Pediatric Musculoskeletal Imaging Guidelines

This policy governs pediatric musculoskeletal imaging—radiographs, MRI, nuclear/PET and associated CPT-coded procedures—for children (<18 years) with conditions such as fractures/dislocations, soft-tissue and bone masses, limping, developmental dysplasia of the hip, AVN/Perthes, suspected child abuse, infection/osteomyelitis, SCFE and other common pediatric musculoskeletal presentations. Major limitations/requirements include assignment to pediatric guidelines for patients <18, a recent face-to-face clinical evaluation within 60 days and basic plain x‑rays (and appropriate labs) required prior to advanced imaging, physician review for atypical presentations, and notation that certain contrast-enhanced MRIs and PET/CT/CT codes are rarely used or limited to specific purposes (e.g., radiation planning/surgical software).

"Upper Extremity MRI non-joint without and with contrast — CPT 73220"