Musculoskeletal Imaging Guidelines

This policy covers musculoskeletal advanced diagnostic imaging (including radiography, tomographic SPECT with/without CT, 3D rendering and related CPT-coded procedures) for evaluation of conditions such as fractures, avascular necrosis/osteonecrosis, infection/osteomyelitis, osteoarthritis and inflammatory arthritis, soft-tissue/muscle-tendon injuries, gout/CPPD, post‑operative joint replacement issues, limb-length discrepancy and other specified musculoskeletal problems. Coverage is limited by CPT technique/area/day descriptors (e.g., single-area single-day imaging generally not covered; minimum two areas for single-day studies and specific SPECT/SPECT‑CT rules), and requires a face-to-face clinical evaluation within 60 days, prior plain radiographs, a recent (within 3 months) six-week provider-directed conservative treatment trial with clinical re-evaluation documenting failure to improve.

"Dislocation"