization of device settings in patients with ventricular assist device (VAD) Echocardiography is indicated for evaluation of signs and/or symptoms suggestive of device related complications in patients with ventricular assist device (VAD) in the 13th bullet add "of LV function" and "with known cardiomyopathy" and "implantable defibrillator (AICD) or ventricular assist device (VAD)", in the 15th bullet add "with new signs or" before symptoms and "of heart failure for" just after Change: add new bullet: In patients who have frequent premature ventricular contractions (PVC) defined as more than ten (10) PVCs per hour on ambulatory EKG (Holter) monitoring Change the word appropriate to clinically indicated and add word infrequent to subbullet Page 13 of 32
57. Evaluation of Patients with Suspected Coronary Artery Disease TTE 104 Change: Add this new indication (note that this used to be a group of bullets in another indication and has been broken into a separate indication for ease of use) 58. Evaluation of Patients with known or suspected coronary artery disease TTE 59. Evaluation of Patients with Pulmonary Embolus TTE 60. Evaluation of Patients with Pulmonary Hypertension TTE 104 106 106 Change: remove "or suspected" from title", remove first bullet "patients with known coronary artery disease" delete the phrase "myocardial infarction" from the next four bullets and add "acute coronary syndrome (myocardial infarction or unstable angina), delete the 6th bullet "patients who have undergone...", delete the comma in the 7th bullet between diagnosis of and aberrant. Delete the bullet "patients with suspected coronary artery disease" and all the bullets that follow. This is being made into its own indication. Change: from the first bullet, delete "or suspected" and add "may be performed as". In the second bullet, add "and pulmonary artery pressure" to the first sentence. change "may be" to "are not" in the second sentence Change: in the third bullet, replace "2 yearly intervals at" with "annually" and replace "adults (age 19 years or older)" with "patients". Delete the fourth bullet, Echocardiography may be performed annually in asymptomatic non adult patients (less than or equal to 18 years old) with an established diagnosis of pulmonary hypertension Page 14 of 32
61. Evaluation of Aortic Disease TTE 62. Evaluation of Pericardial Diseases TTE 106 106 Change: Add the new bullet (first bullet listed), modify the second bullet to remove "in the preoperative or postoperative" text and replace with "for" also add "suspected or established after evaluation of and change dissection to dilation in the parenthesis) completely rewrite the fourth bullet as shown on PDF Change: Add the word suspected to the first bullet. Add new bullet and sub-bullet (second bullet) 63. Congenital Heart Disease Cardiac CT 64. Cardiomyopathy Cardiac CT 109 109 Change: Add the first bullet (new item) For evaluation of suspected congenital anomalies of the coronary arteries modify the third bullet by adding "patients whose echocardiogram suggests a new diagnosis of" and delete "in patients who have undergone echocardiography" Change: Add this new indication 65. Valvular Heart Disease Cardiac CT 109 Change: Add this new indication 66. Evaluation of Patients with Established Coronary Artery Disease Cardiac CT 110 Change: Add this new indication Page 15 of 32
67. Evaluation of Cardiac Venous Anatomy Cardiac CT Cardiac MRI 110 119 Change: Delete the word first from the first bullet. Delete the following bullets from this indication For reevaluation of the pulmonary veins on one occasion following radiofrequency ablation 68. Evaluation of Thoracic Aorta Aneurysm / Dilation and Dissection Cardiac CT MRI Cardiac 69. Congestive Heart Failure / Cardiomyopathy Coronary CTA 70. Evaluation of Patients with Established Coronary Artery Disease Coronary CTA 71. Myocarditis Cardiac MRI 110 120 112 118 For re-evaluation of the pulmonary venous anatomy prior to repeat radiofrequency ablation provided that the patient has not had evaluation of the pulmonary veins following the previous radiofrequency ablation Change: Add "/ dilation" after the word aneurysm in the title, 1st, 2nd, 3rd, and 8th bullet Change: add the phrase "left ventricular ejection fraction <55% and" to the first bullet. Delete the second bullet, For coronary vein mapping in patients with cardiomyopathy for whom cardiac resynchronization therapy (CRT) is planned Change: Delete this indication Change: modify the second bullet to include "whose transthoracic echocardiogram is technically suboptimal" delete the third bullet, Technically suboptimal transthoracic echocardiogram Page 16 of 32
72. Cardiomyopathy Cardiac MRI 118 Change: add the text "an established diagnosis of a", remove the letter s from the word disease, remove of the myocardium and replace with, "(excluding CAD)" in the second bullet 73. Congenital Heart Disease Cardiac MRI 74. Imaging Considerations PET Myocardial Imaging 118 122 Change: add the first bullet For evaluation of suspected congenital anomalies of the coronary arteries modify the second bullet to include "or established" modify the third bullet including "patients whose echocardiogram suggests a new diagnosis of" and deleting "in patients who have undergone echocardiography" delete the last sub bullet, Cardiac MRI or transesophageal echocardiography may be preferable to cardiac CT in order to avoid radiation exposure Change: in the 8th bullet, add the text, cardiac CT" and remove "cardiac PET imaging" 75. Requirements for Myocardial PET Imaging PET Myocardial Imaging 123 Change: to the second bullet, add "When non invasive imaging is required to" to the beginning of this bullet, add the text "with suspected or established CAD" after BMI >40, change "can" to "may" 76. Perfusion PET Imaging For Patients who have BMI > 40 PET Myocardial Imaging 123 Delete the third bullet, it begins with In keeping with CMS Guidelines, Perfusion PET Change: delete "are at least 65 yrs old or" from this indication add sub-bullet to the second bullet as listed above, delete "moderate or" and add "(SCORE)." to the last bullet Page 17 of 32
77. Perfusion PET Imaging For Patients who have BMI < 40 PET Myocardial Imaging 123 Change: Delete, "are < 65 yrs old and" from this indication name 78. Metabolic PET Imaging for Evaluation of Non Coronary Cardiac Diseases PET Myocardial Imaging 79. Abdominal Pain unexplained by clinical findings, including physical examination and other imaging studies CT Abdomen 80. Abnormal Findings on Other Imaging Exams that Require Further Evaluation CT Abdomen CT Abdomen / Pelvis Combo 123 126 126 147 163 Change: Add "for evaluation of non coronary cardiac disease" to the title of this indication, reword the bullet "may be considered..." to "Metabolic PET imaging may be used in the diagnosis or management of cardiac sarcoidosis" Change: add "and / or Pelvic" to the subbullet regarding radiographs, remove the word "many" from the last bullet. remove the entire sub-bullet (number 3) For pelvic symptoms in females Pelvic Ultrasound (trans-abdominal and trans-vaginal scans) usually provides excellent anatomic depiction of the uterus, adnexal structures and cul-de-sac AIM Comments: the third bullet was determined to be more appropriate for the pelvis Change: Modify the name of this indication to read, Abnormalities detected on other imaging studies which require additional clarification to direct treatment Page 18 of 32
81. Infectious or Inflammatory Process CT Abdomen CT Abdomen / Pelvis Combo 126 147 163 Change: Remove the following sub-bullet from Abdomen and add it to combo and pelvis Recurrent cystitis (male with at least two episodes or female with failed antibiotic therapy) 82. Diffuse, unexplained lower extremity edema CT abdomen 83. Post-operative evaluation for complications CT Abdomen CT Abdomen / Pelvis Combo 84. Pre-Operative Evaluation for Complications CT Abdomen CT Abdomen / Pelvis Combo 85. Trauma CT Abdomen 127 127 148 164 127 148 164 127 Add Pyelonephritis; persistent or worsening symptoms after three days of antibiotics to combo AIM Comments: bulleting was adjusted so that abdomen specific and pelvic specific information in the correct location Change: Remove the word pelvic from the bullet, Advanced imaging may be used to exclude an occult pelvic tumor or lesion causing mass effect, not identified by pelvic ultrasound, as the cause of vascular compression and resultant lower extremity edema Change: Remove "particularly during the initial 6-8 weeks" from the bullet AIM Comments: determined that appropriate timeframe differs for different post-operative situations Change: change the word For to including Change: Modify the bullet to remove and pelvis as this is covered in the pelvis guideline as well as the combination guideline Page 19 of 32
86. Tumor Evaluation: Primary Abdominal or Pelvic Neoplasm CT Abdomen CT Abdomen / Pelvis Combo 87. Tumor Evaluation: Metastatic Disease CT Abdomen 127 Change: Combine this indication with the Tumor Evaluation: Metastatic Disease indication (this indication will be deleted and its information moved to the other Tumor indication) Change: Add "primary neoplasm or" to the indication title. Delete the words "after treatment" from the 3rd bullet. remove "may involve the following anatomic structures" and all the sub-bullets, add the note from the other Tumor Evaluation indication 88. Aneurysm of Abdominal Aorta or Branch Vessel CT Abdomen CTA/MRA Abdomen CTA Abd Aorta W/ Runoff CTA/MRA Pelvis CT Abdomen/Pelvis Combo 89. Endovascular Stent Graft Placement for Abdominal Aortic Aneurysm CT Abdomen CTA/MRA Abdomen CTA/MRA Pelvis CT Abdomen/Pelvis Combo 129 140 144 149 160 165 AIM Comments: The sub-bullets served no useful purpose. The language didn t restrict the user and there was an other category that effectively voided the other sub-bullets Change: Complete rewrite of this indication combining the current indication with the stent graft piece Change: Delete this indication AIM Comments: Information from this indication was combined with the AAA indication listed above, also note that the abdominal aorta w/ runoff guideline did not previously have this indication which is why it is not listed as being deleted Page 20 of 32
90. Arteriovenous Malformation (AVM) CT Abdomen 129 Change: Add this indication AIM Comments: This indication already previous existed in the abdomen/pelvis combo guideline as well as the pelvis standalone guideline 91. Thrombosis in the Systemic and Portal Venous Circulations CT Abdomen CT Abdomen/Pelvis Combo 92. MRCP MRCP MRI Abdomen 93. Tumor Evaluation MRI Abdomen MRI Pelvis 94. For clarification or questionable or abnormal findings on other abdominal imaging studies MRI Abdomen MRI Pelvis 129 149 165 132 134 135-139 136 156 136 155 Change: Reword the bullet from, May follow initial evaluation with Doppler Ultrasound, to Following initial evaluation with inconclusive doppler ultrasound Change: Create a brand new guideline using information for MRCP found in the MRI Abdomen guideline. Also remove the MRCP information from Abdomen MRI guideline once complete Change: remove "of the following structures:" from the first bullet. Remove all sub-bullets of both the first and second bullet so that only the bullets themselves remain AIM Comments: The sub-bullets served no useful purpose for operations. The language didn t restrict the user and there was an other category that effectively voided the other sub-bullets Change: Modify this indication to read, Abnormalities detected on other imaging studies which require additional clarification to direct treatment Page 21 of 32
95. Hematoma/Hemorrhage CTA/MRA Abdomen 141 Change: Add this indication 96. Arteriovenous malformation (AVM) or Fistula (AVF) CTA/MRA Abdomen CTA/MRA Pelvis 97. Renal Artery Stenosis CTA/MRA Abdomen 141 161 141 Change: add the word "arteriovenous" before fistula Change: In the sixth bullet, modify the age from 35 to 30 98. Peripheral Arterial Disease CTA Abd Aorta W/ Runoff 145 Change: Add this new indication 99. Stenosis or Occlusion of the Abdominal Aorta or Branch Vessels CTA Abd Aorta W/ Runoff 100. Pre- and Post-operative... Stenosis (Due to atherosclerosis, Thromboembolism ) CTA Abd Aorta W/ Runoff 101. Vascular Evaluation of Lower Extremity Claudication CTA Abd Aorta W/ Runoff Change: Delete this indication AIM Comments: This indication is combined in the new Peripheral Arterial Disease indication Change: Delete this indication AIM Comments: This indication is combined in the new Peripheral Arterial Disease indication Change: Delete this indication AIM Comments: This indication is combined in the new Peripheral Arterial Disease indication Page 22 of 32
102. Surgical Planning for a Kidney Donor CTA Abd Aorta W/ Runoff Change: Delete this indication 103. Ascites CT Abdomen / Pelvis Combo 147 163 Change: Remove the bullet regarding ultrasound being required 104. Palpable Pelvic Mass 105. Pelvic Pain unexplained by clinical findings, physical examination and other imaging studies 106. Tumor Evaluation: Primary Neoplasm or Metastatic Disease 107. Trauma Significant Pelvic Injury 147 147 148 148 Change: Modify the bullet to read "when palpable pelvic mass requires further evaluation following pelvic ultrasound in female patients" add bullet, "Skeletal mass abnormality, osseous or soft tissue, seen on prior imaging exam requiring further clarification by CT Change: Remove the text "pelvic ultrasound..." and the rest of text following from the numbered #2 sub-bullet. Add the hyphen sub-bullet regarding radiographs. Add gastro in front of intestinal in the sub-bullet following. delete "such as pelvic pain secondary to inflammatory bowel disease" Change: delete the original two bullets and replace with the three new bullets, "For diagnosis", "Initial staging", and Periodic follow up". delete all the sub-bullets and add the note Change: Delete significant pelvic injury from the title and add a new bullet, Following significant blunt or penetrating injury to the Pelvis Page 23 of 32
108. Aneurysm of Lower Abdominal Aorta, Iliac Arteries and/or Branch Vessels 149 Change: add "/ DILATION" and add the text "and/" to the title, Add "/ dilation" where the word aneurysm(s) appears. Add the text "may be performed" to the second bullet. add the third and fourth bullets 109. Arteriovenous Malformation (AVM) CT Abdomen / Pelvis Combo 149 165 Change: modify the sub-bullet by adding "a more detailed" and changing evaluating to evaluation 110. Stress / Insufficiency Fracture in the Pelvis 149 Change: Remove / insufficiency from the title of this indication 111. Acute Pelvic Trauma, for Fracture Evaluation 149 Change: remove in most circumstances from the bullet 112. Chronic Hip Pain, With Negative X- Ray and Suspected Osteoid Osteoma 113. Sacroiliac Joint Imaging for Sacroiliitis 114. Intramural Hematoma CTA/MRA Pelvis 149 149 161 Change: Rename this indication Osteoid Osteoma Change: completely replace this indication with the following, SACROILIITIS Following sacroiliac joint radiographs Change: Modify this indication to Hematoma / Hemorrhage Page 24 of 32
115. Venous Thrombosis or Occlusion CTA/MRA pelvis 161 Change: Reword the bullet from, May follow initial evaluation with Doppler Ultrasound, to Following initial evaluation with inconclusive doppler ultrasound 116. Stenosis or Occlusion of the Lower Abdominal Aorta, Iliac Arteries or Other Branch Vessels in the Pelvis CTA/MRA Pelvis 117. Abdominal / Pelvic Pain unexplained by clinical findings, physical examination and other imaging studies CT Abdomen / Pelvis Combo 118. Tumor Evaluation: Metastatic Disease CT Abdomen / Pelvis Combo 119. Palpable Abdominal / Pelvic Mass CT Abdomen / Pelvis Combo 161 163 164 164 Change: Remove "due to" and all the subbullets AIM Comments: The sub-bullets served no useful purpose. The language didn t restrict the user and there was an other category that effectively voided the other sub-bullets Change: to the numbered #3 sub-bullet, delete "pelvic ultrasound..." and the rest of the bullet and then add "with non-specific lower pelvic pain". For the sub-bullet for radiographs. Change the words "upper or lower" to "Barium Examination or". add the last bullet Change: add "primary neoplasm or" to the title. Remove "may involve the following..." and all the sub-bullets. add the note AIM Comments: The sub-bullets served no useful purpose. The language didn t restrict the user and there was an other category that effectively voided the other sub-bullets Change: Modify the bullet to read "when palpable pelvic mass requires further evaluation following pelvic ultrasound in female patients" add bullet, "Skeletal mass abnormality, osseous or soft tissue, seen on prior imaging exam requiring further clarification by CT Page 25 of 32
120. Aneurysm of Abdominal Aorta or Branch Vessel CT Abdomen / Pelvis Combo 165 Change: add, "/ DILATION" and", iliac arteries and/" to the title. Add / dilation wherever the word aneurysm(s) occurs. 121. Aortic Dissection CT Abdomen / Pelvis Combo 165 Change: Modify the name of this indication to Aortic-Iliac Dissection 122. Imaging Considerations CT Cervical Spine 123. Post-Myelogram CT: CT Cervical Spine 124. Less Severe <body part> Spine Trauma CT Cervical Spine MRI Cervical Spine CT Thoracic Spine CT Lumbar Spine 125. Significant Acute Trauma to the <body part> Spine Region CT Thoracic Spine CT Lumbar Spine 126. Post-Traumatic Neurologic Deficit and Spinal Cord Injury or Progressively Worsening <Cervical, Thoracic, Lumbar> Pain CT Cervical Spine MRI Cervical Spine CT Thoracic Spine CT Lumbar Spine 171 171 177 179 186 Change: in the bullet that begins CT is the preferred technique for certain clinical scenarios remove the phrase in the pediatric population Change: Delete this indication (it is a duplicate item and there is another indication that starts the same and has additional information is consistent with other sections) Change: Delete this indication Change: Delete this indication Change: Add this indication using the appropriate location for body part being imaged Page 26 of 32
127. Abnormal <body part> spine radiographs CT Cervical Spine MRI Cervical Spine CT Thoracic Spine MRI Thoracic Spine CT Lumbar Spine MRI Lumbar Spine 171 177 179 184 186 192 Change: modify the name of this indication to the following, using the appropriate body part location (cervical, thoracic, lumbar) Abnormal <body part> spine radiographs which require additional clarification to direct treatment 128. Fracture Evaluation CT Cervical Spine CT Thoracic Spine CT Lumbar Spine MRI Cervical Spine MRI Thoracic Spine MRI Lumbar Spine 129. Signs and symptoms of spinal cord and/or nerve root compression CT Cervical Spine MRI Cervical Spine CT Thoracic Spine MRI Thoracic Spine CT Lumbar Spine MRI Lumbar Spine 130. Demyelinating Disorders, such as Multiple Sclerosis, When MRI is Contraindicated CT Cervical Spine CT Thoracic Spine CT Lumbar Spine 131. Demyelinating Disorders, such as Multiple Sclerosis MRI Cervical Spine MRI Thoracic Spine MRI Lumbar Spine 171 177 179 184 186 192 172 176 181 183 187 191 172 180 187 176 183 191 Change: Add the following bullet to this indication: Following initial evaluation with radiographs Change: modify the name of this diagnosis to the following: SIGNS OF SPINAL CORD AND/OR NERVE ROOT COMPRESSION (FOR EXAMPLE, DUE TO <body part> SPINAL STENOSIS OR DISC HERNIATION) Remove the words and symptoms from the first bullet Change: modify the name of this indication to: Multiple Sclerosis and Other White-Matter Diseases, When MRI is Contraindicated or Not Tolerated Break the paragraph bullet into five separate bullets Change: modify the name of this indication to: Multiple Sclerosis and Other White-Matter Diseases Break the paragraph bullet into five separate bullets Page 27 of 32
132. Post-Traumatic Neurologic Deficit MRI Thoracic Spine MRI Lumbar Spine 184 192 Change: Modify this existing indication to the wording below using appropriate location for body part being imaged 133. New Neurologic Findings Related to the Thoracic Spine MRI Thoracic Spine Post-Traumatic Neurologic Deficit and Spinal Cord Injury or Progressively Worsening <Thoracic or Lumbar> Pain Change: Delete this indication it is a duplicate and is taken care of in another indication 134. CT Following Myelography or Other Lumbar Interventional Procedure: CT Lumbar Spine 135. Spondylolisis and Spondylolisthesis CT Lumbar Spine MRI Lumbar Spine 136. Congenital Spine Anomalies CT Lumbar Spine MRI Lumbar Spine 137. Tethered Cord and Other Anomalies Involving the Lumbar Spine and/or Lower Spinal Cord (Conus Medullaris), Filum Terminale or Nerve Roots, When MRI is Contraindicated MRI Lumbar Spine 186 186 192 188 192 Change: Modify the name of this indication for consistency with other sections to: Post-Myelogram CT or CT Following Other Lumbar Spine Interventional Procedure Change: modify the first bullet so that it reads as follows: Following non-diagnostic or abnormal lumbar spine radiographs (including oblique views) which require additional clarification to direct treatment, in an operative candidate Change: Modify the first bullet to read, Lumbar spine dysraphism and other congenital anomalies involving the lumbar spine and/or lower spinal cord (Conus Medullaris). filum terminale or nerve roots, including tethered cord (for CT only add When MRI is contraindicated to the end) Change: Delete this indication Page 28 of 32
138. Abnormalities Detected on Other Imaging Studies Which Require Additional Clarification to Direct Treatment MRA Spinal Canal 194 Change: Add this indication 139. Pre-Procedural/Pre-Operative and Post-Procedural/Pos-Operative Imaging of Vascular Structures in the Spinal Canal MRA Spinal Canal 140. Imaging Considerations CT Upper Extremity CT Lower Extremity MRI Lower Extremity Joint / Nonjoint 141. Imaging Considerations MRI Upper Extremity (Any Joint) MRI Upper Extremity (Non- Joint) 142. Palpable Mass on Physical Exam CT Upper Extremity MRI Upper Extremity (Any Joint) MRI Upper Extremity (Non- Joint) CT Lower Extremity MRI Lower Extremity Joint / Nonjoint 143. Primary (Benign and Malignant) Bone or Soft Tissue Tumor CT Upper Extremity MRI Upper Extremity Any Joint MRI Upper Extremity Non-joint 194 195 208 211 198 203 Change: Add this indication Change: In the first bullet, Conventional radiographs should be delete the phrase, "in the majority of cases" Change: Modify the first bullet so that it reads as, Conventional radiographs should be obtained before advanced imaging which makes it consistent with the other extremity sections Change: remove this indication it is being combined into a single indication Change: remove this indication it is being combined into a single indication Page 29 of 32
144. Metastatic Tumor CT Upper Extremity 145. Metastatic Tumor MRI Upper Extremity Any Joint MRI Upper Extremity Non-joint 146. Tumor Evaluation CT Lower Extremity MRI Lower Extremity Joint / Nonjoint 147. Soft Tissue Tumors CT Upper Extremity MRI Upper Extremity (Any Joint) MRI Upper Extremity (Non- Joint) CT Lower Extremity MRI Lower Extremity Joint / Nonjoint 148. Fracture Evaluation CT Upper Extremity CT Lower Extremity 195 200 204 208 213 196 209 Change: Modify the name of this indication to "TUMOR EVALUATION: PRIMARY NEOPLASM OR METASTATIC DISEASE" Add the bullet "Palpable mass on physical exam" Add the bullet, When MRI is contraindicated or when evaluating osseous involvement by tumor Change: Modify the name of this indication to "TUMOR EVALUATION: PRIMARY NEOPLASM OR METASTATIC DISEASE" Add the bullet "Palpable mass on physical exam" Change: Change the name of this indication to make it consistent with Upper Extremity changes and add the bullets (Note that MRI should match the upper extremity MRI section and CT should match the upper extremity CT section which includes contraindication language) Change: Remove this indication it is already listed with another indication Change: modify the first bullet to "To confirm a suspected (occult) fracture following initial radiographs, or" and modify the third bullet to "To assess fracture healing for delayed union or non-union" Note: there is no modification to the 2nd bullet for CT - for MRI's there will be a modification to the 2nd bullet Page 30 of 32
149. Fracture Evaluation MRI Upper Extremity (Any Joint) MRI Upper Extremity (Non- Joint) MRI Lower Extremity Joint / Nonjoint 150. Abnormality on X-Ray or Bone Scintigraphy CT Upper Extremity MRI Upper Extremity (Any Joint) MRI Upper Extremity (Non- Joint) 151. Bone Scintigraphy Abnormality CT Lower Extremity MRI Lower Extremity Joint / Nonjoint 199 204 212 196 200 204 209 213 Change: modify the first bullet to "To confirm a suspected (occult) fracture following initial radiographs, or" Modify the second bullet to, "To define the extent of an acute fracture, or" and modify the third bullet to "To assess fracture healing for delayed union or nonunion" Change: Modify this indication to read, Abnormalities detected on other imaging studies which require additional clarification to direct treatment Change: Modify this indication to read, Abnormalities detected on other imaging studies which require additional clarification to direct treatment 152. Suspected Entrapment Neuropathy MRI Upper Extremity (Any Joint) MRI Upper Extremity (Non-joint) 153. Other Glenoid Labral and Associated Ligamentous Lesions MRI Upper Extremity (Any Joint) 154. Adhesive Capsulitis MRI Upper Extremity (Any Joint) 200 204 200 200 Change: Modify this indication by removing the brackets and placing a forward slash between neuropathy and cubital, add the words "AND/OR between detail and carpal, add the word "ARE" between tunnel and not Change: Add a new sub-bullet, SLAP (Superior Labral tear from Anterior to Posterior) tear/lesion Change: insert the word "failed" between following and physical 155. Aneurysm CTA/MRA Upper Extremity CTA/MRA Lower Extremity 206 218 Change: add "/DILATION" to the name of this indication Page 31 of 32
156. Pre-Operative Evaluation for Known Lower Extremity Peripheral Arterial Disease CTA/MRA Lower Extremity Change: Delete this indication 157. Pre- and Post-Operative Evaluation CT Lower Extremity MRI Lower Extremity Joint / Nonjoint 158. When the Patients Condition Meets the Lower CT Lower Extremity 209 213 209 Change: Remove the bullet, When ordered by an operating surgeon in pre-and post-op situations Change: Modify the second portion of this indication name so that it is consistent in language with the Upper Extremity CT section 159. Diabetic Foot Disease MRI Lower Extremity Joint / Nonjoint 160. Paraneoplastic Syndrome Including Neurologic Syndrome PET/CT 214 222 Change: Remove the bullet, If findings are positive for osteomyelitis, the patient should be treated and advanced imaging may not be required Change: Add this new indication Page 32 of 32