UnitedHealthcare Pediatric Musculoskeletal Coverage Update

Coverage Criteria and Medical Necessity Rules

General modality and documentation criteria

Covered when imaging modality and contrast level are appropriate to the clinical indication and documented clinical evaluation supports medical necessity.

General clinical documentation: Adequate clinical information must be submitted: recent history, physical exam since symptom onset or change, pertinent laboratory studies, and prior imaging when applicable (plain X‑rays or ultrasound from the current episode).

See chunks 22,83

Modality selection: Choose modality based on the clinical question: ultrasound for soft tissue, vascular, and bedside dynamic imaging; CT for pulmonary disease, trauma, complex fractures, abdominal/pelvic viscera or when CT provides superior bone detail; MRI for soft tissue, CNS, musculoskeletal soft tissue, infection, and characterization of masses; PET/CT for metabolic oncologic and select neurologic or cardiac indications.

See chunks 23,25,29,33

Contrast selection: Select contrast level (none; with; without and with) per condition-specific guidance; use CT or MRI contrast only when additional vascular or soft-tissue resolution will affect management and consider pregnancy and renal function when deciding contrast use.

See chunks 22,25,26,32

Substitution rules: CT may be approved in place of MRI when MRI criteria are met but MRI is contraindicated (e.g., pacemaker, ICD, neurostimulator); match contrast level when substituting (MRI without contrast → CT without contrast; MRI without and with contrast → CT with contrast or CT without and with contrast).

See chunk 32

Indications for CPT 76376/76377

3D rendering codes (CPT 76376/76377) may be considered in the following clinical scenarios:

Clinical scenarios for 3D rendering: Preoperative planning for congenital skull abnormalities in newborns/infants/toddlers; complex fractures and dislocations when conventional imaging is insufficient (spine fractures, pelvic/acetabular fractures, intra-articular fractures, complex facial fractures); cerebral angiography; selected pelvis and abdomen indications when initial ultrasound is indeterminate (e.g., lost IUD, hydrosalpinx), and other complex surgical planning scenarios requiring volumetric 3D visualization.

Concurrent physician supervision/participation should be documented per ACR recommendations (see chunk 43).

Imaging guidance billing and usage

Imaging guidance codes contain imaging necessary to guide needle or catheter and should be used preferentially with percutaneous procedures:

Guidance billing rules: Guidance procedure codes (e.g., CT, MR, US guidance codes) include the imaging necessary to perform percutaneous procedures and should be used instead of routinely billing a separate diagnostic procedure code; only percutaneous surgical procedure codes should be billed with guidance codes; only one unit of a guidance code should be reported per encounter/date of service; guidance codes represent radiologic supervision and interpretation of the procedure.

77013 is for non-bone ablation only; CPT 20982 includes CT guidance for bone tumor ablations (see chunks 46,51,53).

Unlisted procedure coding guidance

Unlisted CT/MR/nuclear medicine procedure coding rules:

When to use unlisted codes: Report CPT 76497 (unlisted CT) or CPT 76498 (unlisted MR) or CPT 78999 (unlisted diagnostic nuclear medicine) when a diagnostic or interventional study cannot be described by an anatomic site-specific CPT code; when a Category III code exists that describes the procedure, report the Category III code instead of an unlisted code; examples include custom joint arthroplasty planning and studies for navigational/neurosurgical planning requiring non-standard acquisition parameters.

See chunk 54 for scenarios and coding considerations.

Whole-body CT imaging

Whole-body CT/MRI screening and staging

Whole-body CT screening NOT covered for asymptomatic individuals: Whole-body CT or LifeScan for screening of asymptomatic individuals is not indicated due to lack of demonstrated benefit versus radiation risk; exception: low-dose CT supported for oncologic staging in multiple myeloma per Oncology Imaging Guidelines.

See chunk 63.

Whole-body MRI

Whole-body MRI coverage stance

WBMRI generally not supported: Whole-body MRI (WBMRI) is generally not supported because of lack of standardized technique and insufficient evidence of outcome improvement, except for select cancer predisposition syndromes and certain autoimmune conditions (e.g., CRMO) where WBMRI may be approved.

WBMRI is reportable only using CPT 76498; other reporting methods are inappropriate (see chunk 65).

Coding for WBMRI: There are no established CPT or HCPCS codes for WBMRI other than CPT 76498; separate diagnostic MRI codes for multiple body parts may be used when appropriate but reporting WBMRI requires CPT 76498.

See chunk 65.

PET-MRI

PET-MRI generally not supported: PET-MRI is generally not supported for most oncologic and neurologic conditions due to lack of standardization, but may be appropriate when condition-specific criteria are met AND PET‑CT is unavailable at the treating institution; when appropriate, PET-MRI may be reported using CPT 76498 and diagnostic MRI codes may be reported concurrently if clinically indicated.

See chunk 67.

Quantitative multiparametric MRI

Quantitative MR analysis

Quantitative mp-MRI investigational: Category III CPT codes for quantitative multiparametric MRI data analysis (e.g., 0648T/0649T, 0697T/0698T, 0865T/0866T) are considered investigational/experimental and not medically necessary for routine clinical practice; these procedures are primarily used in clinical trials and research settings.

See chunk 59.

General Coverage Criteria for Pediatric Musculoskeletal Advanced Imaging

Covered when ALL of the following are met

Clinical evaluation: A pertinent clinical evaluation (detailed history, physical exam, appropriate labs) has been performed and documented; a telehealth/telephone/email contact can serve as pertinent clinical evaluation when documented.

See chunk 83 and 85.

Conservative care: Provider-directed conservative care attempted when appropriate (e.g., RICE, NSAIDs, analgesics, corticosteroids, home exercise, physical medicine) or documentation provided explaining why conservative care is not appropriate.

See chunk 83.

Imaging prerequisites: Plain X‑ray results from the current episode should be available to the requesting provider prior to advanced imaging unless guideline-stated exceptions apply; plain films help rule out conditions that do not require advanced imaging.

See chunk 83.

Modality-specific Appropriate Use

Indications where modality is appropriate

MRI indications: Tumors, infection, postoperative evaluation, arthrography, juvenile idiopathic arthritis, detection of edema or avascular necrosis; obtain multiple necessary body areas in same session when supported.

See chunks 29 and 88.

CT indications: Complex fractures (particularly involving joints), dislocations, delayed union/non-union assessment, characterization of masses or vascular anatomy when CT is superior or when MRI contraindicated.

See chunks 25 and 89.

Ultrasound indications: Infant hip dysplasia screening and follow-up, detection and aspiration of joint effusion, and initial evaluation of extremity soft tissue masses.

See chunks 23 and 90.

Nuclear medicine indications:

Acute Fracture (PEDMS-2.1)

Covered when ALL of the following are met

Acute fracture pathway: Plain X‑rays performed initially; if X‑ray positive, no further imaging is generally indicated except for complex (comminuted or displaced) joint fractures where MRI or CT without contrast may be approved for preoperative planning; ultrasound may be approved (esp. in infants); if plain X‑ray is negative or equivocal and clinical suspicion persists and results will determine immediate treatment, CT or MRI without contrast is indicated; bone scan may be approved when two X‑rays are negative at least 10 days apart.

See chunk 95.

Joint-Adjacent Fracture (PEDMS-2.2)

Covered when ANY of the following are met

Joint-adjacent fracture indications: CT without contrast can be approved for complex (comminuted or displaced) fractures involving a joint for preoperative planning; CT without contrast can be approved for concern for delayed union or non‑union on follow‑up plain X‑ray.

See chunk 96.

Growth Plate Injuries (PEDMS-2.3)

Covered when ALL of the following are met

Growth plate imaging: Plain X‑ray is usually adequate initially; CT without contrast indicated for concern for delayed union/non‑union or severe displaced fractures prior to surgery; MRI without contrast indicated for suspected physeal bar or complications where CT may miss fibrous bars; MRI indicated for compressive (Salter‑Harris V) injuries difficult to identify on plain films.

MRI is preferred for some physeal assessments because CT can miss fibrous physeal bars (see chunk 97).

Osteochondral or Chondral Fractures (PEDMS-2.4)

Covered when ALL of the following are met

Osteochondral injury imaging: If clinical exam suggests an unstable osteochondral injury, MRI without contrast, MR arthrogram, or CT arthrogram of the involved joint is indicated; MRI or CT without contrast is indicated when healing cannot be adequately assessed on follow‑up plain X‑rays; if plain X‑rays show a non‑displaced fragment, follow‑up with X‑rays only and advanced imaging is not necessary.

See chunk 98.

Stress/Occult Fracture (PEDMS-2.5)

Covered when ALL of the following are met

Stress/occult fracture pathway: Plain X‑rays performed before advanced imaging; if stress or occult fracture is suspected in high‑risk locations (pelvis, sacrum, hip, femur, tibia, tarsal navicular, proximal 5th metatarsal, scaphoid) and initial X‑ray is non‑diagnostic, MRI or CT without contrast is indicated; bone scan or SPECT may be approved in place of MRI/CT if requested; CT without contrast indicated when concern for non‑union; follow-up X‑rays often become positive after ~14 days.

See chunk 99.

Compartment Syndrome (PEDMS-2.6)

Compartment syndrome imaging: Acute compartment syndrome is a clinical diagnosis made by direct compartment pressure measurement and is a surgical emergency; advanced imaging is not indicated for acute compartment syndrome.

See chunk 100.

Soft Tissue and Bone Masses (PEDMS-3.1 to PEDMS-3.4)

Covered when ALL of the following are met

Mass evaluation prerequisites: Detailed clinical evaluation including location, size, duration, and characteristics of the mass, and plain X‑rays of the entire bone containing a lesion are required prior to advanced imaging; evaluation by a surgical specialist or oncologist is strongly recommended; ultrasound indicated for many soft tissue masses; MRI with or without contrast indicated if surgery planned or diagnosis uncertain; CT indicated if MRI contraindicated.

Advanced imaging not indicated for sebaceous cysts, hematomas, and subcutaneous lipomas (see chunk 105).

Soft Tissue Mass with Negative X‑ray and Abnormal Ultrasound (PEDMS-3.2)

Abnormal ultrasound after negative X‑ray: When plain X‑ray is negative and ultrasound is abnormal, MRI without and with contrast is indicated; CT without or with contrast is indicated if MRI is contraindicated.

See chunk 106.

Soft Tissue Mass with Calcification/Ossification on X‑ray (PEDMS-3.3)

Calcified mass imaging: When calcification or ossification is noted on plain X‑ray, MRI without and with contrast is indicated; CT without or with contrast is acceptable if MRI is contraindicated.

See chunk 107.

Mass Involving Bone (PEDMS-3.4)

Bone mass imaging: Plain X‑rays of the entire bone containing the lesion are required before advanced imaging; MRI without and with contrast and/or CT may be indicated for preoperative planning or when diagnosis is uncertain on plain X‑ray; surveillance of benign lesions is with plain films; CT if MRI contraindicated; MRI may be approved for new/worsening symptoms not explained by recent X‑ray; refer to pediatric oncology guidelines when metastatic disease suspected.

See chunk 108.

Mass Involving Bone (PEDMS-3.4) — detailed criteria

Covered when ALL of the following are met

Bone lesion initial imaging: Plain X‑rays of the entire bone containing the lesion are required prior to consideration of advanced imaging because many benign bone tumors have characteristic radiographic appearance.

See chunk 108.

Advanced imaging indicated: MRI without and with contrast OR CT (if MRI contraindicated) may be indicated for preoperative planning or when diagnosis is uncertain on plain X‑ray; MRI preferred when feasible.

See chunk 108.

Limping Child with Suspected Trauma (PEDMS-4.2)

Covered when ALL of the following are met

Initial trauma evaluation: Plain X‑rays are indicated for detection of fractures, destructive lesions, and avascular necrosis; for children under age 4 this may require X‑rays of the entire leg from hip to foot; if fracture is demonstrated additional imaging often not required.

See chunk 113.

When initial X‑rays are negative and suspicion persists: MRI without contrast of the affected area OR radionuclide bone scan/SPECT/SPECT‑CT may be approved if MRI contraindicated or unavailable; follow-up X‑rays in 7–10 days if symptoms persist.

See chunk 113.

Limping Child with Suspected Infection (PEDMS-4.3)

Covered when ALL of the following are met

Suspected septic arthritis of hip: Ultrasound of the hip (CPT 76881/76882) to exclude hip joint effusion; if effusion present, joint aspiration is indicated; if plain films are not diagnostic, MRI without or without and with contrast is indicated.

See chunk 114.

When plain X‑ray not diagnostic and concern remains: Whole‑body bone scan OR SPECT/SPECT‑CT OR MRI of the affected area may be approved as clinically indicated.

See chunk 114.

Limping Child with No Evidence of Trauma or Infection (PEDMS-4.4)

Covered when ALL of the following are met

Non-traumatic/non-infectious limp: Ultrasound of the hip (CPT 76881/76882) is the preferred initial exam for a limp without evidence of trauma or infection; plain X‑rays if no hip effusion; refer to condition-specific guidelines (AVN, JIA, neoplasm, histiocytic disorders, child abuse) as indicated.

See chunk 115.

Developmental Dysplasia of the Hip (PEDMS-5)

Covered when ANY of the following risk-based criteria are met

DDH screening ultrasound indications: Infants between approximately 4 weeks and 4 months with one or more risk factors (breech presentation, abnormal hip exam such as positive Ortolani/Barlow or asymmetric thigh folds/limited abduction, or family history of DDH) should receive screening hip ultrasound (CPT 76885/76886); for infants 4–6 months plain X‑ray is preferred due to ossification.age 4 weeks–4 months

See chunk 119.

Follow-up ultrasound indications: Follow‑up hip ultrasound is indicated for Graf Type IIA hips in children <3 months or after treatment (e.g., Pavlik harness) to document maturation or treatment effect; usual interval is monthly unless earlier imaging indicated for clinical concern.

See chunk 120.

DDH not indicated: Hip ultrasound is NOT indicated for infants >6 months, infants <4 weeks, or for hips requiring treatment rather than follow-up (Graf types I, IIB, IIC, IID, III); use plain X‑ray >6 months or when teratogenic dysplasia suspected.

Avascular Necrosis and Osteonecrosis (PEDMS-6)

Covered when ALL of the following are met

Initial imaging for suspected AVN/Legg–Calve–Perthes: Plain X‑ray is the initial imaging study and may suffice for follow-up; if diagnosis uncertain on X‑ray, MRI without or with contrast is indicated.

See chunk 124.

Alternatives when MRI contraindicated: CT without contrast OR nuclear bone scan OR SPECT/SPECT‑CT may be approved in lieu of MRI; CT may be appropriate for surgical planning.

See chunk 124 and 125.

Suspected Physical Child Abuse - Covered indications

Covered when ordered for the stated pediatric indications and documented clinical findings

Suspected Physical Abuse - Skeletal Injury: Skeletal survey (complete X‑ray survey) is the primary imaging procedure for detecting fractures in children ≤24 months; older children may have tailored X‑ray evaluation based on history and exam; when skeletal survey is negative but suspicion remains, bone scan, SPECT, or CT chest without contrast for suspected rib fracture may be indicated; repeat skeletal survey ~2 weeks may be appropriate when initial study equivocal.age <= 24 months

See chunks 129 and 130.

Suspected Physical Abuse - Head/Spine: CT head without contrast is indicated with clinical evidence of head injury or skull fracture and is indicated in children <1 year even if asymptomatic; MRI brain may be approved to evaluate parenchymal injury; MRI or CT spine indicated when cervical or spinal trauma suspected.age < 1 year => CT head even if no neurologic symptoms

See chunk 131.

Infection/Osteomyelitis - Covered indications

Covered when MRI is not possible or infection is multifocal / associated with hardware

Infection/Osteomyelitis - Nuclear options: Bone scan, SPECT, labeled leukocyte scans (with marrow imaging when indicated), or SPECT/CT are appropriate when MRI cannot be performed, for multifocal infection, or when infection is associated with orthopedic hardware or altered marrow distribution; combining bone scintigraphy with a labeled leukocyte scan improves sensitivity.

See chunk 137.

Inflammatory Musculoskeletal Disease - JIA

Covered for inflammatory musculoskeletal disease when targeted by clinical evaluation

Juvenile Idiopathic Arthritis: Ultrasound (CPT 76881/76882) is indicated for assessment of joint effusion size/characteristics and synovial hypertrophy; MRI of the most symptomatic joint (without or without and with contrast) may be considered if ultrasound is inconclusive and MRI findings would alter management; TMJ MRI (70336) indicated annually for silent TMJ arthritis in JIA; MRI otherwise not indicated for routine follow-up of treatment.

See chunk 144.

Chronic Recurrent Multifocal Osteomyelitis (CRMO)

Covered when evaluating new/worsening pain or treatment response in CRMO

CRMO imaging options: SPECT (CPT 78803/78831), bone scan (CPT 78300/78305/78306/78315), nuclear bone marrow imaging, SPECT/CT (78830/78832), radiopharmaceutical localization (78800–78803), OR MRI without contrast of specific painful areas may be approved when plain X‑ray and bone scan are insufficient to guide care; whole‑body MRI (CPT 76498) may be approved if characteristic MR findings would obviate biopsy and can be repeated every 6–12 months for monitoring when indicated.6-12 months

See chunk 145.

Juvenile Idiopathic Arthritis - Imaging Criteria

Covered when criteria or indications below are met for juvenile idiopathic arthritis (JIA):

Ultrasound indications for JIA: Ultrasound (CPT 76881 or 76882) is indicated for assessment of joint effusions, synovial hypertrophy, and tendon involvement in JIA.

See chunk 144.

MRI for JIA: MRI of the most symptomatic joint without contrast or without and with contrast may be considered if ultrasound is inconclusive and MRI findings would alter management; MRI TMJ (70336) is indicated annually for silent TMJ arthritis; MRI may be used when diagnosis is uncertain prior to initiation of drug therapy or to determine change in treatment.

See chunk 144.

MRI follow-up restriction: MRI (except annual TMJ screening) should NOT be considered for routine follow-up of treatment in JIA.

See chunk 144.

CRMO - Imaging Criteria

Covered when criteria below are met for Chronic Recurrent Multifocal Osteomyelitis (CRMO):

Imaging options for new/worsening pain or treatment response: SPECT (78803/78831), bone scan (78300/78305/78306/78315), nuclear bone marrow imaging, SPECT/CT (78830/78832), radiopharmaceutical localization (78800–78803), OR MRI without contrast of specific painful areas when plain X‑ray and bone scan are insufficient to direct acute care are indicated.

See chunk 145.

WBMRI indications: Whole‑body MRI (CPT 76498) may be approved if characteristic MR findings of CRMO would avoid biopsy; WBMRI may be repeated every 6–12 months for monitoring when clinically indicated.6-12 months

See chunk 145.

Inflammatory Myopathies - Imaging Criteria

Covered when criteria below are met for inflammatory muscle diseases (including juvenile dermatomyositis):

Pre-imaging evaluation: A pertinent clinical face‑to‑face evaluation including detailed history, physical exam, and plain X‑rays should be performed prior to considering advanced imaging.

See chunk 147.

MRI indications in inflammatory myopathies: MRI without contrast of a single site is indicated for selection of biopsy site, treatment monitoring, clinical concern for progression, or detection of occult malignancy; in juvenile dermatomyositis MRI without contrast can often confirm diagnosis and avoid biopsy; CT without contrast may be used rarely (e.g., to follow progressive muscle calcification).

See chunks 148–149.

Osgood-Schlatter Disease - Imaging Criteria

Covered stance for Osgood-Schlatter disease:

Osgood-Schlatter imaging: Diagnosis is by clinical examination and plain X‑ray; treatment is conservative and advanced imaging is not indicated for routine care.

See chunk 157.

Popliteal (Baker) Cyst - Imaging Criteria

Covered stance for popliteal (Baker) cyst in children:

Initial imaging: Ultrasound (CPT 76881 or 76882) is the appropriate initial imaging study for a suspected popliteal (Baker) cyst in children.

See chunk 161.

When MRI is indicated: MRI without contrast (CPT 73721) is indicated for preoperative planning or if ultrasound is non‑diagnostic.

See chunk 161.

Imaging indications for selected pediatric musculoskeletal conditions

Covered when imaging is indicated per the guideline statements below:

Suspected SCFE: Obtain AP and lateral (frog‑leg or cross‑table lateral) x‑rays of both hips to confirm/exclude SCFE and evaluate the contralateral hip; if radiographs are negative but suspicion persists, MRI without contrast (CPT 73721) or without and with contrast (CPT 73723) is indicated to detect pre‑slip or for preoperative planning.

See chunks 164 and 165.

Tarsal coalition: If plain radiographs are inconclusive and tarsal coalition suspected (restricted hindfoot motion), CT without contrast (CPT 73700) or MRI without contrast (CPT 73718) is indicated.

See chunk 170.

Club foot (infant): Plain x‑rays for older children/adults; in infants with non‑ossified tarsal bones ultrasound (CPT 76881/76882) can characterize cartilaginous tarsal bones and alignment; ultrasound is not required prior to MRI/CT if those studies are appropriate and MRI is not routinely used for clubfoot imaging.

See chunk 171.

Imaging studies requested solely for data collection in clinical trials or that are inconsistent with established clinical standards and not intended to directly inform individual patient management are not supported and may be denied. Documentation should demonstrate how the requested study will affect clinical care when such imaging is submitted for coverage review.

Certain procedures and technologies are considered investigational or experimental and are not routinely covered. Examples include MRI using Xenon Xe 129 (C9791) and Category III quantitative multiparametric MRI analyses (e.g., CPT 0648T/0649T, 0697T/0698T, 0865T/0866T), which currently lack widely recommended clinical indications and are primarily used in research settings. Contrast use (gadolinium) requires clinical justification given safety considerations (e.g., NSF risk in low GFR) and should be limited to circumstances where additional information will affect management.

CPT codes for 3D rendering (CPT 76376, 76377) are intended for bona fide 3D post-processing and must not be used to bill for routine 2D reformatting. Concurrent physician supervision/participation should be documented when these codes are reported. Avoid billing 3D rendering with incompatible or duplicative services (for example, with stereotactic localization CPT 77011 or diagnostic codes that already include 3D reformats).

Whole-body CT or so-called LifeScan examinations for screening of asymptomatic individuals are not indicated due to unfavorable benefit-to-radiation risk; such studies will not be supported except as specifically allowed in disease‑specific oncology guidance (e.g., low‑dose CT for multiple myeloma).

CPT 76380 (limited or follow‑up CT) is a code for technical limited-slice studies and is not intended for treatment planning purposes. It should not be used to cover additional slices or to substitute for a full diagnostic CT when treatment‑planning imaging is required.

When MRI is contraindicated or precluded by implanted hardware or devices that degrade image quality, CT is an acceptable alternative and may be the preferred modality. Modality selection should match the clinical question and documented contraindications to MRI; prior plain radiographs and clinical evaluation remain prerequisites before advanced imaging.

Advanced imaging is not indicated for superficial benign lesions such as sebaceous cysts, simple hematomas, or subcutaneous lipomas when clinical examination and, if performed, ultrasound or plain radiograph findings are consistent with these diagnoses. Plain radiographs and focused ultrasound are the usual initial evaluations; MRI/CT/NM are reserved only if findings suggest otherwise.

Acute compartment syndrome is a clinical and surgical diagnosis established by direct compartment pressure measurement and is a surgical emergency; advanced imaging is not indicated in the acute setting and should not delay urgent treatment.

Hip ultrasound is not appropriate for certain age groups and situations: it is not indicated for infants older than 6 months (plain radiographs preferred due to ossification), for infants under 4 weeks (physiologic laxity commonly resolves), and for Graf-classified hips that require treatment rather than imaging follow‑up. Follow-up hip sonography after treatment is typically performed monthly unless clinical concern dictates earlier evaluation.

Routine serial MRI for monitoring treatment response is discouraged in most cases. For juvenile idiopathic arthritis (JIA), MRI of the most symptomatic joint may be used when ultrasound is inconclusive or would change management, but routine MRI follow‑up is not recommended except for annual TMJ MRI screening to detect silent TMJ arthritis.

Osgood‑Schlatter disease (traction apophysitis of the tibial tubercle) is diagnosed clinically with plain radiographs when indicated; advanced imaging is not indicated for routine evaluation or management.

MRI is not routinely used to evaluate infant clubfoot; ultrasound may be used to characterize cartilaginous tarsal bones in infants with non‑ossified elements, and plain radiographs are appropriate for older children. Given limited published experience, MRI is not indicated as a routine study for clubfoot assessment.

Repeat advanced imaging of the same body area without documented clinical progression, recurrence, or a clear likelihood that results will change management is generally not medically necessary. Providers should document reasons why repeat imaging is expected to alter care; absence of such justification may lead to denial.

For MRI‑guided breast biopsy, CPT 77021 is not the appropriate code. Use CPT 19085 (first lesion) and CPT 19086 (each additional lesion) to report percutaneous breast biopsy with MR guidance and specimen imaging as described in the coding guidance.

Volumetric or quantitative MRI analyses of the brain and other multiparametric quantitative MR procedures (Category III codes such as CPT 0648T/0649T, 0697T/0698T, 0865T/0866T) are considered investigational/ not medically necessary for routine clinical practice and are generally not supported outside of research contexts.

Providers should attempt or document a trial of appropriate conservative therapy (e.g., RICE, NSAIDs, physical therapy, immobilization) when clinically indicated prior to ordering advanced imaging unless the clinical scenario warrants immediate advanced imaging. Imaging should be ordered when results are expected to affect management decisions.

When plain radiographs clearly demonstrate an uncomplicated, non‑displaced fracture that does not involve joint displacement or comminution, additional advanced imaging is generally not indicated. CT or MRI may be appropriate for complex fractures, preoperative planning, or when radiographs are inconclusive and results will change immediate management.

Some benign bone tumors have characteristic appearances on plain X‑ray; when the radiograph is typical and there are no additional concerning features, advanced imaging may be unnecessary. Advanced imaging is reserved for lesions with atypical features, diagnostic uncertainty, or when imaging will affect treatment planning.

In investigations of suspected physical child abuse, asymptomatic contact children older than 24 months do not require routine imaging. Contact children <12 months should have neuroimaging and skeletal survey; those 12–24 months should undergo a skeletal survey per the guideline.

For juvenile idiopathic arthritis (JIA), routine MRI for treatment follow‑up is discouraged except for annual TMJ MRI screening. MRI of symptomatic joints may be used when ultrasound is inconclusive and MRI findings would alter management; repeat MRIs for routine surveillance are generally not supported.

Specific Covered Indications by Clinical Condition

General modality indications — 4 top-level nodes

Documentation for clinical justification: Clinical justification must describe why advanced imaging is necessary for the clinical question and how results will affect management; include recent history, focused physical exam, and prior imaging from the current episode when applicable.

See chunks 22 and 83.

When conventional imaging is insufficient for complex surgical or preoperative planning

When conventional imaging insufficient: Consider advanced imaging or 3D rendering when conventional imaging (plain film, CT, MRI, or ultrasound) does not answer the clinical question and preoperative planning requires volumetric or spatial visualization beyond standard reconstructions.

See chunk 44.

Whole-body MRI / CT covered indications

CPT and Related Coding Guidance

Referenced guideline sections and policy identifiersmixed

No codes listed

Experimental/Investigational CodesCPTExperimental

C9791

MRI utilizing Xenon Xe 129 (contrast) — considered investigational/experimental

3D Rendering CodesCPTCovered

76376	3D rendering; not requiring image post-processing on an independent workstation
76377	3D rendering; requiring image post-processing on an independent workstation

Imaging Guidance Procedure CodesCPTCovered

76942	Ultrasonic guidance for needle placement
75989	Imaging guidance for percutaneous drainage with placement of catheter (all modalities)
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

Unlisted Procedure CodesCPT

76497	Unlisted CT procedure (diagnostic or interventional)
76498	Unlisted MR procedure (diagnostic or interventional)
78999	Unlisted procedure, diagnostic nuclear medicine

MRI-guided breast biopsy codesCPTCovered

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, with placement of breast localization device(s), when performed, and imaging of the specimen, when performed, percutaneous; each additional lesion, including MR guidance

Unlisted procedure codesCPT

76497	Unlisted CT procedure
76498	Unlisted MR procedure
78999	Unlisted diagnostic nuclear medicine procedure

Limited CTCPTCovered

76380

Limited or Follow-up CT

Interpretation codesCPTCovered

76140

Interpretation of an outside diagnostic imaging study

Category III quantitative MRI codesCPTExperimental

0648T	Quantitative mp-MRI analysis without diagnostic MRI
0649T	Quantitative mp-MRI analysis with diagnostic MRI
0697T	Quantitative multi-organ MRI analysis without diagnostic MRI
0698T	Quantitative multi-organ MRI analysis with diagnostic MRI
0865T	Volumetric and quantitative MRI analysis of the brain (Category III)
0866T	Volumetric and quantitative MRI analysis of the brain (Category III)

Nuclear hybrid imaging codesCPT

78072	SPECT/CT parathyroid nuclear imaging (effective 2013)
78830	Hybrid Nuclear/CT scan, single area single day
78831	Hybrid Nuclear/CT scan, 2 or more days
78832	Hybrid Nuclear/CT scan, 2 areas with one day and 2-day study

MRI/MRA Codes (upper & lower extremity)CPT

73218	MRI Upper Extremity non-joint without contrast
73220	MRI Upper Extremity non-joint without and with contrast
73221	MRI Upper Extremity joint without contrast
73223	MRI Upper Extremity joint without and with contrast
73718	MRI Lower Extremity non-joint without contrast
73720	MRI Lower Extremity non-joint without and with contrast
73721	MRI Lower Extremity joint without contrast
73723	MRI Lower Extremity joint without and with contrast
76498	Unlisted MRI procedure (for radiation planning or surgical software)
73225	MRA Upper Extremity

CT CodesCPT

73200	CT Upper Extremity without contrast
73201	CT Upper Extremity with contrast
73202	CT Upper Extremity without and with contrast
73700	CT Lower Extremity without contrast
73701	CT Lower Extremity with contrast
73702	CT Lower Extremity without and with contrast
71250	CT Chest without contrast
71260	CT Chest with contrast
74160	CT Abdomen with contrast
72193	CT Pelvis with contrast

1–10 of 13

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PET / Nuclear Medicine CodesCPT

78811	PET Imaging; limited area
78812	PET Imaging: skull base to mid-thigh
78813	PET Imaging: whole body
78814	PET with concurrently acquired CT; limited area
78815	PET with concurrently acquired CT; skull base to mid-thigh
78816	PET with concurrently acquired CT; whole body
78102	Bone Marrow Imaging Limited Areas
78103	Bone Marrow Imaging Multiple Areas
78104	Bone Marrow Imaging Whole Body
78300	Nuclear Bone Scan Limited

1–10 of 20

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Ultrasound & Vascular Duplex CodesCPT

76881	Ultrasound, extremity, nonvascular; complete joint
76882	Ultrasound, extremity, nonvascular; limited
76885	Ultrasound, infant hips; dynamic
76886	Ultrasound, infant hips; limited, static
76604	Ultrasound, upper back
76705	Ultrasound, lower back
76999	Ultrasound, other soft tissue areas not otherwise specified
93922	Limited bilateral noninvasive physiologic studies of extremity arteries
93923	Complete bilateral noninvasive physiologic studies of extremity arteries
93930	Duplex scan of upper extremity arteries; complete bilateral

1–10 of 14

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Referenced imaging CPT codes (Ultrasound, Bone scan, SPECT)CPT

76881	Ultrasound, pediatric (as referenced for fracture/mass evaluation)
76882	Ultrasound, bilateral or limited (as referenced for fracture/mass evaluation)
78300	Bone scan, whole body (mentioned as CPT 78300 in bone scan combinations)
78305	Bone scan, limited (mentioned)
78306	Bone scan, three-phase (mentioned)
78315	Triple phase bone scan (mentioned for CRPS/reflex sympathetic dystrophy and stress fracture)
78803	SPECT distribution of radiopharmaceutical agent (mentioned)
78830	SPECT-CT (mentioned)

Referenced imaging CPT codesCPT

76881	Ultrasound of hip (limited) / used to exclude hip joint effusion
76882	Ultrasound of hip (complete)
76885	Screening hip ultrasound (DDH) static/dynamic
76886	Screening hip ultrasound (second code variant)
73721	MRI without contrast of hip/affected area
73723	MRI without and with contrast of hip/affected area
73700	CT without contrast of body area (used for DDH post-reduction evaluation)
78300	Radionuclide bone scan, three-phase
78305	Bone scan, limited area
78306	Bone scan, whole body

1–10 of 13

1/2

Bone scan / Nuclear medicine (skeletal injury guidance)CPT

78300	Bone scan (planar)
78305	Bone scan, additional code variant
78306	Bone scan, additional code variant
78315	Bone scan, additional code variant
78830	Distribution of Radiopharmaceutical Agent SPECT

CT and MRI codes (head/spine/chest guidance)CPT

71250	CT Chest without contrast
70450	CT Head without contrast
70551	MRI Brain without contrast
70553	MRI Brain without and with contrast
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

1–10 of 13

1/2

Abdomen/pelvis/chest imagingCPT

76700	Abdominal ultrasound
76856	Pelvic ultrasound
74160	CT Abdomen without contrast
74177	CT Abdomen and Pelvis with contrast
71250	CT Chest without contrast
71260	CT Chest with contrast

Ultrasound, TMJ, Whole-body MRICPT

76881	Ultrasound, extremity, real time w/ image documentation; limited
76882	Ultrasound, extremity, real time w/ image documentation; complete
70336	MRI TMJ
76498	Whole body MRI

Nuclear medicine / SPECT for CRMO and infectionCPT

78803	SPECT distribution of radiopharmaceutical agent
78831	SPECT additional code
78832	SPECT-CT code variant
78800	Radiopharmaceutical localization (tumor/inflammatory)
78801	Radiopharmaceutical localization variant
78802	Radiopharmaceutical localization variant

Imaging codes mentioned for JIA and related nuclear studiesmixed

76881	Ultrasound joint; complete
76882	Ultrasound joint; limited
78802	Radiopharmaceutical localization, other than parathyroid
78803	Same as 78802 (distribution of radiopharmaceutical agent SPECT listed)
78830	SPECT/CT, single area
70336	MRI TMJ

Imaging codes for CRMO and bone imagingmixed

78803	SPECT
78831	SPECT bone imaging (code variant listed)
78300	Bone scan, planar
78305	Bone scan with flow
78306	Bone scan with blood pool
78315	Whole body bone scan
78830	SPECT/CT
78832	SPECT/CT additional area
76498	Whole body MRI

Imaging codes for popliteal (Baker) cystmixed

76881	Ultrasound joint; complete
76882	Ultrasound joint; limited
73721	MRI knee without contrast (used here for popliteal cyst imaging reference)

Referenced imaging CPT codesCPT

CPT 73721	MRI lower extremity without contrast (hip MRI referenced for SCFE)
CPT 73723	MRI lower extremity without and with contrast (hip MRI referenced for SCFE)
CPT 73700	CT lower extremity without contrast (referenced for tarsal coalition and torsion measurements)
CPT 73718	MRI lower extremity without contrast (referenced for tarsal coalition and vertical talus)
CPT 76881	Ultrasound, pediatric hip (referenced for infant club foot evaluation)
CPT 76882	Ultrasound, pediatric hip with Doppler (referenced for infant club foot evaluation)

Minimum slices/sequences for CT — coding note

Minimum/maximum sequences or slicesNo minimum or maximum number of sequences or slices is defined in CT CPT codes; AMA CPT does not assign specific slice/sequence counts.

Use of CPT 76380

Prior Authorization, Documentation, and Ordering Expectations

Prior Authorization

Prior Authorization May Be Required for Advanced Nuclear and Whole‑Body MR Imaging

Prior authorization may be required for advanced nuclear imaging and whole-body MRI (WBMRI) in many situations. Obtain prior authorization when requesting PET‑MRI or WBMRI unless the applicable benefit contract or condition-specific guideline explicitly waives authorization. Failure to obtain required authorization may result in claim denial or reduced reimbursement.

PET‑MRI: prior authorization expected when used instead of PET‑CT or when PET‑CT is unavailable at the treating institution
WBMRI: prior authorization expected except for select cancer predisposition syndromes or approved indications such as CRMO

Prior Authorization

Prior Authorization for PET‑MRI / WBMRI

PET‑MRI is generally not supported for most oncologic and neurologic indications due to limited standardization and outcome data. PET‑MRI may be considered only when guideline criteria for PET‑MRI or PET‑CT are met, PET‑CT is unavailable, and when the PET‑MRI use will affect management. When approved, PET‑MRI should be reported using the appropriate whole‑body PET/MRI reporting combination (see coding guidance) rather than ad hoc code combinations.

Prior Authorization Triggers and Frequency Limits

Note

Guidance on Use of Contrast Agents

Note

Imaging Frequency and Monitoring Intervals

Ultrasound follow-up cadence for DDH

Usual follow‑up cadenceFollow‑up hip ultrasound after DDH treatment is typically performed monthly to document maturation or treatment effectiveness.

Earlier imaging indicationObtain earlier ultrasound if clinical suspicion exists for treatment failure, subluxation, or dislocation.

Post‑reduction imagingMRI (73721/73723) or CT (73700) may be used to evaluate alignment following reduction; follow clinical context for modality selection.

MRI WBMRI interval for monitoring CRMO

WBMRI interval for CRMO monitoringWhole‑body MRI (CPT 76498) may be approved every 6–12 months to monitor treatment response or identify clinically occult lesions in CRMO.

Indications for WBMRI

Not Medically Necessary / Not Covered Services

Unbundling, duplicate billing, or misuse of imaging CPT codes (for example, using 3D rendering codes for routine 2D reformatting, reporting CPT 76380 improperly to cover extra slices, or billing stereotactic localization concurrently with diagnostic reads when inappropriate) is a billing risk and may result in denial. Documentation of physician supervision for 3D rendering and correct use of guidance and limited CT codes is expected.

Inappropriate use of CPT 76380 to represent treatment‑planning CT or to cover extra diagnostic slices is not supported. CPT 76380 is intended for limited or follow‑up CT studies and should not be used to bill for full diagnostic or treatment‑planning examinations.

CPT 76376 and 76377 require documentation of active physician participation and concurrent supervision of the 3D reconstruction process; lacking such documentation or billing these codes when not meeting the defined requirements may lead to denial.

When CPT 77011 is used for stereotactic CT localization as a technical (non‑interpreted) scan, document that the scan was technical‑only; it is inappropriate to report CPT 70486 together with CPT 77011 for the same session. Billing inconsistencies in stereotactic procedures may be denied.

Whole‑body MRI must be reported using CPT 76498 when used; reporting whole‑body MRI with other standard MRI CPTs or attempting to unbundle WBMRI is inappropriate and may be denied.

Category III quantitative MRI codes (multiparametric quantitative MR analyses) are investigational; requests for these services without research justification or trial context are at high risk for denial.

Definitions and Key Terms

Investigational/Experimental definition

DefinitionInvestigational/experimental: studies, treatments, procedures, or devices considered investigational when evidence has not demonstrated improved health outcomes, supporting evidence is lacking, clinical utility is unproven, or collective opinion of support is absent.

Evidence standardsSupporting evidence includes peer‑reviewed literature, well‑conducted trials or cohort studies with sufficient power, and specialty society recommendations when available.

Impact on coverageServices deemed investigational/experimental may not be supported under these guidelines and can require special justification or be denied.

Clinical trial imaging definition

DefinitionClinical trial imaging: imaging requested for data collection or that is inconsistent with established clinical standards and not used in direct clinical management may not be supported.

Background and Scope

These guidelines evaluate the appropriateness of advanced imaging modalities (NM, US, CT, MRI, PET) for pediatric musculoskeletal conditions, emphasize the need for a pertinent clinical evaluation and baseline imaging prior to advanced studies, and recommend modality selection based on the clinical question (e.g., MRI preferred for soft tissue evaluation; CT preferred for complex bony anatomy or when MRI is contraindicated).

Policy Revision History

2024-11-??revision

Policy compiled into version V1.0.2025 and prepared for publication with substantive pediatric musculoskeletal imaging guidelines and criteria.

2025-11-01effective_dateLatest

Policy V1.0.2025 became effective November 1, 2025, implementing the Pediatric Musculoskeletal Imaging Guidelines for Ohio.

OpenPayer

Pediatric Musculoskeletal Imaging Guidelines (Ohio)

Coverage Criteria and Medical Necessity Rules

Specific Covered Indications by Clinical Condition

CPT and Related Coding Guidance

Prior Authorization, Documentation, and Ordering Expectations

Prior Authorization Triggers and Frequency Limits

Guidance on Use of Contrast Agents

Imaging Frequency and Monitoring Intervals

Not Medically Necessary / Not Covered Services

Definitions and Key Terms

Background and Scope

Policy Revision History