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Appropriateness Criteria

Variant 1: Chronic cough lasting more than 8 weeks. No known risk factors for lung cancer. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Strong ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 0 1 2 2 8
References Study Quality
34 (23083885) 3
30 (24788998) 4
32 (25968285) 4
29 (20694945) 4
10 (26165783) 4
3 (29960277) 2
16 (26937758) 4
15 (31757237) 4
26 (26861744) 2
33 (26662264) 2
31 (25316135) 2
35 (24698073) 4
1 (29080708) 4
7 (15684286) 2
17 (23347748) 2
CT chest with IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 2 1 3 2 4 0 1 0 0
References Study Quality
39 (19926869) 3
32 (25968285) 4
29 (20694945) 4
10 (26165783) 4
3 (29960277) 2
16 (26937758) 4
40 (22795504) 4
36 (21461855) 2
15 (31757237) 4
4 (21127394) 2
37 (28298729) 4
38 (26246280) 4
42 (25731735) 2
41 (24922562) 2
35 (24698073) 4
6 (12461244) 2
1 (29080708) 4
7 (15684286) 2
17 (23347748) 2
CT chest without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 1 1 0 8 3 1 0 0 0
References Study Quality
39 (19926869) 3
32 (25968285) 4
29 (20694945) 4
10 (26165783) 4
3 (29960277) 2
16 (26937758) 4
40 (22795504) 4
36 (21461855) 2
15 (31757237) 4
4 (21127394) 2
37 (28298729) 4
38 (26246280) 4
42 (25731735) 2
41 (24922562) 2
35 (24698073) 4
6 (12461244) 2
1 (29080708) 4
7 (15684286) 2
17 (23347748) 2
MRI chest without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 7 3 2 0 0 1 0 0 0
References Study Quality
45 (27337056) 2
47 (26223818) 2
29 (20694945) 4
10 (26165783) 4
15 (31757237) 4
48 (29271239) 4
46 (26154442) 2
35 (24698073) 4
44 (24608108) 4
1 (29080708) 4
MRI chest without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 7 2 3 1 0 0 0 0 0
References Study Quality
45 (27337056) 2
47 (26223818) 2
29 (20694945) 4
10 (26165783) 4
15 (31757237) 4
48 (29271239) 4
46 (26154442) 2
35 (24698073) 4
44 (24608108) 4
1 (29080708) 4
CT chest without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 7 1 3 1 0 0 1 0 0
References Study Quality
39 (19926869) 3
32 (25968285) 4
29 (20694945) 4
10 (26165783) 4
3 (29960277) 2
16 (26937758) 4
40 (22795504) 4
36 (21461855) 2
15 (31757237) 4
4 (21127394) 2
37 (28298729) 4
38 (26246280) 4
42 (25731735) 2
41 (24922562) 2
35 (24698073) 4
6 (12461244) 2
1 (29080708) 4
7 (15684286) 2
17 (23347748) 2
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 0 2 0 1 0 0 0 0
References Study Quality
43 (25030279) 4
1 (29080708) 4
Variant 2: Chronic cough lasting more than 8 weeks. Increased risk for lung cancer. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Strong ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 0 1 2 2 8
References Study Quality
25 (21714641) 3
51 (24131487) 4
50 (28108179) 4
3 (29960277) 2
16 (26937758) 4
36 (21461855) 2
33 (26662264) 2
31 (25316135) 2
1 (29080708) 4
7 (15684286) 2
17 (23347748) 2
49 (28142680) 2
CT chest with IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 0 4 8 0 0 2 0
References Study Quality
25 (21714641) 3
51 (24131487) 4
53 (27542423) 4
29 (20694945) 4
13 (29094873) 4
50 (28108179) 4
16 (26937758) 4
15 (31757237) 4
1 (29080708) 4
7 (15684286) 2
17 (23347748) 2
49 (28142680) 2
52 (28823540) 4
CT chest without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 0 5 7 2 0 0
References Study Quality
25 (21714641) 3
51 (24131487) 4
53 (27542423) 4
29 (20694945) 4
13 (29094873) 4
50 (28108179) 4
16 (26937758) 4
15 (31757237) 4
1 (29080708) 4
7 (15684286) 2
17 (23347748) 2
49 (28142680) 2
52 (28823540) 4
MRI chest without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 7 2 2 1 0 1 0 0 0
References Study Quality
47 (26223818) 2
46 (26154442) 2
1 (29080708) 4
7 (15684286) 2
17 (23347748) 2
MRI chest without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 7 2 2 2 0 0 0 0 0
References Study Quality
47 (26223818) 2
46 (26154442) 2
1 (29080708) 4
7 (15684286) 2
17 (23347748) 2
CT chest without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 0 1 0 0 0 1 0 0
References Study Quality
25 (21714641) 3
51 (24131487) 4
53 (27542423) 4
29 (20694945) 4
13 (29094873) 4
50 (28108179) 4
16 (26937758) 4
15 (31757237) 4
1 (29080708) 4
7 (15684286) 2
17 (23347748) 2
49 (28142680) 2
52 (28823540) 4
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 0 2 1 0 0 0 1 0
References Study Quality
43 (25030279) 4
Variant 3: Chronic cough lasting more than 8 weeks. Persistent symptoms despite initial clinical evaluation and empiric treatment. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 7 7 0 0 1 0 2 2 3 2 3
CT chest with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 1 0 1 2 2 3 2 3
References Study Quality
39 (19926869) 3
32 (25968285) 4
29 (20694945) 4
3 (29960277) 2
16 (26937758) 4
40 (22795504) 4
4 (21127394) 2
5 (26184784) 4
46 (26154442) 2
31 (25316135) 2
27 (23122673) 2
2 (17285786) 2
6 (12461244) 2
1 (29080708) 4
7 (15684286) 2
17 (23347748) 2
54 (-3191717) 4
CT chest without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 1 0 0 0 2 2 2 3 3
References Study Quality
39 (19926869) 3
32 (25968285) 4
29 (20694945) 4
3 (29960277) 2
16 (26937758) 4
40 (22795504) 4
4 (21127394) 2
5 (26184784) 4
46 (26154442) 2
31 (25316135) 2
27 (23122673) 2
2 (17285786) 2
6 (12461244) 2
1 (29080708) 4
7 (15684286) 2
17 (23347748) 2
54 (-3191717) 4
CT maxillofacial without IV contrast May be appropriate Strong ☢☢ 0.1-1mSv 5 5 1 0 1 3 4 4 0 0 0
References Study Quality
53 (27542423) 4
58 (29121436) 2
16 (26937758) 4
56 (21853442) 2
57 (29202870) 2
12 (22287379) 2
55 (22287369) 2
2 (17285786) 2
1 (29080708) 4
7 (15684286) 2
17 (23347748) 2
59 (26889651) 4
Fluoroscopy biphasic esophagram Usually not appropriate Strong ☢☢☢ 1-10 mSv 2 2 2 7 3 2 0 0 0 0 0
References Study Quality
66 (25910367) 4
67 (27614002) 4
64 (27455157) 4
63 (8222816) 2
69 (29430111) 2
65 (24950025) 4
1 (29080708) 4
7 (15684286) 2
17 (23347748) 2
68 (24473762) 4
MRI heart function and morphology without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 8 1 2 0 1 1 0 0 0
References Study Quality
1 (29080708) 4
CT maxillofacial with IV contrast Usually not appropriate Strong ☢☢ 0.1-1mSv 2 2 5 3 3 0 3 0 0 0 0
References Study Quality
53 (27542423) 4
58 (29121436) 2
16 (26937758) 4
56 (21853442) 2
57 (29202870) 2
12 (22287379) 2
55 (22287369) 2
2 (17285786) 2
1 (29080708) 4
7 (15684286) 2
17 (23347748) 2
59 (26889651) 4
CT chest without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 0 0 1 0 0 1 0 0
References Study Quality
39 (19926869) 3
32 (25968285) 4
29 (20694945) 4
3 (29960277) 2
16 (26937758) 4
40 (22795504) 4
4 (21127394) 2
5 (26184784) 4
46 (26154442) 2
31 (25316135) 2
27 (23122673) 2
2 (17285786) 2
6 (12461244) 2
1 (29080708) 4
7 (15684286) 2
17 (23347748) 2
54 (-3191717) 4
CT maxillofacial without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv 3 3 5 0 3 3 0 2 0 0 0
References Study Quality
53 (27542423) 4
58 (29121436) 2
16 (26937758) 4
56 (21853442) 2
57 (29202870) 2
12 (22287379) 2
55 (22287369) 2
2 (17285786) 2
1 (29080708) 4
7 (15684286) 2
17 (23347748) 2
59 (26889651) 4
V/Q scan lung Usually not appropriate Strong ☢☢☢ 1-10 mSv 1 1 9 1 1 1 0 1 0 0 0
References Study Quality
16 (26937758) 4
2 (17285786) 2
7 (15684286) 2
17 (23347748) 2
FDG-PET/CT skull base to mid-thigh Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 1 1 1 0 1 0 0 0
References Study Quality
60 (19289428) 3
43 (25030279) 4
61 (30152649) 2
62 (23942907) 2
SPECT or SPECT/CT MPI rest and stress Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 8 1 1 1 0 2 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.