Pediatric Head Imaging Guidelines

This policy covers pediatric head imaging—primarily MRI—using the eviCore Clinical Decision Support Tool for children (generally <18 years) with common head symptoms and symptom complexes, including headache, head/face trauma, epilepsy/seizures, macrocephaly/microcephaly/hydrocephalus, craniosynostosis, Chiari/skull-base malformations, intracranial vascular lesions, stroke, demyelinating disease, pituitary dysfunction, sinus/ear disorders, autism and behavioral/psychiatric conditions. Major limitations/requirements: imaging is intended only for symptomatic patients (not routine screening), atypical or unaddressed presentations require physician review, a recent (within 60 days) face‑to‑face exam is expected before advanced imaging, MRI is preferred with anesthesia considerations for infants/young children (typically <7 years) and repeat or contrast studies are limited to situations that will affect management or are specifically indicated.

"Radiopharmaceutical Dacryocystography — CPT 78660"