This General Policy section provides an overview of the basic criteria for which pediatric abdomen imaging may be medically necessary. Details regarding specific conditions or clinical presentations and the associated criteria for which imaging is medically necessary are described in subsequent sections.

PEDAB-1.1: Pediatric Abdominal Imaging Age Considerations

For this condition imaging is medically necessary based on the following criteria:

Many conditions affecting the abdomen in the pediatric population are different diagnoses than those occurring in the adult population. For those diseases which occur in both pediatric and adult populations, differences may exist in management due to member age, comorbidities, and differences in disease natural history between children and adults.

† Members age <18 years old should be imaged according to the Pediatric Abdomen Imaging Guidelines, and members age ≥18 years should be imaged according to the Abdomen Imaging Guidelines, except where directed otherwise by a specific guideline section.

PEDAB-1.2: Pediatric Abdomen Imaging Appropriate Clinical Evaluation and Conservative Treatment

For this condition imaging is medically necessary based on the following criteria:

† A recent (within 60 days) face to face evaluation including a detailed history, physical examination, appropriate laboratory studies, and basic imaging such as plain radiography or ultrasound should be performed prior to considering advanced imaging (CT, MRI, Nuclear Medicine), unless the member is undergoing guideline-supported follow-up imaging evaluation.

† These guidelines are based upon using advanced imaging to answer specific clinical questions that will affect member management. Imaging is not indicated if the results will not affect member management decisions. Standard medical practice would dictate continuing conservative therapy prior to advanced imaging in members who are improving on current treatment programs.

† Unless otherwise stated in a specific guideline section, the use of advanced imaging to screen asymptomatic members for disorders involving the abdomen is not supported. Advanced imaging should only be approved in members who have documented active clinical signs or symptoms of disease.

† Unless otherwise stated in a specific guideline section, repeat imaging studies of the same body area are not necessary unless there is evidence for progression of disease, new onset of disease, and/or documentation of how repeat imaging will affect member management or treatment decisions.

PEDAB-1.3: Pediatric Abdomen Imaging Modality General Considerations

For this condition imaging is medically necessary based on the following criteria:

† Ultrasound

® Ultrasound should be the initial imaging study of choice in most children with abdominal conditions and should be done prior to advanced imaging.
® For those members who do require advanced imaging after ultrasound, ultrasound can be very beneficial in selecting the proper modality, body area, image sequences, and contrast level that will provide the most definitive information for the member.
® CPT^® codes vary by body area and presence or absence of Doppler imaging and are included in the table at the beginning of this guideline.

® MRI Abdomen is generally performed without and with contrast (CPT^® 74183) unless the member has a documented contraindication to gadolinium or otherwise stated in a specific guideline section.
® Due to the length of time required for MRI acquisition and the need to minimize member movement, anesthesia is usually required for almost all infants (except neonates) and young children (age <7 years) as well as older children with delays in development or maturity. This anesthesia may be administered via oral or intravenous routes. In this member population, MRI sessions should be planned with a goal of minimizing anesthesia exposure by adhering to the following considerations:
¡ MRI procedures can be performed without and/or with contrast use as supported by these condition-based guidelines. If intravenous access will already be present for anesthesia administration and there is no contraindication for using contrast, imaging without and with contrast may be appropriate if requested. By doing so, the requesting provider may avoid repetitive anesthesia administration to perform an MRI with contrast if the initial study without contrast is inconclusive.
■ Recent evidence based literature demonstrates the potential for gadolinium deposition in various organs including the brain, after the use of MRI contrast.
■ The U.S. Food and Drug Administration (FDA) has noted that there is currently no evidence to suggest that gadolinium retention in the brain is harmful and restricting gadolinium-based contrast agents (GBCAs) use is not warranted at this time. It has been recommended that GBCA use should be limited to circumstances in which additional information provided by the contrast agent is necessary and the necessity of repetitive MRIs with GBCAs should be assessed.
¡ If multiple body areas are supported by Horizon BCBSNJ’s guidelines for the clinical condition being evaluated, MRI of all necessary body areas should be obtained concurrently in the same session.
® The presence of surgical hardware or implanted devices may preclude MRI.
® The selection of best examination may require coordination between the provider and the imaging service. CT may be the procedure of choice in these cases.

® CT Abdomen typically extends from the dome of the diaphragm to the upper margin of the sacroiliac joints, and CT Abdomen and Pelvis extends from the dome of the diaphragm through the ischial tuberosities.
¡ In general, CT Abdomen is appropriate when evaluating solid abdominal organs.
¡ In general, CT Abdomen and Pelvis is appropriate when evaluating inflammatory or infectious processes, hematuria, or conditions which appear to involve both the abdomen and the pelvis.
¡ In some cases, especially in follow-up of a known finding, it may be appropriate to limit the exam to the region of concern to reduce radiation exposure.
® The contrast level in pediatric CT imaging is specific to the clinical indication, as listed in the specific guideline sections.
® CT Abdomen or Abdomen and Pelvis may be indicated for further evaluation of abnormalities suggested on prior US or MRI studies.
® CT may be indicated without prior MRI or US, as indicated in specific sections of these guidelines.
® CT should not be used to replace MRI in an attempt to avoid sedation unless listed as a recommended study in a specific guideline section.
® The selection of the best examination may require coordination between the provider and the imaging service.

® Nuclear medicine studies are commonly used in evaluation of the pediatric kidney and gallbladder. Other less common indications exist as well:
¡ Esophageal motility study (CPT^® 78258) and/or Gastroesophageal reflux study (CPT^® 78262) is indicated in the evaluation of gastroesophageal reflux.
® Nuclear intestinal imaging (Preferred code for Meckel’s Scan, CPT^® 78290) or Gastric mucosa imaging (Alternate code Meckel’s scan, CPT^® 78261) is indicated for the following:
¡ Suspected Meckel’s diverticulum.
¡ Gastric mucosa imaging (CPT^® 78261) is also indicated for:
■ Barrett’s esophagus.
■ Thoracic masses suspected of containing gastric mucosa.
® Gastric emptying study (CPT^® 78264) is indicated for evaluation of either suspected delayed or rapid gastric emptying.
® Gastric emptying study with small bowel transit (CPT^® 78265) is indicated for evaluation of suspected abnormalities in both total and regional times for gastrointestinal transit in the small bowel.
® Gastric emptying study with small bowel and colon transit (CPT^® 78266) is indicated for evaluation of suspected abnormalities in both total and regional times for gastrointestinal transit to the colon.
® Gastrointestinal bleeding scintigraphy (CPT^® 78278) is indicated for evaluation of brisk active GI bleeding with indeterminate endoscopy.
® Gastrointestinal protein loss study (CPT^® 78282) is indicated for decreased serum albumin or globulins and no evidence of GI bleeding.
® Peritoneal-venous shunt patency study (CPT^® 78291) is indicated for evaluation of shunt patency and function in a member with ascites.
® Nuclear renal imaging (CPT^® 78701, CPT^® 78707, CPT^® 78708, or CPT^® 78709) is indicated for evaluation of the following:
¡ Renal transplant follow-up.
¡ Kidney salvage vs. nephrectomy surgical decisions.
¡ Acute renal failure with no evidence of obstruction on recent ultrasound.
¡ Chronic renal failure to estimate prognosis for recovery.

® 3D Rendering indications in pediatric abdomen imaging are identical to those for adult members.

References

1. Bridges MD. ACR–SPR Practice parameter for the performance and interpretation of magnetic resonance imaging (MRI). Revised 2017 (Resolution 10).
2. Karmazyn BK, John SD, Siegel MJ, et al. ACR–ASER–SCBT-MR–SPR Practice parameter for the performance of pediatric computed tomography (CT). Last review date: 2014 (Resolution 3).
3. Ing C, Dimaggio C, Whitehouse A, et al. Long-term Differences in Language and Cognitive Function After Childhood Exposure to Anesthesia. Pediatrics. 2012;130(3). doi:10.1542/peds.2011-3822.
4. Monteleone M, Khandji A, Cappell J, Lai WW, Biagas K, Schleien C. Anesthesia in Children. Journal of Neurosurgical Anesthesiology. 2014;26(4):396-398. doi:10.1097/ana.0000000000000124.
5. DiMaggio C, Sun LS, Li G. Early Childhood Exposure to Anesthesia and Risk of Developmental and Behavioral Disorders in a Sibling Birth Cohort. Anesthesia & Analgesia. 2011;113(5):1143-1151. doi:10.1213/ane.0b013e3182147f42.
6. Abell TL, Camilleri M, Donohoe K, et al. Consensus Recommendations for Gastric Emptying Scintigraphy: A Joint Report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine. The American Journal of Gastroenterology. 2008;103(3):753-763. doi:10.1111/j.1572-0241.2007.01636.x.
7. Raju GS, Gerson L, Das A, Lewis B. American Gastroenterological Association (AGA) Institute Medical Position Statement on Obscure Gastrointestinal Bleeding. Gastroenterology. 2007;133(5):1694-1696. doi:10.1053/j.gastro.2007.06.008.
8. Zuckerman GR, Prakash C, Askin MP, Lewis BS. AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding. Gastroenterology. 2000;118(1):201-221. doi:10.1016/s0016-5085(00)70430-6.
9. Morton KA, Clark PB, Christensen CR, et al. Diagnostic nuclear medicine. Amirsys. 2000 1st Ed. Chapter 8, pp 122-125.


PEDAB-2: Generalized Abdominal Pain

For this condition imaging is medically necessary based on the following criteria:

† Children with generalized abdominal pain and physical examination and laboratory studies, including stool for blood (and stool culture if diarrhea), should initially be evaluated by ultrasound (CPT^® 76700 or CPT^® 76705) and treated conservatively.

® Gastroenterology (GI) specialist evaluation is helpful in determining the need for advanced imaging.

® PEDAB-3: Right Lower Quadrant Pain.
® PEDAB-4: Flank Pain, Renal Stone.
® PEDAB-8: Right Upper Quadrant Pain.
® PEDAB-25: Left Upper Quadrant Pain.
® PEDAB-29: Left Lower Quadrant Pain.

® Pain that wakes the child from sleep.
® Unexplained fever (T >100.4°F).
® Dysphagia.
® GI bleeding.
® Significant vomiting.
® Guarding, rebound tenderness, or other peritoneal signs.
® Severe chronic diarrhea or nocturnal diarrhea in a toilet-trained child.
® Failure to thrive, involuntary weight loss, or delay in linear growth or pubertal development.
® Family history of inflammatory bowel disease, familial polyposis syndrome, celiac disease, or peptic ulcer disease.
® Abdominal mass, hepatomegaly, and/or splenomegaly on exam.
® Jaundice.
® Arthritis.
® Costovertebral angle tenderness.
® Perianal disease.
® Spinal tenderness.

1. Sreedharan R and Liacouras CA. Major symptoms and signs of digestive tract disorders. Nelson Textbook of Pediatrics, Chapter 306. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp 1758-1767.
2. Sreedharan R and Liacouras CA, Functional abdominal pain (nonorganic chronic abdominal pain). Nelson Textbook of Pediatrics, Chapter 342. eds Kliegman RM, Stanton BF, St. Geme JW III, Schor NF, 20th edition 2016, pp 1884-1887.
3. Reust CE, Williams A. Acute abdominal pain in children. Am Fam Physician. 2016 May 15;93(10):830-6.
4. Cogley JR, O’Connor SC, Houshyar R, Dulaimy KA. Emergent Pediatric US: What Every Radiologist Should Know. RadioGraphics. 2012;32(3):651-665. doi:10.1148/rg.323115111.
5. Sanchez TR, Corwin MT, Davoodian A, Stein-Wexler R. Sonography of Abdominal Pain in Children. Journal of Ultrasound in Medicine. 2016;35(3):627-635. doi:10.7863/ultra.15.04047.

PEDAB-3: Right Lower Quadrant Pain

For this condition imaging is medically necessary based on the following criteria:

† For members age ≤14 years:

® Ultrasound (CPT^® 76700 or CPT^® 76705) is indicated as the initial examination. If positive or negative, no further diagnostic imaging is necessary.
¡ If the appendix is not visualized on ultrasound and the white blood cell count is not elevated, no further imaging is necessary in nearly all cases, although the referring physician should make the final determination of the need for advanced imaging.
® If insufficient local ultrasound expertise exists or the ultrasound findings are inconclusive, any of the following studies are indicated for evaluation of right lower quadrant pain:
¡ CT Abdomen and Pelvis with contrast (CPT^® 74177).
¡ CT Abdomen and Pelvis without contrast (CPT^® 74176).
¡ MRI Pelvis without contrast (CPT^® 72195).
¡ MRI Pelvis without and with contrast (CPT^® 72197).

® Any of the following studies are indicated:
¡ CT Abdomen and Pelvis with contrast (CPT^® 74177).
¡ CT Abdomen and Pelvis without contrast (CPT^® 74176).
¡ MRI Pelvis without contrast (CPT^® 72195).
¡ MRI Pelvis without and with contrast (CPT^® 72197).

References

1. Smith MP, Katz DS, Lalani T, et al. ACR Appropriateness Criteria^® Right Lower Quadrant Pain—Suspected Appendicitis. Ultrasound Quarterly. 2015;31(2):85-91. doi:10.1097/ruq.0000000000000118.
2. Aiken JJ and Oldham KT. Acute Appendicitis. Nelson Textbook of Pediatrics, Chapter 343. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition 2016. pp 1887-1894.
3. Aspelund G, Fingeret A, Gross E, et al. Ultrasonography/MRI Versus CT for Diagnosing Appendicitis. Pediatrics. 2014;133(4):586-593. doi:10.1542/peds.2013-2128.
4. Moore MM, Gustas CN, Choudhary AK, et al. MRI for clinically suspected pediatric appendicitis: an implemented program. Pediatric Radiology. 2012;42(9):1056-1063. doi:10.1007/s00247-012-2412-4.
5. Kotagal M, Richards MK, Chapman T, et al. Improving ultrasound quality to reduce computed tomography use in pediatric appendicitis: the Safe and Sound campaign. The American Journal of Surgery. 2015;209(5):896-900. doi:10.1016/j.amjsurg.2014.12.029.
6. Kotagal M, Richards MK, Flum DR, Acierno SP, Weinsheimer RL, Goldin AB. Use and accuracy of diagnostic imaging in the evaluation of pediatric appendicitis. Journal of Pediatric Surgery. 2015;50(4):642-646. doi:10.1016/j.jpedsurg.2014.09.080.
7. Cohen B, Bowling J, Midulla P, et al. The non-diagnostic ultrasound in appendicitis: is a non-visualized appendix the same as a negative study? Journal of Pediatric Surgery. 2015;50(6):923-927. doi:10.1016/j.jpedsurg.2015.03.012.
8. Bachur RG, Levy JA, Callahan MJ, Rangel SJ, Monuteaux MC. Effect of Reduction in the Use of Computed Tomography on Clinical Outcomes of Appendicitis. JAMA Pediatrics. 2015;169(8):755. doi:10.1001/jamapediatrics.2015.0479.
9. Dibble EH, Swenson DW, Cartagena C, Baird GL, Herliczek TW. Effectiveness of a Staged US and Unenhanced MR Imaging Algorithm in the Diagnosis of Pediatric Appendicitis. Radiology. 2018;286(3):1022-1029. doi:10.1148/radiol.2017162755.
10. Koberlein GC, Trout AT, Rigsby CK, et al. ACR Appropriateness Criteria^® Suspected Appendicitis-Child. Journal of the American College of Radiology. 2019;16(5). doi:10.1016/j.jacr.2019.02.022.
11. Repplinger MD, Pickhardt PJ, Robbins JB, et al. Prospective Comparison of the Diagnostic Accuracy of MR Imaging versus CT for Acute Appendicitis. Radiology. 2018;288(2):467-475. doi:10.1148/radiol.2018171838.


PEDAB-4: Flank Pain, Renal Stone

For this condition imaging is medically necessary based on the following criteria:

† Flank Pain imaging indications in pediatric members are very similar to those for adult members. See Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section); AB-4: Flank Pain, Rule Out or Known Renal/Ureteral Stone in the Abdomen Imaging Guidelines.

† Pediatric-specific imaging considerations include the following:

® In children, ultrasound (CPT^® 76770 or CPT^® 76775) is the preferred initial study
® If ultrasound is inconclusive, CT Abdomen and Pelvis without contrast (CPT^® 74176) is indicated.
® If CT is inconclusive or there is significant concern for radiation exposure from frequent CT use for a particular member, MRI Abdomen (CPT^® 74183) and Pelvis (CPT^® 72197) without and with contrast is indicated.
® If hematuria is present, See PEDAB-7: Hematuria for imaging guidelines.

References
1. Coursey CA, Casalino DD, Remer EM, et al. ACR Appropriateness Criteria^® Acute Onset Flank Pain–Suspicion of Stone Disease. Ultrasound Quarterly. 2012;28(3):227-233. doi:10.1097/ruq.0b013e3182625974.
2. Kim CK, Biyyam DR, Becker MD, et al. ACR–SPR Practice parameter for the performance of renal scintigraphy. Revised 2017 (Resolution 29).
3. Tekgül S, Dogan HS, Koèvara R, et al. European Association of Urology. European Society for Paediatric Urology. Guidelines on Paediatric Urology 2015 with limited text update March 2017.
4. Mendichovszky I, Solar BT, Smeulders N, Easty M, Biassoni L. Nuclear Medicine in Pediatric Nephro-Urology: An Overview. Seminars in Nuclear Medicine. 2017;47(3):204-228. doi:10.1053/j.semnuclmed.2016.12.002.
5. Dillman JR, Rigsby CK, Iyer RS, Alazraki AL, Anupindi SA, Brown BP, Chan SS, Dorfman SR, Falcone RA, Garber MD, Nguyen JC. ACR Appropriateness Criteria^® Hematuria-Child. Journal of the American College of Radiology. 2018 May 31;15(5):S91-103.


PEDAB-5: Urinary Tract Infection (UTI)

PEDAB-5.1: Upper Urinary Tract

PEDAB-5.2: Lower Urinary Tract

PEDAB-5.1: Upper Urinary Tract

For this condition imaging is medically necessary based on the following criteria:

† All children with first time UTI should undergo ultrasound evaluation (CPT^® 76770 or CPT^® 76775), as the initial imaging modality to diagnose hydronephrosis, pyelonephritis, or congenital renal anomaly.

® If hydronephrosis is present, this should be further evaluated with voiding cystourethrography (VCUG), to evaluate for vesicoureteral reflux. In boys, this is generally accomplished using fluroroscopic imaging and iodinated contrast to exclude urethral abnormalities. In girls, Ureteral Reflux Study (Radiopharmaceutical Voiding Cystogram) (CPT^® 78740) is commonly used as urethral abnormalities are rare and this technique results in lower radiation exposure.

® Differentiating a dilated non-obstructed urinary system from a true stenosis (e.g., UPJ obstruction; ureteral-vesical junction [UVJ] obstruction).
® Quantifying renal parenchymal function.
® Ultrasound findings that are compatible with a multicystic dysplastic kidney to evaluate function of the affected kidney or a ureteral-pelvic junction (UPJ) obstruction of the contralateral kidney.
® Diagnostic evaluation of upper tract dilatation when VCUG is negative.
® Renal function evaluation in members with hydronephrosis.

† Magnetic resonance urography (MRU) (CPT^® 74183 and CPT^® 72197), is not a first line test for the routine evaluation of a UTI, but may be appropriate (where available) for investigation of a dilated upper urinary tract.

® NOTE: MRU requires sedation in young children.
® MRU can also quantitate renal function.

® DSMA is recommended for Detection of post-pyelonephritic renal scarring at least 6 months after the documented upper tract UTI in high risk members with recurrent UTIs.

† Nuclear non-imaging renal function study (CPT^® 78725) is a quantitative study that can be used to evaluate renal function.

PEDAB-5.2: Lower Urinary Tract

For this condition imaging is medically necessary based on the following criteria:

† All children with first time UTI should undergo ultrasound evaluation (CPT^® 76770 or CPT^® 76775), as the initial imaging modality to diagnose hydronephrosis, pyelonephritis, or congenital renal anomaly

® Fluoroscopic Voiding cystourethrography (VCUG) is indicated for detection of possible vesico-ureteral reflux (VUR) in neonates or young children when hydronephrosis is seen on ultrasound.

® The current recommendation is to postpone the VCUG until the second febrile UTI UNLESS there are:
¡ Atypical or complex clinical circumstances.
¡ Renal/bladder ultrasound reveals hydronephrosis, scarring, or obstructive uropathy.

® Fluoroscopic VCUG is typically performed for diagnosis and grading of VUR, and should be the first modality used for diagnosis.
® Ureteral Reflux Study (Radiopharmaceutical Voiding Cystogram) (CPT^® 78740), because of its lower radiation exposure and higher sensitivity for reflux > Grade I, is recommended for follow-up imaging of VUR, and investigation of VUR in siblings of affected members.

† For female members, radionuclide cystography (CPT^® 78740) may replace fluoroscopic VCUG as the initial study, since urethral anatomy is rarely abnormal except in complex malformations.

† MR urography is indicated for evaluation of ectopic distal ureteral insertion, or other complex lower urinary tract anatomy.

† Siblings of members with known vesicoureteral reflux can undergo Ureteral Reflux Study (Radiopharmaceutical Voiding Cystogram) (CPT^® 78740) if they have renal scarring on ultrasound or history of UTI and no prior evaluation for VUR.

References
1. Mandell GA, Eggli DF, Gilday DL, et al. Society of Nuclear Medicine Procedure guideline for renal cortical scintigraphy in children. Society Nuclear of Medicine Procedure Guidelines Manual. Version 3.0, Approved June 20, 2003. pp.195-198.
2. Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics. 2011;128(3):595-610. doi:10.1542/peds.2011-1330.
3. Karmazyn BK, Alazraki AL, Anupindi SA, et al. ACR Appropriateness Criteria ^® Urinary Tract Infection—Child. Journal of the American College of Radiology. 2017;14(5). doi:10.1016/j.jacr.2017.02.028.
4. Elder JS. Urinary tract infections. Nelson Textbook of Pediatrics, Chapter 538. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp 2556-2562.
5. Jackson EC. Urinary Tract Infections in Children: Knowledge Updates and a Salute to the Future. Pediatrics in Review. 2015;36(4):153-166. doi:10.1542/pir.36-4-153.
6. Peters CA, Skoog SJ, Arant BS, et al. Management and screening of primary vesicoureteral reflux in children. American Urological Association. Published 2010. Reviewed and Validity Confirmed 2017.
7. Fettich J, Colarinha P, Fischer S, et al. Guidelines for direct radionuclide cystography in children. European Journal of Nuclear Medicine and Molecular Imaging. 2003;30(5). doi:10.1007/s00259-003-1137-x.
8. Palestro CJ, Brown ML, Forstrom LA et al. Society of Nuclear Medicine Procedure guideline for 111In-Leukocyte scintigraphy for suspected infection/inflammation, Version 3.0, approved June 2, 2004.
9. Vries EFJD, Roca M, Jamar F, Israel O, Signore A. Guidelines for the labelling of leucocytes with 99mTc-HMPAO. European Journal of Nuclear Medicine and Molecular Imaging. 2010;37(4):842-848. doi:10.1007/s00259-010-1394-4.
10. Mendichovszky I, Solar BT, Smeulders N, Easty M, Biassoni L. Nuclear Medicine in Pediatric Nephro-Urology: An Overview. Seminars in Nuclear Medicine. 2017;47(3):204-228. doi:10.1053/j.semnuclmed.2016.12.002.
11. Riccabona M. Imaging in childhood urinary tract infection. La radiologia medica. 2015;121(5):391-401. doi:10.1007/s11547-015-0594-1.


PEDAB-6: Pediatric Acute Gastroenteritis

For this condition imaging is medically necessary based on the following criteria:

† Imaging is not indicated in pediatric acute gastroenteritis unless there is a concern for diagnosis other than acute gastroenteritis.

† When necessary, imaging in children with suspected gastroenteritis should begin with plain x-rays of the abdomen, including supine and left lateral decubitus views. The left lateral decubitus view is useful for the detection of air-fluid levels and for detection of gas in the rectum and to exclude obstruction or bowel perforation.

† Ultrasound (CPT^® 76700 or CPT^® 76705) should be performed if there is organomegaly, palpable mass, or suspicion for complications in the form of intussusception. See PEDAB-27: Intussusception

® While ultrasound (CPT^® 76700 or CPT^® 76705) may detect findings of gastroenteritis, imaging is not necessary to make the diagnosis of uncomplicated gastroenteritis.

References

1. Bhutta ZA. Acute gastroenteritis in children. Nelson Textbook of Pediatrics. Chapter 340. eds Kliegman RM, Stanton BF, St. Geme JW III, Schor NF. 20th edition. 2016, pp 1863-1874.
2. Parkin PC, Macarthur C, Khambalia A, Goldman RD, Friedman JN. Clinical and Laboratory Assessment of Dehydration Severity in Children With Acute Gastroenteritis. Clinical Pediatrics. 2009;49(3):235-239. doi:10.1177/0009922809336670.


PEDAB-7: Hematuria

For this condition imaging is medically necessary based on the following criteria:

Hematuria is a relatively common complaint in pediatric members, and the imaging considerations are different than those occurring in adult members.

† For members with asymptomatic gross hematuria or microscopic hematuria with proteinuria present, ultrasound kidneys (CPT^® 76770 or CPT^® 76775) and bladder (CPT^® 76856 or CPT^® 76857) are indicated.

† No imaging is appropriate for asymptomatic microscopic hematuria without proteinuria.

† For members with painful hematuria and no recent trauma, ANY of the following studies can be approved:

® CT Abdomen and Pelvis without contrast (CPT^® 74176)
® Ultrasound kidneys (CPT^® 76770 or CPT^® 76775)
® Ultrasound bladder (CPT^® 76856 or CPT^® 76857)

® CT Abdomen and Pelvis with contrast (CPT^® 74177)
® CT Cystography (CT Pelvis with bladder contrast – CPT^® 72193), if gross hematuria is present and pelvic fracture or traumatic bladder injury is suspected.

For this condition imaging is medically necessary based on the following criteria:

† Right upper quadrant pain imaging indications in pediatric members are very similar to those for adult members. See Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section); AB-2: Abdominal Pain in the Abdomen Imaging Guidelines.

† Pediatric-specific imaging considerations include the following:

® In members with complaints of RUQ pain with fever, elevated white blood cell count, positive Murphy sign with suspicion of acute cholecystitis or suspicion of acalculous cholecystitis, the diagnosis should be confirmed or excluded using US abdomen (CPT^® 76700) and/or Nuclear medicine imaging of the hepatobiliary system (HIDA scan, CPT^® 78226 or CPT^® 78227).
¡ MRI Abdomen with and without contrast (CPT^® 74183) when US or NM is equivocal.
¡ CT Abdomen with contrast (CPT^® 74160) when US or NM is equivocal.
® In members with complaints of RUQ pain with no fever and normal white blood cell count where a diagnosis of stones and bile duct obstruction are suspected, the diagnosis should be confirmed with US abdomen (CPT^® 76700) and/or Nuclear medicine imaging of the hepatobiliary system (HIDA scan, CPT^® 78226 or CPT^® 78227).
¡ MRI Abdomen with and without contrast (CPT^® 74183) when US or NM is equivocal.
¡ CT Abdomen with contrast (CPT^® 74160) when US or NM is equivocal.
® In members with complaints of RUQ pain with no fever and an ultrasound shows only gallstones, MRI Abdomen without contrast (CPT^® 74181), MRI Abdomen without and with contrast (CPT^® 74183) or Nuclear medicine imaging of the hepatobiliary system (HIDA scan, CPT^® 78226) is indicated to exclude other sources of pain.

PEDAB-9: Inflammatory Bowel Disease, Crohn Disease, or Ulcerative Colitis

For this condition imaging is medically necessary based on the following criteria:

Enterography is the most appropriate advanced imaging study for members with inflammatory bowel disease (IBD).

† For children with suspected IBD, MR enterography (CPT^® 74183 and CPT^® 72197) is preferred to avoid radiation exposure.

® CT enterography (CPT^® 74177) is indicated if MR enterography is inconclusive or unavailable.

® Monitoring response to disease-modifying treatment on an annual basis or when treatment change is being considered.
® Members with new or worsening symptoms or suspected complications including abscess, perforation, fistula, or obstruction.
® CT enterography (CPT^® 74177) can be approved if MR enterography is inconclusive or unavailable.

For this condition imaging is medically necessary based on the following criteria:

† Abdominal sepsis imaging indications in pediatric members are identical to those for adult members.

® See Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section); AB-3: Abdominal Sepsis (Suspected Abdominal Abscess) for imaging guidelines.

PEDAB-11: Postoperative Pain within 60 Days Following Abdominal Surgery

For this condition imaging is medically necessary based on the following criteria:

† CT Abdomen and Pelvis with contrast (CPT^® 74177) is indicated in members with suspected postoperative complications (e.g. bowel obstruction, abscess, anastomotic leak, etc.).

® Children can also be evaluated with ultrasound (CPT^® 76700 or CPT^® 76705) initially (especially in small children or in thin older children) or MRI Abdomen and Pelvis without and with contrast (CPT^® 74183 and CPT^® 72197).
® Because MRI may not be practical for the timely evaluation of post-operative abscesses, MRI should only replace CT when the study can be completed in a similar time frame as CT.

® Peritonitis.
® Postoperative fever without localizing signs or symptoms.

References
1. Katz DS, Baker MF, Rosen MP, et al. Suspected small bowel obstruction. ACR Appropriateness Criteria^®. Date of origin: 1996. Last review date: 2013.
2. Yagmhai V, Rosen MP, Lalani T, et al. Acute (nonlocalized) abdominal pain and fever or suspected abdominal abscess. ACR Appropriateness Criteria^®. Date of origin: 1996. Last review date: 2012.
3. Palestro CJ, Brown ML, Forstrom LA et al. Society of Nuclear Medicine Procedure guideline for ¹¹¹In-Leukocyte scintigraphy for suspected infection/inflammation, Version 3.0, approved June 2, 2004.
4. Vries EFJD, Roca M, Jamar F, Israel O, Signore A. Guidelines for the labelling of leucocytes with 99mTc-HMPAO. European Journal of Nuclear Medicine and Molecular Imaging. 2010;37(4):842-848. doi:10.1007/s00259-010-1394-4.

PEDAB-12: Constipation, Diarrhea, and Irritable Bowel Syndrome

For this condition imaging is medically necessary based on the following criteria:

† Constipation and diarrhea are extremely common complaints in children. The overwhelming majority of members do not require advanced imaging for evaluation of constipation or diarrhea.

† Irritable bowel is rare in young children, but more common in adolescents. The overwhelming majority of members do not require advanced imaging for evaluation of irritable bowel syndrome.

® In most cases, causes of constipation can be excluded on the basis of a careful history and physical examination. Advanced Imaging should be performed if warning signs of other diseases are present.

® Red flag symptoms for abdominal pain: See PEDAB-2: Generalized Abdominal Pain.
® Clinical suspicion of tethered cord based on abnormal physical findings over the spine or failure of maximal laxative therapy: See Pediatric Spine Imaging Policy (Policy # 170 in the Radiology Section); PEDSP-5: Tethered Cord in the Pediatric Spine Imaging Guidelines.

† Irritable bowel syndrome that is associated with additional red flag signs or symptoms may require advanced imaging: See PEDAB-2: Generalized Abdominal Pain.

† A barium enema and rectal biopsy are indicated for diagnosis of Hirschsprung disease in children with features suggestive of this disorder. MRI Pelvis without and with contrast (CPT^® 72197) may be indicated in post-operative members who have signs of complications related to treatment to assess the position of the pulled-through bowel, the sphincter muscles, and the area of the posterior urethra.

References

1. Sreedharan R and Liacouras CA. Major symptoms and signs of digestive tract disorders. Nelson Textbook of Pediatrics, Chapter 306. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp 1758-1767.
2. Sreedharan R and Liacouras CA. Functional abdominal pain (nonorganic chronic abdominal pain). Nelson Textbook of Pediatrics, Chapter 342. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp 1884-1887.
3. Fiorino KN and Liacouras CA. Encorpresis and functional constipation. Nelson Textbook of Pediatrics, Chapter 332.3 eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016. pp 1807-1809.
4. Guarino A, Branski D, and Winter HS. Chronic diarrhea. Nelson Textbook of Pediatrics, Chapter 341. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, p 1875-1882.
5. Zella GC, Israel EJ. Chronic Diarrhea in Children. Pediatrics in Review. 2012;33(5):207-218. doi:10.1542/pir.33-5-207


PEDAB-13: Abdominal Mass

PEDAB-13.1: Abdominal Wall Mass

PEDAB-13.2: Intra-Abdominal Mass

PEDAB-13.1: Abdominal Wall Mass

For this condition imaging is medically necessary based on the following criteria:

† For initial imaging of a newly discovered abdominal wall mass, ANY of the following studies are indicated:

® Ultrasound (CPT^® 76700 or CPT^® 76705).
® MRI Abdomen without contrast (CPT^® 74181) or without and with contrast (CPT^® 74183).
® If below the umbilicus, MRI Pelvis without contrast (CPT^® 72195) or without and with contrast (CPT^® 72197) may be added to MRI Abdomen.

® CT Abdomen with contrast (CPT^® 74160) or without contrast (CPT^® 74150).
® If below the umbilicus, CT Abdomen and Pelvis with contrast (CPT^® 74177) or without contrast (CPT^® 74176).

For this condition imaging is medically necessary based on the following criteria:

† Ultrasound (CPT^® 76700) should be the initial imaging study for children with an intra-abdominal mass.

† Additional imaging studies will be determined by the results of the ultrasound, and will depend on the location and organ involvement associated with the mass as well as history, physical exam, and laboratory findings. See the following sections for additional imaging guidelines:

® Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-1: General Guidelines in the Pediatric Oncology Imaging Guidelines.
® Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-5: Pediatric Lymphomas in the Pediatric Oncology Imaging Guidelines.
® Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-6: Neuroblastoma in the Pediatric Oncology Imaging Guidelines.
® Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-7: Pediatric Renal Tumors in the Pediatric Oncology Imaging Guidelines.
® Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-10: Pediatric Germ Cell Tumors in the Pediatric Oncology Imaging Guidelines.
® Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-11: Pediatric Liver Tumors in the Pediatric Oncology Imaging Guidelines.
® Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-14: Pediatric Adrenocortical Carcinoma in the Pediatric Oncology Imaging Guidelines.
® PEDAB-15: Liver Lesion Characterization.
® PEDAB-17: Adrenal Lesions.
® PEDAB-19: Indeterminate Renal Lesion.
® PEDAB-26: Spleen.

1. Allen-Rhoades W and Steuber CP. Clinical assessment and differential diagnosis of the child with suspected cancer. Principles and Practice of Pediatric Oncology. eds Pizzo PA and Poplack DG. 7^th edition 2016. pp. 101-111.
2. Malkan AD, Loh A, Bahrami A, et al. An Approach to Renal Masses in Pediatrics. Pediatrics. 2014;135(1):142-158. doi:10.1542/peds.2014-1011.
3. Crane GL, Hernanz-Schulman M. Current Imaging Assessment of Congenital Abdominal Masses in Pediatric Patients. Seminars in Roentgenology. 2012;47(1):32-44. doi:10.1053/j.ro.2011.07.004.
4. Chung EM, Graeber AR, Conran RM. Renal Tumors of Childhood: Radiologic-Pathologic Correlation Part 1. The 1st Decade:From the Radiologic Pathology Archives. RadioGraphics. 2016;36(2):499-522. doi:10.1148/rg.2016150230.
5. Chung EM, Lattin GE, Fagen KE, et al. Renal Tumors of Childhood: Radiologic-Pathologic Correlation Part 2. The 2nd Decade: From the Radiologic Pathology Archives. RadioGraphics. 2017;37(5):1538-1558. doi:10.1148/rg.2017160189.

PEDAB-14: Renovascular Hypertension and Other Secondary Causes of Hypertension

For this condition imaging is medically necessary based on the following criteria:

† Clinical evaluation for suspected hypertension should include repeated blood pressure measurements (generally ≥3 measurements). If these measurements are at or above the age-dependent systolic or diastolic blood pressures requiring further evaluation, as listed in the following table, further evaluation is warranted. Blood pressure may be obtained in-clinic, at home, or by using a wearable ambulatory blood pressure measurement (ABPM) device which records blood pressure at frequent intervals during normal activities and is downloaded later for computer analysis.

Age-Dependent Systolic or Diastolic Blood Pressures Requiring Further Evaluation16
	Boys	Boys	Girls	Girls
Age	Systolic	Diastolic	Systolic	Diastolic
1	98	52	98	54
2	100	55	101	58
3	101	58	102	60
4	102	60	103	62
5	103	63	104	64
6	105	66	105	67
7	106	68	106	68
8	107	69	107	69
9	107	70	108	71
10	108	72	109	72
11	110	74	111	74
12	113	75	114	75
>13	120	80	120	80

† ANY of the following studies are indicated for initial evaluation of a pediatric member with suspected secondary hypertension.

® Doppler or Duplex Ultrasound (CPT^® 93975 or CPT^® 93976).
® Complete retroperitoneal ultrasound (CPT^® 76770).
® Captopril renography (CPT^® 78709) has largely been abandoned in clinical practice, replaced by CTA and MRA Abdomen, but may be supported for unusual circumstances. All such requests should be forwarded to Medical Directors Review.

Other considerations for imaging evaluation:

† MRA (CPT^® 74185) or CTA (CPT^® 74175) Abdomen may be indicated for pediatric members with hypertension to exclude fibromuscular dysplasia or other blood-flow restricting lesions of the renal arteries.

† Echocardiography (CPT^® 93306) is indicated at initial evaluation to screen for cardiac abnormalities, coarctation of the aorta, and end-organ damage such as left ventricular hypertrophy.

† Nuclear renal imaging (CPT^® 78707, CPT^® 78708, or CPT^® 78709) is indicated for evaluation of the following:

® Severe hypertension with progressive renal insufficiency or failure to respond to 3 drug therapy.
® Malignant or accelerated hypertension.
® Acute worsening of previously stable hypertension.
® Diastolic BP >100 in member <35 years old.
® New onset severe hypertension.
® Hypertension in presence of asymmetric kidneys.
® Hypertension in presence of acute elevation in creatinine either unexplained or after treatment with ACE inhibitor.
® Abdominal bruit.
® Recurrent acute pulmonary edema and hypertension.
® Hypokalemia with normal or elevated plasma renin level in absence of diuretic therapy.
® Hypertension with known neurofibromatosis.

PEDAB-15: Liver Lesion Characterization

For this condition imaging is medically necessary based on the following criteria:

† Liver lesion characterization imaging indications in pediatric members are very similar to those for adult members. See Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section); AB-29: Liver Lesion Characterization for imaging guidelines.

† Nuclear medicine liver imaging (ONE of CPT^® codes: CPT^® 78201, CPT^® 78202, CPT^® 78803, CPT^® 78215, or CPT^® 78216) is rarely performed, but can be approved for the following when ultrasound, CT, and MRI are unavailable or contraindicated:

® Evaluation of liver mass, trauma, or suspected focal nodular hyperplasia (FNH).
® Differentiation of hepatic hemangioma from FNH.
® Diffuse hepatic disease or elevated liver function tests.
® Suspected accessory spleen (CPT^® 78215 or CPT^® 78216 only).

® US abdomen (CPT^® 76700 or CPT^® 76705) is the initial study of choice in children. MRI is preferred over CT when possible to reduce radiation exposure.

PEDAB-16: Pediatric Liver Failure and Cirrhosis

For this condition imaging is medically necessary based on the following criteria:

† Elevated liver function testing imaging indications in pediatric members are very similar to those for adult members. See Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section); AB-30: Elevated Liver Function (LFT) Levels for imaging guidelines.

† Causes of liver failure or cirrhosis in pediatric members are different from adults, and are frequently idiopathic, but commonly due to ONE of the following:

® Biliary dysfunction (biliary atresia, cystic fibrosis, etc.).
® Metabolic disease.
® Post-infectious.

® MRI Abdomen without and with contrast (CPT^® 74183) is indicated for evaluation of ultrasound findings that are inconclusive or technically limited, and is preferred over CT when possible to reduce radiation exposure.

® Known chronic liver dysfunction or cirrhosis of any cause may be reimaged on an annual basis in the absence of new or worsening findings.
® New or worsening findings on history, physical exam, or laboratory results that suggest progression of liver disease.
® Doppler ultrasound liver (CPT^® 93975 or CPT^® 93976) is indicated when portal venous congestion or portal hypertension is suspected.

® Diffuse hepatic disease or elevated liver function tests.

For this condition imaging is medically necessary based on the following criteria:

† Adrenal masses in infants and young children usually present as palpable abdominal masses or are detected on in utero US. In the neonates, the common masses are adrenal hemorrhage and neuroblastoma. Abdominal US is the initial imaging study of choice.

® If an adrenal mass is detected, it can often be adequately evaluated with short interval follow-up retroperitoneal ultrasound (CPT^® 76770) in 7 to 10 days.
¡ If repeat ultrasound is concerning for neuroblastoma or there is high clinical concern for neuroblastoma, MRI Abdomen without and with contrast (CPT^® 74183) or CT Abdomen without and with contrast (CPT^® 74170) are indicated to confirm the diagnosis. MRI is preferred over CT when possible to reduce radiation exposure. If these studies, confirm neuroblastoma ¹²³I-Metaiodobenzylguanidine (MIBG) scintigraphy is indicated for staging.
® Neuroblastoma is the most common primary adrenal tumor in pediatric members between day 1 and 5 years of age. See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-6: Neuroblastoma.

® Adrenal Nuclear Imaging of the cortex and/or medulla (CPT^® 78075) is indicated for the following:
¡ Distinguishing adrenal adenoma from adrenal hyperplasia.
¡ Evaluation of suspected pheochromocytoma or paraganglioma.
■ MIBG preferred (ONE of CPT^® codes: CPT^® 78800, CPT^® 78801, CPT^® 78802, CPT^® 78803, or CPT^® 78804).
■ For known pheochromocytoma or paraganglioma, See Adult Oncology Imaging Policy (Policy #155 in the Radiology Section); ONC-15: Neuroendocrine Cancers and Adrenal Tumors.
¡ Evaluation of suspected neuroblastoma, ganglioneuroblastoma, or ganglioneuroma.
■ MIBG preferred (ONE of CPT^® codes: CPT^® 78800, CPT^® 78801, CPT^® 78802, CPT^® 78803, or CPT^® 78804 or hybrid SPECT/CT CPT^® 78830, CPT^® 78831, or CPT^® 78832), See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-6: Neuroblastoma.
¡ History of multiple endocrine neoplasia syndromes: See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-2.8: Multiple Endocrine Neoplasias (MEN).
¡ History of neurofibromatosis: See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-2.3: Neurofibromatosis 1 and 2 (NF1 and NF2)
¡ History of von Hippel-Lindau disease: See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-2.10: Von Hippel-Lindau Syndrome (VHL)

For this condition imaging is medically necessary based on the following criteria:

† Hereditary hemochromatosis imaging indications in pediatric members are identical to those for adult members. See Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section); AB-11.2: Hereditary (Primary) Hemochromatosis (HH) and Other Iron Storage Diseases in the Abdomen Imaging Guidelines.

PEDAB-18.2: Transfusion-Associated (Secondary) Hemochromatosis

For this condition imaging is medically necessary based on the following criteria:

† Transfusion-associated hemochromatosis is a common complication of exposure to repeated red blood cell transfusions. This can occur in any member with exposure to >20 transfusion episodes, but is most common among sickle cell disease, thalassemia, bone marrow failure (aplastic anemia, Fanconi anemia, etc.), oncology members, and hematopoietic stem cell transplant members.

† T2* MRI has been well established in the determination of organ iron burden in transfusion-associated hemochromatosis. Contrast use is not necessary for evaluation of iron burden. The following studies are indicated for evaluation of transfusion-associated hemochromatosis:

® MRI Abdomen without contrast (CPT^® 74181) for liver iron evaluation.
® MRI Cardiac without contrast (CPT^® 75557) for cardiac iron evaluation.
® MRI Chest without contrast (CPT^® 71550) can be approved as a single study to evaluate both heart and liver iron burden.
® CPT^® 74181 and CPT^® 75557 can be approved alone, or together.
® If requested, CPT^® 71550 will evaluate both heart and liver and should not be approved with any other codes.

† Imaging is indicated every 3 months for treatment response in members receiving active treatment (chelation and/or phlebotomy).

References

1. Evidence-Based Management of Sickle Cell Disease: Expert Panel Report, 2014. Pediatrics. 2014;134(6). doi:10.1542/peds.2014-2986.
2. Chavhan GB, Babyn PS, Thomas B, Shroff MM, Haacke EM. Principles, Techniques, and Applications of T2*-based MR Imaging and Its Special Applications. RadioGraphics. 2009;29(5):1433-1449. doi:10.1148/rg.295095034.
3. Children’s Oncology Group. Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers. Version 4.0 – October 2013, Monrovia, CA.


PEDAB-19: Indeterminate Renal Lesion

For this condition imaging is medically necessary based on the following criteria:

† Indeterminate renal lesion characterization imaging indications in pediatric members are very similar to those for adult members. See Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section); AB-35: Indeterminate Renal Lesion in the Abdomen Imaging Guidelines

† Indeterminate renal lesion imaging indications in pediatric members are uncommon and are usually cysts or congenital anomalies.

† Pediatric-specific imaging considerations include the following:

® Pediatric renal cysts have a lower risk of malignant progression than do renal cysts in adults.
® For members who have simple cysts but are symptomatic and surgical intervention is being considered, CT Abdomen with contrast (CPT^® 74160) or MRI Abdomen without and with contrast (CPT^® 74183) is indicated.
® For pediatric members with complex renal cyst identified on ultrasound, CT Abdomen without and with contrast (CPT^® 74170) or MRI Abdomen without and with contrast (CPT^® 74183) is indicated.
® For members with congenital anomalies, nuclear medicine studies with diuretic renography (CPT^® 78708 or CPT^® 78709) can be performed to determine function and cystography to determine presence of associated reflux.
® Members with solid renal masses should be imaged according to guidelines in section Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-7: Pediatric Renal Tumors in the Pediatric Oncology Imaging Guidelines.

References
1. Karmazyn B, Tawadros A, Delaney L, et al. Ultrasound classification of solitary renal cysts in children. Journal of Pediatric Urology. 2015;11(3). doi:10.1016/j.jpurol.2015.03.001.
2. Kim CK, Biyyam DR, Becker MD, et al. ACR–SPR Practice parameter for the performance of renal scintigraphy. Revised 2017 (Resolution 29).
3. Mandell GA, Eggli DF, Gilday DL, et al. Society of Nuclear Medicine, Procedure guideline for renal cortical scintigraphy in children, Version 3.0, approved June 20, 2003.

PEDAB-20: Hydronephrosis

For this condition imaging is medically necessary based on the following criteria:

Hydronephrosis is a relatively common finding in pediatric members, with the following imaging considerations:

† Members with prenatal hydronephrosis can be evaluated with retroperitoneal ultrasound (CPT^® 76770) within the first week of life, and again after 6 weeks of age.

† Members with known hydronephrosis can be followed with retroperitoneal ultrasound (CPT^® 76770) every 3 to 12 months.

® This imaging represents a guideline-supported, scheduled follow-up imaging evaluation, as described in General Guidelines for Advanced Imaging Studies (Policy #011 in the Introduction Section); PREFACE-3: Clinical Information in the Preface Imaging Guidelines. A Current evaluation (within 60 days) would not be required for authorization.

† Members with obstructive uropathy (including ureteropelvic junction obstruction (UPJO), ureterovesical junction obstruction (UVJO), and bladder outlet obstruction) can be evaluated with retroperitoneal ultrasound (CPT^® 76770), and diuretic renography (CPT^® 78707, CPT^® 78708, or CPT^® 78709) for preoperative planning and postoperatively at 3 to 12 months.

® If hydronephrosis has resolved on postoperative imaging then no further routine imaging is indicated.

† CT Abdomen with contrast (CPT^® 74160) is rarely indicated, but can be approved in members with inconclusive ultrasound and a suspected vascular cause of UPJO.

References

1. Darge K, Siegel MJ. Kidney. In: Seigel MJ, editor Pediatric Sonography, 5th ed, Philadelpia, Wolters Kluwer, 2019. p 396-466.
2. Sinha A, Bagga A, Krishna A, et al. Revised guidelines on management of antenatal hydronephrosis. Indian Journal of Nephrology. 2013;23(2):83. doi:10.4103/0971-4065.109403.
3. Dervoort KV, Lasky S, Sethna C, et al. Hydronephrosis in Infants and Children: Natural History and Risk Factors for Persistence in Children Followed by a Medical Service. Clinical medicine Pediatrics. 2009;3. doi:10.4137/cmped.s3584.
4. Hsi RS, Holt SK, Gore JL, Lendvay TS, Harper JD. National Trends in Followup Imaging after Pyeloplasty in Children in the United States. Journal of Urology. 2015;194(3):777-782. doi:10.1016/j.juro.2015.03.123.
5. Elder JS. Obstruction of the urinary tract. Nelson Textbook of Pediatrics, Chapter 540. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp 2567-2575.
6. Nguyen HT, Benson CB, Bromley B, et al. Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system). Journal of Pediatric Urology. 2014;10(6):982-998. doi:10.1016/j.jpurol.2014.10.002.
7. Chow JS, Koning JL, Back SJ, Nguyen HT, Phelps A, Darge K. Classification of pediatric urinary tract dilation: the new language. Pediatric Radiology. 2017;47(9):1109-1115. doi:10.1007/s00247-017-3883-0.

PEDAB-21: Polycystic Kidney Disease

For this condition imaging is medically necessary based on the following criteria:

† An abdominal ultrasound (CPT^® 76700) or a retroperitoneal ultrasound (CPT^® 76770) is indicated if there is clinical concern for polycystic kidney disease, or for screening individuals who are at risk for autosomal dominant polycystic kidney disease (ADPCKD).

References
1. Belibi FA, Edelstein CL. Unified Ultrasonographic Diagnostic Criteria for Polycystic Kidney Disease. Journal of the American Society of Nephrology. 2008;20(1):6-8. doi:10.1681/asn.2008111164.
2. Porter CC and Avner ED. Autosomal Recessive polycystic kidney disease. Nelson Textbook of Pediatrics, Chapter 521.2. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp 2513-2514.
3. Porter CC and Avner ED. Autosomal dominant polycystic kidney disease. Nelson Textbook of Pediatrics, Chapter 521.3. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, p 2515.
4. Gimpel C, Avni EF, Breysem L, et al. Imaging of Kidney Cysts and Cystic Kidney Diseases in Children: An International Working Group Consensus Statement. Radiology. 2019;290(3):769-782. doi:10.1148/radiol.2018181243.

PEDAB-22: Blunt Abdominal Trauma

For this condition imaging is medically necessary based on the following criteria:

† Blunt abdominal trauma imaging indications in pediatric members are identical to those for adult members. See Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section); AB-10.1: Blunt Abdominal Trauma for imaging guidelines.

PEDAB-23: Hernias

For this condition imaging is medically necessary based on the following criteria:

† Hernia imaging indications in pediatric members are identical to those for adult members. See Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section); AB-12: Hernias for imaging guidelines.

PEDAB-24: Abdominal Lymphadenopathy

For this condition imaging is medically necessary based on the following criteria:

† Abdominal lymphadenopathy imaging indications in pediatric members are identical to those for adult members. See Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section); AB-8: Abdominal Lymphadenopathy for imaging guidelines.

PEDAB-25: Left Upper Quadrant Pain

For this condition imaging is medically necessary based on the following criteria:

† Left upper quadrant pain imaging indications in pediatric members are identical to those for adult members. See Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section); AB-2: Abdominal Pain for imaging guidelines.

† Nuclear medicine spleen imaging (CPT^® 78185) is rarely performed, but can be approved for left upper quadrant pain when neither ultrasound nor CT is available.

References
1. Royal HD, Brown ML, Drum DE, et al. Society of Nuclear Medicine Procedure guideline for hepatic and splenic imaging 3.0, version 3.0, approved July 20, 2003.


PEDAB-26: Spleen

For this condition imaging is medically necessary based on the following criteria:

† Spleen imaging indications in pediatric members are very similar to those for adult members. See Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section); AB-34: Spleen for imaging guidelines.

† Nuclear medicine spleen imaging (CPT^® 78185) is rarely performed, but can be approved for the following indications when CT is unavailable:

® Splenic trauma.
® Evaluation of splenic function.
® Suspected splenic mass, cyst, abscess, infarct, or metastasis.
® Radiation treatment planning.
® Asplenia.
® Suspected functional accessory spleen:
¡ Can approve CPT^® 78215 or CPT^® 78216 instead of CPT^® 78185, if requested.

® MRI is preferred over CT when possible to reduce radiation exposure.

1. Brandow AM and Camitta BM. Splenomegaly. Nelson Textbook of Pediatrics, Chapter 486. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp. 2408-2410.
2. Brandow AM and Camitta BM. Hyposplenism, splenic trauma, and splenectomy. Nelson Textbook of Pediatrics, Chapter 487. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp. 2410-2412
3. Navarro OM, Siegel MJ. Spleen and Peritoneal Cavity. In: Siegel MJ, editor. Pediatric Sonography, 5^th ed. Philadelphia. Wolters Kluwer. 2019. p 304-345.

PEDAB-27: Intussusception

For this condition imaging is medically necessary based on the following criteria:

† Intussusception, telescoping of one bowel loop into another, is a frequent cause of abdominal pain in young children. It may be associated with bloody stool. Plain x-rays (supine and left lateral decubitus views) should be performed initially to exclude mass or bowel obstruction from other causes and to detect possible bowel perforation which may be an indication for emergent surgical intervention.

® Ultrasound (CPT^® 76700 or CPT^® 76705) is indicated as an initial study if there is a strong suspicion for intussusception, but if negative, plain x-rays of the abdomen should follow.
® In some institutions, Ultrasound guidance (CPT^® 76942) may be used for reduction of colonic or ileocolic intussusception. Generally, this is an urgent or emergent procedure and may not require prior authorization. See Health Plan specific guidance for prior authorization requirements.

For this condition imaging is medically necessary based on the following criteria:

† Bowel obstruction imaging indications in pediatric members are identical to those for adult members. See Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section); AB-20: Bowel Obstruction and Gastroparesis for imaging guidelines.

PEDAB-29: Left Lower Quadrant Pain

For this condition imaging is medically necessary based on the following criteria:

Diverticulitis is the most common cause of left lower quadrant pain in adults but is extremely rare in children.

Gastroenterologist evaluation is helpful in determining the appropriate diagnostic pathway in members with left lower quadrant pain with or without heme-positive stools or rectal bleeding, since advanced imaging is rarely helpful in the initial evaluation of these members.

† Pelvic ultrasound (CPT^® 76856) is the initial imaging study of choice for children for detecting gynecologic abnormalities that may cause left lower quadrant pain.

† For male members or if ultrasound is inconclusive, advanced imaging may be appropriate for management as directed by gastroenterologic evaluation

References
1. Sreedharan R and Liacouras CA. Major symptoms and signs of digestive tract disorders. Nelson Textbook of Pediatrics, Chapter 306. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp 1758-1767.
2. Sreedharan R and Liacouras CA. Functional abdominal pain (nonorganic chronic abdominal pain). Nelson Textbook of Pediatrics, Chapter 342. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp 1884-1887.


PEDAB-30: Celiac Disease (Sprue)

For this condition imaging is medically necessary based on the following criteria:

† Celiac disease imaging indications in pediatric members are identical to those for adult members. See Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section); AB-24: Celiac Disease (Sprue) for imaging guidelines.

PEDAB-31: Transplant

For this condition imaging is medically necessary based on the following criteria:

† Liver and kidney transplant imaging indications in pediatric members are identical to those for adult members. See Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section); AB-42: Transplant for imaging guidelines.

† For post-transplant lymphoproliferative disorder in pediatric members, See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-5.3: Pediatric Aggressive Mature B-Cell Non-Hodgkin Lymphomas (NHL) for imaging guidelines.

PEDAB-32: Gaucher Disease

For this condition imaging is medically necessary based on the following criteria:

See Pediatric Peripheral Nerve Disorder Imaging Policy (Policy #168 in the Radiology Section); PEDPN-4: Gaucher Disease for imaging guidelines.

PEDAB-33: Vomiting Infant, Malrotation, and Hypertrophic Pyloric Stenosis

For this condition imaging is medically necessary based on the following criteria:

† Vomiting in infants is generally classified as either bilious (implying obstruction distal to the Sphincter of Oddi) or non-bilious.

† Bilious vomiting may be a true emergency, as some of the conditions causing this could result in compromise of blood supply to the intestines, a potentially life-threatening situation.

† Suspected malrotation is an indication for emergent imaging. If malrotation with mid-gut volvulus is suspected, acute abdominal series (Chest X-ray and abdominal views, including supine and upright or supine and left lateral decubitus views), followed by Ultrasound abdomen, limited (CPT^® 76705) and/or UGI series should be performed. If the abdominal X-rays suggest distal bowel obstruction, water soluble contrast enema should be considered.

† Hypertrophic Pyloric Stenosis is an idiopathic condition wherein the circular muscle controlling emptying of the stomach thickens, causing a relative obstruction of the gastric outlet. The condition can occur at any age (including occasionally in adults), but the typical child is male, aged 2 to 6 weeks. Projectile non-bilious vomiting is the most common presenting complaint, but the description of projectile vomiting is subjective. The differential diagnosis for non-bilious vomiting includes common conditions such as viral gastroenteritis and gastro-esophageal reflux.

® Infants with projectile non-bilious vomiting should be evaluated with Ultrasound abdomen, limited (CPT^® 76705). If initial studies are not diagnostic, repeat studies should be performed, as frequently as daily, until the vomiting resolves or the diagnosis is made. UGI series may be useful as a confirmatory test, may be preferred if ultrasound expertise is not available for this condition, or if the clinical presentation is atypical for Hypertrophic Pyloric Stenosis. Ultrasound is preferred when available, as it involves no contrast or ionizing radiation use.

For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.

FIDE SNP:

For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.

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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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Index:
Pediatric Abdomen Imaging Policy
Abdomen Imaging Policy, Pediatric
Computed Tomography, Abdomen, Pediatric
CT, Abdomen, Pediatric
Computed Tomography Angiography, Abdomen, Pediatric
CTA, Abdomen, Pediatric
Magnetic Resonance Imaging, Abdomen, Pediatric
MRI, Abdomen, Pediatric
Magnetic Resoance Angiography, Abdomen, Pediatric
MRA, Abdomen, Pediatric
Positron Emission Tomography, Abdomen, Pediatric
PET, Abdomen, Pediatric
Nuclear Medicine Imaging, Abdomen, Pediatric
Ultrasound, Abdomen, Pediatric
Ultrasound, Retroperitoneal, Pediatric
Duplex Scan, Abdomen, Pediatric
Doppler, Abdomen, Pediatric
Radiopharmaceutical Nuclear Medicine Imaging, Abdomen, Pediatric

References:


Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*