Clinical UM Guideline



Subject: Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists
Guideline #:  CG-ADMIN-01 Publish Date:    12/27/2017
Status: Revised Last Review Date:    02/02/2017

Description

The Company reviews services provided, or proposed to be provided, to its members to determine benefits coverage based on whether the services are medically necessary or not medically necessary. In making such benefit decisions, the Company determines whether such services are in accordance with generally accepted standards of medical practice, taking into account credible scientific evidence published in peer reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, and the views of physicians practicing in relevant clinical areas, and other relevant factors, as they relate to the member's clinical circumstances.

This document provides guidance to be followed and a list of resources available to Company Medical Reviewers when the Company does not have a Clinical UM Guideline directly applicable to a particular medical necessity determination for a request for review or claim related to the services and codes noted in the table below in connection with a provider who is on pre-payment review. These services and corresponding codes may be modified when additional inappropriate use of services is identified; services and codes may be added to the table accordingly.

After Company Medical Reviewers have made their determination, they should document their decision and the resources used in the appropriate medical management system.  Utilization Management departments will follow their standard procedures to meet relevant timeframes and notification requirements as appropriate for urgent and non-urgent requests. 

Coding and References

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT Codes: References:
71010  Radiologic examination, chest; single view, frontal
  1. American College of Radiology. ACR Appropriateness Criteria® routine chest radiography. 2015. Available at: https://acsearch.acr.org/docs/69451/Narrative/ . Accessed on December 19, 2016.
  2. American College of Radiology. ACR Appropriateness Criteria® blunt chest trauma. 2013. Available at: https://acsearch.acr.org/docs/3082590/Narrative/ . Accessed on December 19, 2016.
  3. American College of Radiology. ACR Appropriateness Criteria® blunt chest trauma — suspected aortic injury. 2014. Available at: https://acsearch.acr.org/docs/69410/Narrative/ . Accessed on December 19, 2016.
  4. American College of Radiology (ACR) and the Society for Pediatric Radiology (SPR). ACR–SPR practice parameter for the performance of chest radiography. 2014. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Chest_Radiography.pdf. Accessed on December 19, 2016.
  5. American College of Radiology. ACR Appropriateness Criteria® acute nonspecific chest pain — low probability of coronary artery disease. 2015. Available at: https://acsearch.acr.org/docs/69401/Narrative/ . Accessed on December 19, 2016.
  6. American College of Radiology (ACR) and the Society for Pediatric Radiology (SPR). ACR–SPR practice parameter for the performance of portable (mobile unit) chest radiography. 2014. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Portable_Chest.pdf. Accessed on December 19, 2016.
  7. American College of Radiology. ACR Appropriateness Criteria® renal cell carcinoma staging. 2015. Available at: https://acsearch.acr.org/docs/69372/Narrative/ . Accessed on December 19, 2016.
  8. American College of Radiology. ACR Appropriateness Criteria® known or suspected congenital heart disease in the adult. 2011. Available at: https://acsearch.acr.org/docs/69355/Narrative/ . Accessed on December 19, 2016.
  9. American College of Radiology (ACR), Society for Pediatric Radiology (SPR). ACR–SPR practice parameter for general radiography. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/General_Radiography.pdf. Accessed on December 19, 2016.
71020  Radiologic examination, chest, 2 views, frontal and lateral
  1. American College of Radiology. ACR Appropriateness Criteria® routine chest radiography. 2015. Available at: https://acsearch.acr.org/docs/69451/Narrative/ . Accessed on December 19, 2016.
  2. American College of Radiology. ACR Appropriateness Criteria® blunt chest trauma. 2013. Available at: https://acsearch.acr.org/docs/3082590/Narrative/ . Accessed December 19, 2016.
  3. American College of Radiology. ACR Appropriateness Criteria® blunt chest trauma — suspected aortic injury. 2014. Available at: https://acsearch.acr.org/docs/69410/Narrative/ . Accessed on December 19, 2016.
  4. American College of Radiology (ACR) and the Society for Pediatric Radiology (SPR). ACR–SPR practice parameter for the performance of chest radiography. 2014. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Chest_Radiography.pdf. Accessed on December 19, 2016.
  5. American College of Radiology. ACR Appropriateness Criteria® acute nonspecific chest pain — low probability of coronary artery disease. 2015. Available at: https://acsearch.acr.org/docs/69401/Narrative/ . Accessed on December 19, 2016.
  6. American College of Radiology (ACR) and the Society for Pediatric Radiology (SPR). ACR–SPR practice parameter for the performance of portable (mobile unit) chest radiography. 2014. Available at: https://www.acr.org/~/media/38249F67D295479A8B3F2BE073C37B65.pdf . Accessed on December 19, 2016.
  7. American College of Radiology. ACR Appropriateness Criteria® renal cell carcinoma staging. 2015. Available at: https://acsearch.acr.org/docs/69372/Narrative/ . Accessed on December 19, 2016.
  8. American College of Radiology. ACR Appropriateness Criteria® known or suspected congenital heart disease in the adult. 2011. Available at: https://acsearch.acr.org/docs/69355/Narrative/ . Accessed on December 19, 2016.
  9. American College of Radiology (ACR), Society for Pediatric Radiology (SPR). ACR–SPR practice parameter for general radiography. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/General_Radiography.pdf. Accessed on December 19, 2016.
71021  Radiologic examination, chest, 2 views, frontal and lateral; with apical lordotic procedure
  1. American College of Radiology. ACR Appropriateness Criteria® routine chest radiography. 2015. Available at: https://acsearch.acr.org/docs/69451/Narrative/ . Accessed on December 19, 2016.
  2. American College of Radiology. ACR Appropriateness Criteria® blunt chest trauma. 2013. Available at: https://acsearch.acr.org/docs/3082590/Narrative/ . Accessed on December 19, 2016.
  3. American College of Radiology. ACR Appropriateness Criteria® blunt chest trauma — suspected aortic injury. 2014. Available at: https://acsearch.acr.org/docs/69410/Narrative/ . Accessed on December 19, 2016.
  4. American College of Radiology (ACR) and the Society for Pediatric Radiology (SPR). ACR–SPR practice parameter for the performance of chest radiography. 2014. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Chest_Radiography.pdf. Accessed on December 19, 2016.
  5. American College of Radiology. ACR Appropriateness Criteria® acute nonspecific chest pain — low probability of coronary artery disease. 2015. Available at: https://acsearch.acr.org/docs/69401/Narrative/ . Accessed on December 19, 2016.
  6. American College of Radiology (ACR) and the Society for Pediatric Radiology (SPR). ACR–SPR practice parameter for the performance of portable (mobile unit) chest radiography. 2014. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Portable_Chest.pdf. Accessed on December 19, 2016.
  7. American College of Radiology. ACR Appropriateness Criteria® renal cell carcinoma staging. 2015. Available at: https://acsearch.acr.org/docs/69372/Narrative/ . Accessed on December 19, 2016.
  8. American College of Radiology. ACR Appropriateness Criteria® known or suspected congenital heart disease in the adult. 2011. Available at: https://acsearch.acr.org/docs/69355/Narrative/ . Accessed on December 19, 2016.
  9. American College of Radiology (ACR), Society for Pediatric Radiology (SPR). ACR–SPR practice parameter for general radiography. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/General_Radiography.pdf. Accessed on December 19, 2016.
72020  Radiologic examination, spine, single view, specify level
  1. American College of Radiology, American Society of Spine Radiology, the Society for Pediatric Radiology, Society of Skeletal Radiology. ACR–ASSR–SPR–SSR practice parameter for the performance of spine radiography. 2012. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Spine_Radiography.pdf Accessed on December 19, 2016.
  2. American College of Radiology, Society of Pediatric Radiology. Pediatric radiology practice parameters and technical standards - ACR–SPR practice parameter for skeletal surveys in children. 2014. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Skeletal_Surveys.pdf. Accessed on December 19, 2016.
  3. American Academy of Orthopaedic Surgeons. Treatment of symptomatic osteoporotic spinal compression fractures. 2010. Available at: http://www.aaos.org/research/guidelines/SCFguideline.pdf. Accessed on December 19, 2016.
  4. The Scoliosis Research Society (SRS), American Academy of Orthopedic Surgeons (AAOS), Pediatric Orthopedic Society of North America (POSNA), and American Academy of Pediatrics (AAP). Position Statement - Screening for the early detection for idiopathic scoliosis in adolescents. 2015. Available at: https://www.srs.org/about-srs/news-and-announcements/position-statement---screening-for-the-early-detection-for-idiopathic-scoliosis-in-adolescents . Accessed on December 19, 2016.
  5. American College of Radiology (ACR), the Society for Pediatric Radiology (SPR), and the Society of Skeletal Radiology (SSR). 2014. ACR–SPR–SSR practice parameter for the performance of radiography for scoliosis in children. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Scoliosis.pdf. Accessed on December 19, 2016.
  6. American College of Radiology (ACR), American Society of Spine Radiology (ASSR), Society for Pediatric Radiology (SPR), Society of Skeletal Radiology (SSR). ACR–ASSR–SPR–SSR Practice parameter for the performance of spine radiography. 2012. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Spine_Radiography.pdf. Accessed on December 19, 2016.
  7. American College of Radiology. ACR Appropriateness Criteria® suspected spine trauma. 2007. Available at: https://www.guideline.gov/content.aspx?id=37931&search=appropriateness+criteria%C2%AE+suspected+spine+trauma . Accessed on December 19, 2016.
  8. American College of Radiology. ACR Appropriateness Criteria® low back pain. 2015. Available at: https://acsearch.acr.org/docs/69483/Narrative/ . Accessed on December 19, 2016.
72040  Radiologic examination, spine, cervical; 2 or 3 views
  1. American College of Radiology, American Society of Spine Radiology, the Society for Pediatric Radiology, Society of Skeletal Radiology. ACR–ASSR–SPR–SSR practice parameter for the performance of spine radiography. 2012. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Spine_Radiography.pdf. Accessed on December 19, 2016.
  2. American College of Radiology, Society of Pediatric Radiology. Pediatric radiology practice parameters and technical standards - ACR–SPR practice parameter for skeletal surveys in children. 2014. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Skeletal_Surveys.pdf. Accessed on December 19, 2016.
  3. American Academy of Orthopaedic Surgeons. Treatment of symptomatic osteoporotic spinal compression fractures. 2010. Available at: http://www.aaos.org/research/guidelines/SCFguideline.pdf. Accessed on December 19, 2016.
  4. The Scoliosis Research Society (SRS), American Academy of Orthopedic Surgeons (AAOS), Pediatric Orthopedic Society of North America (POSNA), and American Academy of Pediatrics (AAP). Position Statement - Screening for the early detection for idiopathic scoliosis in adolescents. 2015. Available at: https://www.srs.org/about-srs/news-and-announcements/position-statement---screening-for-the-early-detection-for-idiopathic-scoliosis-in-adolescents . Accessed on December 19, 2016.
  5. American College of Radiology (ACR), the Society for Pediatric Radiology (SPR), and the Society of Skeletal Radiology (SSR). 2014. ACR–SPR–SSR practice parameter for the performance of radiography for scoliosis in children. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Scoliosis.pdf. Accessed on December 19, 2016.
  6. American College of Radiology (ACR), American Society of Spine Radiology (ASSR), Society for Pediatric Radiology (SPR), Society of Skeletal Radiology (SSR). ACR–ASSR–SPR–SSR Practice parameter for the performance of spine radiography. 2012. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Spine_Radiography.pdf. Accessed on December 19, 2016.
  7. American College of Radiology. ACR Appropriateness Criteria® suspected spine trauma. 2007. Available at: https://www.guideline.gov/content.aspx?id=37931&search=appropriateness+criteria%C2%AE+suspected+spine+trauma . Accessed on December 19, 2016.
  8. American College of Radiology. ACR Appropriateness Criteria® low back pain. 2015. Available at: https://acsearch.acr.org/docs/69483/Narrative/ . Accessed on December 19, 2016.
72050  Radiologic examination, spine, cervical; 4 or 5 views
  1. American College of Radiology, American Society of Spine Radiology, the Society for Pediatric Radiology, Society of Skeletal Radiology. ACR–ASSR–SPR–SSR practice parameter for the performance of spine radiography. 2012. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Spine_Radiography.pdf. Accessed on December 19, 2016.
  2. American College of Radiology, Society of Pediatric Radiology. Pediatric radiology practice parameters and technical standards - ACR–SPR practice parameter for skeletal surveys in children. 2014. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Skeletal_Surveys.pdf. Accessed on December 19, 2016.
  3. American Academy of Orthopaedic Surgeons. Treatment of symptomatic osteoporotic spinal compression fractures. 2010. Available at: http://www.aaos.org/research/guidelines/SCFguideline.pdf. Accessed on December 19, 2016.
  4. The Scoliosis Research Society (SRS), American Academy of Orthopedic Surgeons (AAOS), Pediatric Orthopedic Society of North America (POSNA), and American Academy of Pediatrics (AAP). Position Statement - Screening for the early detection for idiopathic scoliosis in adolescents. 2015. Available at: https://www.srs.org/about-srs/news-and-announcements/position-statement---screening-for-the-early-detection-for-idiopathic-scoliosis-in-adolescents . Accessed on December 19, 2016.
  5. American College of Radiology (ACR), the Society for Pediatric Radiology (SPR), and the Society of Skeletal Radiology (SSR). 2014. ACR–SPR–SSR practice parameter for the performance of radiography for scoliosis in children. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Scoliosis.pdf. Accessed on December 19, 2016.
  6. American College of Radiology (ACR), American Society of Spine Radiology (ASSR), Society for Pediatric Radiology (SPR), Society of Skeletal Radiology (SSR). ACR–ASSR–SPR–SSR Practice parameter for the performance of spine radiography. 2012. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Spine_Radiography.pdf. Accessed on December 19, 2016.
  7. American College of Radiology. ACR Appropriateness Criteria® suspected spine trauma. 2007. Available at: https://www.guideline.gov/content.aspx?id=37931&search=appropriateness+criteria%C2%AE+suspected+spine+trauma . Accessed on July 12, 2016.
  8. American College of Radiology. ACR Appropriateness Criteria® low back pain. 2015. Available at: https://acsearch.acr.org/docs/69483/Narrative/ . Accessed on  December 19, 2016.
72052  Radiologic examination, spine, cervical; 6 or more views
  1. American College of Radiology, American Society of Spine Radiology, the Society for Pediatric Radiology, Society of Skeletal Radiology. ACR–ASSR–SPR–SSR practice parameter for the performance of spine radiography. 2012. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Spine_Radiography.pdf. Accessed on December 19, 2016.
  2. American College of Radiology, Society of Pediatric Radiology. Pediatric radiology practice parameters and technical standards - ACR–SPR practice parameter for skeletal surveys in children. 2014. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Skeletal_Surveys.pdf. Accessed on December 19, 2016.
  3. American Academy of Orthopaedic Surgeons. Treatment of symptomatic osteoporotic spinal compression fractures. 2010. Available at: http://www.aaos.org/research/guidelines/SCFguideline.pdf. Accessed on December 19, 2016.
  4. The Scoliosis Research Society (SRS), American Academy of Orthopedic Surgeons (AAOS), Pediatric Orthopedic Society of North America (POSNA), and American Academy of Pediatrics (AAP). Position Statement - Screening for the early detection for idiopathic scoliosis in adolescents. 2015. Available at: https://www.srs.org/about-srs/news-and-announcements/position-statement---screening-for-the-early-detection-for-idiopathic-scoliosis-in-adolescents . Accessed on December 19, 2016.
  5. American College of Radiology (ACR), the Society for Pediatric Radiology (SPR), and the Society of Skeletal Radiology (SSR). 2014. ACR–SPR–SSR practice parameter for the performance of radiography for scoliosis in children. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Scoliosis.pdf. Accessed on December 19, 2016.
  6. American College of Radiology (ACR), American Society of Spine Radiology (ASSR), Society for Pediatric Radiology (SPR), Society of Skeletal Radiology (SSR). ACR–ASSR–SPR–SSR Practice parameter for the performance of spine radiography. 2012. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Spine_Radiography.pdf. Accessed on December 19, 2016.
  7. American College of Radiology. ACR Appropriateness Criteria® suspected spine trauma. 2007. Available at: https://www.guideline.gov/content.aspx?id=37931&search=appropriateness+criteria%C2%AE+suspected+spine+trauma . Accessed on December 19, 2016.
  8. American College of Radiology. ACR Appropriateness Criteria® low back pain. 2015. Available at: https://acsearch.acr.org/docs/69483/Narrative/ . Accessed on December 19, 2016.
72070  Radiologic examination, spine; thoracic, 2 views
  1. American College of Radiology (ACR) and the Society for Pediatric Radiology (SPR). ACR–SPR practice parameter for the performance of chest radiography. 2014. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Chest_Radiography.pdf. Accessed on December 19, 2016.
  2. American College of Radiology. ACR Appropriateness Criteria® imaging in the diagnosis of thoracic outlet syndrome. 2014. Available at: https://acsearch.acr.org/docs/3083061/Narrative/ . Accessed on December 19, 2016.
72074  Radiologic examination, spine; thoracic, minimum of 4 views
  1. American College of Radiology (ACR) and the Society for Pediatric Radiology (SPR). ACR–SPR practice parameter for the performance of chest radiography. 2014. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Chest_Radiography.pdf. Accessed on December 19, 2016.
  2. American College of Radiology. ACR Appropriateness Criteria® imaging in the diagnosis of thoracic outlet syndrome. 2014. Available at: https://acsearch.acr.org/docs/3083061/Narrative/ . Accessed on December 19, 2016.
72082 Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 2 or 3 views
  1. American College of Radiology, American Society of Spine Radiology, the Society for Pediatric Radiology, Society of Skeletal Radiology. ACR–ASSR–SPR–SSR practice parameter for the performance of spine radiography. 2012. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Spine_Radiography.pdf. Accessed on December 19, 2016.
  2. American College of Radiology, Society of Pediatric Radiology. Pediatric radiology practice parameters and technical standards - ACR–SPR practice parameter for skeletal surveys in children. 2014. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Skeletal_Surveys.pdf. Accessed on December 19, 2016.
  3. American Academy of Orthopaedic Surgeons. Treatment of symptomatic osteoporotic spinal compression fractures. 2010. Available at: http://www.aaos.org/research/guidelines/SCFguideline.pdf. Accessed on December 19, 2016.
  4. The Scoliosis Research Society (SRS), American Academy of Orthopedic Surgeons (AAOS), Pediatric Orthopedic Society of North America (POSNA), and American Academy of Pediatrics (AAP). Position Statement - Screening for the early detection for idiopathic scoliosis in adolescents. 2015. Available at: https://www.srs.org/about-srs/news-and-announcements/position-statement---screening-for-the-early-detection-for-idiopathic-scoliosis-in-adolescents . Accessed on December 19, 2016.
  5. American College of Radiology (ACR), the Society for Pediatric Radiology (SPR), and the Society of Skeletal Radiology (SSR). 2014. ACR–SPR–SSR practice parameter for the performance of radiography for scoliosis in children. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Scoliosis.pdf. Accessed on December 19, 2016.
  6. American College of Radiology (ACR), American Society of Spine Radiology (ASSR), Society for Pediatric Radiology (SPR), Society of Skeletal Radiology (SSR). ACR–ASSR–SPR–SSR Practice parameter for the performance of spine radiography. 2012. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Spine_Radiography.pdf. Accessed on December 19, 2016.
  7. American College of Radiology. ACR Appropriateness Criteria® suspected spine trauma. 2007. Available at: https://www.guideline.gov/content.aspx?id=37931&search=appropriateness+criteria%C2%AE+suspected+spine+trauma . Accessed on December 19, 2016.
  8. American College of Radiology. ACR Appropriateness Criteria® low back pain. 2015. Available at: https://acsearch.acr.org/docs/69483/Narrative/ . Accessed on December 19, 2016.
72110  Radiologic examination, spine, lumbosacral; minimum of 4 views
  1. American College of Radiology. ACR Appropriateness Criteria® plexopathy. 2012. Available at: https://acsearch.acr.org/docs/69487/Narrative/ . Accessed on  December 19, 2016.
72114  Radiologic examination, spine, lumbosacral; complete, including bending views, minimum of 6 views
  1. American College of Radiology, American Society of Spine Radiology, the Society for Pediatric Radiology, Society of Skeletal Radiology. ACR–ASSR–SPR–SSR practice parameter for the performance of spine radiography. 2012. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Spine_Radiography.pdf. Accessed on December 19, 2016.
  2. American College of Radiology. ACR Appropriateness Criteria® suspected spine trauma. 2012. Available at: https://www.guideline.gov/content.aspx?id=37931&search=appropriateness+criteria%C2%AE+suspected+spine+trauma . Accessed on December 19, 2016.
  3. American College of Radiology. ACR Appropriateness Criteria® low back pain. 2015. Available at: https://www.guideline.gov/content.aspx?id=49915&search=appropriateness+criteria%C2%AE+suspected+spine+trauma . Accessed on December 19, 2016.
72170  Radiologic examination, pelvis; 1 or 2 views
  1. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR Practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.
  2. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR ACR–SPR Practice parameter for the performance of abdominal radiography. 2014. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Abdominal_Radiography.pdf. Accessed on December 19, 2016.

 

73030  Radiologic examination, shoulder; complete, minimum of 2 views
  1. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR Practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.
  2. American College of Radiology. ACR Appropriateness Criteria® upper extremity swelling. Available at: https://acsearch.acr.org/docs/69417/Narrative/ . 2014. Accessed on December 19, 2016. 
  3. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.
  4. American Academy of Orthopaedic Surgeons. American Academy of Orthopaedic Surgeons appropriate use criteria for optimizing the management of full-thickness rotator cuff tears. 2013. Available at: http://www.aaos.org/research/Appropriate_Use/rotatorcuffaucfull.pdf. Accessed on December 19, 2016.
73060  Radiologic examination; humerus, minimum of 2 views
  1. American Academy of Orthopaedic Surgeons. Treatment of pediatric diaphyseal femur fractures. 2015. Available at: http://www.aaos.org/research/guidelines/PDFF_ReIssue.pdf. Accessed on December 19, 2016.
  2. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.
73070  Radiologic examination, elbow; 2 views
  1. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016. 
73080  Radiologic examination, elbow; complete, minimum of 3 views
  1. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.
73090  Radiologic examination; forearm, 2 views
  1. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.
73110  Radiologic examination, wrist; complete, minimum of 3 views
  1. American Academy of Orthopaedic Surgeons. The treatment of distal radius fractures guideline and evidence report. 2009. Available at: http://www.aaos.org/research/guidelines/drfguideline.pdf. Accessed on December 19, 2016.
  2. American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome. Available at: http://www.orthoguidelines.org/topic?id=1020. Accessed on December 19, 2016.
  3. American Academy of Orthopaedic Surgeons, American Association of Neuromuscular & Electrodiagnostic Medicine. Clinical practice guideline on the treatment of carpal tunnel syndrome. 2008. Available at: http://www.aaos.org/research/guidelines/CTSTreatmentGuideline.pdf. Accessed on December 19, 2016.
  4. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016
73130  Radiologic examination, hand; minimum of 3 views
  1. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016. 
73502 Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views
  1. American Academy of Orthopaedic Surgeons. Management of hip fractures in the elderly. 2014. Available at: http://www.aaos.org/research/guidelines/HipFxGuideline_rev.pdf. Accessed on December 19, 2016.
  2. American College of Radiology. ACR Appropriateness Criteria® imaging after total hip arthroplasty. 2015. Available at: https://acsearch.acr.org/docs/3094200/Narrative/ . Accessed on December 19, 2016.
  3. American Academy of Orthopaedic Surgeons. Detection and nonoperative management of pediatric developmental dysplasia of the hip in infants up to six months of age. Available at: http://www.aaos.org/research/guidelines/DDHGuidelineFINAL.pdf. Accessed on December 19, 2016.
  4. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.  
73503  Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views
  1. American Academy of Orthopaedic Surgeons. Management of hip fractures in the elderly. 2014. Available at: http://www.aaos.org/research/guidelines/HipFxGuideline_rev.pdf. Accessed on December 19, 2016.
  2. American College of Radiology. ACR Appropriateness Criteria® imaging after total hip arthroplasty. 2015. Available at: https://acsearch.acr.org/docs/3094200/Narrative/ . Accessed on December 19, 2016.
  3. American Academy of Orthopaedic Surgeons. Detection and nonoperative management of pediatric developmental dysplasia of the hip in infants up to six months of age. Available at: http://www.aaos.org/research/guidelines/DDHGuidelineFINAL.pdf. Accessed on December 19, 2016.
  4. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.  
73521  Radiologic examination, hips, bilateral, with pelvis when performed; 2 views
  1. American Academy of Orthopaedic Surgeons. Management of hip fractures in the elderly. 2014. Available at: http://www.aaos.org/research/guidelines/HipFxGuideline_rev.pdf. Accessed on December 19, 2016.
  2. American College of Radiology. ACR Appropriateness Criteria® imaging after total hip arthroplasty. 2015. Available at: https://acsearch.acr.org/docs/3094200/Narrative/ . Accessed on December 19, 2016.
  3. American Academy of Orthopaedic Surgeons. Detection and nonoperative management of pediatric developmental dysplasia of the hip in infants up to six months of age. Available athttp://www.aaos.org/research/guidelines/DDHGuidelineFINAL.pdf. Accessed on December 19, 2016.
  4. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.  

73522  Radiologic examination, hips, bilateral, with pelvis when performed 3-4 views

 

  1. American Academy of Orthopaedic Surgeons. Management of hip fractures in the elderly. 2014. Available at: http://www.aaos.org/research/guidelines/HipFxGuideline_rev.pdf. Accessed on December 19, 2016.
  2. American College of Radiology. ACR Appropriateness Criteria® imaging after total hip arthroplasty. 2015. Available at: https://acsearch.acr.org/docs/3094200/Narrative/ . Accessed on December 19, 2016.
  3. American Academy of Orthopaedic Surgeons. Detection and nonoperative management of pediatric developmental dysplasia of the hip in infants up to six months of age. Available at: http://www.aaos.org/research/guidelines/DDHGuidelineFINAL.pdf.  Accessed on December 19, 2016.
  4. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.  

73523  Radiologic examination, hips, bilateral, with pelvis when performed; minimum of 5 views

 

  1. American Academy of Orthopaedic Surgeons. Management of hip fractures in the elderly. 2014. Available at: http://www.aaos.org/research/guidelines/HipFxGuideline_rev.pdf. Accessed on December 19, 2016.
  2. American College of Radiology. ACR Appropriateness Criteria® imaging after total hip arthroplasty. 2015. Available at: https://acsearch.acr.org/docs/3094200/Narrative/ . Accessed on December 19, 2016.
  3. American Academy of Orthopaedic Surgeons. Detection and nonoperative management of pediatric developmental dysplasia of the hip in infants up to six months of age. Available at: http://www.aaos.org/research/guidelines/DDHGuidelineFINAL.pdf.  Accessed on December 19, 2016.
  4. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.  
73560  Radiologic examination, knee; 1 or 2 views
  1. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.  
  2. American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee (2nd edition). 2013. Available at: http://www.aaos.org/research/guidelines/TreatmentofOsteoarthritisoftheKneeGuideline.pdf. Accessed on December 19, 2016.  
  3. American Academy of Orthopaedic Surgeons, National Academy of Sports Medicine, National Athletic Trainers Association. ASSOM, American Academy of Physical Medicine and Rehabilitation. Management of anterior cruciate ligament injuries. Available at: http://www.aaos.org/research/guidelines/ACLGuidelineFINAL.pdf. Accessed on December 19, 2016.
  4. Infectious Disease Society of America. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Available at: http://www.guideline.gov/content.aspx?id=39267&search=diagnosis+of+periprosthetic+joint+infections+of+the+hip+and+knee. Accessed on December 19, 2016.
  5. American College of Radiology. ACR Appropriateness Criteria® nontraumatic knee pain. 2012. Available at: https://acsearch.acr.org/docs/69432/Narrative/ . Accessed on December 19, 2016.
  6. American Academy of Orthopaedic Surgeons. Treatment of pediatric diaphyseal femur fractures. 2015. Available at: http://www.aaos.org/research/guidelines/PDFF_ReIssue.pdf. Accessed on December 19, 2016.
  7. American Academy of Orthopaedic Surgeons. Surgical management of osteoarthritis of the knee. 2015. Available at: http://www.orthoguidelines.org/topic?id=1019. Accessed on December 19, 2016.
73564  Radiologic examination, knee; complete, 4 or more views
  1. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.  
  2. American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee (2nd edition). 2013. Available at: http://www.aaos.org/research/guidelines/TreatmentofOsteoarthritisoftheKneeGuideline.pdf. Accessed on December 19, 2016.  
  3. American Academy of Orthopaedic Surgeons, National Academy of Sports Medicine, National Athletic Trainers Association. ASSOM, American Academy of Physical Medicine and Rehabilitation. Management of anterior cruciate ligament injuries. Available at: http://www.aaos.org/research/guidelines/ACLGuidelineFINAL.pdf. Accessed on December 19, 2016.
  4. Infectious Disease Society of America. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Available at: http://www.guideline.gov/content.aspx?id=39267&search=diagnosis+of+periprosthetic+joint+infections+of+the+hip+and+knee. Accessed on December 19, 2016.
  5. American College of Radiology. ACR Appropriateness Criteria® nontraumatic knee pain. 2012. Available at: https://acsearch.acr.org/docs/69432/Narrative/ . Accessed on December 19, 2016.
  6. American Academy of Orthopaedic Surgeons. Treatment of pediatric diaphyseal femur fractures. 2015. Available at: http://www.aaos.org/research/guidelines/PDFF_ReIssue.pdf. Accessed on December 19, 2016.
  7. American Academy of Orthopaedic Surgeons. Surgical management of osteoarthritis of the knee. 2015. Available at: http://www.orthoguidelines.org/topic?id=1019. Accessed on December 19, 2016.
73590  Radiologic examination, tibia and fibula, 2 views
  1. American Academy of Orthopaedic Surgeons. Diagnosis and treatment of osteochondritis dissecans. 2010. Available at: http://www.aaos.org/research/guidelines/OCD_guideline.pdf. Accessed on December 19, 2016.
  2. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.  
73600  Radiologic examination, ankle; 2 views
  1. American Academy of Orthopaedic Surgeons. Diagnosis and treatment of osteochondritis dissecans. 2010. Available at: http://www.aaos.org/research/guidelines/OCD_guideline.pdf. Accessed on December 19, 2016.
  2. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.  
73610  Radiologic examination, ankle; complete, minimum of 3 views
  1. American Academy of Orthopaedic Surgeons. Diagnosis and treatment of osteochondritis dissecans. 2010. Available at: http://www.aaos.org/research/guidelines/OCD_guideline.pdf. Accessed on December 19, 2016.
  2. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.  
73620  Radiologic examination, foot; 2 views
  1. American Academy of Orthopedic Surgeons. Diagnosis and treatment of acute Achilles tendon rupture. 2009. Available at: http://www.aaos.org/research/guidelines/atrguideline.pdf.  Accessed on December 19, 2016.  
  2. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.  
73630  Radiologic examination, foot; complete, minimum of 3 views
  1. American Academy of Orthopedic Surgeons. Diagnosis and treatment of acute Achilles tendon rupture. 2009. Available at: http://www.aaos.org/research/guidelines/atrguideline.pdf . Accessed on December 19, 2016.  
  2. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.  
73660  Radiologic examination; toe(s), minimum of 2 views
  1. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), and Society of Skeletal Radiology (SSR). ACR–SPR–SSR practice parameter for the performance of radiography of the extremities. 2013. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Extremity_Radiography.pdf. Accessed on December 19, 2016.  
74020  Radiologic examination, abdomen; complete, including decubitus and/or erect views
  1. American College of Radiology (ACR) and the Society for Pediatric Radiology (SPR). ACR–SPR practice parameter for the performance of abdominal radiography. 2014. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Abdominal_Radiography.pdf. Accessed on December 19, 2016.
  2. American College of Radiology. ACR Appropriateness Criteria® renal trauma. 2014. Available at: https://acsearch.acr.org/docs/69373/Narrative/ . Accessed on December 19, 2016.
  3. American College of Radiology. ACR Appropriateness Criteria® palpable abdominal mass. 2014. Available at: https://acsearch.acr.org/docs/69473/Narrative/ . Accessed on December 19, 2016.
  4. American College of Radiology. ACR Appropriateness Criteria® right lower quadrant pain — suspected appendicitis. 2013. Available at: https://acsearch.acr.org/docs/69357/Narrative/ . Accessed on December 19, 2016.
  5. American College of Radiology. ACR Appropriateness Criteria® acute (nonlocalized) abdominal pain and fever or suspected abdominal abscess. 2012. Available at: https://acsearch.acr.org/docs/69467/Narrative/ . Accessed on December 19, 2016.
76536  Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), read time with image documentation
  1. American College of Rheumatology. American College of Rheumatology report on reasonable use of musculoskeletal ultrasonography in rheumatology clinical practice. 2012. Available at: http://www.rheumatology.org/Portals/0/Files/ACR%20Report%20on%20Reasonable%20Use%20of%20Musculoskeletal%20Ultrasonography%20in%20Rheumatology%20Clinical%20Practice.pdf. Accessed on December 19, 2016.
  2. American College of Radiology. ACR Appropriateness Criteria® cerebrovascular disease. 2016. Available at: https://acsearch.acr.org/docs/69478/Narrative/ . Accessed on December 19, 2016.
76700  Ultrasound, abdominal, real time with image documentation; complete
  1. American College of Radiology. ACR Appropriateness Criteria® right upper quadrant pain. 2013. Available at: https://acsearch.acr.org/docs/69474/Narrative/ . Accessed on December 19, 2016.
  2. American College of Radiology. ACR Appropriateness Criteria® acute (nonlocalized) abdominal pain and fever or suspected abdominal abscess. 2012. Available at: https://acsearch.acr.org/docs/69467/Narrative/ . Accessed on December 19, 2016.
  3. American College of Radiology. ACR Appropriateness Criteria® right lower quadrant pain — suspected appendicitis. 2011. Available at: http://doseoptimization.jacr.org/Content/PDF/Rosen-ACR-Ped.pdf. Accessed on J December 19, 2016.
  4. American College of Radiology. ACR Appropriateness Criteria® left lower quadrant pain — suspected diverticulitis. 2014. Available at: https://acsearch.acr.org/docs/69356/Narrative/ . Accessed on December 19, 2016.
  5. American College of Radiology. ACR Appropriateness Criteria® acute pelvic pain in the reproductive age group. 2015. Available at: https://acsearch.acr.org/docs/69503/Narrative . Accessed on December 19, 2016.
76705  Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)
  1. American College of Radiology. ACR Appropriateness Criteria® known or suspected congenital heart disease in the adult. 2011. Available at: https://acsearch.acr.org/docs/69355/Narrative/ . Accessed on December 19, 2016.
76770  Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete
  1. American College of Radiology (ACR), American College of Obstetrics and Gynecology (ACOG), American Institute of Ultrasound in Medicine (AIUM), and Society of Pediatric Radiology (SPR). 2014. ACR–ACOG–AIUM–SRU practice parameter for the performance of ultrasound of the female pelvis. 2012. Available at: http://www.acr.org/~/media/a79db56d3b054a04bee05e8250a67a5a.pdf. Accessed on December 19, 2016.
  2. American College of Radiology. ACR Appropriateness Criteria® suspected liver metastases. 2011. Available at: https://acsearch.acr.org/docs/69475/Narrative/ . Accessed on December 19, 2016.
  3. American College of Radiology. ACR Appropriateness Criteria® renal trauma. 2012. Available at: https://acsearch.acr.org/docs/69373/Narrative/ . Accessed on December 19, 2016.
  4. American College of Radiology (ACR), American College of Obstetrics and Gynecology (ACOG), American Institute of Ultrasound in Medicine (AIUM), and Society of Pediatric Radiology (SPR). ACR–AIUM–SPR–SRU practice parameter for the performance of an ultrasound examination of the abdomen and/or retroperitoneum. 2012. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/US_Abdomen_Retro.pdf. Accessed on December 19, 2016.
76775  Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited
  1. American College of Radiology (ACR), American College of Obstetrics and Gynecology (ACOG), American Institute of Ultrasound in Medicine (AIUM), and Society of Pediatric Radiology (SPR). ACR–ACOG–AIUM–SRU practice parameter for the performance of ultrasound of the female pelvis. 2012. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/US_Abdomen_Retro.pdf. Accessed on December 19, 2016.

 

76881  Ultrasound, extremity, nonvascular, real-time with image documentation; complete
  1. American Academy of Orthopaedic Surgeons (AAOS). American Academy of Orthopaedic Surgeons clinical practice guideline on management of carpal tunnel syndrome. 2016. Available at: https://www.guideline.gov/summaries/summary/50092/american-academy-of-orthopaedic-surgeons-clinical-practice-guideline-on-management-of-carpal-tunnel-syndrome . Accessed on December 19, 2016.
76882  Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific
  1. European Society of Musculoskeletal Radiology. Klauser AS, Tagliafico A, Allen GM, et al. Clinical indications for musculoskeletal ultrasound: A Delphi-based consensus paper of the European Society of Musculoskeletal Radiology. Eur Rad. 2012; 22(5):1140-1148. Available at: http://link.springer.com/article/10.1007/s00330-011-2356-3 . Accessed on December 19, 2016.
  2. American Academy of Orthopaedic Surgeons (AAOS). American Academy of Orthopaedic Surgeons clinical practice guideline on management of carpal tunnel syndrome. 2016. Available at: https://www.guideline.gov/summaries/summary/50092/american-academy-of-orthopaedic-surgeons-clinical-practice-guideline-on-management-of-carpal-tunnel-syndrome . Accessed on December 19, 2016.
93975  Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study
  1. American College of Radiology (ACR), the American Institute of Ultrasound in Medicine (AIUM), the Society for Pediatric Radiology (SPR), and the Society of Radiologists in Ultrasound (SRU). ACR–AIUM–SPR–SRU. Practice parameter for the performance of native renal artery duplex sonography. Revised 2013 (Resolution 14) Available at: https://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/US_Renal_Sonography.pdf . Accessed on December 19, 2016.
93976  Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study
  1. American College of Radiology (ACR), the American Institute of Ultrasound in Medicine (AIUM), the Society for Pediatric Radiology (SPR), and the Society of Radiologists in Ultrasound (SRU). ACR–AIUM–SPR–SRU. Practice parameter for the performance of native renal artery duplex sonography. Revised 2013 (Resolution 14) Available at: https://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/US_Renal_Sonography.pdf . Accessed on December 19, 2016.
ICD-10 Diagnosis  
  All diagnoses

**Note: In determining if there is a relevant Clinical UM Guideline, the reviewer will not consider procedure code alone. If an 'unlisted' or 'not otherwise classified' code is reported, the detailed description of service will be the determining factor.

Discussion/General Information

As noted above, this document provides guidance to be followed when the Company does not have a Clinical UM Guideline directly applicable to a particular medical necessity determination for a claim related to the above services and codes in connection with a provider who is on pre-payment review. The list of resources included herein is not meant to be exhaustive. Reviewers should use those resources that may be relevant to the decision at hand, but not necessarily use every resource in every case. Reviewers should use more than one resource when more than one resource is relevant to their decision. Reviewers should exercise their professional judgment in selecting appropriate resources and in rendering their determination.

Definitions

Physician Specialty Society: A United States medical specialty society that represents diplomats certified by a board recognized by the American Board of Medical Specialties.

Index

Radiograph
Ultrasound
X-Ray

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status

Date

Action

Revised 02/02/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Updated document with references for added CPT codes 76881, 76882, 93975 and 93976.
New 08/04/2016 MPTAC review. Initial document development.