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HOME BREAST IMAGINGOrdering Guidelines For Breast Imaging (continued)Is the patient under age 40 with the following high risk factors ?Patients may begin EARLY SCREENING if identified with the following high risk. Strong Family History –Mother, Sister, DaughterBegin screening mammogram 10 years prior to onset in relative but not before age 25Chest Irradiation between ages 10-30Begin screening 8 years after radiation but not before age 25Gene Mutations (current examples-BRCA1, BRCA2, CHEK,ATM, CDH1, NBN, NF1, PALB2, PTEN, STK11, TP53)Personally tested positive or is untested with first degree relative (mother, sister, daughter) who tested positiveBegin screening at age 25High risk biopsy resultsBegin annual screening from time of diagnosisIs this a male patient with current breast problem or high risk factor?New clinical breast problem If 25 years of age or older- order as bilateral 2D (not tomo) diagnostic mammogram with diagnostic US order if neededIf 24 years of age or younger- order diagnostic US on affected side with 2D diagnostic mammogram if neededMay continue annual surveillance with a 2D diagnostic mammogram if patient has a personal breast cancer history or is athigh risk (strong family history, BRCA positive, etc.)Is the patient transgender?Male to FemaleOver age 40 and have taken hormones for more than 5 years –Annual Screening MammogramFemale to MaleOver age 40 with breast reduction (not mastectomy) – Annual Screening MammogramExceptionsFamily history of breast cancer – begin 10 years prior to age of onset in first degree relative but not before age 30Genetic mutation (positive) or Klinefelt Syndrome– begin screening at age 25POST-LUMPECTOMY PROTOCOLIf patient has hadRemainder of Follow-upReturn to screening (with negative exam)1 year of 3D DX2 years of 3D4th year1 year of 2D DX2 years of 3D4th year2 years of 3D DX1 year 3D4th year2 years of 2D DX1 year 3D4th year3 years of 2D DX1 year 3D5th yearPatient who declines ANY 3D DX would have 2D DX for full five-years.4

BREAST IMAGINGHOME CT Public Act No. 18-159 effective 1/1/2019An Act Concerning Mammograms, Breast Ultrasounds and Magnetic Resonance Imaging of BreastsEach individual policy in the state of Connecticut must guarantee:A baseline mammogram for women 35-39 years of age, which may be provided by breast tomosynthesis (3D)A mammogram, which may be provided by breast tomosynthesis (3D) at the option of woman covered under the policy,every year for any woman who is forty years of age or older.Breast ImagingSIGNS & SYMPTOMSPARAMETERSORDER/PERFORMSUGGESTED TEXT FOR REQUISITIONAnnual Screening(Asymptomatic)One baseline exambetween age 35-39Annual exam age 40 noupper age limit3D ScreeningMammogramRequisition is not needed - butsuggest using JR Conditional orderwhich allows progression to Diagnostic Mammogram if recommended orScreening Breast US if qualified.Early Screening age 40ExceptionsGenetic Mutation-Maybegin screening 10 yearsprior to onset of the familymember but not beforeage 25.3D ScreeningMammogramOrder as screening mammogramDocument reason for early screeningsuch as personal Hx of positivegenetic mutation testing, strongFamily Hx, etc.Strong Family Hx-Beginscreening 10 years prior toonset of the familymember but not beforeage 25.Family History Examples:Diagnosis of a high riskBx- Begin annual screeningat time of diagnosisregardless of age. Mother age 41- patient beginsscreening at age 31 Sister age 35- patient beginsscreening at age 30NOTE: Patients under age 30 that do notfall into these exceptions are not typicallyimaged with Mammography, Ultrasoundor MRI due to the limited visibility ofdense breast tissue.Chest irradiation betweenages of 10-30. Beginimaging 8 years aftertreatment but not beforeage 25.ImplantsGenetic mutations (current examplesBRCA1, BRCA2, CHEK,ATM, CDH1,NBN, NF1, PALB2, PTEN, STK11, TP53)Same as Annual Screeningabove3D ScreeningMammogramRequisition is not needed - but if usedplease specify: 3D Screening Mammogram-Implants (When orderingidentify that the patient has implantsand is asymptomatic)If patient has signs orsymptoms see ClinicalSigns and Symptomsbelow3D Dx Mammogramproceed to Dx US ifneededRequisition is required. Identify thatthe patient has implants and describesymptoms(continued on next page)TO SCHEDULE AN APPOINTMENT: Call 860.289.3375 or Fax Requisition to 860.290.41085These guidelines are protocol standards for Jefferson Radiology facilities only. Information is subject to change.

HOME Breast Imaging (continued)SIGNS & SYMPTOMSPARAMETERSORDER/PERFORMSUGGESTED TEXT FOR REQUISITIONPersonal History ofBreast CancerLumpectomy 3D Protocol3D Dx MammogramRequisition requiredLumpectomy 2D Protocol(if patient declines 3Dexam)2D Dx MammogramMastectomy3D Unilateral ScreeningMammogramPatient has 3 years of 3D diagnosticmammograms and returns toscreening on 4th yearRequisition requiredPatient has 5 years of 2D diagnosticmammograms and returns to screening on 6th year.Requisition not required forscreening.Note: Post Mastectomy breast w or w/obreast reconstruction are not typicallyimaged. New clinical findings would beevaluated with ultrasound.Clinical Sign orSymptomClinical Sign orSymptom- under age30Mass/PalpableAbnormality3D Dx Mammogramproceed to US if needed(identify area of mass)Focal Pain - new onset/persistent3D Dx Mammogramproceed to Dx US ifneededNipple Discharge- newonset3D Dx Mammogramproceed to Dx US ifneeded(See Clinical Signs orSymptoms above)Breast US proceed tomammo if neededIdentify location of abnormality or painDescribe focal pain or nipple dischargeImaging of Contralateral breastPALPABLE ABNORMALITY Negative bilateral mammo withinlast THREE months- unilateral DXUS Negative bilateral mammobetween 5-9 months - unilateralDX MM proceed to US if needed Negative bilateral mammo overTEN months ago- Bil DX MM &unilateral USFOCAL PAIN/NIPPLE DISCHARGE Negative bilateral mammo withinlast FOUR months-unilateral DXUS Follow guidelines for PalpableAbnormality if last mammogramwas performed over FIVE monthsagoUltrasound exam is scheduled first tolimit Radiation exposure(continued on next page)TO SCHEDULE AN APPOINTMENT: Call 860.289.3375 or Fax Requisition to 860.290.41086These guidelines are protocol standards for Jefferson Radiology facilities only. Information is subject to change.

HOME SIGNS & SYMPTOMSPARAMETERSORDER/PERFORMSUGGESTED TEXT FOR REQUISITIONPregnantPost Partum-LactatingAsymptomatic - ResumeScreening 4 monthspost-partum and/orpost-lactating3D ScreeningMammogram Screening not performed on pregnant orlactating patients due to denseparenchymal tissue.High Risk patients - may screen after 6months regardless of lactation status.Patients at normal risk who continue tobreast feed after 12 months may resumescreening mammography.Breast feeding patients should express milk orbreast feed prior to imaging.Clinical Sign or Symptom(see above)3D DxMammogramRequisition is required with description ofpatient’s symptomsPatient should express milk or breast feedprior to imaging examPersonal history of geneticmutations.Strong family history.Palpable mass/abnormality2D DxMammogramProceed with DxUS if neededPatients with high risk factor (see femaleearly screening for list) may have annualsurveillance as a diagnostic mammogramMale Patients- underage 25New Clinical BreastProblemDiagnostic US onaffected sideproceed with 2DDX Mammogramif neededMale patients should have 2Dmammography due to thin, fatty breasttissue. 3D is not beneficialTransgenderMale to FemaleOver age 40 on hormonesfor 5 yearAnnual ScreeningFamily Hx of Breast Cancer -begin 10 yearsprior to age of onset in first degree relativebut not before age 30Female to MaleOver age 40 with breastreduction (notmastectomy)Annual ScreeningGenetic Mutation (positive) begin screeningat age 25Klinefelter Syndrome (male to femalept.)-begin screening at age 25 yearsMale Patients- overage 25Abnormal ScreeningMammogramBIRADS CAT0-AdditionalEvaluation NeededOrder as 3D Diagnostic:Recall for asymmetry, focal asymmetry ordistortionORIf recommendation on report is for 3DOrder as 2D Diagnostic:Recall for calcifications (ONLY- no otherfindings)ORRecall for mass-order as 2D diagnosticMale patients should have 2Dmammography due to thin, fatty breasttissue. 3D is not beneficialMedicare rules require an order for alldiagnostic imaging including recall exams.A customer care agent will contact thepatient to schedule recommended imagingException: Health Care Provider is responsiblefor scheduling MRI due to authorization orpre-determination requirements.(continued on next page) 7BREAST IMAGINGBreast Imaging (continued)

HOME BREAST IMAGINGBreast Imaging (continued)ORDER/PERFORMSIGNS & SYMPTOMSPARAMETERSShort-intervalFollow-upBIRADS CAT 3(6mo-12mo-18mo)Asymmetry-focal asymmetry or distortion - 3D DXBreast MRICRITERIA FOR BREAST MRI Requires and order andpre-authorization or pre-determination. Signs & Symptoms orrecommendation fromabnormal breast imaging Breast Cancer - extent ofdisease. Breast implant evaluation. High Risk Screening(lifetime risk 20%)Mass2D DX @ 6 months and 18 months3D DX @ 12 months and 24 monthsBreast MRIBilateralSUGGESTED TEXT FOR REQUISITIONThe Health Care Provider will receive areminder letter 30 days prior to due daterequesting an order. Please disregard, iforder has already been provided.Health Care Provider is responsible forscheduling due to insurance authorizationor pre-determination requirements forMRI exams.CT Public Act No. 18-159 effective 1/1/2019An Act Concerning Mammograms, Breast Ultrasounds and Magnetic Resonance Imaging of BreastsEach individual policy in the state of Connecticut must guarantee:Comprehensive ultrasound screening of the entire breast if mammogram demonstrates heterogeneous or extremely dense breast tissue or if awoman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, or positive genetictesting. No policy shall impose a copayment that exceed a maximum of twenty dollars.Screening BreastUltrasoundCRITERIA FOR SBUS Requires an order indicatingthe reason for the exam ie:dense breast/Hx of breastcancer. Breast composition mustbe C - heterogeneouslydense or D - extremelydense. 35 years of age A minimum of 12 monthssince last SBUS exam Patient cannot replace aMammogram exam withan SBUS exam Documentation of negativeBirads - 1 or 2 Mammogram in previous 13 months A copy of the report isneeded if exam wasperformed elsewhere. Patient will be required tosign an insurance S - EXCLUSIONS ALLOWED Patient with a personal history of breastcancer may have SBUS exam regardlessof breast compositionPatient with DENSE BREASTCOMPOSITION under the age of 35 witha very strong pre-menopausal familyhistory of breast cancerPatients over the age of 30 with geneticmutations may have SBUS.To provide optimal interpretive quality andensure insurance coverage we discouragesame day scheduling of SBUS andscreening mammograms.Patients with High Risk LobularCarcinoma In Situ/Atypical ductalHyperplasia would be in general screeningpopulation and only qualify for SBUS withnegative mammogram and dense breastcomposition.Patients with short intervalrecommendation for Dx US may have anSBUS following a Dx US evaluating theprevious area of concern.Patients with short intervalrecommendation for Dx MM only mayhave SBUS at their regular yearly SBUSinterval.8

HOME CT ORDERING GUIDECTCT GeneralHead.9Neck. 10Spine. 11Chest (includes lung cancer screening). 12Abdomen & Pelvis. 13Extremities. 15MRICT Angiography (CTA)CT Arthrography. 16Head & Neck. 16Chest. 17Abdomen & Pelvis. 18Extremities. 18NUCLEAR MEDICINEULTRASOUNDTO SCHEDULE AN APPOINTMENT: Call 860.289.3375 or Fax Requisition to 860.290.4108These guidelines are protocol standards for Jefferson Radiology facilities only. Information is subject to change.TAB3

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HOME CT - GENERALCT General - HeadBODY PARTREASON FOR EXAMPROCEDURE TO PRE-CERTCPT CODEHead/BrainTraumaHeadachesCVA, StrokeBleed, HemorrhageAlzheimer’sMemory Loss, ConfusionVertigo, DizzinessShunt CheckHydrocephalusCT Head, Brain Without Contrast70450Metastatic StagingMass/TumorInfectionHeadache w. Associated NeurologicSignsCT Head, Brain With Contrast70460MelanomaHIVToxoplasmosisCT Head, Brain Without andWith Contrast70470TraumaFractureForeign BodyGraves DiseaseCT Orbit Without Contrast70480Pseudo TumorMassExophthalmusPainAbscessCT Orbit With Contrast70481RetinoblastomaCT Orbit Without andWith Contrast70482Orbits(continued on next page)TO SCHEDULE AN APPOINTMENT: Call 860.289.3375 or Fax Requisition to 860.290.4108These guidelines are protocol standards for Jefferson Radiology facilities only. Information is subject to change.9

CT - GENERALHOME CT General - Head (continued)BODY PARTREASON FOR EXAMPROCEDURE TO PRE-CERTCPT CODEFacial BonesTraumaFractureCT Maxilofacial Without contrast70486CellulitisCT Maxilofacia With Contrast70487Sinuses LimitedSinusitis (billing will apply modifier 52)***This is for limited exam ONLY***CT Limited76380Sinus FullOstiomeatal Complex Sinusitis PolypsFunctional Endoscopic Sinus Surgery***VTI, Landmark, Stryker***CT Landmark SinusCT Landmark or CT Maxilofacia70486Temporal BoneHearing Loss, Conductive*CholesteatomaTrauma*Sensory neuro hearing loss,order MRI with contrast.CT Inner Ears, Temporal BonesWithout Contrast70480CT Inner Ears, Temporal BonesWith Contrast70481BODY PARTREASON FOR EXAMPROCEDURE TO PRE-CERTCPT CODENeckMassInfectionCancer WorkupsParotid MassHoarsenessVocal Chord ParalysisVoice ChangesCT Neck With Contrast70491If elevated creatinine,order without contrastCT Neck Without Contrast70490Submandibular StoneInfection of Submandibular GlandInfection of Parotid GlandParotid StoneCT Soft Tissue NeckWithout and With ContrastCT General - Neck70492TO SCHEDULE AN APPOINTMENT: Call 860.289.3375 or Fax Requisition to 860.290.410810These guidelines are protocol standards for Jefferson Radiology facilities only. Information is subject to change.

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Radiology is a partnership of over 60 radiologists, offering sub-specialized diagnostic and interventional imaging services. All the physicians in the group are board certified, and are committed to delivering the highest quality of radiology and imaging services possible. Diagnostic Services Bone Densitometry CT Scan (multi-slice)