Pediatric Spine Imaging Guidelines

This policy covers pediatric spine imaging—primarily MRI (cervical, thoracic, lumbar), MRA, CT and related procedures—for patients <18 years with spine-related conditions such as back pain, kyphosis/scoliosis, spinal dysraphism, tethered cord and other congenital or acquired pediatric spine disorders. Advanced imaging generally requires a recent (within 60 days) face-to-face visit with detailed history and neurologic exam plus basic imaging/labs, is limited to patients with documented active signs or symptoms (no asymptomatic screening), restricts repeat studies and routine gadolinium use unless results will change management, and atypical presentations require physician review; MRI is preferred and anesthesia considerations apply for young children (<7 years).

"CT - Thoracic CT with contrast: (no code listed in excerpt)"

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