Pediatric Abdomen Imaging Guidelines

This policy covers pediatric abdominal diagnostic imaging (including advanced imaging procedure codes) for children under 18 for common symptom complexes and conditions such as generalized and focal abdominal pain (e.g., RLQ, RUQ, flank), renal stones, UTI, gastroenteritis, hematuria, inflammatory bowel disease, liver/adrenal lesions, postoperative pain, and related indications. Major limitations require physician review for atypical or non‑addressed presentations, routine clinical evaluation and basic imaging (plain radiography or ultrasound) prior to advanced imaging, restriction of repeat studies absent documented change or impact on management, avoidance of advanced imaging that will not alter care, and adherence to pediatric‑only guidance (with adults following general abdomen guidelines) and contraindications to gadolinium.

"CPT 78811 (PET Imaging; limited area) — 'this code not used in pediatrics' (document note)."