First Things First
This study must have been performed within the last 6 weeks and there is documentation that CPT 76497 (Unlisted CT procedure) is needed for a Navigational Bronchoscopy
What is a CT Chest w/o (CPT 71250)
CH 1.7
Incidentally found mediastinal lymph node < 15mm with no other findings
MDO requesting PET /CT (CT 78815)
Send to MD Review per CH 2.3 Advanced imaging may not be indicated
This imaging can be approved with an Alvarado Score of greater than or equal to 4?
What is a CT Abdomen and Pelvis with (74177) OR without contrast (74176) for RLQ Abd pain (including suspected appendicitis)
AB 2.2
For suspected pathological rib fractures, with or without a history of trauma
What is CH 21.1 Chest Trauma in the MedSurg Guidelines ?
We would not reroute
This study should be completed prior to advanced imaging for Arterial Thoracic Outlet Syndrome
What is a CXR?
CH 31.1
Epigastric pain with moderate tenderness
MDO requesting MRCP/MRI Abdomen w w/o
Approve per AB 2.5
This study can be allowed for the further evaluation of an abnormal Ultrasound or CT finding of a dilated pancreatic duct, enlargement or fullness of the pancreas
What is an MRCP MRI Abdomen without OR with and without
AB 27.1
Thromboembolic complications including pulmonary embolism, stroke and mesenteric ischemia are recognized complications of COVID-19. Aside from the MedSurg guidelines, which other specialty would these studies possibly be rerouted to?
What is Head/Neuro ?
CH 13.2
This is required prior to considering advanced imaging
What is a pertinent clinical evaluation.
For an established patient a meaningful technological contact (telehealth visit, telephone call, electronic mail or messaging) can serve as a pertinent clinical evaluation
Dipstick at MDO shows 3+ blood.
CT Abd/pelv w w/o requested
What is Send to MD Review per AB 39.2
( A positive dipstick should prompt a microscopic examination)
If Transient Elastography failure despite use of an XL -probe, OR BMI is greater than or equal to 35, this study can be approved.
What is MRE (CPT 76391)
AB 45 Liver Elastography
If ultrasound is indeterminate or non diagnostic, and osteitis pubis or athletic pubalgia are in the differential reroute to this Specialty
What is MSK? MS-23
AB 12.1
For individuals with diarrhea predominant IBS (IBS-D), which testing should be performed
What is Celiac testing?
AB 21.4
A complex and/or solid adnexal mass incompletely evaluated by ultrasound
MRI Pelvis w w/o requested by MDO
What is send to MD Review per PV 5.3 for repeat ultrasound
An equivocal or non diagnostic ultrasound prompts this advanced imaging for RUQ pain
What is a CT Abdomen with or MRCP/MRI Abdomen without or with and without
AB 2.3
If concern is expressed for hiccups with cerebrovascular disease, brain tumors and intracranial injury, reroute to this Specialty
What is Head/Neuro?
AB 46
Prior to imaging, for confirmation of hepatic etiology, if ALKP is elevated with other LFTS, this testing is necessary.
What is none. No confirmatory test is necessary.
AB 30.1
Request for Low Dose CT Chest for 50 yo smoker. Smoked 1/2 ppd for 30 years.
Send to MD Review per CH 33.1. Smoking pack year history not met.
1/2 ppd x 30 years = 15 pack year history
If Estradiol is low with finding of inappropriately normal or low gonadotropins, this study may be performed.
What is MRI Brain (pituitary protocol) with and without contrast.
PV 3.2
If the Limited CT (CPT 76380) is not indicated for treatment planning purposes, which Specialty should the study be referred?
What is Oncology
Preface 4.5