Pediatric Spine Imaging Guidelines

This policy covers pediatric spine imaging procedures (e.g., cervical/thoracic/lumbar MRI CPT 72141–72149/72156–72158 and related spine imaging, including unlisted MRI CPT 76498) for evaluation of common pediatric spine indications such as back/neck pain, trauma, kyphosis/scoliosis, spinal dysraphism, tethered cord, myelopathy and other congenital pediatric spine disorders in patients <18 years. Major limitations/requirements: imaging is for documented active clinical signs (not asymptomatic screening), generally requires a recent (within 60 days) face‑to‑face evaluation with exam/labs/basic imaging, repeat studies are limited to situations that alter management or show progression, atypical presentations need physician review, and anesthesia is usually required for infants and most children <7 years.

"Altered Mental Status"

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