Musculoskeletal Imaging Guidelines

Covers advanced musculoskeletal imaging (MRI, CT, ultrasound, nuclear medicine and selective 3‑D rendering) for specified indications (fractures, AVN, infection, soft‑tissue mass, tendon injuries, osteoarthritis/RA, post‑op prosthesis evaluation, osteoporosis screening, etc.) while excluding or deeming investigational certain procedures (positional/weight‑bearing MRI, dGEMRIC, routine PET, many 3‑D rendering reports/separate billing, routine surveillance imaging, and imaging for conditions diagnosable by exam such as ganglions or muscle‑belly strains). Key requirements: an initial face‑to‑face evaluation within 60 days and plain radiographs after the current episode (unless noted), documentation of failure of a recent (within 3 months) six‑week provider‑directed conservative treatment with clinical re‑evaluation before most advanced studies, condition‑specific documentation (e.g., joint aspiration results, EMG/NCV, lesion descriptors), modality substitution rules when MRI cannot be performed, and Medical Director review for non‑specified or restricted requests.