Pediatric and Special Populations Spine Imaging Guidelines

This policy authorizes advanced pediatric spine imaging (MRI preferred; CT, nuclear medicine/SPECT, bone scan and ultrasound allowed for specific indications such as spondylolysis, suspected fracture, infection, trauma, tethered cord/occult dysraphism, preoperative bony detail and surveillance) and excludes routine screening of asymptomatic individuals and many non‑specific cutaneous findings. Key requirements are a documented pertinent clinical evaluation including a detailed history and neurologic exam (telehealth acceptable) with plain x‑rays available when required; children ≤5 are generally eligible for MRI for symptomatic disease, children ≥6 need one or more pediatric “red flags” or a documented recent (within 3 months) 4‑week provider‑supervised conservative treatment before advanced imaging is approved, and modality‑specific documentation is required for CT/SPECT/nuclear studies with limits on repeat imaging and on substituting CT to avoid sedation.