Musculoskeletal Imaging Guidelines

Advanced musculoskeletal imaging (MRI, CT, ultrasound, nuclear medicine, and limited 3‑D rendering) is covered for specified clinical indications across hand/wrist, hip/pelvis, knee, ankle/foot and post‑op prostheses (e.g., occult or complex fractures, AVN, osteochondral injuries, foreign bodies, infection workups, preop planning), while positional MRI, dGEMRIC, PET, routine serial surveillance scans and imaging for conditions diagnosable by exam (simple ganglion, asymptomatic lipoma, muscle strains) are considered investigational or not routinely indicated. Key requirements include an initial face‑to‑face clinical evaluation within 60 days, plain radiographs after the current symptom episode before advanced imaging, documentation of failure of a 6‑week trial of provider‑directed conservative treatment with clinical re‑evaluation (exceptions apply for acute/explicitly exempt conditions), adherence to single‑study‑per‑area rules, and submission of specific supporting documentation (x‑ray reports, conservative care records, aspiration/culture results when applicable).