New case law could put radiologists on hook for imaging-order appropriateness
New case law could potentially put radiologists on the hook for the appropriateness of imaging orders, according to one expert.
Yale Medicine’s Jonathan L. Mezrich, MD, JD, MBA, recently discussed this emerging legal concern in an opinion piece published by the American Journal of Roentgenology. He cited a 2025 Ohio appellate case, Kelley v. Horton, which challenged a neurologist for ordering the wrong type of imaging.
As part of the proceedings, attorneys successfully convinced a judge to allow the American College of Radiology’s Appropriateness Criteria to be used in the case, Mezrich noted. He believes this development should open the eyes of radiologists, who in the future may be expected to speak up about the merits of referrer requests.
“Radiology practices are increasingly implementing workflows to allow certain examination types to be protocoled without direct radiologist oversight (e.g., by technologists, artificial intelligence algorithms, or other so-called ‘auto-protocolling’ solutions),” Mezrich, an emergency imaging specialist at Yale and former practicing attorney, wrote April 15. “Radiologists should exercise caution when implementing such protocoling workflows that bypass independent radiologist review and remain diligent in contacting ordering practitioners regarding requests for inappropriate examination types,” he added.
In the case, a patient presented to a neurologist with chronic headaches that had increased in frequency, with the source of pain changing. The physician ordered an unenhanced MRI, which the radiologist then interpreted as negative. Two years later, the patient returned with significant vision loss in their right eye. This time, a different neurologist ordered another MRI, both with and without contrast.
The radiologist interpreted this new exam as demonstrating meningioma encapsulating the right optic nerve. At trial, the rad testified that the tumor was subtly present on the first exam but only detectable with the benefit of hindsight from the subsequent contrast-enhanced MRI.
The court eventually ruled in favor of the defendants, deeming that no malpractice had occurred, with the decision upheld on appeal. However, the court permitted use of the appropriateness criteria at trial. First launched in 1993, ACR’s criteria cover nearly 4,000 clinical scenarios, helping referring physicians avoid ordering wasteful and unnecessary scans. Mezrich noted that the case challenges conventional views that the ACR criteria are only advisory and questioning rads’ role in these scenarios.
“If a practitioner orders a study that is objectively inappropriate or otherwise does not satisfy the [appropriateness criteria], does the radiologist have legal exposure if they perform the study and patient harm ensues?” the author pondered.
In Kelley v. Horton, the neurologist attorney’s expert witness introduced the appropriateness criteria during trial. The appeals court did not ultimately address whether the ACR guidelines reflect standard of care, Mezrich noted. However, the court offered that the use of the criteria would not have impacted the final decision, with other testimony already proving the neurologist did not breach their duties as a doc.
Mezrich contends the implications of the case derive, not from the proceedings, but the “mere allowance” of appropriateness criteria to help determine liability.
“The import of the Kelley case is the unopposed introduction of the AC in court, potentially elevating radiologists’ legal obligations to apply the AC and not simply perform imaging as ordered,” Mezrich concluded. “The potential for the AC to serve as the basis for radiologist liability in court...could raise challenges for practicing radiologists. In the context of growing imaging volumes and a radiologist shortage, it would likely be impractical for radiologists to thoroughly review every imaging order for AC adherence and discuss nonadherent requests with ordering practitioners.”
The American College of Radiology declined to comment on the opinion piece Wednesday.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.