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MRI Upper Extremity Joint 73221 73222 73223

Nonsteroidal anti-inflammatory drugs for at least three weeks (Requirement is waived if NSAIDS are not tolerated or contraindicated, or if condition worsens while under treatment.)

Activity modification or physical therapy if appropriate

1.1.1 Failed Conservative Management

1.1.2 Known Malignancy Elsewhere, suspect metastasis (Conservative Management NOT required)

1.2.1 See Suspect Compartment Syndrome

1.2.2 X-rays non diagnostic

1.3.1 Failed conservative management

1.4.1 X-ray, CT or Ultrasound nondiagnostic

2.1.1 Alcoholism

2.1.2 Cushing’s disease

2.1.3 History of pancreatitis

2.1.4 Sickle Cell disease

2.1.5 Steroid use in recent past (up to one year)

2.1.6 Systemic Lupus (SLE)

2.2.1 Note Plexopathy refers to an abnormality of the complex of nerve roots exiting the spine and organizing into the nerves serving the arm, trunk or legs. Symptoms may include burning, tingling, or numbness in a circumferential or dermatomal distribution. The symptoms may radiate to the hand or remain localized in the neck.

2.2.2.1.1 Breast or lung cancer

2.2.2.1.2 History of radiation therapy to the chest, breast or axilla

2.2.2.1.3 Palpable mass in neck or shoulder area

2.2.2.1.4 Truama, including at birth

2.2.2.2.1 Numbness

2.2.2.2.2 Paresthesias

2.2.2.2.3 Radiating pain

2.2.2.2.4 Weakness

2.2.2.3.1 ACR Appropriateness Criteria Plexopathy p10 Accessed 12/28/08

2.2.2.3.2 Aliya Qayyum, A. David MacVicar, Anwar R. Padhani, Patrick Revell, and Janet E. S. Husband Symptomatic Brachial Plexopathy following Treatment for Breast Cancer: Utility of MR Imaging with Surface-Coil Techniques Radiology 2000 214: 837-842.

2.2.2.3.3 BC Bowen, A Verma, AH Brandon, and JA Fiedler Radiation-induced brachial plexopathy: MR and clinical findings AJNR Am. J. Neuroradiol., Nov 1996; 17: 1932 – 1936. Neurosurgical Focus Posted 04/02/2007 Accessed 1/4/09 @ http://www.medscape.com/viewarticle/553963_1

2.2.2.3.4 Bowen B, Seidenwurm DJ, Davis P, et al, Expert Panel on Neurologic Imaging, American College of Radiology, Appropriateness Criteria, Plexopathy, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/PlexopathyDoc12.asp 12/28/08

2.2.2.3.5 Devin K. Binder, M.D., Ph.D.; Justin S. Smith, M.D., Ph.D.; Nicholas M. Barbaro, M.D Primary Brachial Plexus Tumors: Imaging, Surgical, and Pathological Findings in 25 Patients Neurosurgical Focus Medscape Radiology accessed 12/28/08

2.2.2.3.6 Edward Fathers, David Thrush, Susan M Huson, and Andrew Norman Radiation-induced brachial plexopathy in women treated for carcinoma of the breast Clinical Rehabilitation, Feb 2002; 16: 160 – 165.

2.2.2.3.7 Neoplastic Brachial Plexopathy Author: Mark A Wren, MD, MPH, Medical Director, Department of Physical Medicine and Rehabilitation, HealthSouth Rehabilitation Hospital of Texarkana eMedicine Specialties > Physical Medicine and Rehabilitation > Plexopathy Updated: Jan 19, 2010 Accesed 3/15/10

2.2.2.3.8 Vincent J. Miele, M.D.; John A. Norwig, A.T.C.; Julian E. Bailes, M.D. Sideline and Ringside Evaluation for Brain and Spinal Injuries

2.2.2.3.9 Walker, AT, Chaloupka, JC, de Lotbiniere, AC, Wolfe, SW, Goldman, R, Kier, EL Detection of nerve rootlet avulsion on CT myelography in patients with birth palsy and brachial plexus injury after trauma Am. J. Roentgenol. 1996 167: 1283-1287

2.2.2.3.10 T. Yoshikawa, N. Hayashi, S. Yamamoto, Y. Tajiri, N. Yoshioka, T. Masumoto, H. Mori, O. Abe, S. Aoki, and K. Ohtomo Brachial Plexus Injury: Clinical Manifestations, Conventional Imaging Findings, and the Latest Imaging Techniques RadioGraphics, October 1, 2006; 26(suppl_1): S133 – S143.

2.2.2.3.11 A. TAVAKKOLIZADEH, A. SAIFUDDIN, and R. BIRCH Imaging of Adult Brachial Plexus Traction Injuries J Hand Surg Eur Vol., June 1, 2001; 26(3): 183 – 191

2.3.1.1.1 Equivocal or nondiagnostic EMG (electromyogram)

2.3.1.2.1 Equivocal or nondiagnostic EMG (electromyogram)

2.3.2.1.1 Equivocal or nondiagnostic EMG (electromyogram)

2.3.3.1 J. G. Jarvik, E. Yuen, D. R. Haynor, C. M. Bradley, D. Fulton-Kehoe, T. Smith-Weller, R. Wu, M. Kliot, G. Kraft, L. Wang, V. Erlich, P. J. Heagerty, and G. M. Franklin MR nerve imaging in a prospective cohort of patients with suspected carpal tunnel syndrome Neurology June 11, 2002 58:1597-1602

2.3.3.2 Mallouhi, Ammar, Pultzl, Petra, Trieb, Thomas, Piza, Hildgunde, Bodner, Gerd Predictors of Carpal Tunnel Syndrome: Accuracy of Gray-Scale and Color Doppler Sonography Am. J. Roentgenol. 2006 186: 1240-1245

2.3.3.3 ACR Appropriateness Criteria® chronic wrist pain. 1998 (revised 2009). NGC:007772 American College of Radiology – Medical Specialty Society.

2.3.3.4 Occupational therapy practice guidelines for individuals with work-related injuries and illnesses. 2009. NGC:007510 American Occupational Therapy Association, Inc. – Professional Association

2.3.3.5 Hellmann David B, Imboden John B, “Chapter 20. Musculoskeletal & Immunologic Disorders” (Chapter). McPhee SJ, Papadakis MA: CURRENT Medical Diagnosis & Treatment 2012: http://www.accessmedicine.com/content.aspx?aID=10083.

2.4.1 X-rays non diagnostic on two occasions

2.5.1 Decreased ROM

2.5.2 Locking of joint

2.5.3 Pain

2.6.1.1 Apley Scratch test

2.6.1.2 Apprehension test

2.6.1.3 Clunk sign

2.6.1.4 Drop Arm test

2.6.1.5 Hawkins test

2.6.1.6 Relocation test

2.6.1.7 Sulcus sign

2.6.2 Shoulder pain interfering with use of shoulder

2.7 Locking

2.8.1 Decreased ROM

2.8.2 Locking of joint

2.8.3 Pain

2.8.4.1 Padhraig F. O’Loughlin, Benton E. Heyworth, and John G. Kennedy Clinical Sports Medicine Update: Current Concepts in the Diagnosis and Treatment of Osteochondral Lesions of the Ankle Am J Sports Med February 2010 38:392-404;

2.8.4.2 SCHENCK, ROBERT C., JR., GOODNIGHT, JON MARC Current Concept Review – Osteochondritis Dissecans J Bone Joint Surg Am 1996 78: 439-56

2.9 Osteochondritis Dissecans See Loose body.

2.10.1.1 C reactive Protein elevated

2.10.1.2 Elevated ESR

2.10.1.3 Fever

2.10.1.4 Leukocytosis

2.10.1.5 Positive Blood Cultures

2.10.2.1 Parsonnet Jeffrey, “Chapter 120. Osteomyelitis” (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison’s Principles of Internal Medicine, 17th Edition: http://www.accessmedicine.com/content.aspx?aID=2893649.

2.10.2.2 Alok Kapoor, Stephanie Page, Michael LaValley, Daniel R. Gale, and David T. Felson Magnetic Resonance Imaging for Diagnosing Foot Osteomyelitis: A Meta-analysis Arch Intern Med, Jan 2007; 167: 125 – 132.

2.10.2.3 J. Herman Kan, Melissa A. Hilmes, Jeffrey E. Martus, Chang Yu, and Marta Hernanz-Schulman Value of MRI After Recent Diagnostic or Surgical Intervention in Children with Suspected Osteomyelitis Am. J. Roentgenol., Nov 2008; 191: 1595 – 1600.

2.10.2.4 Kuo-Chen Lee, Yi-Ting Tsai, Chih-Yuan Lin, and Chien-Sung Tsai Vertebral osteomyelitis combined streptococcal viridans endocarditis Eur. J. Cardiothorac. Surg., Jan 2003; 23: 125.

2.10.2.5 D Allen, S Ng, K Beaton, and D Taussig Sternal osteomyelitis caused by Aspergillus fumigatus in a patient with previously treated Hodgkin’s disease J. Clin. Pathol., Aug 2002; 55: 616 – 618.

2.10.2.6 M Ida, H Watanabe, A Tetsumura, and T Kurabayashi CT findings as a significant predictive factor for the curability of mandibular osteomyelitis: multivariate analysis Dentomaxillofac. Radiol., Mar 2005; 34: 86 – 90.

2.10.2.7 Jyri K. Koort, Tatu J. Mäkinen, Juhani Knuuti, Jari Jalava, and Hannu T. Aro Comparative 18F-FDG PET of Experimental Staphylococcus aureus Osteomyelitis and Normal Bone Healing J. Nucl. Med., Aug 2004; 45: 1406 – 1411.

2.10.2.8 Susan A. Connolly, Leonard P. Connolly, Laura A. Drubach, David Zurakowski, and Diego Jaramillo MRI for Detection of Abscess in Acute Osteomyelitis of the Pelvis in Children Am. J. Roentgenol., Oct 2007; 189: 867 – 872.

2.11.1 Failed Conservative Management

2.11.2.1 Decreased ROM

2.11.2.2 Pain

2.11.2.3 Tenderness at supraspinatus insertion

2.11.2.4 Weakness to abduction

2.12.1 Confirmed by x-ray, for surgical planning

2.13.1.1 Failed Conservative Management

2.13.2 Palable gap in tendon

2.13.3 Evidence of tendon abnormality on US

2.14.1 Failed Conservative management

2.14.2 Surgery contemplated

2.14.3 Ulnar-sided wrist pain, swelling, and limitation of motion

3.1.1 See Labral or Rotator Cuff Tear, suspected (Loss of range of motion: rotator cuff problem)

3.2.1 See Labral or Rotator Cuff Tear, suspected (Anterior glenohumeral instability)

3.3.1 See Labral or Rotator Cuff Tear, suspected (Labral disorder)

3.4 Crepitus

3.5.1 Failed Conservative Management

3.6 Drop arm test positive

3.7.1 Failed conservative management

3.8.1 See Rotator Cuff Tear, suspected (Supraspinatus tendon impingement)

3.9 Joint instability

3.10.1 Failed Conservative Management

3.11.1 X-ray, CT or Ultrasound nondiagnostic

3.12.1 See Labral or Rotator Cuff Tear, suspected

3.13.1 See Labral Tear, suspected

3.14.1.1 Interval follow up during and after treatment

3.14.1.2 Preoperative

3.14.1.3 Worsening clinical situation

3.14.2.1.1 C reactive Protein elevated

3.14.2.1.2 Elevated ESR

3.14.2.1.3 Fever

3.14.2.1.4 Leukocytosis

3.14.2.1.5 Positive Blood Cultures

3.14.3.1 Parsonnet Jeffrey, “Chapter 120. Osteomyelitis” (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison’s Principles of Internal Medicine, 17th Edition: http://www.accessmedicine.com/content.aspx?aID=2893649.

3.14.3.2 Alok Kapoor, Stephanie Page, Michael LaValley, Daniel R. Gale, and David T. Felson Magnetic Resonance Imaging for Diagnosing Foot Osteomyelitis: A Meta-analysis Arch Intern Med, Jan 2007; 167: 125 – 132.

3.14.3.3 J. Herman Kan, Melissa A. Hilmes, Jeffrey E. Martus, Chang Yu, and Marta Hernanz-Schulman Value of MRI After Recent Diagnostic or Surgical Intervention in Children with Suspected Osteomyelitis Am. J. Roentgenol., Nov 2008; 191: 1595 – 1600.

3.14.3.4 Kuo-Chen Lee, Yi-Ting Tsai, Chih-Yuan Lin, and Chien-Sung Tsai Vertebral osteomyelitis combined streptococcal viridans endocarditis Eur. J. Cardiothorac. Surg., Jan 2003; 23: 125.

3.14.3.5 D Allen, S Ng, K Beaton, and D Taussig Sternal osteomyelitis caused by Aspergillus fumigatus in a patient with previously treated Hodgkin’s disease J. Clin. Pathol., Aug 2002; 55: 616 – 618.

3.14.3.6 M Ida, H Watanabe, A Tetsumura, and T Kurabayashi CT findings as a significant predictive factor for the curability of mandibular osteomyelitis: multivariate analysis Dentomaxillofac. Radiol., Mar 2005; 34: 86 – 90.

3.14.3.7 Jyri K. Koort, Tatu J. Mäkinen, Juhani Knuuti, Jari Jalava, and Hannu T. Aro Comparative 18F-FDG PET of Experimental Staphylococcus aureus Osteomyelitis and Normal Bone Healing J. Nucl. Med., Aug 2004; 45: 1406 – 1411.

3.14.3.8 Susan A. Connolly, Leonard P. Connolly, Laura A. Drubach, David Zurakowski, and Diego Jaramillo MRI for Detection of Abscess in Acute Osteomyelitis of the Pelvis in Children Am. J. Roentgenol., Oct 2007; 189: 867 – 872.

3.15.1 See Labral or Rotator Cuff Tear, suspected (Inferior glenohumeral instability)

4.1 Abnormality on plain film, images not diagnostic

5.1.1 Evaluation of joint prior to aggressive therapy, and interval follow up.

5.2.1.1 Reduced ability to flex or extend at elbow

5.2.2.1 Failed Conservative Management

5.2.2.2 Increased varus with passive stretch

5.2.2.3 Lateral tenderness

5.2.3.1 Failed conservative management

5.2.3.2 Increased valgus with passive stretch

5.2.3.3 Medial tenderness

5.3.1 Interval follow up during and after treatment

5.3.2 Preoperative

5.3.3 Worsening clinical situation

5.3.4.1 Parsonnet Jeffrey, “Chapter 120. Osteomyelitis” (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison’s Principles of Internal Medicine, 17th Edition: http://www.accessmedicine.com/content.aspx?aID=2893649.

5.3.4.2 Alok Kapoor, Stephanie Page, Michael LaValley, Daniel R. Gale, and David T. Felson Magnetic Resonance Imaging for Diagnosing Foot Osteomyelitis: A Meta-analysis Arch Intern Med, Jan 2007; 167: 125 – 132.

5.3.4.3 J. Herman Kan, Melissa A. Hilmes, Jeffrey E. Martus, Chang Yu, and Marta Hernanz-Schulman Value of MRI After Recent Diagnostic or Surgical Intervention in Children with Suspected Osteomyelitis Am. J. Roentgenol., Nov 2008; 191: 1595 – 1600.

5.3.4.4 Kuo-Chen Lee, Yi-Ting Tsai, Chih-Yuan Lin, and Chien-Sung Tsai Vertebral osteomyelitis combined streptococcal viridans endocarditis Eur. J. Cardiothorac. Surg., Jan 2003; 23: 125.

5.3.4.5 D Allen, S Ng, K Beaton, and D Taussig Sternal osteomyelitis caused by Aspergillus fumigatus in a patient with previously treated Hodgkin’s disease J. Clin. Pathol., Aug 2002; 55: 616 – 618.

5.3.4.6 M Ida, H Watanabe, A Tetsumura, and T Kurabayashi CT findings as a significant predictive factor for the curability of mandibular osteomyelitis: multivariate analysis Dentomaxillofac. Radiol., Mar 2005; 34: 86 – 90.

5.3.4.7 Jyri K. Koort, Tatu J. Mäkinen, Juhani Knuuti, Jari Jalava, and Hannu T. Aro Comparative 18F-FDG PET of Experimental Staphylococcus aureus Osteomyelitis and Normal Bone Healing J. Nucl. Med., Aug 2004; 45: 1406 – 1411.

5.3.4.8 Susan A. Connolly, Leonard P. Connolly, Laura A. Drubach, David Zurakowski, and Diego Jaramillo MRI for Detection of Abscess in Acute Osteomyelitis of the Pelvis in Children Am. J. Roentgenol., Oct 2007; 189: 867 – 872.

5.4.1 Evaluation of joint prior to aggressive therapy, and interval follow up.

5.5.1.1.1.1 Apley Scratch test

5.5.1.1.1.2 Apprehension test

5.5.1.1.1.3 Clunk sign

5.5.1.1.1.4 Drop Arm test

5.5.1.1.1.5 Hawkins test

5.5.1.1.1.6 Relocation test

5.5.1.1.1.7 Sulcus sign

5.5.2.1 Failed Conservative Management and

5.5.2.2.1 Decreased ROM

5.5.2.2.2 Pain

5.5.2.2.3 Tenderness at supraspinatus insertion

5.5.2.2.4 Weakness to abduction

5.6.1 Failed Conservative Management

5.6.2 Pain with movement and palpation

5.6.3 Weakness (decreased grasp strength)

5.6.4 X-ray nondiagnostic

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