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Acute Respiratory Illness in Immunocompetent Patients

Variant: 1   Adult. Acute respiratory illness in immunocompetent patients with negative physical examination, normal vital signs, and no other risk factors for poor outcome. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography chest May Be Appropriate (Disagreement) ☢
US chest Usually Not Appropriate O
MRI chest without and with IV contrast Usually Not Appropriate O
MRI chest without IV contrast Usually Not Appropriate O
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
CTA chest with IV contrast Usually Not Appropriate ☢☢☢
V/Q scan lung Usually Not Appropriate ☢☢☢

Variant: 2   Adult. Acute respiratory illness in immunocompetent patients with positive physical examination, or abnormal vital signs, or organic brain disease, or other risk factors for poor outcome. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography chest Usually Appropriate ☢
US chest Usually Not Appropriate O
MRI chest without and with IV contrast Usually Not Appropriate O
MRI chest without IV contrast Usually Not Appropriate O
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
CTA chest with IV contrast Usually Not Appropriate ☢☢☢
V/Q scan lung Usually Not Appropriate ☢☢☢

Variant: 3   Adult. Acute respiratory illness in immunocompetent patients with positive physical examination, abnormal vital signs, organic brain disease, or other risk factors and negative or indeterminate initial chest radiograph. Next imaging study.
Procedure Appropriateness Category Relative Radiation Level
CT chest with IV contrast Usually Appropriate ☢☢☢
CT chest without IV contrast Usually Appropriate ☢☢☢
CTA chest with IV contrast May Be Appropriate ☢☢☢
US chest Usually Not Appropriate O
MRI chest without and with IV contrast Usually Not Appropriate O
MRI chest without IV contrast Usually Not Appropriate O
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
V/Q scan lung Usually Not Appropriate ☢☢☢

Variant: 4   Adult. Acute respiratory illness in immunocompetent patients with pneumonia complicated by suspected parapneumonic effusion or abscess on initial chest radiograph. Next imaging study.
Procedure Appropriateness Category Relative Radiation Level
CT chest with IV contrast Usually Appropriate ☢☢☢
CT chest without IV contrast Usually Appropriate ☢☢☢
US chest May Be Appropriate O
MRI chest without and with IV contrast Usually Not Appropriate O
MRI chest without IV contrast Usually Not Appropriate O
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CTA chest with IV contrast Usually Not Appropriate ☢☢☢
V/Q scan lung Usually Not Appropriate ☢☢☢

Variant: 5   Adult. Acute asthma exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography chest May Be Appropriate ☢
US chest Usually Not Appropriate O
MRI chest without and with IV contrast Usually Not Appropriate O
MRI chest without IV contrast Usually Not Appropriate O
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
CTA chest with IV contrast Usually Not Appropriate ☢☢☢
V/Q scan lung Usually Not Appropriate ☢☢☢

Variant: 6   Adult. Acute asthma exacerbation in immunocompetent patients, complicated. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography chest Usually Appropriate ☢
US chest Usually Not Appropriate O
MRI chest without and with IV contrast Usually Not Appropriate O
MRI chest without IV contrast Usually Not Appropriate O
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
CTA chest with IV contrast Usually Not Appropriate ☢☢☢
V/Q scan lung Usually Not Appropriate ☢☢☢

Variant: 7   Adult. Acute COPD exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography chest Usually Appropriate ☢
US chest Usually Not Appropriate O
MRI chest without and with IV contrast Usually Not Appropriate O
MRI chest without IV contrast Usually Not Appropriate O
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
CTA chest with IV contrast Usually Not Appropriate ☢☢☢
V/Q scan lung Usually Not Appropriate ☢☢☢

Variant: 8   Adult. Acute COPD exacerbation in immunocompetent patients with accompanying chest pain, or fever, or leukocytosis, or a history of coronary artery disease, or heart failure. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography chest Usually Appropriate ☢
CTA chest with IV contrast May Be Appropriate ☢☢☢
US chest Usually Not Appropriate O
MRI chest without and with IV contrast Usually Not Appropriate O
MRI chest without IV contrast Usually Not Appropriate O
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
V/Q scan lung Usually Not Appropriate ☢☢☢

Variant: 9   Adult. Acute respiratory illness in immunocompetent patients with suspected pneumonia on initial imaging. Follow-up imaging to ensure resolution.
Procedure Appropriateness Category Relative Radiation Level
Radiography chest Usually Appropriate ☢
CT chest with IV contrast May Be Appropriate ☢☢☢
CT chest without IV contrast May Be Appropriate ☢☢☢
US chest Usually Not Appropriate O
MRI chest without and with IV contrast Usually Not Appropriate O
MRI chest without IV contrast Usually Not Appropriate O
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CTA chest with IV contrast Usually Not Appropriate ☢☢☢
V/Q scan lung Usually Not Appropriate ☢☢☢

Panel Members
Kiran Batra, MDa; Christopher M. Walker, MDb; Brent P. Little, MDc; Tami J. Bang, MDd; Twyla B. Bartel, DO, MBAe; Anupama G. Brixey, MDf; Jared D. Christensen, MD, MBAg; Christian W. Cox, MDh; Michael Hanak, MDi; Sandhya Khurana, MDj; Rachna Madan, MBBSk; Naseema Merchant, MDl; William H. Moore, MDm; Sahil Pandya, MDn; Leon D. Sanchez, MD, MPHo; Girish S. Shroff, MDp; Marianna Zagurovskaya, MDq; Jonathan H. Chung, MDr.
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition
Discussion of Procedures by Variant
Variant 1: Adult. Acute respiratory illness in immunocompetent patients with negative physical examination, normal vital signs, and no other risk factors for poor outcome. Initial imaging.
Variant 1: Adult. Acute respiratory illness in immunocompetent patients with negative physical examination, normal vital signs, and no other risk factors for poor outcome. Initial imaging.
A. CT chest with IV contrast
Variant 1: Adult. Acute respiratory illness in immunocompetent patients with negative physical examination, normal vital signs, and no other risk factors for poor outcome. Initial imaging.
B. CT chest without and with IV contrast
Variant 1: Adult. Acute respiratory illness in immunocompetent patients with negative physical examination, normal vital signs, and no other risk factors for poor outcome. Initial imaging.
C. CT chest without IV contrast
Variant 1: Adult. Acute respiratory illness in immunocompetent patients with negative physical examination, normal vital signs, and no other risk factors for poor outcome. Initial imaging.
D. CTA chest with IV contrast
Variant 1: Adult. Acute respiratory illness in immunocompetent patients with negative physical examination, normal vital signs, and no other risk factors for poor outcome. Initial imaging.
E. MRI chest without and with IV contrast
Variant 1: Adult. Acute respiratory illness in immunocompetent patients with negative physical examination, normal vital signs, and no other risk factors for poor outcome. Initial imaging.
F. MRI chest without IV contrast
Variant 1: Adult. Acute respiratory illness in immunocompetent patients with negative physical examination, normal vital signs, and no other risk factors for poor outcome. Initial imaging.
G. Radiography chest
Variant 1: Adult. Acute respiratory illness in immunocompetent patients with negative physical examination, normal vital signs, and no other risk factors for poor outcome. Initial imaging.
H. US chest
Variant 1: Adult. Acute respiratory illness in immunocompetent patients with negative physical examination, normal vital signs, and no other risk factors for poor outcome. Initial imaging.
I. V/Q scan lung
Variant 2: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination, or abnormal vital signs, or organic brain disease, or other risk factors for poor outcome. Initial imaging.
Variant 2: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination, or abnormal vital signs, or organic brain disease, or other risk factors for poor outcome. Initial imaging.
A. CT chest with IV contrast
Variant 2: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination, or abnormal vital signs, or organic brain disease, or other risk factors for poor outcome. Initial imaging.
B. CT chest without and with IV contrast
Variant 2: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination, or abnormal vital signs, or organic brain disease, or other risk factors for poor outcome. Initial imaging.
C. CT chest without IV contrast
Variant 2: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination, or abnormal vital signs, or organic brain disease, or other risk factors for poor outcome. Initial imaging.
D. CTA chest with IV contrast
Variant 2: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination, or abnormal vital signs, or organic brain disease, or other risk factors for poor outcome. Initial imaging.
E. MRI chest without and with IV contrast
Variant 2: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination, or abnormal vital signs, or organic brain disease, or other risk factors for poor outcome. Initial imaging.
F. MRI chest without IV contrast
Variant 2: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination, or abnormal vital signs, or organic brain disease, or other risk factors for poor outcome. Initial imaging.
G. Radiography chest
Variant 2: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination, or abnormal vital signs, or organic brain disease, or other risk factors for poor outcome. Initial imaging.
H. US chest
Variant 2: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination, or abnormal vital signs, or organic brain disease, or other risk factors for poor outcome. Initial imaging.
I. V/Q scan lung
Variant 3: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination or abnormal vital signs or organic brain disease or other risk factors and negative or indeterminate initial chest radiograph. Next imaging study.
Variant 3: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination or abnormal vital signs or organic brain disease or other risk factors and negative or indeterminate initial chest radiograph. Next imaging study.
A. CT chest with IV contrast
Variant 3: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination or abnormal vital signs or organic brain disease or other risk factors and negative or indeterminate initial chest radiograph. Next imaging study.
B. CT chest without and with IV contrast
Variant 3: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination or abnormal vital signs or organic brain disease or other risk factors and negative or indeterminate initial chest radiograph. Next imaging study.
C. CT chest without IV contrast
Variant 3: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination or abnormal vital signs or organic brain disease or other risk factors and negative or indeterminate initial chest radiograph. Next imaging study.
D. CTA chest with IV contrast
Variant 3: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination or abnormal vital signs or organic brain disease or other risk factors and negative or indeterminate initial chest radiograph. Next imaging study.
E. MRI chest without and with IV contrast
Variant 3: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination or abnormal vital signs or organic brain disease or other risk factors and negative or indeterminate initial chest radiograph. Next imaging study.
F. MRI chest without IV contrast
Variant 3: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination or abnormal vital signs or organic brain disease or other risk factors and negative or indeterminate initial chest radiograph. Next imaging study.
G. US chest
Variant 3: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination or abnormal vital signs or organic brain disease or other risk factors and negative or indeterminate initial chest radiograph. Next imaging study.
H. V/Q scan lung
Variant 4: Adult. Acute respiratory illness in immunocompetent patients with pneumonia complicated by suspected parapneumonic effusion or abscess on initial chest radiograph. Next imaging study.
Variant 4: Adult. Acute respiratory illness in immunocompetent patients with pneumonia complicated by suspected parapneumonic effusion or abscess on initial chest radiograph. Next imaging study.
A. CT chest with IV contrast
Variant 4: Adult. Acute respiratory illness in immunocompetent patients with pneumonia complicated by suspected parapneumonic effusion or abscess on initial chest radiograph. Next imaging study.
B. CT chest without and with IV contrast
Variant 4: Adult. Acute respiratory illness in immunocompetent patients with pneumonia complicated by suspected parapneumonic effusion or abscess on initial chest radiograph. Next imaging study.
C. CT chest without IV contrast
Variant 4: Adult. Acute respiratory illness in immunocompetent patients with pneumonia complicated by suspected parapneumonic effusion or abscess on initial chest radiograph. Next imaging study.
D. CTA chest with IV contrast
Variant 4: Adult. Acute respiratory illness in immunocompetent patients with pneumonia complicated by suspected parapneumonic effusion or abscess on initial chest radiograph. Next imaging study.
E. MRI chest without and with IV contrast
Variant 4: Adult. Acute respiratory illness in immunocompetent patients with pneumonia complicated by suspected parapneumonic effusion or abscess on initial chest radiograph. Next imaging study.
F. MRI chest without IV contrast
Variant 4: Adult. Acute respiratory illness in immunocompetent patients with pneumonia complicated by suspected parapneumonic effusion or abscess on initial chest radiograph. Next imaging study.
G. US chest
Variant 4: Adult. Acute respiratory illness in immunocompetent patients with pneumonia complicated by suspected parapneumonic effusion or abscess on initial chest radiograph. Next imaging study.
H. V/Q scan lung
Variant 5: Adult. Acute asthma exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
Variant 5: Adult. Acute asthma exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
A. CT chest with IV contrast
Variant 5: Adult. Acute asthma exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
B. CT chest without and with IV contrast
Variant 5: Adult. Acute asthma exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
C. CT chest without IV contrast
Variant 5: Adult. Acute asthma exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
D. CTA chest with IV contrast
Variant 5: Adult. Acute asthma exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
E. MRI chest without and with IV contrast
Variant 5: Adult. Acute asthma exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
F. MRI chest without IV contrast
Variant 5: Adult. Acute asthma exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
G. Radiography chest
Variant 5: Adult. Acute asthma exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
H. US chest
Variant 5: Adult. Acute asthma exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
I. V/Q scan lung
Variant 6: Adult. Acute asthma exacerbation in immunocompetent patients, complicated. Initial imaging.
Variant 6: Adult. Acute asthma exacerbation in immunocompetent patients, complicated. Initial imaging.
A. CT chest with IV contrast
Variant 6: Adult. Acute asthma exacerbation in immunocompetent patients, complicated. Initial imaging.
B. CT chest without and with IV contrast
Variant 6: Adult. Acute asthma exacerbation in immunocompetent patients, complicated. Initial imaging.
C. CT chest without IV contrast
Variant 6: Adult. Acute asthma exacerbation in immunocompetent patients, complicated. Initial imaging.
D. CTA chest with IV contrast
Variant 6: Adult. Acute asthma exacerbation in immunocompetent patients, complicated. Initial imaging.
E. MRI chest without and with IV contrast
Variant 6: Adult. Acute asthma exacerbation in immunocompetent patients, complicated. Initial imaging.
F. MRI chest without IV contrast
Variant 6: Adult. Acute asthma exacerbation in immunocompetent patients, complicated. Initial imaging.
G. Radiography chest
Variant 6: Adult. Acute asthma exacerbation in immunocompetent patients, complicated. Initial imaging.
H. US chest
Variant 6: Adult. Acute asthma exacerbation in immunocompetent patients, complicated. Initial imaging.
I. V/Q scan lung
Variant 7: Adult. Acute COPD exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
Variant 7: Adult. Acute COPD exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
A. CT chest with IV contrast
Variant 7: Adult. Acute COPD exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
B. CT chest without and with IV contrast
Variant 7: Adult. Acute COPD exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
C. CT chest without IV contrast
Variant 7: Adult. Acute COPD exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
D. CTA chest with IV contrast
Variant 7: Adult. Acute COPD exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
E. MRI chest without and with IV contrast
Variant 7: Adult. Acute COPD exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
F. MRI chest without IV contrast
Variant 7: Adult. Acute COPD exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
G. Radiography chest
Variant 7: Adult. Acute COPD exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
H. US chest
Variant 7: Adult. Acute COPD exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
I. V/Q scan lung
Variant 8: Adult. Acute COPD exacerbation in immunocompetent patients with accompanying chest pain, or fever, or leukocytosis, or a history of coronary artery disease, or heart failure. Initial imaging.
Variant 8: Adult. Acute COPD exacerbation in immunocompetent patients with accompanying chest pain, or fever, or leukocytosis, or a history of coronary artery disease, or heart failure. Initial imaging.
A. CT chest with IV contrast
Variant 8: Adult. Acute COPD exacerbation in immunocompetent patients with accompanying chest pain, or fever, or leukocytosis, or a history of coronary artery disease, or heart failure. Initial imaging.
B. CT chest without and with IV contrast
Variant 8: Adult. Acute COPD exacerbation in immunocompetent patients with accompanying chest pain, or fever, or leukocytosis, or a history of coronary artery disease, or heart failure. Initial imaging.
C. CT chest without IV contrast
Variant 8: Adult. Acute COPD exacerbation in immunocompetent patients with accompanying chest pain, or fever, or leukocytosis, or a history of coronary artery disease, or heart failure. Initial imaging.
D. CTA chest with IV contrast
Variant 8: Adult. Acute COPD exacerbation in immunocompetent patients with accompanying chest pain, or fever, or leukocytosis, or a history of coronary artery disease, or heart failure. Initial imaging.
E. MRI chest without and with IV contrast
Variant 8: Adult. Acute COPD exacerbation in immunocompetent patients with accompanying chest pain, or fever, or leukocytosis, or a history of coronary artery disease, or heart failure. Initial imaging.
F. MRI chest without IV contrast
Variant 8: Adult. Acute COPD exacerbation in immunocompetent patients with accompanying chest pain, or fever, or leukocytosis, or a history of coronary artery disease, or heart failure. Initial imaging.
G. Radiography chest
Variant 8: Adult. Acute COPD exacerbation in immunocompetent patients with accompanying chest pain, or fever, or leukocytosis, or a history of coronary artery disease, or heart failure. Initial imaging.
H. US chest
Variant 8: Adult. Acute COPD exacerbation in immunocompetent patients with accompanying chest pain, or fever, or leukocytosis, or a history of coronary artery disease, or heart failure. Initial imaging.
I. V/Q scan lung
Variant 9: Adult. Acute respiratory illness in immunocompetent patients with suspected pneumonia on initial imaging. Follow-up imaging to ensure resolution.
Variant 9: Adult. Acute respiratory illness in immunocompetent patients with suspected pneumonia on initial imaging. Follow-up imaging to ensure resolution.
A. CT chest with IV contrast
Variant 9: Adult. Acute respiratory illness in immunocompetent patients with suspected pneumonia on initial imaging. Follow-up imaging to ensure resolution.
B. CT chest without and with IV contrast
Variant 9: Adult. Acute respiratory illness in immunocompetent patients with suspected pneumonia on initial imaging. Follow-up imaging to ensure resolution.
C. CT chest without IV contrast
Variant 9: Adult. Acute respiratory illness in immunocompetent patients with suspected pneumonia on initial imaging. Follow-up imaging to ensure resolution.
D. CTA chest with IV contrast
Variant 9: Adult. Acute respiratory illness in immunocompetent patients with suspected pneumonia on initial imaging. Follow-up imaging to ensure resolution.
E. MRI chest without and with IV contrast
Variant 9: Adult. Acute respiratory illness in immunocompetent patients with suspected pneumonia on initial imaging. Follow-up imaging to ensure resolution.
F. MRI chest without IV contrast
Variant 9: Adult. Acute respiratory illness in immunocompetent patients with suspected pneumonia on initial imaging. Follow-up imaging to ensure resolution.
G. Radiography chest
Variant 9: Adult. Acute respiratory illness in immunocompetent patients with suspected pneumonia on initial imaging. Follow-up imaging to ensure resolution.
H. US chest
Variant 9: Adult. Acute respiratory illness in immunocompetent patients with suspected pneumonia on initial imaging. Follow-up imaging to ensure resolution.
I. V/Q scan lung
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.