Pediatric Oncology Imaging Guidelines

This policy covers pediatric oncology imaging—including conventional and advanced modalities (CT, MRI, PET/nuclear medicine) for evaluation, staging, surveillance, and screening across a broad range of childhood cancers and cancer predisposition syndromes (e.g., leukemias, CNS tumors, lymphomas, neuroblastoma, renal tumors, sarcomas, germ cell tumors, retinoblastoma, and long-term survivors). Major limitations/requirements include a documented clinical evaluation or meaningful contact within 60 days before advanced imaging, histologic confirmation and staging (unless a disease‑specific guideline states otherwise), routine avoidance of advanced imaging in asymptomatic patients except for specified screening syndromes, and physician review for atypical presentations.

"GBCA use should be limited to circumstances in which additional information provided by the contrast agent is necessary"