Pediatric Musculoskeletal Imaging Guidelines

This policy covers pediatric musculoskeletal imaging—including radiographs, MRI, CT, SPECT/nuclear studies and related CPT-coded procedures—for evaluation of common pediatric conditions such as fractures and dislocations, soft tissue and bone masses, limping child, developmental dysplasia of the hip, avascular necrosis/Legg–Calvé–Perthes, suspected child abuse, infection/osteomyelitis, SCFE, Osgood–Schlatter, limb length discrepancy and other congenital or inflammatory musculoskeletal disorders. Major limitations/requirements include physician review for atypical presentations, proprietary CRC use limited to individual clinical reference for delegated patients, certain contrast-enhanced MRI codes and some nuclear medicine CPT codes are noted as rarely or not used in pediatrics, and code-specific procedural constraints apply.

"Ultrasound, infant hips; dynamic (requiring physician manipulation) — CPT 76885"