Pediatric Head Imaging Guidelines

This policy covers pediatric head imaging (CT, MRI, functional MRI, nuclear medicine, PET and related procedures) for common pediatric symptoms and symptom complexes, including but not limited to headache, head and face trauma, sinusitis, epilepsy/seizure disorders, macrocephaly/microcephaly/hydrocephalus, craniosynostosis, Chiari and skull base malformations, intracranial aneurysms/AVM, pediatric stroke, demyelinating diseases, pituitary dysfunction, ear disorders, autism spectrum and behavioral/psychiatric disorders. Major limitations and requirements include that atypical presentations require physician review, a recent (typically within 60 days) face‑to‑face evaluation with detailed history, neurologic exam and appropriate labs is recommended before advanced imaging, screening asymptomatic patients is generally not supported, and repeat imaging is discouraged unless there is disease progression or a clear impact on management.

"The necessity of repetitive MRIs with GBCAs should be assessed (repeat contrast-enhanced MRIs are limited and require assessment of necessity)."