Pediatric Spine Imaging Guidelines

This policy covers pediatric spine imaging procedures (MRI, CT, SPECT/SPECT‑CT and radiopharmaceutical localization, vascular flow/blood pool studies and associated CPT codes) for patients under 18 with spine-related complaints such as back/neck pain, trauma, kyphosis/scoliosis, spinal dysraphism, tethered cord, myelopathy and other congenital pediatric spine disorders. Major limitations require documented active clinical signs/symptoms and a recent (≤60 days) face‑to‑face evaluation prior to advanced imaging (with basic evaluation/labs/plain radiographs first), exclude routine screening of asymptomatic patients, restrict repeat studies unless progression or management impact is documented, and mandate physician review for atypical presentations not addressed by the tool.

"This tool addresses common symptoms and symptom complexes."

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