CurrentColorado Rocky Mountain Health PlansPolicy CSRAD019OH.E

Pediatric Musculoskeletal Imaging Guidelines (For Ohio Only)

Clinical guidelines governing advanced imaging and related procedures for pediatric musculoskeletal conditions for members in Ohio; describes documentation, clinical evaluation, and policy application for medical necessity determinations.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPediatric Musculoskeletal Imaging Guidelines (For Ohio Only)

Policy CodePolicy CSRAD019OH.E

Change TypeMinor revision / no material changes

Effective DateFeb 3, 2026

Next Review DateN/A

Key ActionObtain and submit pertinent clinical evaluation including history, physical exam and current plain x‑rays to support prior authorization for advanced imaging.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Ohiojurisdiction

V1.0.2026guideline version

Pediatric (≤18)age routing

Plain x‑ray firstx‑ray prerequisite

6-12 moCRMO monitoring

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Clinical Indications

inv-29: Avascular necrosis / Legg‑Calvé‑Perthes

Covered when ALL of the following are met:

paragraphs[]

inv-34: Infection / osteomyelitis

Covered when ALL of the following are met:

paragraphs[]

Condition- and Modality-Specific Covered Indications

CPT/HCPCS Codes and Coding Guidance

Prior Authorization, Documentation, and Billing Actions

Prior Authorization

Prior authorization and evaluation requirement

Advanced imaging or other designated procedures require submission of medical records demonstrating a pertinent clinical evaluation and should not be ordered prior to clinical evaluation by the treating physician; other meaningful technological contact (telehealth, telephone, video, electronic messaging) may suffice. Spine and musculoskeletal guideline requests must include x-ray studies from when the current episode of symptoms started or changed.

Do not order advanced imaging before a clinical evaluation or documented meaningful technological contact.
Include x-rays from the onset or change in symptoms for spine and musculoskeletal requests.
Submit detailed history, physical exam, relevant labs, and prior imaging to establish medical necessity.

Prior Authorization

Prior authorization / necessity review

Medical records and clinical documentation must be submitted to establish clinical necessity for advanced imaging; repeat imaging, double-contrast CT, or questionable substitutions (e.g., MRI in place of CT without guideline support) may require prior authorization or will be reviewed for medical necessity.

Follow-up and Frequency Limits

Repeat imaging of same body area — frequency guidance

General frequency principleRepeat imaging of the same body area is generally not necessary unless there is documented progression, new onset of disease, or evidence that repeat imaging will affect management.

Documentation requirementRequesting providers should document how repeat imaging will change individual management and have recent plain x‑rays available when applicable.

Conservative care expectationProviders are expected to trial conservative care prior to advanced imaging when clinically appropriate and improvement is occurring.

Ultrasound — monthly interval guidance

Usual intervalFollow‑up hip ultrasound intervals are usually monthly when indicated (e.g., Graf IIA hips, post‑treatment checks), with earlier imaging if clinical concern for treatment failure exists.

Early use

Prior Authorization Requirements

Note

Contrast Use and Safety Considerations

Note

Definitions and Terms

Investigational/Experimental — definition

DefinitionInvestigational or experimental interventions are those lacking sufficient supporting evidence, demonstrated clinical utility, or collective professional support, including insufficient peer‑reviewed data or immature evidence for improved outcomes.

Evidence standardsSupporting evidence includes well‑conducted randomized trials, cohort studies with adequate power, specialty society recommendations, or collective physician opinion when societies lack guidance.

Policy implicationServices deemed investigational/experimental will be evaluated for medical necessity and may be denied for lack of evidence per applicable regulations.

Pediatric Imaging Guidelines — age routing

Age routing ruleIndividuals 18 years old or younger should be imaged according to the Pediatric Imaging Guidelines when discussed in condition‑specific sections; otherwise follow the General Imaging Guidelines.

Background and Scope

These evidence‑based pediatric imaging guidelines evaluate the appropriate use of advanced modalities (MRI, CT, nuclear medicine, PET, ultrasound) for children and adolescents, emphasizing that pediatric imaging decisions should be guided by specific clinical presentation, age‑based considerations, and referenced condition‑specific sections; the guidance is reviewed annually.

Not Covered / Not Medically Necessary

Examples of services generally not covered include PET/MRI when PET/CT is the standard and PET/CT criteria are not met, use of CPT 77021 for breast biopsy (use CPT 19085/19086 instead), billing both CPT 70486 and CPT 77011 for the same stereotactic CT session, whole‑body CT for asymptomatic screening, advanced imaging for acute compartment syndrome, routine screening hip ultrasound for infants without risk factors and hip ultrasound for infants older than 6 months, and requests for investigational techniques such as MRI with Xenon Xe129.

Advanced imaging for the diagnosis of acute compartment syndrome is not supported because this is a clinical, pressure‑measurement diagnosis and a surgical emergency; imaging should not be used in lieu of prompt clinical assessment and compartment pressure measurement.

Routine screening hip ultrasound is not indicated for neonates/infants without documented risk factors. Additionally, hip ultrasound is not medically necessary for infants older than 6 months; in that age group plain radiography is the preferred initial modality.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPediatric Musculoskeletal Imaging Guidelines (For Ohio Only)

Policy CodePolicy CSRAD019OH.E

Change TypeMinor revision / no material changes

Effective DateFeb 3, 2026

Next Review DateN/A

Key ActionObtain and submit pertinent clinical evaluation including history, physical exam and current plain x‑rays to support prior authorization for advanced imaging.

SourceLink

On This Page

Provide documentation showing how results will affect immediate management when requesting repeat or advanced studies.
Questionable duplicate studies or CT without and with contrast requests may be denied or require prior auth.

Prior Authorization

Prior authorization for 3D rendering

Providers may be required to obtain prior authorization for 3D rendering codes (CPT 76376, 76377) even when the base imaging (e.g., ultrasound, CT, MRI) does not itself require authorization; document physician concurrent supervision or participation in the 3D reconstruction process.

CPT 76376 and 76377 require documentation of active physician participation in design, tissue selection, archived images, and monitoring/adjustment of the 3D product.
Prior authorization may be required on the 3D codes even if the base study appears pre-authorized.

Prior Authorization

Prior authorization / reporting for unlisted whole‑body MRI and PET/MRI

Use CPT 76498 to report unlisted whole‑body MRI; when PET/MRI is allowed it must be reported using CPT 78813 together with CPT 76498. Prior authorization may be required per condition-specific guidelines when these unlisted code combinations are used.

Report PET/MRI when allowed as CPT 78813 + CPT 76498.
Prior authorization for CPT 76498 (and PET/MRI combinations) may be required per payer policy.

Documentation Required

Advanced imaging and contrast justification

Justification for advanced imaging should include prior clinical evaluation and conservative treatment when applicable; when MRI with contrast is requested in pediatric patients, provide rationale for contrast to minimize unnecessary gadolinium exposure and repeat anesthesia.

Document why contrast is necessary and whether IV access for anesthesia is present to consider combined without-and-with contrast imaging to avoid repeat anesthesia.
Limit GBCA use to circumstances where contrast adds information that will change management.

Prior Authorization

Nuclear medicine studies for occult/stress fracture

Bone scan, SPECT, or SPECT‑CT (listed CPT codes) are described as medically necessary alternatives to MRI/CT for suspected stress or occult fractures or when MRI is contraindicated; prior authorization requirements follow payer policy for these nuclear medicine codes.

Bone scan is medically necessary when two x-rays are negative at least 10 days apart (CPT 78300/78305/78306/78315).
SPECT/CT (CPT 78830) or SPECT (CPT 78803) are alternatives when MRI is precluded or upon provider request.

Prior Authorization

Prior authorization for advanced/pediatric imaging

Advanced imaging modalities (MRI, CT, nuclear bone scan, SPECT/CT) and hip ultrasound for specified pediatric indications are described as medically necessary when guideline criteria are met; prior authorization may be required per payer process for listed CPT codes.

When requesting MRI/CT/nuclear studies or hip ultrasound, include clinical documentation and prior plain radiographs as specified by the guideline.
Prior authorization may be required for these CPTs according to payer rules.

Prior Authorization

Whole‑body MRI for CRMO

Whole‑body MRI (CPT 76498) is medically necessary for suspected CRMO when characteristic MR findings would preclude biopsy, and for monitoring established CRMO every 6–12 months; prior authorization may be required per payer policies for whole‑body MRI.

Use CPT 76498 for whole‑body MRI in CRMO when MR findings can avoid biopsy.
Interval monitoring with WBMRI is typically every 6–12 months in established CRMO.

Prior Authorization

Advanced MRI prior authorization

Whole‑body MRI (CPT 76498) and regional hip MRI (CPT 73721/73723) are medically necessary only in specified indications (e.g., CRMO, persistent SCFE suspicion after negative x‑rays); prior authorization is likely required for non‑standard use per payer rules.

Document why WBMRI or hip MRI is necessary and include prior plain films and clinical exam findings when submitting authorization requests.
Payer prior authorization likely required for these advanced MRIs when used outside specified guideline indications.

Prior Authorization

Prior authorization for pediatric hip and lower extremity advanced imaging

Prior authorization may be required when requesting MRI (CPT 73721, 73723, 73718) or CT (CPT 73700) for pediatric hip and lower extremity evaluation because these modalities are medically necessary only in defined situations (e.g., persistent suspicion after negative x‑rays, preoperative planning, or inconclusive radiographs).

Include bilateral AP and lateral hip x‑rays and documentation of clinical suspicion (e.g., limp, groin/thigh/knee pain) when requesting hip MRI/CT.
If plain films are negative but suspicion persists, document rationale for MRI to support authorization.

Step Therapy

Step or sequencing notes for follow-up imaging

Guideline-supported scheduled follow-up imaging may not require a new recent clinical evaluation; condition-specific sections indicate exceptions where a new evaluation is unnecessary.

Document that the request is a guideline-supported scheduled follow-up to avoid unnecessary repeat evaluations.
Otherwise, a recent clinical evaluation is expected prior to new advanced imaging.

Documentation Required

Clinical evaluation prior to advanced imaging

Providers should perform or document a clinical evaluation (history, physical exam, and when appropriate labs and prior imaging) prior to ordering advanced imaging; meaningful technological contact may serve as the evaluation except for guideline-specified exceptions.

A face-to-face evaluation may be required for some conditions per condition-specific sections.
Include documentation of onset or change in symptoms and how imaging will affect management.

Documentation Required

Stereotactic/technical scan documentation requirements

Documentation requirements for stereotactic or technical-only scans should specify whether the scan is technical-only (no radiologist interpretation) and avoid billing diagnostic CT codes with technical stereotactic codes for the same session.

If scan is technical-only (e.g., CPT 77011), document that no radiologist interpretation was provided.
Do not bill both CPT 70486 and CPT 77011 for the same CT stereotactic localization session.

Documentation Required

Unlisted code documentation when used

When reporting unlisted procedure codes (e.g., CPT 76497/76498/78999), provide detailed clinical rationale and documentation since these codes are used when no anatomic site-specific code exists or specialized acquisition is required.

Report a Category III code if available; otherwise document navigation/planning need (e.g., neurosurgical navigation, custom arthroplasty planning) to support use of unlisted codes.
Provide operative planning details and imaging parameters that differ from standard diagnostic studies.

Step Therapy

Conservative therapy before advanced imaging

Providers are expected to trial conservative care (R.I.C.E., NSAIDs, immobilization, physical modalities) prior to advanced imaging when clinically appropriate and when improvement is occurring; imaging may proceed sooner if clinical indicators require it.

Document conservative therapy attempts and response in the medical record when requesting advanced imaging.
Exceptions apply for high‑risk stress fractures or when imaging will change immediate management.

Step Therapy

Imaging modality selection for suspected stress/occult fractures

For many suspected stress or occult fractures, MRI or CT without contrast is preferred; bone scan/SPECT may be used in place of MRI/CT if requested by the provider or if MRI is contraindicated.

High‑risk locations (pelvis, sacrum, hip, femur, tibia, navicular, proximal 5th metatarsal, scaphoid) warrant MRI/CT without contrast immediately if x‑ray non-diagnostic.
Bone scan (CPT 78300/78305/78306/78315) or SPECT/CT (CPT 78830) are acceptable alternatives.

Step Therapy

Imaging escalation sequence — x‑ray first

Begin with plain radiographs for suspected trauma, infection, DDH, or osteonecrosis; advance to MRI, nuclear medicine, or CT only if radiographs are negative/inconclusive and clinical suspicion remains or if results will alter management.

If initial x‑rays are negative but symptoms persist, obtain follow-up x‑rays in 7–10 days for limping child scenarios.
Document how advanced imaging results will change immediate treatment to support authorization.

Step Therapy

Imaging sequencing for osteomyelitis when MRI not possible

When MRI cannot be performed for suspected osteomyelitis, bone scan, SPECT/SPECT‑CT, or labeled leukocyte imaging (with marrow imaging) is recommended as the next step, particularly for multifocal infection or presence of hardware.

Consider Tc‑99m bone scan (78300/78305/78306/78315), SPECT/CT (78830/78832), or labeled leukocyte imaging (78800–78803) with marrow imaging (78102–78104) as indicated.
Combine bone scintigraphy with labeled leukocyte scan to enhance sensitivity when marrow distribution is altered.

Step Therapy

Initial imaging step for Baker cyst — ultrasound first

Ultrasound (CPT 76881 or 76882) is the medically necessary initial imaging study for popliteal (Baker) cyst in children prior to MRI.

If ultrasound is non‑diagnostic or preoperative planning is needed, MRI without contrast (CPT 73721) is medically necessary.

Step Therapy

Imaging escalation sequence for select pediatric MSK — x‑ray then advanced imaging

For suspected pediatric musculoskeletal conditions, begin with plain radiographs and escalate to MRI, CT, or ultrasound only when radiographs are inconclusive or when preoperative planning or management decisions require advanced imaging.

Document localization of pain and prior x‑rays or ultrasound to justify escalation.
Include clinical details such as age, exam findings, and specific suspicion (e.g., non‑accidental trauma, focal neurologic signs) when requesting advanced studies.

Documentation Required

Required clinical documentation for advanced imaging requests

Requesting providers must submit pertinent clinical evaluation documentation including detailed history, physical exam, relevant labs, prior imaging, and specify how the imaging results will change management; spine and musculoskeletal requests require x-rays from when the current episode began or changed.

Include onset/change in symptoms, prior treatments, and objective findings to support medical necessity.
Attach prior plain radiographs performed after onset/change in symptoms when applicable.

Documentation Required

Required clinical documentation (onset/change in symptoms)

Include clinical information since the onset or change in symptoms (detailed history, physical exam, labs, prior imaging) when submitting imaging requests; provide documentation that supports timing and progression of symptoms.

Document symptom onset/change dates and prior imaging dates.
Explain how the new imaging will affect immediate treatment or surgical planning.

Documentation Required

3D rendering documentation — physician participation required

For 3D rendering (CPT 76376/76377), document active physician concurrent supervision or participation including the anatomic region to reconstruct, tissue types to display, images to archive, and monitoring/adjustment of the 3D product to support billing.

Ensure documentation of the physician's role in design and monitoring of the 3D reconstruction.
Do not report 3D rendering with modalities where it is expressly excluded (see policy exclusions).

Billing Rule

Stereotactic CT documentation and billing rules

For stereotactic CT localization scans (CPT 77011), document whether the scan is technical-only (no radiologist interpretation); if a diagnostic CT is interpreted, use the appropriate diagnostic CT code and do not report both CPT 77011 and a diagnostic CT code for the same session.

If a diagnostic CT is interpreted, report the diagnostic CT code instead of CPT 77011.
Avoid billing both CPT 70486 and CPT 77011 for the same stereotactic localization session.

Documentation Required

Secondary interpretation documentation — CPT 76140

When a secondary interpretation of images performed elsewhere is requested, use CPT 76140; do not use diagnostic imaging codes for interpretation of outside exams.

Document origin of outside exam and request for secondary interpretation to support use of CPT 76140.

Documentation Required

Plain x‑ray availability and documentation for repeat/advanced imaging

Requesting providers should have results of plain x‑rays performed after the current episode of symptoms available and must document the clinical reason for repeat or advanced imaging when prior x‑rays exist.

If prior plain films exist, include them and document why repeat or advanced imaging is necessary.
Plain x‑rays often obviate the need for advanced imaging when positive for simple fractures.

Documentation Required

Clinical justification required for advanced imaging

To justify advanced imaging, document suspected fracture, specific treatment decisions that depend on imaging results, or need for preoperative planning so that the imaging request shows clear potential to change management.

For suspected fractures, indicate whether imaging will determine immediate operative versus non-operative management.
For masses, specify whether imaging will alter biopsy planning or surgical approach.

Documentation Required

Document localization of symptoms and prior imaging

Document precise clinical localization of pain (hip versus distal to hip versus non-localized) and include prior plain x‑rays or ultrasound results to support selection of advanced imaging.

Localization guides modality choice (e.g., hip ultrasound for effusion, MRI for distal soft tissue concerns).
Attach prior imaging reports and images when available.

Documentation Required

Clinical history and specific suspicion documentation

Include clinical history, patient age, physical exam findings, and specific suspicions (e.g., suspected non‑accidental trauma, focal neurologic signs, spine injury) when requesting imaging to support the indicated studies such as skeletal survey, CT head/chest, or MRI.

For suspected child abuse, document why skeletal survey or further neuroimaging is indicated and provide age-based rationale.
Detail neurologic deficits or focal signs when requesting spine or brain MRI.

Documentation Required

Pre-imaging clinical evaluation required

A pertinent clinical evaluation including detailed history, physical exam, and plain x‑rays should be performed prior to considering advanced imaging for inflammatory muscle diseases and other conditions per the guideline.

Document examinations and plain x‑rays before requesting MRI for muscle disease or other advanced studies.
Provide rationale for imaging selection and how results will influence biopsy or treatment.

Documentation Required

Documentation required for SCFE imaging

For suspected SCFE, document clinical suspicion (history of limp and groin/thigh/knee pain, especially in obese adolescents), include bilateral AP and lateral hip x‑rays, and document rationale for MRI (CPT 73721/73723) when plain films are negative but clinical concern persists.

If MRI is requested after negative films, note concern for pre-slip widening of the physis and whether contralateral hip evaluation is requested.
Include weight/BMI and duration of symptoms when available.

Documentation Required

Documentation for club foot imaging (infants)

For infants with club foot, document use of ultrasound (CPT 76881/76882) to characterize cartilaginous tarsal bones when indicated; if MRI (CPT 73718) or CT (CPT 73700) is performed for residual deficits post-repair, document findings and surgical planning needs.

Ultrasound supports assessment in non‑ossified infants; it is not required prior to MRI/CT when those studies are appropriate.
Provide treatment history and timing of repairs when requesting advanced imaging for residual deficits.

Denial Risk

Denial triggers — investigational or out-of‑scope services

Requests for services designated investigational, or services exceeding coverage or quantity limits, will be evaluated under Ohio Administrative Code 5160-1-01 and may be denied if considered investigational or lacking supporting evidence.

MRI utilizing Xenon Xe 129 (CPT C9791) is considered investigational/experimental and may be denied.
Provide peer‑reviewed evidence if requesting non-standard or investigational studies.

Denial Risk

Overutilization triggers — duplicate or questionable imaging

Requests for duplicate or questionably medically necessary imaging (including CT double‑contrast studies and MRI requested in place of CT without guideline support) may be flagged for overutilization review and are subject to denial.

Ensure prior imaging history is reviewed and documented to avoid duplicate testing.
Document why substitution of modality is clinically indicated when deviating from guideline-preferred modalities.

Denial Risk

Prior authorization risk for 3D rendering

Failure to obtain prior authorization for 3D rendering codes (CPT 76376/76377) when required may result in denial of those services.

Confirm whether the payer requires prior authorization for CPT 76376/76377 even if the base study was pre-authorized.

Denial Risk

Limited CT (CPT 76380) not appropriate for treatment planning

Use of CPT 76380 (limited CT) for treatment planning is not medically necessary and may be denied when used for planning purposes.

Do not report CPT 76380 to cover 'extra slices' or for treatment planning; use appropriate diagnostic or unlisted codes as indicated.

Denial Risk

Prerequisite clinical evaluation — risk of denial without documentation

Failure to perform or document a pertinent clinical evaluation (history, exam, labs, and basic imaging such as plain x‑ray or ultrasound) prior to advanced imaging may result in non‑support of the imaging request.

Include documentation of conservative therapy and clinical response when applicable.
A meaningful technological contact may suffice in some cases; otherwise document face‑to‑face evaluation if required by condition-specific guidance.

Denial Risk

Plain x‑ray prerequisite — ensure x‑rays obtained and documented

Failure to obtain plain x‑rays prior to advanced imaging when indicated may lead to denial; plain radiographs should be performed initially in suspected acute fracture, soft tissue mass workup, and many other scenarios.

Attach current plain x‑rays and explain why advanced imaging is needed despite x‑ray findings.
If plain films are positive for simple fracture, advanced imaging is usually not medically necessary except for complex joint fractures.

Denial Risk

Screening hip ultrasound limitations

Routine screening hip ultrasound is not indicated for neonates/infants without risk factors; ordering screening ultrasound outside the stated risk framework may not be supported and could be denied.

Screening hip ultrasound (CPT 76885/76886) is medically necessary only for infants 4 weeks to 4 months with specified risk factors (breech, family history, abnormal hip exam).
For infants older than 4–6 months, plain x‑ray is the initial imaging modality.

Denial Risk

Imaging omission risk in suspected child abuse — follow skeletal survey guidance

Failure to perform recommended skeletal survey and follow-up imaging (repeat survey approximately 2 weeks) when child abuse is suspected may lead to missed findings and could result in denials for incomplete evaluation; include age‑based rationale and requested adjunct studies.

For children ≤24 months, perform a complete skeletal survey as primary imaging.
If initial skeletal survey is abnormal or equivocal, schedule repeat survey ~2 weeks later and document rationale.

Denial Risk

MRI routine follow‑up limitation — exceptions stated

Routine MRI for follow‑up of treatment (except annual TMJ MRI in JIA) is not medically necessary; using MRI routinely for follow-up may be denied unless condition‑specific guidelines state otherwise.

MRI TMJ (CPT 70336) is medically necessary annually for silent TMJ arthritis in JIA; other routine MRI follow-up generally is not supported.
Document specific management questions that MRI will address if requesting follow-up MRI outside the annual TMJ indication.

Denial Risk

Imaging sequence for suspected SCFE — x‑rays required before advanced imaging

Failure to obtain AP and lateral hip x‑rays (including frog‑leg or cross‑table lateral) to confirm or exclude SCFE before proceeding to preoperative MRI/CT may lead to unnecessary advanced imaging claims being denied; document clinical suspicion and include required plain films.

Obese adolescents with limp and groin/thigh/knee pain should have plain hip radiographs first; if films are negative but suspicion persists, document rationale for MRI.
Include contralateral hip x‑rays when SCFE is suspected due to frequent bilaterality.

Ultrasound is medically necessary earlier than 4 weeks of age in infants with unstable/dislocated hips undergoing brace treatment.

Indications for follow‑upFollow‑up hip ultrasound indicated for Graf type IIA hips, documented subluxation/dislocation previously, and to document effectiveness of treatment such as Pavlik harness.

X‑ray skeletal survey — repeat interval

Repeat skeletal survey timingWhen initial skeletal survey is abnormal or equivocal in suspected child abuse, perform a repeat skeletal survey approximately 2 weeks after the initial exam.

Purpose of repeat surveyRepeat survey helps age fractures and detect additional injuries that may not have been visible on the initial study.

Primary modalityInitial imaging for suspected physical child abuse is the x‑ray skeletal survey, especially in children ≤24 months.

Whole‑body MRI — every 6–12 months

Recommended intervalWhole‑body MRI for CRMO monitoring and follow‑up is recommended every 6–12 months for established disease.

Clinical roleWBMRI is used to monitor treatment response and detect clinically occult but radiographically active lesions in CRMO.

Code to reportWhen no site‑specific code applies, report whole‑body MRI using CPT 76498.

MRI — annual frequency (e.g., TMJ screening)

Annual MRI guidanceMRI of the temporomandibular joint (TMJ) is medically necessary annually for screening silent TMJ arthritis in children with juvenile idiopathic arthritis (JIA).

Other MRI follow‑up stanceMRI (except annual TMJ MRI) is not medically necessary for routine follow‑up of treatment in inflammatory arthritis.

When MRI is indicatedMRI of the most symptomatic joint is medically necessary when ultrasound is inconclusive and MRI findings would alter management (diagnosis uncertainty, treatment change, DMARD decisions).

Whole-body MRI (duplicate) — every 6-12 months

CRMO whole‑body MRI intervalWhole‑body MRI for CRMO monitoring is recommended every 6–12 months in established cases.

Initial diagnostic roleWBMRI is medically necessary in suspected CRMO if characteristic MR findings would preclude biopsy.

Alternate imagingWhen plain x‑rays are non‑diagnostic, bone scan, SPECT, nuclear bone marrow imaging, or SPECT/CT are medically necessary options for evaluation of new or worsening symptoms.

Clinical evaluation requirementAdvanced imaging should not be ordered prior to a clinical evaluation by the treating physician; meaningful technological contact may suffice in some cases.

Applicability notePediatric disease presentations may differ from adults; condition‑specific sections can override general rules where specified.

Concurrent supervision (3D rendering) — definition

Definition of concurrent supervisionConcurrent supervision for 3D rendering requires active physician participation and monitoring of the reconstruction process, including design of the anatomic region, selection of tissues/structures to display, images/cine loops to archive, and adjustment of the 3D work product.

Documentation expectationThe ACR recommends documenting physician supervision or participation in 3D reconstruction to support CPT 76376/76377 usage.

Code distinctionCPT 76376 reports 3D rendering not requiring an independent workstation; CPT 76377 reports rendering that requires an independent workstation.

Guidance codes — definition

DefinitionGuidance codes describe procedures that include imaging necessary to guide a needle or catheter (e.g., CPT 76942, 77011–77013, 77021–77022) and generally include the necessary imaging so separate diagnostic imaging codes should not be routinely billed for the same encounter.

Billing ruleIt is inappropriate to routinely bill a diagnostic imaging code in conjunction with a guidance code for the same encounter; guidance codes generally represent all imaging needed for the percutaneous procedure.

Common applicationsGuidance codes apply to biopsies, drainages, ablations, and other percutaneous interventions across CT, MR, ultrasound, and fluoroscopy modalities.

CPT 76497 / 76498 — unlisted CT/MR

Unlisted CT/MR definitionCPT 76497 and 76498 are unlisted CT and MR procedure codes used when no appropriate anatomic site–specific code exists or for specialized acquisition parameters.

Use guidanceReport a Category III code if available rather than using an unlisted code; otherwise report 76497/76498 when site‑specific codes are not applicable.

Example scenariosExamples include navigation/planning for neurosurgical procedures, custom joint arthroplasty planning, or procedures requiring thinner cuts or different positional acquisition than standard diagnostic studies.

CPT 78830/78831/78832 — hybrid SPECT/CT

DefinitionCPT 78830/78831/78832 describe hybrid SPECT/CT acquisitions combining functional SPECT with CT for anatomic localization, attenuation correction, and improved accuracy; reporting depends on area and timing of study.

Typical usesCommonly used for bone/labeled agent localization and certain parathyroid and neuroendocrine applications where combined anatomic and functional data improve diagnostic accuracy.

Reporting noteSelect the appropriate CPT based on single area/single day (78830), multi‑day (78831), or multi‑area/combined day studies (78832).

Advanced imaging — definition

Definition of advanced imagingAdvanced imaging refers to modalities such as CT, MRI, and Nuclear Medicine used to answer specific clinical questions beyond plain radiography or ultrasound.

PurposeThese modalities address questions about complex anatomy, soft tissue characterization, occult fractures, infection, tumor staging, and preoperative planning.

Modality selectionChoose modality based on clinical presentation: MRI preferred for soft tissue and marrow pathology; CT preferred for complex fractures and bone detail; nuclear medicine for multifocal or whole‑body functional assessment when MRI contraindicated.

Osteochondral fracture / OCD — definition

DefinitionOsteochondral fracture / Osteochondritis Dissecans (OCD) is a tear of cartilage covering the end of a bone within a joint; fragments may separate and form loose bodies within the joint.

Imaging noteIf x‑rays are negative but suspicion remains, MRI without contrast, MR arthrogram, or CT arthrogram is medically necessary; non‑displaced fragments on x‑ray may be followed with plain films.

Follow‑upMRI without contrast or CT without contrast is medically necessary when healing cannot be adequately assessed on follow‑up plain x‑rays.

Physeal bar — definition and imaging note

DefinitionA physeal bar is a bony or fibrous bridge across the growth plate that may lead to abnormal growth; suspected physeal bars are best evaluated with MRI without contrast because some fibrous bars may be missed on CT.

Imaging roleMRI without contrast is preferred for evaluation of suspected physeal bar or other growth plate complications; CT can detect bony bridges but may miss fibrous bars.

Clinical implicationIdentification of physeal bars affects management and surgical planning; document indication for MRI when plain x‑ray/CT suggest growth plate complication.

DDH — definition

DefinitionDevelopmental dysplasia of the hip (DDH) encompasses a spectrum from reducible subluxation to irreducible dislocation and includes abnormal acetabular shape and femoral head malposition.

Screening noteUltrasound identifies >90% of abnormalities; two sonographic methods exist: dynamic Harcke and static Graf techniques.

Management implicationInfants with risk factors or abnormal exam should undergo hip ultrasound per age‑based guidance; older infants (>4–6 months) use plain x‑ray as ossification occurs.

Osteonecrosis / Legg‑Calvé‑Perthes disease — definition and imaging pathway

DefinitionOsteonecrosis (avascular necrosis) / Legg‑Calvé‑Perthes disease is avascular necrosis of the femoral head in children; initial imaging is x‑ray with MRI for uncertain diagnoses or preoperative planning.

Imaging pathwayStart with plain x‑ray; MRI without contrast (CPT 73721) is medically necessary if x‑ray is inconclusive or for early disease detection; CT without contrast is used for surgical planning when MRI contraindicated.

Clinical contextsSuspected in patients with corticosteroid exposure, leukemia survivors, or clinical signs of early AVN; MRI detects early phase disease even when x‑ray is normal.

Classic metaphyseal lesion — definition

DefinitionClassic metaphyseal lesion (corner or bucket handle fracture) is a fracture pattern highly correlated with non‑accidental trauma in infants and young children.

Forensic importanceRecognition of this fracture pattern should prompt evaluation for suspected physical child abuse including skeletal survey and appropriate follow‑up imaging.

Imaging relevanceSkeletal survey is primary imaging; repeat survey and adjunct nuclear imaging may be needed if initial evaluations are equivocal and suspicion persists.

CRMO — definition and clinical context

DefinitionChronic recurrent multifocal osteomyelitis (CRMO) is a rare autoimmune inflammatory bone disorder affecting multiple bones, most common in adolescents and managed with anti‑inflammatory and immunomodulatory therapy.

Clinical contextImaging for CRMO is guided by symptoms; plain x‑rays often non‑diagnostic and MRI or nuclear studies are used for diagnosis and monitoring.

Characteristic lesionsLesions often involve juxtaphyseal/periphyseal portions of tibia/femur, clavicle, and thoracolumbar spine on MRI.

Synovial hypertrophy — definition

DefinitionSynovial hypertrophy is marked synovial thickening seen in juvenile idiopathic arthritis; ultrasound assesses extent and is a hallmark finding in JIA.

Imaging roleUltrasound (CPT 76881/76882) is medically necessary to assess effusion size, synovial hypertrophy extent, and tendon involvement; repeat imaging is used for monitoring or planned treatment changes.

MRI relevanceMRI is used when ultrasound is inconclusive and MRI findings would alter management; MRI is not routinely used for follow‑up except annual TMJ screening.

Osgood‑Schlatter disease — definition and imaging stance

DefinitionOsgood‑Schlatter disease is traction apophysitis of the tibial tubercle in skeletally immature individuals; diagnosis is clinical and with x‑ray, and advanced imaging is not indicated.

Imaging stanceAdvanced imaging is not medically necessary for Osgood‑Schlatter disease; plain x‑ray suffices for diagnosis when imaging is needed.

Treatment noteManagement is conservative; imaging reserved for atypical presentations or refractory symptoms where other pathology is suspected.

SCFE — definition

DefinitionSlipped capital femoral epiphysis (SCFE) is a slip of the femoral head at the growth plate in young adolescents/preadolescents, presenting with groin/anterior thigh or referred knee pain and often an intermittent limp; obese adolescents with limp and thigh/knee/groin pain should be presumed to have SCFE.

Initial imagingConfirm or exclude SCFE with bilateral AP and lateral (frog‑leg or cross‑table) hip x‑rays; if films negative but suspicion persists, MRI without contrast (CPT 73721) is medically necessary.

Bilateral evaluationEvaluate contralateral hip because SCFE is frequently bilateral and contralateral imaging is often medically necessary.

Vertical talus — definition

DefinitionVertical talus (congenital rocker‑bottom foot) is a fixed foot deformity with irreducible talonavicular dislocation; the talus is plantar flexed and does not articulate with the navicular.

Initial imagingPlain x‑rays should be performed initially; MRI or CT (CPT 73718 or 73700) are medically necessary to determine residual deficits following repair.

Clinical noteEarly diagnosis and appropriate specialist referral improve outcomes; ultrasound may be used in infants when tarsal bones are nonossified.

Club foot — definition and referral guidance

DefinitionClub foot (talipes equinovarus) is a congenital foot contracture with the foot in equinus and heel/forefoot in varus/adduction; early diagnosis and specialty evaluation within the first week of life improve correction outcomes.

Imaging rolePlain x‑rays initially; ultrasound (CPT 76881/76882) is medically necessary to characterize cartilaginous tarsal bones in infants with nonossified bones; MRI (73718) or CT (73700) for residual deficits post‑repair.

Referral guidanceImmediate specialty referral in first week of life is recommended for optimal correction; imaging supports surgical planning if needed.

Condition‑specific imaging indications (index)

Index referenceThis guideline contains condition‑specific sections (fracture/dislocation, masses, limping child, DDH, AVN, suspected child abuse, infection, foreign body, inflammatory disease, SCFE, club foot, tarsal coalition, etc.) to guide modality selection and appropriateness.

Use instructionRefer to the appropriate condition‑specific section for detailed indications, prerequisites (e.g., plain x‑rays), and modality preferences for pediatric individuals (≤18 years).

Clinical evaluationA pertinent clinical evaluation since onset or change of symptoms is required to establish medical necessity for advanced imaging per these sections.