0067T CT Colonography – Added references and comments
70450 CT Head – Added references in several criteria, clarified “suspected infection or abscess”
70480 CT Orbit – Added asymmetric hearing loss to criteria
70486 CT Maxillofacial – Added definitions, references and some images for sinusitis, mucocele and polyps.
73721 MR LE Joint – Added requirement for conservative management prior to imaging for torn menisci in patients 46 or older
74150 CT Abdomen – Added indications “Complex renal cyst” and “Indeterminate renal Mass”
78111 PET – Clarified colorectal PET and Routine standards regarding tumor markers and added glossary note.
70486 CT Maxollofacial – Added reference and note
70551 MRI Brain – Added section on Lyme disease
71555 MRI Chest – Added Pain, acute “ripping, tearing, searing” chest, back or abdominal
72148 MRI L Spine – Added positive Straight Leg raising to indications under Radiculopathy
73721 MRI LE Joint – Added references and notes
74181 MRI Abdomen – Updated section on Cirrhosis added references and comment
74185 MRA Abdomen- Added Pain, acute “ripping, tearing, searing” chest, back or abdominal
78607 SPECT Brain – Added section
78608 PET Brain Metab. – Added section
78609 PET Brain Perf. – Added section
0 – Revised Introduction to include provision for expedited reviews
70486 CT Maxillofacial – Added details about cranial nerve signs and reference.
71250 CT Chest – Added weight loss as an indication, added references in several criteria
72125 CT Cervical – Spine – removed requirements for any working diagnosis if there is loss of bowel or bladder control
72128 CT Thoracic – Spine – removed requirements for any working diagnosis if there is loss of bowel or bladder control
74150 CT Abdomen – Added weightloss as an indication
74181 MRI Abdomen – Added weight loss as an indication
74181 MRI Abdomen – Added weight loss as an indication
77021 – 77022 MRI Giudane Procedures Added automatic approval
Added criteria to “altered level of consciousness”
Added criteria to “altered level of consciousness”
72141 – clarified epidural abscess criteria
72146 – clarified epidural abscess criteria
72148 – clarified epidural abscess criteria
70551 – Added references and indications for Mult. Sclerosis
72192 – Added criteria for “night sweats.”
74150 – Added criteria for “night sweats.”
78811 – Added criteria for Solitary Pulmonary Nodule; rearranged Lung criteria.
Added CPT codes for related imaging procedures
Alphabetized Criteria list
Glossary reformatted and expanded
70551 – Added criteria concerned with cranial nerves, added references to MS.
71250 – Added criteria for follow up of Ground Glass Opacities
72192 – Added criteria for Testicular Cancer
72195 – Added criteria for Testicular Cancer
Added criteria for Testicular Cancer
Added requirement for microscopic confirmation of hematuria
Added criteria for Complex Renal Cysts
AAdded criteria for Testicular Cancer
Added kidney tumors as indication
Added requirement for microscopic confirmation of hematuria
Added initial work up of thymic tumors as an indication
Revised criteia for Testicular malignancies
Added Kidney and Thymic malignancies
Minor revisions and new references for Testicular malignancies
73700 – added criteria for suspected nonunion of known feracture 8-6-09
Glossary – Added Romberg test 7/31
72192 – Added Criteria for Diverticulitis 090109
Criteria for Diverticulitis 090109
Criteria for truma 092509
77058 – added references for implant screening 100509
70496 – Added references and criteria for screening for aneurysm
Added vertebrobassilar insufficiency as an indication 110609
Deleted “cardiac irregularities” as too vague to be helpful as a risk factor for ICA.
Deleted “Risk Factors” as not useful in determining appropriateness.
Updated several references
Added criteria and reference for Coarctation 111609
Clarified language and updated references 110609
Added explanatory note to PAD 111709
Clarified PAD 111609
73706 – Added notes for ABI 111609
74175 – Clarified language and updated references 110509
Amnesia, added Suspect Stroke or TIA 121609
several criteria reworded, no substative changes 121609
“Pain” removed as a free statnding indication as too vague. 121609
70490 – several criteria reworded, no substative changes 121609
72131 – several criteria reworded, no substative changes 121609
72192 – Added criteria for aneuryms, RLQ pain, Weight loss, hematuria.
73700 – several criteria reworded, no substative changes 121609
74181 – Revised language, added references 010210
72148 – Added criteria for suspected metastasis 011110
72146 – Added criteria for suspected metastasis 011110
72141 – Added criteria for suspected metastasis 011110
75571 – Added criteria 012810
75572 – Added criteria 012810
75573 – Added criteria 012810
75574 – Added criteria 012810
72131 – Simplified criteria for Loss of bladder or bowel control
78491 – Clarified indications and added referrences 030810
74181 – Added monitoring of Crohn Disease as indication 030810
72125 – Clarified indications for brachial plexopathy 031210
73221 – Added indications for brachial plexopathy 031510
72141 – Clarified indications for brachial plexopathy
General – Updated references for several of the exams in the CT section, added introductory page and remarks.
72131 CT L Spine – Added references and clarified several criteria. 040510
Updated and added references
Updated criteria for Suspected Osteomyelitis, throughout.
Updated criteria for Suspected Radiculopathy throghout.
Compartment Syndrome
74181 MRI Abdomen – Required US prior to MRI for suspected biliary stone
Added Criteria for Carotid Dissection to CTA and MRA of the carotid and MRI of the brain 041610
70551 – Added references to several indications, also cleared up inconsistencies. 041610
72141 MRI C Spine – Improved consistency of criteria for osteomyelitis and epidural abscess
70450 CT Head – Added criterion for post surgery follow up. 042610
Added CT Neck and MUG to work up of Lymphoma
Updated Hepatocellualr Carcinoma
74150 CT Abdomen – Reformatted criteria for abdominal pain 050710
Corrected Plexopathy from “Brachial” to Lumboscaral, and updated references. 050710
Updated criteria for Erectile Dysfunction 051710
72131 CT Lumbar spine – Updated criteria for Erectile Dysfunction 051710
Added indications and references for Fibroids 051810
Updated other references 051810
75574 Coronary Computed Tomographic Arteriography CCTA – Added criteria to CTA and CT Chest sections. 060110
73221 MRI Upper Extremity Joint – Added references 060210
78607 Brain SPECT – Added criteria and references for the diagnosis of dementia 061010
70450 CT Head – Revised criteria for Dementia 061010
78465 Myocardial perfusion Scan – Added criteria adapted from 2009 AHA guideline updates
General added several glossary entries, and corrected formatting errors, distributed updated criteria to Web site. 062810
Added reference to VIDEOS IN CLINICAL MEDICINE Schraeder, Teresa L., Terek, Richard M., Smith, C. Christopher Clinical Evaluation of the Knee
N Engl J Med 2010 363: e5 7/22/10
Vertigo – Added criteria and references to each entry for vertigo, and made them uniform. Also revised dizziness criteria to coincide with those for vertigo recognizing that these terms are used interchagably by many clinicians, and the criteria for imaging are essentially identical. Changes made to CT, and CTA of the head, and MRI and MRA of the brain. 7/22/10
Pulmonary Embolus Suspected Reviewed criteria, added indication and risk factors, updated references. CT, CTA and MRA of the Chest 7/23/2010
CTA of COronary Arteries 75574 – Updated criteria and references. 7/29/2010
Breast Cancer, updated PET criteria and routine surveillance recommendations to conform with latest NCCN Guidelines. 8/11/10
Oncology Guidelines. Updated follow up imaging recommendations for head and neck tumors in 9/10/10
MRI of Brain Deleted superseded Dizziness criteria set from . 9/10/10
CT Abdomen Added reference 10/11/10
PET Lung Added references 10/18/10
CT Chest Reworked Nodules sections to clarify indications for multiple nodules, and added references 10/18/10
Abdominal Pain After Meals 10/20/10
Ischemic Bowel Suspected 10/20/10
Intetinal Angina 10/20/10
Carcinoma of Pancreas, added references 10/20/10
Claudication added references 10/20/10
Suspected Obstruction updated references added clinical requirements to support indication.
Abdominal Pain After Meals 10/20/10
Ischemic Bowel Suspected 10/20/10
Intetinal Angina 10/20/10
MUGA scans, added criteria set with references 10/29/10
Added criteria for Brachial Plexus Pathology (Plexopathy) 11/4/10
Added criteria and references for trauma to Brachial Plexus Pathology 11/4/10
Added reference for Aneurysm previously repaired 11/24/10
Added Criteria for Esophageal Rupture (Boerhaave’s Syndrome,) with refrences 11/23/10
Added criteria for Asthma with references 11/26/10
MR Chest Added criteria and references for trauma to Brachial Plexus Pathology 11/4/10
MR Upper extremity Joint updated criteria and references for trauma to Brachial Plexus Pathology 11/4/10
Added criteria and references for trauma to Brachial Plexus Pathology 11/4/10
Added criteria and references for Arthrography of the shoulder 11/30/10
PET Body Added size criteria for solitary pulmonary nodules
Myocardial Perfusion Imaging SPECT updated CPT code information. 11/16/10
CT Head Updated references for seizures and several other indications 11/6/10
CT Lower Extremity added criteria for CT Arthrography of knee and ankle, with references. 11/30/10
CT Colonography (Virtual Colonoscopy) 74261 74262 74263 Updated CPT codes, and criteria 11/30/10
MRI Breast reorganized criteria for clarity and added references 12/02/10
PET of the Body added criteria for cancers not specifically addressed. 12/13/10
Added Leukocytosis as an indication 12/16/10
Added Metastasis suspected as an indication 12/16/10
CT of Abdomen and Pelvis Added criteria sets 12/16/10
Oncology Guideline Testicular Cancer Corrected the omission of guidelines for follow up of nonseminima testicular cancers 12/28/10
CT Lower Extremity Added criteria for Necrotizing Fasciitis 1/12/11
CT Upper Extremity Added criteria for Necrotizing Fasciitis 1/12/11
MRI Brain Added criteria for Trigeminal Neuralgia 1/21/11
MRI Lower Extremity other than Joint Added criteria for Necrotizing Fasciitis 1/12/11
MRI Upper Extremity Joint Added criteria for carpal Tunnel Syndrome 1/23/11
MRI Upper Extremity other than Joint Added criteria for Necrotizing Fasciitis 1/12/11
Anal Carcinoma Revised and updated section, added references 1/1/11
Bladder Cancer Revised and updated section, added references 1/1/11
Uterine Cancer Added surveillance guidelines 1/12/11
MRI Breast Updated references 2/14/11
MRI Lumbar Spine corrected omission of criteria for bilateral radiculopathy, now consistent with unilateral 2/25/11
Added criteria for post surgical evaluation 3/8/11
Updated criteria for abscess, known and suspected. 3/8/11
Clarified auto approvals for new combined exam 3/8/11
Updated criteria for abscess, known and suspected. 3/8/11
Added criteria for asymptomatic abnormal stress test 3/25/11
Added hydronephrosis on recent imaging to obstructive uropathy indications 3/8/11
Updated criteria for abscess, known and suspected. 3/8/11
Added criteria for Tumor 3/10/11
Added criteria for Tumor 3/10/11
Clarified criterion for Invasive Lobular Carcinoma to initial staging, not as a routine follow up 3/29/11
Updated references 3/29/11
MRS (Magnetic Resonance Spectroscopy) 76390 added instructions regarding being a non covered service for most plans 3/10/11
PET Brain for Metabolism 78608 Added to criteria for dementia to be consistent with CMS
PET Heart 78491 78492 Reviewed and clarified criteria and reference 3/17/11
CT Abdomen Added Elevated Bilirubin as a criterion 4/20/2012
CT C Spine Revised criteria for myelopathy and radiculopathy for clarity 4/20/2012
Added clinical criteria for Superior Vena Cava syndrome 4/25/2012
Added clinical criteria for Thymoma
Added criteria for Sarcoidosis 4/7/11
CT Pelvis Added note to Criteria for obstructive uropathy that CT abdomen and pelvis is preferred, 4/15/11
CTA Pelvis Added symptoms and findings as criteria for PAD 4/12/2012
Added criterion 1.1.6 Two close relatives (mother or sibling) with breast or ovarian cancer 4/6/2012
Moved criteria for Search for Primary tumor to Other category 4/6/2012
CT Chest added clarification of criteria for hoarseness 5/11/11
CT Neck added clarification of criteria for hoarseness 5/11/11
CT Thoracic Spine removed “discography” as a sufficient indication 5/12/11
Reformatted most criteria sets to improve ease of use. Completed 5/25/11
Standardized criteria for “Osteomyelitis Suspected,” and “osteomyelitis Known” through out all occurrences 5/24/11
MRI Face Orbit or Neck Added criteria for salivary gland stones and facial pain 5/23/11
MRI Lower Extremity Joint Added criteria for MR arthrography of hip, knee and ankle. 5/13/11
Complete update of Thyroid Carcinoma criteria 5/16/11
QCT Added brief criteria set 5/26/2012
1.CT Head Added Criterion to Working Diagnosis section on Aneurysm Suspected 6/23/2012
2.CTA Aorta and Runoff Added criteria set 6/8/2012
3.CTA Head Updated criteria and references for Aneurysm Suspected 6/23/2012
4.CTA Lower Extremity Added criteria to Prior Medical History category 6/22/2012
5.CTA Upper Extremity Added criteria to Prior Medical History category 6/22/2012
6.MRA Head Updated criteria and references for Aneurysm Suspected 6/23/2012
7.MRA Lower Extremity Added criteria to Prior Medical History category 6/22/2012
8.MRA Upper Extremity Added criteria to Prior Medical History category 6/22/2012
Added Criterion to Working Diagnosis section on Aneurysm Suspected 6/23/2012
Corrected a typographic error regarding Prolactin level 6/22/2012
Added criteria to complaint category 6/22/2012
Added criteria to prior imaging section 6/18/11
Standardized criteria for tendon tear 6/1/2012
11.MRI of the Lower Extremity Standardized criteria for tendon tear 6/1/2012
Added criteria to complaint category 6/22/2012
Added criteria to prior imaging section 6/18/11
Standardized criteria for tendon tear 6/1/2012
13.MRI of the Upper Extremity Joint Standardized criteria for tendon tear 6/1/2012
Modified langiuage to permit PET when there is a strong clinical suspicion of malignancy but no tissue daignosis 6/3/2012
Updated references for many tumor types 6/3/2012
15.PET of the Heart Rewrote criteria to include search for “hibernating myocardium.” 6/8/2012
Appendices Removed Section on Mucoceles. 7/5/2012
clarified that suspiciion of inguinal or femoral hernias are not indications for CT Abd 7/21/2012
Brought Breast indication into conformity with Oncology Guidelines. 7/27/2012
Added note concerning extent of neck CT exams into thorax 7/7/2012
Added requirement of laryngoscopy before CT of Neck for hoarseness 7/15/2012
Added Stroke as criterion 7/7/2012
Deleted Alternating neurologic deficits as a crtiterion 7/5/2012
Changed title to Cerebral Venous Thrombosis and added a new reference
Deleted Alternating Neurologic Deficits as a criterion
Added Pulsatile Mass to criteria for Suspected AVM 7/5/2012
Deleted Alternating neurologic deficits as a crtiterion 7/5/2012
Changed title to Cerebral Venous Thrombosis and added a new reference
Deleted Alternating Neurologic Deficits as a criterion
Added requirement that certain tests be performed prior to approval for Dementia 7/5/2012
Deleted Alternating neurologic deficits as a crtiterion 7/5/2012
Changed title to Cerebral Venous Thrombosis and added a new reference
Deleted Alternating Neurologic Deficits as a criterion
Added Criteria for Congestive Heart Failure 7/7/2012
Added note to “Aortic DIssection Suspected” that CTA or MRA were preferred, and a reference. 7/7/2012
Changed Title of criterion from “Myocardial viability Assessment ” to “Myocardial Viability Assessment for Planned Revascularization” and added sub criterion and references 7/7/2012
Removed redundant Aortic Dissection Criterion. 7/7/2012
Acute Myelogenous Leukemia Revised and updated 7/8/2012
Anal Carcinoma Revised and updated 7/8/2012
Bladder Carcinoma Revised and updated 7/8/2012
Bone Cancer added Criteria set 7/18/2012
Breast Cancer revised and updated criteria 7/22/2012
Central Nervous System Cancers Updated and added criteria and references 7/18/2012
Colon Cancer reviewed and updated 7/22/2012
Esophageal Cancer reviewed and updated 7/22/2012
Rectal Cancer reviewed and updated 7/22/2012
Stomach Cancer updated 7/22/2012
Upper GU Tract Carcinoma added Criteria set 7/8/2012
Urothelial Carcinoma of the Prostate added Criteria set 7/8/2012
Brought Breast indication into conformity with Oncology Guidelines. 7/22/2012
Added criteria for liver nodule found on other imaging 8/2/2012
Cholagiocarcinoma criteria added 8/2/2012
CML reviewed and updated 8/8/2012
Gall Bladder Cancer criteria added 8/2/2012
Head and Neck Cancers revised and updated 8/2/2012
Hepatocellular Cancer revised and updated 8/2/2012
Hodgkin / Lymphoma reference updated 8/8/2012
Kidney Cancer revised and updated 8/8/2012
Melanoma revised and updated 8/4/2012
Multiple Myeloma and Plasmacytomas updated 8/8/2012
Non-small Cell Lung Cancer NSCLC revised and updated 8/8/2012
Occult Primary Revised and updated 8/8/2012
Ovarian Cancer updated 8/8/2012
Pancreatic Adenocarcinoma updated 8/8/2012
Prostate Cancer updated 8/8/2012
Small Cell Lung Cancer SCLC added new criteria updated references 8/8/2012
Soft Tissue Sarcoma reformatted criteria added reference 8/8/2012
Testicular Cancer reviewed and updated 8/8/2012
Thymic Cancer reviewed and updated 8/8/2012
Added criteria for Tremor and Parkinson’s Disease 9/21/2012
Numerous typographic and formatting errors and inconsistencies were repaired no clinical criteria were materially changed.
CT Chest added Sarcoidosis to working diagnosis section. 10/18/2012
MRA Pelvis criteria expanded to be consistent with CTA Pelvis 10/7/11
Oncology guidelines Updated and expanded Gastric Cancer Guidelines 10/10/11
Added “with no prior cancer diagnosis” to clarify criteria for examination and follow up of nodules 11/22/2012
Added criteria for pneumonia to working diagnosis and prior medical sections 11/21/2012
Added Sputum cytology positive to section on abnormal lab results 11/21/2012
CT Head Added “Thunderlap” headache to criteria 11/18/2012
CTA Abdomen Added interval criteria for follow up of abdominal aneurysm repairs 11/18/2012
CTA Pelvis Added criteria to Significant Prior History section 11/29/2012
MRA Head Added “Thunderclap” headache to criteria 11/18/2012
MRA Pelvis Added criteria to Significant Prior History section 11/29/2012
Added “Thunderclap” headache to criteria 11/18/2012
Updated criteria for Optic neuritis, and added it to Working Diagnosis section 11/25/2012
Updated criteria for Optic neuritis, 11/25/2012
Clarified meaning of bladder wall invasion to include stages T2 and above 11/15/2012
Updated Initial work up to include CT abdomen of bladder wall is invaded 11/23/2012
CT Abdomen Removed “Renal Carcinoma” as separate entry from group 5, diagnosis is covered by “Cancer, Intra abdominal (any cell type)” 12/28/2012
CTA Abdomen and Pelvis Created criteria set for new CPT code. 12/28/2012
CTA Pelvis Clarified criteria for aneurysm and updated reference 12/21/2012
MRA Pelvis Clarified criteria for aneurysm and updated reference 12/21/2012
MRI Abdomen Added criteria for use of MRCP as a preoperative tool to exckude choledocholithiasis in cases of cholelithiasis 12/23/2012
added Carcinoid tumors 1/3/2012
added surveillance criteria for Hodkins 1/16/2012
Breast MRI Added several syndromes to indications for screening 2/13/2012
added requirements to indication “Arthritis” in the Prior History section 2/13/2012
Added requirement for negative X-rays under post trauma 2/16/2012
Changed requirement to a single prior nondiagnostc x-ray under pain 2/16/2012
Added “Family history of polycystic kidney disease” to indications for screening 2/21/2012
Altered intervals allowable for screening exams to one year or more without physician review. 2/21/2012
Confirmed microscopically (required only when hematuria is detected by dip stick test alone)
Urine is grossly (visibly) bloody
Ramesh Mazhari and Paul L Kimmel Hematuria: an algorithmic approach to finding the cause. Cleveland Clinic Journal of Medicine 2002; 69(11):870;
American College of Radiology ACR Apprpriateness Criteria Hematuria 2005 page 4 accessed 2/11/09
Confirmed microscopically (required only when hematuria is detected by dip stick test alone)
Urine is grossly (visibly) bloody
Ramesh Mazhari and Paul L Kimmel Hematuria: an algorithmic approach to finding the cause. Cleveland Clinic Journal of Medicine 2002; 69(11):870;
American College of Radiology ACR Apprpriateness Criteria Hematuria 2005 page 4 accessed 2/11/09
Confirmed microscopically (required only when hematuria is detected by dip stick test alone)
Urine is grossly (visibly) bloody
Ramesh Mazhari and Paul L Kimmel Hematuria: an algorithmic approach to finding the cause. Cleveland Clinic Journal of Medicine 2002; 69(11):870;
American College of Radiology ACR Apprpriateness Criteria Hematuria 2005 page 4 accessed 2/11/09
Added criteria under Abnormal Prior Imaging category. 4/3/2012
Added Red Flags warnings as “Important Note”
Added criteria to Pain, Suspected Perforated Bowel. Added Tenderness, Rebound, Fever, and Air Seen on imaging. 5/2/2012
Deleted Pregnancy as an indication under epigastric pain 5/3/2012
Deleted Liver abscess under RUQ pain as redundant 5/3/2012
Deleted Pneumomia as an indication 5/3/2012
Deleted Lactase Deficiency as an indication under Pain 5/18/2012
Deleted Appendicitis as an indication for CT of the Abdomen unless there is a specific reason for not also ordering CT of the Pelvis 5/18/2012
Interval Follow Up, no new symptoms, no recent similar exam in past year.
Worsening condition
Revised criteria for new and known evaluation of aortic dilatation 5/18/2012
Deleted “Prior screening exam for AAA … as inconsistent with Widening of the abdominal aorta criteria 5/18/2012
Made all references to Pulmonary Embolism Suspected uniform, no new criteria added 5/21/2012
Clarified and made uniform several sets of criteria without substantial changes in requirements 6/4/2012
Added requirement for pain or a one year follow up for Known Aneurysm 6/4/2012
Removed requirement for barium studies before MR for suspected Crohn Disease 6/15/212
Oncology guideline for surveillance go kidney cancer updated 7/30/2012
Added criteria for Ischemic Bowel to Working diagnosis sections of CT Abdomen, CT Pelvis, and CT of Abdomen and Pelvis. Updated references 9/17/2012
78466 Infarct avid Imaging 10/22/202
78453 78454 Planar Myocardial Perfusion imaging 10/22/202
75565 Cardiac Velocity Flow Mapping 10/22/202
Minor wording changes for clarification purposes
Added post neoadjuvant therapy for surgical planning purposes to indications 11/13/2012
72131 CT Lumbar Spine Corrected entry error substituting Sacral for Brachial 11/14/2012
74150 CT Abdomen Deleted redundant requirement for abdominal pain under suspected pancreatitis 11/20/2012