Pediatric Spine Imaging Guidelines

This policy covers pediatric spine imaging—primarily MRI of the cervical, thoracic, and lumbar spine (including listed CPTs and select unlisted codes for procedural/radiation planning)—for evaluation and surgical or radiation planning. It applies to pediatric patients with back/neck pain, trauma, kyphosis/scoliosis, spinal dysraphism/tethered cord, myelopathy and other congenital spine disorders, requires physician review for atypical presentations, notes certain PET codes are not used in pediatrics, and restricts unlisted MRI/CT codes to radiation planning/surgical software while the CRC content is proprietary and for clinician use only.

"MRI Lumbar without and with contrast | 72158"

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