CurrentColorado Rocky Mountain Health PlansPolicy CSRAD025OH.D
Pediatric and Special Populations Spine Imaging Guidelines (For Ohio Only)
Imaging guidelines for pediatric and special populations focused on spine imaging for Ohio members; governs medical necessity evaluation of advanced imaging requests and applies to providers requesting services for Ohio members.
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyPediatric and Special Populations Spine Imaging Guidelines (For Ohio Only)
Policy CodePolicy CSRAD025OH.D
Change TypeAnnual and interim evidence-based updates (2024–2025)
Effective DateNov 1, 2025
Next Review DateN/A
Key ActionSubmit recent detailed history, focused neurologic exam, and relevant prior imaging when requesting advanced spine imaging to support medical necessity and prior authorization.
02/01/2024, Summary of Changes = Annual evidence-based updates.
07/01/2024, Summary of Changes = Interim evidence-based updates.
05/01/2025, Summary of Changes = Annual evidence-based updates.
V1.0.2025Guideline version
OhioState
107Pages
6 moUltrasound age limit
GFR <30
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.
Contrast GFR threshold
C9791Investigational
Medical Necessity and Coverage Criteria
General Appropriateness and Medical Necessity
Coverage and appropriateness guided by clinical presentation and prior evaluation; imaging should impact management.
Documentation for Medical Necessity: Recent detailed history, physical exam since onset/change in symptoms, and relevant laboratory and prior imaging must be submitted
Condition-specific sections may add requirements
Modality Selection Principles: Select modality based on the clinical question; prefer lower-risk/less-invasive options when adequate and avoid advanced imaging prior to clinical evaluation
Includes guidance on contrast use and modality substitution when MRI contraindicated
Contrast and Renal Function: Exercise caution with iodinated or gadolinium contrast in individuals with renal impairment; adjust modality/contrast choices when GFR <30 mL/min or when MRI contraindicatedGFR <30 mL/min
Gadolinium contraindicated in pregnancy unless benefit outweighs risk; limit GBCA use to necessary indications
Age-based Imaging Pathway: Individuals ≤18 years should follow Pediatric Spine Imaging Guidelines; individuals >18 years follow General Imaging Guidelines unless a section directs otherwiseage <=18
Some pediatric conditions differ from adult management
Overutilization Safeguards: Obtain results of prior diagnostic tests before repeating imaging; repeat imaging only when progression, new onset, or when results will affect management
Unbundling PET/CT into separate PET and diagnostic CT codes is not supported
Appropriate clinical indications for 3D rendering
CPT 76376/76377 can be considered in the following clinical scenarios:
3D rendering appropriate indications: Evaluation of congenital skull abnormalities in newborns/infants/toddlers for pre-operative planning; complex fractures/dislocations (including spine, pelvic/acetabulum, intra-articular) when conventional imaging is insufficient; complex facial fractures; pre-operative planning for other complex surgical cases; cerebral angiography; select pelvis and abdomen conditions when initial imaging is indeterminate as referenced in pelvis/abdomen guideline sections.
Concurrent physician supervision/participation must be documented for CPT 76376/76377
Imaging guidance billing and use criteria
Guidance codes represent imaging necessary to guide needles/catheters and include modality-specific scopes:
Guidance code billing rules: CT, MR, and ultrasound guidance procedure codes include all imaging necessary to guide a needle or catheter; it is inappropriate to routinely bill a diagnostic procedure code in conjunction with a guidance procedure; guidance codes apply to percutaneous procedures only (not open/excisional/incisional).
Examples: CPT 77012 (CT), 77013 (CT ablation monitoring; non-bone only), 77021/77022 (MR guidance), 76942 (US guidance), 75989 (drainage with catheter). Only one unit of guidance code should be reported per encounter/date of service.
Breast biopsy coding
MRI-guided breast biopsy billing
Breast biopsy coding: Use CPT 19085 for the first MRI-guided breast biopsy lesion and CPT 19086 for each additional concurrent lesion; CPT 77021 is not appropriate for breast biopsy.
Document procedure details and relationship to imaging guidance as applicable
Modality-specific coverage statements
Coverage stance and conditional approvals
Whole-body CT (LifeScan) for screening of asymptomatic individuals is not indicated; limited low-dose whole-body CT may be supported for specific oncologic staging (e.g., Multiple Myeloma).
Refer to oncology-specific guidelines for Multiple Myeloma
Whole-body MRI (WBMRI): Whole-body MRI is generally not supported due to lack of standardization and insufficient evidence to improve outcomes; exceptions include select cancer predisposition syndromes and specified autoimmune conditions; report WBMRI with unlisted MR code CPT 76498 when approved.
WBMRI technique and reporting limited to CPT 76498
PET-MRI may be appropriate ONLY when the individual meets PET-CT criteria, PET-CT is unavailable, and the provider requests PET-MRI in lieu of PET-CT; approved PET-MRI should be reported as CPT 78813 plus CPT 76498.
Other reporting combinations are inappropriate
Quantitative mpMRI:
General Spine Imaging Medical Necessity
Covered when ALL of the following are met
Pertinent clinical evaluation: A pertinent clinical evaluation since onset or change in symptoms, including detailed history, focused neurologic exam, appropriate labs, and basic imaging (plain radiography or ultrasound), must be performed prior to advanced imaging unless scheduled surveillance is guideline-supported.
Plain x-rays must be from after the current episode onset/change when required by condition-specific guidance
Active signs or symptoms: Advanced imaging is supported only in individuals with documented active clinical signs or symptoms of disease involving the spine; screening asymptomatic individuals is not supported.
Repeat imaging justification: Repeat advanced imaging is not necessary unless there is evidence of progression, new onset of disease, or documentation that repeat imaging will affect management or treatment decisions.
Pediatric Spine Imaging Criteria
Covered when criteria specific to pediatric population are met
Age application: Patients ≤18 years should be imaged according to the Pediatric Spine Imaging Guidelines; individuals >18 years follow General Spine Imaging Guidelines unless stated otherwise.
Document patient age to apply pediatric rules
Modality preference: MRI is the preferred modality for pediatric spine imaging unless a specific guideline section lists an alternative or CT is specifically indicated (e.g., trauma, hardware limitation).
Consider anesthesia planning for MRI in young children
Anesthesia planning: Plan MRI sessions to minimize anesthesia exposure; when IV access is present for anesthesia and no contraindication, obtain MRI without and with contrast in the same session if clinically indicated to avoid repeat anesthesia.
Assess GBCA necessity given deposition concerns
Coverage criteria by indication and age
Covered when criteria below are met according to age group and clinical indication
Children age ≤5 (Back and Neck Pain ≤5): Advanced imaging appropriate in virtually all individuals in this age group except those with mild/transient pain; MRI of the symptomatic region should be approved; sedation commonly required.
CT without contrast only for isolated vertebral bony abnormality or when MRI insufficient
Children age ≥6 (Back and Neck Pain ≥6): Detailed clinical evaluation and plain x-rays are required prior to advanced imaging; advanced imaging approved after recent x-ray when one or more pediatric red flags are present; without red flags a recent (within 3 months) 4-week trial of provider-supervised conservative treatment is expected.
MRI without contrast preferred; MRI with and without contrast for infection, mass, cancer, or fever >=100°F
Red flags (children ≥6): Accompanying systemic symptoms; functional disability; severe or night pain; constant or radicular pain ≥4 weeks; pain worsening despite treatment; neurologic symptoms/abnormal exam; established non-leukemia cancer; abnormal x-rays; bowel/bladder dysfunction
Thoracolumbar Spine (Children)
Covered when ANY of the following are met:
Thoracolumbar MRI approval: Children may be approved for advanced imaging of the thoracolumbar spine following a recent x-ray when x-rays are inconclusive or when there is an abnormal neurological examination.
Plain x-rays must be available to the requesting provider
Suspected Physical Child Abuse
Covered when ALL of the following are met:
MRI for suspected abuse: In children with suspected physical child abuse and documented findings suggesting abuse (e.g., fractures on skeletal survey or other clinical indicators), MRI cervical (CPT 72141), thoracic (CPT 72146), and lumbar (CPT 72148) spine without contrast are indicated; if IV access for anesthesia is present and no contraindication, MRI without and with contrast may be approved.
Document clinical findings suggesting abuse
Juvenile Thoracic Kyphosis (Scheuermann Disease)
Covered with prior plain radiography and clinical evaluation:
Imaging sequence for Scheuermann Disease: Perform detailed history, neurologic exam, and plain radiography prior to advanced imaging; MRI is not generally effective diagnostically for Scheuermann disease but MRI thoracic/lumbar without contrast may be approved preoperatively to evaluate for associated spinal cord problems when indicated.
Avoid routine MRI for Scheuermann disease without preoperative concern
Scoliosis (Congenital, Idiopathic, Neuromuscular)
Modalities and indications vary by scoliosis type and clinical features:
Initial imaging: Standing PA and lateral x-rays are the initial imaging studies and are used for follow-up; use breast shields if AP x-rays are performed.
MRI for congenital/idiopathic features: MRI cervical/thoracic/lumbar without contrast is indicated to search for underlying anomalies in congenital scoliosis and should be approved when risk features (e.g., age <10, neurologic abnormalities, atypical curve features) are present or when preoperative evaluation requested.
MRI without contrast preferred; consider with contrast if IV access present and indicated
Neuromuscular scoliosis: MRI without contrast or without and with contrast or CT without contrast of appropriate spinal levels can be approved in individuals with painful neuromuscular scoliosis or when actively evaluated for corrective surgery; bone scans may be useful for painful scoliosis.
Bone scans CPTs: 78300/78305/78306/78315
Occult Spinal Dysraphism / Tethered Cord
Covered when criteria depending on age and findings are met:
Infant initial imaging: Spinal ultrasound (CPT 76800) can be approved for initial evaluation in infants up to 6 months corrected age (including premature infants with corrected age ≤6 months); repeat ultrasound in 4–6 weeks if cord termination uncertain in premature infants.age <=6 months
Plain x-rays are not indicated for suspected occult dysraphism except when x-ray suggests absent/distorted pedicle prompting MRI
MRI/CT approval: MRI (CPT 72141/72146/72148 or without and with contrast CPT 72156/72157/72158) may be approved for individuals older than 6 months or earlier when ultrasound abnormal or specialist requests MRI; CT can be approved for surgical planning when complex bony deformity present or MRI contraindicated.
Appropriate level and contrast determined by specialist
Tethered cord diagnosis note: Tethering is likely when conus terminates at or below L4 with supporting findings (limited pulsatility, posterior positioning, thick filum terminale, intraspinous mass or lipoma); normal conus position varies by age and does not exclude tethering if other abnormalities present.
Cutaneous Indications (screening and diagnostic imaging)
Covered when ANY of the following cutaneous findings are present (screening pathway summarized):
Cutaneous screening indications: Spinal dimples; deviated or bifid gluteal cleft; dermal sinuses; subcutaneous midline masses (including cysts and lipomas); caudal extensions or tail-like appendages; midline skin tags; abnormal patches of hair over the spine; infantile hemangiomas overlying any spinal level; complex midline birthmarks above the upper sacral region.
For infants ≤6 months, spinal ultrasound may be approved as initial screening; MRI preferred for midline masses or in individuals >6 months or when ultrasound abnormal
Non-cutaneous Indications
Covered when ANY of the following non-cutaneous conditions or neurologic findings are present:
Non-cutaneous syndromic and neurologic indications: Imperforate anus; VACTERL association; Currarino triad; OEIS; caudal regression; sacral agenesis; DiGeorge syndrome when tethered cord suspected; neurologic findings such as asymmetric feet/neuroorthopedic syndrome, cavus foot, toe walking with UMN signs, ataxia, absent perineal sensation, lower urinary tract dysfunction, constipation with spine-related findings, and back/leg pain when tethered cord suspected.
Spinal ultrasound may be approved for infants ≤6 months; MRI lumbar or other levels per clinical indication; follow-up of a normal screening MRI or ultrasound is not appropriate
Spinal Dysraphism (open and closed) Imaging
Covered for clinically significant dysraphism when imaging is needed for diagnosis or preoperative planning:
Open dysraphism: MRI brain (CPT 70551/70553) is indicated in all cases of open dysraphism because Chiari II malformation will be present; MRI of the entire spine may be approved for preoperative planning; spinal canal ultrasound may be an alternative if requested and acoustic window exists.
Diagnosis often made prenatally or by visual inspection; MRI in neonates rare
Closed dysraphism: MRI of the entire spine without or without and with contrast is appropriate at initial diagnosis; MRI brain or CT brain may be approved if hydrocephalus or cerebral signs present; MRI pelvis may be approved once for pelvic/anorectal anomalies; postoperative MRI reserved for recurrent/worsening symptoms.
Contrast level per ordering specialist
Achondroplasia
MRI of symptomatic spinal region is approvable when specific conditions are met
Achondroplasia MRI: MRI without contrast or without and with contrast of the symptomatic spinal region can be approved when new or worsening clinical symptoms suggest achondroplasia-related spinal stenosis; plain radiography and clinical evaluation recommended prior to advanced imaging.
MRI brain/CT head may be approved when hydrocephalus suspected
Inflammatory Spondylitis / JIA
Imaging approach for juvenile idiopathic arthritis and related conditions
Inflammatory spondylitis MRI: For pediatric patients with juvenile idiopathic arthritis, MRI without and with contrast or without contrast of the involved levels is appropriate; an initial x-ray is not necessary prior to MRI in these patients.
Whole-body radiopharmaceutical localization or SPECT/SPECT-CT may be appropriate for facet arthropathy
Atlantoaxial Instability (Trisomy 21)
Criteria for MRI in trisomy 21 with suspected atlantoaxial instability or myelopathy
Atlantoaxial instability MRI: MRI cervical spine without contrast or without and with contrast is appropriate when lateral cervical spine x-ray demonstrates an atlantodental interval ≥4.5 mm and/or neural canal width ≤14 mm, or when new/worsening clinical symptoms suggest myelopathy in an individual with trisomy 21.atlantodental >=4.5 mm OR canal width <=14 mm
Also indicated with new/worsening neurologic symptoms
Klippel-Feil Anomaly
Klippel-Feil anomaly imaging
Klippel-Feil advanced imaging: Advanced imaging (MRI cervical without contrast or CT cervical without contrast) is indicated if there are acute or worsening neurologic symptoms (including pain) or if multiple levels are involved; plain x-rays often sufficient to establish diagnosis and should be obtained first.
Perform detailed history and neurologic exam prior to advanced imaging
Marfan Syndrome
Marfan syndrome imaging indications
Marfan MRI: MRI without contrast of the symptomatic spinal region can be approved when new or worsening clinical symptoms suggest complicated dural ectasia or when the individual is under active consideration for surgery; plain radiography and clinical evaluation recommended prior to advanced imaging.
Von Hippel-Lindau Syndrome (spinal hemangioblastoma)
Imaging for known spinal hemangioblastoma in VHL
Spinal hemangioblastoma MRI: MRI without and with contrast of the affected spinal level can be approved annually for asymptomatic patients with unresected spinal hemangioblastoma(s), for preoperative planning, or for new or worsening symptoms suggesting progression of a known hemangioblastoma.annual for surveillance; clinical change for progression
Applies to patients with known spinal hemangioblastomas
Imaging requests submitted solely for data collection or research — for example, certain clinical trial imaging that is not intended to influence the individual member’s direct clinical management — are considered investigational/experimental and are not supported. The investigational designation applies when there is a paucity of supporting evidence, lack of demonstrated clinical utility, immature evidence of improved health outcomes, or absence of a collective opinion of support from relevant specialty sources.
Do not unbundle PET/CT into separate PET and diagnostic CT CPT codes; PET/CT is performed as a single combined examination and reporting the PET and diagnostic CT components as independent studies is not supported.
CPT 76376 and 76377 for 3D rendering must not be billed in conjunction with a range of listed studies (for example CAD, MRA, CTA, nuclear medicine SPECT, PET/PET‑CT, mammography, breast ultrasound, CT colonography, cardiac CT/MRI and coronary CTA). In addition, guidance/ablation billing rules clarify appropriate modality-specific use and unit reporting for related guidance services; follow those modality-specific billing rules when considering 3D rendering charges.
For CT stereotactic localization sessions report CPT 77011 (technical stereotactic localization) when no diagnostic CT interpretation is performed; it is not appropriate to report both a diagnostic CT code (e.g., CPT 70486) and CPT 77011 for the same stereotactic CT session. Similarly, avoid billing diagnostic CT codes together with stereotactic localization when the localization code alone describes the technical dataset.
Whole‑body CT or routine whole‑body MRI performed for screening of asymptomatic individuals is not indicated as a general practice. Whole‑body CT screening is specifically not supported; whole‑body MRI is generally not supported except in narrowly defined situations (for example, select cancer predisposition syndromes) and must be reported using an unlisted MR code (CPT 76498) when performed.
Use of advanced imaging modalities to screen asymptomatic individuals for spine disorders is not supported. Advanced spine imaging should be reserved for individuals with documented active clinical signs or symptoms or other guideline‑specified indications.
Do not use CPT 76800 (spinal canal ultrasound) for intraoperative spinal canal evaluation; CPT 76998 (intraoperative ultrasonic guidance) is the appropriate code in that setting. Note that spinal canal ultrasound is generally limited to infants up to 6 months corrected age except when a persistent acoustic window exists (for example, in posterior spinal defects).
Plain radiographs are not indicated for the routine evaluation of suspected occult spinal dysraphism or tethered cord. An incidental finding of isolated spina bifida occulta on x‑ray in an asymptomatic individual is not an indication for further imaging.
An isolated incidental finding of spina bifida occulta in an asymptomatic patient does not warrant additional imaging. Imaging for suspected occult dysraphism should be driven by cutaneous or neurologic findings rather than incidental x‑ray findings.
For pediatric patients with juvenile idiopathic arthritis, an initial plain x‑ray is not required prior to obtaining MRI of the involved levels; MRI (with or without contrast as clinically indicated) may be ordered without a prior radiograph.
Requests for repeat or higher‑level imaging that do not document an expected impact on management, or that bypass appropriate lower‑cost or less‑invasive alternatives, risk denial as overutilization. Examples include repeat advanced imaging without evidence of progression or imaging ordered instead of appropriate initial lower‑cost tests.
Pre‑operative or pre‑procedural advanced imaging is not indicated when the planned surgery or procedure itself is not indicated or approved. Authorization for preoperative imaging generally follows approval or indication for the procedure.
Volumetric and quantitative MRI analyses (including Category III and related codes) are considered investigational or not medically necessary for routine clinical practice; routine volumetric/quantitative brain MRI (e.g., CPT 0865T/0866T) is not medically necessary.
Repeat imaging of the spine is not supported unless there is documented evidence of progression, new onset of disease, or clear documentation that the repeat study will affect clinical management or treatment decisions.
For children age ≥6 without pediatric red flags, advanced imaging should not be approved until a recent (within 3 months) 4‑week trial of provider‑supervised conservative treatment has been attempted. Presence of any pediatric red flag removes that prerequisite.
MRI is not an effective general diagnostic modality for Scheuermann disease due to a high rate of false‑positive vertebral changes; routine MRI for Scheuermann disease without preoperative concern is not indicated. MRI of the thoracic or lumbar spine without contrast may be appropriate preoperatively if concern for associated spinal cord pathology exists.
Follow‑up imaging after a normal screening spinal ultrasound or a normal screening MRI is not appropriate. A normal screening ultrasound should not routinely prompt repeat ultrasound surveillance; similarly, routine repeat MRI following a normal screening MRI is not indicated.
Adults with congenital spine disorders may be managed following the pediatric guidance in these sections except where specific statements in the general adult imaging guidelines or condition‑specific guidance indicate otherwise.
When Advanced Imaging is Appropriate
Situations where MRI is generally superior
Top-level indications where MRI is generally preferred or superior
MRI preferred indications: Imaging the brain and spinal cord; characterizing visceral and musculoskeletal soft tissue masses; evaluating musculoskeletal soft tissues (ligaments, tendons); evaluating inconclusive findings on ultrasound or CT; pregnancy or high radiation sensitivity; suspected infection; when superior soft-tissue contrast is required.
See condition-specific sections for details
Situations where CT is generally superior
Top-level indications where CT is generally preferred or superior
CT preferred indications: Trauma screening; pulmonary disease imaging; abdominal and pelvic visceral evaluation; complex fractures and detailed bony anatomy; when ultrasound or MRI is inconclusive or contraindicated.
Contrast level chosen based on clinical question
CPT / HCPCS Coding Guidance
Investigational CPT/HCPCSCPTExperimental
C9791
MRI utilizing Xenon Xe 129 (listed as investigational/experimental)
3D rendering CPT codesCPT
76376
3D rendering; not requiring image post-processing on an independent workstation
76377
3D rendering; requiring image post-processing on an independent workstation
Image-guidance and procedure CPT codesCPT
19085
Biopsy, breast, with placement of breast localization device(s), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including MR guidance
19086
Biopsy, breast; each additional lesion, including MR guidance
75989
Imaging guidance for percutaneous drainage with placement of catheter (all modalities)
76942
Ultrasonic guidance for needle placement
77011
CT guidance for stereotactic localization
77012
CT guidance for needle placement
77013
CT guidance for, and monitoring of parenchymal tissue ablation
77021
MR guidance for needle placement
77022
MR guidance for, and monitoring of parenchymal tissue ablation
Breast biopsy guidanceCPTCovered
77021
MR guidance for needle placement — not appropriate for breast biopsy
19085
First breast biopsy site
19086
Additional concurrent breast biopsies
Guidance for ablation and modality-specific guidance codesCPTCovered
77013
CT guidance for percutaneous ablation — includes initial guidance, monitoring, multiple ablations, confirmation; use only for non-bone ablations; one unit per encounter
77022
MR guidance for percutaneous ablation — includes initial guidance, monitoring, multiple ablations, confirmation; one unit per encounter
20982
CT guidance for bone tumor ablations
77012
Radiologic guidance by different modalities (listed as alternative guidance codes)
76942
Ultrasound guidance
77002
Fluoroscopy guidance
77003
Fluoroscopy guidance
Unlisted procedure codesCPT
76497
Unlisted CT procedure
76498
Unlisted MR procedure (used for whole-body MRI and other unclassifiable MR studies)
MRI Pelvis without and with contrast (alternate listing)
Referenced imaging CPT codesCPT
70551
MRI Brain without contrast
70450
CT Head without contrast
72141
MRI Cervical Spine without contrast
72156
MRI Cervical Spine without and with contrast
72125
CT Cervical Spine without contrast
78802
Whole body radiopharmaceutical localization imaging
78803
SPECT
78830
SPECT/CT
Renal function threshold for contrast caution
Renal function thresholdGFR <30 mL/min
Contrast risk note
Prior Authorization, Documentation, and Operational Requirements
Prior Authorization
Prior Authorization, Clinical Evaluation, and PET‑MRI Authorization
Advanced imaging and related procedures may require prior authorization and adherence to legislative and guideline-based requirements. Pre-procedural (pre-operative or pre-surgical planning) imaging will only be approved when the underlying surgery or procedure itself is indicated and either has been prior authorized or does not require authorization. PET‑MRI is generally not supported except in select circumstances: the member must meet condition‑specific PET‑CT criteria, PET‑CT must be unavailable at the treating institution, and the provider must request PET‑MRI in lieu of PET‑CT. When approved, PET‑MRI should be reported as the CPT combination PET whole body (78813) + MRI unlisted (76498); other reporting methods are inappropriate. Ordering providers must ensure an appropriate clinical evaluation has been performed and documented (history, focused neurologic exam where relevant, and prior plain radiographs when required by the spine guidelines) before requesting advanced spine imaging. Prior authorization requests for advanced and nuclear imaging are expected to include documentation that supports the indication (clinical findings, prior x‑rays, conservative treatment trials when required for the condition/age group).
Pre‑procedural imaging approved only when the planned procedure/surgery is indicated and authorized.
PET‑MRI may be approved only when PET‑CT criteria are met and PET‑CT is unavailable; report as CPT 78813 + CPT 76498.
Providers must document a pertinent clinical evaluation (history, physical, neurologic exam) and any condition‑specific prerequisites (e.g., plain x‑rays) prior to advanced spine imaging requests.
Surveillance and Repeat Imaging Intervals
Repeat imaging general rule
General repeat imaging ruleRepeat imaging is not generally necessary unless there is evidence of progression/recurrence or documentation that repeat imaging will affect management
Documentation requirementRepeat studies should include evidence that results will change management to support approval
ApplicabilityApplies across advanced imaging modalities unless condition-specific frequency guidance exists
Any advanced imaging
Advanced imaging repeat ruleRepeat advanced imaging (MRI/CT/Nuclear) is appropriate only when there is evidence of progression, new onset, or documentation that repeat imaging will affect management
Denial risk
Prior Authorization Rules and Exceptions
Note
Note
Note
Note
Note
Note
Note
Note
Contrast Agent Considerations and Safety
Note
Note
Note
Note
Note
Note
Note
Note
Key Definitions and Terminology
Investigational/Experimental definition
Investigational/Experimental definitionStudies, treatments, procedures, or devices considered investigational if there is a paucity of supporting evidence, lack of demonstrated clinical utility, immature evidence for improved outcomes, or absence of collective opinion of support
Supporting evidence examplesPeer-reviewed trials, cohort studies, and specialty society recommendations are cited as supporting evidence
Coverage implicationInvestigational designation may render a procedure not covered for routine clinical practice
Standard/Conventional Imaging
Standard/Conventional ImagingPlain film, CT, MRI, or ultrasound used most often in initial and subsequent evaluations
Role
Unsupported or Excluded Imaging
PET/MRI is generally not supported for routine clinical use. PET‑MRI may only be considered when the individual meets PET‑CT criteria, PET‑CT is unavailable, and the provider specifically requests PET‑MRI as a substitute; when approved, report as CPT 78813 (PET whole body) plus an unlisted MR code (CPT 76498).
CPT 77021 (MR guidance for needle placement) is not appropriate for MRI‑guided breast biopsy; use CPT 19085 for the first lesion and CPT 19086 for additional concurrent breast biopsy lesions. Also, 3D rendering CPTs (76376/76377) are excluded from billing in conjunction with the listed modalities and studies (see 3D rendering exclusions).
The guideline explicitly states that CPT 77021 is not appropriate to report for MRI‑guided breast biopsy; use CPT 19085/19086 for first and additional MRI‑guided breast biopsy lesions. Additionally, 3D rendering codes must not be billed with the excluded modalities/studies described in the 3D rendering section.
Billing of 3D rendering codes (CPT 76376/76377) is prohibited in conjunction with the modalities and studies listed (for example CAD, MRA, CTA, SPECT, PET/PET‑CT, mammography, breast MRI/US, CT colonography, cardiac CT/MRI). Follow modality‑specific guidance and prior authorization requirements for 3D rendering.
Modality‑specific guidance and billing exclusions also apply to guidance and stereotactic localization codes: e.g., CPT 77013 is limited to non‑bone ablations (bone ablation guidance is CPT 20982), and CPT 77011 should not be reported together with diagnostic CT codes for the same stereotactic session. 3D rendering should not be reported with stereotactic localization because the localization inherently generates a 3D dataset.
Additional billing exclusions reiterate that 3D rendering codes must not be reported with the enumerated modalities and that whole‑body MRI has coding limitations (report as CPT 76498) when used in the rare, supported clinical scenarios.
Scope and Background
These evidence‑based pediatric and special‑population spine imaging guidelines summarize modality‑specific recommendations, prerequisite clinical evaluation requirements, and condition‑specific indications to guide appropriate test selection and reduce low‑value imaging. They are informed by peer‑reviewed literature, specialty society guidance, and clinician input, and are intended to support ordering providers and utilization review for members in the applicable jurisdiction.
Policy Revision History
2025-05-01annual_updateLatest
Annual evidence-based updates to the policy.
2024-07-01interim_update
Interim evidence-based updates to the policy.
2024-02-01annual_update
Annual evidence-based updates to the policy.
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyPediatric and Special Populations Spine Imaging Guidelines (For Ohio Only)
Policy CodePolicy CSRAD025OH.D
Change TypeAnnual and interim evidence-based updates (2024–2025)
Effective DateNov 1, 2025
Next Review DateN/A
Key ActionSubmit recent detailed history, focused neurologic exam, and relevant prior imaging when requesting advanced spine imaging to support medical necessity and prior authorization.
Quantitative multiparametric MRI analyses (Category III CPT codes such as 0648T/0649T/0697T/0698T and volumetric brain analyses 0865T/0866T) are considered investigational/experimental and not routinely medically necessary.
Primarily used in clinical trials
CT indications in pediatrics: CT is preferred in trauma and for limited indications such as hardware-limiting MRI, severe congenital deformity when MRI inconclusive, or detailed bony anatomy for preoperative planning.
CT exposes to ionizing radiation; use judiciously
Ultrasound pediatric use: Spinal canal ultrasound (CPT 76800) is generally limited to infants up to 6 months of age (corrected age); exception for persistent acoustic window in posterior spinal defects (dysraphism).age <=6 months
Follow-up ultrasound of a normal screening exam is not appropriate
Nuclear medicine pediatric use: Nuclear medicine studies are rarely used but indicated for suspected hardware loosening when x-ray nondiagnostic, suspected spondylolysis when MRI inconclusive, or other specific indications per guideline.
Codes include 78315, 78803, 78830-78832
Presence of any red flag supports approval of advanced imaging
Spondylolysis: Screen with plain x-rays; MRI without contrast indicated after failed recent (within 3 months) 4-week conservative care or for preoperative planning; if radiographically occult, SPECT (CPT 78803) or SPECT/CT (78830) indicated; CT without contrast for detailed bony anatomy if preoperative planning needed.
Bone scan/SPECT often superior for active spondylolysis detection
Infectious causes (discitis/osteomyelitis): Initial imaging: plain x-rays and MRI with and without contrast of symptomatic level are very sensitive and can be approved when infection suspected; nuclear medicine studies (bone scan, bone marrow imaging, radiopharmaceutical inflammatory imaging, SPECT/SPECT-CT) are also indicated for initial evaluation.
Follow-up imaging options include MRI with and without contrast or CT as indicated
Trauma: Imaging directed by clinical exam; MRI without contrast or CT without contrast indicated when advanced imaging appropriate; if initial CT/MRI inconclusive, the alternate modality may be approved; cervical indications vary by age and red flags.
Children under 3: approve after recent x-ray with red flags; children ≥3: recent (within 60 days) x-ray plus red flags
Suspected physical child abuse: When abuse is suspected with documented findings (e.g., fractures on skeletal survey), MRI cervical, thoracic, and lumbar spine without contrast are indicated to search for associated abnormalities; MRI with and without contrast may be approved if IV access present and no contraindication.
Documented findings suggesting abuse required
Conus position norms by age referenced
Situations where PET/PET-CT may be indicated
Top-level node for PET indications
PET/PET-CT indications: Oncologic evaluation of tumor metabolic activity, cardiac myocardial metabolic assessment, and brain metabolic evaluation for procedural planning; PET/CT typically combined study and PET not indicated for routine surveillance unless condition-specific guidance states otherwise.
Unbundling PET/CT into separate PET and diagnostic CT codes is not supported
3D rendering criteria
When 3D rendering is expected to materially affect preoperative planning or management
3D rendering criteria: 3D rendering (CT/MR/US) is appropriate when conventional imaging is insufficient and a 3D reconstruction is expected to materially affect preoperative planning or clinical management (examples include congenital skull abnormalities, complex fractures, spine/pelvic/acetabular fractures, complex facial fractures, cerebral angiography, and select pelvis/abdomen indications).
Physician supervision/participation for CPT 76376/76377 should be documented
Imaging guidance for percutaneous procedures
Imaging needed to direct needle/catheter placement and monitoring
Guidance for percutaneous procedures: Use CT/MR/US guidance codes to direct needle/catheter placement, monitor device position, and confirm ablation when performing percutaneous biopsies, drainages, or ablations; guidance codes include modality-specific scopes and should be billed per encounter (one unit), not per lesion.
Statement regarding non-indication for routine use
Whole-body CT screening not indicated: Whole-body CT for screening asymptomatic individuals is not indicated; exceptions limited to specific oncologic indications (e.g., Multiple Myeloma).
Whole-body MRI
Whole-body MRI is not supported as routine screening except select indications
Whole-body MRI restrictions: Whole-body MRI is generally not supported due to lack of technique standardization and outcome evidence; may be considered for select cancer predisposition syndromes or certain autoimmune conditions; report with CPT 76498 when approved.
PET-MRI
PET-MRI allowed only in narrow circumstances when PET-CT criteria met and unavailable
PET-MRI allowance: PET-MRI may be appropriate when PET-CT criteria are met AND PET-CT is unavailable AND the provider requests PET-MRI in lieu of PET-CT; approved PET-MRI should be reported as CPT 78813 + CPT 76498.
Other reporting methods are inappropriate
Appropriate use indications for spine imaging modalities
Appropriate use indications for spine imaging modalities
Prerequisite clinical evaluation: Documented pertinent clinical evaluation (history, neurologic exam, labs, and basic imaging) since onset or change in symptoms is required prior to advanced imaging unless guideline-supported surveillance applies.
Modality preference: MRI is preferred for pediatric spine imaging unless otherwise specified; CT preferred for trauma or when MRI contraindicated; ultrasound for infants ≤6 months for screening of dysraphism.
Nuclear medicine role: Nuclear medicine studies (bone scan, SPECT, SPECT/CT, bone marrow imaging) are indicated in selected scenarios (e.g., suspected spondylolysis, hardware loosening, MRI nondiagnostic cases).
Spinal canal ultrasound (CPT 76800)
Spinal canal ultrasound indications and age limits
Spinal canal ultrasound (76800): Spinal canal ultrasound (CPT 76800) is useful primarily in infants up to 6 months of age due to acoustic window limitations; not appropriate for intraoperative use (use CPT 76998 instead); exception for persistent acoustic window in posterior spinal defects allows use at older ages.age <=6 months
Follow-up of a normal screening ultrasound with additional ultrasound is not appropriate
Suspected spinal infection/osteomyelitis/discitis
Imaging indications for suspected spinal infection/osteomyelitis/discitis
Infection imaging pathway: Initial imaging: plain x-rays and MRI with and without contrast of the symptomatic spinal level (MRI very sensitive); nuclear medicine options (bone scan, bone marrow imaging, radiopharmaceutical inflammatory imaging, SPECT, SPECT/CT) are also indicated for initial evaluation; follow-up imaging may include MRI with and without contrast or CT as clinically indicated.
Specific CPT codes: 78300/78305/78306/78315, 78102-78104, 78800-78804, 78830-78832
Suspected spondylolysis
Imaging indications for suspected spondylolysis
Spondylolysis imaging: Screen with plain x-rays; MRI without contrast indicated after failed recent conservative care or for preoperative planning; if radiographically occult, SPECT (CPT 78803) or SPECT/CT (CPT 78830) indicated; CT without contrast useful for detailed bony anatomy if preoperative planning required.
SPECT/bone scan may be superior to MRI for active spondylolysis detection
Suspected physical child abuse
Dedicated imaging indications for suspected physical child abuse
Child abuse imaging: When suspected physical child abuse has documented findings (e.g., fractures on skeletal survey), MRI cervical/thoracic/lumbar spine without contrast is indicated; MRI with and without contrast may be approved if IV access present and no contraindication; thoracolumbar MRI approved after recent x-ray when inconclusive or with abnormal neurologic exam.
Documented findings suggesting abuse required
Thoracolumbar advanced imaging in children
Thoracolumbar-specific indications in children
Thoracolumbar advanced imaging: Approve advanced imaging of the thoracolumbar spine in children after a recent x-ray when x-rays are inconclusive or when neurologic examination is abnormal.
Plain x-rays should be available to requesting provider
MRI for suspected abuse: MRI cervical, thoracic, and lumbar spine without contrast indicated when child abuse suspected with documented findings; consider contrast if IV access present and appropriate.
See pediatric spine imaging modality considerations
Occult spinal dysraphism and tethered cord evaluation
Infant imaging sequencing: If infant ≤6 months corrected age, spinal ultrasound (CPT 76800) may be approved as initial evaluation; repeat ultrasound in 4–6 weeks if cord termination uncertain in premature infants; MRI may be approved earlier if ultrasound abnormal or specialist requests MRI.age <=6 months
Plain x-rays are not indicated for suspected occult dysraphism except when x-ray suggests absent/distorted pedicle
Scoliosis evaluation and preoperative planning
Scoliosis evaluation and preoperative planning
Scoliosis imaging indications: Standing PA and lateral x-rays are the initial and follow-up studies; MRI without contrast preferred to evaluate underlying anomalies when risk features present or for preoperative planning; CT chest perioperatively may be indicated in severe/early onset scoliosis to assess lung development.Cobb angle thresholds apply
Use breast shields for AP x-rays; bone scans useful for painful scoliosis
Infants with cutaneous or non-cutaneous indications
Infant screening and diagnostic pathways for cutaneous and non-cutaneous indications
Infant pathway: For infants with cutaneous or non-cutaneous indications and corrected age ≤6 months, spinal ultrasound (CPT 76800) is preferred initial imaging; MRI of the involved spinal level may be approved if ultrasound abnormal or specialist requests MRI; follow-up of a normal screening ultrasound with repeat ultrasound is not appropriate.age <=6 months
Repeat ultrasound in premature infants with uncertain cord termination can be performed in 4–6 weeks
MRI indications
General MRI indications
MRI indications: MRI of the appropriate spinal level may be approved for individuals >6 months, for preoperative planning, for new/worsening neurologic signs suggestive of tethering or myelopathy, for midline masses, or when ultrasound shows abnormalities; MRI brain or CT brain may be approved with hydrocephalus or cerebral signs; MRI pelvis may be approved once for pelvic/anorectal anomalies.age >6 months or symptomatic
Postoperative MRI reserved for recurrent/worsening symptoms
Specific clinical symptoms or known lesion surveillance/preoperative planning
Surveillance, preoperative planning, and new/worsening symptom indications across several conditions
New or worsening neurologic symptoms: New or worsening clinical symptoms suggesting spinal stenosis, myelopathy, progression of a known lesion, or complicated dural ectasia warrant MRI of the symptomatic region; surveillance imaging intervals (e.g., annual for unresected spinal hemangioblastoma) apply as specified.
Applies across achondroplasia, trisomy 21 myelopathy, Klippel-Feil, Marfan, VHL, and related conditions
Both contrast CT and MRI have similar increased risk profile when GFR <30 mL/min
Clinical implicationExercise caution and consider avoiding or modifying contrast-enhanced studies in individuals with GFR <30 mL/min
Guidance unit of service
Guidance unit reportingOnly one unit of a guidance code should be reported per individual encounter/date of service (unit = encounter, not per lesion)
ScopeApplies to guidance codes including CT, MR, US, and fluoroscopy guidance (e.g., 77012, 77021, 76942, 77002-77003)
Billing consequenceReporting multiple units per date of service may trigger denial
Guidance code unit limit
Unit limit1 unit per individual encounter (date of service)
Unit definitionThe unit of service is the individual encounter, not the number of lesions, aspirations, biopsies, injections, or localizations
Applicable codesIncludes CPT codes such as 77013, 77022, 77012, 77021, 76942, 77002, 77003
Ultrasound age limit
Age limit (general)Spinal canal ultrasound generally limited to infants up to 6 months of age
Use caseSpinal ultrasound (CPT 76800) is an initial evaluation modality in infants ≤6 months prior to MRI
Conservative treatment duration
Required conservative treatment duration4-week trial of provider-supervised conservative treatment within the prior 3 months
ApplicabilityExpected before advanced imaging in children ≥6 years without red flags
ExceptionsNot required when pediatric red flags are present or when being evaluated by a pediatric spine surgeon
Cobb angle thresholds
Cobb angle: normalCurve <10°
Cobb angle: mildly abnormalCurve 10–20°
Cobb angle: significantCurve >20°
Cobb angle: severeCurve >40°
Closed Dysraphism
Closed DysraphismSkin-covered variants of dysraphism
Imaging implicationMRI entire spine without or without and with contrast appropriate at initial diagnosis; MRI brain/CT if hydrocephalus suspected
Pelvic imagingMRI pelvis may be approved once for pelvic malformation or anorectal anomaly
Infant age for ultrasound
Infant ultrasound age criterionInfant corrected age ≤ 6 months
Premature infant noteUse corrected age (subtract weeks of prematurity) when determining eligibility for spinal ultrasound
RoleSpinal ultrasound (CPT 76800) is preferred initial imaging in infants ≤6 months prior to MRI
Atlantodental (pre-dens) interval
Atlantodental interval thresholdAtlantodental (pre-dens) interval ≥ 4.5 mm
ActionLateral cervical spine x-ray meeting this threshold indicates need for cervical MRI
ContextUsed in screening for atlantoaxial instability (e.g., Trisomy 21)
Neural canal width
Neural canal width thresholdNeural canal width ≤ 14 mm
ActionMeasurement ≤14 mm on lateral cervical spine x-ray indicates need for cervical MRI
Clinical contextApplied in screening for atlantoaxial instability (e.g., Trisomy 21)
Prior authorization requests for advanced/nuclear imaging must include supporting records: prior imaging, trial of conservative care when required, and documentation of findings that justify imaging.
When PET‑MRI is clinically appropriate, diagnostic MRI codes may be reported concurrently if indicated.
Documentation Required
Clinical Documentation, Evidence Support, and Overutilization Risk
Documentation must be evidence‑based and sufficient to avoid overutilization denials. Submit a recent detailed history, focused physical and neurologic examination, relevant laboratory data when applicable, and prior imaging (plain radiographs performed after onset/change in symptoms when the guideline requires them). Requests lacking adequate clinical information or pertinent records are at risk for denial as medically not necessary. Providers should reference current society guidelines and peer‑reviewed evidence to support requests when clinical indications are borderline.
Include prior x‑rays/results when required by the spine guidelines; plain radiographs must be from after the current episode onset or change.
Document conservative management attempts when the guideline requires a trial (e.g., children ≥6 without red flags).
Insufficient documentation or failure to provide requested medical records may result in denial for overutilization or lack of medical necessity.
Billing Rule
3D Rendering, Stereotactic CT Localization, and Guidance Code Billing
Certain post‑processing, guidance, and localization codes carry specific billing and documentation rules. CPT 76376 and 76377 (3D rendering) require documented concurrent physician supervision/participation in the reconstruction process and may require prior authorization even if the base study does not. CPT 77011 should be reported when a stereotactic CT localization scan is performed as a technical‑only service without radiologist interpretation; do not report both a diagnostic CT interpretation code and CPT 77011 for the same dataset. Guidance codes (e.g., CPT 77013, 77022, 77012, 77021, 76942, 77002‑77003) and similar modality guidance codes should be reported as a single unit per encounter — one unit per date of service, not per lesion or needle pass.
CPT 76376 / 76377 require physician concurrent supervision and documentation of the 3D reconstruction process; prior authorization may be required for these codes separately.
Report CPT 77011 for technical stereotactic CT localization scans without radiologist interpretation; if interpreted, use the appropriate diagnostic CT code instead and do not report both.
Only one unit of procedure guidance codes should be reported per encounter (date of service).
Documentation Required
Pediatric Age Documentation and Infant Imaging Sequencing
Pediatric age must be documented to ensure application of the Pediatric Spine Imaging Guidelines when applicable. Imaging sequencing in infants: spinal ultrasound (CPT 76800) is the preferred initial advanced imaging up to 6 months (or corrected prematurity age ≤6 months) for evaluation of occult dysraphism/tethered cord; MRI of the involved spinal level (CPT 72141/72146/72148 or 72156/72157/72158) is the preferred or next‑step study after 6 months or earlier when ultrasound is abnormal or when ordered by/after consultation with a specialist. For conditions such as congenital scoliosis or midline masses, ultrasound may be initial in infants but MRI is preferred for midline masses regardless of age; plain radiographs are not indicated for suspected occult dysraphism except in specific circumstances.
Document patient age (≤18 years) on the authorization request to trigger Pediatric Spine Imaging Guidelines.
Infants ≤6 months: spinal ultrasound (CPT 76800) is initial test; repeat ultrasound after a normal screening is not appropriate.
MRI of the involved spinal level may be approved after 6 months of age or earlier if ultrasound or symptoms indicate need, or when ordered by/after consultation with an appropriate specialist.
Plain x‑rays are generally not indicated for suspected occult spinal dysraphism; use only when guideline criteria call for them.
Note
Imaging Modality Sequencing and Stepwise Approach
Imaging modality sequencing and stepwise approach for advanced spine imaging: prefer plain radiography when required by the specific guideline (e.g., scoliosis, achondroplasia, Klippel‑Feil) prior to advanced imaging; MRI is the preferred advanced modality for most pediatric spine indications unless contraindicated or CT is specifically indicated (e.g., acute trauma or bony detail for surgical planning). For certain conditions and preoperative planning, specialists may appropriately order MRI and CT together. Repeat advanced imaging is supported only when there is evidence of progression, recurrence, or when repeat imaging will change management.
Obtain plain x‑rays when the guideline requires them and ensure they are from after the onset/change in symptoms.
MRI is preferred for pediatric spine evaluation; CT is reserved for trauma or when bony detail is required for surgical planning.
Repeat imaging should be justified by clinical progression, recurrence, or impact on management.
Lack of documented progression or clinical change may prompt denial of repeat advanced imaging
ScopeApplies to any advanced imaging of the spine per guideline
Retroperitoneal ultrasound (CPT 76770)
Retroperitoneal ultrasound surveillance intervalEvery 6 to 12 months
IndicationsSurveillance for neurogenic bladder, myelomeningocele, or occult spinal dysraphism
CPT exampleRetroperitoneal ultrasound CPT 76770
MRI without and with contrast
MRI surveillance intervalAnnually
IndicationFor certain surveillance indications such as asymptomatic patients with unresected spinal hemangioblastoma(s)
Modality/contrastMRI without and with contrast of affected spinal level as specified
Note
Often performed first; advanced imaging used when conventional imaging does not answer the clinical question
Modality selectionAppropriate use of contrast and modality selection determined by condition-specific guidance
PET/PET-CT definition
PET/PET-CT definitionNuclear medicine study using a positron-emitting radiotracer to create cross-sectional and volumetric images based on tissue metabolism, typically combined with CT
Typical roleUsed for oncologic evaluation of tumor metabolic activity; not routinely used for surveillance unless condition-specific guidance allows
PET/MRI stancePET/MRI is generally not supported except in limited, specified circumstances
Concurrent supervision (3D rendering)
Concurrent supervision (3D rendering)Active physician participation in and monitoring of the 3D reconstruction process including design of anatomic region, tissue types to display, image selection, and monitoring/adjustment of the 3D work product
DocumentationACR recommends documenting physician supervision/participation for CPT 76376/76377
Prior authorization noteProviders may be required to obtain prior authorization for these 3D codes even if the base study does not require it
Unit of service for imaging guidance
Unit of service for imaging guidanceOnly one unit of guidance code should be reported per individual encounter/date of service regardless of number of lesions or localizations
Billing implicationReporting more than one unit per encounter may trigger denial
Quantitative mp-MRI
Quantitative mp-MRI definitionSoftware-based analysis of multiparametric MRI data assessing tissue physiology with or without associated diagnostic MRI
ExamplesIncludes Category III CPT codes like 0648T/0649T/0697T/0698T and volumetric brain codes 0865T/0866T
Coverage stanceConsidered investigational/experimental and primarily used in clinical trials
Spinal canal ultrasound (76800)
Spinal canal ultrasound (76800)Ultrasonic evaluation of the spinal canal generally limited to infants up to 6 months; may be used at older ages if persistent acoustic window exists (eg open dysraphism)
Coding noteDo not use CPT 76800 for intraoperative ultrasound; use CPT 76998 instead
Clinical rolePreferred initial advanced imaging in infants ≤6 months for suspected tethered cord or dysraphism
GBCAs
GBCAs guidanceGadolinium-based contrast agents (GBCAs) should be limited to circumstances where contrast provides necessary additional information; assess necessity of repetitive GBCA use due to potential deposition
Safety notesFDA notes no proven harm from gadolinium retention to date, but practitioners should consider cumulative dosing and necessity
Anesthesia coordinationIf IV access present for anesthesia and no contraindication, consider obtaining MRI without and with contrast in same session to avoid repeat anesthesia
Spondylolysis definition
Spondylolysis definitionStress injury/fracture of the pars interarticularis from repeated microtrauma; common cause of low back pain in children >10 years
Initial managementActivity modification, NSAIDs, physical therapy, and bracing; surgery reserved for disabling symptoms unresponsive to conservative care
Imaging pathwayScreen with plain x-rays; MRI after failed 4-week conservative care or for preoperative planning; SPECT/SPECT-CT if radiographically occult
Spinal dysraphism
Spinal dysraphism definitionGroup of disorders with incomplete or absent fusion of posterior midline structures, including open and occult (closed) dysraphism
Open vs closedOpen dysraphism: non-skin-covered (eg myelomeningocele); Closed dysraphism: skin-covered variants
Clinical implicationImaging choice (ultrasound vs MRI) depends on age, presence of acoustic window, and specific findings
Tethered Cord Syndrome
Tethered Cord SyndromeSymptoms and abnormal findings caused by pathologic attachment of the spinal cord leading to abnormal spinal tension (eg low back/leg pain, decreased reflexes, urinary/bowel dysfunction)
Conus relationMay or may not have low-lying conus; other imaging findings (thick filum, lipoma) support diagnosis
Imaging implicationSpinal ultrasound in infants ≤6 months or MRI of appropriate level when indicated
Open Dysraphism
Open DysraphismLack of skin covering with exposed neural elements (eg myelomeningocele)
Imaging implicationMRI brain indicated (Chiari II present); MRI entire spine may be approved for preoperative planning
Ultrasound roleSpinal canal ultrasound may be alternative if posterior bony defect provides acoustic window
Atlantoaxial screening thresholds
Atlantoaxial screening thresholdsAtlantodental interval ≥4.5 mm OR neural canal width ≤14 mm on lateral cervical spine x-ray indicates need for cervical MRI
ApplicationUsed for screening in trisomy 21 and when new/worsening clinical symptoms suggest myelopathy
Recommended MRIMRI cervical spine without contrast or without and with contrast (CPT 72141 or 72156)
Hemangioblastoma surveillance interval
Hemangioblastoma surveillance intervalAnnual MRI of the affected spinal level for asymptomatic patients with unresected spinal hemangioblastoma(s)
Other indicationsAlso appropriate for preoperative planning and for new/worsening symptoms suggesting progression
Modality/contrastMRI without and with contrast of affected spinal level as specified
Advanced imaging used to screen asymptomatic individuals for spine disorders is not supported. Approvals require documentation of pertinent clinical evaluation and, where applicable, meeting pediatric red‑flag criteria or following the stepwise conservative care prerequisites.
Plain spinal radiographs are not indicated for suspected occult spinal dysraphism or tethered cord and are not required to approve other imaging when suspicion is present; do not use plain x‑rays as a screening step in these cases. Additionally, 3D rendering codes are excluded from billing with specific modalities described elsewhere in the guideline.
There are no additional explicit modality/indication combinations listed as universally not covered beyond the stated exclusions; coverage decisions rely on meeting the described clinical criteria and documentation requirements.