Pediatric and Special Populations Spine Imaging Guidelines
Customize your policy alerts
Sign up for all evicore policy alerts
Know when evicore releases new policies or updates existing guidance.
Monitor payer policy activity
Guidelines governing advanced and basic imaging of the pediatric spine and special populations for Cigna-administered health benefit plans; affects ordering providers, radiology providers, and medical directors involved in imaging prior authorization and coverage determinations.
No material clinical or coverage changes in this revision.
Coverage Criteria — Pediatric and Special Populations Spine Imaging
inv-01: Prerequisite clinical evaluation
Covered when ALL of the following are met
A meaningful technological contact (telehealth, telephone, electronic messaging) can serve as the pertinent clinical evaluation.
inv-02: Plain radiography timing
Covered when ALL of the following are met
Plain radiography is required prior to advanced imaging where specified in guideline sections.
inv-03: Modality-specific coverage stance
Modality selection considerations
If intravenous access will already be present for anesthesia and there is no contraindication, obtaining imaging without and with contrast may be appropriate; balance GBCA use against retention concerns.
Myelogram with post-myelogram CT is rarely indicated and reserved for hardware-limited MRI, severe congenital deformity with inconclusive MRI, nerve root avulsion, or assessing paraspinal cyst continuity.
inv-04: Spinal ultrasound indications and limits
Covered when ALL of the following are met
Do not use CPT 76800 for intraoperative spinal canal ultrasound; CPT 76998 is the appropriate intraoperative code.
inv-05: Back and Neck Pain in Children Age 5 and Under
Covered when ALL of the following are met for children age 5 and under (unless mild/transient pain):
Young children will generally require sedation for MRI; follow modality considerations in PEDSP-1.3.
inv-06: CT indications for Children Age 5 and Under
CT without contrast covered in children age 5 and under when ALL of the following apply:
Use CT without contrast in these limited circumstances.
inv-07: Back and Neck Pain in Children Age 6 and Older
Covered when ALL of the following are met for children age 6 and older:
Plain x-rays must be performed after onset/change of current symptoms.
If red flags present, conservative trial not required.
CT should be avoided as replacement for MRI unless specifically indicated.
inv-08: Spondylolysis
Covered when ALL of the following are met for suspected spondylolysis:
inv-09: Spine Pain Due to Infectious Causes
Covered when ALL of the following are met for suspected infectious spine causes:
inv-10: Spine infection (discitis/osteomyelitis)
Covered when ALL of the following are met
MRI is very sensitive for early infectious changes.
inv-11: Follow-up imaging for spinal infection or epidural abscess
Follow-up imaging covered when ANY of the following are present
Used for follow-up of osteomyelitis or concern for epidural abscess.
inv-12: Trauma-related advanced imaging
Advanced imaging of traumatic spine is medically necessary when the specified criteria are met
CT is preferred in trauma per modality guidance; MRI or CT without contrast appropriate depending on clinical scenario.
See guideline for full red-flag list.
See guideline for full red-flag list.
Clinical decision rule to avoid unnecessary imaging.
inv-13: Scoliosis imaging
Scoliosis and perioperative imaging
Plain radiography required before advanced imaging; surgical specialists may request MRI and CT together for preoperative planning.
Modality selection depends on surgical planning needs.
inv-14: Scheuermann Disease
Juvenile thoracic kyphosis (Scheuermann Disease)
MRI is generally not effective diagnostically and is not medically necessary except preoperatively due to high false positive rate.
Routine MRI not effective for diagnosis; reserve for preoperative assessment.
inv-15: Congenital scoliosis imaging
Congenital scoliosis
inv-16: Congenital Scoliosis Imaging
Congenital scoliosis — covered when ANY of the following modalities/conditions apply
inv-17: Idiopathic Scoliosis — High-risk Features Indicating MRI
Idiopathic scoliosis — MRI covered when ALL of the following are met
inv-18: Neuromuscular Scoliosis Imaging
Neuromuscular scoliosis — covered when ANY of the following are met
inv-19: Occult Spinal Dysraphism and Tethered Cord Imaging
Occult spinal dysraphism / tethered cord — stepwise criteria
inv-20: Cutaneous indications — screening and initial imaging
Covered when ANY of the following cutaneous findings suggesting occult spinal dysraphism/tethered cord are present:
Spinal ultrasound (CPT 76800) is medically necessary as initial evaluation in infants up to 6 months; MRI of the involved spinal level is medically necessary for initial evaluation in individuals older than 6 months or earlier if symptomatic or abnormal ultrasound.
inv-21: Non-covered cutaneous conditions
Not medically necessary for screening advanced imaging when ONLY the following are present:
These findings alone do not justify advanced spine imaging.
inv-22: Non-cutaneous indications and syndromic conditions
Covered when ANY of the following syndromes or non-cutaneous conditions associated with increased risk are present:
For infants ≤6 months these warrant spinal ultrasound (CPT 76800) as initial evaluation; MRI lumbar/pelvis as specified is medically necessary per guideline.
inv-23: Neurologic, urologic, and progressive symptom indications
MRI of the involved spinal level is medically necessary when ANY of the following new or concerning neurologic or urologic findings are present:
In these settings plain x-ray or a period of conservative care is not required prior to MRI approval.
inv-24: Spinal dysraphism imaging
Covered when the diagnosis of dysraphism (open or closed) is present or suspected:
Spinal canal ultrasound can be used as an alternative to MRI in open dysraphism when requested.
inv-25: Follow-up imaging stance
Follow-up imaging after a normal screening study
inv-26: Achondroplasia — advanced imaging
Covered when ALL of the following are met for achondroplasia-related concerns:
MRI brain without contrast or CT head without contrast is medically necessary when new or worsening symptoms suggest hydrocephalus.
inv-27: Inflammatory spondylitis in juvenile idiopathic arthritis
Covered when ANY of the following are met for juvenile idiopathic arthritis-associated inflammatory spondylitis:
An initial x-ray is not necessary prior to MRI in these individuals.
inv-28: Atlantoaxial instability (trisomy 21)
Covered when ALL of the following are met for atlantoaxial instability in trisomy 21:
MRI also indicated for symptomatic trisomy 21 individuals.
inv-29: Klippel-Feil anomaly — imaging indications
Covered when ALL of the following are met for Klippel-Feil anomaly:
Advanced imaging reserved for specified clinical triggers.
inv-30: Hydrocephalus evaluation in achondroplasia
Covered when ALL of the following are met for suspected hydrocephalus in achondroplasia:
inv-31: Klippel-Feil — When Advanced Imaging is Medically Necessary
Advanced imaging for Klippel-Feil is medically necessary when ANY of the following are present:
Plain x-rays are sufficient to establish diagnosis otherwise.
These must be documented prior to approval of advanced imaging.
inv-32: Marfan Syndrome — MRI Indications
Advanced imaging for Marfan syndrome is medically necessary when ALL of the following apply:
Initial evaluation required before MRI.
inv-33: Von Hippel-Lindau — Spinal Hemangioblastoma Imaging
MRI (with and without contrast) for known spinal hemangioblastomas is medically necessary when ANY of the following are present:
Perform MRI of the affected spinal level with and without contrast.
Unless a specific guideline section states otherwise, advanced imaging to screen asymptomatic individuals for disorders involving the spine is not supported. Advanced imaging should only be approved for individuals with documented active clinical signs or symptoms of spinal disease, and a pertinent clinical evaluation (detailed history, physical including a thorough neurologic exam, appropriate labs, and basic imaging such as plain radiography or ultrasound) should be performed prior to considering advanced imaging.
Do not report CPT 76800 for intraoperative spinal canal ultrasound; CPT 76998 (intraoperative ultrasonic guidance) is the appropriate code for intraoperative use.
Routine MRI is not an effective diagnostic modality for juvenile thoracic kyphosis (Scheuermann Disease) due to a high incidence of false positive vertebral changes; therefore MRI is not medically necessary for routine diagnosis. MRI Thoracic (CPT 72146) or MRI Lumbar (CPT 72148) is medically necessary only for preoperative evaluation or when clinical or radiographic findings specifically indicate the need for MRI.
Plain spine radiographs are not indicated for suspected occult spinal dysraphism or tethered cord. Routine screening advanced imaging is not medically necessary for incidental findings such as asymptomatic spina bifida occulta; evaluation for dysraphism should follow the guideline-directed stepwise approach (e.g., spinal ultrasound in infants or MRI when indicated).
When a midline subcutaneous or cutaneous mass overlying the spine raises concern for occult dysraphism or tethered cord, plain x-rays are not required as a prerequisite to approve further imaging. MRI of the involved spinal level (without or without and with contrast) is the preferred initial advanced imaging modality in patients older than 6 months and is medically necessary when clinically indicated.
Adults with congenital spine disorders may generally follow these pediatric imaging guidelines except where the general adult imaging guidelines explicitly contraindicate doing so. Apply the pediatric recommendations unless a specific statement in the general imaging guidelines indicates otherwise.
Plain radiographs are commonly sufficient to establish a diagnosis of Klippel-Feil anomaly. Routine advanced imaging is not supported unless there are acute or worsening neurologic symptoms (including pain), involvement of multiple levels, or other specified indications that would change management.
Repeat advanced imaging of the spine is not routinely necessary. Repeat imaging should be performed only when there is evidence of disease progression, new onset of disease, or documentation that repeat imaging will affect management or treatment decisions.
For children under age 5 with mild and transient back pain, advanced imaging is not necessary. A pertinent clinical evaluation including history, physical with neurologic exam, and plain radiography should precede advanced imaging; most children in this age group with benign, transient symptoms do not require MRI or CT.
Cervical spine advanced imaging is not medically necessary in children older than 2 years who meet all specified low-risk criteria (absence of posterior midline cervical pain, absence of focal neurologic deficit, normal alertness, no evidence of intoxication, and absence of other clinically apparent distracting pain). If one or more age-appropriate red flags are present after relevant x-rays, advanced imaging is medically necessary.
Follow-up imaging with ultrasound after a normal screening spinal ultrasound is not medically necessary. If a screening spinal ultrasound is normal but clinical concern persists, a screening MRI of the involved spinal level is medically necessary; however, routine repeat MRI after a normal screening MRI is not medically necessary.
Screening advanced imaging of the spine is not medically necessary for isolated pilonidal cysts below the intergluteal fold, nonspecific sacral dermal melanosis, or other nonspecific sacral skin findings without additional midline abnormalities or concerning features.
Requests for advanced imaging without documentation of new or worsening clinical symptoms, or without documentation of a prior relevant clinical evaluation (detailed history, neurologic exam) and plain radiographs where recommended, are not supported. Prior clinical evaluation and indicated basic imaging must be documented before approving routine advanced MRI or CT.
Coding — CPT and Procedure Codes
| 72141 | MRI Cervical without contrast |
| 72142 | MRI Cervical with contrast |
| 72156 | MRI Cervical without and with contrast |
| 72146 | MRI Thoracic without contrast |
| 72147 | MRI Thoracic with contrast |
| 72157 | MRI Thoracic without and with contrast |
| 72148 | MRI Lumbar without contrast |
| 72149 | MRI Lumbar with contrast |
| 72158 | MRI Lumbar without and with contrast |
| 76498 | MRI Unlisted procedure (for radiation planning or surgical software) |
| 76800 | Spinal canal ultrasound |
| 76998 | Intraoperative ultrasonic guidance |
| 76800 | Spinal ultrasound |
| 72141 | MRI Cervical Spine without contrast |
| 72146 | MRI Thoracic Spine without contrast |
| 72148 | MRI Lumbar Spine without contrast |
| 72156 | MRI Cervical Spine without and with contrast |
| 72157 | MRI Thoracic Spine without and with contrast |
| 72158 | MRI Lumbar Spine without and with contrast |
| 76700 | Complete abdominal ultrasound |
| 76770 | Complete retroperitoneal ultrasound |
| 76775 | Renal ultrasound (specific CPT listed) |
| 76800 | Spinal ultrasound |
| 72148 | MRI Lumbar spine without contrast |
| 72158 | MRI Lumbar spine without and with contrast |
| 72195 | MRI Pelvis without contrast |
| 72196 | MRI Pelvis without and with contrast |
| 72141 | MRI Cervical spine without contrast |
| 72146 | MRI Thoracic spine without contrast |
| 72156 | MRI Cervical spine without and with contrast |
| 72157 | MRI Thoracic spine without and with contrast |
| MRI with and without contrast | MRI of affected spinal level with and without contrast (per guideline - no specific CPT listed in chunk) |
Provider Actions — Prior Authorization and Documentation Requirements
Coverage applies to listed spine imaging CPT codes
These guidelines apply to imaging procedures associated with pediatric spine imaging for Cigna-administered plans and list the CPT codes for MRI, CT, CT guidance, ultrasound, and unlisted procedures; providers should refer to Cigna's CPT code list for high‑tech studies reviewed by EviCore.
Prior authorization expectations for advanced imaging
Prior authorization for advanced imaging (MRI/CT) generally requires documentation of a pertinent clinical evaluation and that plain radiographs (when required by the guideline) were performed after the current episode of symptoms started or changed and are available to the requesting provider.
- Document detailed history, thorough neurologic exam, and results of plain x‑rays performed after onset/change of symptoms.
Prior authorization for listed spine and related imaging CPTs
Prior authorization is expected for the advanced imaging CPTs cited as medically necessary for specific age groups and clinical scenarios; ordering providers must select the CPT that matches the recommended modality, region, and contrast level.
Imaging prior authorization for initial evaluations
For initial evaluation of suspected occult spinal dysraphism in infants up to 6 months, spinal ultrasound (CPT 76800) is the required initial imaging; MRI lumbar/pelvis codes (e.g., 72148/72158, 72195/72197) are medically necessary as indicated and may require specialist ordering.
Prior authorization for specified advanced imaging
Prior authorization is expected for advanced imaging studies specified as medically necessary for particular conditions (for example, MRI cervical spine CPT 72141/72156 for atlantoaxial instability or MRI brain/CT head for suspected hydrocephalus).
- Document clinical findings and prior evaluation when requesting these condition‑specific studies.
Modality sequencing preference
MRI is the preferred modality for pediatric spine imaging; CT should be reserved for the conditions where it is the study of choice (e.g., trauma) and should not replace MRI solely to avoid sedation unless specifically recommended.
- Plan MRI sessions to minimize anesthesia exposure; use CT only when guideline sections list it as preferred (trauma, specific bony evaluation).
Conservative therapy trial expectation
In children aged ≥6 years without red flags, a documented 4‑week trial of provider‑supervised conservative treatment is expected prior to approval of advanced imaging.
- If red flags are present, advanced imaging may be approved without the conservative trial.
Imaging progression
Begin evaluation with plain radiography and a clinical examination; advance to MRI or CT only when indicated by pediatric 'red flags', suspicion for infection, trauma inconclusive on x‑ray, or for preoperative planning.
- Plain x‑rays must be performed after onset/change of current symptoms and results available to the requesting provider when required by the guideline.
Imaging sequencing
For infants ≤6 months with suspected dysraphism, spinal ultrasound (CPT 76800) is the initial imaging step; MRI is the next step for older infants or when ultrasound/clinical findings indicate the need for more prompt MRI.
- Repeat spinal ultrasound in 4–6 weeks for premature infants if cord termination is uncertain.
Preferred initial modality in infants ≤6 months
Preferred initial modality in infants ≤6 months is spinal ultrasound (CPT 76800); MRI is reserved after 6 months of age or earlier if symptomatic, ultrasound is abnormal, or a specialist orders MRI.
- A screening MRI may be performed after a normal screening spinal ultrasound when indicated; follow‑up of a normal screening MRI is not medically necessary.
Required clinical evaluation and prior basic imaging
Providers should perform the required clinical evaluation and basic imaging (detailed history, physical including neurologic exam, appropriate labs, and plain radiography or ultrasound) and ensure results are available prior to requesting advanced imaging unless the guideline supports scheduled imaging.
- A thorough neurologic exam should document motor testing, dermatomal sensory findings, reflexes, and nerve root tension signs.
Requesting provider documentation obligations
Requesting providers must document a detailed history, thorough neurologic examination, and availability of plain x‑ray results performed after the current episode of symptoms started or changed; also document red flags or failure of a provider‑supervised 4‑week conservative trial when applicable.
- Plain x‑rays performed after symptom onset/change must be available to the requesting provider for approval.
Required clinical documentation
A detailed history and physical including a thorough neurologic exam and relevant plain x‑rays from the current episode must be performed and available to the requesting provider prior to advanced imaging.
- Failure to document these elements may lead to denial of advanced imaging requests.
Genitourinary imaging documentation and surveillance
Complete abdominal or retroperitoneal ultrasound (CPT 76700 or 76770) is medically necessary as initial evaluation for newly diagnosed neurogenic bladder, myelomeningocele, or occult spinal dysraphism, with retroperitoneal ultrasound every 6–12 months for follow‑up when indicated.
- Document the indication when requesting surveillance ultrasounds at 6–12 month intervals.
Required clinical evaluation documentation
Obtain a pertinent clinical evaluation including detailed history, thorough neurologic exam, and plain radiography prior to considering advanced imaging for many congenital spine disorders; document these findings when submitting requests.
- This documentation expectation applies to conditions such as achondroplasia, Klippel‑Feil, and Marfan syndrome.
Requesting provider documentation obligations
Document a detailed history, physical including a thorough neurologic examination, and plain radiographs prior to requesting advanced imaging for Klippel‑Feil and Marfan syndrome; these initial evaluation steps are prerequisites.
- Plain x‑rays of the cervical spine are sufficient to establish Klippel‑Feil diagnosis unless acute/worsening neurologic symptoms or multiple levels involved.
Coverage determination dependencies
Coverage determinations require consideration of the applicable benefit plan document, laws/regulations, relevant collateral materials, and the specific facts of the case; in conflicts, the benefit plan document supersedes the guideline.
- Providers should confirm member benefits and any plan‑specific exclusions prior to ordering.
Denial risk for missing prior evaluations
Advanced imaging requests that lack documentation of the required prior evaluations (detailed history, thorough neurologic exam, and plain radiography where specified) or lack documentation of conservative therapy when indicated may be denied.
- Ensure radiographs are performed after the onset/change of current symptoms and results are available to the requesting provider.
Pre‑imaging requirements
Failure to have plain x‑rays performed and available from the current episode prior to requesting advanced imaging (when the guideline requires x‑rays) may trigger denial of the advanced imaging request.
- X‑rays must be performed after the current episode of symptoms started or changed.
Plain x‑ray exception for occult dysraphism
Plain x‑rays are not indicated for suspected occult spinal dysraphism and/or tethered cord; do not order plain radiographs solely for these indications and note that incidental spina bifida occulta in asymptomatic individuals is not an indication for further imaging.
- If x‑ray suggests absent/distorted pedicle ('winking owl sign'), initial MRI without or without and with contrast is medically necessary.
Not medically necessary for specific sacral findings
Spine imaging is not medically necessary for pilonidal cysts below the intergluteal fold, nonspecific sacral dermal melanosis, or incidental occult bony dysraphism on x‑ray; ordering advanced imaging for these findings alone risks denial.
- Consider guideline exclusions before requesting advanced imaging for isolated cutaneous findings.
Documentation expectations for initial evaluation
Failure to document the required initial evaluation (detailed history, physical and neurologic exam) and plain radiography prior to advanced imaging for conditions such as achondroplasia and Klippel‑Feil may trigger denial.
- Document clinical indicators that justify advanced imaging when present (e.g., new/worsening symptoms, thresholds).
Advanced imaging indicated after initial evaluation
Advanced imaging is indicated only after an appropriate initial evaluation (detailed history, thorough neurologic exam, and plain radiograph when required); providers must document these prerequisites to support medical necessity.
- Examples include documenting history/exam and x‑rays before ordering MRI/CT for Klippel‑Feil, Marfan, or VHL surveillance indications.
Required clinical evaluation and prior basic imaging
When requesting advanced imaging, ensure documentation includes a pertinent clinical evaluation since onset/change in symptoms (detailed history, physical exam with neurologic testing), appropriate labs, and basic imaging such as plain radiography or ultrasound; these must be available to the requesting provider unless guideline‑supported scheduled imaging applies.
- Meaningful technological contacts (telehealth, telephone, electronic messaging) can serve as the pertinent clinical evaluation.
Frequency Limits and Surveillance Intervals
Prior Authorization — High-Tech Imaging and Documentation
Refer to Cigna/EviCore CPT code list
Refer to the Cigna CPT code list for the current list of high‑tech imaging procedures that EviCore reviews for Cigna; prior authorization procedures and which studies EviCore reviews are determined by that code list.
- Providers should confirm the specific CPT codes subject to EviCore review via Cigna's published list.
Prior plain x‑rays and documentation required
Requests for MRI or CT require prior imaging results (plain x‑rays) to be available and documentation of red flags or failure of a conservative therapy trial when described by the guideline.
- If no red flags and patient ≥6 years, document a 4‑week provider‑supervised conservative trial prior to imaging.
Support imaging requests with prior clinical documentation
Requests for advanced imaging (MRI, CT) and ultrasound must be supported by prior clinical documentation: detailed history, thorough neurologic exam, and recent plain x‑rays when required by the guideline.
- For suspected infection or abuse, document clinical signs (e.g., fever ≥100°F) and prior study results as applicable.
Retroperitoneal ultrasound surveillance requires indication
Complete retroperitoneal ultrasound (CPT 76770) is medically necessary for initial evaluation of genitourinary involvement in dysraphism/myelomeningocele, and surveillance with retroperitoneal ultrasound every 6–12 months requires documented indication.
- Document the clinical reason when requesting surveillance imaging at 6–12 month intervals.
Infant ultrasound then MRI sequencing
Initial spinal ultrasound in infants ≤6 months is the preferred initial imaging; MRI after 6 months or per specialist order is the expected sequencing, and prior authorization guidance applies to these pathways.
- MRI may be medically necessary at younger ages if symptomatic, ultrasound abnormal, or ordered by an appropriate specialist.
Prior authorization typically required for specified MRI indications
Imaging studies specified as medically necessary for named indications (e.g., symptomatic spinal MRI; cervical MRI for atlantoaxial instability thresholds) typically require prior authorization per program rules.
- Include documentation of x‑ray thresholds (e.g., atlanto‑dental interval ≥4.5 mm) or new/worsening symptoms when requesting approval.
Prior authorization for MRI/CT after initial evaluation in syndromic cases
MRI or CT of the spine (specific CPTs cited) is required to have prior authorization when advanced imaging is requested after initial evaluation for the listed syndromic indications.
Contrast Use — Condition-specific Guidance
Contrast use when IV access already present
If IV access for anesthesia is already present and there is no contraindication, performing MRI without and with contrast may be appropriate to minimize repeat anesthesia sessions; document rationale for contrast use given gadolinium considerations.
- Limit repeated GBCA administration unless additional information from contrast is necessary.
Contrast indicated for suspected infection or mass
MRI with and without contrast is medically necessary when there is clinical suspicion of infection (e.g., fever ≥100°F), a mass lesion suggested by exam/x‑ray, or new/worsening pain with known cancer; document these clinical triggers when ordering contrast studies.
- Fever ≥100°F or suspicion for discitis/osteomyelitis are specific indications for MRI with and without contrast.
Contrast rules for infection and abscess evaluation
MRI without and with contrast is medically necessary for suspected discitis/osteomyelitis, epidural abscess evaluation, or when IV access for anesthesia is present and no contraindication exists; document infection suspicion and IV access status.
- Use contrast for follow‑up imaging of osteomyelitis or concern for epidural abscess.
Contrast rules when anesthesia IV access present
If IV access will already be present for anesthesia and no contraindication exists, MRI without and with contrast is medically necessary in congenital scoliosis evaluations and may be appropriate per specialist in dysraphism/tethered cord cases; document the presence of IV access when ordering.
- Document specialist recommendations and anesthesia/IV access to justify combined non‑contrast and contrast imaging.
Not Medically Necessary — Exclusions and Non-Covered Uses
Advanced imaging to screen asymptomatic individuals for spinal disorders is not covered unless expressly stated elsewhere in these guidelines. Imaging is reserved for individuals with documented active clinical signs or symptoms or where a specific guideline section allows screening.
CPT 76800 should not be used for intraoperative spinal canal ultrasound. For intraoperative ultrasonic guidance, use CPT 76998. Use of 76800 in the intraoperative setting is not covered.
Routine MRI for juvenile thoracic kyphosis (Scheuermann Disease) is not covered as it is not an effective diagnostic test due to frequent false positive findings; MRI is medically necessary only for preoperative assessment or when clinical/radiographic indications specifically require it.
Plain spine x-rays are not indicated for suspected occult spinal dysraphism or tethered cord, and routine screening advanced imaging for incidental or low-risk cutaneous findings is not covered. Asymptomatic incidental spina bifida occulta on x-ray does not justify further imaging.
Screening advanced imaging for pilonidal cysts below the intergluteal fold, nonspecific sacral dermal melanosis, and routine repeat imaging after a normal screening study is not covered.
Routine advanced MRI or CT without prior clinical evaluation (detailed history and neurologic exam) and without plain radiographs where recommended is not covered. Advanced imaging for conditions such as Klippel-Feil or Marfan syndrome requires documentation of the initial evaluation and meeting the specified clinical triggers; absent those, routine advanced imaging is not supported.
Background and Scope
Many pediatric spinal conditions differ from adult presentations. For individuals who are ≤18 years old, the Pediatric Spine Imaging Guidelines apply; individuals older than 18 years should be managed according to the General Spine Imaging Guidelines unless otherwise specified. These pediatric-specific recommendations address modality preference, age-based ultrasound use, and age-appropriate thresholds for advanced imaging.
Definitions and Key Terms
Covered Indications — Top-level Imaging Pathways
inv-110: CT/myelogram indications — top-level node
Usually after specialist consultation; code as appropriate for myelogram/CT.
inv-111: Spinal ultrasound — top-level node
Should not be reported multiple times for different spinal canal areas.
inv-112: Spinal canal ultrasound — top-level node
Repeat in 4–6 weeks if uncertain cord level in premature infants.
inv-113: MRI for pediatric spine — top-level node
Sedation often required in young children; plain x-rays should be available where specified.
inv-114: CT for pediatric spine — top-level node
CT is the study of choice in trauma per guidance.
inv-115: Suspected spinal infection — top-level node
MRI is very sensitive for early infectious changes.
inv-116: Suspected traumatic spine injury — top-level node
If initial modality inconclusive, obtain the other modality to direct management.
inv-117: Suspected physical child abuse — top-level node
inv-118: Scoliosis / perioperative assessment — top-level node
Surgical specialists may request both MRI and CT together for preoperative planning.
inv-119: Idiopathic scoliosis with high-risk clinical features — MRI spine without contrast — top-level node
MRI is also indicated when actively evaluating for corrective surgery.
inv-120: Cutaneous signs suspicious for occult spinal dysraphism — top-level node
Plain x-rays are not indicated as initial test for suspected occult dysraphism.
inv-121: Neuromuscular scoliosis with pain or preoperative evaluation — top-level node
Postoperative CT chest with 3D reconstruction indicated in early onset scoliosis for lung volume measurement.
inv-122: Cutaneous lesions suspicious for occult spinal dysraphism — top-level node
Follow-up of a normal screening ultrasound with ultrasound is not medically necessary; screening MRI may be performed after ultrasound if indicated.
inv-123: Syndromic or congenital conditions with increased risk — top-level node
Appropriate MRI of other spinal levels determined by specialist consultation.
inv-124: Neurologic, urologic, or progressive symptoms suggesting tethered cord — top-level node
These findings justify direct advanced imaging.
inv-125: Achondroplasia — suspected spinal stenosis — top-level node
MRI brain or CT head indicated for suspected hydrocephalus.
inv-126: Inflammatory spondylitis in juvenile idiopathic arthritis — top-level node
inv-127: Atlantoaxial instability screening/diagnosis in trisomy 21 — top-level node
Routine screening performed with lateral x-rays; MRI indicated per thresholds or symptoms.
inv-128: Klippel-Feil anomaly — indication for advanced imaging — top-level node
Detailed history, neurologic exam, and plain x-rays recommended prior to advanced imaging.
inv-129: Suspected hydrocephalus in achondroplasia — top-level node
inv-130: Klippel-Feil anomaly — top-level node (duplicate entry)
Plain x-rays sufficient to establish diagnosis in absence of specified triggers.
inv-131: Marfan syndrome — top-level node
inv-132: Von Hippel-Lindau syndrome with known spinal hemangioblastoma(s) — top-level node
Revision History
Pediatric and Special Populations Spine Imaging Guidelines published (version v1.0.2026) and became effective; establishes pediatric-specific imaging criteria, modality preferences, and prior-authorization expectations.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.