Application / Medical Necessity Evaluation
Applicability and documentation requirements for Ohio.
ALL of the following
This policy applies only to members in the state of Ohio. Requests for services identified as investigational, unproven, or subject to coverage or quantity limits will be evaluated under Ohio Administrative Code 5160-1-01.
Request must include adequate clinical documentation: recent detailed history, focused physical examination findings since onset or change in symptoms, pertinent laboratory results, and prior imaging studies when available.
For pediatric members (<=18 years), indicate age in years and weight in kg on the request when relevant to modality choice, contrast dosing, or radiation dose considerations.
When imaging is requested as follow-up surveillance per an established schedule, include prior imaging dates and findings to justify interval imaging.
Ultrasound Indications / Limitations (general)
General indications and limitations for diagnostic ultrasound of the pediatric abdomen.
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Abdominal ultrasound is preferred as the initial advanced imaging modality for pediatric abdominal complaints when clinically appropriate due to lack of ionizing radiation.
Indications include evaluation of RUQ pain (hepato-biliary disease), suspected appendicitis when ultrasound-first pathway is appropriate, palpable abdominal mass, hydronephrosis, intussusception (real-time ultrasound), and targeted evaluation of focal organ pathology (liver, spleen, kidneys, pancreas, bladder).
Ultrasound is limited for detection of small bowel obstruction distal to gas-filled loops, bowel wall pneumatosis, or when evaluating for active extraluminal air; CT or MRI may be indicated in those settings.
Operator dependence: quality and diagnostic value depend on sonographer skill and patient cooperation; if ultrasound is non-diagnostic, document attempted views and limitations (body habitus, bowel gas, patient movement).
CT Use and Contrast Guidance (general)
Principles for CT use and IV/oral contrast in pediatric abdominal imaging.
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CT is indicated when ultrasound is non-diagnostic or when clinical suspicion requires detection of findings not reliably seen on ultrasound (e.g., free intraperitoneal air, certain bowel injuries, complex trauma, stone disease when US unavailable or inconclusive).
When CT is used in children, use pediatric dose-reduction techniques (ALARA), weight-based protocols, and limit scan length to the area of clinical concern; document justification for multiphase studies.
IV contrast: recommended when vascular enhancement improves diagnostic accuracy (e.g., solid organ injury, suspected abscess, neoplasm, bowel ischemia). Contraindications and renal function should be considered; for emergent indications, IV contrast may be given as clinically necessary with documented risk-benefit assessment.
Oral contrast: may be used selectively for bowel evaluation when it will change management; routine use is not required for many pediatric abdominal CT indications.
MRI Use and Contrast Guidance (general)
MRI use and contrast guidance for pediatric abdominal imaging.
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MRI is preferred for problem-solving when ultrasound is non-diagnostic and when avoiding ionizing radiation is desirable (e.g., hepatic lesion characterization, biliary evaluation, pelvic/retroperitoneal soft tissue masses, and staging of inflammatory bowel disease).
Use sedation only when necessary and per institutional pediatric sedation protocols; document necessity and alternatives attempted (feed-and-wrap, distraction, immobilization devices).
IV gadolinium-based contrast agents are indicated when contrast enhancement is needed for lesion detection or characterization (e.g., liver lesion characterization, abscess, tumor). Use weight-based dosing and consider macrocyclic agents in patients at risk for retained gadolinium; document renal function when relevant.
MR enterography protocols are preferred for evaluation of suspected Crohn disease in pediatrics when feasible and when clinical condition permits the oral contrast and imaging time required.
PET/PET-CT Guidance (general)
Guidance for PET and PET-CT in pediatric abdominal indications.
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PET and PET-CT are generally reserved for oncologic indications, staging, restaging, or when metabolic imaging will alter management. Routine use for non-oncologic abdominal complaints is not supported.
When PET is requested, specify the clinical question, prior imaging results, histopathology if applicable, and how PET results will change management.
Consider sedation needs and limit ionizing radiation exposure by conforming to pediatric PET dosing guidelines; document expected benefit over alternative modalities.
Overutilization and Repeat Imaging
Avoid unnecessary repeat imaging and excess radiation exposure.
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Repeat advanced imaging within a short interval is discouraged unless there is new or worsening clinical information, change in examination findings, or treatment response/complication question that cannot be answered by prior studies.
When repeat imaging is requested, include prior imaging dates, modalities, and a brief rationale describing why the new study is necessary and how it will affect management.
For interval diagnostic uncertainty after an initial ultrasound, consider targeted repeat ultrasound or escalation to MRI before routine CT in pediatric patients when clinically feasible.
3D Rendering (CPT 76376, 76377) Criteria
Criteria for 3D rendering (CPT 76376, 76377) in pediatric abdominal imaging.
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3D rendering (CPT 76376 for non-vascular and 76377 for vascular) may be considered when reconstructions will materially affect pre-procedural planning or surgical approach (e.g., complex vascular anatomy for transplant planning, complex tumor resection planning).
Requests for 3D rendering should reference the primary cross-sectional study (CT or MRI), state the procedural or surgical decision that will be informed by the rendering, and document that standard 2D reformats are insufficient.
Imaging Guidance Procedure Codes (CT/MR/US-guided procedures)
Guidance for imaging guidance procedure codes used with CT/MR/US-guided interventions.
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Image-guided procedures should use the appropriate guidance code corresponding to modality and level of assistance (US, CT, or MR guidance).
Documentation must include indication, targeted lesion or fluid collection, approach, and confirmation imaging. For pediatric procedures, note sedation/anesthesia used and monitoring.
If diagnostic sampling or drainage is performed, include CPT codes for aspiration/biopsy/drainage in addition to the image-guidance code as appropriate.
General Guidelines (PEDAB-1.0) - When Advanced Imaging is Indicated
When advanced imaging is indicated in pediatric abdominal complaints - ALL of the following must be met (ultrasound-first preference).
ALL of the following
There has been a pertinent clinical evaluation (history and focused physical exam) since onset or change of symptoms, or the request is for an established scheduled surveillance indication documented in the chart.
Initial imaging (when applicable) has been performed and is included with the request, or there is a clear reason why initial imaging is not appropriate or available.
The requested advanced imaging is likely to answer a specific clinical question that will change management, guide intervention, or evaluate for complications; nonspecific requests without targeted clinical questions are discouraged.
Whenever clinically appropriate and feasible, an ultrasound should be performed first for pediatric abdominal pain or suspected biliary, renal, or appendiceal pathology unless a documented red flag (see Red Flags) precludes an ultrasound-first approach.
Red Flags (precluding ultrasound-first approach)
Clinical presentations that preclude an ultrasound-first approach (red flags).
ANY of the following
Hemodynamic instability or peritonitis requiring urgent surgical evaluation; imaging may be emergent CT or operative exploration as clinically indicated.
Concern for bowel perforation (suspected free intraperitoneal air) — CT is preferred for detection of free air.
Penetrating abdominal trauma or multisystem trauma where comprehensive CT assessment is required for triage and management.
Known complex congenital or postsurgical anatomy where ultrasound cannot adequately evaluate the concern (e.g., suspected vascular or deep retroperitoneal injury requiring cross-sectional imaging).
When the clinical question requires whole-abdomen cross-sectional assessment that cannot be reliably answered by ultrasound (e.g., staging for malignancy, extensive bowel ischemia evaluation).
Pediatric Age Consideration (PEDAB-1.1)
Age-specific considerations for pediatric abdominal imaging.
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Pediatric patients (<=18 years) should have imaging protocols tailored for age and size; include weight (kg) on requests when relevant for dosing and protocol selection.
Non-ionizing modalities (ultrasound, MRI) are preferred when they can provide the needed diagnostic information; balance need for rapid diagnosis against radiation exposure.
Infants and very young children may require alternative imaging strategies (contrast enema for malrotation, targeted ultrasound for pyloric stenosis) and communication about sedation risks should be documented if MRI is planned.
Modality Selection - MRI (PEDAB-1.3)
Modality selection guidance favoring MRI in specific pediatric scenarios.
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MRI is preferred for liver lesion characterization in children when ultrasound is indeterminate and when lesion characterization will alter management; use hepatobiliary contrast agents per institutional protocols when indicated.
MRI is preferred for pelvic and soft tissue masses, complex biliary or pancreaticobiliary disease, and for assessment of inflammatory bowel disease activity when feasible without undue delay or sedation risk.
MR enterography is preferred over CT enterography for pediatric Crohn disease assessment when available and clinically appropriate to avoid ionizing radiation.
Modality Selection - CT (PEDAB-1.3)
Modality selection guidance favoring CT in specific pediatric scenarios.
ALL of the following
CT is appropriate when ultrasound is non-diagnostic and rapid cross-sectional assessment is required (e.g., suspected bowel perforation, complex trauma, high clinical suspicion of renal/ureteral calculi when ultrasound unavailable or inconclusive).
Use single-phase targeted protocols when possible; multiphase studies require explicit justification and documentation of how each phase will affect management.
Adhere to pediatric dose-reduction strategies and weight-based IV contrast dosing; document rationale for CT over MRI when radiation exposure is a concern.
Nuclear Medicine Indications (PEDAB-1.3)
Nuclear medicine studies relevant to pediatric abdominal conditions.
ANY of the following
99mTc-HMPAO or leukocyte scintigraphy may be considered when there is suspected intra-abdominal abscess and other modalities are equivocal or unavailable; document prior imaging and rationale.
Hepatobiliary iminodiacetic acid (HIDA) scans can be used for functional evaluation of biliary dyskinesia or cystic duct obstruction when ultrasound is inconclusive and clinical suspicion remains.
Renal scintigraphy (MAG3 or DMSA) is indicated for functional assessment in hydronephrosis or after urinary tract infection when indicated by clinical guidelines; include prior ultrasound and creatinine when relevant.
Generalized Abdominal Pain (PEDAB-2)
Approach to generalized abdominal pain in pediatrics.
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For non-focal generalized abdominal pain in stable pediatric patients without red flags, initial evaluation with clinical assessment and targeted ultrasound when indicated is preferred; advanced imaging only if clinical course, labs, or exam suggest specific pathology or worsening condition.
Laboratory evaluation (e.g., CBC, inflammatory markers, urinalysis) should be used to guide imaging decisions; include results with imaging requests.
Right Lower Quadrant Pain / Suspected Appendicitis (PEDAB-3)
Evaluation pathway for right lower quadrant pain and suspected appendicitis in children.
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Start with ultrasound as first-line in hemodynamically stable pediatric patients when there are no red flags; document graded-compression technique and appendix visualization attempts.
If ultrasound is non-diagnostic or appendix not visualized and clinical suspicion remains moderate to high, consider MRI (if available) or low-dose CT per institutional protocols. For high clinical concern or unstable patients, proceed with CT or surgical evaluation as clinically indicated.
Include Alvarado or Pediatric Appendicitis Score and pertinent labs (WBC, CRP) with imaging request to support modality selection.
Whole-Body CT / MRI / PET-MRI (Preface-5)
Whole-body cross-sectional imaging guidance.
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Whole-body CT, MRI, or PET-MRI should be reserved for oncologic staging, metastatic survey, or specific clinical scenarios where full-body assessment will directly impact management; routine whole-body imaging for non-oncologic abdominal complaints is not indicated.
When whole-body imaging is requested, provide prior imaging, histology if oncologic, and clear rationale for why targeted imaging is insufficient.
Flank Pain, Renal Stone (PEDAB-4)
Evaluation of flank pain and suspected renal/ureteral stone in pediatric patients.
ALL of the following
Initial imaging with ultrasound is preferred for suspected renal colic or flank pain in children to assess for hydronephrosis and stones when feasible; include urinalysis and prior stone history.
If ultrasound is non-diagnostic and clinical suspicion for obstructing stone is high, consider low-dose non-contrast CT targeted to the urinary tract with pediatric dose-reduction techniques; document weight and renal function when available.
Upper Urinary Tract (PEDAB-5.1)
Evaluation of upper and lower urinary tract issues in pediatric patients.
ANY of the following
Upper urinary tract: ultrasound is first-line for suspected hydronephrosis, congenital anomalies, and renal masses. Use MAG3 diuretic renography for functional assessment when obstruction is suspected and findings will change management.
Lower urinary tract: ultrasound and voiding cystourethrogram (VCUG) are indicated for recurrent febrile urinary tract infections or when bladder dysfunction or reflux is suspected; include prior culture results and indications.
Lower Urinary Tract (PEDAB-5.2)
Evaluation of lower urinary tract (UTI) and bladder concerns in pediatrics.
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For febrile UTI in infants and young children, obtain renal and bladder ultrasound to evaluate for anatomic abnormalities per pediatric UTI guidelines; include urine culture results with imaging request.
VCUG is indicated when recurrent febrile UTI, abnormal renal ultrasound, or atypical organisms are present; document indications and prior imaging.
Pediatric Acute Gastroenteritis (PEDAB-6)
Imaging guidance for pediatric acute gastroenteritis.
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Most cases of pediatric acute gastroenteritis are managed clinically without imaging. Imaging (often ultrasound) is reserved for complications or atypical presentations, persistent vomiting, concern for intussusception, or when obstruction is suspected.
For persistent bilious vomiting or signs of obstruction, plain radiographs or contrast studies (upper GI series) may be indicated; include clinical red flags to justify imaging.
Hematuria (PEDAB-7)
Approach to hematuria in pediatric patients.
ALL of the following
Initial evaluation includes urinalysis and ultrasound of the kidneys and bladder for structural causes when hematuria is persistent, gross, or associated with pain or other concerning features.
CT urography is generally reserved for older adolescents or when ultrasound and clinical evaluation suggest a need for cross-sectional evaluation; minimize radiation exposure in children when possible.
Right Upper Quadrant Pain (PEDAB-8)
Assessment of right upper quadrant pain in children.
ALL of the following
Right upper quadrant pain: begin with ultrasound to evaluate the gallbladder, biliary tree, liver, and subhepatic space; include labs (LFTs, bilirubin) with the request.
If ultrasound is non-diagnostic and clinical concern persists (e.g., suspected choledocholithiasis, complex biliary disease), consider MRI/MRCP as next modality to avoid ionizing radiation when feasible.
Inflammatory Bowel Disease (PEDAB-9)
Imaging approach for inflammatory bowel disease in pediatric patients.
ALL of the following
MR enterography is preferred for assessment of small bowel Crohn disease activity and complications in pediatric patients when feasible; include clinical indicators and prior imaging/endoscopy findings.
Ultrasound with bowel Doppler can be a problem-solving or monitoring tool in experienced centers but is operator-dependent; CT enterography is reserved for acute settings when rapid assessment is necessary and MRI is not available.
Abdominal Sepsis / Suspected Abscess (PEDAB-10)
Evaluation of suspected abdominal abscess or sepsis in children.
ALL of the following
For suspected intra-abdominal abscess, ultrasound may be used for initial assessment and for image-guided drainage when feasible; CT with IV contrast is preferred when ultrasound is non-diagnostic or for comprehensive evaluation.
Provide relevant laboratory data (WBC, cultures), prior antibiotic therapy, and prior imaging. For drainage procedures, indicate desired approach and whether culture/aspiration is planned.
Postoperative Pain within 60 Days (PEDAB-11)
Postoperative imaging considerations within 60 days of abdominal surgery in pediatric patients.
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Imaging within 60 days post-op should be reserved for suspected complications (abscess, leak, obstruction) or unexpected clinical deterioration. Ultrasound may be used for superficial fluid collections; CT with IV contrast is preferred for deep or complex postoperative concerns.
Include operative notes, date of surgery, and current clinical concern when ordering imaging in the postoperative period.
Constipation, Diarrhea, and Irritable Bowel Syndrome (PEDAB-12)
Management of constipation, diarrhea, and IBS in pediatrics with respect to imaging.
ALL of the following
Routine imaging for uncomplicated constipation or functional diarrhea is not indicated. Abdominal radiographs may be used selectively to assess fecal burden when it will change management.
For suspected structural causes or alarm features (weight loss, GI bleeding, severe pain), pursue targeted imaging per the respective sections (e.g., contrast studies, MRI) and include clinical rationale.
Abdominal Wall / Intra-Abdominal Mass (PEDAB-13)
Evaluation of abdominal wall or intra-abdominal mass in pediatrics.
ALL of the following
Start with ultrasound to characterize palpable abdominal or abdominal wall masses, define cystic vs solid components, and assess vascularity; include history of painless vs painful, growth rate, and prior imaging.
If ultrasound is indeterminate or suggests deep retroperitoneal or complex solid mass, proceed to MRI for further characterization and staging; CT reserved when MRI unavailable or for calcified lesions where CT adds value.
Renovascular Hypertension (PEDAB-14)
Evaluation of renovascular hypertension and other secondary causes of hypertension in pediatric patients.
ALL of the following
When renovascular disease is suspected, initial imaging often includes duplex ultrasound of renal arteries in experienced centers; CTA or MRA may be used for further evaluation, with modality choice guided by need for contrast, radiation concerns, and patient size.
Document blood pressure data, antihypertensive treatment, and relevant labs when requesting vascular imaging; consider nephrology/vascular surgery consultation.
Liver Lesion Characterization (PEDAB-15) - Coverage Criteria
Coverage criteria for liver lesion characterization in pediatric patients.
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Characterization of a focal liver lesion identified on ultrasound: MRI with IV contrast is preferred for definitive characterization in children when it will alter management or obviate biopsy; include lesion size, ultrasound description, and tumor markers (AFP) when applicable.
CT liver protocol may be used if MRI is contraindicated or unavailable, using pediatric dose-reduction techniques and IV contrast; document rationale for CT over MRI.
Pediatric Liver Failure and Cirrhosis (PEDAB-16.1) - Coverage Criteria
Coverage criteria for pediatric liver failure and cirrhosis.
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Ultrasound with Doppler is first-line to assess for biliary obstruction, portal venous flow, and splenomegaly in suspected pediatric liver failure or cirrhosis; include labs (INR, bilirubin, ALT/AST) with request.
MRI with MRCP may be indicated for noninvasive biliary evaluation or parenchymal assessment when ultrasound is inconclusive and results would change management, including transplant evaluation.
Biliary Disease (PEDAB-16.2) - Coverage Criteria
Coverage criteria for biliary disease in pediatric patients.
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Ultrasound is first-line for biliary colic, cholelithiasis, and acute cholecystitis evaluation. For suspected choledocholithiasis or complex biliary disease, MRCP is preferred over CT when available to avoid radiation.
HIDA scanning may be used to evaluate cystic duct patency or functional biliary dyskinesia when ultrasound is inconclusive and clinical management depends on the result.
Liver Elastography (PEDAB-16.3) - Coverage Criteria
Liver elastography guidance for pediatric patients.
ALL of the following
Liver elastography (US-based or MR elastography) may be used for noninvasive assessment of hepatic fibrosis when results will influence management; use age-appropriate protocols and document clinical context (elevated LFTs, known chronic liver disease).
Adrenal Lesions (PEDAB-17) - Coverage Criteria
Assessment of adrenal lesions in pediatric patients.
ALL of the following
Incidental adrenal lesions on ultrasound should be further characterized with MRI (preferred) or CT when imaging characterization will change management or when there are clinical signs of hormonal activity or malignancy; include hormonal evaluation results when available.
Hemochromatosis (PEDAB-18) - Coverage Criteria
Imaging for hemochromatosis in pediatric patients.
ALL of the following
MRI with appropriate sequences (including T2*/R2 or other iron quantification techniques) is indicated when clinical concern for iron overload exists and results will affect therapy; include ferritin and transferrin saturation results when available.
Indeterminate Renal Lesion (PEDAB-19) - Coverage Criteria
Approach to indeterminate renal lesion in pediatrics.
ALL of the following
Renal lesions seen on ultrasound that are indeterminate should be further evaluated with MRI (preferred) for tissue characterization when feasible; CT with contrast may be used if MRI contraindicated or unavailable.
Hydronephrosis (PEDAB-20) - Coverage Criteria
Guidance for evaluation of hydronephrosis in pediatric patients.
ALL of the following
Renal and bladder ultrasound is first-line to evaluate hydronephrosis and possible causes. If obstruction is suspected and anatomic detail is required, consider MAG3 diuretic renography for functional assessment or MR urography when available to avoid radiation.
Polycystic Kidney Disease (PEDAB-21) - Coverage Criteria
Polycystic kidney disease imaging considerations in pediatrics.
ALL of the following
Ultrasound is preferred for screening and surveillance of polycystic kidney disease in children; MRI may be used for further characterization or pre-transplant planning when indicated.
Blunt Abdominal Trauma (PEDAB-22) - Coverage Criteria
Blunt abdominal trauma imaging guidance for pediatric patients.
ALL of the following
In hemodynamically stable pediatric patients with blunt abdominal trauma and concerning mechanism or exam, ultrasound (FAST) may be used as an initial triage tool; CT with IV contrast is indicated when FAST is positive or clinical concern remains high for intra-abdominal injury.
Use CT selectively with pediatric dose optimization and limit multiphase imaging unless specifically indicated for vascular injury characterization.
Hernias (PEDAB-23) - Coverage Criteria
Imaging evaluation for hernias in pediatric patients.
ALL of the following
Ultrasound is useful to evaluate reducible vs incarcerated abdominal wall or groin hernias and to assess vascular compromise; report attempt at reduction and vascular flow when applicable.
CT or MRI is reserved for complex or recurrent hernias or when deeper pelvic/abdominal pathology is suspected that ultrasound cannot assess.
Abdominal Lymphadenopathy (PEDAB-24) - Coverage Criteria
Approach to abdominal lymphadenopathy in pediatrics.
ALL of the following
Start with ultrasound to assess size, morphology, and vascularity of abdominal lymph nodes. If findings suggest malignancy or deep retroperitoneal disease, MRI is preferred for further characterization; CT may be used when MRI is unavailable or when calcification assessment is required.
Left Upper Quadrant Pain (PEDAB-25) - Coverage Criteria
Evaluation for left upper quadrant pain in pediatric patients.
ALL of the following
Begin with ultrasound to evaluate the spleen, left kidney, and pancreatic tail; consider CT with contrast or MRI if ultrasound is non-diagnostic and clinical concern persists (e.g., splenic injury, pancreatitis).
Spleen (PEDAB-26)
Imaging considerations for the spleen in pediatric patients.
ALL of the following
Ultrasound is first-line to evaluate splenic size, focal lesions, and trauma-related injury. CT with IV contrast is indicated for comprehensive trauma assessment or when ultrasound is inconclusive for deep parenchymal injury.
Intussusception (PEDAB-27) - Coverage Criteria
Imaging for suspected intussusception in infants and children.
ALL of the following
Ultrasound with real-time evaluation is the preferred diagnostic test for intussusception and can also guide pneumatic or hydrostatic reduction when performed by experienced teams.
If reduction is unsuccessful or contraindicated, further cross-sectional imaging (CT or MRI) is rarely required but may be used when complications are suspected.
Bowel Obstruction (PEDAB-28.1) - Coverage Criteria
Evaluation of bowel obstruction in pediatric patients.
ALL of the following
Plain radiographs are useful initial tests; ultrasound may assess for intussusception and some obstructive causes. CT is reserved for cases where cross-sectional detail is required to identify transition point, ischemia, or closed-loop obstruction; minimize radiation exposure and use targeted protocols.
Left Lower Quadrant Pain (PEDAB-29) - Coverage Criteria
Approach to left lower quadrant pain in pediatric patients.
ALL of the following
Start with clinical evaluation and ultrasound when gynecologic or appendiceal etiologies are possible; consider MRI or CT if ultrasound is non-diagnostic and clinical concern persists.
Celiac Disease (PEDAB-30) - Coverage Criteria
Imaging for celiac disease in pediatric patients.
ALL of the following
Imaging is not routinely required for uncomplicated celiac disease; consider cross-sectional imaging if complications (e.g., refractory disease with suspected lymphoma or enteropathy-associated pathology) are suspected, and include prior endoscopic/histologic data.
Transplant (PEDAB-31) - Pediatric
Transplant-related pediatric imaging guidance (PEDAB-31) - pediatric-specific requirements consolidated and clarified.
ALL of the following
Imaging for pediatric transplant candidates and post-transplant surveillance should follow pediatric-specific protocols and, where applicable, cross-reference adult transplant imaging policies for procedures not otherwise specified in the pediatric section.
Pre-transplant imaging: provide indication (evaluation of anatomy, vascular mapping, hepatic lesion characterization, or other organ-specific assessment), recent labs, and prior imaging. Use MRI (preferred for liver and biliary anatomy) or CT angiography when vascular mapping is required; CT may be used if MRI contraindicated or unavailable, using pediatric dose-reduction techniques.
Post-transplant complications: ultrasound with Doppler is first-line for evaluation of vascular patency, graft perfusion, biliary dilatation, and fluid collections. If ultrasound is inconclusive or concern for deep or complex complication exists (e.g., vascular thrombosis, anastomotic leak, parenchymal necrosis), proceed to contrast-enhanced MRI or CT as clinically indicated.
Gaucher Disease (PEDAB-32) - Coverage Criteria
Imaging guidance for Gaucher disease in pediatric patients.
ALL of the following
Use MRI for assessment of organomegaly (liver/spleen) and marrow involvement when results will influence therapy; include relevant hematologic and enzyme assay data when available.
Vomiting Infant, Malrotation, and Hypertrophic Pyloric Stenosis (PEDAB-33) - Coverage Criteria
Imaging approaches for vomiting infant, malrotation, and hypertrophic pyloric stenosis.
ALL of the following
For suspected hypertrophic pyloric stenosis, ultrasound is the diagnostic test of choice; include clinical signs (projectile non-bilious vomiting) and age of the infant.
For suspected malrotation with bilious vomiting, upper GI contrast study (fluoroscopic) is preferred to evaluate for malrotation/volvulus; include clinical urgency and prior imaging.