Pediatric Abdomen Imaging Guidelines

This policy covers pediatric abdominal imaging procedures (ultrasound and advanced imaging modalities) for a broad array of pediatric abdominal conditions including generalized abdominal pain, right lower quadrant pain/suspected appendicitis, flank pain/renal stones, UTI, acute gastroenteritis, hematuria, liver and adrenal lesion characterization, inflammatory bowel disease, postoperative pain, abdominal mass, renovascular hypertension workup, and other specified indications. Major limitations require prior pertinent clinical evaluation (history, exam, labs and usually ultrasound before advanced imaging), restrict routine screening/asymptomatic imaging and unnecessary repeat studies, and mandate physician review for atypical presentations; several PET codes are rarely or not used in pediatrics.

"This tool addresses common symptoms and symptom complexes."

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