Pediatric Abdomen Imaging Guidelines

This policy covers pediatric abdominal imaging—criteria for ordering ultrasound, plain radiography, CT, MRI and nuclear medicine studies in children and adolescents for common presentations such as generalized abdominal pain, right lower quadrant pain, flank pain/renal stones, UTI, gastroenteritis, hematuria, IBD, suspected abscess, postoperative pain, masses, liver/adrenal lesions, renovascular hypertension and other pediatric abdominal conditions. Major limitations require a recent (within 60 days) face‑to‑face evaluation with history, physical, appropriate labs and basic imaging (plain radiography or ultrasound) before advanced imaging (CT/MR/nuclear medicine), use of age‑specific pathways (<18 vs ≥18), trial of conservative therapy when clinically appropriate, imaging only when results will affect management, and physician review for atypical presentations; certain PET CPT codes are rarely or not used in pediatrics.

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