PEDHD-1.1: Pediatric Head Imaging Age Considerations

PEDHD-1.2: Pediatric Head Imaging Appropriate Clinical Evaluation

PEDHD-1.3: Pediatric Head Imaging Modality General Considerations

This General Policy section provides an overview of the basic criteria for which Pediatric Head 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.

PEDHD-1.1: Pediatric Head Imaging Age Considerations

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

Many conditions affecting the head 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, minor differences may exist in management due to member age, comorbidities, and differences in disease natural history between children and adults.

† Members who are<18 years old should be imaged according to the pediatric head imaging guidelines and members who are ≥18 years old should be imaged according to the adult head imaging guidelines, except where directed otherwise by a specific guideline section.

PEDHD-1.2: Pediatric Head Imaging Appropriate Clinical Evaluation

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

† A recent (within 60 days) face to faceevaluation including a detailed history, physical examination with a thorough neurologic examination, and appropriate laboratory studies should be performed prior to considering the use of an advanced imaging (CT, MRI, Nuclear Medicine) procedure. An exception can be made if the member is undergoing a guideline-supported,scheduled follow-up imaging evaluation.

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

† Advanced imaging of the head is not indicated for evaluation of recurrent isolated vomiting in members without associated headache or focal neurologic findings unless a gastrointestinal workup (labs, imaging, and endoscopy) does not reveal a cause.

† Unless otherwise stated in a specific guideline section, repeat imaging studies of the head 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.

Requests for Studies with Overlapping Fields

† There are many CPT^® codes for imaging the head that have significantly overlapping fields. In the majority of cases where multiple head CPT^® codes are requested, only one CPT^® code should be approved unless there is clear documentation of a need for the additional codes to cover all necessary body areas.

† See Adult Head Imaging Policy (Policy #151 in the Radiology Section);HD-1.1: General Guidelines - Anatomic Issues for the correct coding of these studies.

PEDHD-1.3: Pediatric Head Imaging Modality General Considerations

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

† MRI

® MRI is the preferred modality for imaging the pediatric head unless otherwise stated in a specific guideline section.
® Due to the length of time required for MRIacquisition 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 guidelines for the clinical condition being evaluated, MRI of all necessary body areas should be obtained concurrently in the same anesthesia session.

® CT is generally inferior to MRI for imaging the pediatric head, but has specific indications in which it is the preferred modality listed 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.

® Cranial ultrasound (CPT^® 76506) is a non-invasive means of evaluating for intracranial abnormalities in infants with an open anterior fontanelle.
® Transcranial Doppler ultrasonography has some utility in select populations of older children with known or suspected intracranial vascular disease.

® Nuclear medicine studies other than metabolic PET imaging on the pediatric brain or head are rarely performed in an elective outpatient setting, but the following studies can be approved when requested for the following indications:
¡ Brain Scintigraphy with or without vascular flow (any one of CPT^® codes: CPT^® 78600, CPT^® 78601, CPT^® 78605, or CPT^® 78606)
¡ Establish brain death (rarely done in outpatient setting).
¡ Radiopharmaceutical Localization Imaging SPECT(CPT^® 78803)
¡ Immunocompromised members with mass lesion detected on CT or MRI for differentiation between lymphoma and infection.
¡ Brain Imaging Vascular Flow (CPT^® 78610)
¡ Cerebral ischemia.
¡ Establish brain death (rarely done in outpatient setting).
¡ CSF Leakage Detection (CPT^® 78650)
¡ Evaluation of CSF rhinorrhea or otorrhea, or refractory post-lumbar puncture headache.
¡ Radiopharmaceutical Dacryocystography (CPT^® 78660)
¡ Suspected obstruction of nasolacrimal duct due to excessive tearing.

References
1. Siegel MJ. Brain. In: Pediatric sonography.5^th ed.Philadelphia, Wolters Kluwer.2018.
2. Nadgir R, andYousem DM. Neuroradiology.The requisites. 4th Ed. Philadelphia, Mosby.2017:40-111,
3. Latchaw RE, Kucharczyk J, and Moseley ME. Imaging of the nervous system diagnostic and therapeutic applications. Philadelphia, Elsevier. 2005. pp 2000.
4. Louis ED, Mayer SA, andRowland LP (Ed.). Merritt’s Neurology. 13^thEd. Philadelphia, Lippincott.2013.
5. Menkes JH, Sarnat HB, and Maria BL. Child Neurology. 7^th Ed. Philadelphia, Lippincott. 2006.
6. Barkovich AJ. Diagnostic imaging:pediatric neuroradiology. Amirsys.2^nd Edition.Salt Lake City, UT.2014.
7. Prabhu SP,and Young-Poussaint Ty. Pediatric central nervous system emergencies.Neuroimag Clin N Am.2010 Nov;20(4):663-683.
8. Patra KP, Lancaster JD, Hogg J,et al. Pediatric MRI of the Brain: a primer. Pediatr Rev.2014 Mar;35(3):106-113.
9. Ing C, DiMaggio C, Whitehouse A, et al. Long-term differences in language and cognitive function after childhood exposure to anesthesia. Pediatrics. 2012 Sep;130(3):e476-e485.
10. Monteleone M, Khandji A, Cappell J, et al. Anesthesia in children: perspectives from nonsurgical pediatric specialists.J Neurosurg Anesthesiol. 2014;26(4):396-398.
11. DiMaggio C, Sun LS, and Li G. Early childhood exposure to anesthesia and risk of developmental and behavioral disorders in a sibling birth cohort.Anesth Analg. 2011;113:1143-1151.
12. New York State Department of Health. Guidelines for determining brain death. December 2011, Available at:https://www.health.ny.gov/professionals/hospital_administrator/letters/2011/brain_death_guidelines.htm.
13. Donohoe KJ, Frey KA, Gerbaudo VH, et al. Society of nuclear medicine procedure guideline for brain death scintigraphy. Version 1.0.Approved February 25, 2003, available at:http://www.onelegacy.org/site/docs/SocietyNuclearMedicine_BrainDeathIdentification_022503.pdf.
14. Vlaar AMM, van Kroonenburgh MJPG, Kessels AGH, et al. Meta-analysis of the literature on diagnostic accuracy of SPECT in parkinsonian syndromes.BMC Neurol. 2007 Feb;7:27..
15. Relkin N, Marmarou A, Klinge P, et al. Diagnosing idiopathic normal-pressure hydrocephalus.Neurosurgery. 2005;57(3 Suppl):S2-4-S2-16.
16. MacDonald A, and Burrell S. Infrequently performed studies in nuclear medicine: Part 2. J Nucl Med Technol. 2009 Mar;37:1-13.
17. Fraum TJ, Ludwig DR, Bashir MR, et al.Gadolinium-based contrast agents: a comprehensive risk assessment. J Magn ResonImaging. 2017;46:338–353.
18. FDA Drug Safety Communication: FDA identifies no harmful effects to date with brain retention of gadolinium-based contrast agents for MRIs; review to continue. FDA Drug Safety Communication. May 22, 2017. https://www.fda.gov/Drugs/DrugSafety/ucm559007.htm
19. ACR -AIUM -SPR -SRU Practice parameter for the performance of neurosonography in neonates and infants. American College of Radiology. http://www.acr.org/guidelines Revised 2014
20. Sodhi K, Gupta P, Saxena A, Khandelwal N, Singhi P. Neonatal cranial sonography: A concise review for clinicians. Journal of Pediatric Neurosciences. 2016;11(1):7. doi:10.4103/1817-1745.181261.


PEDHD-2: Specialized Imaging Techniques

PEDHD-2.1: Magnetic Resonance Spectroscopy (MRS, CPT® 76390)

PEDHD-2.2: Functional Magnetic Resonance Imaging (fMRI, CPT® 70554 and CPT® 70555)

PEDHD-2.3: PET Brain Imaging (CPT® 78608 and CPT® 78609)

PEDHD-2.1: Magnetic Resonance Spectroscopy (MRS, CPT^® 76390)

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

Magnetic Resonance Spectroscopy involves the analysis of the levels of certain chemicals in pre-selected voxels (small regions) on an MRI scan done at the same time.

NOTE: *Certain payers consider MRS investigational, and their coverage policies may take precedence over Horizon BCBSNJ healthcare guidelines.

Uses in pediatric neuro-oncology: See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-4: Pediatric CNS Tumors.

Uses in Metabolic Disorders:

† These cases should be forwarded for Medical Director Review.

† MRS is indicated in members with neonatal hypoxic ischemic encephalopathy to help estimate the age of the injury.

† MRS is associated with disease-specific characteristics findings and is indicated for diagnosis and disease monitoring in the following metabolic disorders:

® Canavan disease.
® Creatine deficiency.
® Nonketotic hyperglycinemia.
® Maple Syrup Urine disease.

® Metachromatic leukodystrophy.
® Pelizaeus-Merzbacher disease.
® Hypomyelination and Congenital Cataract.
® Globoid Cell Leukodystrophy (Krabbe disease).
® X-linked adrenoleukodystrophy.
® Mitochondrial disorders.
® Alexander disease.
® Megalencephalic leukoencephalopathy with subcortical cysts.
® Vanishing White Matter disease.
® MRS can be approved for disease monitoring of these diagnoses when recent MRI findings are inconclusive and a change in therapy is being considered.

PEDHD-2.2: Functional Magnetic Resonance Imaging (fMRI, CPT^® 70554 and CPT^® 70555)

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

† These cases should be forwarded for Medical Director Review.

† fMRI is indicated to define eloquent areas of the brain as part of preoperative planning for epilepsy surgery or removal of a mass lesion.

® The documentation should be clear that brain surgery is planned.
® Can be approved concurrently with MRI Brain (CPT^® 70551 or CPT^® 70553) and/or PET Brain Metabolic (CPT^® 78608 or CPT^® 78609).

PEDHD-2.3: PET Brain Imaging (CPT^® 78608 and CPT^® 78609)

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

† These cases should be forwarded for Medical Director Review.

† Uses in pediatric neuro-oncology: See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-4: Pediatric CNS Tumors.

† PET Brain is indicated to define active areas of the brain as part of preoperative planning for epilepsy surgery.

® The documentation should be clear that brain surgery is planned.
® Can be approved concurrently with MRI Brain (CPT^® 70551 or CPT^® 70553) and/or fMRI (CPT^® 70554 or CPT^® 70555).

References
1. Rossi A, and Biancheri R. Magnetic resonance spectroscopy in metabolic disorders. Neuroimaging Clin N Am.2013 Aug;23(3):425–48.
2. Hertz-Pannier L, Noulhaine M, Rodrigo S, et al. Pretherapeutic functional magnetic resonance imaging in children.Neuroimag Clin N Am. 2014 Nov;24(4):639-653.
3. Patra KP, Lancaster JD, Hogg J, et al. Pediatric MRI of the brain: a primer.Pediatr Rev.2014 Mar;35(3):106-111.
4. Schneider JF. MR Spectroscopy in children: protocols and pitfalls in non-tumorous brain pathology.Pediatr Radiol.2016 Jun;46(7):963-982..
5. Dory CE, Coley BD, Karmazyn B, et al. Seizures—child.ACR Appropriateness Criteria^®.2012:1-10.
6. Ramey WL, Martirosyan NL, Lieu CM, et al. Current management and surgical outcomes of medically intractable epilepsy.Clin Neurol Neurosurg.2013 Dec;115(12):2411-2418.
7. Ghei SK, Zan E, Nathan JE, et al. MR Imaging of Hypoxic-Ischemic Injury in Term Neonates: Pearls and Pitfalls. RadioGraphics. 2014;34(4):1047-1061. doi:10.1148/rg.344130080.
8. Schwartz ES, Barkovich AJ. Brain and spine injuries in infancy and childhood. In: Barkovich AJ, Raybaud C, eds. Pediatric Neuroimaging, 6th ed. Philadelphia PA. Wolters Kluwer. 2019; 263-404.



PEDHD-3: Pediatric Headache

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

Headache is a very common complaint in school aged children and adolescents. Many of these children have a family history of one of the primary headache disorders, such as migraine or tension headache.

† A recent (within 60 days) evaluation including a detailed headache history, physical examination with a thorough neurologic examination, and appropriate laboratory studies should be performed prior to considering advanced imaging.

† Advanced imaging is not indicated for pediatric members with headache in the absence of red flag symptoms. Sensitivity and specificity of MRI are greater than that of CT for intracranial lesions.

† MRI Brain without contrast (CPT^® 70551) or without and with contrast (CPT^® 70553) is indicated for children with headaches and at least ONEof the following red flags:

® Age ≤5 years.
® Headaches awakening from sleep or always present in the morning.
® Focal findings on neurologic examination including diplopia.
® Clumsiness (common description of gait or coordination problems in young children).
® Headaches associated with morning nausea/vomiting.
® New onset of seizure activity with focal features.
® Papilledema on physical exam.
® Headache precipitated by coughing, sneezing, or Valsalva.
® Thunderclap headache.
® Progressive worsening in headache frequency and severity without period of temporary improvement.
® Systemic symptoms such as persistent fever, weight loss, rash, or joint pain.
® Immunocompromised member.
® Member with hypercoagulable state or bleeding disorder.
® Known history of cancer of any type.
® Known autoimmune or rheumatologic disease.
® Known genetic disorder with predisposition to intracranial mass lesions.
® History of stable chronic headaches with recent significant change in frequency or severity.

† CT Head poorly visualizes the posterior fossa in children and is generally insufficient to evaluate pediatric headaches with red flag symptoms. CT should not be approved in lieu of MRI solely to avoid sedation.

† CT Head without contrast is indicated for pediatric headache with one or more of the following:

® Recent head trauma.
® Suspected skull or other bony involvement.
® MRI is contraindicated due to implantable device or rapid clinical deterioration.
® Ventriculoperitoneal shunt with suspected shunt malfunction. See PEDHD-7: Macrocephaly, Microcephaly, and Hydrocephalus for additional imaging.

† MRA Head or CTA Head are not generally medically necessary in the evaluation of headache in children unless a vascular lesion has been seen or suspected on a prior MRI Brain or CT Head.

® Concurrent approval of both MRI and MRA is generally not indicated.

References

1. Hayes LL, Coley BD, Karmazyn B, et al. Headache—child.ACR Appropriateness Criteria^®. 2017:1-16.
2. Ryan ME, Palasis S, Saigal G, et al. Head trauma—child. ACR Appropriateness Criteria^®.2014:1-13
3. Hershey A, Kabbouche MA, and O’Brien H. Headaches.Nelson Textbook of Pediatrics, Chapter 595. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp 2863-2874.
4. Blume HK. Pediatric headache: a review.Pediatr Rev. 2012 Dec;33:562-574.
5. De Bries A, Young PC, Wall E,et al. CT scan utilization patterns in pediatric patients with recurrent headache. Pediatrics. 2013 July;132(1); e1-e8.
6. Lewis DW, Ashwal S, Dahl G, et al. Practice parameter: Evaluation of children and adolescents with recurrent headache. Neurology. 2002 Aug 27;59(4):490–498.
7. Trofimova A, Vey BL, Mullins ME, Wolf DS, Kadom N. Imaging of Children WithNontraumatic Headaches. American Journal of Roentgenology, 2018;210(1), 8-17.
8. Dao JM, Qubty W. Headache Diagnosis in Children and Adolescents. Current Pain and Headache Reports. 2018;22(3).
9. Bear JJ, Gelfand AA, Goadsby PJ, Bass N. Occipital headaches and neuroimaging in children. Neurology. 2017;89(5):469-474
10. Loder E, Weizenbaum E, Frishberg B, Silberstein S. Choosing Wisely in Headache Medicine: The American Headache Societys List of Five Things Physicians and Patients Should Question. Headache: The Journal of Head and Face Pain. 2013;53(10):1651-1659. doi:10.1111/head.12233.
11. Lewis DW, Ashwal S, Dahl G, et al; Quality Standards Subcommittee of the American Academy of Neurology; Practice Committee of the Child Neurology Society. Practice parameter: evaluation of children and adolescents with recurrent headaches—report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2002; 59:490–498.
12. Gofshteyn JS, Stephenson DJ. Diagnosis and Management of Childhood Headache. Current Problems in Pediatric and Adolescent Health Care. 2016;46(2):36-51. doi:10.1016/j.cppeds.2015.11.003.
13. Dalvi N, Sivaswamy L. Life-Threatening Headaches in Children: Clinical Approach and Therapeutic Options. Pediatric Annals. 2018;47(2). doi:10.3928/19382359-20180129-04.


PEDHD-4: Pediatric Head and Face Trauma

PEDHD-4.1: Head Trauma

PEDHD-4.2: Facial Trauma

PEDHD-4.1: Head Trauma

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

In members with recent head trauma, a history focused on the incident and careful examination of the head, neck, and neurological function should be performed prior to considering advanced imaging.

† Advanced imaging is indicated for children with head trauma with ANY of the following red flags:

® Loss of consciousness
® Altered mental status
® Known or suspected skull fracture
® Glasgow Coma Score <15
® Age younger than 2 years
® Vomiting
® Severe mechanism of injury
® Severe or worsening headache
® Amnesia
® Nonfrontal scalp hematoma

® CT Maxillofacial without contrast (CPT^® 70486), CT Orbits/Temporal Bone without contrast (CPT^® 70480), or CT Cervical Spine without contrast (CPT^® 72125) is indicated if there has been associated injury to those structures.

® Children with an abnormal neurological exam that is not explained by the CT findings.
® Children suspected of being the victims of physical abuse. See Pediatric Musculoskeletal Imaging Policy (Policy # 164 in the Radiology Section); PEDMS-7: Suspected Physical Child Abuse.

† Follow-up of known or treated parenchymal subdural or epidural hematoma may require frequent imaging during the initial 8 weeks following injury, and these requests should generally be approved.

® These cases should be forwarded for Medical Director Review.

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

† CT without contrast is the preferred imaging study in facial trauma.

Coding of Facial Imaging

Both CT Orbital/Facial Bone (CPT^® 70480) and CT Maxillofacial (CPT^® 70486) cover the structures of the orbits, sinuses, and face. Unless there is a grounded suspicion of simultaneous involvement of more posterior lesions, especially of the region involving the middle or inner ear, one of these studies only should be sufficient.

CT Maxillofacial (CPT^® 70486) is the usual study (except in obvious orbital or temporal bone trauma), but either study is appropriate.

References
1. Ryan ME, Palasis S, Saigal G, et al. Head trauma—child.ACR Appropriateness Criteria^®.2014:1-13.
2. Osmond MH, Klassen TP, Wells GA, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury.CMAJ. 2010 Mar 9;182(4):341-348.
3. Maguire JL, Boutis K, Uleryk EM, et al.Should a head-injured child receive a head CT scan? A systematic review of clinical prediction rules.Pediatrics. 2009;124:e145-e154.
4. Nigrovic LE, Stack AM, Mannix RC, et al. Quality improvement effort to reduce Cranial CTs for children with minor blunt head trauma. Pediatrics. 2015;136(1):e227-e233.
5. Homme J(JL. Pediatric Minor Head Injury 2.0. Emergency Medicine Clinics of North America. 2018;36(2):287-304.
6. Lumba-Brown A, Yeates KO, Sarmiento K, et al. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatr. 2018;172(11):e182853. doi:10.1001/jamapediatrics.2018.2853.
7. Babl FE, Borland ML, Phillips N, Kochar A, Dalton S, McCaskill M, Cheek JA, Gilhotra Y, Furyk J, Neutze J, Lyttle MD. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. The Lancet. 2017 Jun 17;389(10087):2393-402.
8. O’Brien WT, Caré MM, Leach JL. Pediatric Emergencies: Imaging of Pediatric Head Trauma. Seminars in Ultrasound, CT and MRI. 2018;39(5):495-514. doi:10.1053/j.sult.2018.01.007.


PEDHD-5: Sinusitis and Allergic Rhinitis

PEDHD-5.1: General Considerations

PEDHD-5.2: Imaging Indications in Sinusitis

PEDHD-5.3: Stereotactic CT Localization (CPT® 77011)

PEDHD-5.4: Requests for both Head and Sinus Imaging

PEDHD-5.5: Allergic Rhinitis

PEDHD-5.6: Other Indications for Sinus Imaging

PEDHD-5.1: General Considerations

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

† Acute sinusitis is a clinical diagnosis, and imaging is not indicated to establish a diagnosis. Acute bacterial sinusitis can be presumptively diagnosed in a child with acute upper respiratory infection (URI) symptoms and any of the following:

® Persistent symptoms lasting >10 days without improvement.
® Worsening symptoms after initial period of improvement.
® Severe symptoms including purulent nasal discharge and fever >102.2°F for at least 3 consecutive days.
® Presumed bacterial infections should be treated empirically with appropriate antibiotics.
® Imaging of any kind cannot distinguish bacterial from viral sinusitis.

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

† Mild mucosal thickening in the paranasal sinuses or mastoids is an extremely common incidental finding noted on head imaging studies done for other indications. If there are no other abnormalities of facial structures noted, this finding is not an indication for advanced imaging of the sinuses or temporal bone.

† CT Sinuses without contrast (CPT^® 70486) is indicated if ANY of the following is present:

® No improvement after 10 days of appropriate antibiotic treatment.
¡ Generally this will be amoxicillin/clavulanate, amoxicillin, cefdinir, cefuroxime, cefpodoxime, or ceftriaxone.
® Recurrence of a treated infection within 8 weeks of effective treatment.
® Chronic sinusitis (persistent residual URI symptoms for >90 days).
® Known or suspected fungal sinusitis.
® Preoperative evaluation to assess surgical candidacy.

® Orbital or facial cellulitis.
® Proptosis.
® Abnormal visual examination.
® Ophthalmoplegia.
® Cystic fibrosis.
® Immunocompromised member.
® Fungal or vascular lesions visualized in nasal cavity.

® Focal neurologic findings.
® Altered mental status.
® Seizures.
® Concern for orbital complications.
® Concern for invasive fungal sinusitis.
® MRA Head(CPT^® 70544) or CTA Head (CPT^® 70496) can be approved with these findings as well if there is clinical concern for associated vascular complications including but not limited to mycotic aneurysm or venous sinus thrombosis.

® These cases should be forwarded for Medical Director Review.

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

Stereotactic CT localization is frequently obtained prior to sinus surgery. The dataset is then loaded into the navigational workstation in the operating room for use during the surgical procedure. The information provides exact positioning of surgical instruments with regard to the member’s 3D CT images. In most cases, the preoperative CT is a technical-only service that does not require interpretation by a radiologist.

† The imaging facility should report CPT^® 77011 when performing a scan not requiring interpretation by a radiologist.

† If a diagnostic scan is performed and interpreted by a radiologist, the appropriate diagnostic CT code (e.g. CPT^® 70486) should be used.

† It is not appropriate to report both CPT^® 70486 and CPT^® 77011 for the same CT stereotactic localization imaging session.

† 3D Rendering (CPT^® 76376 or CPT^® 76377) should not be reported in conjunction with CPT^® 77011 (or CPT^® 70486 if used).The procedure inherently generates a 3D dataset.

† Such operative studies are indicated when ordered by the operating surgeon for this purpose.

PEDHD-5.4: Requests for both Head and Sinus Imaging

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

† CT Head does not visualize all of the sinuses.

† MRI Brain provides excellent visualization of the sinuses sufficient to recognize sinusitis, and addition of sinus CT for this purpose is unnecessary.

† In members being evaluated for potential sinus surgery, separate CT Sinus is often appropriate even after a MRI Brain in order to visualize obstructions to spontaneous mucous flow. See PEDHD-5.3: Stereotactic CT Localization (CPT^® 77011).

† Separate head imaging is not generally indicated in members with a normal neurological examination who have headaches associated with sinus symptoms.

† CT or MRI Sinus is not indicated for the evaluation of headaches or neurological complaints without a more specific indication pointing to a sinus etiology.

PEDHD-5.5: Allergic Rhinitis

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

† Advanced imaging is not indicated for diagnosis or management of members with uncomplicated allergic rhinitis.

PEDHD-5.6: Other Indications for Sinus Imaging

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

See PEDHD-4.2: Facial Trauma for imaging guidelines in trauma.

† Congenital anomalies of facial structures - CT Maxillofacial without contrast (CPT^® 70486).

† 3D CT reconstructed images (CPT^® 76377) in conjunction with routine CT should be an integral part of the examination in evaluating craniofacial abnormalities.

† Tumors or other disorders of facial structures – CT Maxillofacial without and with contrast (CPT^® 70488) or MRI Orbits/Face/Neck without and with contrast (CPT^® 70543).

† Obstructive sleep apnea See PEDHD-24: Pediatric Sleep Disorders for imaging guidelines.

References
1. Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years.Pediatrics. 2013 Aug 5;132(1):e262-e280.
2. Tekes A, Palasis S, Durand D, et al. Sinusitis—child. ACR Appropriateness Criteria^®.2018:1-12.
3. Pappas DE, and Hendley JO. Sinusitis.Nelson Textbook of Pediatrics, Chapter 380. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp 2014-2017.
4. Magit A. Pediatric rhinosinusitis.Otolaryngol Clin N Am. 2014 Oct;47(5):733-746.
5. Siedman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: allergic rhinitis executive summary.Otolaryngol Head Neck Surg.2015 Feb 2;152:197-206.
6. AAP Releases Guideline on Diagnosis and Management of Acute Bacterial Sinusitis in Children One to 18 Years of Age. Am Fam Physician. 2014 Apr 15;89:676-681.
7. Tekes A, Palasis S, Durand DJ, et al. ACR Appropriateness Criteria^® Sinusitis-Child. Journal of the American College of Radiology. 2018;15(11). doi:10.1016/j.jacr.2018.09.029.



PEDHD-6: Epilepsy and Other Seizure Disorders

PEDHD-6: Epilepsy and Other Seizure Disorders

PEDHD-6.1: Initial Imaging of Non-Febrile Seizures

PEDHD-6.2: Repeat imaging indications

PEDHD-6.3: Special Imaging Studies in Evaluation for Epilepsy Surgery

PEDHD-6.4: Febrile Seizures

PEDHD-6: Epilepsy and Other Seizure Disorders

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 with a thorough neurologic examination, and appropriate laboratory studies should be performed prior to considering the use of an advanced imaging (CT, MRI, Nuclear Medicine) procedure. An exception can be made if the member is undergoing guideline-supported, scheduled follow-up imaging evaluation. This clinical evaluation should also include family history and (whenever possible) the accounts of eyewitnesses to the event(s).

PEDHD-6.1: Initial Imaging of Non-Febrile Seizures

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

† MRI Brain without contrast (CPT^® 70551) or without and with contrast (CPT^® 70553) is indicated for the following:

® First-time seizure in child that has no known cause and is not associated with fever.
® Partial seizures.
® Focal neurologic deficits.
® Inconclusive findings on recent cranial ultrasound or CT Head.
¡ If member meets criteria for MRI imaging for initial imaging of non-febrile seizure, MRI is approvable even with a recent negative CT.
® Members requiring sedation should generally not have non-contrast MRI studies. See PEDHD-1.3: Pediatric Head Imaging Modality General Considerations.

® First-time seizure in child associated with recent head trauma.
® Member cannot safely undergo MRI (avoidance of sedation is not an indication).

® First-time seizure in child <12 months of age that has no known cause and is not associated with fever if the infant has an open fontanelle.

® CTA Head or Neck.
® MRA Head or Neck.
® MRI Cervical, Thoracic, or Lumbar Spine.

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

† Repeat MRI Brain without contrast (CPT^® 70551) or without and with contrast (CPT^® 70553) is indicated for the following:

® Need to perform MRI using Epilepsy Protocol (typically 3T magnet with thin section angled slices through hippocampus and temporal lobes, either without or without and with contrast).
® New or worsening focal neurologic deficits.
® Increase in severity or frequency of seizures despite documented therapeutic antiepileptic drug levels.
® Change in seizure type.
® Preoperative evaluation for epilepsy surgery.
® Members requiring sedation should generally not have non-contrast MRI studies. See PEDHD-1.3: Pediatric Head Imaging Modality General Considerations.

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

For members with a previous MRI Brain and documentation of intractable epilepsy for which surgical treatment or another interventional modality is under active consideration, ANY of the following are indicated for preoperative planning:

† These cases should be forwarded for Medical Director Review

† PET Brain Metabolic (CPT^® 78608 or CPT^® 78609).

† Functional MRI Brain (CPT^® 70554 or CPT^® 70555).

† MR Spectroscopy (CPT^® 76390).

® NOTE: Certain payers consider MR Spectroscopy investigational, and those coverage policies take precedence over Horizon BCBSNJ Imaging Guidelines.

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

A typical febrile seizure is a generalized seizure occurring in the presence of fever (T >100.4°F) and no central nervous system infection in a child between the age of 6 months and 5 years.

† Neuroimaging should not be performed in the routine evaluation of children with simple febrile seizures.

† MRI Brain without contrast (CPT^® 70551) or without and with contrast (CPT^® 70553) is indicated for febrile seizures in the presence of one or more of the following:

® Seizure lasting >15 minutes.
® Partial seizures.
® Focal neurologic deficits.
® Multiple seizures within 24 hours.
® Macrocephaly (Head circumference that is greater than the 95^th percentile for age and sex, established by use of measurements and CDC growth charts. See PEDHD-7.1: Macrocephaly)
® Signs and symptoms of increased intracranial pressure.

PEDHD-7: Macrocephaly, Microcephaly, and Hydrocephalus

PEDHD-7.1: Macrocephaly

PEDHD-7.2: Microcephaly

PEDHD-7.3: Hydrocephalus

PEDHD-7.1: Macrocephaly

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

Macrocephaly is defined as head circumference that is greater than the 95^th percentile for age and sex, established by use of measurements and CDC growth charts. An online calculator to determine head circumference percentile is available at: http://www.infantchart.com/cdc0to3headforage.php.

Birth to age 12 months:

† Ultrasound Head (CPT^® 76506) is indicated initially in members with an open fontanelle.

† If hydrocephalus or hemorrhage is present on ultrasound, CT Head without contrast (CPT^® 70450) is indicated.

† For any abnormality seen on ultrasound, MRI Brain without contrast (CPT^® 70551) or without and with contrast (CPT^® 70553) is indicated.

Age 13 months and older, or with closed fontanelle:

† MRI Brain without contrast (CPT^® 70551) or without and with contrast (CPT^® 70553)) is indicated.

† CT is generally not indicated in this age group since uncomplicated hydrocephalus is less likely after early infancy.

PEDHD-7.2: Microcephaly

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

† Microcephaly is defined as head circumference that is less than the 5^th percentile for age and sex, established by use of measurements and CDC growth charts. An online calculator to determine head circumference percentile is available at: http://www.infantchart.com/cdc0to3headforage.php.

† MRI Brain without and with contrast (CPT^® 70553) is indicated for all members.

® CT is generally not recommended as that modality lacks the sensitivity to detect the relevant anatomical abnormalities.

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

† This is the most common identifiable cause of macrocephaly. Almost all hydrocephalus is obstructive, except hydrocephalus due to choroid plexus papillomas. See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-4.13: Choroid Plexus Tumors for those lesions.

† Hydrocephalus is traditionally divided into non-communicating (the obstruction lies within the course of the brain’s ventricular system) and communicating (the obstruction is distal to the ventricular system).

† Members requiring sedation should generally not have non-contrast MRI studies. See PEDHD-1.3: Pediatric Head Imaging Modality General Considerations.

Initial Imaging Indications

Age 0-6 months:

† Screening head ultrasound examination (CPT^® 76506)

† If ultrasound shows hydrocephalus, MRI Brain without and with contrast (CPT^® 70553) is indicated.

† Serial US (CPT^® 76506) can be used to monitor ventricular size to determine need and timing of placement of a ventricular catheter, or performance of an endoscopic third venticulostomy (ETV).

Greater than 6 months old:

† MRI Brain without and with contrast (CPT^® 70553) is indicated.

Spine imaging:

† MRI Spine without and with contrast (CPT^® 72156, CPT^® 72157, and CPT^® 72158) may be indicated in individuals with Chiari malformation (multiple spine segments), Dandy-Walker malformation (cervical spine only), or malignant infiltration of the meninges.

Repeat Imaging Indications

† Rapid MRI Brain without contrast (CPT^® 70551) or CT Head without contrast (CPT^® 70450) is indicated for any new signs or symptoms suggesting shunt malfunction (or ETV malfunction, including (but not limited to) sepsis, decreased level of consciousness, protracted vomiting, visual or neurologic deterioration, decline of mentation after initial improvement, or new or changing pattern of seizures.

† Rapid MRI Brain without contrast (CPT^® 70551) or CT Head without contrast (CPT^® 70450) is indicated in the postoperative period following shunt placement or ETV, with further follow-up imaging 6-12months after the procedure and then every 12 months for members with stable clinical findings.

® Rapid MRI provides more anatomical detail and does not involve radiation exposure, but many providers use CT Head as rapid MRI is not universally available.
® For routine follow up imaging with CT a low dose protocol should be used.

® Abdominal ultrasound (CPT^® 76700) can be approved for suspicion of CSF pseudocyst formation or distal shunt outlet obstruction.

Additional Rarely Used Studies

† Cisternogram (CPT^® 78630) is rarely done in children but can be approved for the following:

® Known hydrocephalus with worsening symptoms.
® Suspected obstructive hydrocephalus.
® Suspected normal pressure hydrocephalus with gait disturbance and either dementia or urinary incontinence.

® Evaluation of internal shunt, porencephalic cyst, or posterior fossa cyst.

® Suspected malfunction of ventriculoperitoneal, ventriculopleural, or ventriculovenous shunts.

PEDHD-8.1: Imaging

PEDHD-8.1: Imaging

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

Craniosynostosis is the premature closure of one or more cranial sutures, usually during infancy. Abnormal head shape is the common clinical feature.

† Skull x-rays should be obtained prior to considering advanced imaging.

† CT Head without contrast (CPT^® 70450) is indicated in the diagnosis of craniosynostosis, with reported sensitivity near 100%. CT also detects associated intracranial pathology.

† 3D rendering (CPT^® 76376 or CPT^® 76377) is indicated with the initial diagnostic CT to evaluate the extent of synostosis and determine surgical candidacy or for preoperative planning.

† CT Maxillofacial (CPT^® 70486) and CT Orbits (CPT^® 70480) without contrast are generally not necessary to evaluate members with craniosynostosis but are indicated if the craniosynostosis is part of a larger congenital defect which also involves the bones of the face or orbit.

† Ultrasound Head (CPT^® 76506) can be approved as an alternative method of assessing sutural patency in neonates and infants when radiographs are indeterminate. If inconclusive or for pre-operative planning, CT with 3D rendering can be approved as discussed previously in this section.

† A postoperative CT Head without contrast (CPT^® 70450) may be performed at the discretion of the specialist coordinating the member’s care.

References
1. Hall KM, Besachio DA, Moore MD, et al. Effectiveness of screening for craniosynostosis with ultrasound: a retrospective review. Pediatr Radiol. 2017;47:606-612.
2. Rozovsky K, Udjus K, Wilson N, et al. Cranial ultrasound as a first-line imaging examination for craniosynostosis. Pediatrics 2016. 137:e20152230
3. Kinsman SL, and Johnston MV.Craniosynostosis.Nelson Textbook of Pediatrics, Chapter 591.12. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016,pp 2817-2819.
4. Fearon JA. Evidence-based medicine: craniosynostosis.Plast Reconstr Surg. 2014 May;133(5):1261-1275.

PEDHD-9: Chiari and Skull Base Malformations

PEDHD-9.1: Chiari I Malformations

PEDHD-9.2: Chiari II Malformations (Arnold Chiari Malformation)

PEDHD-9.3: Chiari III and IV Malformations

PEDHD-9.4: Basilar Impression

PEDHD-9.5: Platybasia

PEDHD-9.1: Chiari I Malformations

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

This involves caudal displacement or herniation of the cerebellar tonsils. Chiari I may be associated with syringomyelia, and rarely with hydrocephalus. Most cases are asymptomatic and discovered incidentally on a head scan performed for another indication. When symptoms are present, they are usually nonspecific but can include headache, lower cranial nerve palsies, or sleep apnea.

† For initial evaluation, MRI Brain without contrast (CPT^® 70551) or without and with contrast (CPT^® 70553) and MRI of the entire spine without contrast (CPT^® 72141, CPT^® 72146, CPT^® 72148) or without and with contrast (CPT^® 72156, CPT^® 72157, CPT^® 72158) is indicated.

† Members requiring sedation should generally not have non-contrast MRI studies. See PEDHD-1.3: Pediatric Head Imaging Modality General Considerations.

† Repeat MRI Brain without contrast (CPT^® 70551) or without and with contrast (CPT^® 70553) is indicated for members with a known Chiari I malformation when any of the following are present:

® There are new or worsening signs or symptoms documented on a physical examination within 60 days of the imaging request.
® A surgical procedure is actively being considered.

® These cases should be forwarded for Medical Director Review.

® These cases should be forwarded for Medical Director Review.

PEDHD-9.2: Chiari II Malformations (Arnold Chiari Malformation)

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

These malformations are more severe than Chiari I malformations. These members usually present at birth. Myelomeningocele is always present, and syringomyelia and hydrocephalus are extremely common.

† Ultrasound is the initial examination in infants to determine ventricular size and associated anomalies and to provide a baseline for follow up evaluation.

† For initial advance imaging evaluation, MRI Brain without and with contrast (CPT^® 70553) and MRI of the entire spine without and with contrast (CPT^® 72156, CPT^® 72157, CPT^® 72158) is indicated.

† Repeat brain and spine imaging in individuals with Chiari II malformations is highly individualized and is indicated at the discretion of the specialist coordinating the member’s care for this condition.

® These cases should be forwarded for Medical Director Review.

PEDHD-9.3: Chiari III and IV Malformations

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

Chiari III malformation includes cerebellar herniation into a high cervical myelomeningocele. Chiari IV malformation refers to complete cerebellar agenesis. Both Chiari III and IV malformations are noted at birth, and are rarely compatible with life.

† Repeat brain and spine imaging in individuals with Chiari III and IV malformations is highly individualized and is indicated at the discretion of the specialist coordinating the member’s care for this condition.

® These cases should be forwarded for Medical Director Review.

PEDHD-9.4: Basilar Impression

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

Basilar impression involves malformation of the occipital bone in relation to C1-2 (cervical vertebrae 1 and 2). The top of the spinal cord is inside the posterior fossa and the foramen magnum is undersized. Over time, this can lead to brain stem and upper spinal cord compression. Basilar impression can also be associated with the Chiari malformation, producing very complex anatomical abnormalities.

† MRI Brain (CPT^® 70551) and Cervical Spine (CPT^® 72141) without contrast are indicated.

† If surgery is being considered, CT Head (CPT^® 70450) and Cervical Spine (CPT^® 72125) without contrast are also indicated.

† Basilar impression appears to be genetic, and one-time screening of first-degree relatives with MRI Brain without contrast (CPT^® 70551) can be approved.

PEDHD-9.5: Platybasia

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

Platybasia is a flattening malformation of the skull base, in which the clivus has a horizontal orientation.

† Members are usually asymptomatic, but either MRI Brain without contrast (CPT^® 70551) or CT Head without contrast (CPT^® 70450) is indicated to establish a diagnosis when clinically suspected.

References
1. Siegel MJ. Brain. In: pediatric sonography.5^th ed.Philadelphia. Wolters Kluwer. 201840-111.
2. Kinsman SL, and Johnston MV. Congenital anomalies of the central nervous system. Nelson Textbook of Pediatrics, Chapter 591. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp 2802-2819.
3. Strahle J, Muraszko KM, Kapurch J, et al. Chiari malformation Type I and syrinx in children undergoing magnetic resonance imaging.J Neurosurg Pediatr. 2011 Aug;8(2):205-213.
4. Strahle J, Muraszko KM, Kapurch J, et al. Natural history of Chiari malformation Type I following decision for conservative treatment.J Neurosurg Pediatr. 2011 Aug; 8(2):214-221.
5. Strahle J, Muraszko KM, Garton HJL, et al. Syrinx location and size according to etiology: identification of Chiari-associated syrinx.J Neurosurg Pediatr. 2015 July;16(1):21-9Epub 2015 Apr3.
6. Strahle J, Smith BW, Martinez M, et al. The association between Chiari malformation Type I, spinal syrinx, and scoliosis.J Neurosurg Pediatr. 2015 Jun;15(6):607-611.
7. Victorio MC, Khoury CK. Headache and Chiari I Malformation in Children and Adolescents. Seminars in Pediatric Neurology. 2016;23(1):35-39.
8. Radic JAE, Cochrane DD. Choosing Wisely Canada: Pediatric Neurosurgery Recommendations. Paediatrics & Child Health. 2018;23(6):383-387. doi:10.1093/pch/pxy012.
9. 9. Smoker WRK and Khanna G. Imaging the craniocervical junction.Childs Nerv Syst. 2008 Oct;24(10):1123-1145.


PEDHD-10: Intracranial Aneurysms and AVM

PEDHD-10.1: Pediatric Intracranial Aneurysms

PEDHD-10.2: Pediatric Intracranial Arteriovenous Malformations (AVM)

PEDHD-10.1: Pediatric Intracranial Aneurysms

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

Unlike adults, the majority of pediatric aneurysms are caused by genetic or developmental defects rather than environmental or lifestyle factors.

Pediatric aneurysms most commonly present with subarachnoid hemorrhage, headache, increased intracranial pressure, seizure activity, or focal neurologic findings.

† A recent (within 60 days) evaluation including a detailed history, physical examination with a thorough neurologic examination, and appropriate laboratory studies should be performed prior to considering advanced imaging, unless the member is undergoing guideline-supported scheduled follow-up imaging evaluation.

† For members presenting with suspected subarachnoid hemorrhage, CT Head without contrast (CPT^® 70450) or MRI Brain without contrast (CPT^® 70551) is indicated as an initial study.

® If subarachnoid hemorrhage is present on CT or MRI, or lumbar puncture findings suggest hemorrhage, additional imaging with CTA Head (CPT^® 70496) or MRA Head without contrast (CPT^® 70544) is indicated.

® If findings suspicious for intracranial aneurysm are present on MRI, additional imaging with CTA Head (CPT^® 70496) or MRA Head without contrast (CPT^® 70544) is indicated.

† For members with treated aneurysms, CTA Head (CPT^® 70496) is preferred.

† For members with any of the following conditions and headache, increased intracranial pressure, seizures, or focal neurologic findings, MRI Brain without contrast (CPT^® 70551) or without and with contrast (CPT^® 70553) and MRA Head without contrast (CPT^® 70544) are indicated:

® Polycystic kidney disease.
® Fibromuscular dysplasia.
® Ehlers-Danlos Syndrome.
® Klippel-Trenaunay-Weber Syndrome.
® Tuberous Sclerosis.
® Moyamoya Syndrome.
® Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendu Syndrome).
® Pseudoxanthoma elasticum.
® Neurofibromatosis type 1.

† The timing of follow-up imaging for intracranial aneurysms in children is similar to that in adults. See Adult Head Imaging Policy (Policy #151 in the Radiology Section); HD-12.1: Intracranial Aneurysms in the Head Imaging Guidelines.

† Screening MRI Brain or MRA Head for aneurysms is not supported in asymptomatic members under age 20 since only 0.6% of ruptured aneurysms occur in the pediatric age range.

† Screening MRI Brain or MRA Head for aneurysms is not supported in members with coarctation of the aorta repaired before age 3 since there is not an increased risk for intracranial aneurysm in this member population.

PEDHD-10.2: Pediatric Intracranial Arteriovenous Malformations (AVM)

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

A recent (within 60 days) evaluation including a detailed history, physical examination with a thorough neurologic examination, and appropriate laboratory studies should be performed prior to considering advanced imaging, unless the member is undergoing guideline-supported scheduled follow-up imaging evaluation.

Most intracranial AVMs are congenital, vary widely in their location and type, and are discovered at birth due to associated clinical findings or incidentally later in life. Certain hereditary conditions are associated with an increased risk for AVM development.

Vascular malformations include arteriovenous, venous, cavernous, and capillary malformations. The vein of Galen malformation is the most common arteriovenous malformation, presenting in neonates with signs of high output congestive heart failure or later in infancy of childhood with signs of hydrocephalus. Low flow venous, cavernous, and capillary malformations may be asymptomatic and discovered incidentally or they may present in childhood with seizures or neurologic findings secondary to intracranial hemorrhage.

Ultrasound Head (CPT^® 76506) is the study of choice for evaluation of a suspected vein of Galen malformation in the neonate. Once confirmed, MRI or conventional angiography are required to precisely identify the feeding arteries and draining vein, especially if embolization is planned.

MRA or CTA are indicated for diagnosis of low flow malformations.

† MRI Brain without and with contrast (CPT^® 70553) is the initial study of choice for evaluation of suspected AVM after the neonate period.

® Members requiring sedation should generally not have non-contrast MRI studies. See PEDHD-1.3: Pediatric Head Imaging Modality General Considerations.
® MRA, CTA, or CT are generally not indicated prior to completion of initial MRI.

® New or worsening headaches, seizures, or focal neurologic symptoms.
® Preoperative planning (including embolization).

® Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendu Syndrome).
¡ MRI Brain without and with contrast (CPT^® 70553) is indicated as an initial screening study for infants born to a parent with known HHT.
¡ MRI Brain without and with contrast (CPT^® 70553) at the time of diagnosis, and a single repeat study after the age of 20.
¡ Ongoing surveillance imaging is not indicated for members without new or worsening symptoms.
¡ Repeat MRI alone or with MRA or CTA (as above) is indicated for clinical signs or symptoms concerning for progression in a member with a known AVM.
¡ CTA (as above) is indicated for clinical signs or symptoms concerning for progression in a member with a clipped AVM
® Capillary Malformation-Arteriovenous Malformation (CM-AVM)
¡ Caused by RASA1 mutations.
¡ MRI Brain without and with contrast (CPT^®70553) at the time of diagnosis.
¡ Ongoing surveillance imaging is not indicated for members without new or worsening symptoms.
¡ Repeat MRI alone or with MRA or CTA (as above) is indicated for clinical signs or symptoms concerning for progression in a member with a known AVM.
¡ See Pediatric Peripheral Vascular Disease Imaging Policy (Policy # 169 in the Radiology Section); PEDPVD-2: Vascular Anomalies.
® Sturge-Weber Syndrome:
¡ MRI Brain without and with contrast (CPT^® 70553) and MRI Face/Neck (CPT^® 70543) at the time of diagnosis.
¡ Ongoing surveillance imaging is not indicated for members without new or worsening symptoms.
¡ Repeat MRI alone or with MRA or CTA (as above) is indicated for clinical signs or symptoms concerning for progression in a member with a known AVM.
® Cerebral Cavernous Malformations:
¡ Also known as cavernomas, cavernous angiomas, or cryptic vascular malformations.
¡ MRI Brain without and with contrast (CPT^® 70553) and MRI Cervical (CPT^® 72156) and Thoracic (CPT^® 72157) Spine without and with contrast at the time of diagnosis.
¡ Ongoing surveillance imaging is not indicated for members without new or worsening symptoms.
¡ Repeat MRI alone or with MRA or CTA (as above) is indicated for clinical signs or symptoms concerning for progression in a member with a known AVM.

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

Syncope in children is almost always neurocardiogenic (vasovagal) in nature. Intracranial mass lesions do not cause isolated syncope. Syncope and seizure activity can often be challenging to distinguish for unwitnessed syncope.

† Advanced imaging of the brain is not indicated for members with isolated syncope without focal neurologic findings. See Pediatric Cardiac Imaging Policy (Policy # 161 in the Radiology Section); PEDCD-5: Syncope and PEDHD-6: Epilepsy and Other Seizure Disorders for additional imaging considerations.

References
1. Friedman KG, and Alexander ME. Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease.J Pediatr. 2013 Sep;163(3):896-901.
2. Cannon B, and Wackel P. Syncope.Pediatr Rev. 2016 Apr;37(4):159-168.
3. Fant C, Cohen A. Syncope In Pediatric Patients: A Practical Approach To Differential Diagnosis And Management In The Emergency Department. Pediatric emergency medicine practice. 2017 Apr;14(4):1-28.



PEDHD-12: Pediatric Stroke

PEDHD-12.1: General Considerations

PEDHD-12.2: Pediatric Stroke Initial Imaging

PEDHD-12.3: Pediatric Stroke Subsequent Imaging

PEDHD-12.4: Moyamoya Disease

PEDHD-12.5: Sickle Cell Disease

PEDHD-12.6: CNS Vasculitis and Stroke

PEDHD-12.1: General Considerations

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

Imaging indications are the same for neonates as for older children.

PEDHD-12.2: Pediatric Stroke Initial Imaging

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

† As pediatric strokes may be hemorrhagic, CT Head without contrast (CPT^® 70450) is generally the initial study indicated.

® MRI Brain without contrast (CPT^® 70551) can be performed in lieu of initial CT if emergently available for evaluation of acute stroke symptoms.

® These cases should be forwarded for Medical Director Review.
® MRI Brain without contrast (CPT^® 70551) or without and with contrast (CPT^® 70553).
® MRA Head without contrast (CPT^® 70544) and Neck with contrast (CPT^® 70548).
® CTA Head (CPT^® 70496) and Neck (CPT^® 70498).

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

† MRI Brain without contrast (CPT^® 70551) or without and with contrast (CPT^® 70553) is indicated for any new or worsening neurological findings or seizure activity.

† Most pediatric members do not benefit from surveillance imaging after stroke, but specific surveillance imaging indications for specified conditions are listed in the disease-specific section.

® These cases should be forwarded for Medical Director Review
® MRI Brain without contrast (CPT^® 70551) or without and with contrast (CPT^® 70553).

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

Initial imaging

† MRI Brain without contrast (CPT^® 70551) or without and with contrast (CPT^® 70553), MRA Head (CPT^® 70544) and Neck (CPT^® 70548) are indicated for all members. CTA Head and Neck (CPT^® 70496 and CPT^® 70498) can be approved if MRI is contraindicated or not readily available.

Repeat imaging

† MRA Head (CPT^® 70544) every 12 months. CTA Head (CPT^® 70496) can be approved if MRI is contraindicated or not readily available.

† MRI Brain without contrast (CPT^® 70551) every 12 months.

† Radiopharmaceutical Localization Imaging SPECT (CPT^® 78803) with vasodilating agent acetazolamide (Diamox) challenge can be approved when surgery or other vascular intervention is being considered.

PEDHD-12.5: Sickle Cell Disease

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

Members with sickle cell disease are at significantly increased risk for stroke and silent infarction, beginning at a very young age. Recent advances allow physicians to identify members at high risk for stroke and begin a primary stroke prevention program. Identification of silent cerebral infarction is important because treatment with prophylactic red cell transfusions to maintain hemoglobin S levels at <30% of total hemoglobin may reduce recurrent stroke and extent of neurologic damage.

† The following imaging is indicated for all sickle cell members with a severe phenotype (Hgb SS or Hgb Sβ0):

® Transcranial Doppler Ultrasound (CPT^® 93886 or CPT^® 93888) annually for all members age 2 to 16. Transcranial Doppler is used to screen for overt and silent infarctions and monitor response to transfusion therapy.
¡ A short interval repeat study is indicated for members with conditional (170-199 cm/sec) flow results, or with members undergoing transfusion therapy.
¡ MRI Brain without contrast (CPT^® 70551) or without and with contrast (CPT^® 70553) is indicated in members with persistent abnormal Transcranial Doppler.
® Transcranial Doppler is not indicated for members with other phenotypes (Hgb SC, Hgb Sβ⁺).
® Screening of asymptomatic sickle cell members with MRI or MRA is no longer recommended.

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

† MRI Brain without and with contrast is the recommended initial study for all members with vasculitis and suspected CNS involvement, whether primary or secondary.

® A normal MRI Brain almost always completely excludes intracranial vasculitis
® MRA Head (contrast as requested) is indicated for inconclusive MRI findings suggesting medium or large vessel vasculitis.
® Members with aggressive disease being treated with systemic therapy can have imaging approved for treatment response every 3 months during active treatment.
® Annual surveillance imaging can be approved to detect progressive vascular damage that may require intervention

PEDHD-13.1: Arachnoid Cysts

PEDHD-13.2: Pineal Cysts

PEDHD-13.3: Acoustic Neuromas

PEDHD-13.1: Arachnoid Cysts

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

Arachnoid cysts arise in the middle or posterior fossa, and the majority of lesions are discovered incidentally and do not require surgical intervention.

† MRI Brain without contrast (CPT^® 70551) or without and with contrast (CPT^® 70553) is indicated for initial evaluation of arachnoid cysts if not already completed.

† Repeat MRI Brain is not indicated for most members with arachnoid cysts, but can be approved for the following:

® Annual MRI Brain without contrast (CPT^® 70551) or without and with contrast (CPT^® 70553) until age 4 if diagnosed at a younger age.
® New or worsening headache or focal neurologic deficits suggesting progression of cyst.
® Preoperative planning.

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

Pineal cysts are generally discovered incidentally and do not require surgical intervention.

† MRI Brain without contrast (CPT^® 70551) or without and with contrast (CPT^® 70553) is indicated for initial evaluation of pineal cysts if not already completed.

† Repeat MRI Brain is not indicated for most members with pineal cysts, but MRI Brain without contrast (CPT^® 70551) or without and with contrast (CPT^® 70553) can be approved for the following:

® New or worsening headache or focal neurologic deficits suggesting progression of cyst.
® Preoperative planning.

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); PEDPND-2.2: Neurofibromatosis 2

References
1. Hervey-Jumper SL, Cohen-Gadol AA, and Maher CO. Neurosurgical management of congenital malformations of the brain.Neuroimag Clin N Am. 2011 Aug;21(3):705-717.
2. Chtinis T, Guttman CR, Zaitsev A, et al. Quantitative MRI analysis in children with multiple sclerosis: a multicenter feasibility pilot study.BMC Neurol. 2013 Dec;13:173.
3. Al-Holou WN, Maher CO, Muraszko KM, et al. The natural history of pineal cysts in children and young adults.J Neurosurg Pediatr.2010 Feb;5(2):162-166.
4. Jussila M-P, Olsén P, Salokorpi N, Suo-Palosaari M. Follow-up of pineal cysts in children: is it necessary? Neuroradiology. 2017;59(12):1265-1273.
5. Raybaud C, Patay Z, Barkovich. Intracranial, orbital and neck masses in children. In: Barkovich AJ, Raybaud C, eds. Pediatric Neuroimaging, 6th ed. Philadelphia PA. Wolters Kluwer. 2019; 703-906.

PEDHD-14: Pediatric Demyelinating Diseases

PEDHD-14.1: General Considerations

PEDHD-14.2: Multiple Sclerosis (MS)

PEDHD-14.3: Acute Disseminated Encephalomyelitis (ADEM)

PEDHD-14.1: General Considerations

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

† MRI Brain without and with contrast (CPT^® 70553) is the preferred imaging study for evaluation of pediatric demyelinating disease.

® MRI Spinal Cord without and with contrast (CPT^® 72156 and CPT^® 72157) is also indicated for evaluation of pediatric demyelinating disease.
® MRI Lumbar Spine without and with contrast (CPT^® 72158) is not indicated unless the member has a tethered cord or other anatomic abnormality causing caudal displacement of the filum terminalis.

† PET Brain (CPT^® 78608 and CPT^® 78609) and MR Spectroscopy (CPT^® 76390) are considered investigational for evaluation of pediatric demyelinating diseases.

PEDHD-14.2: Multiple Sclerosis (MS)

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

Multiple sclerosis is less common in children. About 4% of MS cases are diagnosed before age 18, and only ~0.7% of all MS cases begin before age 10.

Ataxia, optic neuritis, diplopia, and transverse myelitis are common presentations. MS can present as an acute encephalitis-like illness, especially in childhood.

Among children with suspected demyelinating diseases, the principal differential diagnosis is often between MS and acute disseminated encephalomyelitis.

† MRI Brain (CPT^® 70553) and Spinal Cord (CPT^® 72156 and CPT^® 72157) without and with contrast is indicated for initial diagnosis in members with clinical signs and/or symptoms suggestive of MS.

® MRI Brain (CPT^® 70551) and Spinal Cord (CPT^® 72141 and CPT^® 72146) without contrast can be approved if there is a contraindication to gadolinium administration.

® MRI Brain (CPT^® 70551) and Spinal Cord (CPT^® 72141 and CPT^® 72146) without contrast can be approved if there is a contraindication to gadolinium.

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

† ADEM has an acute onset, and is more common among younger children than MS, but the signs and symptoms overlap significantly, and distinguishing between MS and ADEM can be challenging based on clinical examination alone.

† MRI Brain (CPT^®70553) and Spinal Cord (CPT^® 72156 and CPT^® 72157) without and with contrast is indicated for initial diagnosis in members with clinical signs and/or symptoms suggestive of ADEM.

® MRI Brain (CPT^® 70551) and Spinal Cord (CPT^® 72141 and CPT^® 72146) without contrast can be approved if there is a contraindication to gadolinium.

® MRI Brain (CPT^® 70551) and Spinal Cord (CPT^® 72141 and CPT^® 72146) without contrast can be approved if there is a contraindication to gadolinium.
® Most members will have complete clinical recovery by 12 months, while stable MRI abnormalities (gliosis) may persist. These findings do not require additional imaging unless the member develops new neurologic symptoms.

PEDHD-15.1: General Considerations

PEDHD-15.2: Panhypopituitarism

PEDHD-15.3: Isolated Growth Hormone Deficiency

PEDHD-15.4: Diabetes Insipidus (DI) and Other Disorders of Anti-Diuretic Hormone

PEDHD-15.5: Precocious Puberty

PEDHD-15.6: Benign Pituitary Tumors

PEDHD-15.7: Pituitary Malignancies

PEDHD-15.1: General Considerations

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

† The initial step in the evaluation of all potential pituitary masses is a detailed history, recent physical examination, and thorough neurological exam, including evaluation of the visual fields.

† Endocrine laboratory studies should be performed prior to considering advanced imaging.

† When pituitary imaging is indicated, MRI Brain without and with contrast (CPT^® 70553) is the correct study.

® One study (either MRI Brain [CPT^® 70553] or MRI Orbit, Face, Neck [CPT^® 70543]) is adequate to image the pituitary. The ordering physician should specify that the study is specifically to evaluate the pituitary gland. The reporting of two CPT^® codes, to image the pituitary, is not indicated.

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

Endocrine testing should be performed initially.

† MRI Brain without and with contrast (CPT^® 70553) with special attention to the pituitary is indicated for newly diagnosed Panhypopituitarism.

† Members with a normal pituitary on initial MRI do not need routine follow up imaging.

† Members with mass lesions should have follow up imaging according to the guidelines for the specific diagnosis.

PEDHD-15.3: Isolated Growth Hormone Deficiency

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

Endocrine testing should be performed initially. For isolated growth hormone deficiency, two measurements of growth hormone stimulation with different stimulation agents are performed. Glucagon, clonidine, levodopa, and arginine are common stimulation agents. Both stimulation tests can be done on the same day, or on separate days.

† MRI Brain without and with contrast (CPT^® 70553) with special attention to the pituitary is indicated for newly diagnosed isolated growth hormone deficiency.

† Members with a normal pituitary on initial MRI do not need routine follow up imaging.

† Members with mass lesions should have follow up imaging according to the guidelines for the specific diagnosis.

PEDHD-15.4: Diabetes Insipidus (DI) and Other Disorders of Anti-Diuretic Hormone

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

The principal evaluation of ADH deficiency is by urine and blood electrolyte and osmolality testing - serum osmolality greater than 300 with urine osmolality less than 300. Deficiencies in ADH can either be central or nephrogenic.

Central Diabetes Insipidus (DI)

† MRI Brain without and with contrast (CPT^® 70553) is indicated for newly diagnosed central DI.

† CT Head without contrast (CPT^® 70450) with attention to the skull base may be approved with history of recent significant head trauma.

† Members with a normal pituitary on initial MRI can have repeat MRI Brain without and with contrast (CPT^® 70553) every 12 months as germinomas may cause central DI while still too small to detect on imaging.

® Serial measurement of â-hCG is also indicated for these members, and MRI should be repeated if a significant rise in â-hCG is detected on screening.

Nephrogenic DI

† Once this diagnosis is firmly established, further advanced imaging is usually not indicated.

Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)

Laboratory studies should be obtained prior to considering advanced imaging—urine osmolality should be high and serum osmolality low.

† MRI Brain without and with contrast (CPT^® 70553) is indicated for initial evaluation of unexplained central SIADH.

† Members with a normal pituitary on initial MRI do not need routine follow up imaging.

† Members with mass lesions should have follow up imaging according to the guidelines for the specific diagnosis.

PEDHD-15.5: Precocious Puberty

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

Defined as the appearance of secondary sexual characteristics before age 8 in girls and before age 9 in boys.

When precocious puberty is documented on physical examination, endocrine lab studies are not necessary prior to advanced imaging. It can be central and gonadotropin dependent in origin or peripheral and gonadotropin independent in origin.

† Initial imaging should include Ultrasound Abdomen (CPT^® 76700) in both genders and Ultrasound Pelvis (CPT^® 76856) in girls to exclude a peripheral cause of precocious puberty.

† MRI Brain without and with contrast (CPT^® 70553) is indicated for evaluation of any child with documented central precocious puberty following ultrasound evaluation.

† Members with a normal pituitary on initial MRI do not need routine follow up imaging.

† Members with mass lesions should have follow up imaging according to the guidelines for the specific diagnosis.

PEDHD-15.6: Benign Pituitary Tumors

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

† Benign pituitary tumor indications in pediatric members are identical to those for adult members. See Adult Head Imaging Policy (Policy #151 in the Radiology Section); HD-19: Pituitary.

PEDHD-15.7: Pituitary Malignancies

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

See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-4.10:Craniopharyngioma and Pituitary Tumors or Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-18: Histiocytic Disorders

References
1. Burns J, Policeni B, Bykowski J, et al. Neuroendocrine Imaging.ACR Appropriateness Criteria^®.Revised 2018.
2. Parks JS, and Felner EI. Disorders of the hypothalamus and pituitary gland.Nelson Textbook of Pediatrics, Chapter 556. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016,pp 2635-2662.


PEDHD-16: Pediatric Ear Disorders

PEDHD-16.1: Hearing Loss

PEDHD-16.2: Ear Pain

PEDHD-16.3: Cholesteatoma

PEDHD-16.4: Vertigo

PEDHD-16.5: Tinnitus

PEDHD-16.1: Hearing Loss

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

A recent (within 60 days) evaluation including a detailed history, physical examination (including otoscopic examination), and age-appropriate audiology testing should be performed on any child with known or suspected hearing loss prior to considering advanced imaging. The selection of imaging testing will depend on the age of the child and type of hearing loss.

† CT Temporal Bone without contrast (CPT^® 70480) is indicated for the following:

® Conductive hearing loss of any cause.
® Preoperative planning for resection of mass lesion or cochlear implant placement.
® Sensorineural hearing loss in members who cannot safely undergo MRI.
® Mixed conductive and sensorineural hearing loss.
® Congenital hearing loss.
® Total deafness.

® Conductive hearing loss secondary to known or suspected mass lesion.
® Preoperative planning for resection of mass lesion or cochlear implant placement.
® Sensorineural hearing loss of any cause.
® Mixed conductive and sensorineural hearing loss.
® Congenital hearing loss.
® Total deafness.
® Hearing loss associated with tinnitus

PEDHD-16.2: Ear Pain

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

A recent (within 60 days) evaluation including a detailed history, physical examination (including otoscopic examination), should be performed on any child with ear pain prior to considering advanced imaging. Common causes of ear pain include external and middle ear infections, dental problems, sinus infection, neck problems, tonsillitis, and pharyngitis.

† Advanced imaging is not indicated in the overwhelming majority of pediatric members with ear pain.

† CT Temporal Bone without contrast (CPT^® 70480) or without and with contrast (CPT^® 70482), OR, MRI Brain without and with contrast with attention to internal auditory canals (CPT^® 70553), OR MRI Orbits/Face/Neck without and with contrast (CPT^® 70543) is indicated for the following:

® Persistent ear pain without obvious cause.
® Clinical suspicion for complicated or invasive infection such as mastoiditis.
® Clinical suspicion of mass lesion causing ear pain.
® Significant trauma with concern for hematoma formation.
® Preoperative planning.

PEDHD-16.3: Cholesteatoma

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

Cholesteatomas are expansive cysts of the middle ear filled with cellular debris. They can be congenital or arise from recurrent middle ear infections or trauma to the tympanic membrane. Hearing loss is usually conductive, although if the lesion is large enough combined conductive and sensorineural hearing loss may be present. Otoscopic exam findings and symptoms may include painless drainage from the ear or chronic/recurrent ear infections.

† CT Temporal Bone without contrast (CPT^® 70480) or without and with contrast (CPT^® 70482), OR MRI Brain without and with contrast with attention to internal auditory canals (CPT^® 70553), OR MRI Orbits/Face/Neck without and with contrast (CPT^® 70543) is indicated for preoperative evaluation in cholesteatoma members.

† CT Temporal Bone without contrast (CPT^® 70480) or without and with contrast (CPT^® 70482), OR MRI Brain without and with contrast with attention to internal auditory canals (CPT^® 70553), OR MRI Orbits/Face/Neck without and with contrast (CPT^® 70543) is indicated one time post-operatively to exclude residual or regrown cholesteatoma to avoid the need for a second-look surgery.

† Members requiring sedation should generally not have non-contrast MRI studies. See PEDHD-1.3: Pediatric Head Imaging Modality General Considerations.

PEDHD-16.4: Vertigo

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

Isolated vertigo is an uncommon complaint during childhood. Middle ear/Eustachian tube problems are the most common cause of isolated vertigo in children. A recent (within 60 days) face-to-face evaluation including a detailed history, physical examination (including otoscopic examination), should be performed on any child with vertigo prior to considering advanced imaging.

† If physical examination is otherwise normal and the vertigo responds to treatment, advanced imaging is not indicated.

† MRI Brain without and with contrast with attention to internal auditory canals (CPT^® 70553) is indicated for the following:

® Vertigo with associated headache or ataxia.
® Vertigo associated with tinnitus.
® Vertigo that does not respond to vestibular treatment.

PEDHD-16.5: Tinnitus

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

Tinnitus without hearing loss is a less common complaint during childhood. Children with hearing loss and tinnitus should be imaged according to PEDHD-16.1: Hearing Loss. A recent (within 60 days) face-to-face evaluation including a detailed history, physical examination (including otoscopic examination), and age-appropriate audiology testing should be performed on any child with known or suspected tinnitus prior to considering advanced imaging.

† Advanced imaging is not indicated in the overwhelming majority of pediatric members with isolated tinnitus and normal hearing.

† CT Temporal Bone without contrast (CPT^® 70480) or without and with contrast (CPT^® 70482), OR MRI Brain without and with contrast with attention to internal auditory canals (CPT^® 70553), OR MRI Orbits/Face/Neck without and with contrast (CPT^® 70543) is indicated for the following:

® Clinical suspicion of mass lesion causing tinnitus.
® Persistent tinnitus after recent significant trauma.

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

The group of diagnoses, including Asperger syndrome, are classified as pervasive development disorders (PDD). These diagnoses are established on clinical criteria, and no imaging study can confirm the diagnosis.

Comprehensive evaluation for autism might include history, physical exam, audiology evaluation, speech, language, and communication assessment, cognitive and behavioral assessments, and academic assessment.

† MRI Brain without and with contrast (CPT^® 70553) is indicated for new or worsening focal neurologic findings documented on a physical examination within 60 days of the imaging request.

† Members requiring sedation should generally not have non-contrast MRI studies. See PEDHD-1.3: Pediatric Head Imaging Modality General Considerations.

† PET imaging is considered investigational in the evaluation of members with autism spectrum disorders.

References
1. Raviola G, Trieu ML, Walter HJ, et al.Autism spectrum disorder.Nelson Textbook of Pediatrics, Chapter 30. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016,pp 176-183.
2. Baker E, and Jeste SS. Diagnosis and management of autism spectrum disorder in the era of genomics.Pediatr Clin N Am.2015 June;62(3):607-618.
3. Zürcher NR, Bhanot A, McDougle CJ, et al.A systematic review of molecular imaging (PET and SPECT) in autism spectrum disorder: current state and future research opportunities. Neuroscience and Biobehavioral Reviews2015;52: 56-73.

PEDHD-18: Behavioral and Psychiatric Disorders

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

† Behavioral and psychiatric disorders of childhood or adolescence generally require no advanced imaging for diagnosis or management.

® MRI Brain without and with contrast (CPT^® 70553) is indicated for new or worsening focal neurologic findings documented on a physical examination within 60 days of the imaging request.

Reference
1. Behavioral and Psychiatric Disorders.Nelson Textbook of Pediatrics, Chapters 20-31. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp 124-191.

PEDHD-19: Intellectual Disability, Cerebral Palsy, and Developmental Motor Delay

PEDHD-19.1: Intellectual Disability

PEDHD-19.2: Cerebral Palsy

PEDHD-19.3: Developmental Motor Delay

PEDHD-19.1: Intellectual Disability

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

Intellectual disability was formerly known as mental retardation, and may be primary or secondary to a variety of heterogeneous disorders.

† MRI Brain without and with contrast (CPT^® 70553) is indicated for new or worsening focal neurologic findings documented on a physical examination within 60 days of the imaging request.

† Members requiring sedation should generally not have non-contrast MRI studies. See PEDHD-1.3: Pediatric Head Imaging Modality General Considerations.

PEDHD-19.2: Cerebral Palsy

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

Many members with intellectual disability also have cerebral palsy, but not all members with cerebral palsy have intellectual disability.

Cerebral palsy is a static motor encephalopathy caused by a variety of entities spanning developmental, metabolic, genetic, infectious, ischemic, and other acquired etiologies.

† MRI Brain without and with contrast (CPT^® 70553) is indicated for:

® Initial evaluation of newly diagnosed cerebral palsy.
® New or worsening focal neurologic findings documented on a physical examination within 60 days of the imaging request, including the presence of developmental delay.

PEDHD-19.3: Developmental Motor Delay

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

There are many causes for developmental motor delay. Members with motor delay can have decreased, normal, or increased muscular tone. Members with low or normal tone do not require imaging unless they have focal neurologic findings.

† MRI Brain without and with contrast (CPT^® 70553) is indicated for:

® Initial evaluation of newly diagnosed developmental motor delay with increased muscle tone.
® Toe walking, when associated with upper motor neuron signs including hyperreflexia, spasticity, or positive Babinski sign.
® New or worsening focal neurologic findings documented on a physical examination within 60 days of the imaging request.

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

Ataxia refers to an abnormally ill-coordinated or unsteady gait for age. “Limb ataxia” refers to impaired coordination (for age) of limbs, especially arms. Developmental failure to acquire the ability to walk is a form of developmental delay, not ataxia.

(See PEDHD-19: Intellectual Disability, Cerebral Palsy, and Developmental Motor Delay)

† A recent (within 60 days) face-to-face evaluation including a detailed history, physical examination with a thorough neurologic examination, and appropriate laboratory studies should be performed prior to considering advanced imaging, unless the member is undergoing guideline-supported scheduled follow-up imaging evaluation.

† MRI Brain without and with contrast (CPT^® 70553) can be performed to evaluate ataxia, hereditary ataxia, and slowly progressive ataxia.

® MRI Cervical Spine without contrast (CPT^® 72141) or without and with contrast (CPT^® 72156) is indicated if MRI Brain is non-diagnostic.

† CT Head without and with contrast (CPT^® 70470) or with contrast (CPT^® 70460) is indicated for members who have a contraindication to MRI.

® CT should not be used in place of MRI solely to avoid sedation in young children because MRI is superior for imaging the posterior fossa.

† Repeat imaging may be appropriate no more frequently than every 12 months when requested by a specialist.

References
1. ACR Appropriateness Criteria^®.Ataxia 2018:1-16.
2. Prabhu SP, and Young-Poussaint Ty. Pediatric central nervous system emergencies.Neuroimag Clin N Am.2010 Nov;20(4):663-683.
3. Salman MS, Chodirker BN, Bunge M. Neuroimaging Findings and Repeat Neuroimaging Value in Pediatric Chronic Ataxia. Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques. 2016;43(06):824-832.
4. Vedolin L, Gonzalez G, Souza C, Lourenço C, Barkovich A. Inherited Cerebellar Ataxia in Childhood: A Pattern-Recognition Approach Using Brain MRI. American Journal of Neuroradiology. 2012;34(5):925-934. doi:10.3174/ajnr.a3055.
5. Alves CAPF, Fragoso DC, Gonçalves FG, Marussi VH, Amaral LLFD. Cerebellar Ataxia in Children. Topics in Magnetic Resonance Imaging. 2018;27(4):275-302. doi:10.1097/rmr.0000000000000175.

PEDHD-21: Epistaxis

PEDHD-21.1: Imaging

PEDHD-21.1: Imaging

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

Initial evaluation of epistaxis (nosebleed), including recurrent epistaxis that is refractory to medical management is by direct or endoscopic visualization of the relevant portions of the upper airway.

† If a mass lesion is detected on direct visualization, any ONE of the following imaging studies is indicated:

® CT Maxillofacial without contrast (CPT^® 70486) or without and with contrast (CPT^® 70488).
® MRI Orbits/Face/Neck without and with contrast (CPT^® 70543).

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

† Pseudotumor cerebri indications in pediatric members are identical to those for adult members. See Adult Head Imaging Policy (Policy #151 in the Radiology Section); HD-17: Papilledema/Pseudotumor Cerebri for imaging guidelines.


PEDHD-23: Cranial Neuropathies

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

† MRI Brain without and with contrast (CPT^® 70553) is indicated for all members with new or worsening specific cranial nerve abnormalities.

† MRI Neck without and with contrast (CPT^® 70543) is also indicated for members with abnormalities in cranial nerves IX, X, XI, or XII.

References
1. Wippold FJ, Cornelius RS, Aiken AH, et al. Cranial neuropathy.ACR Appropriateness Criteria^®.2017:1-22.
2. Rubin M. Overview of neuro-ophthalmologic and cranial nerve disorders. Merck Manual. 2014.https://www.merckmanuals.com/professional/neurologic-disorders/neuro-ophthalmologic-and-cranial-nerve-disorders/overview-of-neuro-ophthalmologic-and-cranial-nerve-disorders..


PEDHD-24~PEDIATRIC SLEEP DISORDERS

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

† Advanced imaging is not indicated for the following:

® Parasomnias.
® Bed wetting (if child is otherwise neurologically normal).
® Insomnia.
® Narcolepsy.
® Restless Leg Syndrome (polysomnography is useful).

® CT Maxillofacial without contrast (CPT^® 70486) may be indicated for evaluation of obstructive anatomy if operative intervention is being considered.

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

† Temporomandibular Joint (TMJ) Imaging in Children indications in pediatric members are very similar to those for adult members. See HD-30.1: Temporomandibular Joint Disease (TMJ) in the Head Imaging Guidelines.

† Pediatric-specific imaging considerations include the following:

® There is a paucity of clinical symptoms and poor sensitivity of conventional x-rays in diagnosing TMJ arthritis in pediatric members with arthritis
¡ MRI TMJ (CPT^® 70336) is indicated annually for detecting silent TMJ arthritis in children with juvenile idiopathic arthritis (JIA).

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

The diagnosis of Tourette’s syndrome is made clinically and advanced neuroimaging is not indicated for either diagnosis or management.

Reference
1. Serajee FJ, and Mahbubl AHM. Advances in tourette syndrome diagnosis and treatment.Pediatr Clin N Am. 2015 June;62(3):687-701.


PEDHD-27: Tuberous Sclerosis

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

† See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-2.9: Tuberous Sclerosis Complex (TSC) for imaging guidelines.


PEDHD-28: Von Hippel Lindau Syndrome (VHL)

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

† See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-2.10: Von Hippel-Lindau Syndrome (VHL) for imaging guidelines.

PEDHD-29: CNS Infection

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

† CNS infection imaging indications in pediatric members are similar to those for adult members. See Adult Head Imaging Policy (Policy #151 in the Radiology Section); HD-14: CNS Infection.

† Pediatric-specific imaging considerations include suspected congenital brain infection and neonatal meningitis. The common causes of prenatal infections of the central nervous system are cytomegalovirus, Toxoplasma gondii, herpes simplex type 2 virus and most recently zika virus. The findings suggesting prenatal brain infection include microcephaly, microphthalmia, chorioretinitis, cataracts, hypotonia, and seizures. The following are performed for congenital brain infections:

® The following imaging is considered for newborn infants with suspected prenatal brain infection regardless of inciting organism.(For additional information see CDC’s Areas with risk of Zika site: https://wwwnc.cdc.gov/travel/page/zika-information)
¡ Ultrasound Head (CPT^© 76506) can be approved as an initial imaging study.
¡ If the ultrasound is abnormal, MRI Brain without and with contrast (CPT^® 70553) is indicated.
® Newborn infants with microcephaly should be evaluated as discussed in PEDHD-7: Macrocephaly, Microcephaly, and Hydrocephalus.

† The following imaging is considered for newborns or older infants with an open fontanelle and suspected meningitis.

® Ultrasound Head (CPT^© 76506) can be approved as an initial imaging study.
® If the ultrasound is abnormal, MRI Brain without and with contrast (CPT^® 70553) is indicated.

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

† Scalp and skull lesion imaging indications in pediatric members are identical to those for adult members with the exception of neonates. See Adult Head Imaging Policy (Policy #151 in the Radiology Section); HD-20: Scalp and Skull Lesions.

® In neonates and young infants, scalp masses include:
¡ Congenital lesions (cephalocele discussed above, dermoid cysts, epidermoid cyst)
¡ Vascular lesions (hemangioma, sinus pericranii)
¡ Extracranial hemorrhage related to birth trauma (caput succedaneum, cephalohematoma, subgaleal hematoma)
¡ After the first year of life, malignant tumors, such as Langerhans cell histiocytosis metastases from neuroblastoma and rhabdomyosarcoma are an additional cause of a scalp mass.

® Ultrasound Head (CPT^® 76506) can be approved as an initial imaging study.
® If the ultrasound is abnormal and associated anomalies are suspected, MRI Brain without and with contrast (CPT^® 70553) (preferred) or CT Head without and with contrast (CPT^® 70470) is indicated.

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

† Eye disorder imaging indications in pediatric members are identical to those for adult members. See Adult Head Imaging Policy (Policy #151 in the Radiology Section); HD-32: Eye Disorders for imaging guidelines.

Medicaid Coverage:

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.

________________________________________________________________________________________

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.

___________________________________________________________________________________________________________________________

Index:
Pediatric Head Imaging Policy
Head Imaging Policy, Pediatric
Computed Tomography, Head, Pediatric
CT, Head, Pediatric
Computed Tomography Angiography, Head, Pediatric
CTA, Head, Pediatric
Magnetic Resonance Imaging, Head, Pediatric
MRI, Head, Pediatric
Magnetic Resoance Angiography, Head, Pediatric
MRA, Head, Pediatric
Positron Emission Tomography, Head, Pediatric
PET, Head, Pediatric
Functional MRI, Pediatric
Magnetic Resonance Spectroscopy, Pediatric
MRS, Pediatric
Nuclear Medicine Imaging, Head, Pediatric
Brain SPECT, Pediatric
SPECT, Brain, Pediatric
SPECT, Head, Pediatric
Brain Imaging Vascular Flow, Pediatric
Cisternogram, Pediatric
Cerebrospinal Ventriculography, Pediatric
CSF Leakage Detection, Pediatric
CSF Flow SPECT, Pediatric
Radiopharmaceutical Dacryocystography, Pediatric
Cranial Ultrasound, Pediatric
Ophthalmic Ultrasound, Pediatric
Trancranial Doppler Ultrasonography, Pediatric
Ultrasound, Head, 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*