Pediatric Chest Imaging

This policy covers pediatric chest imaging services (radiography, CT, MRI and nuclear/PET modalities) for a wide range of indications including lymphadenopathy, mediastinal mass, hemoptysis, cystic fibrosis/bronchiectasis, bronchiolitis, pneumonia, asthma, solitary pulmonary nodule, TB/positive PPD, pectus deformities, vascular malformations, congenital chest diseases and related CPT codes. Major limitations require physician review for atypical presentations, restrict advanced imaging to symptomatic patients after a pertinent clinical evaluation (history, exam, labs and basic imaging), discourage asymptomatic screening and routine repeat studies without evidence of progression or management impact, and note that certain MRI and PET codes are rarely used or not used in pediatrics.

"Documentation of a pertinent clinical evaluation including a detailed history, physical examination, and appropriate laboratory, and basic imaging such as plain radiography or ultrasound prior to a..."