Pediatric Spine Imaging Guidelines

This policy covers pediatric spine imaging procedures (e.g., cervical/thoracic/lumbar MRI with/without contrast, spinal CT, spinal canal MRA and other spine imaging CPT codes) for evaluation of pediatric spinal conditions. It applies to patients <18 years for indications such as back pain, kyphosis/scoliosis, spinal dysraphism, tethered cord, myelopathy and other congenital pediatric spine disorders, and requires a recent (within 60 days) face-to-face evaluation with documented active clinical signs/symptoms for advanced imaging; screening asymptomatic patients, most repeat studies without progression, and atypical presentations require additional physician review, and anesthesia is generally required for children <7 years.

"Documentation demonstrating new onset of disease when repeat spine imaging is requested."

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