Clinically Suspected Adnexal Mass, No Acute Symptoms

Variant: 1 Adult female. Clinically suspected adnexal mass, no acute symptoms. Premenopausal or postmenopausal. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US duplex Doppler pelvis	Usually Appropriate	O
US pelvis transabdominal	Usually Appropriate	O
US pelvis transabdominal and US pelvis transvaginal	Usually Appropriate	O
US pelvis transvaginal	Usually Appropriate	O
MRI pelvis without and with IV contrast	May Be Appropriate	O
MRI pelvis without IV contrast	May Be Appropriate	O
CT pelvis with IV contrast	Usually Not Appropriate	☢☢☢
CT pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 2 Adult female. Adnexal mass, likely benign, no acute symptoms. Premenopausal. Follow-up imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US duplex Doppler pelvis	Usually Appropriate	O
US pelvis transabdominal	Usually Appropriate	O
US pelvis transabdominal and US pelvis transvaginal	Usually Appropriate	O
US pelvis transvaginal	Usually Appropriate	O
MRI pelvis without and with IV contrast	May Be Appropriate	O
MRI pelvis without IV contrast	May Be Appropriate	O
CT pelvis with IV contrast	Usually Not Appropriate	☢☢☢
CT pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 3 Adult female. Adnexal mass, likely benign, no acute symptoms. Postmenopausal. Follow-up Imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US duplex Doppler pelvis	Usually Appropriate	O
US pelvis transabdominal	Usually Appropriate	O
US pelvis transabdominal and US pelvis transvaginal	Usually Appropriate	O
US pelvis transvaginal	Usually Appropriate	O
MRI pelvis without and with IV contrast	May Be Appropriate	O
MRI pelvis without IV contrast	May Be Appropriate	O
CT pelvis with IV contrast	Usually Not Appropriate	☢☢☢
CT pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 4 Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal or postmenopausal. Next imaging study for characterization.

Procedure	Appropriateness Category	Relative Radiation Level
MRI pelvis without and with IV contrast	Usually Appropriate	O
MRI pelvis without IV contrast	May Be Appropriate	O
CT pelvis with IV contrast	Usually Not Appropriate	☢☢☢
CT pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 5 Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal. Follow-up imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US duplex Doppler pelvis	Usually Appropriate	O
US pelvis transabdominal and US pelvis transvaginal	Usually Appropriate	O
US pelvis transvaginal	Usually Appropriate	O
MRI pelvis without and with IV contrast	Usually Appropriate	O
US pelvis transabdominal	May Be Appropriate	O
MRI pelvis without IV contrast	May Be Appropriate	O
CT pelvis with IV contrast	Usually Not Appropriate	☢☢☢
CT pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 6 Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Postmenopausal. Follow-up imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US duplex Doppler pelvis	Usually Appropriate	O
US pelvis transabdominal	Usually Appropriate	O
US pelvis transabdominal and US pelvis transvaginal	Usually Appropriate	O
US pelvis transvaginal	Usually Appropriate	O
MRI pelvis without and with IV contrast	Usually Appropriate	O
MRI pelvis without IV contrast	May Be Appropriate	O
CT pelvis with IV contrast	Usually Not Appropriate	☢☢☢
CT pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 7 Adult female. Adnexal mass, suspicious for malignancy on pelvic US, no acute symptoms. Premenopausal or postmenopausal. Next imaging study for characterization.

Procedure	Appropriateness Category	Relative Radiation Level
MRI pelvis without and with IV contrast	Usually Appropriate	O
MRI pelvis without IV contrast	May Be Appropriate	O
CT pelvis without and with IV contrast	May Be Appropriate (Disagreement)	☢☢☢☢
CT pelvis with IV contrast	Usually Not Appropriate	☢☢☢
CT pelvis without IV contrast	Usually Not Appropriate	☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 8 Female. Clinically suspected adnexal mass, no acute symptoms. Pregnant. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US duplex Doppler pelvis	Usually Appropriate	O
US pelvis transabdominal	Usually Appropriate	O
US pelvis transabdominal and US pelvis transvaginal	Usually Appropriate	O
US pelvis transvaginal	Usually Appropriate	O
MRI pelvis without IV contrast	May Be Appropriate	O
MRI pelvis without and with IV contrast	Usually Not Appropriate	O
CT pelvis with IV contrast	Usually Not Appropriate	☢☢☢
CT pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 9 Female . Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Pregnant. Next imaging study for characterization.

Procedure	Appropriateness Category	Relative Radiation Level
MRI pelvis without IV contrast	Usually Appropriate	O
MRI pelvis without and with IV contrast	Usually Not Appropriate	O
CT pelvis with IV contrast	Usually Not Appropriate	☢☢☢
CT pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Panel Members

Krupa K. Patel-Lippmann, MD^a; Ashish P. Wasnik, MD^b; Esma A. Akin, MD^c; Rochelle F. Andreotti, MD^d; Susan M. Ascher, MD^e; Olga R. Brook, MD^f; Ramez N. Eskander, MD^g; Myra K. Feldman, MD^h; Lisa Po-Lan Jones, ⁱ; Martin A. Martino, MD^j; Maitray D. Patel, MD^k; Michael N. Patlas, MD^l; Margarita A. Revzin, MD, MS^m; Wendaline VanBuren, MDⁿ; Catheryn M. Yashar, MD^o; Stella K. Kang, MD, MS^p.

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Discussion of Procedures by Variant

Variant 1: Adult female. Clinically suspected adnexal mass, no acute symptoms. Premenopausal or postmenopausal. Initial imaging.

Variant 1: Adult female. Clinically suspected adnexal mass, no acute symptoms. Premenopausal or postmenopausal. Initial imaging.
A. CT pelvis with IV contrast

Variant 1: Adult female. Clinically suspected adnexal mass, no acute symptoms. Premenopausal or postmenopausal. Initial imaging.
B. CT pelvis without and with IV contrast

Variant 1: Adult female. Clinically suspected adnexal mass, no acute symptoms. Premenopausal or postmenopausal. Initial imaging.
C. CT pelvis without IV contrast

Variant 1: Adult female. Clinically suspected adnexal mass, no acute symptoms. Premenopausal or postmenopausal. Initial imaging.
D. FDG-PET/CT skull base to mid-thigh

Variant 1: Adult female. Clinically suspected adnexal mass, no acute symptoms. Premenopausal or postmenopausal. Initial imaging.
E. MRI pelvis without and with IV contrast

Variant 1: Adult female. Clinically suspected adnexal mass, no acute symptoms. Premenopausal or postmenopausal. Initial imaging.
F. MRI pelvis without IV contrast

Variant 1: Adult female. Clinically suspected adnexal mass, no acute symptoms. Premenopausal or postmenopausal. Initial imaging.
G. US duplex Doppler pelvis

Variant 1: Adult female. Clinically suspected adnexal mass, no acute symptoms. Premenopausal or postmenopausal. Initial imaging.
H. US pelvis transabdominal

Variant 1: Adult female. Clinically suspected adnexal mass, no acute symptoms. Premenopausal or postmenopausal. Initial imaging.
I. US pelvis transabdominal and US pelvis transvaginal

Variant 1: Adult female. Clinically suspected adnexal mass, no acute symptoms. Premenopausal or postmenopausal. Initial imaging.
J. US pelvis transvaginal

Variant 2: Adult female. Adnexal mass, likely benign, no acute symptoms. Premenopausal. Follow-up imaging.

Variant 2: Adult female. Adnexal mass, likely benign, no acute symptoms. Premenopausal. Follow-up imaging.
A. CT pelvis with IV contrast

Variant 2: Adult female. Adnexal mass, likely benign, no acute symptoms. Premenopausal. Follow-up imaging.
B. CT pelvis without and with IV contrast

Variant 2: Adult female. Adnexal mass, likely benign, no acute symptoms. Premenopausal. Follow-up imaging.
C. CT pelvis without IV contrast

Variant 2: Adult female. Adnexal mass, likely benign, no acute symptoms. Premenopausal. Follow-up imaging.
D. FDG-PET/CT skull base to mid-thigh

Variant 2: Adult female. Adnexal mass, likely benign, no acute symptoms. Premenopausal. Follow-up imaging.
E. MRI pelvis without and with IV contrast

Variant 2: Adult female. Adnexal mass, likely benign, no acute symptoms. Premenopausal. Follow-up imaging.
F. MRI pelvis without IV contrast

Variant 2: Adult female. Adnexal mass, likely benign, no acute symptoms. Premenopausal. Follow-up imaging.
G. US duplex Doppler pelvis

Variant 2: Adult female. Adnexal mass, likely benign, no acute symptoms. Premenopausal. Follow-up imaging.
H. US pelvis transabdominal

Variant 2: Adult female. Adnexal mass, likely benign, no acute symptoms. Premenopausal. Follow-up imaging.
I. US pelvis transabdominal and US pelvis transvaginal

Variant 2: Adult female. Adnexal mass, likely benign, no acute symptoms. Premenopausal. Follow-up imaging.
J. US pelvis transvaginal

Variant 3: Adult female. Adnexal mass, likely benign, no acute symptoms. Postmenopausal. Follow-up Imaging.

Variant 3: Adult female. Adnexal mass, likely benign, no acute symptoms. Postmenopausal. Follow-up Imaging.
A. CT pelvis with IV contrast

Variant 3: Adult female. Adnexal mass, likely benign, no acute symptoms. Postmenopausal. Follow-up Imaging.
B. CT pelvis without and with IV contrast

Variant 3: Adult female. Adnexal mass, likely benign, no acute symptoms. Postmenopausal. Follow-up Imaging.
C. CT pelvis without IV contrast

Variant 3: Adult female. Adnexal mass, likely benign, no acute symptoms. Postmenopausal. Follow-up Imaging.
D. FDG-PET/CT skull base to mid-thigh

Variant 3: Adult female. Adnexal mass, likely benign, no acute symptoms. Postmenopausal. Follow-up Imaging.
E. MRI pelvis without and with IV contrast

Variant 3: Adult female. Adnexal mass, likely benign, no acute symptoms. Postmenopausal. Follow-up Imaging.
F. MRI pelvis without IV contrast

Variant 3: Adult female. Adnexal mass, likely benign, no acute symptoms. Postmenopausal. Follow-up Imaging.
G. US duplex Doppler pelvis

Variant 3: Adult female. Adnexal mass, likely benign, no acute symptoms. Postmenopausal. Follow-up Imaging.
H. US pelvis transabdominal

Variant 3: Adult female. Adnexal mass, likely benign, no acute symptoms. Postmenopausal. Follow-up Imaging.
I. US pelvis transabdominal and US pelvis transvaginal

Variant 3: Adult female. Adnexal mass, likely benign, no acute symptoms. Postmenopausal. Follow-up Imaging.
J. US pelvis transvaginal

Variant 4: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal or postmenopausal. Next imaging study for characterization.

Variant 4: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal or postmenopausal. Next imaging study for characterization.
A. CT pelvis with IV contrast

Variant 5: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal. Follow-up imaging.

Variant 5: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal. Follow-up imaging.
A. CT pelvis with IV contrast

Variant 5: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal. Follow-up imaging.
B. CT pelvis without and with IV contrast

Variant 5: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal. Follow-up imaging.
C. CT pelvis without IV contrast

Variant 5: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal. Follow-up imaging.
D. FDG-PET/CT skull base to mid-thigh

Variant 5: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal. Follow-up imaging.
E. MRI pelvis without and with IV contrast

Variant 5: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal. Follow-up imaging.
F. MRI pelvis without IV contrast

Variant 5: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal. Follow-up imaging.
G. US duplex Doppler pelvis

Variant 5: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal. Follow-up imaging.
H. US pelvis transabdominal

Variant 5: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal. Follow-up imaging.
I. US pelvis transabdominal and US pelvis transvaginal

Variant 5: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal. Follow-up imaging.
J. US pelvis transvaginal

Variant 6: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Postmenopausal. Follow-up imaging.

Variant 6: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Postmenopausal. Follow-up imaging.
A. CT pelvis with IV contrast

Variant 6: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Postmenopausal. Follow-up imaging.
B. CT pelvis without and with IV contrast

Variant 6: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Postmenopausal. Follow-up imaging.
C. CT pelvis without IV contrast

Variant 6: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Postmenopausal. Follow-up imaging.
D. FDG-PET/CT skull base to mid-thigh

Variant 6: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Postmenopausal. Follow-up imaging.
E. MRI pelvis without and with IV contrast

Variant 6: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Postmenopausal. Follow-up imaging.
F. MRI pelvis without IV contrast

Variant 6: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Postmenopausal. Follow-up imaging.
G. US duplex Doppler pelvis

Variant 6: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Postmenopausal. Follow-up imaging.
H. US pelvis transabdominal

Variant 6: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Postmenopausal. Follow-up imaging.
I. US pelvis transabdominal and US pelvis transvaginal

Variant 6: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Postmenopausal. Follow-up imaging.
J. US pelvis transvaginal

Variant 7: Adult female. Adnexal mass, suspicious for malignancy on pelvic US, no acute symptoms. Premenopausal or postmenopausal. Next imaging study for characterization.

Variant 7: Adult female. Adnexal mass, suspicious for malignancy on pelvic US, no acute symptoms. Premenopausal or postmenopausal. Next imaging study for characterization.
A. CT pelvis with IV contrast

Variant 8: Female. Clinically suspected adnexal mass, no acute symptoms. Pregnant. Initial imaging.

Variant 8: Female. Clinically suspected adnexal mass, no acute symptoms. Pregnant. Initial imaging.
A. CT pelvis with IV contrast

Variant 8: Female. Clinically suspected adnexal mass, no acute symptoms. Pregnant. Initial imaging.
B. CT pelvis without and with IV contrast

Variant 8: Female. Clinically suspected adnexal mass, no acute symptoms. Pregnant. Initial imaging.
C. CT pelvis without IV contrast

Variant 8: Female. Clinically suspected adnexal mass, no acute symptoms. Pregnant. Initial imaging.
D. FDG-PET/CT skull base to mid-thigh

Variant 8: Female. Clinically suspected adnexal mass, no acute symptoms. Pregnant. Initial imaging.
E. MRI pelvis without and with IV contrast

Variant 8: Female. Clinically suspected adnexal mass, no acute symptoms. Pregnant. Initial imaging.
F. MRI pelvis without IV contrast

Variant 8: Female. Clinically suspected adnexal mass, no acute symptoms. Pregnant. Initial imaging.
G. US duplex Doppler pelvis

Variant 8: Female. Clinically suspected adnexal mass, no acute symptoms. Pregnant. Initial imaging.
H. US pelvis transabdominal

Variant 8: Female. Clinically suspected adnexal mass, no acute symptoms. Pregnant. Initial imaging.
I. US pelvis transabdominal and US pelvis transvaginal

Variant 8: Female. Clinically suspected adnexal mass, no acute symptoms. Pregnant. Initial imaging.
J. US pelvis transvaginal

Variant 9: Female . Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Pregnant. Next imaging study for characterization.

Variant 9: Female . Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Pregnant. Next imaging study for characterization.
A. CT pelvis with IV contrast

Variant 9: Female . Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Pregnant. Next imaging study for characterization.
B. CT pelvis without and with IV contrast

Variant 9: Female . Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Pregnant. Next imaging study for characterization.
C. CT pelvis without IV contrast

Variant 9: Female . Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Pregnant. Next imaging study for characterization.
D. FDG-PET/CT skull base to mid-thigh

Variant 9: Female . Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Pregnant. Next imaging study for characterization.
E. MRI pelvis without and with IV contrast

Variant 9: Female . Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Pregnant. Next imaging study for characterization.
F. MRI pelvis without IV contrast

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.

Safety Considerations in Pregnant Patients

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.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

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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