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1. Suspicious mass or tumor
a. On initial evaluation or follow up
2. Staging of known cancer
3. Suspected or known infection (septic arthritis or osteomyelitis)
4. Suspected Osteonecrosis
5. Evaluation of Rheumatoid Arthritis or other autoimmune diseases
6. Evaluation of Post-op Complications
a. Infection, delayed union, other
7. Suspected fracture with prior imaging non-diagnostic
8. Abnormal bones scan with non-diagnostic Xray
9. Significant injury with suspected ligament, cartilage, tendon, nerve or bone injury with non-diagnostic prior imaging
a. Suspected massive rotator cuff tear
10. Evaluation of pain or more minor injury with initial imaging non-diagnostic:
a. Pain lasting 3 months or greater
b. Failed conservative therapy: Must include each one:
i. Rest: modified activities or assistive devices/rigid splints or braces
ii. Ice or heat
iii. Medications and/or injections
iv. Physical therapy or a physician directed home exercise program
or chiropractic care
1. Document instructions given
2. Document compliance and results
3. Document duration and dates
1. Tumor, masses, or cancer: suspected or known
2. Neurological Deficits
3. Trauma or acute injury
a. With neurological deficits
b. With progressive symptoms during conservative treatment
4. Infection: known or suspected
5. Inflammation: Ankylosing Spondylitis
6. Pre-op Evaluation
7. Post-op Complications
8. Acute or Chronic Axial or radicular pain
a. Pain lasting 6 weeks or greater
b. ADLs must be affected
c. Progressive neurological deficit or an abnormal EMG
i. Must document specific dermatome, muscle weakness, reflex
abnormalities
d. Failed conservative therapy: Must include each one:
i. Rest: modified activities or bracing
ii. Ice or heat
iii. Medications, acupuncture or stimulators
1. Specific name of medication start date and duration and
results
iv. Epidurals or other injections (not trigger point injections)
v. Physical therapy or a physician directed home exercise program
or chiropractic care
1. Document instructions given
2. Document compliance and results
3. Document duration and dates
1. Musculoskeletal Pelvic MRI:
a. Mass or tumor
b. Significant injury to rule out fracture or other injury
c. Osteonecrosis of hips
d. Sacroiliitis
e. Sacroiliac joint dysfunction
f. Pain lasting 3 months or greater
g. Failed conservative therapy: Must include each one:
i. Rest: modified activities or assistive devices/rigid
splints or braces
ii. Ice or heat
iii. Medications and/or injections
iv. Physical therapy or a physician directed home
exercise program or chiropractic care
1. Document instructions given
2. Document compliance and results
3. Document duration
h. Persistent Pain not responsive to 4 weeks of conservative treatment
2. Prostate Cancer Evaluation, follow up, and surveillance
3. Mass or Tumors
4. Cancer detection, staging, or surveillance
a. 3, 6, or 12 month follow up
5. Infection:
a. Appendicitis
b. Diverticulitis not responding to conservative care
c. Inflammatory bowel disease
d. Abscess suspected
e. Fistula
f. Abnormal fluid collection
6. Pelvic Floor failure
7. Uterine abnormalities
8. Undescended Testes
9. Pre-op Evaluation
10. Post-op Complication
1. Suspicious Mass or Tumor
a. On initial evaluation or follow up
2. Staging of known Cancer
3. Known or suspected infection
4. Suspected Osteonecrosis or Legg-Calve-Perthes Disease
5. Suspected SCFE, tarsal coaltion
6. Evaluation of Post-op complication:
a. Infection, delayed union, other
7. Suspected fracture with prior imaging non-diagnostic
8. Abnormal bone scan with non-diagnostic xray
9. Significant injury with suspected ligament, cartilage, or bone injury
10. Evaluation of pain or more minor injury with initial imaging negative:
a. Pain lasting 3 months or greater
b. Failed conservative therapy: Must include each one:
i. Rest: modified activities or assistive devices/rigid splints or braces
ii. Ice or heat
iii. Medications and/or injections
iv. Physical therapy or a physician directed home exercise program orchiropractic care
1. Document instructions given
2. Document compliance and results
3. Document duration
1. Mediastinal or hilar mass
2. Myasthenia gravis with suspected thymoma
3. Brachial Plexus Dysfunction
4. Thoracic/Thoracoabdominal aneurysm
5. Suspected or confirmed Congenital Heart Disease
6. Thoracic Outlet Syndrome
1. Suspected or known MS
2. Seizure disorder, known or suspected new or refractory
3. Suspected Parkinson’s disorder
4. Neurological symptoms or deficits
a. Acute, new or fluctuating deficits
5. Mental status changes
6. Trauma to the head with neurological changes, vomiting, headache
7. Evaluation of headaches
a. Chronic with change in pattern/character
b. Sudden onset severe headache
c. New onset headache in pregnancy
8. Suspected brain tumor or cancer
9. Known or suspected stroke
10. Suspected Infection
11. Suspected Congenital abnormality
12. New onset tinnitus or vertigo associated with visual changes
MRI
1. Suspicious Mass or Tumor
2. Surveillance of Mass, Tumor, or Cancer
a. 3, 6, 12 month follow up
3. Suspected infection:
a. Appendicitis
b. Peritonitis
c. Pancreatitis
d. Inflammatory bowel disease
e. Cholecystitis
f. Abscess
g. Fistula
h. Hepatitis C
4. Preoperative Evaluation
5. Post-op complication
MRCP
1. Suspected Congenital Abnormality
2. Chronic pancreatitis or related complications
3. Biliary tree symptoms
4. Pre-op Evaluation
5. Post-op complication or surveillance
6. Inconclusive abnormalities identified on other imaging
