Musculoskeletal (MSK) Imaging Guidelines

Covers advanced MSK imaging (MRI, CT, nuclear medicine bone/leukocyte studies, and limited 3‑D rendering) for specified indications such as complex or occult fractures, AVN, infection/osteomyelitis, soft‑tissue masses, preoperative planning and certain post‑op problems, while excluding routine/serial surveillance imaging, PET for routine MSK use, MRI for simple muscle strains, and imaging for conditions readily diagnosed by plain X‑ray or clinical exam (e.g., most CPPD, obvious ganglion/lipoma without planned surgery). Key requirements: a face‑to‑face evaluation within 60 days, current plain radiographs after symptom onset/change, documented failure of a provider‑directed six‑week conservative trial with clinical re‑evaluation (within 3 months) unless exceptions apply, plus condition‑specific documentation, CPT/code rules, and Medical Director review for atypical requests.

"PET: Inadequate evidence to support routine assessment of musculoskeletal disorders—considered experimental/investigational and requires Medical Director review."