Appropriateness Criteria, Insurance Policies, and the Erosion of Clinical Judgement

The American College of Radiology (ACR) Appropriateness Criteria (AC) were designed to guide evidence-based imaging decisions. Increasingly, however, insurers and electronic health record-embedded clinical decision support (CDS) systems use these criteria to determine coverage, shifting their role from clinical guide to gatekeeping tool. This commentary examines the disconnect between policy and practice, driven by low physician awareness, educational gaps, and difficulty navigating the criteria. When applied rigidly, particularly in insurance reimbursement, these shortcomings risk deepening diagnostic inequities. The example of breast cancer screening for patients with dense breast tissue illustrates how restrictive application can limit access to higher-sensitivity imaging and exacerbate disparities. We argue that guidelines should guide, not govern, and that insurer reliance must be paired with physician training, transparent methodology, and adaptability. Policy reform, expanded coverage mandates, and integration of AC education into medical training are needed to align guidelines with both clinical realities and patient needs.