Procedure Codes associated with Musculoskeletal Imaging

MS-1: General Guidelines

MS-2: Imaging Techniques

MS-3: 3D Rendering

MS-4: Avascular Necrosis (AVN)/Osteonecrosis

MS-5: Fractures

MS-6: Foreign Body

MS-7: Ganglion Cysts

MS-8: Gout/Calcium Pyrophosphate Deposition Disease (CPPD)/ Pseudogout/ Chondrocalcinosis

MS-9: Infection/Osteomyelitis

MS-10: Soft Tissue Mass or Lesion of Bone

MS-11: Muscle/Tendon Unit Injuries/Diseases

MS-12: Osteoarthritis

MS-13: Chondral/Osteochondral Lesions

MS-14: Osteoporosis

MS-15: Rheumatoid Arthritis (RA) and Inflammatory Arthritis

MS-16: Post-Operative Joint Replacement Surgery

MS-17: Limb Length Discrepancy

MS-18: Anatomical Area Tables – General Information

MS-19: Shoulder

MS-20: Elbow

MS-21: Wrist

MS-22: Hand

MS-23: Pelvis

MS-24: Hip

MS-25: Knee

MS-26: Ankle

MS-27: Foot

MS-28: Nuclear Medicine

Procedure Codes associated with Musculoskeletal Imaging

MRI/MRA	CPT®
MRI Upper Extremity, other than joint, without contrast	73218
MRI Upper Extremity, other than joint, with contrast	73219
MRI Upper Extremity, other than joint, without and with contrast	73220
MRI Upper Extremity, any joint, without contrast	73221
MRI Upper Extremity, any joint, with contrast	73222
MRI Upper Extremity, any joint, without and with contrast	73223
MR Angiography Upper Extremity without or with contrast	73225
MRI Lower Extremity, other than joint, without contrast	73718
MRI Lower Extremity, other than joint, with contrast	73719
MRI Lower Extremity, other than joint, without and with contrast	73720
MRI Lower Extremity, any joint, without contrast	73721
MRI Lower Extremity, any joint, with contrast	73722
MRI Lower Extremity, any joint, without and with contrast	73723
MR Angiography Lower Extremity without or with contrast	73725
MRI Pelvis without contrast	72195
MRI Pelvis with contrast	72196
MRI Pelvis without and with contrast	72197
CT/CTA	CPT®
CT Upper Extremity without contrast	73200
CT Upper Extremity with contrast	73201
CT Upper Extremity without and with contrast	73202
CT Angiography Upper Extremity without and with contrast	73206
CT Lower Extremity without contrast	73700
CT Lower Extremity with contrast	73701
CT Lower Extremity without and with contrast	73702
CT Angiography Lower Extremity without and with contrast	73706
CT Pelvis without contrast	72192
CT Pelvis with contrast	72193
CT Pelvis without and with contrast	72194
Nuclear Medicine	CPT®
Bone Marrow Imaging, Limited	78102
Bone Marrow Imaging, Multiple	78103
Bone Marrow Imaging, Whole Body	78104
Bone or Joint Imaging Limited	78300
Bone or Joint Imaging Multiple	78305
Bone Scan Whole Body	78306
Bone Scan 3 Phase Study	78315
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, single area (eg, head, neck, chest, pelvis), single day imaging	78800
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, 2 or more areas (eg, abdomen and pelvis, head and chest), 1 or more days imaging or single area imaging over 2 or more days	78801
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, whole body, single day imaging	78802
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT), single area (eg, head, neck, chest, pelvis), single day imaging	78803
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for anatomical review, localization and determination/detection of pathology, single area (eg, head, neck, chest, pelvis), single day imaging	78830
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT), minimum 2 areas (eg, pelvis and knees, abdomen and pelvis), single day imaging, or single area imaging over 2 or more days	78831
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for anatomical review, localization and determination/detection of pathology, minimum 2 areas (eg, pelvis and knees, abdomen and pelvis), single day imaging, or single area imaging over 2 or more days	78832

Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)

MS-1: General Policies

This General Policy section provides an overview of the basic criteria for which musculoskeletal imaging may be medically necessary. Details regarding specific conditions or clinical presentations and the associated criteria for which imaging is medically necessary are described in subsequent sections.

† A face-to-face clinical evaluation is required to have been performed within the last 60 days before advanced imaging can be considered. This may have been either the initial clinical evaluation or the clinical re-evaluation.

† The initial face-to-face clinical evaluation should include a relevant history and physical examination, appropriate laboratory studies, and non-advanced imaging modalities. Other forms of meaningful contact (e.g., telephone call, electronic mail or messaging) are not acceptable as an initial evaluation.

† Prior to advanced imaging consideration, the results of plain X-rays performed after the current episode of symptoms started or changed is required for all musculoskeletal conditions, unless otherwise noted in the guidelines.

† Clinical re-evaluation is required prior to consideration of advanced diagnostic imaging to document failure of significant clinical improvement following a recent (within 3 months) six week trial of provider-directed conservative treatment. Clinical re-evaluation can include documentation of a face-to-face encounter or documentation of other meaningful contact with the requesting provider’s office by the member (e.g. telephone call, electronic mail or messaging).

† Provider-directed conservative treatment may include rest, ice, compression, and elevation (R.I.C.E.), non-steroidal anti-inflammatories (NSAIDs), narcotic and non-narcotic analgesic medications, oral or injectable corticosteroids, viscosupplementation injections, a provider-directed home exercise program, cross-training, and/or physical/occupational therapy or immobilization by splinting/casting/bracing.

† Orthopedic specialist evaluation can be helpful in determining the need for advanced imaging.

® The need for repeat advanced imaging should be carefully considered and may not be indicated if prior imaging has been performed.
® Serial advanced imaging, whether CT or MRI, for surveillance of healing or recovery from musculoskeletal disease is not supported by the medical evidence in the majority of musculoskeletal conditions.

For this condition imaging is medically necessary based on the following criteria:

† The results of an initial plain X-ray are required prior to advanced imaging in all musculoskeletal conditions/disorders, unless otherwise noted in the guidelines, to rule out those situations that do not often require advanced imaging, such as osteoarthritis, acute/healing fracture, dislocation, osteomyelitis, acquired/congenital deformities, and tumors of bone amenable to biopsy or radiation therapy (in known metastatic disease), etc.

MS-2.2: MRI or CT

For this condition imaging is medically necessary based on the following criteria:

† Magnetic Resonance Imaging (MRI) is often the preferred advanced imaging modality in musculoskeletal conditions because it is superior in imaging the soft tissues and can also define physiological processes in some instances [e.g. edema, loss of circulation (AVN), and increased vascularity (tumors)].

† Computed Tomography (CT) is preferred for imaging cortical bone anatomy; thus, it is useful for studying complex fractures (particularly of the joints), dislocations, and assessing delayed union or non-union of fractures, if plain X-rays are equivocal. CT may be the procedure of choice in members who cannot undergo an MRI, such as those with pacemakers.

Positional MRI:
Positional MRI is also referred to as dynamic, weight-bearing or kinetic MRI. Currently,
there is inadequate scientific evidence to support the medical necessity of this study. As such, it should be considered investigational.

dGEMRIC Evaluation of Cartilage
Delayed gadolinium enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC) is a technique where an MRI estimates joint cartilage glycosaminoglycan content after penetration of the contrast agent in order to detect cartilage breakdown. Currently,
there is inadequate scientific evidence to support the medical necessity of this study. As such, it should be considered investigational for the diagnosis and surveillance of, or preoperative planning related to chondral pathology.

MS-2.3: Ultrasound

For this condition imaging is medically necessary based on the following criteria:

† Ultrasound (US) uses sound waves to produce images that can be used to evaluate a variety of musculoskeletal disorders. As with US in general, musculoskeletal US is highly operator-dependent, and proper training and experience are required to perform consistent, high quality evaluations.

MS-2.4: Contrast Issues

For this condition imaging is medically necessary based on the following criteria:

† Most musculoskeletal imaging (MRI or CT) is without contrast; however, the following examples may be considered with contrast:

® Tumors, osteomyelitis, and soft tissue infection (without and with contrast)
® MRI arthrography (with contrast only)
® MRI for rheumatoid arthritis and inflammatory arthritis (contrast as requested)
® For members with a contrast contraindication, if the advanced imaging recommendation specifically includes contrast, the corresponding advanced imaging study without contrast may be approved as an alternative, although the non-contrast study may not provide an adequate evaluation of the condition of concern.

† At the present time, there is inadequate evidence to support the medical necessity of PET for the routine assessment of musculoskeletal disorders. It should be considered investigational and will be forwarded to Medical Director Review.

® See also: MS-16: Post-Operative Joint Replacement Surgery

1. DeMuro JP, Simmons S, Smith K, et al. Utility of MRI in blunt trauma patients with a normal cervical spine CT and persistent midline neck pain on palpation. Global Journal of Surgery. 2013 Mar;1(1):4-7.. www.sciepub.com/journal/JS/articles.
2. Hsu W and Hearty TM. Radionuclide imaging in the diagnosis and management of orthopaedic disease. J Am Acad Orthop Surg. 2012 Mar;20(3):151-159. doi: 10.5435/JAAOS-20-03-151..
3. Kayser R, Mahlfeld K, and Heyde CE. Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging. Br J Sports Med. 2005 Nov;9(11):838–842. doi: 10.1136/bjsm.2005.018416.
4. Ward RJ, Weissman BN, Kransdorf MJ, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Acute hip pain-suspected fracture. Am Coll Radiol (ACR); Date of Origin: 2013. https://acsearch.acr.org/docs/3082587/Narrative/.
5. Mosher TJ, Kransdorf MJ, Adler R, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Acute trauma to the ankle. Am Coll Radiol (ACR); Date of Origin: 2013. https://acsearch.acr.org/docs/69436/Narrative/.
6. Small KM, Adler RS, Shah SH, et al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Shoulder Pain - Atraumatic. Am Coll Radiol (ACR); New 2018. https://acsearch.acr.org/docs/3101482/Narrative/.
7. Amini B, Beckmann NM, Beaman FD, et al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Shoulder Pain - Traumatic. Am Coll Radiol (ACR); Revised 2017. https://acsearch.acr.org/docs/69433/Narrative/.
8. Hayes CW, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® chronic elbow pain. Am Coll Radiol (ACR); Date of Origin:1998. Last Review:2017. https://acsearch.acr.org/docs/69423/Narrative/.
9. Wise JN, Weissman BN, Appel M, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® chronic foot pain. Am Coll Radiol (ACR); Date of Origin:1998. Last Review: 2013. https://acsearch.acr.org/docs/69424/Narrative/.
10. Mintz DN, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® chronic hip pain. Am Coll Radiol (ACR); Revised: 2016. https://acsearch.acr.org/docs/69425/Narrative/.
11. Rubin DA, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® chronic wrist pain. Am Coll Radiol (ACR); Revised: 2017. https://acsearch.acr.org/docs/69427/Narrative/.
12. Bennett DL, Nelson JW, Weissman BN, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® nontraumatic knee pain. Am Coll Radiol (ACR);1995. Last Review: 2012. https://acsearch.acr.org/docs/69432/Narrative/.
13. Murphey MD, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® osteonecrosis of the hip. Am Coll Radiol (ACR);Date of Origin: 1995. Last Review: 2015. https://acsearch.acr.org/docs/69420/Narrative/.
14. Bruno MA, Weissman BN, Kransdorf MJ, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® acute hand and wrist trauma. Am Coll Radiol (ACR); Date of Origin: 1995. Last Review: 2015. https://acsearch.acr.org/docs/69418/Narrative/.
15. Bencardino JT, Stone TJ, Roberts CC, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® stress (fatigue/insufficiency) fracture, including sacrum, excluding other vertebrae. Am Coll Radiol (ACR); Revised: 2016. https://acsearch.acr.org/docs/69435/Narrative/.
16. Luchs JS, Flug JA, Weissman BN, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® chronic ankle pain. Am Coll Radiol (ACR); Date of Origin: 1998. Last Review: 2012https://acsearch.acr.org/docs/69422/Narrative/.
17. Beaman FD, von Herrmann PF, Kransdorf MJ, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® suspected osteomyelitis, septic arthritis, or soft tissue infection (excluding spine and diabetic foot. Am Coll Radiol (ACR); Date of Origin: 2016https://acsearch.acr.org/docs/%203094201/Narrative/.
18. Kransdorf MJ, Weissman BN, Appel M, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® suspected osteomyelitis of the foot in patients with diabetes mellitus. Am Coll Radiol (ACR); Date of Origin: 1995. Last Review: 2012. https://acsearch.acr.org/docs/69340/Narrative/.
19. Zoga AC, Weissman BN, Kransdorf MJ, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® soft-tissue masses. Am Coll Radiol (ACR); Date of Origin: 1995. Last Review: 2012. https://acsearch.acr.org/docs/69434/Narrative/.
20. Morrison WB, Weissman BN, Kransdorf MJ, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® primary bone tumors. Am Coll Radiol (ACR); Date of Origin: 1995. Last Review: 2013. https://acsearch.acr.org/docs/69421/Narrative/.
21. Weissman BN, Palestro CJ, Appel M, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® imaging after total hip arthroplasty. Am Coll Radiol (ACR); Date of Origin:1998. Last Review: 2015. https://acsearch.acr.org/docs/3094200/Narrative/.
22. Hochman MG, Melenevsky YV, Metter DF, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® imaging after total knee arthroplasty. Am Coll Radiol (ACR); Revised: 2017. https://acsearch.acr.org/docs/69430/Narrative/.
23. Gyftopoulos S, Rosenberg ZS, Roberts CC, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® imaging after shoulder arthroplasty. Am Coll Radiol (ACR); Date of Origin: 2016. https://acsearch.acr.org/docs/3097049/Narrative/.
24. Patel ND, Broderick DF, Burns J, et. al. Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria^®: low back pain. Am Coll Radiol (ACR); Date of Origin:1996. Last Review: 2015. https://acsearch.acr.org/docs/69483/Narrative/.
25. Shetty VS, Reis MN, Aulino JM, et. al. Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria^®: head trauma. Am Coll Radiol (ACR); Date of Origin:1996. Last Review: 2015. https://acsearch.acr.org/docs/69481/Narrative/.
26. Li X, Yi P, Curry EJ, et al. Ultrasonography as a Diagnostic, Therapeutic, and Research Tool in Orthopaedic Surgery. J Am Acad Orthop Surg. 2018; 26:187-196.


MS-3: 3D Rendering

For this condition imaging is medically necessary based on the following criteria:

† Indications for musculoskeletal 3-D image post-processing for preoperative planning when conventional imaging is insufficient for:

® Complex fractures/dislocations (comminuted or displaced) of any joint.
® Spine fractures, pelvic/acetabulum fractures, intra-articular fractures.
® Preoperative planning for other complex surgical cases.

® 2-D reconstruction (i.e. reformatting axial images into the coronal plane) is considered part of the tomography procedure, is not separately reportable, and does not meet the definition of 3-D rendering.
® It is not appropriate to report 3-D rendering in conjunction with CTA and MRA because those procedure codes already include the post-processing.
® In addition to the term “3-D,” the following terms may also be used to describe 3-D post-processing:
¡ Maximum intensity projection (MIP)
¡ Shaded surface rendering
¡ Volume rendering

References
1. Bruno MA, Weissman BN, Kransdorf MJ, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® acute hand and wrist trauma. Am Coll Radiol (ACR); Date of Origin:1995. Last Review: 2015. https://acsearch.acr.org/docs/69418/Narrative/.

MS-4: Avascular Necrosis (AVN)/Osteonecrosis

MS-4.1: AVN

MS-4.1: AVN

For this condition imaging is medically necessary based on the following criteria:

† Classification systems use a combination of plain radiographs, MRI, and clinical features to stage avascular necrosis. MRI of the area of concern without contrast can be performed when plain X-ray findings are negative or equivocal and clinical symptoms warrant further investigation for suspected avascular necrosis.

† Advanced imaging for AVN confirmed by plain X-ray is appropriate in the following situations:

® Femoral head collapse:
¡ MRI Hip without contrast (CPT^® 73721) or CT Hip without contrast (CPT^® 73700) for preoperative planning. See: MS-24: Hip.
® Distal Femur:
¡ MRI Knee without contrast (CPT^® 73721) if needed for treatment planning. See: MS-25: Knee.
® Talus:
¡ MRI Ankle without contrast (CPT^® 73721) if needed for treatment planning. See: MS-26: Ankle.
® Tarsal navicular (Kohler Disease):
¡ MRI Foot without contrast (CPT^® 73718) if needed for treatment planning. See: MS-27: Foot.
® Humeral head:
¡ For preoperative planning prior to shoulder replacement: CT Shoulder without contrast (CPT^® 73200) and/or MRI Shoulder without contrast (CPT^® 73221). See: MS-19: Shoulder.
® Lunate (Kienbock's Disease)/Scaphoid (Preiser's Disease):
¡ CT Wrist without contrast (CPT^®73200) or MRI Wrist without contrast (CPT^® 73221). See MS-21: Wrist.

† Known or suspected osteonecrosis in long-term cancer survivors should be imaged according to guidelines in: Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-19.4: Osteonecrosis in Long Term Cancer Survivors

References
1. Calder JD, Hine AL, Pearse MF, et.al. The relationship between osteonecrosis of the proximal femur identified by MRI and lesions proven by histological examination. J Bone Joint Surg Br. 2008 Feb;90(2):154-158.
2. Karantanas AH and Drakonaki EE. The role of MR imaging in avascular necrosis of the femoral head. Semin Musculoskelet Radiol. 2011;15(3):281-300. doi: 10.1055/s-0031-1278427.
3. Karim AR, Cherian JJ, Jauregui JJ, et al. Osteonecrosis of the knee: review. Ann Transl Med. 2015 Jan;3(1).doi: 10.3978/j.issn.2305-5839.2014.11.13.
4. Mintz DN, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® chronic hip pain. Am Coll Radiol (ACR); Revised:2016. https://acsearch.acr.org/docs/69425/Narrative/.
5. Rubin DA, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® chronic wrist pain. Am Coll Radiol(ACR); Revised:2017. https://acsearch.acr.org/docs/69427/Narrative/.
6. Bennett DL, Nelson JW, Weissman BN, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® nontraumatic knee pain. Am Coll Radiol (ACR); Date of Origin:1995. Last Review:2012. https://acsearch.acr.org/docs/69432/Narrative/.
7. Murphey MD, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® osteonecrosis of the hip. Am Coll Radiol (ACR); Date of Origin:1995. Last Review: 2015. https://acsearch.acr.org/docs/69420/Narrative/.


MS-5: Fractures

MS-5.1: Acute

MS-5.2: Suspected Occult/Stress/Insufficiency Fracture/Stress Reaction and Shin Splints

MS-5.3: Other Indications

MS-5.1: Acute

For this condition imaging is medically necessary based on the following criteria:

† CT or MRI without contrast if ANY of the following:

® Complex (comminuted or displaced) fracture with or without dislocation on plain X-ray.
¡ CT is preferred unless it is associated with neoplastic disease when MRI without/with contrast is preferred unless MRI contraindicated.
® Member presents initially to the requesting provider with a documented history of an acute traumatic event at least two weeks prior with a negative plain X-ray at the time of this face-to-face encounter and a clinical suspicion for an occult/stress/insufficiency fracture see: MS-5.2: Suspected Occult/ Stress/ Insufficiency Fracture/ Stress Reaction and Shin Splints.

® Plain X-rays are negative and an osteochondral fracture is still suspected, OR
® Plain X-ray and clinical exam suggest an unstable osteochondral injury. See also MS-13.1: Chondral/ Osteochondral Lesions, Including Osteochondritis Dissecans and Fractures

For this condition imaging is medically necessary based on the following criteria:

† MRI without contrast can be performed for suspected hip/femoral neck, tibia, pelvis/sacrum, tarsal navicular, proximal fifth metatarsal, or scaphoid occult/stress/insufficiency fractures, and suspected atypical femoral shaft fractures related to bisphosphonate use if the initial evaluation of history, physical exam and plain X-ray fails to establish a definitive diagnosis.

® CT without contrast can be performed as an alternative to MRI for suspected occult/insufficiency fractures of the pelvis/hip and suspected atypical femoral shaft fractures related to bisphosphonate see: MS-23: Pelvis and MS-24: Hip, and suspected occult fractures of the scaphoid see: MS-21: Wrist.
® Tc-99m Bone scan whole body (CPT^® 78306) with SPECT of the area of interest (CPT^® 78803) is indicated for suspected fractures if MRI cannot be performed see: MS-28: Nuclear Medicine.
® Tc-99m Bone scan Foot (CPT^® 78315) is indicated for suspected occult or stress fractures of the tarsal navicular if MRI cannot be performed see: MS-27: Foot.

® Repeat plain X-rays remain non-diagnostic for fracture after a minimum of 10 days of provider-directed conservative treatment, or
® Initial plain X-rays obtained a minimum of 14 days after the onset of symptoms are non-diagnostic for fracture

® Initial plain X-ray
® Failure of a 6-week trial of provider-directed conservative treatment.

† MRI without contrast of the area of interest for stress fracture follow-up imaging for "return to play" evaluation at least 3 months after the initial imaging study for stress fracture. Any additional requests for stress fracture advanced imaging will be forwarded for Medical Director Review.

† For periprosthetic fractures related to joint replacement see: MS-16.1: Post-Operative Joint Replacement Surgery, MS-19: Shoulder, MS-20: Elbow, MS-24: Hip, MS-25: Knee, and MS-26: Ankle.

MS-5.3: Other Indications

For this condition imaging is medically necessary based on the following criteria:

† CT or MRI without contrast is appropriate after recent (within 30 days) plain X-ray if ONE of the following is present:

® Concern for delayed union or non-union of fracture or joint fusions.
® As part of preoperative evaluation for a planned surgery of a complex fracture with or without dislocation.

1. Bencardino JT, Stone TJ, Roberts CC, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae. Am Coll Radiol (ACR); Revised: 2016. https://acsearch.acr.org/docs/69435/Narrative/.
2. Mintz DN, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Chronic Hip Pain. Am Coll Radiol (ACR); Revised: 2016. https://acsearch.acr.org/docs/69425/Narrative/.
3. Bruno MA, Weissman BN, Kransdorf MJ, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Acute Hand and Wrist Trauma. Am Coll Radiol (ACR); Date of Origin: 1995. Last Review: 2015. https://acsearch.acr.org/docs/69418/Narrative/.
4. Luchs JS, Flug JA, Weissman BN, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Chronic Ankle Pain. Am Coll Radiol (ACR); Date of Origin: 1998. Last Review: 2012. https://acsearch.acr.org/docs/69422/Narrative/.
5. Ward RJ, Weissman BN, Kransdorf MJ, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Acute Hip Pain-Suspected Fracture. Am Coll Radiol (ACR); Date of Origin: 2013. https://acsearch.acr.org/docs/3082587/Narrative/.
6. Mosher TJ, Kransdorf MJ, Adler R, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Acute Trauma to the Ankle. Am Coll Radiol (ACR); Date of Origin: 2013. https://acsearch.acr.org/docs/69436/Narrative/.
7. Hayes CW, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Chronic Elbow Pain. Am Coll Radiol (ACR); Date of Origin: 1998. Last Review: 2015. https://acsearch.acr.org/docs/69423/Narrative/.
8. Wise JN, Weissman BN, Appel M, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Chronic Foot Pain. Am Coll Radiol (ACR); Date of Origin: 1998. Last Review: 2015. https://acsearch.acr.org/docs/69424/Narrative/.
9. Greene WB. Essentials of Musculoskeletal Care. 3^rd Ed.Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005;pp.568-570.
10. Galbraith RM and Lavallee ME. Medial tibial stress syndrome: conservative treatment options. Curr Rev Muscuolskelet Med. 2009;2:127-133. doi: 10.1007/s12178-009-9055-6.
11. Boks SS, Vroegindeweij D, Kroes BW, et al. MRI follow-up of posttraumatic bone bruises of the knee in general practice. AJR Am J Roentgenol. 2007;189 556-562. doi: 10.2214/AJR.07.2276.
12. Kaeding CC, Yu JR, Wright R, et al. Management and return to play of stress fractures. Clin J Sport Med. 2005;15:442-7.
13. Sormaala MJ, Niva MH, Kiuru MJ, et al. Stress injuries of the calcaneus detected with magnetic resonance imaging in military recruits. J Bone Joint Surg Am. 2006;88:2237-42. doi: 10.2106/JBJS.E.01447.
14. Shin AY, Morin WD, Gorman JD, et al. The superiority of magnetic resonance imaging in differentiating the cause of hip pain in endurance athletes. Am J Sports Med. 1996;24:168-76. doi: 10.1177/036354659602400209.
15. Slocum KA, Gorman JD, Puckett ML, et al. Resolution of abnormal MR signal intensity in patients with stress fractures of the femoral neck. AJR Am J Roentgenol. 1997;168:1295-9. doi: 10.2214/ajr.168.5.9129429.
16. Fredericson M, Bergman AG, Hoffman KL, et al. Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995 Jul-Aug;23(4):472-81. doi: 10.1177/036354659502300418.


MS-6: Foreign Body

MS-6.1: Foreign Body - General

MS-6.1: Foreign Body - General

For this condition imaging is medically necessary based on the following criteria:

† Ultrasound (CPT^® 76882) or CT without contrast or MRI without and with contrast or MRI without contrast of the area of interest can be approved after plain X-rays rule out the presence of radiopaque foreign bodies.

® Ultrasound (CPT^® 76882) is the preferred imaging modality for radiolucent (non-radiopaque) foreign bodies (e.g. wood, plastic).
® CT without contrast is recommended when plain X-rays are negative and a radiopaque foreign body is still suspected, as CT is favored over MRI for the identification of foreign bodies
® MRI without and with contrast is an alternative to US and CT for assessing the extent of infection associated with a suspected foreign body

1. Bancroft LW, Kransdorf MJ, Adler R, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Acute Trauma to the Foot. Am Coll Radiol (ACR); Date of Origin: 2010. Last Review: 2014. https://acsearch.acr.org/docs/70546/Narrative/.
2. Beaman FD, von Herrmann PF, Kransdorf MJ, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Suspected Osteomyelitis, Septic Arthritis, or Soft Tissue Infection (Excluding Spine and Diabetic Foot). Am Coll Radiol (ACR); Date of Origin: 2016. https://acsearch.acr.org/docs/%203094201/Narrative.
3. Chan C and Salam GA. Splinter removal. Am Fam Physician.2003 Jun;67(12):2557-2562.https://www.aafp.org/afp/2003/0615/p2557.html.
4. Peterson JJ, Bancroft LW, and Kransdorf MJ. Wooden foreign bodies: imaging appearance.(AJR)Am J Roentgenol. 2002;178(3):557-562. doi: 10.2214/ajr.178.3.1780557.
5. Jarraya M, Hayashi D, de Villiers RV, et al. Multimodality imaging of foreign bodies of the musculoskeletal system. (AJR) Am J Roentgenol. 2014 Jul;203(1):W92-102. doi: 10.2214/AJR.13.11743.

MS-7: Ganglion Cysts

MS-7.1: Ganglion Cysts – General

MS-7.1: Ganglion Cysts – General

For this condition imaging is medically necessary based on the following criteria:

† Plain X-ray is the initial imaging study for ganglion cysts.

† MRI without contrast or MRI without and with contrast or US (CPT^® 76882) is appropriate for occult ganglions (smaller cysts that remain hidden under the skin; suspected, but not palpable on physical examination) or cysts/masses in atypical anatomic locations.

† Advanced imaging is not indicated for ganglions that can be diagnosed by history and physical examination.

References

1. Rubin DA, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging ACR Appropriateness Criteria^® chronic wrist pain. Am Coll Radiol (ACR); Revised: 2017. https://acsearch.acr.org/docs/69427/Narrative/.
2. Rubin DA, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Soft-Tissue Masses. Am Coll Radiol (ACR); Date of Origin: 1995. Revised: 2012. https://acsearch.acr.org/docs/69434/Narrative/.
3. Freire V, Guerini H, Campagna R, et al. Imaging of hand and wrist cysts: a clinical approach. (AJR) Am J R Roentgenol. 2012 Nov;199(5):W618-W628. doi: 10.2214/AJR.11.8087.
4. Vo P, Wright T, Hayden F, Dell P, et al. Evaluating dorsal wrist pain: MRI diagnosis of occult dorsal wrist ganglion. J Hand Surg Am. 1995 Jul;20(4):667-670. doi: 10.1016/S0363-5023(05)80288-6.
5. Teefey SA, Dahiya N, Middleton WD, et al. Ganglia of the hand and wrist: a sonographic analysis. AJR Am J Roentgenol. 2008 Sept;191(3):716-720. doi: 10.2214/AJR.07.3438


MS-8: Gout/Calcium Pyrophosphate Deposition Disease [(CPPD)/ Pseudogout/ Chondrocalcinosis

MS-8.1: Gout - General

MS-8.2: CPPD (pseudogout /Chondrocalcinosis) - General

MS-8.1: Gout-General

For this condition imaging is medically necessary based on the following criteria:

† CT without contrast, MRI without contrast, or MRI without and with contrast of the area of interest is indicated when BOTH of the following are met:

® Initial plain X-ray has been performed to rule out other potential disease processes
® Infection or neoplasm is in the differential diagnosis for soft-tissue tophi.

† Early stages of gout can be diagnosed clinically since radiographic findings are not present early in the disease course.

MS-8.2: CPPD (Pseudogout/Chondrocalcinosis) - General

For this condition imaging is medically necessary based on the following criteria:

† CPPD can often be diagnosed from plain X-rays; advanced diagnostic imaging is generally not medically necessary.

References

1. Hsu CY, Shih TT, Huang KM, et al. Tophaceous gout of the spine: MR imaging features. Clin Radiol. 2002 Oct;57(10):919.
2. Schumacher HR Jr, Becker MA, Edwards NL, et al. Magnetic resonance imaging in the quantitative assessment of gouty tophi. Int J Clin Pract. 2006 Apr;60(4):408. doi: 10.1111/j.1368-5031.2006.00853.x.
3. McQueen FM, Doyle A, Reeves Q, Gao A. Bone erosions in patients with chronic gouty arthropathy are associated with tophi but not bone oedema or synovitis: new insights from a 3 T MRI study. Rheumatology. 2014 Jan;53(1):95-103. doi: 10.1093/rheumatology/ket329.
4. Dore RK. Gout: What primary care physicians want to know. J Clin Rheumatol. 2008 Oct;14(5S):S47-S54. doi: 10.1097/RHU.0b013e3181896c35.
5. Eggebeen AT. Gout: an update. Am Fam Physician. 2007 Sept;76(6):801-808. https://www.aafp.org/afp/2007/0915/p801.html.
6. Burns C and Wortmann RL. Chapter 44. Gout. In: Imboden JB, Hellmann DB, Stone JH, eds. CURRENT Diagnosis & Treatment: Rheumatology. 3rd ed. New York: McGraw-Hill; 2013.
7. Jacobson JA, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® chronic extremity joint pain-suspected inflammatory arthritis.Am Coll Radiol (ACR); 2017 May;14(5):S81-S89. http://www.jacr.org/article/S1546-1440(17)30183-7/fulltext.


MS-9: Infection/Osteomyelitis

MS-9.1: Infection – General

MS-9.2: Septic Joint

MS-9.1: Infection – General

For this condition imaging is medically necessary based on the following criteria:

† MRI without and with contrast after plain X-ray(s) and:

® Plain X-ray(s) are negative or do not suggest alternative diagnoses such as neuropathic arthropathy or fracture, and soft tissue or bone infection (osteomyelitis) is suspected; or
® Plain X-ray(s) are positive for osteomyelitis, and the extent of infection into the soft tissues and any skip lesions require evaluation.

® To assess the extent of bony destruction from osteomyelitis; CT can guide treatment decisions.
® For preoperative planning
® If MRI is contraindicated

® See: Adult Spine Imaging Policy (Policy #159 in the Radiology Section); SP-1.2: Red Flag Indications for advanced imaging guidelines
® See: MS-27: Foot for advanced imaging guidelines

For this condition imaging is medically necessary based on the following criteria:

† MRI of the joint, without and with contrast is appropriate when standard or image-guided arthrocentesis is contraindicated, unsuccessful, or non-diagnostic, and the clinical documentation satisfies ALL of the following criteria:

® History and physical examination findings [One of the following]:
¡ Development of an acutely hot and swollen joint (< 2 weeks)
¡ Decreased range of motion due to pain
¡ Documented fever
® Laboratory tests [One of the following]:
¡ Leukocytosis
¡ Elevated ESR or C-reactive protein
¡ Analysis of the joint fluid is non-diagnostic
® Plain X-ray of the joint

† CT with contrast can replace MRI without and with contrast if MRI is contraindicated.

Practice Notes

† Analysis of joint fluid is most often sufficient to diagnose a septic joint.

References

1. Coakley G, Mathews C, Field M, et al. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joints in adults. Rheumatology. 2006 Aug;45(8):1039-1041. doi: 10.1093/rheumatology/kel163a.
2. Karchevsky M, Schweitzer ME, Morrison WB, et al. MRI findings of septic arthritis and associated osteomyelitis in adults. (AJR) Am J Roentgenol. 2004 Jan;182(1):119-122. doi: 10.2214/ajr.182.1.1820119.
3. Green WB (Ed.). Essentials of Musculoskeletal Care. 3rd Ed. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, p.918.
4. Staheli LT. Fundamentals of Pediatric Orthopedics. 4th Ed. Philadelphia, Lippincott Williams & Wilkins, 2008, pp.110-111.
5. Kransdorf MJ, Weissman BN, Appel M, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® suspected osteomyelitis of the foot in patients with diabetes mellitus. Am Coll Radiol (ACR). 2012. https://acsearch.acr.org/docs/69340/Narrative/.
6. Beaman FD, von Herrmann PF, Kransdorf MJ, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® suspected osteomyelitis, septic arthritis, or soft tissue infection (excluding spine and diabetic foot). Am Coll Radiol (ACR); Date of Origin: 2016. https://acsearch.acr.org/docs/3094201/Narrative/.
7. Rubin DA, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® chronic wrist pain. Am Coll Radiol (ACR); Revised: 2017. https://acsearch.acr.org/docs/69427/Narrative/.
8. Small KM, Adler RS, Shah SH, et al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Shoulder Pain - Atraumatic. Am Coll Radiol (ACR); New 2018. https://acsearch.acr.org/docs/3101482/Narrative/.
9. Amini B, Beckmann NM, Beaman FD, et al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Shoulder Pain - Traumatic. Am Coll Radiol (ACR); Revised 2017. https://acsearch.acr.org/docs/69433/Narrative/.
10. Mintz DN, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® chronic hip pain. Am Coll Radiol (ACR); Revised: 2016. https://acsearch.acr.org/docs/69425/Narrative/.
11. Reinus WR. Clinician’s Guide to Diagnostic Imaging. 2014. Springer-Verlag New York.
12. Visconti AJ, Biddle J, and Solomon M. Follow-up imaging for vertebral osteomyelitis a teachable moment. JAMA Itern Med. 2014 Feb;174(2):184. doi: 10.1001/jamainternmed.2013.12742.
13. Fabiano V, Franchino G, Napolitano M, et. al. Utility of magnetic resonance imaging in the follow-up of children affected by acute osteomyelitis. Curr Pediatr Res. 2017;21(2):354-358. http://www.alliedacademies.org/articles/utility-of-magnetic-resonance-imaging-in-the-followup-of-children-affectedby-acute-osteomyelitis.pdf.
14. Patel ND, Broderick DF, Burns J, et. al. Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria^®: low back pain. Am Coll Radiol (ACR). 2015; https://acsearch.acr.org/docs/69483/Narrative/.


MS-10: Soft Tissue Mass or Lesion of Bone

MS-10.1: Soft Tissue Mass

MS-10.2: Lesion of Bone

MS-10.1: Soft Tissue Mass

For this condition imaging is medically necessary based on the following criteria:

† History and physical exam should include documentation of: location, size, duration, growing or stable, solid/cystic, fixed/not fixed to the bone, discrete or ill-defined, and an association with pain.

† US of the area of interest (CPT^® 76882) is appropriate for superficial or palpable soft tissue mass(es) after plain X-ray.

† MRI without and with contrast or without contrast is appropriate when EITHER of the following are met:

® Soft tissue mass(es) after plain X-ray
® Known or suspected soft tissue mass in a member with a cancer predisposition syndrome if a recent ultrasound is inconclusive. Plain X-ray is not required for these members. See: Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-2: Screening Imaging in Cancer Predisposition Syndromes

† Advanced imaging is not indicated for:

® Subcutaneous lipoma with no surgery planned
® Ganglia see: MS-7: Ganglion Cysts
® Sebaceous cyst

† Plain X-rays can determine if an advanced imaging procedure is indicated, and if so, which modality is most appropriate. If non-diagnostic, these initial plain X-rays can provide complementary information if advanced imaging is indicated.

MS-10.2: Lesion of Bone

For this condition imaging is medically necessary based on the following criteria:

† History and physical exam should include documentation of: location, size, duration, growing or stable, discrete or poorly defined, and an association with pain.

† Complete radiograph of the entire bone containing the lesion of bone is required prior to consideration of advanced imaging. Many benign bone tumors have a characteristic appearance on plain X-ray and advanced imaging is not necessary.

† MRI without and with contrast, MRI without contrast, or CT without contrast may be indicated if ONE of the following applies:

® Diagnosis uncertain based on plain X-ray appearance.
® Imaging requested for preoperative planning.

† For Paget’s Disease:

® Bone scan see: MS-28: Nuclear Medicine or MRI (contrast as requested) can be considered if the diagnosis (based on plain X-rays and laboratory studies) is in doubt
® MRI (contrast as requested) can be considered if malignant degeneration, which occurs in up to 10% of cases, is suspected.

1. Peterson JJ, Beaman FD, Fox MG, et al. ACR Practice Guideline. ACR-SSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of bone and soft tissue tumors. Am Coll Radiol. Revised 2015. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/MR-SoftTissue-Tumors.pdf.
2. Zoga AC, Weissman BN, Kransdorf MJ, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® soft-tissue masses. Am Coll Radiol (ACR); Revised 2017. https://acsearch.acr.org/docs/69434/Narrative/.
3. Hayes CW, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® chronic elbow pain. Am Coll Radiol (ACR); Revised 2015. https://acsearch.acr.org/docs/69423/Narrative/.
4. Musculoskeletal Tumor Society: Systematic Literature Review on the Use of Imaging Prior to Referral to a Musculoskeletal Oncologist. Rosemont, IL, Musculoskeletal Tumor Society, February 2018.
5. Schneider D, Hofmann MR, and Peterson JA. Diagnosis and treatment of Paget's Disease of Bone. Am Fam Physician. 2002 May;65(10):2069-2072. https://www.aafp.org/afp/2002/0515/p2069.html.
6. Theodorou DJ, Theodorou SJ, and Kakitsubata Y. Imaging of Paget Disease of bone and its musculoskeletal complications: review. (AJR)) Am J Roentgenol. 2012 Jun;196(6):S64-S75.
7. Sinha S and Peach AH. Diagnosis and management of soft tissue sarcoma. BMJ 2010 Dec;341:c7170. doi: 10.1136/bmj.c7170.
8. Wu JS and Hochman MG. Soft-Tissue Tumors and Tumorlike Lesions: A Systematic Imaging Approach. Radiology. 2009 Nov;253(2):297-316. doi: 10.1148/radiol.2532081199.


MS-11: Muscle/Tendon Unit Injuries/Diseases

MS-11.1: Muscle/Tendon Unit Injuries/Diseases

MS-11.2: Acute Compartment Syndrome

MS-11.3: Chronic Exertional Compartment Syndrome

MS-11.1: Muscle/Tendon Unit Injuries/Diseases

For this condition imaging is medically necessary based on the following criteria:

† Plain X-ray is the initial imaging study for Muscle/Tendon Unit Injuries.

† MRI without contrast or US (CPT^® 76882) is supported for EITHER of the following:

® Suspected partial tendon rupture of a specific (named) tendon
® Complete tendon ruptures for preoperative planning (for example, Achilles tendon rupture, posterior tibial tendon rupture, humeral insertion of the pectoralis major rupture, proximal and distal biceps tendon rupture, patellar ligament/tendon rupture, proximal/distal hamstring tendon rupture).

† See: MS-19: Shoulder for clinical suspicion of a partial or complete rotator cuff tear.

† See Adult Peripheral Nerve Disorders Imaging Policy (Policy #157 in the Radiology Section); PN-6.2: Inflammatory Muscle Diseases and Pediatric Musculoskeletal Imaging Policy (Policy # 164 in the Radiology Section); PEDMS-10.3: Inflammatory Muscle Diseases.

MS-11.2: Acute Compartment Syndrome

For this condition imaging is medically necessary based on the following criteria:

† Advanced imaging is not indicated. Diagnosis is made clinically and by direct measurement of compartment pressure and is a surgical emergency.

Practice Notes

† Noninvasive methods of measuring compartment pressures and diagnosing acute compartment syndrome are under study, but are currently investigational.

MS-11.3: Chronic Exertional Compartment Syndrome

For this condition imaging is medically necessary based on the following criteria:

† Advanced imaging should only be considered when ruling out other potential causes of extremity pain following a plain X-ray and conservative treatment as indicated.

Practice Notes

† Direct measurement of compartment pressure remains the diagnostic standard. Noninvasive methods of measuring compartment pressures and diagnosing chronic exertional compartment syndrome are under study, but are currently investigational.

References
1. Luchs JS, Flug JA, Weissman BN, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® chronic ankle pain. Am Coll Radiol (ACR); Date of Origin: 1998. Last Review: 2012. https://acsearch.acr.org/docs/69422/Narrative/.
2. Greene WB.Essentials of Musculoskeletal Care. 3^rd Ed. Rosemont, IL, Academy of Orthopaedic Surgeons. 2005, p.452.
3. Kayser R, Mahlfeld K, and Heyde CE. Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging. Br J Sports Med. 2005;39:838-842. doi: 10.1136/bjsm.2005.018416
4. Rominger MB, Lukosch CJ, and Bachmann GF. MR imaging of compartment syndrome of the lower leg: a case control study. Eur Radiol. 2004;14:1432-1439. doi: 10.1007/s00330-004-2305-5
5. McDonald S and Bearcroft P. Compartment syndromes. Semin Musculoskelet Radiol. 2010;14(2):236-244. doi: 10.1055/s-0030-1253164.
6. Ringler MD, Litwiller DV, Felmlee JP, et al. MRI accurately detects chronic exertional compartment syndrome: a validation study. Skeletal Radiology. 2013;42:385-392. doi: 10.1007/s00256-012-1487-1
7. van den Brand JG, Nelson T, Verleisdonk EJ, and van der Werken C. The diagnostic value of intracompartmental pressure measurement, magnetic resonance imaging, and near-infrared spectroscopy in chronic exertional compartment syndrome: a prospective study in 50 patients. Am J Sports Med. 2005;33:699-704. doi: 10.1177/0363546504270565.
8. Heer ST, Callander JW, Kraeutler MJ, Mei-Dan O, Mulcahey MK. Hamstring Injuries. The Journal of Bone and Joint Surgery. 2019;101(9):843-853. doi:10.2106/jbjs.18.00261.


MS-12: Osteoarthritis

MS-12.1: Osteoarthritis

MS-12.1: Osteoarthritis

For this condition imaging is medically necessary based on the following criteria:

† Plain X-ray is the initial imaging study for osteoarthritis.

† CT without contrast is appropriate for treatment planning when congenital or significant atypical post-traumatic arthritic deformities are present in the shoulder, elbow, wrist, hip, knee, or ankle that would require further evaluation of the clinical significance of the deformity already identified on plain X-rays.

® CT shoulder without contrast (CPT^® 73200) and/or MRI shoulder without contrast (CPT^® 73221) are considered medically necessary for preoperative planning prior to shoulder replacement

® Requests for preoperative imaging are considered not medically necessary if the surgery has been deemed investigational by the health plan

® Suspected concomitant rotator cuff tear of the shoulder - See: MS-19: Shoulder
® Suspected concomitant labral tear of the shoulder - See: MS-19: Shoulder
® Suspected concomitant labral tear of the hip - See: MS-24: Hip
® Suspected concomitant internal derangement of the knee - See: MS-25: Knee

† Refer to the Anatomic Area Tables MS-19: Shoulder, MS-20: Elbow, MS-21: Wrist, MS-24: Hip, MS-25: Knee, and MS-26: Ankle for the clinical imaging criteria regarding preoperative joint replacement surgery for each anatomic area.

† MRI knee without contrast (CPT^® 73721) is appropriate in a member with osteoarthritis for clinical suspicion of a symptomatic degenerative meniscus tear following plain X-rays and conservative treatment. See MS-25: Knee

Practice Notes
Plain X-rays are performed initially and will reveal characteristic joint space narrowing, osteophyte formation, cyst formation, and subchondral sclerosis.

References
1. Mintz DN, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Chronic Hip Pain. Am Coll Radiol (ACR); Revised: 2016. https://acsearch.acr.org/docs/69425/Narrative/.
2. Bennett DL, Nelson JW, Weissman BN, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Nontraumatic Knee Pain. Am Coll Radiol (ACR); Date of Origin: 1995. Last Review: 2012. https://acsearch.acr.org/docs/69432/Narrative/.
3. Manek NJ, Lane NE. Osteoarthritis: Current concepts in diagnosis and management. Am Fam Physician 2000 March;61(6):1795-1804. https://www.aafp.org/afp/2000/0315/p1795.html.
4. Greene WB (Ed.). Essentials of Musculoskeletal Care. 3rd Ed. Rosemont,IL, American Academy of Orthopaedic Surgeons, 2005, p. 84.
5. Quatman CE, Hettrich CM, Schmitt LC, et. al. The Clinical Utility and Diagnostic Performance of MRI for Identification of Early and Advanced Knee Osteoarthritis: A Systematic Review. Am J Sports Med. 2011 Jul;39(7):1557–1568. doi: 10.1177/0363546511407612.
6. Braun HJ and Gold GE. Diagnosis of osteoarthritis: imaging. Bone. 2012 Aug;51(2):278–288. doi: 10.1016/j.bone.2011.11.019.

MS-13: Chondral/Osteochondral Lesions

MS-13.1: Chondral/Osteochondral Lesions, Including Osteochondritis Dissecans and Fractures

MS-13.1: Chondral/Osteochondral Lesions, Including Osteochondritis Dissecans and Fractures

For this condition imaging is medically necessary based on the following criteria:

† MRI without contrast, MRI with contrast (arthrogram), or CT with contrast (arthrogram) of the area of interest is indicated when EITHER of the following are met:

® Plain X-rays are negative and an osteochondral fracture is still suspected
® Plain X-ray and clinical exam suggest an unstable osteochondral injury

† MRI without contrast or CT without contrast is indicated when healing (including post-operative fixation) cannot be adequately assessed on follow-up plain X-rays.

References

1. Bridges MD, Berland LL, Cernigliaro JG, et al. ACR Practice Guideline. ACR-SSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI). Am Coll Radiol (ACR). 2017. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/mr-perf-interpret.pdf?la=en.
2. Bennett DL, Nelson JW, Weissman BN, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Nontraumatic Knee Pain. Am Coll Radiol (ACR); 2012. https://acsearch.acr.org/docs/69432/Narrative/.
3. Rubin DA, Anderson MW, Hastreiter DM, et al. ACR Practice Guideline. ACR-SSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the elbow. Am Coll Radiol (ACR). Revised 2016. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/mr-elbow.pdf?la=en.


MS-14: Osteoporosis

For this condition imaging is medically necessary based on the following criteria:

† Plain X-ray is not required for MS-14: Osteoporosis.

† Quantitative CT (CPT^® 77078) can be approved for screening when DXA scanner is unavailable or known to be inaccurate for ANY of the following populations:

® Women age ≥65 years
® Men age >70 years
® Women age <65 years who have additional risk factors for osteoporosis based on medical history and other findings:
¡ Estrogen deficiency
¡ A history of maternal hip fracture that occurred after age 50 years
¡ Low body mass (<127 lb or 57.6 kg)
¡ History of amenorrhea (>1 year before age 42 years)
® Women age <65 years or men age <70 years who have additional risk factors:
¡ Current use of cigarettes
¡ Loss of height, thoracic kyphosis
® Individuals of any age with bone mass osteopenia or fragility fractures on imaging studies such as radiographs, CT, or MRI
® Individuals age 50 years and older who develop a wrist, hip, spine, or proximal humerus fracture with minimal or no trauma, excluding pathologic fractures
® Individuals of any age who develop 1 or more insufficiency fractures
® Premenopausal females or males age 20 to 50 years with risk factors:
¡ Individuals with medical conditions that could alter bone mineral density
■ Chronic renal failure

■ Rheumatoid arthritis and other inflammatory arthritides

■ Eating disorders, including anorexia nervosa and bulimia

■ Organ transplantation

■ Prolonged immobilization

■ Conditions associated with secondary osteoporosis, such as gastrointestinal malabsorption or malnutrition, sprue, osteomalacia, vitamin D deficiency, endometriosis, acromegaly, chronic alcoholism or established cirrhosis, and multiple myeloma

■ Individuals who have had gastric bypass for obesity

■ Individuals with an endocrine disorder known to adversely affect bone mineral density (e.g., hyperparathyroidism, hyperthyroidism, or Cushing syndrome)


¡ Individuals receiving (or expected to receive) glucocorticoid therapy for >3 months
¡ Hypogonadal men older than 18 years and men with surgically or chemotherapeutically induced castration
¡ Individuals beginning or receiving long-term therapy with medications known to adversely affect BMD (e.g. anticonvulsant drugs, androgen deprivation therapy, aromatase inhibitor therapy, or chronic heparin)

† Quantitative CT scan (CPT^® 77078) can be approved for non-screening/monitoring when DXA scanner is unavailable or known to be inaccurate for ANY of the following circumstances:

® Follow-up in cases where QCT was the original study
® Multiple healed vertebral compression fractures
® Significant scoliosis
® Advanced arthritis of the spine due to increased cortical sclerosis often with large marginal osteophytes. Obese member over the weight limit of the dual-energy X-ray absorptiometry (DXA) exam table
® Severely obese members (BMI >35kg/m2)
® Extremes in body height (i.e. very large and very small members)
® Members with extensive degenerative disease of the spine
® A clinical scenario that requires sensitivity to small changes in trabecular bone density (parathyroid hormone and glucocorticoid treatment monitoring).

References

1. American Association of Clinical Endocrinologists (AACE) Menopause Guidelines Revision Task Force. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of postmenopausal osteoporosis. Endocr Pract. 2016;22(Suppl 4):1-42. https://www.aace.com/files/postmenopausal-guidelines.pdf.
2. Coleman F, de Buer SJ, LeBoff MS, et al. National Osteoporosis Foundation (NOF). Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int. 2014;25(10):2359–2381. doi: 10.1007/s00198-014-2794-2
3. U.S. Preventive Services Task Force (USPSTF). Final Recommendation Statement

Osteoporosis: Screening. January 2011.

For this condition imaging is medically necessary based on the following criteria:

† Plain X-ray, physical exam and appropriate laboratory studies* are required prior to advanced imaging.

† MRI without contrast or MRI without and with contrast or US (CPT^® 76881 or 76882) is appropriate for the most symptomatic joint, or of the dominant hand or wrist, in ALL of the following situations:

® When diagnosis is uncertain prior to initiation of drug therapy.
® To study the effects of treatment with disease modifying anti-rheumatic drug (DMARD) therapy.
® To identify seronegative RA members that might benefit from early DMARD therapy.
® To determine change in treatment, such as:
¡ Switching from standard DMARD therapy to tumor necrosis factor (TNF) therapy.
¡ Changing to a different TNF drug therapy, then one MRI (contrast as requested) of a single joint can be performed.
¡ Addition of other treatments, including joint injections

Practice Notes

† *Examples of appropriate laboratory studies may include: Lyme titers, rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP), sedimentation rate (ESR), C-reactive protein (CRP), and antinuclear antibody (ANA)], joint fluid analysis

MS-15.2: Pigmented Villonodular Synovitis (PVNS)

For this condition imaging is medically necessary based on the following criteria:

† MRI of the affected joint without contrast, or CT of the affected joint with contrast (arthrogram) if MRI contraindicated is supported following plain X-rays.

References

1. Rubin DA, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Chronic Wrist Pain. Am Coll Radiol (ACR); Revised: 2017. https://acsearch.acr.org/docs/69427/Narrative/.
2. Luchs JS, Flug JA, Weissman BN, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Chronic Ankle Pain. Am Coll Radiol (ACR); Date of Origin: 1998. Last Review: 2012. https://acsearch.acr.org/docs/69422/Narrative/.
3. Hayes CW, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Chronic Elbow Pain. Am Coll Radiol (ACR); Date of Origin: 1998. Last Review: 2015. https://acsearch.acr.org/docs/69423/Narrative/.
4. Jacobson JA, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis. Am Coll Radiol (ACR); New: 2016. https://acsearch.acr.org/docs/3097211/Narrative/.
5. Wise JN, Weissman BN, Appel M, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Chronic Foot Pain. Am Coll Radiol (ACR); Date of Origin: 1998. Last Review: 2015. https://acsearch.acr.org/docs/69424/Narrative/.
6. Mintz DN, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Chronic Hip Pain. Am Coll Radiol (ACR); Revised: 2016. https://acsearch.acr.org/docs/69425/Narrative/.
7. Boutry N, Morel M, Flipo RM, et al. Early rheumatoid arthritis: a review of MRI and sonographic findings. AJR Am J Roentgenol. 2007;189:1502-1509. doi: 10.2214/AJR.07.2548.
8. Murphey MD, Rhee JH, Lewis RB, et al. Pigmented villonodular synovitis: radiologic-pathologic correlation. Radiographics. 2008;28:1493-1518. doi: 10.1148/rg.285085134.
9. Conaghan P, Edmonds J, Emery P, et al. Magnetic resonance imaging in rheumatoid arthritis: summary of OMERACT activities, current status, and plans. Journal of Rheumatology. 2001;28(5):1158-1161. http://www.jrheum.org/content/28/5/1158.long.
10. Ostergaard M, McQueen FM, Bird P, et al. Magnetic resonance imaging in rheumatoid arthritis--advances and research priorities. Journal of Rheumatology. 2005;32(12):2462-2464. http://www.jrheum.org/content/32/12/2462.long.
11. Mcqueen FM. The use of MRI in early RA. Rheumatology. 2008 Nov;47(11):1597-1599. doi: 10.1093/rheumatology/ken332.
12. Gossec L, Fautrel B, Pham T, et al. Structural evaluation in the management of patients with rheumatoid arthritis: development of recommendations for clinical practice based on published evidence and expert opinion. Joint Bone Spine. 2005; 72(3):229-234. doi: 10.1016/j.jbspin.2004.10.011.
13. Cohen SB, Potter H, Deodhar A, et al. Extremity magnetic resonance imaging in rheumatoid arthritis: updated literature review. Arthritis Care & Research. 2011 May;63(5):660-665. doi: 10.1002/acr.20413.
14. Singh JA, Furst DE, Bharat A, et al. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care & Research. 2012 May;64(5):625-639. doi: 10.1002/acr.21641.
15. Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis & Rheumatism (Arthritis Care & Research). 2008;59:762-784. doi: 10.1002/art.23721.


MS-16: Post-Operative Joint Replacement Surgery

MS-16.1: Post-Operative Joint Replacement Surgery - General

MS-16.1: Post-Operative Joint Replacement Surgery - General

For this condition imaging is medically necessary based on the following criteria:

† CT without contrast or bone scan (CPT^® 78315) or Distribution Of Radiopharmaceutical Agent SPECT (CPT^® 78803)* or hybrid SPECT/CT (CPT^® 78830, 78831, or 78832)* may be indicated for the evaluation of suspected aseptic loosening of orthopaedic joint replacements when recent plain X-ray is nondiagnostic.

® CT shoulder without contrast (CPT^® 73200) can be performed as additional imaging following plain X-rays regardless of plain X-ray findings. See MS-19: Shoulder

® CT shoulder without contrast (CPT^® 73200) can be performed as additional imaging following plain X-rays regardless of plain X-ray findings. See MS-19: Shoulder

® For suspected infection with negative or inconclusive joint aspiration culture see: MS-28: Nuclear Medicine

® Diagnosis of ALVAL (aseptic lymphocytic-dominated vasculitis-associated lesion) pseudotumors surrounding metal-on-metal (MoM) hip prostheses. One of these two imaging modalities can be approved but not both. See: MS-10.1: Soft Tissue Mass or Lesion of Bone
® Metal-On-Metal (MoM) Hip Prostheses that are considered high risk for implant performance issues from THA cup-neck impingement and subsequent ALTR (adverse local tissue reaction) with Co and Cr ion levels greater than 10 ppb.

† For specific joints post-operative from replacement surgery:

® See MS-19: Shoulder
® See MS-20: Elbow
® See MS-24: Hip
® See MS-25: Knee
® See MS-26: Ankle

† Complications following joint replacement surgery include (not limited to) periprosthetic fracture, infection, aseptic loosening, failure of fixation/component malpostition, and wear.

† *The usefulness of bone scan for the evaluation of suspected aseptic loosening of a shoulder replacement may be limited as bone remodeling–related increased uptake can be seen at the site of joint replacement for up to 1 year following surgery.

References

1. Mintz DN, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Chronic Hip Pain. Am Coll Radiol (ACR); Revised: 2016. https://acsearch.acr.org/docs/69425/Narrative/.
2. Hochman MG, Melenevsky YV, Metter DF, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Imaging After Total Knee Arthroplasty. Am Coll Radiol (ACR); Revised: 2017. https://acsearch.acr.org/docs/69430/Narrative/.
3. Gyftopoulos S, Rosenberg ZS, Roberts CC, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Imaging After Shoulder Arthroplasty. Am Coll Radiol (ACR); Date of Origin: 2016. https://acsearch.acr.org/docs/3097049/Narrative/.
4. Toms AD, Davidson D, Masri BA, et al. Management of peri-prosthetic infection in total joint arthroplasty. J Bone Joint Surg Br. 2006;88(2):149-155. doi: 10.1302/0301-620X.88B2.17058.
5. Love C, Marwin SE, Tomas MB, et al. Diagnosing infection in the failed joint replacement: A comparison of coincidence detection 18F-FDG and 111In-labeled leukocyte/99mTc-sulfur colloid marrow imaging. J Nucl Med. 2004;45(11):1864-1871.
6. Love C, Marwin SE, Tomas MB, et al. Diagnosing infection in the failed joint replacement. A comparison of coincidence detection 18F-FDG and 111In-Labeled leukocyte/99mTc-sulfur colloid marrow imaging. J Nucl Med. 2004;45(11):1864-1871.
7. Nawabi DH, Gold S, Lyman SL, et al. MRI predicts ALVAL and tissue damage in metal-on-metal hip arthroplasty. Clin Orthop Relat Res. 2014 Feb;472(2):471-481. doi: 10.1007/s11999-013-2788-y.
8. Verberne SJ, Raijmakers PG, and Temmerman OP. The accuracy of imaging techniques in the assessment of periprosthetic hip infection: a systematic review and meta-analysis. J Bone Joint Surg Am. 2016 Oct;98(19):1638-45. doi: 10.2106/JBJS.15.00898.


MS-17: Limb Length Discrepancy

MS-17.1: Limb Length Discrepancy

MS-17.1: Limb Length Discrepancy

For this condition imaging is medically necessary based on the following criteria:

† Requests will be sent to Medical Director Review. Either plain radiographic or “CT scanogram,” both reported with CPT^® 77073, is appropriate to radiographically evaluate limb length discrepancy due to congenital anomalies, acquired deformities, growth plate (physeal injuries or surgery), or inborn errors of metabolism.

Reference

1. Leitzes A, Potter HG, Amaral T, et. al. Reliability and accuracy of MRI scanogram in the evaluation of limb length discrepancy. J Pediatr Orthop. 2005;25(6):747-749.


MS-18: Anatomical Area Tables – General Information

For this condition imaging is medically necessary based on the following criteria:

The imaging guidelines for each anatomical area are presented in table format. The table below includes a description of how each column header should be utilized for each guideline MS-19: Shoulder through MS-27: Foot.

Condition	Plain X-Ray?	Conservative Treatment	Advanced Imaging	Comments
Member’s condition	Are the results of an initial plain X-ray required before advanced imaging can be approved? (Yes or No)	Is failure of 6 weeks of provider-directed conservative treatment within the past 12 weeks with clinical re-evaluation required? (Yes or No)	The appropriate advanced imaging indicated for this condition. In some scenarios, advanced imaging may not be indicated.	Additional comments related to the condition.

MS-19: Shoulder

For this condition imaging is medically necessary based on the following criteria:

Condition	Plain X-Ray?	Conservative Treatment	Advanced Imaging	Comments
General Shoulder Pain	Yes	Yes		† MRI shoulder without contrast (CPT® 73221) † CT shoulder with contrast (arthrogram) (CPT® 73201) if MRI contraindicated
Symptomatic Loose Bodies	Yes	No		† MRI shoulder without contrast (CPT® 73221)
Impingement	Yes	Yes		† MRI shoulder without contrast (CPT® 73221) or MRI shoulder with contrast (arthrogram) (CPT® 73222) or US shoulder (CPT® 76881 or 76882) † CT shoulder with contrast (CPT® 73201) if MRI is contraindicated
Tendonitis/ Bursitis	Yes	Yes		† MRI shoulder without contrast (CPT® 73221) or US shoulder (CPT® 76881 or 76882)
Tendon Rupture (Biceps Long Head)	Yes	No		† MRI shoulder without contrast (CPT® 73221) or US shoulder (CPT® 76881 or 76882) when clinical exam is inconclusive due to inability to visualize a “Popeye” sign clinically or for preoperative planning
Tendon Rupture (Pectoralis Major/Minor)	Yes	No		† MRI Shoulder without contrast (CPT® 73221) or MRI Chest without contrast (CPT® 71550) when clinical exam is inconclusive or for preoperative planning
Shoulder Rotator Cuff Tear (Complete and Partial)	Yes	Yes*	† MRI shoulder without contrast (CPT® 73221) or MRI shoulder with contrast (arthrogram) (CPT® 73222) or US shoulder (CPT® 76881 or 76882) † CT shoulder with contrast (arthrogram) (CPT® 73201) if MRI is contraindicated	*Conservative treatment is not required with an acute shoulder injury prior to the onset of symptoms and consideration of surgery.
Partial Tendon Rupture (Excluding Partial Rotator Cuff Tears)	Yes	No	† MRI shoulder without contrast (CPT® 73221) or US shoulder (CPT® 76881 or 76882) for a suspected partial tendon rupture of a specific named tendon not otherwise specified	MRI is NOT needed for muscle belly strains/ muscle tears.
Shoulder Labral Tear (e.g., SLAP, ALPSA, HAGL)	Yes	Yes	† MRI shoulder with contrast (arthrogram) (CPT® 73222) or MRI shoulder without contrast (CPT® 73221) or CT shoulder with contrast (arthrogram) (CPT® 73201)	For surgery criteria, see
Shoulder Dislocation/ Subluxation/ Instability, or Bankart/ Hill-Sachs Lesions	Yes	Yes*	† MRI shoulder with contrast (arthrogram) (CPT® 73222) or MRI shoulder without contrast (CPT® 73221) is medically necessary without conservative treatment in members 40 years of age or younger with a first time dislocation and in members with recurrent dislocations † CT shoulder with contrast (arthrogram) (CPT® 73201) or CT shoulder without contrast (CPT® 73200) if MRI is contraindicated	Conservative treatment is required in members over age 40 with a first time dislocation.
Frozen Shoulder/ Adhesive Capsulitis	Yes	Yes	† Advanced imaging is rarely indicated – in those rare situations, MRI shoulder without contrast (CPT® 73221)	Requests will be forwarded to Medical Director review.
Avascular Necrosis (AVN) of the Humeral Head	Yes	No	† MRI shoulder without contrast (CPT® 73221) when suspected and plain X-ray is negative or equivocal † CT shoulder without contrast (CPT® 73200) and/or MRI shoulder without contrast (CPT® 73221) for preoperative planning prior to shoulder replacement	See also MS-4.1: AVN
Acromiclavicular (AC) Separation	Yes	No		† MRI shoulder without contrast (CPT® 73221) to rule out possible rotator cuff tear following AC separation
Sternoclavicular (SC) Dislocation	Yes	No		† CT Chest without contrast (CPT® 71250) if posterior SC dislocation is evident or suspected
Post-Operative Shoulder Surgery for Impingement, Rotator Cuff Tear, and/or Labral Tear	Yes	Yes	† MRI shoulder without contrast (CPT® 73221) or MRI shoulder with contrast (arthrogram) (CPT® 73222) in symptomatic individuals † US shoulder (CPT® 76881 or 76882) is also appropriate in symptomatic individuals following rotator cuff repair † CT shoulder with contrast (arthrogram) (CPT® 73201) if MRI contraindicated	Other requests for advanced imaging will be forwarded to Medical Director Review.
Preoperative Shoulder (Glenohumeral) Replacement Surgery	Yes	Yes	† CT shoulder without contrast (CPT® 73200) and/or MRI shoulder without contrast (CPT® 73221) for preoperative planning prior to shoulder replacement	See also MS-12: Osteoarthritis
Post-Operative Shoulder (Glenohumeral) Replacement Surgery	Yes	No	† CT shoulder without contrast (CPT® 73200) for suspected aseptic loosening or fracture as additional imaging following plain X-rays † In-111 WBC (CPT® 78800, 78801, 78802, or 78803) or hybrid SPECT/CT (CPT® 78830, 78831, 78832) and Tc-99m sulfur colloid scan shoulder (CPT® 78102 or 78103) for suspected infection with negative or inconclusive joint aspiration culture (see also MS-28: Nuclear Medicine) † CT shoulder with contrast (arthrogram) (CPT® 73201) or US shoulder (CPT® 76881 or 76882) for possible rotator cuff tear † MRI shoulder without contrast (CPT® 73221) or US shoulder (CPT® 76881 or 76882) for possible nerve injury	Other requests for advanced imaging will be forwarded to Medical Director review. See also MS-16: Post-Operative Joint Replacement

References

1. Amini B, Beckmann NM, Beaman FD, et al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Shoulder Pain - Traumatic. Am Coll Radiol (ACR); Revised 2017. https://acsearch.acr.org/docs/69433/Narrative/.
2. Neviaser RJ and Neviaser TJ. Recurrent instability of the shoulder after age 40. J Shoulder Elbow Surg.1995; 4(6):416-418.
3. Bradley M, Tung G, and Green A. Overutilization of shoulder magnetic resonance imaging as a diagnostic screening tool in patients with chronic shoulder pain. J Shoulder Elbow Surgery. 2005;14(3):233-237. doi: 10.1016/j.jse.2004.08.002.
4. Fongemie AE, Buss DD, and Rolnick SJ. Management of shoulder impingement syndrome and rotator cuff tears. Am Fam Physician. 1998;57(4):667-674. https://www.aafp.org/afp/1998/0215/p667.html.
5. Greene WB. Essentials of Musculoskeletal Care. 3rd Ed.Rosemont, IL, American Academy of Orthopaedic Surgeons.2005. p.212.
6. Gyftopoulos S, Rosenberg ZS, Roberts CC, ET. Al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Imaging After Shoulder Arthroplasty. Am Coll Radiol (ACR); Date of Origin: 2016. https://acsearch.acr.org/docs/3097049/Narrative/.
7. Hovelius L, Olofsson A, Sandstrom B, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger: a prospective twenty-five year follow-up. J Bone Joint Surg. 2008;90:945-52. doi: 10.2106/JBJS.G.00070.
8. Lin A, Gasbarro G, Sakr M. Clinical Applications of Ultrasonography in the Shoulder and Elbow. J Am Acad Orthop Surg. 2018; 26:303-312.
9. Magee T. 3-T MRI of the shoulder: is MR arthrography necessary? AJR J Am Roentgenol. 2009:192:86-92. doi: 10.2214/AJR.08.1097.
10. Major NM, Browne J, Domzalski T, Cothran RL, Helms CA. Evaluation of the glenoid labrum with 3-T MRI: is intraarticular contrast necessary. AJR Am J Roentgenol. 2011;196:1139-1144. doi: 10.2214/AJR.08.1734.
11. McDonald LS, Dewing CB, Shupe PG, et al. Disorders of the proximal and distal aspects of the biceps muscle. J Bone Joint Surg. 2013;95:1235-1245. doi: 10.2106/JBJS.L.00221.
12. Petersen SA and Murphy TP. The timing of rotator cuff repair for the restoration of function. Journal of Shoulder and Elbow Surgery. 2011;20(1):62-68. doi: 10.1016/j.jse.2010.04.045.
13. Rehman A and Robinson P. Sonographic evaluation of injuries of the pectoralis muscles. AJR Am J Roentgenol. 2005;184:1205-1211. doi: 10.2214/ajr.184.4.01841205.
14. Small KM, Adler RS, Shah SH, et al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Shoulder Pain - Atraumatic. Am Coll Radiol (ACR); New 2018. https://acsearch.acr.org/docs/3101482/Narrative/.
15. Steinbach LS, Chung CB, and Yoshioka H. Technical Considerations for MRI of Upper Extremity Joints. In: Chung CB, Steinbach LS, eds. MRI of the Upper Extremity Shoulder, Elbow, Wrist and Hand Philadelphia, PA: Lippincott Williams & Wilkins 2010:211.
16. Streubel PN, Krych AJ, Simone JP, et al. Anterior glenohumeral instability: a pathology-based surgical treatment strategy. J Am Acad Orthop Surg. 2014;22:283-294. doi: 10.5435/JAAOS-22-05-283.
17. Werner BC, Brockmeier SF, and Miller MD. Etiology, diagnosis, and management of failed SLAP repair. J Am Acad Orthop Surg. 2014;22(9):554-565. doi: 10.5435/JAAOS-22-09-554.
18. Woodward TW and Best TM. The painful shoulder: Part II. Acute and chronic disorders. Am Fam Physician. 2000;61(11):3291-3300. https://www.aafp.org/afp/2000/0601/p3291.html.
19. Zappia M, Di Pietto F, Aliprandi A, et al. Multi-modal imaging of adhesive capsulitis of the shoulder. Insights Imaging. 2016;7:365-371.
20. Frankle MA, Teramoto A, Luo Z-P, Levy JC, Pupello D. Glenoid morphology in reverse shoulder arthroplasty: Classification and surgical implications. Journal of Shoulder and Elbow Surgery. 2009;18(6):874-885. doi:10.1016/j.jse.2009.02.013.


MS-20: Elbow

For this condition imaging is medically necessary based on the following criteria:

Condition	Plain X-Ray?	Conservative Treatment	Advanced Imaging	Comments
General Elbow Pain	Yes	Yes		† MRI elbow without contrast (CPT® 73221)
Symptomatic Loose Bodies	Yes	No		† MRI elbow without contrast (CPT® 73221) if effusion is present; or † MRI elbow with contrast (arthrogram) (CPT® 73222) if no effusion is present
Tendonitis	Yes	Yes		† MRI elbow without contrast (CPT® 73221) or US elbow (CPT® 76881 or 76882)
Bursitis	Yes	Yes		† MRI elbow without and with contrast (CPT® 73223) or MRI elbow without contrast (CPT® 73221) or US elbow (CPT® 76881 or 76882)
Lateral (tennis elbow) or Medial (golfer's elbow) Epicondylitis	Yes	Yes	† MRI elbow without contrast (CPT® 73221) or US elbow (CPT® 76881 or 76882) can confirm the clinical diagnosis of epicondylitis if symptoms persist for longer than 6 months in cases refractory to conservative treatment.	Epicondylitis, caused by tendon degeneration and tear of the common extensor tendon laterally or of the common flexor tendon medially, is a common clinical diagnosis for which imaging is not medically necessary except as noted. Requests will be forwarded to Medical Director review.
Suspected Osteochondral Injury	Yes	No	† MRI elbow without contrast (CPT® 73221) or MRI elbow with contrast (arthrogram) (CPT® 73222) or CT elbow with contrast (arthrogram) (CPT® 73201) if plain X-rays are negative and an osteochondral fracture is still suspected	See MS-13: Chondral/ Osteochondral Lesions
Ruptured Biceps Insertion at Elbow	Yes	No		† MRI elbow without contrast (CPT® 73221) or US elbow (CPT® 76881 or 76882) when clinical exam is inconclusive or for preoperative planning
Ruptured Triceps Insertion at Elbow	Yes	No		† MRI elbow without contrast (CPT® 73221) or US elbow (CPT® 76881 or 76882) when clinical exam is inconclusive or for preoperative planning
Partial Tendon Rupture	Yes	No	† MRI elbow without contrast (CPT® 73221) or US elbow (CPT® 76881 or 76882) for a suspected partial tendon rupture of a specific named tendon not otherwise specified	MRI is NOT needed for muscle belly strains/muscle tears.
Trauma	Yes	No		† MRI elbow without contrast (CPT® 73221) or CT elbow without contrast (CPT® 73200) when surgery is being considered
Ulnar Collateral Ligament (UCL) Tear	Yes	No		† MRI elbow with contrast (arthrogram) (CPT® 73222) or MRI elbow without contrast (CPT® 73221) or US elbow (CPT® 76881 or 76882) following acute or repetitive (including overhead throwing athletes) elbow trauma
Suspected Nerve Abnormality	Yes	Yes	† MRI elbow without contrast (CPT® 73221) or US elbow (CPT® 76881 or 76882) for surgical planning	Initial EMG/NCV is required prior to advanced imaging in accordance with Adult Peripheral Nerve Disorders Imaging Policy (Policy #157 in the Radiology Section); PN-2: Focal Neuropathy
Post-Operative	Yes	Yes	† CT elbow without contrast (CPT® 73200) in symptomatic post-operative members following surgical treatment of complex fractures; or † MRI elbow without contrast (CPT® 73221) in symptomatic post-operative members following soft-tissue surgery	Other requests for advanced imaging will be forwarded to Medical Director review.
Preoperative Elbow Replacement Surgery	Yes	Yes	† CT elbow without contrast (CPT® 73200) for preoperative planning prior to elbow replacement when congenital or post-traumatic deformities exist	See: MS-12: Osteoarthritis
Post-Operative Elbow Replacement Surgery	Yes	No	† CT elbow without contrast (CPT® 73200) for suspected aseptic loosening or periprosthetic fracture when recent plain X-ray is nondiagnostic † In-111 WBC (CPT® 78800, 78801, 78802, or 78803) or hybrid SPECT/CT (CPT® 78830, 78831, or 78832) and Tc-99m sulfur colloid scan elbow (CPT® 78102 or 78103) for suspected infection with negative or inconclusive joint aspiration culture see: MS-28: Nuclear Medicine	Other requests for advanced imaging will be forwarded to Medical Director review.

References

1. McDonald LS, Dewing CB, Shupe PG, et al. Disorders of the proximal and distal aspects of the biceps muscle. J Bone Joint Surg. 2013;95:1235-1245. doi: 10.2106/JBJS.L.00221.
2. Torp-Pedersen TE, Torp-Pedersen ST, Qvistgaard E, et al. Effect of glucocorticosteroid injections in tennis elbow verified on colour Doppler ultrasonography: evidence of inflammation. Br J Sports Med. 2008;42(12):978-982. doi: 10.1136/bjsm.2007.041285.
3. Johnson GW, Cadwallader K, Scheffel SB, et al.Treatment of lateral epicondylitis. Am Fam Physician. 2007;76(6):843-848. https://www.aafp.org/afp/2007/0915/p843.html.
4. Greene WB . Essentials of Musculoskeletal Care. 3rd Ed. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp. 279-280.
5. Hayes CW, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Chronic Elbow Pain. Am Coll Radiol (ACR); Date of Origin: 1998. Last Review: 2015. https://acsearch.acr.org/docs/69423/Narrative/.
6. Bruce JR and Andrews JR. Ulnar collateral ligament injuries in the throwing athlete. J Am Acad Orthop Surg. 2014;22:315-325.
7. Beltran J, Rosenberg ZS. Diagnosis of compressive and entrapment neuropathies of the upper extremity: value of MR imaging. AJR Am J Roentgenol. 1994;163(3):525-531. doi: 10.2214/ajr.163.3.8079837.
8. Lin A, Gasbarro G, Sakr M. Clinical Applications of Ultrasonography in the Shoulder and Elbow. J Am Acad Orthop Surg. 2018; 26:303-312.

MS-21: Wrist

For this condition imaging is medically necessary based on the following criteria:

Condition	Plain X-Ray?	Conservative Treatment	Advanced Imaging	Comments
General Wrist Pain	Yes	Yes		† MRI wrist without contrast (CPT® 73221)
Tendonitis	Yes	Yes		† MRI wrist without contrast (CPT® 73221) or US wrist (CPT® 76881 or 76882)
Kienbock’s Disease (Avascular Necrosis (AVN) of the Lunate)/ Preiser's Disease (Avascular Necrosis (AVN) of the Scaphoid)	Yes	No	† MRI wrist without contrast (CPT® 73221) when suspected and plain X-ray is negative or equivocal † If diagnosed on plain X-ray, CT wrist without contrast (CPT® 73200) or MRI wrist without contrast (CPT® 73221)	See also MS-4.1: AVN
Suspected Navicular/ Scaphoid Fracture	Yes	No	† MRI wrist without contrast (CPT® 73221) or CT wrist without contrast (CPT® 73200) when suspected based on history and physical exam	See also MS-5.2: Suspected Occult/ Stress/ Insufficiency Fracture/ Stress Reaction and Shin Splints
Distal Radioulnar Joint (DRUJ) Instability	Yes	No		† CT of both wrists without contrast (CPT® 73200) (should include wrists in supination and pronation)
Complex Distal Radius/ Ulna Fracture	Yes	No		† CT wrist without contrast (CPT® 73200)
Carpal Tunnel Syndrome/ Ulnar Tunnel Syndrome	Yes	No	† MRI wrist without contrast (CPT® 73221) or US wrist (CPT® 76881 or 76882) for surgical planning	Initial EMG/NCV is required prior to advanced imaging in accordance with Adult Peripheral Nerve Disorders Imaging Policy (Policy #157 in the Radiology Section); PN-2: Focal Neuropathy
Intrinsic Ligament (e.g. scapholunate)/ Triangular Fibrocartilage Complex (TFCC) Injuries	Yes	Yes		† MRI wrist with contrast (arthrogram) (CPT® 73222) or CT wrist with contrast (arthrogram) (CPT® 73201)
Complete Rupture of a Specific Named Tendon Not Otherwise Specified	Yes	No		† MRI wrist without contrast (CPT® 73221) or US wrist (CPT® 76881 or 76882) for preoperative planning
Partial Tendon Rupture	Yes	No	† MRI wrist without contrast (CPT® 73221) or US wrist (CPT® 76882) for a suspected partial tendon rupture of a specific named tendon not otherwise specified	MRI is NOT needed for muscle belly strains/muscle tears.
Post-Operative	Yes	Yes	† CT wrist without contrast (CPT® 73200) in symptomatic members following surgery for navicular/scaphoid fractures and complex distal radius/ulna fractures; or † MRI wrist with contrast (arthrogram) (CPT® 73222) in symptomatic members following DRUJ or TFCC surgery	Other requests for advanced imaging will be forwarded to Medical Director review.
Preoperative Wrist Replacement Surgery	Yes	Yes	† CT wrist without contrast (CPT® 73200) for preoperative planning prior to wrist replacement when congenital or post-traumatic deformities exist	See: MS-12: Osteoarthritis
Post- Operative Wrist Replacement Surgery	Yes	No	† CT wrist without contrast (CPT® 73200) for suspected aseptic loosening or periprosthetic fracture when recent plain X-ray is nondiagnostic † In-111 WBC (CPT® 78800, 78801, 78802, or 78803) or hybrid SPECT/CT (CPT® 78830, 78831, or 78832) and Tc-99m sulfur colloid scan wrist (CPT® 78102 or 78103) for suspected infection with negative or inconclusive joint aspiration culture see: MS-28: Nuclear Medicine	Other requests for advanced imaging will be forwarded to Medical Director review.

References

1. Bruno MA, Weissman BN, Kransdorf MJ, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Acute Hand and Wrist Trauma. Am Coll Radiol (ACR); Date of Origin: 1995. Last Review: 2013. https://acsearch.acr.org/docs/69418/Narrative/.
2. Rubin DA, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Chronic Wrist Pain. Am Coll Radiol (ACR); Revised: 2017. https://acsearch.acr.org/docs/69427/Narrative/.
3. Hayter CL, Gold SL, and Potter HG. Magnetic resonance imaging of the wrist: bone and cartilage injury. J Magn Reson Imaging. 2013;37(5):1005-19. doi: 10.1002/jmri.23845.
4. Pruitt DL, Gilula LA, Manske PR, et al. Computed tomography scanning with image reconstruction in evaluation of distal radius fractures. J Hand Surg Am.1994;19(5):720-727. doi: 10.1016/0363-5023(94)90174-0.
5. Magee T. Comparison of 3-T MRI and arthroscopy of intrinsic wrist ligament and TFCC tears. AJR Am J Roentgenol. 2009:192:80-85. doi: 10.2214/AJR.08.1089.
6. Lee RK, Ng AW, Tong CS, et al. Intrinsic ligament and triangular fibrocartilage complex tears of the wrist: comparison of MDCT arthrography, conventional 3-T MRI, and MR arthrography. Skeletal Radiol. 2013;42:1277-85. doi: 10.1007/s00256-013-1666-8.
7. Pahwa S, Srivastava DN, Sharma R, et al. Comparison of conventional MRI and MR arthrography in the evaluation wrist ligament tears: A preliminary experience. Indian J Radiol Imaging. 2014;3:259-67. doi: 10.4103/0971-3026.137038.


MS-22: Hand

For this condition imaging is medically necessary based on the following criteria:

Condition	Plain X-Ray?	Conservative Treatment	Advanced Imaging	Comments
General Hand Pain	Yes	Yes		† MRI hand or finger without contrast (CPT® 73218)
Tendonitis	Yes	Yes		† MRI hand or finger without contrast (CPT® 73218) or US hand or finger (CPT® 76881 or 76882)
Occult Fracture	Yes	No		† Advanced imaging guided by MS-5.2: Suspected Occult/ Stress/ Insufficiency Fracture/ Stress Reaction and Shin Splints
Complex Fracture	Yes	No		† CT hand or finger without contrast (CPT® 73200) when plain X-ray shows a complex fracture
Ulnar Collateral Ligament (UCL) Thumb Injury	Yes	No	† MRI thumb without contrast (CPT® 73218) or US thumb (CPT® 76881 or 76882) if rule out for Stener lesion or complete tear of UCL of the thumb MCP joint	Also called “Gamekeeper’s Thumb” or “Skier’s Thumb”
Complete Rupture of a Specific Named Tendon not Otherwise Specified	Yes	No		† MRI hand or finger without contrast (CPT® 73218) or US hand or finger (CPT® 76881 or 76882) for preoperative planning
Partial Tendon Rupture	Yes	No	† MRI hand or finger without contrast (CPT® 73218) or US hand or finger (CPT® 76882) for a suspected partial tendon rupture of a specific named tendon not otherwise specified	MRI is NOT needed for muscle belly strains/muscle tears.
Post-Operative	Yes	Yes	† CT hand or finger without contrast (CPT® 73200) or MRI hand or finger without contrast (CPT® 73218) in symptomatic post-operative members following surgical treatment for complex hand or finger fractures or following soft-tissue surgery	Other requests for advanced imaging will be forwarded to Medical Director review.

References

1. Bruno MA, Weissman BN, Kransdorf MJ, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Acute Hand and Wrist Trauma. Am Coll Radiol (ACR); Date of Origin: 1995. Last Review: 2013. https://acsearch.acr.org/docs/69418/Narrative/.
2. Hayter CL, Gold SL, and Potter HG. Magnetic resonance imaging of the wrist: Bone and cartilage injury. J Magn Reson Imaging. 2013 Dec;37(5):1005-19. doi: 10.1002/jmri.23845.


MS-23: Pelvis

For this condition imaging is medically necessary based on the following criteria:

Condition	Plain X-Ray?	Conservative Treatment	Advanced Imaging	Comments
General Pain-Pelvis	Yes	Yes		† MRI pelvis without contrast (CPT® 72195); or † MRI RT and/or LT hip without contrast (CPT® 73721)
Tendonitis	Yes	Yes		† MRI pelvis without contrast (CPT® 72195); or † MRI RT and/or LT hip without contrast (CPT® 73721)
Occult/ Insufficiency Fracture	Yes	No	† MRI pelvis without contrast (CPT® 72195) or CT pelvis without contrast (CPT® 72192)	See also MS-5.2: Suspected Occult/ Stress/ Insufficiency Fracture/ Stress Reaction and Shin Splints for occult and stress fractures of the pelvis
Complex Fracture/ Dislocation - Pelvis, Sacrum and Acetabulum	Yes	No	† CT pelvis without contrast (CPT® 72192)	Additionally, 3D rendering may be appropriate for preoperative planning. See also MS-3: 3D Rendering
Sacro-iliac (SI) Joint Pain, Sacroiliitis, Coccydynia	Yes	Yes		† Advanced imaging guided by: SP-10.1: Sacroiliac (SI) Joint Pain/ Sacroiliitis and SP-5.2: Coccydynia without Neurological Features
Complete Rupture of a Specific Named Tendon	Yes	No		† MRI pelvis without contrast (CPT® 72195) for preoperative planning
Partial Tendon Rupture	Yes	No	† MRI Pelvis without contrast (CPT® 72195) for a suspected partial tendon rupture of a specific named tendon not otherwise specified	MRI is NOT needed for muscle belly strains/muscle tears.
Osteitis Pubis/ Symphysis Pubis Diastasis	Yes	Yes		† MRI pelvis without contrast (CPT® 72195)
Athletic Pubalgia (Sports Hernia)	Yes	Yes		† MRI pelvis without contrast (athletic pubalgia protocol) (CPT® 72195) or dynamic pelvic ultrasound (CPT® 76857) are appropriate to evaluate for the cause of suspected athletic pubalgia.
Post-Operative	Yes	Yes	† CT pelvis without contrast (CPT® 72192) in symptomatic members following surgery for complex pelvic ring/acetabular fractures	Other requests for advanced imaging will be forwarded to Medical Director review.

References

1. Bencardino JT, Stone TJ, Roberts CC, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae. Am Coll Radiol (ACR); Revised: 2016. https://acsearch.acr.org/docs/69435/Narrative/.
2. Mehta S, Auerbach JD, Born CT, et al. Sacral fractures. J Am Acad Orthop Surg. 2006;14:656-665.
3. Omar IM, Zoga AC, Kavanagh EC, et al. Athletic Pubalgia and "Sports Hernia": Optimal MR Imaging Technique and Findings. RadioGraphics. 2008;28:1415-1438. doi: 10.1148/rg.285075217.
4. Khan W, Zoga AC, and Meyers WC. Magnetic Resonance Imaging of Athletic Pubalgia and the Sports Hernia - Current Understanding and Practice. Magn Reson Imaging Clin N Am. 2013;21:97-110. doi: 10.1016/j.mric.2012.09.008.
5. Morley N, Grant T, Blount K, et al. Sonographic evaluation of athletic pubalgia. Skeletal Radiol. 2016 May;45(5):689-99. doi: 10.1007/s00256-016-2340-8.
6. Caudill P, Nyland J, Smith C, et al. Sports hernias: a systematic literature review. British Journal of Sports Medicine. 2008;42(12):954-964. doi: 10.1136/bjsm.2008.047373.
7. Suarez JC, Ely EE, Mutnal AB, et al. Comprehensive approach to the evaluation of groin pain. Journal of the American Academy of Orthopaedic Surgeons. 2013;21:558-570. doi: 10.5435/JAAOS-21-09-558.
8. Heer ST, Callander JW, Kraeutler MJ, Mei-Dan O, Mulcahey MK. Hamstring Injuries. The Journal of Bone and Joint Surgery. 2019;101(9):843-853. doi:10.2106/jbjs.18.00261.

MS-24: Hip

For this condition imaging is medically necessary based on the following criteria:

Condition	Plain X-Ray?	Conservative Treatment	Advanced Imaging	Comments
General Hip Pain	Yes	Yes		† MRI hip without contrast (CPT® 73721)
Symptomatic Loose Bodies	Yes	No		† MRI hip without contrast (CPT® 73721)
Tendonitis/ Bursitis	Yes	Yes		† MRI hip without contrast (CPT® 73721) or US hip (CPT® 76881 or 76882)
Hip Abductor Tendon Tear/ Avulsion	Yes	No		† MRI hip without contrast (CPT® 73721) or US hip (CPT® 76881 or 76882)
Complete Rupture of a Specific Named Tendon	Yes	No		† MRI hip without contrast (CPT® 73721) or US hip (CPT® 76881 or 76882) for preoperative planning
Partial Tendon Rupture	Yes	No	† MRI hip without contrast (CPT® 73721) or US hip (CPT® 76881 or 76882) for a suspected partial tendon rupture of a specific named tendon not otherwise specified	MRI is NOT needed for muscle belly strains/ muscle tears.
Occult/ Insufficiency Fracture	Yes	No	† MRI hip without contrast (CPT® 73721) or CT hip without contrast (CPT® 73700)	See also MS-5.2: Suspected Occult/ Stress/ Insufficiency Fracture/ Stress Reaction and Shin Splints for occult and stress fractures of the hip
Avascular Necrosis (AVN) of the Femoral Head	Yes	No	† MRI hip without contrast (CPT® 73721) when suspected and plain X-ray is negative or equivocal † MRI hip without contrast (CPT® 73721) or CT hip without contrast (CPT® 73700) with femoral head collapse for preoperative planning	See also MS-4.1: AVN
Labral Tear	Yes	Yes	† MRI hip with contrast (arthrogram) (CPT® 73722) or CT hip with contrast (arthrogram) (CPT® 73701) or MRI hip without contrast (CPT® 73721)
Femoroacetabular Impingement	Yes	Yes	† MRI hip without contrast (CPT® 73721) or MRI hip with contrast (arthrogram) (CPT® 73722) in addition to CT hip without contrast (CPT® 73700) or CT pelvis without contrast (CPT® 72192) for preoperative planning for femoroacetabular impingement
Piriformis Syndrome	Yes	Yes	† MRI pelvis without contrast (CPT® 72195) or CT pelvis without contrast (CPT® 72192) for preoperative planning	EMG/NCV may confirm the diagnosis. Refer to PN-2: Focal Neuropathy
Post-Operative	Yes	Yes	† MRI hip with contrast (arthrogram) (CPT® 73722) in symptomatic members following surgery for labral tears and femoroacetabular impingement † CT hip without contrast (CPT® 73700) or MRI hip without contrast (CPT® 73721) in symptomatic members following surgery for hip fracture and/or hip avascular necrosis	Other requests for advanced imaging will be forwarded to Medical Director review.
Preoperative Hip Replacement Surgery	Yes	Yes	† CT hip without contrast (CPT® 73700) for preoperative planning prior to hip replacement when congenital or post-traumatic deformities exist	See also MS-12: Osteoarthritis

Coding Notes

® Unilateral hip MRI is reported as CPT^® 73721.
® Bilateral hip MRI can be identified in several different ways on the claim.
¡ Horizon BCBSNJ will approve two separate codes (CPT^® 73721 x 2) with RT and LT modifiers.
¡ However, providers are urged to check for individual payer preferences regarding bilateral modifier use.

1. Greene WB (Ed.). Essentials of Musculoskeletal Care. 2nd Ed. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2001.
2. Manek NJ and Lane NE. Osteoarthritis: Current concepts in diagnosis and management. Am Fam Physician. 2000;61(6):1795-1804. https://www.aafp.org/afp/2000/0315/p1795.html.
3. Papadoupoulos EC and Kahn SN. Piriformis syndrome and low back pain: a new classification and review of the literature. Orthop Clin North Am. 2004 Jan;35(1):65-71. doi: 10.1016/S0030-5898(03)00105-6.
4. Reurink G, Sebastian, Bisselink JM, et al. Reliability and Validity of Diagnostic Acetabular Labral Lesions with Magnetic Resonance Arthrography. J Bone Joint Surg A.. 2012;94(181):1643-1648. doi: 10.2106/JBJS.K.01342.
5. Steinbach LS, Palmer WE, and Schweitzer ME. Special Focus Session MR Arthrography1. RadioGraphics.2002;22(5):1223-1246.
6. Redmond JM, Chen AW, and Domb BG. Greater Trochanteric Pain Syndrome. J Am Acad Orthop Surg. 2016;24(4):231-240. doi: 10.5435/JAAOS-D-14-00406.
7. Center for Devices and Radiological Health. Metal-on-Metal Hip Implants - Information for Orthopaedic Surgeons. U S Food and Drug Administration Home Page.
8. Ward RJ, Weissman BN, Kransdorf MJ, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Acute Hip Pain-Suspected Fracture. Am Coll Radiol (ACR); Date of Origin: 2013. https://acsearch.acr.org/docs/3082587/Narrative/.
9. Weissman BN, Palestro CJ, Appel M, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Imaging After Total Hip Arthroplasty. Am Coll Radiol (ACR); Date of Origin: 1998. Last Review: 2015. https://acsearch.acr.org/docs/3094200/Narrative/.
10. Mintz DN, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Chronic Hip Pain. Am Coll Radiol (ACR); Revised: 2016. https://acsearch.acr.org/docs/69425/Narrative/.
11. Murphey MD, Roberts CC, Bencardino JT, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Osteonecrosis of the Hip. Am Coll Radiol (ACR); Date of Origin: 1995. Last Review: 2015. https://acsearch.acr.org/docs/69420/Narrative/.
12. Bencardino JT, Stone TJ, Roberts CC, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae. Am Coll Radiol (ACR); Revised: 2016. https://acsearch.acr.org/docs/69435/Narrative/.
13. Verberne SJ, Raijmakers PG, and Temmerman OP. The Accuracy of Imaging Techniques in the Assessment of Periprosthetic Hip Infection. A Systematic Review and Meta-Analysis. J Bone Joint Surg Am. 2016;98(19):1638-45. doi: 10.2106/JBJS.15.00898.
14. Shin AY, Morin WD, Gorman JD, et al. The superiority of magnetic resonance imaging in differentiating the cause of hip pain in endurance athletes. Am J Sports Med. 1996;24:168-76. doi: 10.1177/036354659602400209.
15. Slocum KA, Gorman JD, Puckett ML, et al. Resolution of abnormal MR signal intensity in patients with stress fractures of the femoral neck. AJR Am J Roentgenol. 1997;168:1295-9. doi: 10.2214/ajr.168.5.9129429.
16. Lee EY, Margherita AJ, Gierada DS, et al. MRI of Piriformis Syndrome. American Journal of Roentgenology. 2004;183:63-64. doi: 10.2214/ajr.183.1.1830063.
17. Jankiewicz JJ, Hennrikus WL, and Houkom JA. The appearance of the piriformis muscle syndrome in computed tomography and magnetic resonance imaging: a case report and review of the literature. Clin Orthop 1991;262:205-09. .
18. Rossi P, Cardinali P, Serrao M, et al.. Magnetic resonance imaging findings in piriformis syndrome: a case report. Arch Phys Med Rehabil 2001;82(4):519-21. doi: 10.1053/apmr.2001.21971.
19. Heer ST, Callander JW, Kraeutler MJ, Mei-Dan O, Mulcahey MK. Hamstring Injuries. The Journal of Bone and Joint Surgery. 2019;101(9):843-853. doi:10.2106/jbjs.18.00261.

MS-25: Knee

For this condition imaging is medically necessary based on the following criteria:

Condition	Plain X-Ray?	Conservative Treatment	Advanced Imaging	Comments
General Knee Pain	Yes	Yes		† MRI knee without contrast (CPT® 73721)
Symptomatic Loose Bodies	Yes	No		† MRI knee without contrast (CPT® 73721) † CT knee with contrast (arthrogram) (CPT® 73701) if MRI cannot be performed
Tendonitis	Yes	Yes		† MRI knee without contrast (CPT® 73721) or US knee (CPT® 76881 or 76882)
Complex Knee Fracture	Yes	No	† CT knee without contrast (CPT® 73700)	See: MS-5: Fractures
Meniscus Tear	Yes	Yes*	† MRI knee without contrast (CPT® 73721) *Conservative treatment is not required if at least 2 of following 4 criteria are met: 1) Positive McMurray’s or positive Thessaly test 2) twisting or acute injury of the knee 3) locked knee/inability to fully extend the knee 4) knee effusion † MRI knee without contrast (CPT® 73721) for clinical suspicion of a symptomatic degenerative meniscus tear in a member with osteoarthritis following conservative treatment
Ligament Tear	Yes	Yes*	† MRI knee without contrast (CPT® 73721) *Conservative treatment is not required if any of the following signs are positive in comparison to the normal knee: ® Anterior drawer ® Lachman ® Pivot shift ® Posterior drawer ® Posterior sag ® Valgus stress ® Varus stress
Knee Joint Dislocation	Yes	No		† MRI knee without contrast (CPT® 73721) and MRA knee without and with contrast (CPT® 73725) following significant trauma to evaluate for ligament and vascular injury
Patellar Dislocation/ Subluxation	Yes	No	† MRI knee without contrast (CPT® 73721) with acute knee injury, consideration of surgery and concern for osteochondral fracture or loose osteochondral fracture fragment
Recurrent Patellar Instability	Yes	Yes	† MRI knee without contrast (CPT® 73721) if consideration for surgery
Patellofemoral Pain Syndrome/ Anterior Knee Pain/ Tracking Disorder	Yes	Yes		† MRI knee without contrast (CPT® 73721) if consideration for surgery
Suspected Osteochondral Injury	Yes	No	† MRI knee without contrast (CPT® 73721) or MRI knee with contrast (arthrogram) (CPT® 73722) or CT knee with contrast (arthrogram) (CPT® 73701) if plain X-rays are negative and an osteochondral fracture is still suspected	See MS-13: Chondral Osteochondral Lesions for other osteochondral injury scenarios.
Avascular Necrosis (AVN) of the Distal Femur	Yes	No	† MRI knee without contrast (CPT® 73721) when suspected and plain X-ray is negative or equivocal or with AVN confirmed by plain X-ray if needed for treatment planning	See: MS-4.1: Avascular Necrosis
Baker’s Cyst (Popliteal Cyst)	Yes	Yes	† US knee (CPT® 76882) is the initial imaging study † MRI knee without contrast (CPT® 73721) for preoperative planning	See also Adult Peripheral Vascular Disease Imaging Policy (Policy #158 in the Radiology Section); PVD-12: Acute Limb Swelling
Plica (Sympomatic Synovial Plica/ Medial Synovial Shelf)	Yes	Yes		† MRI knee without contrast (CPT® 73721)
Hemarthrosis	Yes	No		† MRI knee without contrast (CPT® 73721) for clinical suspicion of cruciate ligament tear (requires a positive objective sign for ACL/PCL tear) or patellar dislocation (requires a positive apprehension sign) † CT knee without contrast (CPT® 73700) for clinical suspicion of non-displaced intra-articular fracture
Complete Rupture of the Distal Quadriceps Tendon or Patellar Ligament/ Tendon	Yes	No		† MRI knee without contrast (CPT® 73721) or US knee (CPT® 76882) for preoperative planning
Partial Tendon Rupture	Yes	No	† MRI knee without contrast (CPT® 73721) or US knee (CPT® 76882) for a suspected partial tendon rupture of a specific named tendon not otherwise specified	MRI is NOT needed for muscle belly strains/ muscle tears.
Post-Operative	Yes	Yes	† MRI knee with contrast (arthrogram) (CPT® 73722) or MRI knee without contrast (CPT® 73721) in symptomatic members following surgery for meniscus tears and reconstruction of the anterior cruciate ligament † CT knee without contrast (CPT® 73700) in symptomatic members following surgery for fracture/dislocation	Other requests for advanced imaging will be forwarded to Medical Director review.
Preoperative Knee Replacement Surgery	Yes	Yes	† CT knee without contrast (CPT® 73700) for preoperative planning prior to knee replacement when congenital or post-traumatic deformities exist of the patella, distal femur and/or proximal tibia	See also MS-12: Osteoarthritis
Post-Operative Knee Replacement Surgery	Yes	No*	† CT knee without contrast (CPT® 73700) or bone scan (CPT® 78315 78803) or hybrid SPECT/CT (CPT® 78830, 78831, or 78832) for suspected aseptic loosening when recent plain X-ray is nondiagnostic † Tc-99m 3-phase bone scan (CPT® 78315) and In-111 WBC scan knee (CPT® 78800, 78801, 78802, or 78803) or In-111 WBC (CPT® 78800-78803) or hybrid SPECT/CT (CPT® 78830, 78831, or 78832) and Tc-99m sulfur colloid scan knee (CPT® 78102 or 78103) for suspected infection with negative or inconclusive joint aspiration culture (see MS-28: Nuclear Medicine) † CT knee without contrast (CPT® 73700) following plain X-ray for suspected periprosthetic fracture † CT knee without contrast (CPT® 73700) or MRI knee without contrast (CPT® 73721) for suspected osteolysis or component instability, rotation, or wear; † MRI knee without contrast (CPT® 73721) or US knee (CPT® 76881 or 76882) for suspected periprosthetic soft tissue abnormality unrelated to infection (e.g., tendinopathy, arthrofibrosis, patellar clunk syndrome, impingement of nerves or other soft tissue) *requires conservative treatment.	Other requests for advanced imaging will be forwarded to Medical Director review. See also MS-16: Post-Operative Joint Replacement Surgery

References

1. Harrison BK, Abell BE, Gibson TW. The Thessaly test for detection of meniscal tears: validation of a new physical examination technique for primary care medicine. Clin J Sport Med. 2009;19:9-12. doi: 10.1097/JSM.0b013e31818f1689.
2. Landewé RBM, Günther KP, Lukas C, et al. EULAR/EFFORT recommendations for the diagnosis and initial management of patients with acute or recent onset swelling of the knee. Ann Rheum Dis. 2010;69:12-19. doi: 10.1136/ard.2008.104406.
3. Johnson MW. Acute knee effusions: a systematic approach to diagnosis. Am Fam Physician. 2000;61(8):2391-2400. https://www.aafp.org/afp/2000/0415/p2391.html.
4. ACR Appropriateness Criteria, Nontraumatic knee pain, 2008.
5. Sung-Jae Kim, Byoung-Yoon Hwang, Choi DH, et al. J Bone Joint Surg A. 2012;94(16):e118 1-7.
6. Kannus P and Järvinen M. Nonoperative treatment of acute knee ligament injuries. A review with special reference to indications and methods. Sports Med.1990;9(4):244-260. doi: 10.2165/00007256-199009040-00005.
7. Manek NJ and Lane NE. Osteoarthritis: Current concepts in diagnosis and management. Am Fam Physician. 2000;61(6):1795-1804. https://www.aafp.org/afp/2000/0315/p1795.html.
8. Greene WB (Ed.). Essentials of Musculoskeletal Care. 3rd Ed. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, p.84; 541-545.
9. Lee IS, Choi JA, Kim TK, et al. Reliability analysis of 16-MDCT in preoperative evaluation of total knee arthroplasty and comparison with intraoperative measurements. Am J Roentgenol. 2006;186(6):1778-1782. doi: 10.2214/AJR.05.1191.
10. Morrissey RT, Weinstein SL (Eds.). Lovell and Winter’s Pediatric Orthopaedics. 6th Ed. Philadelphia, Lippinortt Williams and Wilkins, p.1413.
11. Woolson ST, Harris AHS, Wagner DW, et al; Component alignment during total knee arthroplasty with use of standard or custom instrumentation: A Randomized Clinical Trial Using Computed Tomography for Postoperative Alignment Measurement. Journal of Bone and Joint Surgery. 2014;96:366-372. doi: 10.2106/JBJS.L.01722.
12. Vance K, Meredick R, Schweitzer ME, et al. Magnetic resonance imaging of the postoperative meniscus. Arthroscopy. 2009;25:522-30. doi: 10.1016/j.arthro.2008.08.013.
13. Magee T, Shapiro M, and Williams D. Prevalence of meniscal radial tears of the knee revealed by MRI after surgery. Am J Roentgenol. 2004;184:931-936. doi: 10.2214/ajr.182.4.1820931.
14. Meyers AB, Haims AH, Menn K, et al. Imaging of anterior cruciate ligament repair and its complications. Am J Roentgenol. 2010;194:476-484. doi: 10.2214/AJR.09.3200.
15. Tuite, MJ, Kransdorf MJ, Beaman FD, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Acute Trauma to the Knee. Am Coll Radiol (ACR); Date of Origin: 1998. Last Review: 2014. https://acsearch.acr.org/docs/69419/Narrative. .
16. Bennett DL, Nelson JW, Weissman BN, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Nontraumatic Knee Pain. Am Coll Radiol (ACR); Date of Origin: 1995. Last Review: 2012. https://acsearch.acr.org/docs/69432/Narrative/.
17. Zoga AC, Weissman BN, Kransdorf MJ, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Soft-Tissue Masses. Am Coll Radiol (ACR); Date of Origin: 1995. Last Review: 2012. https://acsearch.acr.org/docs/69434/Narrative/.
18. Hochman MG, Melenevsky YV, Metter DF, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Imaging After Total Knee Arthroplasty. Am Coll Radiol (ACR); Revised: 2017. Available at: https://acsearch.acr.org/docs/69430/Narrative/.


MS-26: Ankle

For this condition imaging is medically necessary based on the following criteria:

Condition	Plain X-Ray?	Conservative Treatment	Advanced Imaging	Comments
General Ankle Pain	Yes	Yes		† MRI ankle without contrast (CPT® 73721)
Symptomatic Loose Bodies	Yes	No		† MRI ankle without contrast (CPT® 73721)
Complex Fracture	Yes	No		† CT ankle without contrast (CPT® 73700)
Ankle Sprain, Including Avulsion Fracture	Yes	Yes		† MRI ankle without contrast (CPT® 73721) or CT without contrast (CPT® 73700)
High Ankle Sprain (Syndesmosis Injury)	Yes	No		† MRI ankle without contrast (CPT® 73721)
Suspected Osteochondral Injury	Yes	No	† MRI ankle without contrast (CPT® 73721) or MRI ankle with contrast (arthrogram) (CPT® 73722) or CT ankle with contrast (arthrogram) (CPT® 73701) if plain X-rays are negative and an osteochondral fracture is still suspected	See MS-13: Chondral/ Osteochondral Lesions for other osteochondral injury scenarios
Avascular Necrosis (AVN) of the Talus	Yes	No	† MRI ankle without contrast (CPT® 73721) when suspected and plain X-ray is negative or equivocal or with plain X-ray-confirmed AVN if needed for treatment planning	See: MS-4.1: AVN
Anterior Impingement Anterior-Lateral Impingement Posterior Impingement (e.g., Os Trigonum Syndrome)	Yes	Yes		† MRI ankle with contrast (arthrogram) (CPT® 73722) or CT ankle with contrast (arthrogram) (CPT® 73701) or MRI ankle without contrast (CPT® 73721)
Tendonitis	Yes	Yes		† MRI ankle without contrast (CPT® 73721) or US ankle (CPT® 76882) for suspected posterior tibial dysfunction, peroneal tendon or subluxation, Achilles tendonitis
Ruptured Achilles Tendon	Yes	No		† MRI ankle without contrast (CPT® 73721) or US ankle (CPT® 76882) for preoperative evaluation
Complete Rupture -Tear of a Specific Named Tendon	Yes	No		† MRI ankle without contrast (CPT® 73721) or US ankle (CPT® 76882) for preoperative planning
Partial Tendon Rupture	Yes	No	† MRI ankle without contrast (CPT® 73721) or US ankle (CPT® 76882) for a suspected partial tendon rupture of a specific named tendon not otherwise specified	MRI is NOT needed for muscle belly strains/ muscle tears.
Instability	Yes	Yes		† MRI ankle without contrast (CPT® 73721) or MRI ankle with contrast (arthrogram) (CPT® 73722) for preoperative evaluation
Charcot Ankle	Yes	Yes		† MRI ankle without contrast (CPT® 73721)
Post-Operative	Yes	Yes	† MRI ankle without contrast (CPT® 73721) in symptomatic members following surgery for ligament/tendon injuries † CT ankle without contrast (CPT® 73700) for symptomatic members following surgery for complex fractures	Other requests for advanced imaging will be forwarded to Medical Director review.
Preoperative Ankle Replacement Surgery	Yes	Yes	† CT ankle without contrast (CPT® 73700) for preoperative planning prior to ankle replacement when congenital or post-traumatic deformities exist	See also MS-12: Osteoarthritis
Post-Operative Ankle Replacement Surgery	Yes	No	† CT ankle without contrast (CPT® 73700) for suspected aseptic loosening or periprosthetic fracture when recent plain X-ray is nondiagnostic † In-111 WBC (CPT® 78800, 78801, 78802, or 78803) and Tc-99m 3-phase bone scan (CPT® 78315), or In-111 WBC (CPT® 78800-78803) or hybrid SPECT/CT (CPT® 78830, 78831, or 78832) and Tc-99 sulfur colloid scan ankle (CPT® 78102 or 78103), for suspected infection with negative or inconclusive joint aspiration culture (see MS-28: Nuclear Medicine)	Other requests for advanced imaging will be forwarded to Medical Director review. See also MS-16: Post-Operative Joint Replacement Surgery

One Study/Area Only

In foot and ankle advanced imaging, studies are frequently ordered of both areas. This is unnecessary since ankle MRI will image from above the ankle to the mid- metatarsal area. Only one CPT^® code should be reported.

References

1. Donovan A, Rosenberg ZS. MRI of ankle and lateral hindfoot impingement syndromes. AJR, 2010; 195: 595-604.
2. Wolfe MW, Uhl TL, and McClusky LC. Management of ankle sprains. Am Fam Physician 2001 Jan;63(1):93-104. https://www.aafp.org/afp/2001/0101/p93.html.
3. Greene WB (Ed.). Essentials of Musculoskeletal Care. 3^rd Ed.Rosemont, IL, American Academy of Orthopedic Surgeons, 2005, pp.593-596; 606-609; 683.
4. Bergkvist D, Astrom I, Josefsson PO, et al. Acute Achilles Tendon Rupture: A Questionnaire Follow-up of 487 Patients. J Bone Joint Surg Am. 2012 Ju; 94(13):1229-1233. doi: 10.2106/JBJS.J.01601.
5. Hartgerink P, Fessell DP, Jacobson JA, et al. Full- versus partial-thickness Achilles tendon tears: sonographic accuracy and characterization in 26 cases with surgical correlation. Radiology 2001;220:406-412. doi: 10.1148/radiology.220.2.r01au41406.
6. Jones MP, Riaz JK, and Smith RLC. Surgical Interventions for Treating Acute Achlles Tendon Rupture: Key Findings from a Recent Cochrane Review. J Bone Joint Surg Am. 2012 Jun;94(12):e88 1-6. doi: 10.2106/jbjs.j.01829.
7. Vaseenon T and Amendola A. Update on anterior ankle impingement. Current Reviews in Musculoskeletal Medicine. 2012;5:140-150. doi: 10.1007/s12178-012-9117-z.
8. Talusan PG, Toy J, Perez J, Milewski MD, et al. Anterior ankle impingement: diagnosis and treatment. J Am Acad Orthop Surg, 2014;22:333-339. doi: 10.5435/JAAOS-22-05-333.
9. Nault ML, Kocher MS, and Micheli LJ. Os Trigonum Syndrome. J Am Acad Orthop Surg. 2014;22:545-553. doi: 10.5435/JAAOS-22-09-545.
10. Peace KAL, Jillier JC, Hulme A, et al. MRI features of posterior ankle impingement syndrome in ballet dancers: a review 25 cases. Clinical Radiology. 2004;59:1025-1033. doi: 10.1016/j.crad.2004.02.010.
11. J Kane and R Zell. Achilles Tendon Rupture. Physician Resource Center. American Orthopaedic Foot & Ankle Society. Last reviewed July 2015.
12. Garras DN, et al. MRI is Unnecessary for Diagnosing Acute Achilles Tendon Ruptures. Clinical Orthopaedics and Related Research. 2012;470:2268–2273 Retrospective Analysis with finding. doi: 10.1007/s11999-012-2355-y.
13. Mosher TJ, Kransdorf MJ, Adler R, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Acute Trauma to the Ankle. Am Coll Radiol (ACR); Date of Origin: 2013. https://acsearch.acr.org/docs/69436/Narrative/.
14. Luchs JS, Flug JA, Weissman BN, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Chronic Ankle Pain. Am Coll Radiol (ACR); Date of Origin: 1998. Last Review: 2012. https://acsearch.acr.org/docs/69422/Narrative/.
15. Dodd A and Daniels TR. Charcot Neuroarthropathy of the Foot and Ankle. J Bone Joint Surg Am. 2018; 100:696-711. doi: 10.2106/JBJS.17.00785.


MS-27: Foot

For this condition imaging is medically necessary based on the following criteria:

Condition	Plain X-Ray?	Conservative Treatment	Advanced Imaging	Comments
General Foot Pain	Yes	Yes		† MRI foot without contrast (CPT® 73718)
Complex Fractures	Yes	No		† CT foot without contrast (CPT® 73700)
Plantar Plate Disorders, Including Turf Toe Injuries	Yes	Yes		† MRI foot without contrast (CPT® 73718)
Sesamoid Disorders	Yes	Yes		† MRI foot without contrast (CPT® 73718) or CT foot without contrast (CPT® 73700)
Lisfranc Tarsometatarsal Fracture or Dislocation	Yes	No		† MRI foot without contrast (CPT® 73718) or CT foot without contrast (CPT® 73700)
Tarsal Navicular Stress/Occult Fracture	Yes	No	† MRI foot without contrast (CPT® 73718) † Tc-99m bone scan foot (CPT® 78315) if MRI cannot be performed † CT foot without contrast (CPT® 73700) for follow-up of healing fractures	See also MS-5.2: Suspected Occult/ Stress/ In-sufficiency Fracture/ Stress Reaction and Shin Splints
Avascular Necrosis (AVN) of the Tarsal Navicular (Kohler Disease)	Yes	No	† MRI foot without contrast (CPT® 73718) when suspected and plain X-ray is negative or equivocal or with AVN confirmed by plain X-ray if needed for treatment planning	See: MS-4.1: AVN
Tendonitis	Yes	Yes		† MRI foot without contrast (CPT® 73718) or US foot (CPT® 76882)
Complete rupture/tear of a specific named tendon	Yes	No		† MRI foot without contrast (CPT® 73718) or US foot (CPT® 76882) for preoperative planning
Partial Tendon Rupture	Yes	No	† MRI foot without contrast (CPT® 73718) or US foot (CPT® 76882) for a suspected partial tendon rupture of a specific named tendon not otherwise specified	MRI is NOT needed for muscle belly strains/muscle tears.
Morton’s Neuroma	Yes	Yes		† MRI foot without and with contrast (CPT® 73720) or US foot (CPT® 76882) for preoperative planning
Plantar Fasciitis	Yes	Yes*	† MRI foot without contrast (CPT® 73718) or US foot (CPT® 76882) for preoperative planning	*Provider-directed conservative treatment must be for 6 months or more.
Suspected Plantar Fascia Rupture or Tear	Yes	Yes		† MRI foot without contrast (CPT® 73718) or US foot (CPT® 76882)
Diabetic Foot Infection	Yes*	No	† MRI foot without and with contrast (CPT® 73720) or MRI foot without contrast (CPT® 73718) for suspected osteomyelitis or soft tissue infection as a complement to plain X-ray (both plain X-ray and MRI are indicated)	* Plain X-ray results do not preclude the necessity for advanced imaging studies. See also MS 9.1: Infection-General
Tarsal Tunnel Syndrome	Yes	Yes		† MRI foot without contrast (CPT® 73718) or MRI foot without and with contrast (CPT® 73720) or US foot (CPT® 76882) for preoperative planning if mass/lesion is suspected as etiology of entrapment
Tarsal Coalition	Yes	Yes		† MRI ankle without contrast (CPT® 73721) or CT without contrast (CPT® 73700) for preoperative planning
Sinus Tarsi Syndrome	Yes	Yes		† MRI ankle without contrast (CPT® 73721) if diagnosis is unclear or for preoperative evaluation
Charcot Foot	Yes	Yes		† MRI foot without contrast (CPT® 73718)
Post-Operative	Yes	Yes	† MRI foot without contrast (CPT® 73718) in symptomatic members following surgery for conditions including the tendons, ligaments and plantar plate † CT foot without contrast (CPT® 73700) in symptomatic members following surgery for complex fractures, sesamoid fractures and subtalar arthrodesis	Other requests for advanced imaging will be forwarded to Medical Director review.

References

1. Greene WB (Ed.). Essentials of Musculoskeletal Care 3rd Ed. Rosemont, IL, American Academy of Orthopaedic Surgeons. 2005;pp.619-622;667-671; 681-684; 697-699; 700-702.
2. Needell S, Cutler J. Morton neuroma imaging. eMedicine, April 11, 2011,
3. Morton’s Neuroma. MDGuidelines™.
4. Berquist TH. Radiology of the Foot and Ankle. 2nd Ed. Philadelphia, Lippincott, 2000, pp.155-156.
5. Bouche R. Sinus Tarsi Syndrome. What is Sinus Tarsi Syndrome, Testing and Treatment. http://www.aapsm.org/sinus_tarsi_syndrome.html.
6. D Resnick. Internal Derangements of Joints 2006: Imaging-Arthroscopic Correlation. Washington, DC.Oct.31- Nov. 4, 2006.
7. Doty JF and Coughlin MJ. Metatarsophalangeal joint instability of the lesser toes and plantar plate deficiency. J Am Acad Orthop Surg. 2014;22(4):235-245. doi: 10.5435/JAAOS-22-04-235.
8. Lareau CR, Sawyer GA, Wang JH, et al. Plantar and medial heel pain: diagnosis and management. J Am Acad Orthop Surg. 2014;22:372-380. doi: 10.5435/JAAOS-22-06-372.
9. Sung, W, Weil L Jr, Weill LS Sr, et al. Diagnosis of plantar plate injury by magnetic resonance imaging with reference to Intraoperative findings. Journal of Foot Ankle Surgery. 2012;51(5):570-574. doi: 10.1053/j.jfas.2012.05.009.
10. Bancroft LW, Kransdorf MJ, Adler R, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Acute Trauma to the Foot. Am Coll Radiol (ACR); Date of Origin: 2010. Last Review: 2014. https://acsearch.acr.org/docs/70546/Narrative/.
11. Wise JN, Weissman BN, Appel M, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Chronic Foot Pain. Am Coll Radiol (ACR); Date of Origin: 1998. Last Review: 2015. https://acsearch.acr.org/docs/69424/Narrative/.
12. Bencardino JT, Stone TJ, Roberts CC, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae. Am Coll Radiol (ACR); Revised: 2016. https://acsearch.acr.org/docs/69435/Narrative/.
13. Kransdorf MJ, Weissman BN, Appel M, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Suspected Osteomyelitis of the Foot in Patients with Diabetes Mellitus. Am Coll Radiol (ACR); Date of Origin: 1995. Last Review: 2012. https://acsearch.acr.org/docs/69340/Narrative/.
14. Thomas JL, Christensen JC, Kravitz SR, et al. The Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline - Revision 2010. J Foot Ankle Surg. 2010;49:S1-S19. doi: 10.1053/j.jfas.2010.01.001.
15. Goff JD and Crawford R. Diagnosis and Treatment of Plantar Fasciitis. Am Fam Physician. 2011 Sep;84(6):676-682. https://www.aafp.org/afp/2011/0915/p676.html.
16. Baxter D and Pfeffer G. Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop. 1992;279:229–236.
17. Schepsis A, Leach R, and Gorzyca J. Plantar fasciitis: etiology, treatment, surgical results, and review of the literature. Clin Orthop 1991;266:185–196.
18. Neufeld SK and Cerato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg. 2008;16:338-46. doi: 10.5435/00124635-200806000-00006.
Dodd A and Daniels TR. Charcot Neuroarthropathy of the Foot and Ankle. J Bone Joint Surg Am. 2018; 100:696-711. doi: 10.2106/JBJS.17.00785.


MS-28: Nuclear Medicine

For this condition imaging is medically necessary based on the following criteria:

† SPECT scan may be approved for any of the indications for which a bone scan can be approved. If the request is for CPT^® 78300 and CPT^® 78803, then only CPT^® 78803 is to be approved if medical necessity is established. If the request is for CPT^® 78305 or CPT^® 78306 and CPT^® 78803, then two CPT codes may be approved if medical necessity is established.

† Nuclear Medicine

® Nuclear medicine studies may be used in the evaluation of some musculoskeletal disorders, and other rare indications exist as well:
¡ Bone scan (CPT^® 78315) or Distribution Of Radiopharmaceutical Agent SPECT (CPT^® 78803) may be indicated for the evaluation of suspected aseptic loosening of orthopedic prostheses when recent plain X-ray is nondiagnostic (see MS-16: Post-Operative Joint Replacement Surgery)
¡ Nuclear medicine bone marrow imaging (CPT^® 78102, CPT^® 78103, or CPT^® 78104) is indicated for detection of ischemic or infarcted regions in sickle cell disease
¡ Triple phase bone scan (CPT^® 78315) is indicated for evaluation of complex regional pain syndrome or reflex sympathetic dystrophy
¡ Bone scan (CPT^® codes: 78300, 78305, 78306, 78315) or Distribution Of Radiopharmaceutical Agent SPECT (CPT^® 78803) is indicated for evaluation of suspected frostbite
¡ Bone scan (CPT^® codes: 78300, 78305, 78306) or Distribution Of Radiopharmaceutical Agent SPECT (CPT^® 78803) is indicated for evaluation of Paget’s disease (see also MS-10: Soft Tissue Mass or Lesion of Bone).

† Bone scan (CPT^® 78315) or Distribution Of Radiopharmaceutical Agent SPECT (CPT^® 78803) or hybrid SPECT/CT (CPT^® 78830, 78831, or 78832) is indicated for the evaluation of suspected bone infection if MRI cannot be done and when infection is multifocal, or when the infection is associated with orthopedic hardware or chronic bone alterations from trauma or surgery. Combining bone scintigraphy with a labeled leukocyte scan enhances sensitivity. A labeled leukocyte scan (radiopharmaceutical inflammatory imaging - one of CPT^® codes: 78800, 78801, 78802, or 78803) in concert with Tc-99m sulfur colloid marrow imaging (one of CPT^® codes: 78102, 78103, or 78104) is particularly useful in cases with altered bone marrow distribution, such as joint prosthesis. See also MS-16: Post-Operative Joint Replacement Surgery.

† For specific joints post-operative from replacement surgery:

® See MS-19: Shoulder
® See MS-20: Elbow
® See MS-24: Hip
® See MS-25: Knee
® See MS-26: Ankle

1. Beaman FD, von Herrmann PF, Kransdorf MJ, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Suspected Osteomyelitis, Septic Arthritis, or Soft Tissue Infection (Excluding Spine and Diabetic Foot). Am Coll Radiol (ACR); Date of Origin: 2016. https://acsearch.acr.org/docs/ 3094201/Narrative/.
2. Kransdorf MJ, Weissman BN, Appel M, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Suspected Osteomyelitis of the Foot in Patients with Diabetes Mellitus. Am Coll Radiol (ACR); Date of Origin: 1995. Last Review: 2012. https://acsearch.acr.org/docs/69340/Narrative/.
3. Wise JN, Weissman BN, Appel M, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Chronic Foot Pain. Am Coll Radiol (ACR); Date of Origin: 1998. Last Review: 2015. https://acsearch.acr.org/docs/69424/Narrative/.
4. Bencardino JT, Stone TJ, Roberts CC, et. al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria^® Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae. Am Coll Radiol (ACR); Revised: 2016. https://acsearch.acr.org/docs/69435/Narrative/.


Medicare Coverage:
Medicare Advantage Products follow CMS National Coverage Determinations, Local Coverage Determinations and other CMS Guidance (eg, Medicare Benefit Policy Manual, Medicare Learning Network Articles (MLN Matters Articles), Medicare Claims Processing Manual)). If CMS does not have a coverage or noncoverage position on a service, Medicare Advantage Products will follow Horizon BCBSNJ Medical Policy. If there is no CMS Guidance and no Horizon BCBSNJ Medical Policy, then eviCore Diagnostic Advanced Imaging Guidelines will be applied.

NCDs available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx

LCDs available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00024370.

DME LCDS available to be accessed at Noridian Healthcare Services, LLC, (DME MAC), Local Coverage Determinations (LCDs) search page: https://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=389&ContrVer=1&CntrctrSelected=389*1&s=38&DocType=All&bc=AggAAAAAAAAAAA%3d%3d&#ResultsAnchor.

Providers are responsible for reviewing CMS Medicare Coverage Center Guidance and in the event of a conflict between the Medicare Coverage section of the medical policy and the CMS Medicare Coverage Center Guidance, the CMS Medicare Coverage Center Guidance will control.

Medicaid Coverage:

For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.

FIDE SNP:

For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.

________________________________________________________________________________________

Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

___________________________________________________________________________________________________________________________

Index:
Adult Musculoskeletal Imaging Policy
Musculoskeletal Imaging Policy, Adult
Computed Tomography, Musculoskeletal, Adult
CT, Musculoskeletal, Adult
Computed Tomography Angiography, Musculoskeletal, Adult
CTA, Musculoskeletal, Adult
Magnetic Resonance Imaging, Musculoskeletal, Adult
MRI, Musculoskeletal, Adult
Magnetic Resoance Angiography, Musculoskeletal, Adult
MRA, Musculoskeletal, Adult
Positron Emission Tomography, Musculoskeletal, Adult
PET, Musculoskeletal, Adult
Ultrasound, Musculoskeletal, Adult
Nuclear Medicine Studies, Musculoskeletal, Adult
Musculoskeletal Nuclear Medicine Studies, Adult
Bone Scan, Adult
Extremity Imaging Policy, Adult

References:


Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*