Pediatric Musculoskeletal Imaging Guidelines

This policy covers pediatric musculoskeletal imaging (plain radiography, ultrasound, CT, MRI, and nuclear medicine/PET as applicable) for evaluation of common pediatric MSK symptoms and diagnoses including suspected fractures/dislocations, soft-tissue and bone masses, limping, DDH, AVN/Legg‑Calvé‑Perthes, non‑accidental trauma, infection/osteomyelitis, foreign bodies, inflammatory and tendon injuries, SCFE, Osgood‑Schlatter, Baker cysts and congenital lower‑extremity anomalies. Scope is limited to the pediatric population and common symptom complexes—atypical presentations require physician review—and advanced imaging generally requires prior clinical evaluation and basic imaging (eg, plain x‑ray or ultrasound) with certain CPT codes noted as rarely or not used in pediatrics.

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