PEDMS-1.1: Age Considerations

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

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

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

PEDMS-1.2: Appropriate Clinical Evaluation and Conservative Treatment

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

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

† Plain x-ray should be done prior to advanced imaging for musculoskeletal conditions to rule out those situations that do not require advanced imaging, such as acute/healing fracture, osteomyelitis, and tumors of bone amenable to biopsy or radiation therapy (in known metastatic disease), etc.

® Even in soft tissue masses, plain x-rays are helpful in evaluating for calcium/bony deposits, e.g. myositis ossificans and invasion of bone.

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

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

PEDMS-1.3: Modality General Considerations

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

† MRI

® MRI without contrast is the preferred modality for pediatric musculoskeletal imaging unless otherwise stated in a specific guideline section, as it is superior in imaging the soft tissues and can also define physiological processes in some instances, e.g. edema, loss of circulation (AVN), and increased vascularity (tumors).
® MRI without and with contrast is frequently recommended for evaluation of tumors, infection, post-operative evaluation, arthrography, and juvenile idiopathic arthritis, as described in the disease-specific guideline sections.
® Due to the length of time required for MRI acquisition and the need to minimize member movement, anesthesia is usually required for almost all infants (except neonates) and young children (age <7 years), as well as older children with delays in development or maturity. This anesthesia may be administered via oral or intravenous route. 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 imaging session.
® The presence of surgical hardware or implanted devices may preclude MRI, as magnetic field distortion may limit detail in adjacent structures. CT may be the procedure of choice in these cases.
® The selection of best examination may require coordination between the provider and the imaging service.

® CT without contrast is generally superior to MRI for imaging bone and joint anatomy; thus it is useful for studying complex fractures (particularly of the joints, dislocations, and assessing delayed union or non-union of fractures, integration of bone graft material, if plain x-rays are equivocal.
¡ 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.
® CT beam attenuation can result in streak artifact which can obscure adjacent details. This can occur with radiopaque material such as metal objects or dense bones.
® The selection of best examination may require coordination between the requesting provider and the rendering imaging facility.

® Ultrasound is frequently used to evaluate infants for hip dysplasia, to detect and/or aspirate joint effusion, and as an initial evaluation of extremity soft tissue masses.
® CPT^® codes vary by body area and the use of Doppler imaging. These CPT^® codes are included in the table at the beginning of this guideline.

® Nuclear medicine studies are commonly used in evaluation of the peripheral musculoskeletal system, and other rare indications exist as well:
¡ Bone scan (CPT^® 78315) or Distribution Of Radiopharmaceutical Agent SPECT (CPT^® 78803) is indicated for evaluation of suspected loosening of orthopedic prostheses when recent plain x-ray is nondiagnostic.
¡ Nuclear medicine bone marrow imaging (CPT^® codes: CPT^® 78102, CPT^® 78103, or CPT^® 78104) is indicated for detection of ischemic or infarcted regions in sickle cell disease.
¡ Triple phase bone scan (CPT^®78315) is indicated for evaluation of complex regional pain syndrome or reflex sympathetic dystrophy.

® 3D Rendering indications in pediatric musculoskeletal imaging are identical to those for adult members. See Adult Musculoskeletal Imaging Policy (Policy #152 in the Radiology Section); MS-3: 3D Rendering for imaging guidelines.

References

1. ACR–ASER–SCBT-MR–SPR Practice Parameter for the performance of pediatric computed tomography (CT) Revised 2014 (Resolution 3), https://www.acr.org/-/media/ACR/Files/Practice-Parameters/CT-Ped.pdf?la=en
2. ACR–SPR–SSR PRACTICE PARAMETER FOR THE PERFORMANCE OF

RADIOGRAPHY OF THE EXTREMITIES Revised 2018 (Resolution 6) https://www.acr.org/-/media/ACR/Files/Practice-Parameters/Rad-Extremity.pdf?la=en

PEDMS-2.1: Acute Fracture

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

† Plain x-rays should be performed initially in any obvious or suspected acute fracture or dislocation.

® If plain x-rays are positive, no further imaging is generally indicated except in complex (comminuted or displaced) joint fractures where MRI or CT without contrast can be approved for preoperative planning.
® 3D Rendering may sometime be indicated for complex fracture repairs. See Adult Musculoskeletal Imaging Policy (Policy #152 in the Radiology Section); MS-3: 3D Rendering for imaging guidelines.

† Bone scan may be approved for evaluation of suspected fracture when two x-rays are negative at least 10 days apart, using any of the following CPT^® code combinations:

® CPT^® 78300, CPT^® 78305, or CPT^® 78306 as a single study
® See PEDMS-2.5: Stress/Occult Fracture for bone scan indications

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

† CT can be approved in complex (comminuted or displaced) fractures involving a joint for preoperative planning.

† CT can be approved when there is clinical concern for delayed union or non-union of fracture or joint fusions on follow-up plain x-ray.

PEDMS-2.3: Growth Plate Injuries (Salter-Harris Fractures)

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

† These fractures can generally be diagnosed and managed adequately with plain x-ray.

† In case of severe injury with displacement of bone fractures, CT may be indicated prior to surgical intervention.

† If there is concern for delayed union or non-union of the bone, CT without contrast is indicated.

† MRI without contrast is indicated for the evaluation of a suspected physeal bar in a healing fracture or other complication of a fracture involving the growth plate, which may result in abnormal growth.

† Compressive injuries of the growth plate (Salter-Harris I) injuries may be difficult to identify on plain films, and MRI without contrast is indicated for confirmation.

PEDMS-2.4: Osteochondral or Chondral Fractures, Including Osteochondritis Dissecans

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

An Osteochondral fracture is a tear of the cartilage which covers the end of a bone, within a joint. It is also known as Osteochondritis Dissecans. In both disorders, loose bone fragments may form in a joint.

† If x-rays are negative and an osteochondral fracture is still suspected, or if x-ray or clinical exam suggests an unstable osteochondral injury, either MRI without contrast, MR arthrogram, or CT arthrogram of the involved joint is indicated.

† If plain x-rays show a non-displaced osteochondral fragment, follow up imaging should be with plain x-rays. Advanced imaging is not necessary.

† MRI without contrast or CT without contrast is indicated when healing cannot be adequately assessed on follow up plain x-rays.

PEDMS-2.5: Stress/Occult Fracture

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

† These fractures can usually be adequately evaluated by history, physical exam, plain x-ray and bone scan.

† Plain x-rays should be performed before advanced imaging. Plain x-rays are often negative initially but may become positive after 4 weeks in stress fractures or 14 days in occult fractures.

† Bone scan (CPT^®78315) or Distribution Of Radiopharmaceutical Agent SPECT (CPT^® 78803) may be approved for evaluation of suspected stress or occult fracture when two x-rays are negative at least 10 days apart.

† If a stress or occult fracture is suspected involving the pelvis, sacrum, hip, femur, tibia, tarsal navicular, proximal 5th metatarsal, or scaphoid and the initial plain x-ray or bone scan fails to establish a definitive diagnosis, an MRI or CT without contrast is indicated without conservative care or follow-up plain x-rays.

† For all other suspected stress or occult fractures, MRI or CT without contrast is indicated if follow-up plain x-rays are negative after 2 weeks of conservative care when occult fracture is still suspected, or 4 weeks of conservative care when stress fracture is still suspected.

† Periodic follow-up plain x-rays will usually show progressive healing.

® CT without contrast is indicated when there is clinical concern for non-union.

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

† Acute compartment syndrome is a clinical diagnosis made by direct measurement of compartment pressure and is a surgical emergency. Advanced imaging is not indicated.

† See Adult Musculoskeletal Imaging Policy (Policy #152 in the Radiology Section); MS-11.3: Chronic Exertional Compartment Syndrome for imaging guidelines.

PEDMS-2.7: Physical Child Abuse

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

† See PEDMS-7: Suspected Physical Child Abuse for imaging guidelines

References
1. Mintz DN, Roberts CC, Bencardino JT, et al. ACR Appropriateness Criteria^®. Chronic hip pain. Date of origin: 1985. Last review date: 2016. https://acsearch.acr.org/docs/69425/Narrative.
2. Bruno MA, Weissman BN, Kransdorf MJ, et al. ACR Appropriateness Criteria^®. Acute hand and wrist trauma. Date of origin: 1998. Last review date: 2013. https://acsearch.acr.org/docs/69418/Narrative/
3. Luchs JS, Flug JA, Weissman BN, et al. ACR Appropriateness Criteria^®. Chronic ankle pain. Date of origin: 1998. Last review date: 2012. https://acsearch.acr.org/docs/69422/Narrative.
4. Bencardino JT, Stone TJ, Roberts CC, et al. ACR Appropriateness Criteria^®. Stress (fatigue/insufficiency) fracture, including sacrum, excluding other vertebrae. Last review date: 2016. https://acsearch.acr.org/docs/69435/Narrative/.
5. Borsa JJ, Peterson HA, and Ehman RL. MR imaging of physeal bars. Radiology. 1996 Jun;199(3):683-687. doi: 10.1148/radiology.199.3.8637987 .
6. Martel JCC, Rodrigo RM, and Vilanova JC. Sports injuries in children and adolescents: a case-Based approach. Heidelberg: Springer; 2014. .
7. Wootton-Gorges SL, Soares BP, Alazraki AL, et al. ACR Appropriateness Criteria^®. Suspected physical abuse—child. Last review date: 2016. https://acsearch.acr.org/docs/69443/Narrative/
8. Christian CW, Crawford-Jakubiak JE, Flaherty EG, et al. AAP Clinical Practice Guideline: The evaluation of suspected physical child abuse. Pediatrics. 2015;135(5):e1337-e1354. doi: 10.1542/peds.2015-0356 .
9. Nguyen JC, Markhardt BK, Merrow AC, Dwek JR. Imaging of pediatric growth plate disturbances. RadioGraphics. 2017 Oct 11;37(6):1791-812.



PEDMS-3: Soft Tissue and Bone Masses

PEDMS-3.1: Soft Tissue and Bone Masses – General Considerations

PEDMS-3.2: Soft Tissue Mass with Negative X-ray and Abnormal Ultrasound

PEDMS-3.3: Soft Tissue Mass with Calcification/Ossification on X-ray

PEDMS-3.4: Mass Involving Bone (Including Lytic and Blastic Metastatic Disease)

PEDMS-3.1: Soft Tissue and Bone Masses – General Considerations

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 detailed information on the mass (including location, size, duration, solid vs. cystic, fixed vs. not fixed to bone) should be performed prior to considering advanced imaging.

† Evaluation by a surgical specialist or oncologist is strongly recommended to help determine the most helpful advanced imaging studies for an individual member.

† Plain x-rays should be performed as initial imaging. This is true even for soft tissue masses that are clearly not directly associated with osseous structures. Details such as soft tissue calcification, presence or absence of phleboliths, radiographic density, and any effect on adjacent bone are all potentially significant plain film findings that may help better identify the etiology of the mass and determine the optimal modality and contrast level when advanced imaging is indicated.

† If initial plain x-ray is negative, ultrasound (CPT^® 76882) can be approved to evaluate:

® Ill-defined masses or areas of swelling
® Hematomas
® Subcutaneous lipomas with inconclusive clinical examination
® Lipomas in other locations
® Masses that have been present and stable for ≥1 year
® Vascular malformations (see PEDPVD-2: Vascular Anomalies for imaging guidelines)

® Ganglion cysts
® Sebaceous cysts
® Hematomas
® Subcutaneous lipomas
¡ MRI without or without and with contrast can be performed if surgery is planned.

PEDMS-3.2: Soft Tissue Mass with Negative X-ray and Abnormal Ultrasound

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

† MRI without and with contrast is indicated.

® CT without or with contrast is indicated if MRI is contraindicated.

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

† MRI without and with contrast is indicated.

® CT without or with contrast is indicated if MRI is contraindicated.

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

† Many benign bone tumors have a characteristic appearance on plain x-ray and advanced imaging is not necessary unless one of the following applies:

® Imaging requested for preoperative planning (MRI without and with contrast and/or CT without may be indicated).
® MRI without and with contrast can be approved when the diagnosis is uncertain based on plain x-ray appearance.
¡ CT without or with contrast can be approved if MRI is contraindicated.

References
1. ACR–SPR–SSR Practice parameter for the performance and interpretation of magnetic resonance imaging (MRI) of bone and soft tissue tumors. Revised 2015 (Resolution 5) https://www.acr.org/-/media/ACR/Files/Practice-Parameters/MR-SoftTissue-Tumors.pdf?la=en
2. Arndt CAS. Soft Tissue Sarcomas. Nelson Textbook of Pediatrics, Chapter 500. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition. 2016, pp 2468-2470. http://www.worldcat.org/title/nelson-textbook-of-pediatrics/oclc/909902899/viewport.
3. Arndt CAS. Neoplasms of bone. Nelson Textbook of Pediatrics, Chapter 501. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition 2016, pp 2471-2476. http://www.worldcat.org/title/nelson-textbook-of-pediatrics/oclc/909902899/viewport.
4. Eutsler EP, Siegel MJ. Musculoskeletal system and vascular imaging. Chapter 15 In: Pediatric sonography. 5^th ed. Philadelphia. Wolters Kluwer. 2018: 601-11.
5. Johnson CM, Navarro OM. Clinical and sonographic features of pediatric soft-tissue vascular anomalies part I: classification, sonographic approach and vascular tumors. Pediatr Radiol 2017; 47:1184-95.
6. Johnson CM, Navarro OM. Clinical and sonographic features of pediatric soft-tissue vascular anomalies part 2: vascular malformations. Pediatr Radiol 2017; 47:1196-1208.
7. Morrison WB, Weissman BN, Kransdorf MJ, et al. ACR Appropriateness Criteria^®. Primary bone tumors. Date of origin: 1995. Last review date: 2013. https://acsearch.acr.org/docs/69421/Narrative/
8. Mintz DN, Roberts CC, Bencardino JT, et al. ACR Appropriateness Criteria^®. Chronic hip pain. Last review 2016 https://acsearch.acr.org/docs/69425/Narrative/
9. Sargar KM, Sheybani EF, Shenoy A, et al. Pediatric fibroblastic and myofiboblastic tumors: a pictorial review. RadioGraphics 2016; 36:1195-1214.
10. Sheybani EF, Eutsler EP, Navarro OM. Fat-containing soft-tissue masses in children. Pediatric radiology. 2016 Dec 1;46(13):1760-73.


PEDMS-4: Limping Child

PEDMS-4.1: General Evaluation of the Limping Child

PEDMS-4.2: Limping Child with Suspected Trauma

PEDMS-4.3: Limping Child with Suspected Infection

PEDMS-4.4: Limping Child with No Evidence of Trauma or Infection

PEDMS-4.1: General Evaluation of the Limping Child

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

† This guideline primarily applies to children under the age of 6 years. It may also be applied to older children with pre-existing conditions who may not be able to communicate, such as a child with severe intellectual disability. Many of these cases will be urgent, because of the risk of adverse outcomes in delay of diagnosis.

† A recent (within 60 days) evaluation, including a detailed history and physical examination, should be performed, which will help determine any indication for advanced imaging. Based on this clinical evaluation, the most likely etiology should be determined, usually trauma, infection, or neither trauma nor infection.

PEDMS-4.2: Limping Child with Suspected Trauma

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

† Plain radiographs are indicated for detection of fractures, destructive lesions, and avascular necrosis. For children under age 4 this may require X-rays of the entire leg from hip to foot. If clinical suspicion is high for “toddler fracture” imaging may start with tibia/fibula radiographs, and if a fracture is demonstrated, additional imaging may not be required.

† If initial radiographs are negative, but limping symptoms or avoidance of weight-bearing persist, follow-up radiographs in 7 to 10 days are indicated. MRI without contrast of the affected body area is indicated if plain films are negative and suspicion remains high for stress fractures or soft tissue injury.

† CT use is limited in the evaluation of the limping child with suspected trauma. Requests should be for Medical Director Review.

† Radionuclide bone scan (CPT^® 78300, CPT^® 78305, or CPT^® 78306) may be indicated in setting of a non-focal exam, especially in younger and non-verbal children. Due to relatively high radiation exposure, bone scan is reserved for high suspicion cases with negative radiographs. It is a preferred examination in a child with implanted hardware or devices precluding MRI.

PEDMS-4.3: Limping Child with Suspected Infection

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

† Pain localized to hip:

® It is essential to exclude septic arthritis. Ultrasound of the hip (CPT^® 76881) is used to exclude hip joint effusion.
¡ If hip joint effusion is demonstrated, hip joint fluid aspiration should be performed to distinguish infection from non-infectious etiologies.
¡ If no hip joint effusion is demonstrated, plain radiographs should be obtained.
¡ If plain films are not diagnostic, MRI without or without and with contrast is indicated.
¡ For unilateral hip use CPT^® 73721 (without contrast) or CPT^® 73723 (without and with contrast).
¡ For bilateral hips use a single CPT^® 73721 (without contrast) or CPT^® 73723 (without and with contrast) and add modifier -50.

® Plain radiographs of the leg should be obtained. If these are not diagnostic, MRI without contrast or without and with contrast of the affected body part is indicated.

® Plain radiographs of the spine, pelvis, and lower extremities may be necessary to localize the abnormality.
® If plain radiography is not diagnostic and suspicion for infection remains high, whole body bone scan (CPT^®78306) or MRI without contrast or without and with contrast of the affected body area is indicated.

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

† This differential diagnosis is quite broad.

® Transient (or toxic) synovitis of the hip:
¡ Ultrasound of the hip (CPT^® 76881) is the preferred initial exam.
¡ If no hip effusion is demonstrated, plain radiographs should be obtained.
¡ If a hip joint effusion is demonstrated, hip joint fluid aspiration is indicated. This is usually performed with US guidance, though fluoroscopic guidance or blind aspiration may be required.
® Avascular Necrosis: See PEDMS-6: Avascular Necrosis (AVN)/ Legg-Calvé-Perthes Disease
® Juvenile Idiopathic Arthritis: See PEDMS-10.1: Juvenile Idiopathic Arthritis
® Histiocytic Disorders: Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); See PEDONC-18: Histiocytic Disorders
® Neoplasm: See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-1: General Guidelines, Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-3: Pediatric Leukemias, Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-6: Neuroblastoma, Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-8: Pediatric Soft Tissue Sarcomas, or Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-9: Bone Tumors
® Child Abuse: See PEDMS-7: Suspected Physical Child Abuse

1. Sadfar NM, Rigsby CK, Iyer RS, et al. ACR Appropriateness Criteria^®. Limping child—Ages 0-5 Years. Date of origin: 1995. Last review date: 2018.
2. Herman MJ and Martinek M. The limping child. Pediatr Rev. 2015 May;36(5):184-197. doi: 10.1542/pir.36-5-184.
3. Chaturvedi A, Rupasov A. The Acutely Limping Preschool and School-Age Child: An Imaging Perspective. InSeminars in musculoskeletal radiology 2018 Feb (Vol. 22, No. 01, pp. 046-056). Thieme Medical Publishers
4. Thapa M, Vo J-N, Shiels WE. Ultrasound-guided musculoskeletal procedures in children. Pediatr Radiol. 2013; 43:55-60.


PEDMS-5: Developmental Dysplasia of the Hip

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

Developmental dysplasia of the hip (DDH) was formerly known as congenital dislocation of the hip. DDH includes a spectrum of abnormalities including abnormal acetabular shape (dysplasia) and malposition of the femoral head ranging from mild subluxation, dislocatable hip to fixed dislocation. 60 to 80% of abnormalities are identified by physical exam, and more than 90% are identified by ultrasound. Treatment may involve placement in a Pavlik harness, casting, or surgery in extreme or refractory cases.

Screening studies

† The routine use of ultrasound in screening neonates and infants without risk factors for DDH is not recommended by the American Academy of Pediatrics and the American Academy of Orthopedic Surgeons. There are two sonographic methods of evaluating the hip: the dynamic stress (Harcke) technique and the static (Graf) technique

† Screening ultrasound (CPT^® 76885 or CPT^® 76886) is recommended for infants between 4 weeks of age and 4 months of age with one or more of the following risk factors:

® Breech presentation
® Family history of DDH
® Abnormal hip exam (e.g. positive Ortolani or Barlow maneuvers, asymmetric thigh folds, shortening of the thigh observed on the dislocated side, limitation of hip abduction).

® If x-ray is inconclusive, ultrasound (CPT^® 76885 or CPT^® 76886) may be indicated

® Type IIA hip was diagnosed on a previous hip ultrasound using the Graf method and follow-up hip ultrasound is requested to confirm normal development.
® Graf type IIA hip has an alpha angle (bony angle) between 50 to 59 degrees in a child less than 3 months of age.
® The overwhelming majority of these hips mature spontaneously, but follow-up may be required to ensure that maturation has occurred.
® Full description of the Graf classification can be found at: http://radiopaedia.org/articles/ultrasound-classification-of-developmental-dysplasia-of-the-hip-1.
® Subluxation or dislocation was diagnosed on previous hip ultrasound using the dynamic Harke imaging method.
® Prior ultrasound demonstrates abnormal hip and treatment has been applied, such as a Pavlik harness or other device. Follow-up ultrasound is indicated to document effectiveness of treatment, to ensure the femoral head remains located in the acetabulum or to identify treatment failure. The usual interval for follow-up sonography is monthly, but earlier imaging is indicated for clinical suspicion of treatment failure, subluxation or dislocation of the hip.

® For unilateral Hip MRI use CPT^® 73721
® For bilateral Hips MRI use a single CPT^® 73721 and add modifier -50
® For unilateral Hip CT use CPT^® 73700
® For bilateral Hips CT use a single CPT^® 73700 and add modifier -50

® Infants less than 2 weeks of age, since hip laxity is normal after birth and usually resolves spontaneously.
® Infants older than 6 months of age as plain x-ray of the hips become more reliable due to femoral head ossification and should be used in infants over 6 months of age.
® Type I, IIB, IIC, IID, and III hips diagnosed on a previous hip ultrasound using the Graf method. Type I hip is normal, and Type IIB, IIC, IID, and III require referral for treatment rather than follow-up imaging.
® Plain x-ray of the hips should be performed rather than ultrasound if there is a clinical suspicion for teratogenic dysplasia.

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

PEDMS-6.1: Avascular Necrosis and Legg-Calvé-Perthes Disease

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

† Plain x-ray is the initial imaging study and may be all that is necessary for follow-up.

† If the diagnosis is uncertain on plain x-ray, hip MRI either without contrast or without and with contrast is indicated.

® For unilateral hip use CPT^® 73721 (without contrast) or CPT^® 73723 (without and with contrast).
® For bilateral hips use a single CPT^® 73721 (without contrast) or CPT^® 73723 (without and with contrast) and add modifier -50
® If MRI is contraindicated or unavailable, any one of the following studies may be approved in lieu of MRI:
¡ CT scan without contrast, with contrast or without and with contrast
¡ Nuclear bone scan (CPT^® codes: CPT^® 78300, CPT^® 78305, CPT^® 78306, or CPT^® 78803)

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

† Osteonecrosis can occur in a number of conditions, including during treatment for developmental dysplasia of the hip.

† Members with acute lymphoblastic leukemia, lymphoblastic lymphoma, or other conditions with recurrent exposure to high dose corticosteroids and known or suspected osteonecrosis should be imaged according to guidelines in: Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-3.2: Acute Lymphoblastic Leukemia (ALL).

† Known or suspected osteonecrosis in long term cancer survivors should be imaged according to guidelines in: Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-19.4: Osteonecrosis in Long Term Cancer Survivors.

† In other members with concern for osteonecrosis and inconclusive recent x-ray, MRI either without contrast or without and with contrast can be approved if imaging results will change current member management.

References

1. Boutault JR, Baunin C, Bérard E, et al. Diffusion MRI of the neck of the femur in Legg-Calvé-Perthes disease: a preliminary study. Diagn Interv Imaging. 2013 Jan; 94(1):78-83. doi: 10.1016/j.diii.2012.10.003.
2. Dillman JR, Hernandez RJ. MRI of Legg-Calvé-Perthes Disease. AJR Am J Roentgenol. 2009 Nov;193(5):1394-1407.
3. Divi SN, Bielski RJ. Legg-Calvé-Perthes Disease. Pediatric annals. 2016 Apr 14;45(4):e144-9.
4. Gough-Palmer A, McHugh K. Investigating hip pain in a well child. BMJ. 2007 Jun;334:1216-1217. doi: 10.1136/bmj.39188.515741.47
5. Hindorf C, Glatting G, Chiesa C, et al. EANM Dosimetry Committee guidelines for bone marrow and whole body dosimetry. Eur J Nucl Med Mol Imaging. 2010 Apr;37(6):1238-1250. doi: 10.1007/s00259-010-1422-4.
6. Kaste SC, Karimova EJ, Neel MD. Osteonecrosis in children after therapy for malignancy. AJR 2011; 196:1011-18.
7. Laine J, Martin BD, Novotny SA, et al. Role of advanced imaging in the diagnosis and management of active Lgg-Calvé-Perthes Disease. J Am Acad Orthop Surg. 2018;26:526-36. doi:10.5435/JAAOS-D-16-00856.
8. Murphey MD, Roberts CC, Bencardino JT, et al. ACR Appropriateness Criteria^®. Osteonecrosis of the Hip. Date of origin: 2009. Last review: 2015. https://acsearch.acr.org/docs/69420/Narrative/
9. Murphey MD, Foreman KL, Klassen-Fischer MK, et al. From the radiologic pathology archives imaging of osteonecrosis: radiologic-pathologic correlation. Radiographics 2014;34:1003-1028.
10. Sankar WN, Horn DB, Wells L, et al. Legg-Calve-Perthes Disease. Nelson Textbook of Pediatrics, Chapter 678. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition 2016, pp 3279-3281. http://www.worldcat.org/title/nelson-textbook-of-pediatrics/oclc/909902899/viewport.


PEDMS-7: Suspected Physical Child Abuse

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

The suspicion of physical abuse of a child often requires imaging, both for clinical management and for forensic purposes. Every effort should be made to support reasonable requests for imaging in these children.

Child abuse injuries may affect any organ or system. Fractures are common, but injuries may also involve solid and hollow visceral organs, and/or superficial and deep soft tissue injuries. Some fracture patterns are highly correlated with non-accidental mechanisms, such as the “classic metaphyseal lesion,” also known as a corner fracture or bucket handle fracture, but fractures may occur in any bone. Unsuspected fractures, multiple fractures at various stages of healing, or fractures of a configuration or distribution inconsistent with the history provided, may raise the suspicion for physical abuse.

Skeletal Injury

† The radiographic skeletal survey is the primary imaging procedure for detecting fractures, especially in children age 24 months or younger. In older children, skeletal survey may be indicated, but more tailored radiographic evaluation based on history and physical examination may be preferable to skeletal survey.

† Bone scan (CPT^® codes: CPT^® 78300, CPT^® 78305, CPT^® 78306) or Distribution Of Radiopharmaceutical Agent SPECT (CPT^® 78803) is complimentary to plain radiographs, and may be used when the skeletal survey is negative but clinical suspicion remains high.

† Suspected injury to the spine should usually first be evaluated with plain radiographs. CT without contrast and/or MRI without contrast or without and with contrast may be required for complete evaluation of osseous and soft tissue spine injuries. If requested for suspected or known physical abuse, both CT without contrast and/or MRI without contrast or without and with contrast of suspected sites should be approved.

† A repeat skeletal survey performed approximately 2 weeks after the initial examination can provide additional information on the presence and age of child abuse fractures and should be performed when abnormal or equivocal findings are found on the initial study and when abuse is suspected on clinical grounds

Head Injury

† CT Head without contrast (CPT^® 70450) is indicated when there is clinical evidence of head injury or when skull fracture of any age is detected on survey skull x-ray.

® CT Head without contrast (CPT^® 70450) is also indicated when known or suspected cervical trauma is present in a pediatric member.
® CT Cervical Spine without contrast (CPT^® 72125) and/or MRI without contrast (CPT^® 72141) or without and with contrast (CPT^® 72156) may be approved when there is clinical evidence of head injury or when skull fracture of any age is detected on survey skull x-ray.

† Infants may require advanced imaging even if no neurologic symptoms are detected due to the great potential morbidity of abusive head trauma.

Other Body Area Injuries

† CT should be performed with IV contrast unless an absolute contraindication exists.

† Any of the following imaging studies are indicated for suspected injury to the abdomen or pelvis:

® Abdominal ultrasound (CPT^® 76700)
® Pelvic ultrasound (CPT^® 76856)
® CT Abdomen with contrast (CPT^® 74160)
® CT Pelvis with contrast (CPT^® 72193)
® CT Abdomen and Pelvis with contrast (CPT^® 74177)

® CT Chest without contrast (CPT^® 71250)
® CT Chest with contrast (CPT^® 71260)

† A skeletal survey, or other imaging, may be requested for siblings of abused children, or for other household members under the age of two due to the high incidence of occult fractures in these children. All such requests should be approved.

References

1. Wooten-Gorges SL, Soares BP, Alazarki AL, et al. ACR Appropriateness Criteria^®. Suspected Physical Abuse—Child. Date of origin: 1984. Last review: 2016. https://acsearch.acr.org/docs/69443/Narrative/
2. Campbell KA, Olson LM, and Keenan HT. Critical elements in the medical evaluation of suspected physical child abuse. Pediatrics. 2015 July;136(1):35-43. doi: 10.1542/peds.2014-4192
3. Christian CW, Crawford-Jakubiak JE, Flaherty EG et al. AAP Clinical Practice Guideline: the evaluation of suspected physical child abuse. Pediatrics. 2015 May;135(5):e1337-e1354. doi: 10.1542/peds.2015-0356
4. Henry MK, Wood JN. Variation in advanced cervical spine imaging in Abusive Head Trauma: An update on recent literature and future directions. Academic pediatrics. 2018 May 30.
5. The radiological investigation of suspected physical abuse in children, The Royal College of Radiologists and Society and College of Radiographers, revised September 2017. available at https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr174_suspected_physical_abuse.pdf


PEDMS-8: Infection/Osteomyelitis

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

† Infection and osteomyelitis imaging indications in pediatric members are similar to those for adult members other than the limping child.

® See MS-9: Infection/Osteomyelitis for imaging guidelines other than in the limping child.
® See PEDMS-4.3: Limping Child with Suspected Infection for imaging guidelines when limping is present.
® See Adult Musculoskeletal Imaging Policy (Policy #152 in the Radiology Section); PEDMS-10: Inflammatory Musculoskeletal Disease for imaging guidelines for chronic recurrent multifocal osteomyelitis (CRMO, which is an autoimmune disease).

References

1. Tuson CE, Hoffman EB, and Mann MD. Isotope bone scanning for acute osteomyelitis and septic arthritis in children. J Bone Joint Surg. 1994 Mar;76(2):306-310.
2. Lazzarini L, Mader JT, and Calhoun JH. Osteomyelitis in long bones. J Bone Joint Surg. 2004 Oct;86-A(10):2305-2318. doi: 10.2106/00004623-200410000-00028
3. Kaplan SL. Osteomyelitis. Nelson Textbook of Pediatrics, Chapter 684. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition 2016, pp 3322-3327. http://www.worldcat.org/title/nelson-textbook-of-pediatrics/oclc/909902899/viewport.
4. Funk SS, Copley LA. Acute Hematogenous Osteomyelitis in Children: Pathogenesis, Diagnosis, and Treatment. Orthopedic Clinics. 2017 Apr 1;48(2):199-208.
5. Palestro CJ. Radionuclide imaging of osteomyelitis. Semin Nucl Med 2015; 45:32-46.



PEDMS-9: Foreign Body

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

† Foreign body imaging indications in pediatric members are similar to those for adult members. See Adult Musculoskeletal Imaging Policy (Policy #152 in the Radiology Section); MS-6.1: Foreign Body – General for imaging guidelines.

† The common soft tissue foreign bodies in children are wood, glass, and metal slivers. The latter two elements are radiopaque and visible to some degree on plain radiographs, whereas wood is usually radiolucent and nearly always imperceptible on radiographs. When a radiolucent foreign body is suspected, ultrasound (CPT^®76881) can be used to identify the foreign body.

References

1. Nung RCH and Lee AWH. Ultrasonographic findings of suspected retained foreign body in soft tissue following penetrating injury. Hong Kong J Radiol. 2017;20:76-83. doi: 10.12809/hkjr1715382 .

PEDMS-10: Inflammatory Musculoskeletal Disease

PEDMS-10.0: Inflammatory Musculoskeletal Disease

PEDMS-10.1: Juvenile Idiopathic Arthritis

PEDMS-10.2: Chronic Recurrent Multifocal Osteomyelitis

PEDMS-10.3: Inflammatory Muscle Diseases

PEDMS-10.0: Inflammatory Musculoskeletal Disease

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

† A recent (within 60 days) evaluation including a detailed history, physical examination, and plain radiography should be performed prior to considering advanced imaging.

† Inflammatory arthritis imaging indications in pediatric members are very similar to those for adult members. See Adult Musculoskeletal Imaging Policy (Policy #152 in the Radiology Section); MS-15: Rheumatoid Arthritis (RA) and Inflammatory Arthritis for imaging guidelines. Specific pediatric considerations are included below.

PEDMS-10.1: Juvenile Idiopathic Arthritis

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

† Ultrasound (CPT^® 76881) is indicted for assessment of: size and characteristics of joint effusions, extent of synovial hypertrophy, which is the hallmark of juvenile idiopathic arthritis, and involvement of tendinous structures.

† Distribution Of Radiopharmaceutical Agent SPECT (CPT^® 78803) is indicated for evaluation of facet arthropathy in members with ankylosing spondylitis, osteoarthritis, or rheumatoid arthritis.

† MRI TMJ (CPT^® 70336) is indicated annually for detecting silent TMJ arthritis in children with juvenile idiopathic arthritis (JIA).

PEDMS-10.2: Chronic Recurrent Multifocal Osteomyelitis

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

Chronic recurrent multifocal osteomyelitis (CRMO) is a rare autoimmune disease affecting multiple bones, arising most commonly during the second decade of life. Treatment consists of anti-inflammatory and immunomodulatory therapies, and is directed predominantly by status of clinical symptoms (most commonly pain).

† Members with CRMO can have the following imaging approved for evaluation of new or worsening pain, or response to treatment in members without complete clinical resolution of pain symptoms, when plain x-rays are non-diagnostic:

® Bone scan (CPT^® codes: CPT^® 78300, CPT^® 78305, CPT^® 78306, CPT^® 78315), or CPT^® 78803 – radiopharmaceutical localization of tumor, inflammatory process, or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT))
® Nuclear Bone Marrow imaging (CPT^® codes: CPT^® 78102, CPT^® 78103, or CPT^® 78104), OR
® Radiopharmaceutical localization of tumor, inflammatory process, or distribution of radiopharmaceutical agent imaging (CPT^® codes: CPT^® 78800, CPT^® 78801, CPT^® 78802, or CPT^® 78803)
® MRI without contrast of specific painful body areas when plain x-ray and bone scan are insufficient to direct acute member care decisions.
® Literature suggests MRI may have greater sensitivity for clinically occult vertebral lesions than bone scan. Given possible complications of vertebral involvement, MRI spine without and with contrast (CPT^® 72156, 72157, 72158) can be approved on an annual basis for screening of clinically occult radiographically active lesions of the vertebral bodies.
® Whole body MRI is considered investigational for CRMO at this time due to lack of standardization in technique and lack of published evidence showing improvement in member outcomes over monitoring with clinical symptoms, plain radiography, and bone scan. See General Guidelines for Advanced Imaging Studies (Policy #011 in the Introduction Section); Preface-4.2: Whole Body MR Imaging for additional details.

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, and plain radiography should be performed prior to considering advanced imaging.

Inflammatory Muscle Diseases:

These include dermatomyositis, polymyositis, and sporadic inclusion body myositis. MRI without contrast of a single site is indicated in these disorders for the following purposes:

† Selection of biopsy site

† Clinical concern for progression

† Treatment monitoring

† Detection of occult malignancy

Juvenile Dermatomyositis:

† MRI without contrast can frequently confirm the diagnosis and thus avoid a biopsy.

† CT without contrast (CPT^® 73700) is indicated to follow progressive calcification in muscles, but MRI (CPT^® 73718) is often used instead since it permits assessment of the primary muscle disease as well.

® Both CT and MRI are rarely indicated concurrently, and these requests should be forwarded for medical director review.

® For members with palpable lymphadenopathy or hepatosplenomegaly, CT Chest (CPT^® 71260) and Abdomen and Pelvis (CPT^® 74177) with contrast are indicated.

1. Chauvin NA and Doria AS. Ultrasound imaging of synovial inflammation in juvenile idiopathic arthritis Pediatr Radiol 2017;47(9):1160-1170. doi: 10.1007/s00247-017-3934-6.
2. Voit AM, Arnoldi AP, Douis H, et al. Whole-body magnetic resonance imaging in chronic recurrent multifocal osteomyelitis: clinical longterm assessment may underestimate activity. J Rhuematol. 2015;42:1357-1537. doi: 10.3899/jrheum.141026..
3. Restrepo R, Lee EY, Babyn PS. Juvenile idiopathic arthritis current practical imaging assessment with emphasis on magnetic resonance imaging. Radiol Clin N Am. 2013 Jul;51(4):703-719. doi: 10.1016/j.rcl.2013.03.003
4. Wu EY, Bryan AR, and Rabinovich CE. Juvenile idiopathic arthritis. Nelson Textbook of Pediatrics, Chapter 155. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition 2016,pp 1162-1170. http://www.worldcat.org/title/nelson-textbook-of-pediatrics/oclc/909902899/viewport.
5. Robinson AB, Reed AM. Juvenile dermatomyositis. Nelson Textbook of Pediatrics, Chapter 159. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition 2016, pp 1181-1186. http://www.worldcat.org/title/nelson-textbook-of-pediatrics/oclc/909902899/viewport.
6. Ackigoz G and Averill LW. Chronic recurrent multifocal osteomyelitis: typical patterns of bone involvement in while-body bone scintigraphy. Nucl Med Commun. 2014 Aug;35(8): 797-807. doi: 10.1097/MNM.0000000000000126.
7. Stern SM, Ferguson PJ. Autoinflammatory Bone Diseases. Rheum Dis Clin N Am. 2013 Nov;39(4):735-749. doi: 10.1016/j.rdc.2013.05.002.
8. Hedrich CM, Hofmann SR, Pablik J, et al. Autoinflammatory bone disorders with special focus on chronic recurrent multifocal osteomyelitis. Pediatr Rheumatol Online J. 2013 Aug;11:47. doi: 10.1186/1546-0096-11-47.
9. Borzutzky A, Stern S, Reiff A et al. Pediatric chronic nonbacterial osteomyelitis. Pediatrics. 2012 Nov;130(5):e1190-e1197 doi: 10.1542/peds.2011-3788
10. Khanna G, Sato TSP, Ferguson P. Imaging of chronic recurrent multifocal osteomyelitis. RadioGraphics, 2009 Jul-Aug;29(4):1159-1177. doi: 10.1148/rg.294085244.
11. Feldman BM, Rider LG, Reed AM, et al. Juvenile dermatomyositis and other idiopathic inflammatory myopathies of childhood. The Lancet. 2008 4 Jul;371(9631):2201-12. doi: 10.1016/S0140-6736(08)60955-1.
12. Morris P, Dare J. Juvenile dermatomyositis as a paraneoplastic phenomenon: an update. J Pediatr Hematol Oncol. 2010 Apr;32(3):189-191. doi: 10.1097/MPH.0b013e3181bf29a2.
13. Colebatch-Bourn AN, Edwards CJ, Collado P, D'agostino M, Hemke R, Jousse-Joulin S, Maas M, Martini A, Naredo E, Østergaard M, Rooney M. EULAR-PReS points to consider for the use of imaging in the diagnosis and management of juvenile idiopathic arthritis in clinical practice. Annals of the rheumatic diseases. 2015 Nov 1;74(11):1946-57.
14. Basra HA, Humphries PD. Juvenile idiopathic arthritis: what is the utility of ultrasound?. The British journal of radiology. 2017 May 3;90(1073):20160920.
15. Arnoldi AP, Schlett CL, Douis H, Geyer LL, Voit AM, Bleisteiner F, Jansson AF, Weckbach S. Whole-body MRI in patients with non-bacterial osteitis: radiological findings and correlation with clinical data. European radiology. 2017 Jun 1;27(6):2391-9
16. Roderick MR, Sen ES, Ramanan AV. Chronic recurrent multifocal osteomyelitis in children and adults: current understanding and areas for development. Rheumatology. 2017 Apr 6;57(1):41-8.
17. Villani, M., de Horatio, L.T., Garganese, M. et al. Pediatr Rheumatol (2015) 13(Suppl 1): P58. https://doi.org/10.1186/1546-0096-13-S1-P58
18. Roderick MR, Sen ES, Ramanan AV. Chronic recurrent multifocal osteomyelitis in children and adults: current understanding and areas for development. Rheumatology. 2017 Apr 6;57(1):41-8
19. Huber AM. Juvenile idiopathic inflammatory myopathies. Pediatric Clinics. 2018 Aug 1;65(4):739-56.
20. Zhao Y, Ferguson PJ. Chronic Nonbacterial Osteomyelitis and Chronic Recurrent Multifocal Osteomyelitis in Children. Pediatric Clinics. 2018 Aug 1;65(4):783-800.
21. Rosendahl K, Maas M. Update on imaging in juvenile idiopathic arthritis. Pediatric radiology. 2018 Jun;48(6):783.

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

† Muscle and tendon unit injury imaging indications in pediatric members are identical to those for adult members. See Adult Musculoskeletal Imaging Policy (Policy #152 in the Radiology Section); MS-11: Muscle/Tendon Unit Injuries/Diseases for imaging guidelines.

PEDMS-12: Osgood-Schlatter Disease

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

† Osgood-Schlatter Disease is defined as traction apophysitis of the tibial tubercle in skeletally immature individuals. Diagnosis is by clinical examination and x-ray, and treatment is conservative.

† Advanced imaging is not indicated in this disorder.

References

1. Alessi S, Depaoli R, Canepari M, et al. Baker’s cysts in pediatric patients: ultrasonographic characteristics. J Ultrasound 2012; 15:76-81.
2. Sarkissian EJ and Lawernce JTR. Osgood-Schlatter Disease and Sinding-Larsen-Johansson Syndrome. Nelson Textbook of Pediatrics, Chapter 677. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition 2016, d pp3271-3272. http://www.worldcat.org/title/nelson-textbook-of-pediatrics/oclc/909902899/viewport.
3. Greene WB (Ed). Essentials of Musculoskeletal Care. 3^rd ed. Rosemont, IL, American Academy of Orthopaedic Surgeons. 2005. pp.713-714
4. Kaneshiro NK. Osgood-Schlatter disease. Medline Plus. December 9, 2016. http://www.nlm.nih.gov/medlineplus/ency/article/001258.htm


PEDMS-13: Popliteal (Baker) Cyst

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

Popliteal or Baker cyst in children is a different clinical entity than in adults and is almost never due to intra-articular pathology. These lesions are usually treated conservatively and rarely require surgery.

† Ultrasound (CPT^® 76881) is the appropriate initial imaging study.

† MRI without contrast (CPT^® 73721) is indicated for preoperative planning or if ultrasound is non-diagnostic.

References

1. Sarkissian EJ and Lawernce JTR. Popliteal cysts (baker cysts). Nelson Textbook of Pediatrics. Chapter 677. eds Kliegman RM, Stanton BF, St. Geme JW III, at al. 20th edition 2016, pp3270 . http://www.worldcat.org/title/nelson-textbook-of-pediatrics/oclc/909902899/viewport.

2. Wheeless CR. Baker’s cyst/popliteal cysts. Wheeless’ Textbook of Orthopaedics. Updated: September 8, 2014, http://www.wheelessonline.com/ortho/bakers_cyst_popliteal_cysts


PEDMS-14: Slipped Capital Femoral Epiphysis (SCFE)

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

Slipped capital femoral epiphysis (SCFE) should be considered in young adolescents or preadolescents with groin, anterior thigh, or atraumatic knee pain. Symptoms often include a history of intermittent limp and pain for several weeks or months that are often poorly localized to the thigh, groin, or knee. Any obese adolescent or preadolescent presenting with a history of a limp and thigh, knee, or groin pain for several weeks to one month should be presumed to have a slipped capital femoral epiphysis (SCFE).

Imaging studies:

† Anteroposterior and lateral x-rays (frog leg or cross table lateral) of both hips will confirm or exclude the diagnosis.

® If clinical suspicion remains after negative plain films, MRI without contrast (CPT^® 73721) or without and with contrast (CPT^® 73723) is indicated to detect widening of the physis before the femoral head is displaced (pre-slip).

® For unilateral hip use CPT^® 73721 (without contrast) or CPT^® 73723 (without and with contrast).
® For bilateral hips use a single CPT^® 73721 (without contrast) or CPT^® 73723 (without and with contrast) and add modifier -50.

References

1. Sankar WN, Horn BD, Wells L, et al. Slipped capital femoral epiphysis. Nelson Textbook of Pediatrics, Chapter 678. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition 2016, pp 3281-3283. http://www.worldcat.org/title/nelson-textbook-of-pediatrics/oclc/909902899/viewport.
2. Kim YJ and Sierra RJ. Report of breakout session: slipped capital femoral epiphysis management 2011. Clin Orthop Relat Res. 2012 Dec;470(12):3464-3466. doi: 10.1007/s11999-012-2587-x.
3. Gough-Palmer A and McHugh K. Investigating hip pain in a well child. BMJ, 2007 Jun; 334:1216-1217. doi: 10.1136/bmj.39188.515741.47
4. Hesper T, Zilkens C, Bittersohl B, Krauspe R. Imaging modalities in patients with slipped capital femoral epiphysis. J Child Orthop 2017; 11:99-106.
5. Jarrett DY, Matheney T, and Kleinman PK. Imaging SCFE: diagnosis, treatment and complications. 2013. Pediatr Radiol. 2013 Mar;43 Suppl 1:S71-S82. doi: 10.1007/s00247-012-2577-x.
6. Peck D. Slipped Capital Femoral Epiphysis: Diagnosis and Management. American family physician. 2017 Jun 15;95(12):779-84.
7. Sucato DJ. Approach to the Hip for SCFE: The North American Perspective. Journal of Pediatric Orthopaedics. 2018 Jul 1;38:S5-12


PEDMS-15: Limb Length Discrepancy

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

† Limb length discrepancy imaging indications in pediatric members are identical to those for adult members. See Adult Musculoskeletal Imaging Policy (Policy #152 in the Radiology Section); MS-17.1: Limb Length Discrepancy for imaging guidelines.

PEDMS-16: Congenital Anomalies of the Foot

PEDMS-16.1: Tarsal Coalition (Calcaneonavicular Bar/Rigid Flat Foot)

PEDMS-16.2: Club Foot

PEDMS-16.3: Vertical Talus

PEDMS-16.1: Tarsal Coalition (Calcaneonavicular Bar/Rigid Flat Foot)

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

† Plain x-rays should be performed initially since the calcaneonavicular bar is readily visible in older children and adults.

® Talocalcaneal coalition is more difficult to evaluate on plain x-rays.

PEDMS-16.2: Club Foot

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

Club Foot is a congenital foot contracture with foot in equinus (plantar flexion) and heel and forefoot in varus/adduction (turned in). Immediate diagnosis and specialty evaluation in the first week of life provide the best chance for successful correction.

† Plain x-rays should be performed initially since the anomaly is readily visible in older children and adults.

† Ultrasound (CPT^® 76881) can be used to characterize the cartilaginous tarsal bones and demonstrate tarsal bone alignment in infants with non-ossified tarsal bones.

† MRI is not currently used to image clubfoot, and limited experiences are published in the literature. MRI (CPT^® 73718) or CT (CPT^® 73700) can be approved to determine residual deficits following repair.

PEDMS-16.3: Vertical Talus

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

† Congenital vertical talus (also known as congenital rocker-bottom foot) is a fixed foot deformity characterized by irreducible talonavicular dislocation. The talus is plantar flexed and does not articulate with the navicular bone.

† Plain x-rays should be performed initially since the anomaly is readily visible in older children and adults.

† MRI (CPT^® 73718) or CT (CPT^® 73700) can be approved to determine residual deficits following repair.

References

1. Miron M-C and Grimard G. Ultrasound evaluation of foot deformities in infants. Pediatr Radiol. 2016;46:193-209.
2. Greene WB (Ed). Essentials of Musculoskeletal Care. 3^rd Ed. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 2005, pp.728-730
3. Wise JN, Weissman BN, Appel M, et al. ACR Appropriateness Criteria^®. Chronic foot pain. Date of origin: 1998. Last review date: 2013. https://acsearch.acr.org/docs/69424/Narrative
4. Winell JJ and Davidson RS. Tarsal Coalition. Nelson Textbook of Pediatrics, Chapter 674. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition 2016, pp 3252-3253. http://www.worldcat.org/title/nelson-textbook-of-pediatrics/oclc/909902899/viewport.
5. Denning JR. Tarsal coalition in children. Pediatric annals. 2016 Apr 14;45(4):e139-43.
6. Winell JJ and Davidson RS. Talipes Equinovarus (Club foot). Nelson Textbook of Pediatrics, Chapter 674. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition 2016, pp 3248-3250.
7. Machida J, Inaba Y, Nakamura N. Management of foot deformity in children. Journal of Orthopaedic Science. 2017 Mar 1;22(2):175-83.

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 Musculoskeletal Imaging Policy
Musculoskeletal Imaging Policy, Pediatric
Computed Tomography, Musculoskeletal, Pediatric
CT, Musculoskeletal, Pediatric
Computed Tomography Angiography, Musculoskeletal, Pediatric
CTA, Musculoskeletal, Pediatric
Magnetic Resonance Imaging, Musculoskeletal, Pediatric
MRI, Musculoskeletal, Pediatric
Magnetic Resoance Angiography, Musculoskeletal, Pediatric
MRA, Musculoskeletal, Pediatric
Positron Emission Tomography, Musculoskeletal, Pediatric
PET, Musculoskeletal, Pediatric
Ultrasound, Musculoskeletal, Pediatric
Nuclear Medicine Studies, Musculoskeletal, Pediatric
Musculoskeletal Nuclear Medicine Studies, Pediatric
Bone Scan, Pediatric
Extremity Imaging Policy, 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*