ACR Appropriateness Criteria®

Breast Microcalcifications — Initial Diagnostic Workup

Nonpalpable Mammographic Findings (Excluding Calcifications)

Palpable Breast Masses

Stage I Breast Carcinoma (Revised)

Acute Chest Pain — Suspected Aortic Dissection (Revised)

Acute Chest Pain — Suspected Pulmonary Embolism (Revised)

Acute Nonspecfic Chest Pain — Low Probability of Coronary Artery Disease (Revised)

Chest Pain Suggestive of Acute Coronary Syndrome

Chronic Chest Pain — High Probability of Coronary Artery Disease

Chronic Chest Pain — Low to Intermediate Probability of Coronary Artery Disease

Dyspnea — Suspected Cardiac Origin

Known or Suspected Congenital Heart Disease in the Adult

Suspected Infective Endocarditis

Acute Abdominal Pain and Fever or Suspected Abdominal Abscess

Acute Pancreatitis

Blunt Abdominal Trauma

Colorectal Cancer Screening

Crohn Disease* (Revised)

Dysphagia

Jaundice

Left Lower Quadrant Pain — Suspected Diverticulitis (Revised)

Liver Lesion — Initial Characterization

Palpable Abdominal Mass

Pretreatment Staging of Colorectal Cancer (Revised)

Right Lower Quadrant Pain — Suspected Appendicitis*

Right Upper Quadrant Pain

Suspected Liver Metastases

Suspected Small Bowel Obstruction

*This topic also includes pediatric imaging recommendations

Acute Hand and Wrist Trauma

Acute Shoulder Pain

Acute Trauma to the Foot

Acute Trauma to the Knee*

Avascular Necrosis (Osteonecrosis) of the Hip

Chronic Ankle Pain

Chronic Elbow Pain (Revised)

Chronic Foot Pain*

Chronic Hip Pain (Revised)

Chronic Neck Pain

Chronic Wrist Pain

Follow-up of Malignant or Aggressive Musculoskeletal Tumors

Imaging after Total Knee Arthroplasty

Metastatic Bone Disease

Nontraumatic Knee Pain*

Osteoporosis and Bone Mineral Density*

Primary Bone Tumors

Soft Tissue Masses

Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae

Suspected Ankle Fracture

Suspected Osteomyelitis of the Foot in Patients with Diabetes Mellitus

Suspected Spine Trauma*

*This topic also includes pediatric imaging recommendations

Ataxia*

Cerebrovascular Disease

Cranial Neuropathy

Dementia and Movement Disorders

Focal Neurologic Deficit

Head Trauma*

Headache

Low Back Pain (Revised)

Myelopathy (Revised)

Neck Mass/Adenopathy*

Neuroendocrine Imaging

Orbits, Vision and Visual Loss*

Plexopathy

Seizures and Epilepsy

Sinonasal Disease

Suspected Spine Trauma*

Vertigo and Hearing Loss

*This topic also includes pediatric imaging recommendations

Developmental Dysplasia of the Hip — Child

Fever Without Source — Child (Revised)

Headache — Child

Hematuria — Child

Limping Child — Ages 0-5 Years

Seizures — Child

Sinusitis — Child

Suspected Physical Abuse — Child

Urinary Tract Infection — Child

Vomiting in Infants up to 3 Months of Age

Additional topics that include pediatric imaging recommendations

Acute Trauma to the Knee*

Ataxia*

Chronic Foot Pain*

Crohn Disease*

Head Trauma*

Neck Mass / Adenopathy*

Nontraumatic Knee Pain*

Orbits, Vision and Visual Loss*

Osteoporosis and Bone Mineral Density

Right Lower Quadrant Pain — Suspected Appendicitis*

Suspected Spine Trauma*

Acute Respiratory Illness Illness in Immunocompetent Patients

Acute Respiratory Illness in Immunocompromised Patients (Revised)

Chronic Dyspnea — Suspected Pulmonary Origin

Hemoptysis

Non-Invasive Clinical Staging of Bronchogenic Carcinoma

Rib Fractures (Revised)

Routine Admission and Preoperative Chest Radiography (Revised)

Routine Chest Radiograph in ICU Patients (Revised)

Routine Chest Radiographs in Uncomplicated Hypertension (Revised)

Screening for Pulmonary Metastases

Solitary Pulmonary Nodule

Acute Onset Flank Pain — Suspicion of Stone Disease

Acute Onset of Scrotal Pain — without Trauma, without Antecedent Mass

Acute Pyelonephritis

Follow-up Imaging of Bladder Carcinoma

Follow-up of Renal Cell Carcinoma

Hematospermia

Hematuria

Incidentally Discovered Adrenal Mass

Indeterminate Renal Masses

Obstructive Voiding Symptoms Secondary to Prostate Disease

Post-treatment Follow-up of Prostate Cancer

Pretreatment Staging of Invasive Bladder Cancer

Pretreatment Staging Prostate Cancer

Recurrent Lower Urinary Tract Infections in Women

Renal Cell Carcinoma Staging (Revised)

Renal Failure

Renal Trauma

Renovascular Hypertension

Staging of Testicular Malignancy

Suspected Lower Urinary Tract Trauma

Abdominal Aortic Aneurysm: Interventional Planning and Follow-up

Blunt Abdominal Trauma

Blunt Chest Trauma — Suspected Aortic Injury (Revised)

Claudication — Suspected Vascular Etiology

Follow-up of Lower Extremity Arterial Bypass Surgery

Pulsatile Abdominal Mass, Suspected Abdominal Aortic Aneurysm

Radiologic Management of Upper Gastrointestinal Bleeding

Recurrent Symptoms Following Lower Extremity Angioplasty

Sudden Onset of Cold, Painful Leg

Suspected Lower Extremity Deep Vein Thrombosis

Suspected Upper Extremity Deep Vein Thrombosis (Revised)

Abnormal Vaginal Bleeding

Acute Pelvic Pain in the Reproductive Age Group

Assessment of Gravid Cervix (Revised)

Clinically Suspected Adnexal Mass

First Trimester Bleeding

Growth Disturbances—Risk of Intrauterine Growth Restriction

Multiple Gestations (Revised)

Ovarian Cancer Screening

Pretreatment Evaluation and Follow-up of Endometrial Cancer of the Uterus

Pretreatment Planning of Invasive Cancer of the Cervix (Revised)

Second and Third Trimester Bleeding

Staging and Follow-up of Ovarian Cancer

Abdominal Aortic Aneurysm: Interventional Planning and Follow-up

Radiologic Management of Benign and Malignant Biliary Obstruction

Radiologic Management of Hepatic Malignancy (Revised)

Radiologic Management of Iliac Artery Occlusive Disease

Radiologic Management of Infected Fluid Collections (Revised)

Radiologic Management of Inferior Vena Cava Filters

Radiologic Management of Lower Gastrointestinal Tract Bleeding (Revised)

Radiologic Management of Lower Extremity Venous Insusfficiency

Radiologic Management of Mesenteric Ischemia

Radiologic Management of Thoracic Nodules and Masses

Radiologic Management of Upper Gastrointestinal Bleeding

Radiologic Management of Urinary Tract Obstruction

Radiologic Management of Uterine Leiomyomas

Radiologic Management of Vertebral Compression Fractures

Non-Spine Bone Metastases (Revised)

Follow-up and Retreatment of Brain Metastases (Revised)

Multiple Brain Metastases (Revised)

Pre-Irradiation Evaluation and Management of Brain Metastases (Revised)

Single Brain Metastasis

Conservative Surgery and Radiation — Stage I and II Breast Carcinoma

Ductal Carcinoma in Situ (Revised)

Local Regional Recurrence and Salvage Surgery — Breast Cancer

Locally Advanced Breast Cancer

Postmastectomy Radiotherapy

Advanced Cervical Cancer

Pretreatment Evaluation and Follow-up of Endometrial Cancer of the Uterus

Role of Adjuvant Therapy in the Management of Early Stage Cervical Cancer

Adjuvant Therapy for Resected Squamous Cell Carcinoma of the Head and Neck

Ipsilateral Radiation for Squamous Cell Carcinoma of the Tonsil (New)

Local-Regional Therapy for Resectable Oropharyngeal Squamous Cell Carcinomas

Retreatment of Recurrent Head and Neck Cancer after Prior Definitive Radiation

Induction and Adjuvant Therapy for N2 Non-Small-Cell Lung Cancer

Non-Invasive Clinical Staging of Bronchogenic Carcinoma

Nonsurgical Treatment for Non-Small-Cell Lung Cancer: Good Performance Status/Definitive Intent

Nonsurgical Treatment for Non-Small-Cell Lung Cancer: Poor Performance Status or Palliative Intent

Postoperative Adjuvant Therapy in Non-Small-Cell Lung Cancer

Follow-up of Hodgkin's Lymphoma

Hodgkin's Lymphoma — Favorable Prognosis Stage I and II

Hodgkin's Lymphoma — Stage III and IV

Hodgkin's Lymphoma — Unfavorable Clinical Stage I and II

Definitive External Beam Irradiation in Stage T1 and T2 Prostate Cancer

External Beam Radiation Therapy Treatment Planning for Clinically Localized Prostate Cancer (Revised)

Locally Advanced (High Risk) Prostate Cancer

Permanent Source Brachytherapy for Prostate Cancer

Postradical Prostatectomy Irradiation in Prostate Cancer

Pretreatment Staging Prostate Cancer

Anal Cancer

Local Excision in Early Stage Rectal Cancer

Rectal Cancer—Metastatic Disease at Presentation

Recurrent Rectal Cancer (Revised)

Resectable Rectal Cancer

The ACR Task Force on Appropriateness Criteria was created and panel chairs were appointed in late 1993. In 1994, deliberations had begun to develop nationally accepted, scientifically-based guidelines to assist referring physicians in making appropriate imaging decisions for given patient clinical conditions in order to provide the College’s perspective on how to best use limited health care resources.

In creating the ACR AC, the Task Force incorporated attributes for developing acceptable medical practice guidelines used by the Agency for Healthcare Research and Quality (AHRQ) as designed by the Institute of Medicine. From the beginning, the methodology relied on a combination of evidence and when the data from scientific outcome and technology assessment studies are insufficient, expert consensus. Additionally, the methodology employs the input of physicians from other medical specialties to provide important clinical perspectives.

The AHRQ is explicit in stating its intent that scientific evidence should be used as much as possible but that judgment and group consensus will be necessary in the development of medical guidelines. The National Guidelines Clearinghouse (NGC), one of the initiatives of AHRQ, is a public resource for evidence-based clinical practice guidelines. The ACR AC topics are posted on the NGC site.

Currently, the ACR AC are the most comprehensive evidence based guidelines for diagnostic imaging selection, radiotherapy protocols, and image guided interventional procedures. They embody the best, current evidence for selecting appropriate diagnostic imaging and interventional procedures for numerous clinical conditions.

¹ Cascade PN. Setting appropriateness guidelines for Radiology. Radiology 1994; 192(1):50A-54A.
² Cascade PN. The American College of Radiology. ACR Appropriateness Criteria project. Radiology 2000; 214 Suppl:3-46.

Topic Review Process-Diagnostic Imaging

Topic Review Process-Interventional Radiology

Topic Review Process-Radiation Oncology

Rating Round Information

Sample Rating Round Form

Sample Rating Round Tabulation Form

ACR Appropriateness Criteria® Citation Information

The American College of Radiology suggests the following format when citing the ACR Appropriateness Criteria®:

American College of Radiology. ACR Appropriateness Criteria®: <title>. Available at: <URL>. Accessed <DATE>.

Example:

American College of Radiology. ACR Appropriateness Criteria®: acute chest pain — suspected aortic dissection. Available at:  http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/
AcuteChestPainSuspectedAorticDissectionDoc2.aspx. Accessed 12 December 2011.

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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.

The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply society endorsement of the final document.

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