Pediatric Musculoskeletal Imaging Guidelines

This policy covers pediatric musculoskeletal imaging for common pediatric symptoms and symptom complexes—including fractures/dislocations, soft tissue and bone masses, limping child, developmental dysplasia of the hip, AVN/Legg‑Calvé‑Perthes, suspected child abuse, infection/osteomyelitis, SCFE, muscle/tendon injuries, and associated CPT codes. Major limitations require physician review for atypical presentations, mandate plain radiography prior to advanced imaging, generally require a recent (≤60 days) face‑to‑face evaluation with history/physical and appropriate labs before CT/MR/NM, and restrict repeat or advanced imaging unless there is progression or documentation that the results will affect management; MRIs with contrast are noted as rarely used.

"PEDMS-15: Limb Length Discrepancy"

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