Pediatric Musculoskeletal Imaging Guidelines

This policy covers pediatric musculoskeletal imaging for patients <18 years, including radiography, CT, MRI and related procedures for common pediatric conditions such as fractures/dislocations, soft‑tissue and bone masses, limping child, developmental dysplasia of the hip, AVN/Legg‑Calvé‑Perthes, suspected child abuse, infection/osteomyelitis, SCFE and other listed indications. Major limitations require a recent (≤60 days) face‑to‑face evaluation with basic imaging (plain x‑ray or ultrasound) before advanced imaging, prefer MRI without contrast unless specified, reserve advanced imaging only if it will change management, atypical presentations need physician review, and anesthesia is often required for very young children (<7 years).

"CT - Upper Extremity CT with contrast — 73201"

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