Procedure Codes Associated with Spine Imaging
MRI	CPT®
Cervical MRI without contrast	72141
Cervical MRI with contrast	72142
Cervical MRI without and with contrast	72156
Thoracic MRI without contrast	72146
Thoracic MRI with contrast	72147
Thoracic MRI without and with contrast	72157
Lumbar MRI without contrast	72148
Lumbar MRI with contrast	72149
Lumbar MRI without and with contrast	72158
Unlisted MRI procedure (for radiation planning or surgical software)	76498
Spinal Canal MRA	72159
CT	CPT®
Cervical CT without contrast	72125
Cervical CT with contrast	72126
Cervical CT without and with contrast	72127
Thoracic CT without contrast	72128
Thoracic CT with contrast	72129
Thoracic CT without and with contrast	72130
Lumbar CT without contrast	72131
Lumbar CT with contrast	72132
Lumbar CT without and with contrast	72133
Pelvis CT without contrast	72192
Pelvis CT with contrast	72193
Pelvis CT without and with contrast	72194
CT Guidance for Placement of Radiation Therapy Fields	77014
Unlisted CT procedure (for radiation planning or surgical software)	76497
Nuclear Medicine	CPT®
PET Imaging; limited area (this code not used in pediatrics)	78811
PET Imaging: skull base to mid-thigh (this code not used in pediatrics)	78812
PET Imaging: whole body (this code not used in pediatrics)	78813
PET with concurrently acquired CT; limited area (this code rarely used in pediatrics)	78814
PET with concurrently acquired CT; skull base to mid-thigh	78815
PET with concurrently acquired CT; whole body	78816
Bone Marrow Imaging Limited Areas	78102
Bone Marrow Imaging Multiple Areas	78103
Bone Marrow Imaging Whole Body	78104
Nuclear Bone Scan Limited	78300
Nuclear Bone Scan Multiple Areas	78305
Nuclear Bone Scan Whole Body	78306
Bone Scan Three Phase	78315
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, single area (eg, head, neck, chest, pelvis), single day imaging	78800
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, 2 or more areas (eg, abdomen and pelvis, head and chest), 1 or more days imaging or single area imaging over 2 or more days	78801
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, whole body, single day imaging	78802
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT), single area (eg, head, neck, chest, pelvis), single day imaging	78803
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, whole body, requiring 2 or more days imaging	78804
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for anatomical review, localization and determination/detection of pathology, single area (eg, head, neck, chest, pelvis), single day imaging	78830
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT), minimum 2 areas (eg, pelvis and knees, abdomen and pelvis), single day imaging, or single area imaging over 2 or more days	78831
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for anatomical review, localization and determination/detection of pathology, minimum 2 areas (eg, pelvis and knees, abdomen and pelvis), single day imaging, or single area imaging over 2 or more days	78832
Ultrasound	CPT®
Ultrasound, spinal canal and contents	76800

PEDSP-1.1: Pediatric Spine Imaging Age Considerations

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

Many conditions affecting the spine 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 Spine Imaging Guidelines, and members who are ≥18 years old should be imaged according to the Adult Spine Imaging Guidelines, except where directed otherwise by a specific guideline section.

PEDSP-1.2: Pediatric Spine Imaging Appropriate Clinical Evaluation

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, 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 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 spine is not supported. Advanced imaging of the spine should only be approved in members who have documented active clinical signs or symptoms of disease involving the spine.

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

PEDSP-1.3: Pediatric Spine 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 spine unless otherwise stated in a specific guideline section.
® Due to the length of time required for MRI acquisition and the need to minimize member movement, anesthesia is usually required for almost all infants (except neonates) and young children (age <7 years), as well as older children with delays in development or maturity. This anesthesia may be administered via oral or intravenous routes. In this member population, MRI sessions should be planned with a goal of minimizing anesthesia exposure by adhering to the following considerations:
¡ MRI procedures can be performed without and/or with contrast use as supported by these condition based guidelines. If intravenous access will already be present for anesthesia administration and there is no contraindication for using contrast, imaging without and with contrast may be appropriate if requested. By doing so, the requesting provider may avoid repetitive anesthesia administration to perform an MRI with contrast if the initial study without contrast is inconclusive.
¡ Recent evidence based literature demonstrates the potential for gadolinium deposition in various organs including the brain, after the use of MRI contrast.
§ The U.S. Food and Drug Administration (FDA) has noted that there is currently no evidence to suggest that gadolinium retention in the brain is harmful and restricting gadolinium-based contrast agents (GBCAs) use is not warranted at this time. It has been recommended that GBCA use should be limited to circumstances in which additional information provided by the contrast agent is necessary and the necessity of repetitive MRIs with GBCAs should be assessed.
¡ If multiple body areas are supported by eviCore 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 spine, 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 it is listed as a recommended study in a specific guideline section.
® Myelogram with post-myelogram CT imaging is rarely indicated in children except in certain limited indications (usually requested after specialist consultation), including:
¡ Evaluation of spine in members with fixation hardware which limits utility of MRI.
¡ Severe congenital scoliosis with inconclusive MRI.
¡ Evaluation of nerve root avulsion in members with a brachial plexus injury and inconclusive MRI.
¡ Evaluation of paraspinal cyst to assess continuity with the subarachnoid space.
¡ Coding note: CT of appropriate spinal level with or without contrast may be appropriate. If the radiologist performs the myelogram the exam should be coded with contrast. If a clinician performs the myelogram the exam should be coded without contrast.

® Spinal canal ultrasound (CPT^® 76800) describes the ultrasonic evaluation of the spinal cord (canal and contents) and should not be reported multiple times for imaging of different areas of the spinal canal.
® Do not use CPT^® 76800 for intraoperative spinal canal ultrasound as CPT^® 76998 (intraoperative ultrasonic guidance) is the appropriate code in this circumstance.
® Spinal canal ultrasound (CPT^® 76800) is generally limited to infants up to 6 months of age because of the bone mass surrounding the spinal cord limits evaluation of the intraspinal contents in older infants.
¡ Exception: the persisting acoustic window in children with posterior spinal defects of spinal dysraphism enables spinal canal ultrasound to be performed at any age (see: PEDSP-4: Spinal Dysraphism).
¡ In general, additional imaging studies of the spine are not indicated in asymptomatic members with normal spinal ultrasound findings.

® Nuclear medicine studies are rarely used in the evaluation of the spine, but are indicated in the following circumstances:
¡ 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, for suspected spondylolysis, or if MRI for evaluation of back pain is inconclusive.

References
1. Berland LL, Cernigliaro JG, Ho VB, et al. ACR Practice parameter for performing and interpreting magnetic resonance imaging (MRI). American College of Radiology. Revised 2017. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/mr-perf-interpret.pdf?la=en.
2. Biassoni L, Easty M. Pediatric nuclear medicine imaging. Br Med Bull 2017;123:127-48.
3. Karmazyn BK, Dillman JR, Epelman MS, et al. ACR–ASER–SCBT-MR–SPR Practice parameter for the performance of pediatric computed tomography (CT) Revised 2014 (Resolution 3). American College of Radiology. 2014. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/ct-ped.pdf?la=en.
4. Ing C, DiMaggio C, Whitehouse A, et al. Long-term differences in language and cognitive function after childhood exposure to anesthesia. Pediatrics. 2012;130: (3). doi: 10.1542/peds.2011-3822 .
5. Monteleone M, Khandji A, Cappell J, et al. Anesthesia in children: perspectives from nonsurgical pediatric specialists. J Neurosurg Anesthesiol. 2014 Oct;26(4):396-398.doi: 10.1097/ana.0000000000000124 .
6. 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 Nov;113(5):1143-1151. doi: 10.1213/ANE.0b013e3182147f42..
7. Donohoe KJ, Brown ML, Collier D, et al. Society of nuclear medicine procedure guideline for bone scintigraphy, version 3.0 approved June 20, 2003. Society of Nuclear Medicine procedure guidelines manual. 2003 Aug. http://snmmi.files.cms-plus.com/docs/pg_ch34_0403.pdf
8. Hochman MG, Melenevsky YV, Metter DF, et al. ACR Appropriateness Criteria^®. Imaging after total knee arthroplasty. American College of Radiology. Date of origin: 1986. Last reviewed: 2017. https://acsearch.acr.org/docs/69430/Narrative/.
9. Cook GJR and I Fogelman. Bone single photon emission computed tomography. The British Institute of Radiology. 2001;13(3):149-154.doi: 10.1259/img.13.3.130149..
10. Fraum TJ, Ludwig DR, Bashir MR, et al. Gadolinium-based contrast agents: a comprehensive risk assessment. J Magn Reson Imaging. 2017 Aug;46(2):338–353. doi: 10.1002/jmri.25625. .
11. FDA Medical Imaging Drug Advisory Committee meeting 9/8/17 Minutes. https://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/MedicalImagingDrugsAdvisoryCommittee/UCM574746.pdf.
Siegel MJ. Spinal Ultrasonography. Pediatric sonography. 5^th ed. Philadelphia. Wolters Kluwer. 2018;653-76.

PEDSP-2: Pediatric Back and Neck Pain

PEDSP-2.1: Introduction

PEDSP-2.2: Back and Neck Pain in Children Age 5 and Under

PEDSP-2.3: Back and Neck Pain in Children Age 6 and Over

PEDSP-2.4: Spondylolysis

PEDSP-2.5: Spine Pain Due to Infectious Causes

PEDSP-2.6: Spine Pain Related to Trauma

PEDSP-2.1: Introduction

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

† Currently, only about 20% of back pain in children over age 5 is from a discoverable cause. Scoliosis, spondylitic disorders, Scheuermann disease, tumor, and trauma are the most common causes.

† Back pain in children under age 5 is uncommon and often reflects underlying serious disease when present.

† Disc herniations are rare in children, but become more frequent as activity increases during adolescence.

PEDSP-2.2: Back and Neck Pain in Children Age 5 and Under

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 thorough neurologic examination and documentation of any specific radicular features, and plain radiography should be performed prior to considering advanced imaging.

† Advanced imaging is appropriate in all members in this age group except those with mild and transient back pain.

® MRI of the symptomatic spinal region should be approved
¡ Members in this age group will require sedation to complete MRI imaging. See PEDSP-1.3: Pediatric Spine Imaging Modality General Considerations for contrast and body area considerations.
® CT without contrast of the symptomatic spinal region may be approved when:
¡ Plain x-rays suggest an isolated vertebral bone abnormality without any concern for spinal canal or cord abnormalities (which is rare in this age group).
¡ A recent MRI does not provide sufficient detail of the bony anatomy to allow for acute member care decision making.
® Bone scan is indicated for evaluation of suspected spinal fracture when x-ray is negative using any of the following CPT^® code combinations:
¡ CPT^® 78300, CPT^® 78305, or CPT^® 78306 as a single study
¡ CPT^® 78315 or CPT^® 78803 can be approved as a single study when stress fracture is suspected.
® Bone scan is indicated for evaluation of suspected spondylolysis, or if recent spine MRI is inconclusive using any of the following CPT code combinations: SPECT bone scans are especially sensitive for detecting spondylolysis, revealing areas of bone turnover; and the findings are generally positive for a prolonged period.
¡ CPT^® codes: CPT^® 78300, CPT^® 78305, CPT^® 78306, CPT^® 78315, or CPT^® 78803 as a single study
¡ CPT^® 78305 and CPT^® 78803 concurrently
¡ CPT^® 78306 and CPT^® 78803 concurrently

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

Radicular back and neck pain is common in adult members but is uncommon in adolescents and rare in children.

† A recent (within 60 days) evaluation including a detailed history, physical examination with thorough neurologic examination and documentation of any specific radicular features, should be performed prior to considering advanced imaging.

† X-rays, while not required prior to conservative treatment, must be obtained before advanced imaging can be approved.

† Advanced imaging should be approved following a recent x-ray when one or more of the following pediatric “red flags” are present:

® Accompanying systemic symptoms (fever, weight loss, etc.)
® Functional disability (daily limitation in normal activities because of pain)
® Pain which is extremely severe or worse at night
® Early morning stiffness
® Pain which worsens despite an attempt at symptomatic treatment
® Neurological symptoms or abnormal neurological examination findings
® An established diagnosis of cancer other than leukemia
® Abnormal x-rays
® Spinal imaging for members having undergone spinal surgery
® Associated bowel or bladder dysfunction

® It can be assumed that children who are being evaluated by a pediatric spine surgeon have failed a reasonable trial of conservative treatment under the care of the primary care provider as this is by far the most common reason for such referrals.

† MRI without contrast of the symptomatic spinal region is the preferred study for the evaluation of pediatric spine pain, and should be approved unless one of the following conditions applies, in which case MRI without and with contrast should be approved:

® Fever (100° F or higher)
® Clinical suspicion of infection (discitis, osteomyelitis, paraspinous or epidural abscess)
® Physical examination or plain x-ray suggests a mass lesion
® New or worsening pain in a member with an established diagnosis of cancer

® The request is for re-evaluation of a known vertebral bony disorder.
® Plain x-rays show spondylotic changes or suggest an isolated vertebral bone abnormality without any concern for spinal canal or cord abnormalities (which is rare in this age group).
® A recent MRI does not provide sufficient detail of the bony anatomy to allow for acute member care decision making.

® CPT^® codes: CPT^® 78300, CPT^® 78305, or CPT^® 78306 as a single study
® CPT^® 78315 or CPT^® 78803 can be approved as a single study when stress fracture is suspected.

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

Most cases of childhood spondylolysis are believed to be caused by repeated microtrauma, resulting in stress fracture of the pars interarticularis. Heredity is also believed to be a factor in some cases. It is the most common cause of low back pain in children older than age 10.

† Activity modification, NSAID treatment, physical therapy, and/or immobilization with various braces are the initial treatments for symptomatic members.

† Surgical treatment is only recommended for members with disabling symptoms that have not responded to non-surgical care.

† A recent (within 60 days) evaluation including a detailed history, physical examination with thorough neurologic examination and documentation of any specific radicular features, and plain radiography should be performed prior to considering advanced imaging.

† Spondylolysis is best recognized on plain x-rays, and advanced imaging is generally not indicated.

® If additional imaging is needed because of radiological uncertainty or associated spondylolisthesis, SPECT Radiopharmaceutical Localization Imaging (CPT^® 78803) is indicated to identify stress reaction in early spondylolysis cases which are radiographically occult. Bone scan has been demonstrated to be superior to MRI in detecting active spondylolysis.
¡ SPECT bone scans are especially sensitive for detecting spondylolysis, revealing areas of bone turnover; and the findings are generally positive for a prolonged period.
® MRI without contrast of the symptomatic spinal level is indicated to evaluate for stress reaction in bone and visualizing nerve roots, if symptoms have continued despite a recent 4 week course of conservative care, or there is a documented need for preoperative planning.
® CT without contrast of the symptomatic spinal level is indicated to provide detailed evaluation of bony anatomy, if there is a documented need for preoperative planning. CT scans have been considered the criterion standard for characterizing fractures and for detailing bone morphology and anatomy.

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

Entities include discitis and vertebral osteomyelitis, and typically present with sudden onset of back pain, fever, and elevated white blood cell count, occurring most commonly in prepubescent children.

† A detailed history and physical examination with thorough neurologic examination and plain x-rays should be performed initially.

Initial Imaging Studies

† MRI without and with contrast of the symptomatic spinal level is very sensitive at detecting early changes and can be approved when discitis or osteomyelitis is suspected. Nuclear medicine imaging also can be positive as soon as 1 to 2 days after the onset of symptoms

† Any of the following studies are indicated for initial evaluation of suspected osteomyelitis:

® Bone scan (one of CPT^® codes: CPT^® 78300, CPT^® 78305, CPT^® 78306, or CPT^® 78315)
® Nuclear Bone Marrow imaging (one of CPT^® codes: CPT^® 78102, CPT^® 78103, or CPT^® 78104)
® Radiopharmaceutical inflammatory imaging (one of CPT^® codes: CPT^® 78800, CPT^® 78801, CPT^® 78802, CPT^® 78803, or CPT^® 78804)

† Follow-up plain x-rays may show disc space narrowing and bony changes of osteomyelitis.

† MRI without and with contrast of the symptomatic spinal level or CT with contrast (including myelography) may be useful in follow-up for evaluating bony changes of osteomyelitis or concern for epidural abscess.

† Any of the following studies are indicated for evaluation of response to treatment in established osteomyelitis:

® Bone scan (one of CPT^® codes: CPT^® 78300, CPT^® 78305, CPT^® 78306, or CPT^® 78315)
® Nuclear Bone Marrow imaging (one of CPT^® codes: CPT^® 78102, CPT^® 78103, or CPT^® 78104)
® Radiopharmaceutical localization imaging (one of CPT^® codes: CPT^® 78800, CPT^® 78801, CPT^® 78803, CPT^® 78830, CPT^® 78831, or CPT^® 78832)

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

Imaging evaluation of traumatic spine injury in children is generally directed based on clinical examination.

† A recent (within 60 days) evaluation including a detailed history, physical examination with thorough neurologic examination and documentation of any specific radicular features, should be performed prior to considering advanced imaging.Children under 3 years of age should be approved for advanced imaging of the cervical spine following a recent x-ray when one or more of the following “red flags” are present:

® Glasgow Coma Scale <14
® Member does not open eyes regardless of stimulus
® Motor Vehicle Collision

® Altered Mental Status
® Focal Neurologic Findings
® Neck pain
® Torticollis not present prior to trauma
® Substantial torso injury
® Diving injury
® High speed motor vehicle collision

® Absence of posterior midline cervical pain
® Absence of focal neurologic deficit
® Normal level of alertness
® No evidence of intoxication

† When advanced imaging is appropriate, MRI without contrast or CT without contrast of the involved level may be approved as discussed in PEDSP-1.3: Pediatric Spine Imaging Modality General Considerations

If the initial imaging study in considered inconclusive, an exam of the other modality may be approved if needed to direct clinical management.

References
1. American College of Radiology.ACR Appropriateness Criteria^® back pain-child; 2-16.
2. Booth TN, Iyer RS, Falcon RA, et al. ACR Appropriateness Criteria^® back pain–child, American College of Radiology. 2016 Nov.
3. Calloni SF, Huisman TA, Poretti A, Soares BP. Back pain and scoliosis in children: When to image, what to consider. The neuroradiology journal. 2017 Oct;30(5):393-404.
4. Eckel T, Lehman R, and Paik H. Spondylolisthesis. Scoliosis Research Society. Scoliosis Research Society E-Text ©, 2017. http://etext.srs.org/book/.
5. Faingold R, Saigal G, Azouz EM, et al. Imaging of low back pain in children and adolescents. Semin Ultrasound CT MR. 2004 Dec;25(6):490-505.doi: 10.1053/j.sult.2004.09.005
6. Kjaer P, Leboeuf-Yde C,Sorensen JS, et al. An epidemiologic study of MRI and low back pain in 13-year-old children. Spine. 2005 Apr;30(7):798-806. doi: 10.1097/01.brs.0000157424.72598.ec.
7. MacDonald J, Stuart E, Rodenberg R. Musculoskeletal low back pain in school-aged children: a review. JAMA pediatrics. 2017 Mar 1;171(3):280-7.
8. Matesan M, Behnia F, Bermo M, et al. SPECT/CT bone scintigraophy to evaluate low back pain in young athletes: common and uncommon etiologies. J Ortho Surg 2016;11:76.
9. Mistovich RJ and Spiegel DA. The spine. Nelson Textbook of Pediatrics, Chapter 679. eds. Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition 2016;19:3283-3296.
10. Ramirez N, Flynn JM, Hill BW, et al. Evaluation of a systematic approach to pediatric. J Pediat Ortho 2015;35-28-32.
11. Rodriguez DP and Toussaint TY. Imaging of back pain in children. AJNR Am J Neuroradiol. 2010;31(5):787-802..
12. Taxter AH, Chauvin NA, Weiss PF. Diagnosis and treatment of low back pain in the pediatric population. Phys Sportsmed 2014;42:94-104.
13. Trout AT, Sharp SE, Anton CG, et al. Spondylolysis and beyond: value of SPECT/CT in evaluation of low back pain in children and young adults. Radiographic 2015;35:819-34.
14. Kadom N, Palasis S, Pruthi S, et al ACR Appropriateness Criteria^® Suspected Spine Trauma–Child, American College of Radiology 2018.
15. Kim H, Crawford C, Ledonio C, et al. Current Evidence Regarding the Diagnostic Methods for Pediatric Lumbar Spondylolisthesis: A Report From the Scoliosis Research Society Evidence Based Medicine Committee. Spine Deform. 2018 Mar - Apr;6(2):185-188Oetgen ME. Current Use of Evidence-Based Medicine in Pediatric Spine Surgery. Orthopedic Clinics. 2018 Apr 1;49(2):191-4.

PEDSP-3: Kyphosis and Scoliosis

PEDSP-3.1: Juvenile Thoracic Kyphosis (Scheuermann Disease)

PEDSP-3.2: Scoliosis

The term “kyphosis” refers to a curve convex posteriorly. Kyphosis generally affects the thoracic spine.

The term “lordosis” refers to a curve convex anteriorly.

The term “scoliosis” refers to a lateral curvature.

PEDSP-3.1: Juvenile Thoracic Kyphosis (Scheuermann Disease)

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

† This condition is also known as Scheuermann Kyphosis, and these members generally present with chronic and recurrent back pain.

† A recent (within 60 days) evaluation including a detailed history, physical examination with thorough neurologic examination and documentation of any specific radicular features, and plain radiography should be performed prior to considering advanced imaging.

† X-rays will typically show anterior wedging in three or more adjacent vertebral bodies.

® Lower thoracic kyphosis from developmental vertebral wedging with thoracic kyphosis totaling over 15˚ to 20˚ should be identified by plain x-rays before considering advanced imaging.
® MRI is not an effective diagnostic modality for this condition since the incidence of false positive vertebral changes in normal members is high.

† MRI without contrast of the lumbar spine CPT^® 72148) can be approved preoperatively to rule out any associated spinal cord conditions when there is clinical or radiographic evidence of lumbar abnormalities.

PEDSP-3.2: Scoliosis

For this condition imaging is medically necessary based on the following criteria:
Scoliosis is an abnormal lateral curve of the thoracic or thoraco-lumbar spine in the frontal plane. A small lateral curve is not uncommon and generally does not require further investigation.

† Using the Cobb technique for measuring these curves, a curve of under 10˚ is normal, a curve from 10 to 20˚ is mildly abnormal, a curve over 20˚ is significantly abnormal, and a curve > 40˚ is severely abnormal.

† Most members with significant scoliosis have some element of kyphosis as well.

® There are many ways of classifying scoliosis. These guidelines will classify scoliosis as congenital, idiopathic, and neuromuscular scoliosis.

® Standing posteroanterior (PA) and lateral x-rays of the spine are the initial imaging studies and are used for follow-up. If anteroposterior (AP) x-rays are to be performed, breast shields should be used to reduce breast radiation exposure.
® Spine surgical specialists sometimes appropriately request both MRI and CT together for preoperative planning of scoliosis surgery.
¡ In addition, MR and CT are useful to identify an underlying cause of scoliosis, such as congenital and developmental anomalies.
¡ Concurrent requests for both MRI and CT will be forwarded for Medical Director Review.
¡ Postoperative spine MR or CT may be appropriate when recent postoperative x-rays are inconclusive for managing member treatment.
§ Members with severe scoliosis may have compromised lung development. Chest CT with contrast (CPT 71260) or without contrast (CPT 71250) may be obtained in the perioperative period as well as 2 and 5 years post operatively to access lung growth.

† In infants, spinal ultrasound (CPT^® 76800) can be approved after initial imaging with plain x-rays.

† MRI of the cervical (CPT^® 72156), thoracic (CPT^® 72157), and lumbar (CPT^® 72158) spine without and with contrast is indicated to search for underlying anomalies.

† Brain MRI without and with contrast can be approved if the clinical evaluation or preliminary imaging studies suggest an associated intracranial anomaly.

† Renal ultrasound (CPT^® 76770 or CPT^® 76775) should be performed, since nearly one-third of members also have genitourinary anomalies.

† CT, MRI, or nuclear medicine studies of the genitourinary tract may be necessary if the ultrasound is abnormal. These requests should be forwarded for Medical Director Review.

Idiopathic Scoliosis

Idiopathic scoliosis is the most common form of pediatric scoliosis, and typically has its onset in late childhood or adolescence.

† The following clinical features are associated with an increased risk of underlying vertebral or spinal cord abnormality:

® Associated back pain
® Neurological abnormalities on examination or neurological symptoms.
® Left sided curve (concave to right)
® Double curves or high thoracic curves
® Spinal x-ray abnormalities other than the curve itself (widened spinal canal, dysplastic changes in spine or ribs, etc.)
® Midline spinal cutaneous markers (esp. sacral) such as dermal tracts, tufts of hair, skin tags, etc.
® Abnormal number or size of café au lait spots (neurofibromatosis)—these requests should be forwarded for Medical Director Review.

† There is uncertainty regarding the clinical value of MRI in the routine evaluation or preoperative work-up of members with typical idiopathic scoliosis (with none of the above clinical features present).

® Noncontrast MRI or CT of the cervical, thoracic, and/or lumbar spine can be approved in these members when they are being actively evaluated for corrective surgery.

The appropriate spinal level, modality, and contrast level of advanced imaging will depend on the nature of the underlying disease.

† MRI without contrast or without and with contrast or CT without contrast of the cervical, thoracic, and/or lumbar spine can be approved in these members when they are actively being evaluated for spinal deformity corrective surgery.

† MRI without contrast or without and with contrast or CT without contrast of the symptomatic spinal region can be approved in patents with painful neuromuscular scoliosis

† Bone scans (one of CPT^® codes: CPT^® 78300, CPT^® 78305, CPT^® 78306, or CPT^® 78315) are useful to evaluate cases of painful scoliosis and to identify tumors or infections. They are more sensitive than plain radiography.

References
1. ACR-SPR-SSR Practice parameter for the performance of radiography for scoliosis in children. Revised 2014.
1. Alsharief AN, El-Hawary R, Schmit P. Pediatric spine imaging post scoliosis surgery. Pediatric radiology. 2018 Jan 1;48(1):124-40.
2. Calloni SF, Huisman TA, Poretti A, Soares BP. Back pain and scoliosis in children: When to image, what to consider. The neuroradiology journal. 2017 Oct;30(5):393-404.
3. El-Hawary R, Chuckwunyerenwa C. Update on evaluation and treatment of scoliosis. Pediat Clin N Am. 2014;61:1223-41.
4. Kim H, Kim HS, Moon ES, et al. Scoliosis imaging: what radiologist should know. Radiographics 2010;30:1823-42.
5. Mayfair D, Flemming AK, Dvorak MR, et al. Radiographic evaluation of scoliosis: review. AJR 2010;194:S8-S22.
6. Mistovich RJ and Spiegel DA. The Spine. Nelson Textbook of Pediatrics, chapter 679. eds Kliegman RM, Stanton BF, St. Geme JW III, et al. 20th edition 2016;3283-3296.
7. Shafa E and Shah SA. Scheuermann Kyphosis. Scoliosis Research Society E-Text ©. 2019.
8. Oetgen ME. Current Use of Evidence-Based Medicine in Pediatric Spine Surgery. Orthopedic Clinics. 2018 Apr 1;49(2):191-4.

PEDSP-4: Spinal Dysraphism

PEDSP-4.1: Introduction

PEDSP-4.2: Cutaneous Lesions of the Back

PEDSP-4.3: Spina Bifida Occulta or Closed Spinal Dysraphism

PEDSP-4.4: Open Dysraphism

PEDSP-4.1: Introduction

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

† The term spinal dysraphism refers to a group of disorders characterized by incomplete or absent fusion of posterior midline structures, including neural, mesenchymal and cutaneous structures. Based on clinical classification, dysraphic are grouped into two categories: (a) open dysraphism (spina bifida aperta) which are non-skin-covered, open neural tube defects (myelomeningocele) and (b) closed or occult spinal dysraphism. The latter group includes skin-covered defects associated with a subcutaneous mass

† A complete abdominal ultrasound (CPT^® 76700) or retroperitoneal ultrasound (CPT^® 76770) can be approved as an initial evaluation for members with newly diagnosed neurogenic bladder, myelomeningocele (open spinal dysraphism), hydronephrosis, or spina bifida.

® A complete retroperitoneal ultrasound (CPT^® 76770) can be approved every 6 to 12 months for follow-up/surveillance for any of the above conditions.

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

† The spinal cord arises from an infolding of the skin of the back, so certain lesions of the overlying skin are associated with an underlying spinal deformity, which include:

® high risk dimples (greater than 5 mm in diameter and more than 2.5 cm above the anus)
® skin tags or tails
® hairy patches
® sinus tracts

® “Simple dimple” which is defined as a midline soft tissue depression ≤ 2.5 cm above the anus (regardless of size or depth).
® Deviated gluteal fold which is defined as any abnormal gluteal fold (including bifid or split gluteal cleft) without an underlying mass.
® Coccygeal pits and pilonidal cysts at or below the level of the intergluteal fold.
® Strawberry nevi
® Non-specific darkened areas of skin over the sacrum (such as dermal melanosis) unless there are associated midline cutaneous abnormalities.

® Dermal sinuses overlying the lumbar, thoracic, or cervical spine, and sacral dermal sinuses.
¡ Spinal ultrasound (CPT^® 76800) may be approved for initial evaluation in infants up to 6 months of age.
¡ MRI of the involved spinal level without and with contrast should be approved if the ultrasound shows abnormalities other than a cutaneous dermal cleft.
¡ MRI of the involved spinal level without and with contrast may be approved for initial evaluation in members older than 6 months of age.
¡ Follow-up of a normal screening imaging study is not appropriate.
¡ The appropriate spinal level, modality, and contrast level of follow-up advanced imaging will depend on the nature of the underlying disease, usually requested after specialist consultation.
® Subcutaneous midline masses at any level, caudal extensions, midline skin tags, abnormal patches of hair over the spine, and complex midline birthmarks above the upper sacral region:
¡ Spinal ultrasound (CPT^® 76800) may be approved for initial evaluation in infants up to 6 months of age, but if a mass is present it is appropriate to proceed directly to MRI of the involved spinal level without and with contrast.
¡ MRI of the involved spinal level without and with contrast may be approved for initial evaluation in members older than 6 months of age.
¡ Follow-up of a normal screening imaging study is not appropriate.
¡ The appropriate spinal level, modality, and contrast level of follow-up advanced imaging will depend on the nature of the underlying disease, usually requested after specialist consultation.
® Congenital anorectal abnormalities are often associated with dysraphism
¡ Lumbar spine MRI without and with contrast (CPT^® 72158) should be approved when these are present.
¡ Follow-up of a normal screening imaging study is not appropriate.
¡ The appropriate spinal level, modality, and contrast level of follow-up advanced imaging will depend on the nature of the underlying disease, usually requested after specialist consultation.
® Café au lait spots are a marker for type 1 neurofibromatosis
¡ See imaging indications in PEDONC-2.3: Neurofibromatosis 1 and 2 (NF1 and NF2)
® Toe walking, when associated with upper motor neuron signs including hyperreflexia, spasticity, and positive Babinski sign

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

These guidelines apply to adult as well as pediatric members.

† Unless additional abnormalities described above are present, routine advanced imaging is not indicated.

® Cutaneous lesions below the gluteal crease are often pilonidal sinuses and need no further evaluation.
® Tracts, pits, or lesions above the gluteal fold should be evaluated further for underlying spinal pathology using MRI of the involved spinal level without contrast or without and with contrast.

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

† Clinically significant dysraphism includes findings ranging from complex vertebral anomalies to meningomyelocele.

® MRI of the involved spinal level without contrast or without and with contrast is appropriate.
® MRI of the cervical, thoracic, and lumbar spine without contrast or without and with contrast may be approved in members with open neural tube defects, or when ordered for preoperative planning.
® MRI Brain or CT Head without contrast of the brain may be approved in cases with associated hydrocephalus, signs of cerebral involvement, or the presence of multiple hydromyelia (which suggests hydrocephalus).
® MRI of the pelvis without contrast or without and with contrast may be approved if there are clinical signs of pelvic malformation or anorectal anomaly.
® The appropriate spinal level, modality, and contrast level of follow-up advanced imaging will depend on the nature of the underlying disease, usually requested after specialist consultation.

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

Normal position of spinal cord

The conus medullaris in newborns should terminate at L2-3 or higher. After 3 months of age, the conus should lie at or above the L2 level. The spinal cord normally ends in the conus medullaris, which is positioned at L1-2 in normal infants and children.

Tethered cord

If the conus terminates below L2-3, the cord may be tethered by an abnormal structure. Abnormalities can be found in both lumbosacral and thoracic regions and are often associated with spinal lipomas in either region. Tethering is certain when the cord terminates at or below L4 and there is other supporting evidence of tethering such as limited spinal cord pulsatility, posterior positioning in the spinal canal, thick filum terminale, intraspinous mass, or lipoma.

Clinical findings which can be associated with tethered cord include low back or leg pain, decreased or absent lower extremity reflexes, urinary urgency and incontinence.

Imaging Studies to Evaluate Tethered Cord

† Spinal ultrasound (CPT^® 76800) may be approved for initial evaluation in infants up to 6 months of age.

® If the conus terminates below the L2-L3 disk space in a term infant the diagnosis of tethered cord is likely. Of note, however, in premature infants, the conus medullaris may be located at the mid L3-level if there is uncertainty as to whether cord termination is low, repeat spinal ultrasound can be performed in 4 to 6 weeks, since a normal cord will have “moved” higher within the spinal canal by this time.

® If a tethered cord is found, follow-up MRI studies to complete imaging of the entire spine (cervical, thoracic, and lumbar) without and with contrast should be approved to rule out associated spinal cord deformities such as syringomyelia. See PEDSP-4: Spinal Dysraphism for additional information.
® For members requiring general anesthesia to complete MRI, MRI without and with contrast of the cervical (CPT^® 72156), thoracic (CPT^® 72157), and lumbar (CPT^® 72158) spine can be approved for initial evaluation.
® The appropriate spinal level, modality, and contrast level of follow-up advanced imaging will depend on the nature of the underlying disease, usually requested after specialist consultation.

PEDSP-6: Myelopathy

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

† Myelopathy imaging indications in pediatric members are similar to those for adult members. See Adult Spine Imaging Policy (Policy #159 in the Radiology Section); SP-7: Myelopathy for imaging guidelines.

PEDSP-7: Other Congenital and Pediatric Spine Disorders

PEDSP-7.1: Achondroplasia

PEDSP-7.2: Inflammatory Spondylitis

PEDSP-7.3: Atlantoaxial Instability in trisomy 21 (Down Syndrome)

PEDSP-7.4: Basilar Impression

PEDSP-7.5: Chiari Malformation

PEDSP-7.6: Klippel-Feil Anomaly (congenital fusion of cervical vertebrae)

PEDSP-7.7: Marfan Syndrome

PEDSP-7.8: Neurofibromatosis

PEDSP-7.9: Von Hippel-Lindau Syndrome (VHL)

PEDSP-7.1: Achondroplasia

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

The diagnosis of achondroplasia is made clinically. Achondroplasia members are at risk for hydrocephalus as well as myelopathy from spinal stenosis with increasing age.

† A recent (within 60 days) evaluation including a detailed history, physical examination with thorough neurologic examination and documentation of any specific radicular features, and plain radiography should be performed prior to considering advanced imaging.

† MRI without contrast of the symptomatic spinal region can be approved when new or worsening clinical symptoms suggest achondroplasia-related spinal stenosis.

† Brain MRI without contrast (CPT^® 70551) or Head CT without contrast (CPT^® 70450) can be approved when new or worsening clinical symptoms suggest hydrocephalus.

PEDSP-7.2: Inflammatory Spondylitis

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

Except as listed below, imaging considerations in pediatric and adult members are identical for this condition, and these members should be imaged according to Adult Spine Imaging Policy (Policy #159 in the Radiology Section); SP-10.2: Inflammatory Spondylitis.

For pediatric members with juvenile idiopathic arthritis:

† MRI without and with contrast of the involved levels is appropriate.

† An initial x-ray is not necessary prior to MRI in these members.

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

PEDSP-7.3: Atlantoaxial Instability in trisomy 21 (Down Syndrome)

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

The diagnosis of atlantoaxial instability is a recognized complication of trisomy 21, and members are routinely screened with lateral x-rays of the cervical spine.

† MRI of the cervical spine without contrast (CPT^® 72141) or without and with contrast (CPT^® 72156) can be approved in members where the lateral cervical spine x-ray demonstrates a pre dens interval of ≥ 4.5 mm, and a neural canal width of ≤ 14 mm.

† MRI of the cervical spine without contrast (CPT^® 72141) or without and with contrast (CPT^® 72156) can also be approved when new or worsening clinical symptoms suggest myelopathy in a trisomy 21 member.

PEDSP-7.4: Basilar Impression

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

See Pediatric Head Imaging Policy (Policy # 163 in the Radiology Section); PEDHD-9.4: Basilar Impression for imaging guidelines.

PEDSP-7.5: Chiari Malformation

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

See Pediatric Head Imaging Policy (Policy # 163 in the Radiology Section); PEDHD-9: Chiari and Skull Base Malformations

PEDSP-7.6: Klippel-Feil Anomaly (congenital fusion of cervical vertebrae)

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

This is generally an incidental finding. A detailed history and physical examination with thorough neurologic examination, and plain x-rays should be performed initially. Klippel-Feil can occur in conjunction with platybasia and/or Chiari malformation.

† Plain x-rays of the cervical spine are sufficient to establish the diagnosis. Advanced imaging is indicated if there are acute or worsening neurologic symptoms (including pain), or if multiple levels are involved.

† Either MRI cervical spine without contrast (CPT^® 72141) or CT cervical spine without contrast (CPT^® 72125) can be approved for these indications.

PEDSP-7.7: Marfan Syndrome

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

Marfan syndrome members are at risk for scoliosis (See PEDSP-3.2) and dural ectasias. Dural ectasias are usually asymptomatic but can be associated with other spinal lesions.

† A recent (within 60 days) evaluation including a detailed history, physical examination with thorough neurologic examination and documentation of any specific radicular features, and plain radiography should be performed prior to considering advanced imaging.

† MRI without contrast of the symptomatic spinal region can be approved when:

® New or worsening clinical symptoms suggest a complicated dural ectasia
® The member is under active consideration for surgery

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

See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-2.3: Neurofibromatosis 1 and 2 (NF1 and NF2) Imaging Guidelines for screening recommendations in neurofibromatosis

See Pediatric Peripheral Nerve Disorder Imaging Policy (Policy #168 in the Radiology Section); PEDPN-2: Neurofibromatosis for imaging considerations in neurofibromatosis members with known plexiform neurofibromas

See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-8.3: Non-Rhabdomyosarcoma Soft Tissue Sarcomas for imaging in members with neurofibromatosis and malignant peripheral nerve sheath tumors.

PEDSP-7.9: 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) Imaging Guidelines for screening recommendations in VHL members.

† MRI without and with contrast of the affected spinal level can be approved for members with known spinal hemangioblastomas in the following conditions:

® Annually for asymptomatic members with unresected spinal hemangioblastoma(s)
® Preoperative planning for resection of a hemangioblastoma
® New or worsening symptoms suggesting progression of a known hemangioblastoma

1. Child AH. Non-cardiac manifestations of marfan syndrome. Ann Cardiothorac Surg. 2017;6:599-609.
2. Frantzen C, Klasson TF, Links TP, et al. Von Hippel-lindau disease. GeneReviews™.[Internet] eds. Pagon RA, Adam MP, Bird TD et al. https://www.ncbi.nlm.nih.gov/books/NBK1463/
3. Jaremko JL, Liu L, Winn NJ, et al. Diagnostic utility of magnetic resonance imaging and radiography in juvenile spondyloarthritis: evaluation of the sacroiliac joints in controls and affected subjects. J Rheumatol. 2014;41:963-70. doi: 10.3899/jrheum.131064
4. Kao SC, Waziri MH, Smith WL, et al. MR imaging of the craniovertebral junction, cranium, and brain in children with achondroplasia. American Journal of Roentgenology. 1989 Sep: 153(3):565-9. doi: 10.2214/ajr.153.3.565
5. Lambert RG, Bakker PA, van der Heijde D, et al. Defining active sacroiliitis on MRI for classification of axial spondyloarthritis: update by the ASAS MRI working group [epub ahead of print]. Ann Rheum Dis. 2016. doi: 10.1136/annrheumdis-2015-208642..
6. Lin C, MacKenzie JD, Courtier JL, et al. Magnetic resonance imaging findings in juvenile spondyloarthropathy and effects of treatment observed on subsequent imaging. Ped Rheumat. 2014;12:25. doi: 10.1186/1546-0096-12-25.
7. Rossi A. Pediatric spinal infection and inflammation. Neuroimaging Clinics. 2015 May 1;25(2):173-91.
8. Restropo R, Lee EY, and 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.
9. Smoker WRK and Khanna G. Imaging the craniocervical junction. Childs Nerv Syst. 2008 Oct; 24(10):1123-1145. doi: 10.1007/s00381-008-0601-0.
10. Vezina G, Barkovich AJ. Neurocutaneous disorders. In: Barkovich AJ, Raybaud C, eds. Pediatric Neuroimaging, 6^th ed. Philadelphia PA. Wolters Kluwer. 2015;633-702.
11. White KK, Bompadre V, Goldberg MJ, et al. Best practices in the evaluation and treatment of foramen magnum stenosis in achondroplasia during infancy. Am J MedGenet A. 2016;170A:42-51.
12. Dweck J, Lachman RS “Skeletal Dysplasias and Selected Chromosomal Disorders (Chapter 132)” in Caffey’s Pediatric Diagnostic Imaging. 13th edition Brian Coley editor, Elsevier Saunders, Philadelphia PA, 2019. 1258-1295

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

FIDE SNP:

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

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Horizon BCBSNJ Medical Policy Development Process:

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

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Index:
Pediatric Spine Imaging Policy
Spine Imaging Policy, Pediatric
Computed Tomography, Spine, Pediatric
CT, Spine, Pediatric
Computed Tomography Angiography, Spine, Pediatric
CTA, Spine, Pediatric
Magnetic Resonance Imaging, Spine, Pediatric
MRI, Spine, Pediatric
Magnetic Resoance Angiography, Spine, Pediatric
MRA, Spine, Pediatric
Positron Emission Tomography, Spine, Pediatric
PET, Spine, Pediatric
Cervical Spine Imaging Policy, Pediatric
Thoracic Spine Imaging Policy, Pediatric
Lumbar Spine Imaging Policy, Pediatric
Lumbosacral Spine Imaging Policy, Pediatric
Spinal Canal Ultrasound, Pediatric
Ultrasound, Spinal Canal, Pediatric
Nuclear Medicine Studies, Spine, Pediatric
Spine Nuclear Medicine Studies, 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*