First Things First
What is the initial imaging for a esophageal fistula?
CT Neck, Chest, and/or Abdomen, preferably with contrast, as requested, depending on location
Neck 3.1
An 11 year old male with sickle cell has developed transfusion related hemochromatosis. The doctor wants to evaluate both the liver and the heart and has ordered a 71552
Approve or Send to MD Review?
Send to MD review-
MRI Chest without contrast (CPT® 71550) can be approved as a single study to evaluate both heart and liver iron burden
PEDAB-18.2
What would be the next study for a ped member with concern for a Congenital Diaphragmatic Hernia after a recent inconclusive Chest XRAY
CT Chest with contrast (CPT® 71260) or MRI Chest with and without contrast (CPT® 71552) may be approved when Chest x-ray and/or US are inconclusive, or if requested for treatment planning.
PEDCH 14.3
If a chest xray or US shows an obvious lipoma what specialty would this be re routed to?
MS 10
see CH 22.1
What is needed initially to evaluate a woman with amenorrhea?
Negative pregnancy test which must be done at the mdo or lab.
PV 3.1
A member with an adnexal mass has had an MRI which was equivocal and the mdo has ordered a follow up MRI Approve or MD Review and why?
MD Review: Request for follow up MRI studies should be sent to Medical Director Review
PV 5.3
What is the next step after a normal Pelvic US for a female with unexplained pelvic pain
If initial ultrasound is normal, consider urological work-up, gastroenterology work-up or laparoscopic evaluation(s) in evaluation of pelvic pain
PV 11.1
A female with a lost IUD and positive pregnancy test would be re routed to this specialty
OB
OB 3.1 see PV 10.1
A CT abdomen 74150 is the initial study for PCOS if what is elevated and what is suspected?
elevated serum levels of androgens are found and an adrenal etiology is suspected.
PV 8.1
A member who on 2 week trial treatment for cervical adenopathy has not yet finished his treatment and a request has been made for a CT Neck 70491 due to an US suspicious for malignancy
Approve or MD Review and why?
Approve: If an US happen to have been done prior to completing the 2 week trial an it was indeterminate or suspicious for malignancy we can proceed to a CT Neck prior to finishing the trial
comprehensive PP Neck 5.1
What would the follow up study be for a ped member with suspected intussusception who had a negative US?
if negative US, plain x-rays of the abdomen should follow
PEDAB-27
If male hypogonadism is suspected is a member the study may be rerouted to this specialty
Head-Neuro
see PV-17.1
What is needed for imaging for Classic Primary hyperparathyroidism ?
ALL of the following conditions are met:
Both PTH and Calcium levels are elevated above the reference range for lab testing facility Individual is a surgical candidate Intention of the study is preoperative localization
Neck8.3
Member at mdo for follow up of pulmonary nodules. XRAY on 2/2018 showed 6.5 mm lung nodule. CT 3/2018 showed 6.5 mm lung nodule. Follow up CT 3/2020 showed stable 6.5 mm lung nodule. LOV 6/2021 mdo orders follow up CT.
Approve or MD Review?
MD Review
CH 16.3
No further advanced imaging is necessary if a nodule has been:
Stable for 2 years ≥6mm stable on CT Chest
This study would follow invasive treatment post mesenteric stenting
Baseline Duplex ultrasound (CPT® 93975 or CPT® 93976) within 1 month of the procedure
AB 6.1
For a request to follow up on a sebaceous cyst of the neck what would be the competency change?
Spine Ortho
MS 10-see Neck 5.1 in comprehensive PP
What must happen first for a boy with suspected undescended testis in order for imaging studies to be ordered?
Suspected undescended testis is an indication for referral to a surgical subspecialist who should make the decision or be consulted on necessary imaging studies
PedPV-11
Clinical states mdo wants to assess for Primary Sclerosing Cholangitis.
Member with elevated alkaline phosphate on labs
MRCP is ordered
Approve or Send to Review?
MD Review
AB 23.4-AB 30.1
No known IBD stated in clinical only elevated alk phosphate
This study would follow a lung transplant
CT Chest with and without contrast (CPT® 71270), CT Chest with contrast (CPT® 71260), or CT Chest without contrast (CPT® 71250) for initial post-transplant follow-up.
CH 32.1
A member with Amenorrhea and Estradiol is low with finding of inappropriately normal or low gonadotropins or Prolactin (PRL) level is elevated above normal maybe rerouted to this specialty
Head-Neuro
see PV 3.1