GENERAL INFORMATION

It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted. 

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Purpose
Computed tomography (CT) may be used for the diagnosis, evaluation, and management of conditions of the hand, wrist, elbow, and shoulder. CT is not usually the initial imaging test, but it is performed after standard radiographs. CT may be used for preoperative evaluation or to evaluate specific abnormalities of the bones, joints, and soft tissues of the upper extremities.

Special Note

• Plain radiographs must precede CT evaluation, unless otherwise indicated.
• Some indications are for MRI, CT, or MR or CT Arthrogram. More than one should not be approved at the same time.
• If a CT Arthrogram fits approvable criteria below, approve as CT.

Policy
INDICATIONS FOR UPPER EXTREMITY CT
Joint or Muscle Pain^1,2
Negative Findings on Orthopedic Exam and after X-ray Completed and when MRI is contraindicated or cannot be performed, or requested as a CT arthrogram

NOTE: Does not apply to young children (up to age 12)

• Persistent joint or musculotendinous pain unresponsive to conservative treatment*, within the last 6 months, which includes active medical therapy (physical therapy, chiropractic treatments, and/or physician supervised exercise**) of at least four weeks
• With progression or worsening of symptoms during the course of conservative treatment

Joint Specific Provocative Exam Tests and Suspected 
Injuries
NOTE: when MRI is contraindicated or cannot be performed, or requested as a CT arthrogram

NOTE: With a positive orthopedic sign, an initial X-ray is always preferred. However, it is not required to approve advanced imaging. A positive sign is weakness or pain. Any test that suggests joint instability requires further imaging (the below list is not all inclusive)

Shoulder³

• Rotator cuff weakness on exam
• Subscapularis tendon tear⁴
  • Belly press off test
  • Napoleon test
  • Bear Hug test
  • Internal rotation lag
  • Lift-off test
• Supraspinatus tendon tear^5,6
  • Drop Arm
  • Full Can test
  • Empty Can (aka Jobe or Supraspinatus test)
  • Hawkins or Neer test⁷ (only when ordered by an orthopedic surgeon if there is clear documentation in the records that an actual rotator cuff tear is suspected, and NOT just for the evaluation of impingement)
• Infraspinatus/Teres Minor / Biceps tendon tear⁷
  • External rotation lag sign at 0 and 90 degrees
  • Pain or weakness with resisted external rotation testing
  • Hornblower test
  • Popeye sign (if acute finding or for evaluation of surgical correction)
• Labral tear/Instability⁸
  • Grind test
  • Clunk test
  • Crank test, Compression-rotation test
  • O’Brien’s test
  • Anterior load and shift
  • Apprehension test
  • Posterior load and shift test
  • Jerk Test
  • Sulcus sign

Elbow⁹

• Biceps tendon¹⁰
  • Bicipital aponeurosis (BA) flex test
  • Biceps squeeze test
  • Hook test
  • Passive forearm pronation test
  • Reverse Popeye sign (if acute finding or for evaluation of surgical correction)
• Instability⁹
  • Posterolateral rotatory drawer test
  • Tabletop relocation test
  • Valgus stress
  • Varus stress
  • Milking maneuver
  • Push-up test

Wrist^11,12,13

• Lunotriquetral ligament
  • Derby relocation test
  • Reagan test (lunotriquetral ballottement test)
• Triangular Fibrocartilage Complex (TFCC) tear
  • Press test
  • Ulnar foveal sign/test
  • Ulnocarpal stress test
• Scaphoid ligament
  • Watson test (scaphoid shift test)
  • Scapholunate ballottement test

Tendon or Muscle Rupture¹⁴
After X-ray and/ or ultrasound and not listed above
If MRI is contraindicated or cannot be performed
High clinical suspicion of specific tendon rupture based on mechanism of injury and physical findings (i.e., triceps or pectorals tendon rupture)

Shoulder Dislocations^15,16,17,18
If MRI is contraindicated or cannot be performed, unless requested as CT arthrogram or to evaluate glenoid bone stock or size of Hill-Sachs lesion

• Recurrent
• First time in any of the situations below that increase the risk or repeated dislocation
  • Anterior glenoid or humeral(Hill-Sachs lesion) bone loss on X-ray
  • Bony ankart lesion on radiographs
  • 14 – 40-year-old
  • > 40 with exam findings concerning for rotator cuff tear (i.e., weakness on exam)

NOTE: Glenoid bone loss occurs in anterior shoulder dislocation. Severe degrees of glenoid bone loss are shown on axial radiography, but it can be quantified more definitively using CT. This information is important to confirm that an "off-track" lesion is not present, as it helps to predict the likelihood of further dislocation and the need for bone augmentation (Latarjet) or additional soft tissue (Remplissage) surgery. The number of dislocations cannot reliably predict the degree of glenoid bone loss; it is important to quantify glenoid bone loss, initially by arthroscopy and later by CT.

Bone Fracture or Ligament Injury¹⁹
If MRI is contraindicated or cannot be performed

• Suspected occult scaphoid fracture with snuffbox pain after initial X-ray
• Non scaphoid suspected occult, stress or insufficiency fracture with a negative initial X-ray
  • Repeat X-rays in 10 – 14 days if negative or non-diagnostic
• Pathologic fracture on X-ray or CT
• Suspected ligamentous/tendon injury with known fractures on X-ray/CT that may require surgery

Tendon or Muscle Rupture¹⁴
After X-ray and/ or ultrasound and not listed above
If MRI is contraindicated or cannot be performed
High clinical suspicion of specific tendon rupture based on mechanism of injury and physical findings (i.e., triceps or pectorals tendon rupture)

Shoulder Dislocations^15,16,17,18
If MRI is contraindicated or cannot be performed, unless requested as CT arthrogram or to evaluate glenoid bone stock or size of Hill-Sachs lesion

• Recurrent
• First time in any of the situations below that increase the risk or repeated dislocation
  • Anterior glenoid or humeral (Hill-Sachs lesion) bone loss on X-ray
  • Bony ankart lesion on radiographs
  • 14 – 40-year-old
  • > 40 with exam findings concerning for rotator cuff tear (i.e., weakness on exam)

NOTE: Glenoid bone loss occurs in anterior shoulder dislocation. Severe degrees of glenoid bone loss are shown on axial radiography, but it can be quantified more definitively using CT. This information is important to confirm that an "off-track" lesion is not present, as it helps to predict the likelihood of further dislocation and the need for bone augmentation (Latarjet) or additional soft tissue (Remplissage) surgery. The number of dislocations cannot reliably predict the degree of glenoid bone loss; it is important to quantify glenoid bone loss, initially by arthroscopy and later by CT.

Bone Fracture or Ligament Injury¹⁹
If MRI is contraindicated or cannot be performed

• Suspected occult scaphoid fracture with snuffbox pain after initial X-ray
• Non scaphoid suspected occult, stress or insufficiency fracture with a negative initial X-ray
  • Repeat X-rays in 10 – 14 days if negative or nondiagnostic
• Pathologic fracture on X-ray or CT
• Suspected ligamentous/tendon injury with known fractures on X-ray/CT that may require surgery

Fracture Nonunion²⁰
Nonunion or delayed union as demonstrated by no healing between two sets of X-rays. If a fracture has not healed by 4 – 6 months, there is delayed union. Incomplete healing by 6 – 8 months is nonunion.

Osteochondral Lesions^21,22
Defects, Fractures, Osteochondritis Dissecans
In the setting of joint pain or mechanical symptoms
NOTE: X-ray completed

Loose Body or Synovial Chondromatosis²³
After X-ray or ultrasound completed
In the setting of joint pain or mechanical symptoms

Osteonecrosis²⁴
When MRI is contraindicated or cannot be performed

• To further characterize a prior abnormal X-ray
• Normal X-rays but symptomatic and high-risk (e.g. glucocorticosteroid use, renal transplant recipient, glycogen storage disease, alcohol abuse, sickle cell anemia)
• Known osteonecrosis to evaluate a contralateral joint after initial X-rays

e.g., Avascular Necrosis (AVN)

Joint Prosthesis/Replacement²⁵

• Suspected joint prosthesis loosening, infection, or dysfunction, after initial X-rays

Extremity Mass^26,27

• Mass or lesion after non-diagnostic X-ray or ultrasound. (MRI is preferred, CT is better than MRI to evaluate mass calcification or bone involvement and may complement or replace MRI)
  • If superficial mass, then ultrasound is the initial study
  • If deep mass, then X-ray is the initial study
• Vascular malformations
  • After initial evaluation with ultrasound, and results will change management
  • Inconclusive ultrasound
  • Preoperative planning
    • CTA is also approvable
  • Follow up after treatment/embolization

Known Primary Cancer of the Extremity^28,29,30,31

• Initial staging primary extremity tumor
• Follow-up of known primary cancer of patient undergoing active treatment within the past year or as per surveillance imaging guidance for that cancer
• Signs or symptoms or imaging findings suspicious for recurrence
• Suspected metastatic disease with signs/symptoms and after initial imaging with radiographs

Further Evaluation of Indeterminate Findings on Prior Imaging
When MRI cannot be performed, or CT is preferred (i.e. tumor matrix) unless follow-up is otherwise specified within the guideline

• For initial evaluation of an inconclusive finding on a prior imaging report (i.e. X-ray, ultrasound or MRI) that requires further clarification
• One follow-up exam of a prior indeterminate MR/CT finding to ensure no suspicious interval change has occurred (No further surveillance unless specified as highly suspicious or change was found on last follow-up exam.)

Infection of Bone, Joint, or Soft Tissue Abscess^32,33
MRI and nuclear medicine studies are recommended for acute infection as they are more sensitive in detecting early changes of osteomyelitis. CT is better at demonstrating findings of chronic osteomyelitis (sequestra, involucrum, cloaca, sinus tracts) as well as detecting soft tissue gas and foreign bodies.

• Abnormal X-ray or ultrasound
• Negative X-ray or ultrasound but with a clinical suspicion of infection based on either of the following:
  • Signs and symptoms of joint or bone infection include: 
    • Pain and swelling
    • Decreased range of motion
    • Fevers
  • Laboratory findings of infection include any of the following:
    • Elevated ESR or CRP
    • Elevated white blood cell count
    • Positive joint aspiration
• Ulcer (diabetic, pressure, ischemic, traumatic) with signs of infection (redness, warmth, swelling, pain, discharge which may range from white to serosanguineous) that is not improving despite treatment and bone, or deep infection is suspected
  • Increased suspicion if size or temperature increases, bone is exposed/positive probe-to-bone test, new areas of breakdown, new smell

Pre-Operative/Procedural Evaluation

• Pre-operative evaluation for a planned surgery or procedure

Post-Operative/Procedural Evaluation

• When imaging, physical examination or laboratory findings indicate joint infection, delayed or non-healing or other surgical/procedural complications

Arthropathy
Evaluation of Known or Suspected Auto-immune Diseases^34,35
When MRI is contraindicated or cannot be performed

• Further evaluation of an abnormality or non-diagnostic findings on prior imaging
• Initial imaging of a single joint for diagnosis or response to therapy after plain films and appropriate lab tests (e.g., RF, ANA, CRP, ESR)
• To determine change in treatment or when diagnosis is uncertain prior to start of treatment
• Follow-up to determine treatment efficacy in the following:
  • Early rheumatoid arthritis
  • Advanced rheumatoid arthritis if x-ray and ultrasound are equivocal or noncontributory

Known or suspected inflammatory myopathies (If MRI contraindicated or cannot be performed): (such as polymyositis, dermatomyositis, immune-mediated necrotizing myopathy, inclusion body myositis)

• For diagnosis
• For biopsy planning

e.g., Rheumatoid Arthritis

Crystalline Arthropathy³⁶

• Dual-energy CT can be used to characterize crystal deposition disease (i.e., gout) after
  • Appropriate rheumatological work up and initial X-rays and/or ultrasound AND
  • After inconclusive joint aspiration or when joint aspiration cannot be performed OR
  • In the setting of extra-articular crystal deposits (i.e., tendons or bursa)

Foreign Body³⁷
Indeterminate X-ray and ultrasound

Peripheral Nerve Entrapment
When MRI is contraindicated or cannot be performed

• Abnormal electromyogram or nerve conduction study
• Abnormal X-ray or ultrasound
• Clinical suspicion and failed 4 weeks conservative treatment including at least two of the following (active treatment with physical therapy is not required):
  • Activity modification
  • Rest, ice, or heat
  • Splinting or orthotics
  • Medication

NOTE: e.g., carpal tunnel

Brachial Plexopathy^38,39
When MRI is contraindicated or cannot be performed

• Traumatic Brachial Plexopathy: If mechanism of injury is highly suspicious for brachial plexopathy (such as mid-clavicular fracture, shoulder dislocation, contact injury to the neck (burner or stinger syndrome) or penetrating injury)⁴⁰
• Non-traumatic Brachial Plexopathy when Electromyography/Nerve Conduction Velocity (EMG/NCV) studies are suggestive of brachial plexopathy

NOTE: Either Neck MRI, Shoulder MRI or Chest MRI may be appropriate depending on the location of the injury/plexopathy. Only one of these three studies is indicated.

Pediatrics (Up to Age 18)⁴¹
Osteoid osteoma after an X-ray is done

Rationale 
*Conservative Therapy
Musculoskeletal therapy should include a multimodality approach consisting of a combination of active and inactive components. 

Inactive components such as rest, ice, heat, modified activities, medical devices, (including crutches, immobilizer, metal braces, orthotics, rigid stabilizer, or splints, etc. and not to include neoprene sleeves), medications, injections (bursal, and/or joint, not including trigger point), and diathermy, can be utilized.

Active modalities may consist of physical therapy, a physician supervised home exercise program**, and/or chiropractic care.

**Home Exercise Program (HEP)
The following two elements are required to meet guidelines for completion of conservative therapy:

• Information provided on exercise prescription/plan AND
• Follow-up with member with information provided regarding completion of HEP (after suitable 4-week period), or inability to complete HEP due to physical reason- i.e., increased pain, inability to physically perform exercises. 

NOTE: Patient inconvenience or noncompliance without explanation does not constitute “inability to complete” HEP

Contraindications and Preferred Studies

• Contraindications and reasons why a CT/CTA cannot be performed may include: impaired renal function, significant allergy to IV contrast, pregnancy (depending on trimester)
• Contraindications and reasons why an MRI/MRA cannot be performed may include: impaired renal function, claustrophobia, non-MRI compatible devices (such as non-compatible defibrillator or pacemaker), metallic fragments in a high-risk location, patient exceeds wight limit/dimensions of MRI machine

References  

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2. Park V, Kim E, Kim M, Moon H, Yoon J. Breast magnetic resonance imaging for surveillance of women with a personal history of breast cancer: outcomes stratified by interval between definitive surgery and surveillance MR imaging. BMC Cancer. 2018; 18: true. 10.1186/s12885-018-3998-1. 
3. Varacallo M, El Bitar Y, Mair S. Comprehensive Shoulder Evaluation Strategies. [Updated 2023 Aug 4]. StatPearls Publishing. 2023; Accessed Feb 26, 2024: https://www.ncbi.nlm.nih.gov/books/NBK538309/. 
4. Ghasemi S A, McCahon J A, Yoo J C, Toussaint B, McFarland E G et al. Subscapularis tear classification implications regarding treatment and outcomes: consensus decision-making. JSES Reviews, Reports & Techniques. 2023; 3: 201 - 208. 10.1016/j.xrrt.2022.12.004. 
5. Katepun S, Boonsun P, Boonsaeng W S, Apivatgaroon A. Reliability of the Single-Arm and Double-Arm Jobe Test for the Diagnosis of Full-Thickness Supraspinatus Tendon Tear. Orthopaedic Journal of Sports Medicine. 2023; 11: 10.1177/23259671231187631. 
6. Anauate Nicolao F, Yazigi Junior J, Matsunaga F, Archetti Netto N, Belloti J. Comparing shoulder maneuvers to magnetic resonance imaging and arthroscopic. World journal of orthopedics. 2022; 13: 102-111. 10.5312/wjo.v13.i1.102. 
7. Diplock B, Hing W, Marks D. The long head of biceps at the shoulder: a scoping review. BMC Musculoskeletal Disorders. 2023; 24: true. 10.1186/s12891-023-06346-5. 
8. Dean R S, Onsen L, Lima J, Hutchinson M R. Physical Examination Maneuvers for SLAP Lesions: A Systematic Review and Meta-analysis of Individual and Combinations of Maneuvers. The American Journal of Sports Medicine. 2022; 51: 3042 - 3052. 10.1177/03635465221100977. 
9. Karbach L, Elfar J. Elbow Instability: Anatomy, Biomechanics, Diagnostic Maneuvers, and Testing. The Journal of hand surgery. 2017; 42: 118-126. 10.1016/j.jhsa.2016.11.025. 
10. Vishwanathan K, Soni K. Distal biceps rupture: Evaluation and management. Journal of Clinical Orthopaedics & Trauma. 2021; 19: 132 - 138. 10.1016/j.jcot.2021.05.012. 
11. Margulies I, Xu H, Gopman J, Freeman M, Dayan E et al. Narrative Review of Ligamentous Wrist Injuries. Journal of hand and microsurgery. 2021; 13: 55-64. 10.1055/s-0041-1724224. 
12. Pandey T, Slaughter A, Reynolds K, Jambhekar K, David R. Clinical orthopedic examination findings in the upper extremity: correlation with imaging studies and diagnostic efficacy. Radiographics. Mar-Apr 2014; 34: e24-40. 10.1148/rg.342125061. 
13. Ruston J, Konan S, Rubinraut E, Sorene E. Diagnostic accuracy of clinical examination and magnetic resonance imaging for common articular wrist pathology. Acta Orthop Belg. Aug 2013; 79: 375-80. 
14. Shamrock A, Dreyer M, Varacallo M. Achilles Tendon Rupture. [Updated 2023 Aug 17]. StatPearls Publishing. 2023; Accessed on February 15, 2024: https://www.ncbi.nlm.nih.gov/books/NBK430844/. 
15. Doehrmann R, Frush T. Posterior Shoulder Instability. [Updated 2023 July 10]. StatPearls Publishing. 2023; https://www.ncbi.nlm.nih.gov/books/NBK557648/. 
16. Nunna Jr B, Parihar P, Wanjari M, Shetty N, Bora N. High-Resolution Imaging Insights into Shoulder Joint Pain: A Comprehensive Review. Cureus. 2023; 15: e48974. 10.7759/cureus.48974. 
17. Tupe R, Tiwari V. Anteroinferior Glenoid Labrum Lesion (Bankart Lesion). [Updated 2023 Aug 3]. StatPearls Publishing. 2023; https://pubmed.ncbi.nlm.nih.gov/36508533/. 
18. White A, Patel N, Hadley C, Dodson C. An Algorithmic Approach to the Management of Shoulder Instability. Journal of the American Academy of Orthopaedic Surgeons, Global Research and Reviews. 2019; 3: 10.5435/JAAOSGlobal-D-19-00168. 
19. Bencardino J T, Stone T J, Roberts C, Appel M, Baccei S J et al. ACR Appropriateness Criteria® Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae. J Am Coll Radiol. 2017; 14: S293-s306. 10.1016/j.jacr.2017.02.035. 
20. Thomas J, Kehoe J. Bone Nonunion. [Updated 2023 Mar 6]. StatPearls Publishing. 2023; https://www.ncbi.nlm.nih.gov/books/NBK554385/. 
21. van Bergen C, van den Ende K, Ten Brinke B, Eygendaal D. Osteochondritis dissecans of the capitellum in adolescents. World J Orthop. Feb 18, 2016; 7: 102-8. 10.5312/wjo.v7.i2.102. 
22. Anderson M W, Chung C B. Elbow Imaging with an Emphasis on MRI. In: Hodler, J., Kubik-Huch, R.A., von Schulthess, G.K. (eds) Musculoskeletal Diseases 2021-2024. IDKD Springer Series. Springer, Cham. 2021; 23 - 39. 10.1007/978-3-030-71281-5_3. 
23. Habusta S, Mabrouk A, Tuck J. Synovial Chondromatosis. [Updated 2023 Apr 22]. StatPearls Publishing. 2023; https://www.ncbi.nlm.nih.gov/books/NBK470463/. 
24. Ha A S, Chang E Y, Bartolotta R J, Bucknor M D, Chen K C et al. ACR Appropriateness Criteria® Osteonecrosis: 2022 Update. Journal of the American College of Radiology. 2022; 19: S409 - S416. 10.1016/j.jacr.2022.09.009. 
25. Ong N, Zailan I, Tandon A. Imaging update in arthroplasty. Journal of clinical orthopaedics and trauma. 2021; 23: 101649. 10.1016/j.jcot.2021.101649. 
26. Kransdorf M J, Murphey M D, Wessell D E, Cassidy R C, Czuczman G J et al. ACR Appropriateness Criteria® Soft-Tissue Masses. J Am Coll Radiol. 2018; 15: S189-s197. 10.1016/j.jacr.2018.03.012. 
27. Obara P, McCool J, Kalva S P, Majdalany B S, Collins J D et al. ACR Appropriateness Criteria® Clinically Suspected Vascular Malformation of the Extremities. Journal of the American College of Radiology. 2019; 16: S340 - S347. 10.1016/j.jacr.2019.05.013. 
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29. Bestic J M, Wessell D E, Beaman F D, Cassidy R C, Czuczman G J et al. ACR Appropriateness Criteria® Primary Bone Tumors. Journal of the American College of Radiology. 2020; 17: S226 - S238. 10.1016/j.jacr.2020.01.038. 
30. Murphey M D, Kransdorf M J. Staging and Classification of Primary Musculoskeletal Bone and Soft-Tissue Tumors According to the 2020 WHO Update, From the AJR Special Series on Cancer Staging. American Journal of Roentgenology. 2021; 217: 1038 - 1052. 10.2214/AJR.21.25658. 
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33. Pierce J L, Perry M T, Wessell D E, Lenchik L, Ahlawat S et al. ACR Appropriateness Criteria® Suspected Osteomyelitis, Septic Arthritis, or Soft Tissue Infection (Excluding Spine and Diabetic Foot): 2022 Update. Journal of the American College of Radiology. 2022; 19: S473 - S487. 10.1016/j.jacr.2022.09.013. 
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36. Shang J, Zhou L, Wang H, Liu B. Diagnostic Performance of Dual-energy CT Versus Ultrasonography in Gout: A . Academic radiology. 2022; 29: 56-68. 
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Coding Section 

Code	Number	Description
CPT	73200	Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections
	73201	Computed tomography, upper extremity; with contrast material(s)
	73202	Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2019 Forward     

11/06/2024	Annual review, no change to policy intent, policy being reformatted for clarity and consistency. Purpose statement and contraindication/preferred studies statement added, also for clarity and consistency. Updating references.
11/15/2023	Annual review, updating entire policy for clarity. Adding verbiage regarding updated orthopedic signs, dual energy CT, known AVN, vascular malformations, indeterminate findings, Popeye and reverse Popeye sign.
11/11/2022	Annual review, removing table one and updating coverage criteria for clarity.
11/01/2021	Annual review, adding additional information about rotator cuff tear, impingement, non traumatic should instability and glenoid labral tears. Also adding detail regarding shoulder dislocation and medical necessity for suspected bone infection. Also updating description/ overview and references.
11/01/2020	Annual review, updating policy for clarity, adding table 1 and updating references.
11/18/2019	New Policy