AIM_PEDS_Guidelines_HeadNeck

Clinical Appropriateness Guidelines:
Advanced Imaging
Appropriate Use Criteria: Pediatric Head & Neck
Effective Date: May 4, 2015
Proprietary
Date of Origin: 10/29/2014
Last revised: 10/29/2014
Last reviewed: 10/29/2014
Copyright © 2015. AIM Specialty Health. All Rights Reserved
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Table of Contents | Copyright © 2015. AIM Specialty Health. All Rights Reserved. 2
Table of Contents
Administrative Guideline...........................................................................................................3
Disclaimer...............................................................................................................................................................3
Use of AIM’s Diagnostic Imaging Guidelines..........................................................................................................4
Multiple Simultaneous Imaging Requests...............................................................................................................5
General Imaging Considerations.............................................................................................................................6
Head & Neck Imaging................................................................................................................8
CT Head – Pediatrics..............................................................................................................................................8
CTA, CTV Head: Cerebrovascular – Pediatrics....................................................................................................16
MRI Head/Brain – Pediatrics.................................................................................................................................19
MRA, MRV Head: Cerebrovascular – Pediatrics...................................................................................................27
Functional MRI (fMRI) Brain – Pediatrics..............................................................................................................30
PET Brain Imaging – Pediatrics............................................................................................................................31
CT Orbit, Sella Turcica, Posterior Fossa, Temporal Bone, including Mastoids – Pediatrics.................................32
MRI Orbit, Face & Neck (Soft Tissues) – Pediatrics.............................................................................................35
CT Paranasal Sinus & Maxillofacial Area – Pediatrics..........................................................................................39
MRI Temporomandibular Joint (TMJ) – Pediatrics................................................................................................42
CT Neck for Soft Tissue Evaluation – Pediatrics...................................................................................................44
CTA, CTV Neck – Pediatrics.................................................................................................................................48
MRA, MRV Neck – Pediatrics...............................................................................................................................50

Administrative Guideline | Copyright © 2015. AIM Specialty Health. All Rights Reserved. 3
BY ACCEPTING THESE DOCUMENTS, I ACKNOWLEDGE ACCEPTANCE OF THE FOLLOWING
TERMS AND CONDITIONS FOR ACCESS AND USE OF THE CLINICAL GUIDELINES:
AIM Specialty Health (AIM) has developed proprietary clinical appropriateness guidelines (together with
any updates, referred to collectively as the “Guidelines”). The Guidelines are designed to evaluate and
direct the appropriate utilization of high technology diagnostic imaging services. They are based on
data from the peer-reviewed scientific literature, from criteria developed by specialty societies and from
guidelines adopted by other health care organizations. Access to these Guidelines is being provided
for informational purposes only. AIM is under no obligation to update its Guidelines. Therefore, these
Guidelines may be out of date.
The Guidelines are protected by copyright of AIM as permitted by and to the full extent of the law.
These rights are not released, transferred, or assigned as a result of allowing access. You agree that
you do not have any ownership rights to the Guidelines and you are expressly prohibited from selling,
assigning, leasing, licensing, reproducing or distributing the Guidelines, unless authorized in writing by
AIM.
The Guidelines do not constitute medical advice and/or medical care, and do not guarantee results
or outcomes. The Guidelines are not a substitute for the experience and judgment of a physician or
other health care professionals. Any clinician seeking to apply or consult the Guidelines is expected
to use independent medical judgment in the context of individual clinical circumstances to determine
any patient’s care or treatment. The Guidelines do not address coverage, benefit or other plan specific
issues.
The Guidelines are provided “as is” without warranty of any kind, either expressed or implied. AIM
disclaims all responsibility for any consequences or liability attributable or related to any use, non-use
or interpretation of information contained in the Guidelines.
Administrative Guideline:
Disclaimer

Use of AIM’s Diagnostic Imaging Guidelines:
AIM’s proprietary clinical appropriateness guidelines are designed to evaluate and direct the appropriate utilization of elective,
high technology advanced imaging services. In the process, multiple functions are accomplished:
●● To promote the most efficient and cost-effective use of evidence-based advanced imaging services
●● To assist the practitioner as an educational tool
●● To encourage standardization of medical practice patterns and reduce variation in clinical evaluation
●● To curtail the performance of inappropriate, elective advanced imaging studies
●● To reduce the performance of duplicate advanced imaging studies
●● To advocate biosafety issues, including unnecessary radiation exposure (for CT and plain film radiography) and MRI
safety concerns
●● To enhance quality of healthcare for elective advanced imaging studies, using evidence-based medicine and
outcomes research from numerous resources
AIM Guideline Development Process and Resources:
AIM reviews its proprietary clinical appropriateness guidelines on an ongoing basis, throughout the year based on the results
of the research and development process and feedback from physicians and other providers. New Guidelines are also
developed as needed.
Development of appropriate use criteria within AIM guidelines is based on objective medical evidence including assessment of
potential benefits and harms. The resources considered during AIM guideline development can include but are not limited to:
●● Professional Society Guidelines
●● Professional Society Appropriate Use Criteria
●● Agency for Healthcare Research and Quality (AHRQ) Comparative Effectiveness Guidelines
●● Recommendations from the United States Preventive Services Task Force
●● National Guideline Clearinghouse
●● Centers for Medicare and Medicaid Services (CMS) * When variances occur, Medicare NCD and LCD
determinations will be used instead of AIM guidelines for Medicare Advantage patients
●● Initiatives sponsored by Specialty Licensing Boards, including but not limited to Choosing Wisely recommendations
●● National Guideline Clearinghouse
●● The latest scientific and clinical peer-reviewed literature
Guideline Review:
AIM’s proprietary guidelines for appropriate use of advanced imaging are reviewed routinely by:
●● An External Expert Panel, consisting of physicians from multiple specialties and practice settings across the United
States
●● Health Plan Medical Directors
●● Other clinical reviewers, under the governance of our clients’ state regulatory agencies
●● Subject matter specialty physician experts and primary care physicians
Use, Development and
Review of AIM Guidelines

Standard Anatomic Coverage for Multiple Simultaneous Imaging Requests
The major area of concern is contiguous body parts where clinical signs and symptoms may be coming from abnormalities
involving either region or different modalities can be considered to evaluate the same anatomy for the same clinical problem.
These are areas where ordering multiple tests before the results of any of the tests are known lead to inappropriate imaging.
General Considerations for Multiple Simultaneous Imaging Requests
Rapid breakthroughs in technology, with attendant rise of new imaging tests available to improve patient management, have
created a dilemma for clinicians. Many factors in choosing the right test now come into play. One must consider basic data in
the decision-making process. Considerations include the possible effect on patient management, the pretest probability that
the patient is affected by a particular disease, the prevalence of the disease in the population, and the accuracy (sensitivity/
specificity) of the test. When a screening approach is adopted, rather than targeting the particular test or anatomic site with
the highest pretest probability of success, the possibility of one or more of the tests being superfluous and not contributing
meaningfully to patient management increases to an unacceptable level.
For this reason, simultaneous ordering of multiple examinations may subject these examinations to more intensive levels
of review than would be the case if these same tests were ordered sequentially. Depending on the clinical situation,
one or more of the requested studies might not meet medical necessity criteria until the results of the lead study are
known.
Common Indications for Multiple Simultaneous Imaging Requests
●● The initial diagnosis/staging or follow-up of oncology patients
●● Follow-up of patients who have had operative procedures on multiple anatomic sites
●● Patients in whom the suspected anatomic abnormality might extend into multiple regions, such as diverticulitis or
suspected syringomyelia
Common Inappropriate Multiple Simultaneous Imaging Requests
●● Brain MRA ordered routinely with brain MRI without vascular indications
●● Brain CT ordered simultaneously with sinus CT for headache
●● Multiple levels of spine MRI’s or CT’s for diffuse back pain or radicular symptoms
●● Cervical spine and shoulder MRI’s ordered simultaneously for shoulder pain
●● Pelvic or hip MRI’s ordered simultaneously with lumbar spine MRI for hip pain
●● Pelvic CT ordered routinely with abdominal CT for suspected upper quadrant disease processes
●● CT Angiography (CTA) utilizes the data obtained from standard CT imaging. Request for a CT exam, in addition to
CT Angiography of the same anatomic area AND during the same imaging session, is inappropriate
General Imaging Considerations for
All Modalities, Body Parts, and CPT
Codes

Imaging Considerations for all Exams
●● Duplicative testing or repeat imaging of the same anatomic area with same or similar technology may be subject
to high-level review and may not be medically necessary unless there is a persistent diagnostic problem or there
has been a change in clinical status (e.g., deterioration) or there is a medical intervention which warrants interval
reassessment
●● Request for re-imaging due to technically limited exams is the responsibility of the imaging providers
●● In general, follow-up exams should be performed only when there is a clinical change, with new signs or symptoms
●● AIM’s clinical guidelines do not supersede the enrollee’s health plan medical policy specific to a given exam for a
given anatomic structure
Imaging Considerations Specific to CT and CTA
●● Advantages of CTA over MRA include higher sensitivity for detection of mural calcification; usually shorter scan time,
which results in less motion, pulsation and turbulent flow artifact; avoidance of MRA in-plane flow as a cause of
apparent exaggerated stenosis; more facile detection of surgical clips and stents
●● Disadvantages of CTA include radiation exposure and use of intravascular iodinated contrast material
●● Multi-detector row CT is preferred but not required in the performance of CTA, when compared with single detector
CT
●● CTA studies are typically performed through acquisition of thin CT sections, during intravenous bolus infusion of
iodinated contrast material
●● Contrast-enhancement for CT/CTAmay be contraindicated in certain circumstances, such as a documented allergy to
intravenous contrast material and renal insufficiency. Special consideration should also be given to patients with multiple
myeloma
●● CT Angiography (CTA) utilizes imaging data from standard CT acquisitions. Request for a CT exam in addition to CT
Angiography of the same anatomic area during the same imaging session is inappropriate
Imaging Considerations Specific to MRI and MRA
Patient Compatibility Issues:
●● Artifact due to patient motion may have a particularly significant impact on exam quality
●● Metallic implants present in spine and brain
●● Eye and brain for metallic foreign bodies
●● Breath hold requirements:
○○ Some imaging sequences require breath holding and this may be difficult or impossible for some patients
●● Claustrophobic patients:
○○ Patients with claustrophobia may need to be premedicated in order to tolerate the imaging procedure. Rarely
patients with severe claustrophobia will not be suitable candidates for imaging
Biosafety Issues:
●● Ordering and imaging providers are responsible for considering biosafety issues prior to MRI/MRA examination,
to ensure patient safety. Among the generally recognized contraindications to MRI/MRA exam performance are
permanent pacemakers (some newer models are MRI/MRA compatible and others may be safe depending on
sequences used; contact imaging facility for substantiation), implantable cardioverter-defibrillators (ICD), intracranial
aneurysm surgical clips that are not compatible with MR imaging, as well as other devices considered unsafe in
MRI scanners (including certain implanted materials in the patient as well as external equipment, such as portable
oxygen tanks)
●● Contrast utilization is at the discretion of the ordering and imaging providers

Ordering Issues:
●● The CPT code assignment for an MRI procedure is based on the anatomic area imaged. Requests for multiple MRI
exams of the same anatomic area to address patient positional changes, additional sequences or equipment are not
allowed. These variations or extra sequences are included within the original imaging request.
●● There are rare circumstances when both CT and MRI exams should be ordered for the same clinical presentation.
The specific rationale for each study must be delineated at the time of request.
●● There are uncommon circumstances when both MRA and CTA should be ordered for the same clinical presentation.
The specific rationale must be delineated at the time of request.
●● Advantages of MRA, compared with CTA include avoidance of radiation exposure as well as intravascular
administration of iodinated contrast material.
●● Disadvantages of MRA, compared with CTA, include lower sensitivity for detection of mural calcification; usually
longer scanning time, with potential for greater motion, pulsation and turbulent flow artifact; in-plane flow causing
apparent exaggerated stenosis; greater difficulty in identifying surgical clips and stents.
Reference/Literature Review
1. Bossuyt PM, Irwig L, Craig J, Glasziou P. Comparative accuracy: assessing new tests against existing diagnostic
pathways. BMJ. 2006;332(7549):1089-1092.
2. Centers for Medicare and Medicaid Services. National Coverage Determination for Magnetic Resonance Imaging (NCD
220.2). Medicare Coverage Database. Effective July 7, 2011; Implementation September 26, 2011. http://www.cms.gov/
medicare-coverage-database/details/ncd-details.aspx?NCDId=177. Accessed October 27, 2011.
3. Dodd JD. Evidence-based practice in radiology: steps three and four–appraise and apply diagnostic radiology literature.
Radiology. 2007;242(2):342-354.
4. Dubilet PM, Cain KC. The superiority of sequential over simultaneous testing. Med Decis Making. 1985;5(4):447-451.
5. Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decis Making. 1991;11(2):88-94.
6. Hollingworth W, Jarvik JG. Technology assessment in radiology: putting the evidence in evidence-based radiology.
Radiology. 2007;244(1):31-38.
7. Kuhns LR, Thornberry JR, Freyback DG. Decision Making in Imaging. Chicago: Year Book Medical Publishers;1989.
8. Ng CS, Palmer CR. Analysis of diagnostic confidence and diagnostic accuracy: a unified framework. Br J Radiol.
2007;80(951):152-160.
9. Owens DK, Qaseem A, Chou R, Shekelle P; Clinical Guidelines Committee of the American College of Physicians.
High-value, cost-conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical
interventions. Ann Intern Med. 2011;154(3):174-180.

♦ List may not be exclusive | CT Head | Copyright © 2015. AIM Specialty Health. All Rights Reserved. 8
CPT Codes
70450 �� CT of head, without contrast
70460 �� CT of head, with contrast
70470 �� CT of head, without contrast, followed by re-imaging with contrast
Standard Anatomic Coverage
●● From the skull base to vertex, covering the entire calvarium and intracranial contents
●● Scan coverage may vary, depending on the specific clinical indication
Technology Considerations
●● MRI of the head is preferable to CT in most clinical scenarios, due to its superior contrast resolution and lack of
beam-hardening artifact adjacent to the petrous bone (which may limit visualization in portions of the posterior fossa
and brainstem on CT)
●● Exceptions to the use of brain MRI as the neuroimaging study of choice and clinical situations where CT head is
preferred: osseous assessment of the calvarium, skull base and maxillofacial bones, including detection of calvarial
and facial bone fractures; calcified lesions; initial evaluation of recent craniocerebral trauma; and acute intracranial
hemorrhage (parenchymal, subarachnoid, subdural, epidural)
●● MRI is more sensitive for detection of shearing trauma to the brain and diffuse axonal injury. It is also the preferred
technique for assessment of subacute and chronic intracranial hemorrhage
●● CT of the head is an alternative exam in patients for whom MRI is contraindicated or who cannot tolerate MRI
●● Imaging studies of the head and neck are inherently bilateral, thus duplicate requests for these studies are inappropriate
●● CT is not typically indicated for sudden hearing loss in the absence of other neurological findings1,2
Common Diagnostic Indications
The following diagnostic indications for head CT are accompanied by pre-test considerations as well as clinical supporting data
and prerequisite information
Abnormality detected on other imaging study which requires additional clarification to direct
treatment
Ataxia, congenital or hereditary
(any one♦ of the following)
●● Ataxia-telangiectasia
●● Congenital anomaly (particularly one of the posterior fossa)
●● Fragile X syndrome
Cerebrovascular accident (CVA or stroke) or transient ischemic attack (TIA)
●● Sudden onset of new clinical finding on exam that suggests CVA or TIA
Note: Includes acute vascular injury. Among patients being evaluated for CVA and possible thrombolytic therapy,
unenhanced CT is generally preferred as the initial modality (within the first 24 hours of symptom onset) to detect a
possible hemorrhagic stroke or mass lesion
Chiari malformation (Arnold-Chiari malformation)
CT Head – Pediatrics

Congenital anomaly, not otherwise listed
●● Diagnosis or management (any one♦ of the following)
○○ Agenesis of the corpus callosum
○○ Blake pouch cyst
○○ Cephalocele
○○ Dandy walker spectrum
○○ De Morsier syndrome (septo-optic dysplasia)
○○ Encephalocele
○○ Focal cortical dysplasia
○○ Grey mater heterotopia
○○ Hemimegalencephaly
○○ Holoprosencephaly
○○ Joubert syndrome
○○ Nasal glioma
○○ Rhombencephalosynapsis
○○ Schizencephaly
Contraindication to MRI
●● Patient meets criteria for MRI exam (any one of the following)
○○ Patient has a contraindication to MRI (examples include metallic foreign bodies, permanent pacemaker,
implantable cardioverter-defibrillators, and intracranial aneurysm surgical clips that are not compatible with MR
imaging)
○○ Patient is claustrophobic and unable to tolerate MRI
Craniosynostosis
Note: This includes brachycaphaly (coronal synostosis), plagiocephaly (unilateral coronal or lambdoidal synostosis),
scaphocephaly/dolichocephaly (sagittal synostosis), syndromic craniosynostosis (Apert syndrome or Crouzon
syndrome), and trigonocephaly (metopic synostosis)
Developmental delay3-8
(any one of the following)
●● Cerebral palsy
●● Global developmental delay (any two of the following)
○○ Activities of daily living
○○ Cognition
○○ Motor skills (gross/fine)
○○ Social/personal
○○ Speech/language
Note: Global developmental delay is defined as significant delay or loss of milestones in at least two of the domain’s listed
above

Headache, new onset9-10
●● Family or personal history of disorders with predisposition to CNS lesions and clinical/laboratory findings that
suggest CNS involvement, for example aneurysm or tumor
●● Headache that awakens the patient repeatedly from sleep or develops upon awakening
●● Neurological abnormalities such as nystagmus, papilledema, gait or motor disturbances
●● Patient is developmentally delayed
●● Sudden onset and severe headache (includes thunderclap headache or worst headache of life)
Note: New onset headaches are headaches that have occurred for the first time within 30 days of the imaging request. If
associated with trauma or infection, see separate indication for Trauma or Infectious/Inflammatory
Headache, persistent or recurrent
●● Abnormal neurological exam11-15
○○ Abnormal reflexes (hyperreflexia/hyporeflexia)
○○ Altered mental status (confused or disoriented)
○○ Cranial nerve deficit
○○ Gait /motor dysfunction
○○ Nystagmus
○○ Seizure
○○ Sensory deficit (numbness, paresthesia)
○○ Sign of increased intracranial pressure (increased head circumference, vomiting, papilledema, headache worse
with valsalva)
○○ Vomiting
●● Change in quality (pattern or intensity) of a previously stable headache10,11
●● Headache persisting for a period of up to 6 months duration and not responsive to medical treatment
●● No family history of migraines
Note: Persistent headaches are those lasting more than 30 days; recurrent headaches are those where the resolution and
recurrence are separated by at least a 30 day period. If separated by less than 30 days, these headaches would be
considered persistent
Hearing loss
Note: This includes conductive, sensorineural16-18
, and mixed hearing loss. CT is generally preferred for conductive and
mixed. MRI is generally preferred for sensorineural
Hemorrhage or hematoma
●● For non-traumatic, non-CVA and non-tumor-related intracranial bleed (includes hemorrhage secondary to
anticoagulation or blood dyscrasia)
Note: CT is the preferred technique for evaluation of acute intracranial hemorrhage; MRI is generally preferred for
evaluation of subacute and chronic hemorrhage
Hydrocephalus (ventriculomegaly)
●● Patient is younger than five (5) months of age following an abnormal or non-diagnostic ultrasound
Note: MRI is generally preferred for initial evaluation of patients with hydrocephalus. For patients with an indwelling shunt,
CT is usually adequate in the diagnostic follow-up of hydrocephalus

Increased intracranial pressure
●● Bulging fontanelle
●● Headache worse with valsalva
●● Increased head circumference
●● Papilledema
●● Vomiting
Infectious or inflammatory process
●● Cerebral or cerebellar abscess
●● Encephalitis (including limbic encephalitis)
●● Meningitis
●● Neurocysticercosis
●● Opportunistic infection, particularly with immunosuppressed or other immunodeficient conditions
●● Subdural empyema
Macrocephaly
●● Patient’s head circumference is greater than two (2) standard deviations from the mean for his/her age and gender
○○ Patient is younger than five (5) months of age following non-diagnostic ultrasound
○○ Patient is five (5) months of age or older
Mental status change
●● Abnormality on a neurologic exam
Microcephaly19
●● Patient’s head circumference is less than two (2) standard deviations from the mean for his/her age and gender
Multiple sclerosis or other white-matter diseases, when MRI is contraindicated or not tolerated
●● Diagnosis
●● Evaluation of changes in neurologic signs and symptoms
●● For multiple sclerosis (any one of the following)
○○ Assess asymptomatic disease progression
○○ Evaluate response to treatment
○○ Track disease progression to establish a prognosis
Neurocutaneous disorder (phakomatosis)
●● Neurofibromatosis
●● Sturge-Weber syndrome
●● Tuberous sclerosis
●● Von Hippel-Lindau disease (VHL)
Neuroendocrine abnormality
●● When clinical findings are suggestive of a pituitary lesion
Note: MRI is generally preferred over CT for evaluation of pituitary lesions

Neurological findings/deficits
●● New onset or progressively worsening findings (any one♦ of the following)
○○ Anosmia (loss or impairment in sense of smell)
○○ Bell’s palsy
○○ Dysgeusia (dysfunction in sense of taste)
○○ Facial numbness
○○ Gait abnormality
○○ Hoarseness
○○ Hypotonia
○○ Nystagmus (rapid, involuntary, oscillating ocular movements)
○○ Other movement disorders
○○ Other cranial nerve impairment
○○ Paresis or paralysis
○○ Spasticity
○○ Tinnitus20-23
Note: Contrast-enhanced MRI, unless contraindicated, is generally recommended for evaluation of cranial nerve impairment.
Papilledema
Post-operative or post-procedure evaluation
Note: For post-operative evaluation of conditions not specifically referenced elsewhere in this guideline
Pre-operative evaluation or pre-procedure evaluation
Note: For pre-operative evaluation of conditions not specifically referenced elsewhere in this guideline
Pseudotumor cerebri
Seizures and epilepsy
Complex febrile seizure
●● Patient is between 6 months and five years of age and febrile (any one of the following)
○○ More than one seizure during a febrile period
○○ Prolonged seizure lasting more than 15 minutes
Note: Imaging is not generally indicated for simple febrile seizures24-28
Neonatal/Infantile seizure29
●● Patient is age two years or younger (any one of the following)
○○ Afebrile
○○ If initial MRI is non-diagnostic, periodic follow-up could be considered at 6-month intervals up to 30 months27
Childhood/Adolescent seizure
●● Patient is older than two years of age (any one of the following)
○○ Focal neurologic finding of cognitive impairment, motor impairment, or persistent neurologic deficit after the
seizure (postictal) 28
○○ Idiopathic epilepsy with atypical clinical course26-30
○○ Partial seizures26,28
○○ Seizures increasing in frequency and severity despite optimal medical management
○○ When there is an electroencephalogram (EEG) abnormality that is inconsistent with idiopathic epilepsy (Also
referred to as benign epilepsy)
Note: Seizure, defined as a single episode of excessive neuronal activity that causes changes in attention and behavior.31
Epilepsy, defined as the presence of recurrent seizures. Idiopathic epilepsy includes benign childhood epilepsy
with centrotemporal spikes (rolandic) (BECTS), childhood absence epilepsy, juvenile absence epilepsy, juvenile
myoclonic epilepsy, and simple febrile seizures)

Syncope or near syncope
●● Abnormality on neurological examination
●● Persistent neurological symptom
●● Seizure activity was witnessed or highly suspected at the time of the syncope
Note: Syncope is defined as complete loss of consciousness. Near syncope is defined as partial loss of consciousness.
Trauma, head
●● Evaluation and/or management unless the patient is low risk (see table below for what constitutes low risk24,32-36
●● Non-accidental injury (NAI)37
Note: Guideline does not apply to patients with bleeding diathesis or intracranial shunts.
Pediatric patient is considered to be Low Risk when all of the following clinical features are present:
Infants (younger than 2 years of age) Children (2 years of age and older)
●● Normal mental status
●● Normal behavior
●● No loss of consciousness
●● No scalp hematoma other than frontal
●● No history of high risk motor vehicle collision (MVC)
(High risk MVCs are those with patient ejection,
passenger death, or rollover, or pedestrian or
unhelmeted bicyclist struck by a motor vehicle)
●● No history of high risk non-MVC trauma (High risk non-
MVC trauma are falls greater than 3 feet or head struck
by a high-impact object [e.g. baseball])
●● Normal mental status
●● Normal behavior
●● No loss of consciousness
●● No vomiting
●● No severe headache
●● No signs of basilar skull fracture (hemotympanum,
rhinorrhea, otorrhea, “raccoon” eyes, post auricular
hematoma)
●● No history of high risk motor vehicle collision (MVC)
(High risk MVCs are those with patient ejection,
passenger death, or rollover, or pedestrian or
unhelmeted bicyclist struck by a motor vehicle)
●● No history of high risk non-MVC trauma (High risk non-
MVC trauma are falls greater than 5 feet or head struck
by a high-impact object [e.g. baseball])
Tumor, benign or malignant
●● Evaluation of metastatic disease
●● Evaluation of primary intracranial tumors
●● Surveillance of unexplained mass/lesion identified on prior imaging without pathologic tissue confirmation (examples
include suspected arachnoid cyst or epidermoid cyst)
Vascular abnormality
●● Structural abnormality (any one♦ of the following)
○○ Aneurysm
○○ Arteriovenous malformation (AVM)
○○ Cavernous malformation
○○ Cerebral vein thrombosis
○○ Dural arteriovenous fistula (DAVF)
○○ Dural venous sinus thrombosis
○○ Venous angioma
Note: Either CTA or MRA may be preferred
Ventricular shunt assessment

Vertigo and dizziness
(All of the following)
●● Abnormal audiogram or auditory brainstem response
●● Evaluation for other etiologies has not been revealing
●● Symptoms are recurrent or persistent
Visual disturbance
●● When unexplained by ophthalmologic exam and patient history
Note: Includes visual field loss, diplopia, and other alterations in vision
CT is generally not indicated in the following clinical situations
The indications listed in this section generally do not require advanced imaging using CT. If there are circumstances that
require CT imaging, a peer-to-peer discussion may be required.
Migraine
Note: Imaging is not generally indicated for typical presentations. For atypical cases see headache, new onset or
headache, persistent or recurrent
References
1. American Academy of Otolaryngology — Head and Neck Surgery Foundation. Choosing Wisely: Five Things
Physicians and Patients Should Question. ABIM Foundation; February 21, 2013. www.choosingwisely.org
2. Stac hler RJ, Chandrasekhar SS, Archer SM, et al. Clinical practice guideline: Sudden hearing loss. Otolaryngol Head
Neck Surg. 2012;146(3 Suppl):S1-S35.
3. Accardo J, Kammann H, Hoon AH Jr. Neuroimaging in cerebral palsy. J Pediatr. 2004;145(2 Suppl):S19-S27.
4. Momen AA, Jelodar G, Dehdashti H. Brain magnetic resonance imaging findings in developmentally delayed children.
Int J Pediatr. 2011;2011:386984.
5. Shevell M, Ashwal S, Donley D, et al. Practice parameter: evaluation of the child with global developmental delay: report
of the Quality Standards Subcommittee of the American Academy of Neurology and The Practice Committee of the Child
Neurology Society. Neurology. 2003;60(3):367-380.
6. Truiwit CL, Barkovich AJ, Koch TK, Ferriero DM. Cerebral palsy: MR finding in 40 patients. Am J Neuroradiol.
1992;13:67-78.
7. Candy EJ, Hoon AH, Capute AJ, Bryan RN. MRI in motor delay: important adjunct to classification of cerebral palsy.
Pediatr Neurol. 1993;9:421-429.
8. Ashwal S, Russman BS, Blasco P, et al. Practice parameter: diagnostic assessment of the child with cerebral palsy:
report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of
the Child Neurology Society. Neurology. 2004;62(6):851-863.
9. Medina LS, D’Souza B, Vasconcellos E. Adults and children with headache: evidence-based diagnostic evaluation.
Neuroimag Clin N Am. 2003;13:225-235.
10. Alexiou GA, Argyropoulou MI. Neuroimaging in childhood headache: a systematic review. Pediatr Radiol.
2013;43(7):777-784.
11. Frishberg BM, Rosenberg JH, Matchar DB, et al; U.S. Headache Consortium. Evidence-Based Guidelines in the Primary
Care Setting: Neuroimaging in Patients with Non-acute Headache. American Academy of Neurology; April 2000.
12. Alehan FK. Value of neuroimaging in the evaluation of neurologically normal children with recurrent headache. J Child
Neurol. 2002 Nov;17(11):807-809.
13. Dooley JM, Camfield PR, O’Neill M, Vohra A. The value of CT scans for children with headaches. Can J Neurol Sci.
1990;17:309-310.
14. Medina LS, Pinter JD, Zurakowski D, Davis R, Kuban K, Barnes PD. Children with headache: clinical predictors of the
surgical space-occupying lesions and the role of neuroimaging. Radiology. 1997;202:819-824.
15. Strain JD. ACR Appropriateness Criteria on headache-child. J Am Coll Radiol. 2007;4(1):18-23.
16. Huang BY, Zdanski C, Castillo M. Pediatric sensorineural hearing loss, part 1: Practical aspects for neuroradiologists.
AJNR Am J Neuroradiol. 2012 Feb;33(2):211-217.

17. Huang BY, Zdanski C, Castillo M. Pediatric sensorineural hearing loss, part 2: syndromic and acquired causes. AJNR
Am J Neuroradiol. 2012 Mar;33(3):399-406.
18. Morzaria S, Westerberg BD, Kozak FK. Evidence-based algorithm for the evaluation of a child with bilateral
sensorineural hearing loss. J Otolaryngol. 2005 Oct;34(5):297-303.
19. Ashwal S, Michelson D, Plawner L, Dobyns WB, Quality Standards Subcommittee of the American Academy of
Neurology and the Practice Committee of the Child Neurology Society. Practice parameter: Evaluation of the child with
microcephaly (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of
Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2009;73(11):887-897.
20. Baguley D, McFerran D, Hall D. Tinnitus. Lancet. 2013 Nov 9;382(9904):1600-1607.
21. Sajisevi M, Weissman JL, Kaylie DM. What is the role of imaging in tinnitus? Laryngoscope. 2014 Mar;124(3):583-4.
22. Vattoth S, Shah R, Curé JK. A compartment-based approach for the imaging evaluation of tinnitus. AJNR Am J
Neuroradiol. 2010 Feb;31(2):211-218.
23. Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology. 2000;216:342-349
24. American Academy of Pediatrics. Choosing Wisely: Five Things Physicians and Patients Should Question. ABIM
Foundation; February 21, 2013. www.choosingwisely.org
25. American Academy of Pediatrics.Subcommittee on Febrile Seizures. Febrile seizures: Guideline for the neurodiagnostic
evaluation of the child with a simple febrile seizure. Pediatrics. 2011 Feb;127(2):389-394.
26. National Health Services, National Institute for Clinical Excellence. The epilepsies: The diagnosis and management of
the epilepsies in adults and children in primary and secondary care. October 2004. http://www.nice.org.uk/guidance/
cg137. Accessed September 10, 2014.
27. Gaillard WD, Chiron C, Cross JH, et al; ILAE, Committee for Neuroimaging, Subcommittee for Pediatric. Guidelines for
imaging infants and children with recent-onset epilepsy. Epilepsia. 2009 Sep;50(9):2147-2153.
28. Hirtz D, Ashwal S, Berg A, et al. Practice parameter: evaluating a first nonfebrile seizure in children: report of the quality
standards subcommittee of the American Academy of Neurology, The Child Neurology Society, and The American
Epilepsy Society. Neurology. 2000 Sep 12;55(5):616-623.
29. Hsieh DT, Chang T, Tsuchida TN, et al. New-onset afebrile seizures in infants: role of neuroimaging. Neurology.
2010;74(2):150-156.
30. Berg AT, Mathern GW, Bronen RA, et al. Frequency, prognosis and surgical treatment of structural abnormalities seen
with magnetic resonance imaging in childhood epilepsy. Brain. 2009;132(Pt 10):2785-2797.
31. Fisher RS, van Emde Boas W, Blume W, et al. Epileptic seizures and epilepsy: definitions proposed by the International
League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia. 2005;46(4):470-472.
32. Duhaime AC, Alario AJ, Lewander WJ, et al. Head injury in very young children: mechanisms, injury types, and
ophthalmologic findings in 100 hospitalized patients younger than 2 years of age. Pediatrics.1992; 90:179-185.
33. Easter JS, Bakes K, Dhaliwal J, Miller M, Caruso E, Haukoos JS. Comparison of PECARN, CATCH, and CHALICE rules
for children with minor head injury: a prospective cohort study. Ann Emerg Med. 2014 Aug;64(2):145-152, 152.e1-5.
34. Schonfeld D, Bressan S, Da Dalt L, Henien MN, Winnett JA, Nigrovic LE. Pediatric Emergency Care Applied Research
Network head injury clinical prediction rules are reliable in practice. Arch Dis Child. 2014;99(5):427-431.
35. American Association of Neurological Surgeons. Choosing Wisely: Five Things Physicians and Patients Should
Question. ABIM Foundation; 2014. Available at www.choosingwisely.org.
36. Kuppermann N, Holmes, JF, Dayan PS, et al; Pediatric Emergency Care Applied Research Network (PECARN).
Identification of children at very low-risk of clinically-important brain injuries after head trauma: A prospective cohort
study. Lancet. 2009;374(9696):1160-1170.
37. Meyer JS, Gunderman R, Coley BD, et al. ACR Appropriateness Criteria® on suspected physical abuse-child. J Am Coll
Radiol. 2011;8(2):87-94.

♦ List may not be exclusive | CTA of the Head | Copyright © 2015. AIM Specialty Health. All Rights Reserved. 16
CPT Codes
70496 �� Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if
performed, and image postprocessing
Angiography includes imaging of all blood vessels, including arteries and veins. The code above includes CT Venography.
●● CTA may be performed to assess the major intracranial arteries of the anterior and posterior circulations (including
the Circle of Willis) as well as the venous structures (major veins and dural venous sinuses)
●● For specific clinical indications, exams may be tailored to the region of interest
●● CTA of the head is an alternative exam in patients who cannot undergo MRA
●● During diagnostic interpretation, it is extremely useful to have images displayed on a workstation capable of
multiplanar reformations and three-dimensional reconstructions
The following diagnostic indications for head CTA are accompanied by pre-test considerations as well as clinical supporting
data and prerequisite information
treatment
Aneurysm
●● Family history of intracranial aneurysm
●● Follow-up of known or suspected intracranial aneurysm
●● Hereditary disorder, such as autosomal dominant polycystic kidney disease (10%-20% occurrence of aneurysm),
Ehlers Danlos syndrome type IV, and Neurofibromatosis type 1
Arteriovenous malformation (AVM)
Congenital anomaly of the cerebral circulation
●● Diagnosis prior to an interventional procedure
Note: This includes persistent fetal carotid vertebrobasilar anastomosis (e.g. hypoglossal artery, otic artery, proatlantal
artery, or trigeminal artery). Most congenital variations are incidental findings with no clinical significance1
Dural arteriovenous fistula (DAVF)
Dissection
Endovascular neurointerventional procedure
●● For post-treatment evaluation (any one of the following)
○○ Intracranial aneurysm
CTA, CTV Head: Cerebrovascular –
Pediatrics

Headache
●● Exertional headache
●● Positional headache
●● Sudden onset of worst headache of life
Intracranial hemorrhage
●● For identification of the source of hemorrhage
Note: CT is the preferred technique for evaluation of acute intracranial hemorrhage. MRI is generally preferred for
Intramural hematoma
Recent cerebrovascular accident (CVA)
●● Demonstrated on head CT or MRI
Stenosis or occlusion of the carotid or cerebral arteries
●● Clinically suspected or known steno-occlusive disease especially (any one♦ of the following):
○○ Idiopathic progressive arteriopathy of childhood
○○ Moyamoya disease
○○ Sickle cell disease
●● Clinical manifestation (any one♦ of the following)
○○ Confusion
○○ Difficulty speaking or understanding speech
○○ Dizziness
○○ Gait disturbance
○○ Loss of balance or coordination
○○ Loss of consciousness
○○ Numbness, weakness or paralysis of the face, arm or leg, on one side of the body
○○ Sudden severe headache, that is unexplained
○○ Visual disturbance, particularly in one eye
Note: Stenosis or occlusion in the pediatric population is usually a result of vascular abnormalities from a systemic or
congenital disease and rarely from atherosclerotic disease

Stenosis or occlusion of the vertebral or basilar arteries
●● Signs or symptoms of vertebrobasilar insufficiency (VBI) or vertebral basilar ischemia (any one♦ of the following)
○○ Acute sensorineural hearing loss
○○ Ataxia
○○ Diplopia
○○ Dysarthria
○○ Dysphagia
○○ Facial numbness or paresthesia
○○ Limb or trunk sensory deficit
○○ Loss of taste sensation
○○ Motor paresis
○○ Nystagmus
○○ Syncope
○○ Vertigo
○○ Visual field defect
Note: Symptoms of VBI are usually temporary, due to diminished blood flow in the posterior circulation of the brain.
Stenosis or occlusion in the pediatric population is usually a result of vascular abnormalities from a systemic or
Thromboembolic disease of major intracranial arterial or venous systems
Note: Includes dural venous sinus thrombosis
Tinnitus
●● Pulsatile tinnitus for vascular etiology
Traumatic vascular injury
Vascular supply to tumor
Vasculitis
References
1. Uchino A, Sawada A, Takase Y, Kudo S.MR angiography of anomalous branches of the internal carotid artery. AJR Am J
Roentgenol. 2003 Nov;181(5):1409-1414.

♦ List may not be exclusive | MRI of the Head/Brain | Copyright © 2015. AIM Specialty Health. All Rights Reserved. 19
CPT Codes
70551 �� MRI Head, without contrast
70552 �� MRI Head, with contrast
70553 �� MRI Head, without contrast, followed by re-imaging with contrast
●● From skull base to vertex, covering the entire calvarium and intracranial contents, including the internal auditory canals
Modality overview
●● MRI of the head is preferable to CT in most clinical scenarios, due to its superior contrast resolution and lack of
beam-hardening artifact adjacent to the petrous bone (which may limit visualization in portions of the posterior fossa
and brainstem on CT). Exceptions to the use of brain MRI as the neuroimaging procedure of choice and situations
with preferred head imaging using CT include: osseous assessment of the calvarium, skull base and maxillofacial
bones, including detection of calvarial and facial bone fractures; calcified lesions; initial evaluation of recent
craniocerebral trauma; and acute intracranial hemorrhage (parenchymal; subarachnoid; subdural; epidural)
●● MRI is more sensitive for detection of shearing trauma to the brain and diffuse axonal injury. It is also the preferred
technique for assessment of subacute and chronic intracranial hemorrhage
●● CT of the head is an alternative exam in patients who cannot undergo MRI
●● Images of the pituitary gland, maxillary sinuses or internal auditory canals (IACs) are included within the single assigned
CPT code for MRI imaging of the head and are not separately billable as multiple concurrent head MRI exams
●● Imaging studies of the head and neck are inherently bilateral, thus duplicate requests for these studies are
inappropriate
Indications for contrast
The majority of indications for brain MRI do not require contrast (CPT 70551). MRI brain with and without contrast (CPT
70553) is appropriate when there is concern for neoplasm, infection/inflammation and vascular malformations, and may be
indicated for the following pathways (note some clinical scenarios within these indications may not require contrast):
●● Abnormality detected on other imaging study which
requires additional clarification to direct treatment
●● Ataxia
●● Headache
●● Hearing loss
●● Hydrocephalus
●● Infectious or inflammatory process
●● Multiple sclerosis or other demyelinating white matter
disease
●● Neurocutaneous disorder
●● Neuroendocrine abnormality
●● Neurological findings/deficits
●● Post-operative or post-procedure evaluation
●● Pseudotumor cerebri
●● Seizures and epilepsy
●● Tumor
●● Vascular abnormality
●● Visual disturbance
Imaging with contrast is rarely appropriate for the evaluation of other indications for brain MRI
in this guideline
MRI Head/Brain – Pediatrics

The following diagnostic indications for head MRI are accompanied by pre-test considerations as well as supporting clinical
treatment
Ataxia, congenital or hereditary
●● Ataxia-telangiectasia
●● Congenital anomaly (particularly one of the posterior fossa)
●● Fragile X syndrome
Cerebrovascular accident (CVA or stroke) or transient ischemic attack (TIA)
●● Sudden onset of new clinical finding on exam that suggests CVA or TIA
Note: Includes acute vascular injury. Among patients being evaluated for CVA and possible thrombolytic therapy,
unenhanced CT is generally preferred as the initial modality (within the first 24 hours of symptom onset) to detect a
possible hemorrhagic stroke or mass lesion
Chiari malformation (Arnold-Chiari malformation)
●● Diagnosis or management (any one♦ of the following)
○○ Agenesis of the corpus callosum
○○ Blake pouch cyst
○○ Cephalocele
○○ Dandy walker
○○ De Morsier syndrome
○○ Encephalocele
○○ Focal cortical dysplasia
○○ Grey mater heterotopia
○○ Hemimegalencephaly
○○ Holoprosencephaly
○○ Joubert syndrome
○○ Nasal glioma
○○ Rhombencephalosynapsis
○○ Schizencephaly
Developmental delay4-6
●● Cerebral palsy4, 8-10
●● Global developmental delay (any two of the following)
○○ Activities of daily living
○○ Cognition7
○○ Motor skills (gross/fine)
○○ Social/personal
○○ Speech/language
Note: Global developmental delay is defined as significant delay or loss of milestones in at least two of the domain’s listed
above
Diffuse axonal injury

Encephalopathy
Headache, new onset12,13,19
●● Family or personal history of disorders with predisposition to CNS lesions and clinical/laboratory findings that
suggest CNS involvement, for example aneurysm or tumor
●● Headache that awakens the patient repeatedly from sleep or develops upon awakening
●● Neurological abnormalities such as nystagmus, papilledema, gait or motor disturbances
●● Patient is developmentally delayed
●● Sudden onset and severe headache (includes thunderclap headache or worst headache of life)
Note: New onset headaches are headaches that have occurred for the first time within 30 days of the imaging request. If
associated with trauma or infection, see separate indication for Trauma or Infectious/Inflammatory
Headache, persistent or recurrent
●● Abnormal neurological exam14-17
○○ Abnormal reflexes (hyperreflexia/hyporeflexia)
○○ Altered mental status (confused or disoriented)
○○ Cranial nerve deficit
○○ Gait /motor dysfunction
○○ Nystagmus
○○ Seizure
○○ Sensory deficit (numbness, paresthesia)
○○ Sign of increased intracranial pressure (increased head circumference, vomiting, papilledema, headache worse
with valsalva)
○○ Vomiting
●● Change in quality (pattern or intensity) of a previously stable headache13,14
●● Headache persisting for a period of up to 6 months duration and not responsive to medical treatment
●● No family history of migraines
Note: Persistent headaches are those lasting more than 30 days; recurrent headaches are those where the resolution and
recurrence are separated by at least a 30 day period. If separated by less than 30 days, these headaches would be
considered persistent
Hearing loss
Note: This includes conductive, sensorineural, and mixed hearing loss. CT is generally preferred for conductive and mixed.
MRI is generally preferred for sensorineural25-27
Hemorrhage or hematoma
●● For non-traumatic, non-CVA and non-tumor-related intracranial bleed (includes hemorrhage secondary to
anticoagulation or blood dyscrasia)
Note: CT is the preferred technique for evaluation of acute intracranial hemorrhage; MRI is generally preferred for
Hydrocephalus (ventriculomegaly)
●● Patient is younger than five (5) months of age following an abnormal or non-diagnostic ultrasound
Note: MRI is generally preferred for initial evaluation of patients with hydrocephalus. For patients with an indwelling shunt,
CT is usually adequate in the diagnostic follow-up of hydrocephalus

Increased intracranial pressure
●● Bulging fontanelle
●● Headache worse with valsalva
●● Increased head circumference
●● Papilledema
●● Vomiting
●● Cerebral or cerebellar abscess
●● Encephalitis (including limbic encephalitis)
●● Meningitis
●● Neurocysticercosis
●● Opportunistic infection, particularly with immunosuppressed or other immunodeficient conditions
●● Subdural empyema
Macrocephaly
●● Patient’s head circumference is greater than two (2) standard deviations from the mean for his/her age and gender
○○ Patient is younger than five (5) months of age following non-diagnostic ultrasound
○○ Patient is five (5) months of age or older
Mental status change
●● Abnormality on a neurologic exam
Microcephaly3
●● Patient’s head circumference is less than two (2) standard deviations from the mean for his/her age and gender
Multiple sclerosis or other white-matter diseases
●● Diagnosis
●● Evaluation of changes in neurologic signs and symptoms
●● For multiple sclerosis (any one of the following)
○○ Assess asymptomatic disease progression
○○ Evaluate response to treatment
○○ Track disease progression to establish a prognosis
Neurocutaneous disorder (phakomatosis)
●● Neurofibromatosis
●● Sturge-Weber syndrome
●● Tuberous sclerosis
●● Von Hippel-Lindau disease (VHL)
Neuroendocrine abnormality
●● When clinical findings are suggestive of a pituitary lesion

Neurological findings/deficits
●● New onset or progressively worsening findings (any one♦ of the following)
○○ Anosmia (loss or impairment in sense of smell)
○○ Bell’s palsy
○○ Dysgeusia (dysfunction in sense of taste)
○○ Facial numbness
○○ Gait abnormality
○○ Hoarseness
○○ Hypotonia
○○ Paresis or paralysis
○○ Spasticity
○○ Tinnitus28-31
Note: Contrast-enhanced MRI, unless contraindicated, is generally recommended for evaluation of cranial nerve
impairment.
Papilledema
Pseudotumor cerebri
Seizures and epilepsy
Complex febrile seizure19
●● Patient is between 6 months and five years of age and febrile (any one of the following)
○○ More than one seizure during a febrile period
○○ Prolonged seizure lasting more than 15 minutes
Note: Imaging is not generally indicated for simple febrile seizures1,2,21,23,24
Neonatal/Infantile seizure20
●● Patient is age two years or younger (any one of the following)
○○ Afebrile
○○ If initial MRI is non-diagnostic, periodic follow-up could be considered at 6-month intervals up to 30 months21
Childhood/Adolescent seizure
●● Patient is older than two years of age (any one of the following)
○○ Focal neurologic finding of cognitive impairment, motor impairment, or persistent neurologic deficit after the
seizure (postictal)23
○○ Idiopathic epilepsy with atypical clinical course20-24
○○ Partial seizures23,24
○○ Seizures increasing in frequency and severity despite optimal medical management
○○ When there is an electroencephalogram (EEG) abnormality that is inconsistent with idiopathic epilepsy (Also
referred to as benign epilepsy)
Note: Seizure, defined as a single episode of excessive neuronal activity that causes changes in attention and behavior18
.
Epilepsy, defined as the presence of recurrent seizures11
. Idiopathic epilepsy includes benign childhood epilepsy
with centrotemporal spikes (rolandic) (BECTS), childhood absence epilepsy, juvenile absence epilepsy, juvenile
myoclonic epilepsy, and simple febrile seizures)

Syncope or near syncope
●● Abnormality on neurological examination
●● Persistent neurological symptom
●● Seizure activity was witnessed or highly suspected at the time of the syncope
Note: Syncope is defined as complete loss of consciousness. Near syncope is defined as partial loss of consciousness.
Trauma
Note: Includes non-accidental trauma.32
Acute bleeding is better imaged with CT
●● Surveillance of unexplained mass/lesion identified on prior imaging without pathologic tissue confirmation (Examples
include suspected arachnoid cyst or epidermoid cyst)
Vascular abnormality
●● Structural abnormality (any one♦ of the following)
○○ Aneurysm
○○ Cavernous malformation
○○ Cerebral vein thrombosis
○○ Dural venous sinus thrombosis
○○ Venous angioma
Note: CTA or MRA may be preferred
Ventricular shunt assessment
Visual disturbance
●● When unexplained by ophthalmologic exam and patient history
Note: Includes visual field loss, diplopia, and other alterations in vision
MRI is generally not indicated in the following clinical situations
The indications listed in this section generally do not require advanced imaging using MRI. If there are circumstances that
require MRI imaging, a peer-to-peer discussion may be required.
Migraine
Note: Imaging is not generally indicated for typical presentations. For atypical cases see headache, new onset or
headache, persistent or recurrent

References
1. American Academy of Pediatrics. Five Things Physicians and Patients Should Question. ABIM Foundation; February 21,
2013. www.choosingwisely.org
2. American Academy of Pediatrics.Subcommittee on Febrile Seizures. Febrile seizures: Guideline for the neurodiagnostic
evaluation of the child with a simple febrile seizure. Pediatrics. 2011 Feb;127(2):389-394.
3. Ashwal S, Michelson D, Plawner L, et al. Practice parameter: Evaluation of the child with microcephaly (an evidence-
based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice
Committee of the Child Neurology Society. Neurology. 2009;73(11):887-897.
4. Accardo J, Kammann H, Hoon AH Jr. Neuroimaging in cerebral palsy. J Pediatr. 2004;145(2 Suppl):S19-S27.
5. Momen AA, Jelodar G, Dehdashti H. Brain magnetic resonance imaging findings in developmentally delayed children.
Int J Pediatr. 2011;2011:386984.
6. Shevell M, Ashwal S, Donley D, et al. Practice parameter: evaluation of the child with global developmental delay: report
of the Quality Standards Subcommittee of the American Academy of Neurology and The Practice Committee of the Child
Neurology Society. Neurology. 2003 Feb 11;60(3):367-380.
7. Curry CJ, Stevenson RE, Aughton D, et al. Evaluation of mental retardation: recommendations of a Consensus
Conference: American College of Medical Genetics. Am J Med Genet. 1997;72(4):468-477.
8. Truiwit CL, Barkovich AJ, Koch TK, Ferriero DM. Cerebral palsy: MR finding in 40 patients. Am J Neuroradiol.
1992;13:67-78.
9. Candy EJ, Hoon AH, Capute AJ, Bryan RN. MRI in motor delay: important adjunct to classification of cerebral palsy.
Pediatr Neurol. 1993;9:421-9.
10. Ashwal S, Russman BS, Blasco P, et al. Practice parameter: diagnostic assessment of the child with cerebral palsy:
report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of
the Child Neurology Society. Neurology. 2004;62(6):851-863.
11. Rastogi S, Lee C, Salamon N. Neuroimaging in pediatric epilepsy: a multimodality approach. Radiographics.
2008;28(4):1079-1095
12. Medina LS, D’Souza B, Vasconcellos E. Adults and children with headache: evidence-based diagnostic evaluation.
Neuroimag Clin N Am. 2003;13:225-235.
13. Alexiou GA, Argyropoulou MI. Neuroimaging in childhood headache: a systematic review. Pediatr Radiol. 2013
Jul;43(7):777-784.
14. Frishberg BM, Rosenberg JH, Matchar DB, et al; U.S. Headache Consortium. Evidence-Based Guidelines in the Primary
Care Setting: Neuroimaging in Patients with Non-acute Headache. American Academy of Neurology; April 2000.
15. Alehan FK. Value of neuroimaging in the evaluation of neurologically normal children with recurrent headache. J Child
Neurol. 2002;17(11):807-809.
16. Strain JD. ACR Appropriateness Criteria on headache-child. J Am Coll Radiol. 2007;4(1):18-23.
17. Medina LS, Pinter JD, Zurakowski D, Davis R, Kuban K, Barnes PD. Children with headache: clinical predictors of the
surgical space-occupying lesions and the role of neuroimaging. Radiology. 1997;202:819-824.
18. Fisher RS, van Emde Boas W, Blume W, et al. Epileptic seizures and epilepsy: definitions proposed by the International
League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia.2005;46(4):470-472.
19. Committee on Quality Improvement, Subcommittee on Febrile Seizures. Practice Parameter: Long-term Treatment of
the Child With Simple Febrile Seizures. Pediatrics. 1999;103;1307.
20. Hsieh DT, Chang T, Tsuchida TN, et al. New-onset afebrile seizures in infants: role of neuroimaging. Neurology.
2010;74(2):150-156.
21. Gaillard WD, Chiron C, Cross JH, et al.; ILAE, Committee for Neuroimaging, Subcommittee for Pediatric. Guidelines for
imaging infants and children with recent-onset epilepsy. Epilepsia. 2009;50(9):2147-2153.
22. Berg AT, Mathern GW, Bronen RA, et al. Frequency, prognosis and surgical treatment of structural abnormalities seen
with magnetic resonance imaging in childhood epilepsy. Brain. 2009;132(Pt 10):2785-2597.
23. National Health Services, National Institute for Clinical Excellence. The epilepsies: The diagnosis and management of
the epilepsies in adults and children in primary and secondary care. October 2004. http://www.nice.org.uk/guidance/
cg137. Accessed September 10, 2014.
24. Hirtz D, Ashwal S, Berg A, et al. Practice parameter:evaluating a first nonfebrile seizure in children: report of the quality
standards subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American

Epilepsy Society. Neurology. 2000; 55:616-623.
25. Huang BY, Zdanski C, Castillo M. Pediatric sensorineural hearing loss, part 1: Practical aspects for neuroradiologists.
AJNR Am J Neuroradiol. 2012 Feb;33(2):211-217.
Am J Neuroradiol. 2012 Mar;33(3):399-406.
27. Morzaria S, Westerberg BD, Kozak FK. Evidence-based algorithm for the evaluation of a child with bilateral
sensorineural hearing loss. J Otolaryngol. 2005 Oct;34(5):297-303.
28. Baguley D, McFerran D, Hall D. Tinnitus. Lancet. 2013 Nov 9;382(9904):1600-1607.
29. Sajisevi M, Weissman JL, Kaylie DM. What is the role of imaging in tinnitus? Laryngoscope. 2014 Mar;124(3):583-584.
30. Vattoth S, Shah R, Curé JK. A compartment-based approach for the imaging evaluation of tinnitus. AJNR Am J
Neuroradiol. 2010 Feb;31(2):211-218.
31. Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology. 2000;216:342-349
32. Meyer JS, Gunderman R, Coley BD, et al. ACR Appropriateness Criteria® on suspected physical abuse-child. J Am Coll
Radiol. 2011;8(2):87-94.

♦ List may not be exclusive | MRA of the Head | Copyright © 2015. AIM Specialty Health. All Rights Reserved. 27
CPT Codes
70544 �� Magnetic resonance angiography, head, without contrast
70545 �� Magnetic resonance angiography, head, with contrast
70546 �� Magnetic resonance angiography, head, without contrast, followed by re-imaging with contrast
Angiography includes imaging of all blood vessels, including arteries and veins. The codes above include MR Venography.
●● MRA may be performed to assess the major intracranial arteries of the anterior and posterior circulations (including
the Circle of Willis) as well as the venous structures (major cerebral veins and dural venous sinuses)
●● For specific clinical indications, exams may be tailored to the region of interest
●● MRA refers to a group of diverse MR pulse sequences. These include time-of-flight (TOF) imaging, phase contrast
(PC) techniques and three-dimensional (3-D), T1-weighted gradient echo acquisitions obtained during intravenous
bolus infusion of a paramagnetic contrast agent (gadolinium chelate)
●● A workstation is necessary for most MRA studies, to acquire multiplanar reformations, shaded surface displays,
volume renderings and maximum intensity projection (MIP) images. Post-processing of MRA data with a MIP
reconstruction algorithm allows for 3-dimensional images to be rotated and viewed in different planes, improving
visualization of superimposed vessels
●● CTA of the head is an alternative exam in patients who cannot undergo MRA
●● An MRA of the head includes imaging of the entire arteriovenous system of the brain. Separate requests for
concurrent imaging of the arteries and the veins in the head are inappropriate
The following diagnostic indications for head MRI are accompanied by pre-test considerations as well as supporting clinical
treatment
Aneurysm
●● Family history of intracranial aneurysm
●● Follow-up of known or suspected intracranial aneurysm
●● Hereditary disorder, such as autosomal dominant polycystic kidney disease (10%-20% occurrence of aneurysm),
Ehlers Danlos syndrome type IV, and Neurofibromatosis type I
Arteriovenous malformation (AVM)
Congenital anomaly of the cerebral circulation
●● Diagnosis prior to an interventional procedure
Note: This includes persistent fetal carotid vertebrobasilar anastomosis (e.g. hypoglossal artery, otic artery, proatlantal
artery, or trigeminal artery). Most congenital variations are incidental findings with no clinical significance1
Dural arteriovenous fistula (DAVF)
Dissection
MRA, MRV Head: Cerebrovascular –
Pediatrics

Endovascular neurointerventional procedure
●● For post-treatment evaluation (any one of the following)
○○ Intracranial aneurysm
Headache
●● Exertional headache
●● Positional headache
●● Sudden onset of worst headache of life
Intracranial hemorrhage
●● For identification of the source of hemorrhage
Note: CT is the preferred technique for evaluation of acute intracranial hemorrhage. MRI is generally preferred for
Intramural hematoma
Multiple sclerosis
Note: Evaluation of venous structures to assess for venous stenosis as a cause of multiple sclerosis (referred to as chronic
cerebrospinal venous insufficiency [CCSVI]) is considered not medically appropriate. MRV in preparation for either a
neurosurgical or percutaneous procedure to treat multiple sclerosis is therefore inappropriate.
Recent cerebrovascular accident (CVA)
●● Demonstrated on head CT or MRI
Stenosis or occlusion of the carotid or cerebral arteries
●● Clinically suspected or known steno-occlusive disease especially (any one♦ of the following):
○○ Idiopathic progressive arteriopathy of childhood
○○ Moyamoya disease
○○ Sickle cell disease
●● Clinical manifestation (any one♦ of the following)
○○ Confusion
○○ Difficulty speaking or understanding speech
○○ Dizziness
○○ Gait disturbance
○○ Loss of balance or coordination
○○ Loss of consciousness
○○ Numbness, weakness or paralysis of the face, arm or leg, on one side of the body
○○ Sudden severe headache, that is unexplained
○○ Visual disturbance, particularly in one eye
Note: Stenosis or occlusion in the pediatric population is usually a result of vascular abnormalities from a systemic or

Stenosis or occlusion of the vertebral or basilar arteries
●● Sign or symptom of vertebrobasilar insufficiency (VBI) or vertebral basilar ischemia (any one♦ of the following)
○○ Acute sensorineural hearing loss
○○ Ataxia
○○ Diplopia
○○ Dysarthria
○○ Dysphagia
○○ Facial numbness or paresthesia
○○ Limb or trunk sensory deficit
○○ Loss of taste sensation
○○ Motor paresis
○○ Nystagmus
○○ Syncope
○○ Vertigo
Note: Symptoms of VBI are usually temporary, due to diminished blood flow in the posterior circulation of the brain.
Stenosis or occlusion in the pediatric population is usually a result of vascular abnormalities from a systemic or
Thromboembolic disease of major intracranial arterial or venous systems
Note: Includes dural venous sinus thrombosis
Tinnitus
●● Pulsatile tinnitus for vascular etiology
Traumatic vascular injury
Vascular supply to tumor
Vasculitis
References
1. Uchino A, Sawada A, Takase Y, Kudo S.MR angiography of anomalous branches of the internal carotid artery. AJR Am J
Roentgenol. 2003 Nov;181(5):1409-1414.

♦ List may not be exclusive | Functional MRI of the Brain | Copyright © 2015. AIM Specialty Health. All Rights Reserved. 30
CPT Codes
70554 �� Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive
body part movement and/or visual stimulation, not requiring physician or psychologist administration
70555 �� Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive
body part movement and/or visual stimulation, requiring physician or psychologist administration of entire
neurofunctional testing
●● From the skull base to vertex, covering the intracranial contents
●● Functional MRI of the brain may be used to localize eloquent areas in the brain, prior to resection of neoplasm or
medically intractable epileptogenic foci
●● Studies have shown excellent agreement in language localization, when comparing functional brain MRI with the
Wada test and direct electrical stimulation
●● Advantages of functional brain MRI over a Wada test include the non-invasive technique (not requiring catheter
placement and contrast injection), lack of ionizing radiation, shorter time-requirement, lower cost and quicker post-
procedural recovery. Additionally, the Wada test is considered limited in right hemisphere dominance
●● Advantages of functional brain MRI over intraoperative electrocortical stimulation include its non-invasive technique
and more extensive anatomic brain mapping. Direct electrical stimulation is an invasive procedure, which usually
evaluates only one hemisphere (limiting assessment for partial or bilateral language dominance) and usually
identifies only eloquent brain regions on the surface of the brain
●● Functional MRI may successfully map primary brain activities related to motor, sensory and language functions.
Examples of tasks which may be used include sentence completion (to map language) and bilateral hand squeeze
task (for sensory motor mapping)
The following diagnostic indications for functional MRI (fMRI) of the brain are accompanied by pre-test considerations and
supporting clinical data
Brain tumor
●● For pre-operative neurosurgical planning, as a replacement for a Wada test or direct electrical stimulation mapping
Seizures/epilepsy refractory to medical treatment
●● For pre-operative neurosurgical planning, as a replacement for a Wada test or direct electrical stimulation mapping
Functional MRI (fMRI) Brain – Pediatrics

♦ List may not be exclusive | PET Brain Imaging | Copyright © 2015. AIM Specialty Health. All Rights Reserved. 31
CPT Codes
78608 �� PET brain, metabolic evaluation
Commonly Used Radiopharmaceuticals
●● 2-(fluorine-18) fluoro-2-deoxy-d-glucose (FDG) Scan coverage may vary, depending on the specific clinical
indication
●● Coding conventions call for this code to be used for oncologic scanning of brain tumors
The following diagnostic indications for brain PET are accompanied by pre-test considerations as well as supporting clinical
Brain tumor
(Any one of the following)
●● Initial treatment strategy (diagnosis, staging)
●● Subsequent treatment strategy (follow up to differentiate post-treatment (radiation, surgery, chemotherapy) scarring
from residual/recurrent disease)
Seizures/epilepsy refractory to medical treatment1
●● Patient has failed conventional medical therapy
●● Pre-surgical evaluation to locate the foci of intractable seizure activity
References
1. Rastogi S, Lee C, Salamon N. Neuroimaging in pediatric epilepsy: a multimodality approach. Radiographics.
2008;28(4):1079-1095.
PET Brain Imaging – Pediatrics

♦ List may not be exclusive | CT of Orbit, Sella, Fossa | Copyright © 2015. AIM Specialty Health. All Rights Reserved. 32
CPT Codes
70480 �� CT of orbit, sella or posterior fossa and outer, middle or inner ear, without contrast
70481 �� CT of orbit, sella or posterior fossa and outer, middle or inner ear, with contrast
70482 �� CT of orbit, sella or posterior fossa and outer, middle or inner ear, without contrast, followed by re-imaging
with contrast
●● The anatomic coverage and protocol specifications will vary, depending on the clinical indication. Anatomic
evaluation includes the internal auditory canals (IACs), posterior fossa, sella turcica, orbits and temporal bone, with
the mastoid air cells
●● Targeted evaluation, such as CT of the temporal bones, involves collimated views through the region of
interest, often in two imaging planes: axial images (petrous bones through mastoid tips) and coronal views
(temporomandibular joints through temporal bones)
●● CT is often the preferred study for suspected fracture or follow-up of a known fracture, foreign body detection,
assessment of calcified lesions and temporal bone evaluation
●● With capability for high-resolution osseous imaging, CT can provide detailed anatomic depiction of the temporal
bone anatomy, including the middle and inner ear structures
●● MRI (unless contraindicated) is usually preferred over CT for evaluation of the sella turcica, internal auditory canal
regions and visual pathways, as well as for most soft tissue tumor evaluation
●● Bony changes from a sellar, parasellar or orbital mass or infectious process are usually well demonstrated by CT
●● Ordering a CT of the head (CPT codes 70450-70470) in addition to a CT of the orbits is not necessary in most cases
inappropriate
The following diagnostic indications for CT of the orbit, sella, posterior fossa and temporal bone are accompanied by pre-test
considerations as well as supporting clinical data and prerequisite information
treatment
Cholesteatoma
Note: CT is the preferred modality of evaluation for cholesteatoma. This includes both acquired and congenital types of
cholesteatoma. Acquired (secondary) cholesteatoma: more common form (98%), presenting as a mass comprised
of keratin debris and lined by squamous epithelium. Predisposing conditions are recurrent otitis media or trauma.
Congenital (primary) cholesteatoma (epidermoid): uncommon lesion (2%), arising from aberrant embryonic
ectodermal rests in middle ear, mastoids or petrous bone.
Cochlear implant
●● Pre-operative or post-operative evaluation
Congenital anomaly of the orbit, temporal bone, sella turcica, or posterior fossa
CT Orbit, Sella Turcica, Posterior Fossa,
Temporal Bone, including Mastoids –
Pediatrics

Foreign body
●● Following non-diagnostic radiograph (any one of the following):
○○ Evaluation for metallic foreign bodies in the orbits
○○ High clinical suspicion for a foreign body
Note: Conventional radiographs detect the majority of radiopaque foreign bodies
Hearing loss
Note: This includes conductive, sensorineural1-3
, and mixed hearing loss. CT is generally preferred for conductive and
mixed. MRI is generally preferred for sensorineural
●● Abscess
●● Cellulitis (including orbital cellulitis)
●● Malignant otitis externa
●● Osteomyelitis
●● Otomastoiditis
Orbital/ocular evaluation
●● Evaluation of the symptoms and objective findings (any one♦ of the following):
○○ Exophthalmos (abnormal protrusion of the eyeball)
○○ Extraocular myopathy
○○ Optic neuritis
○○ Papilledema
○○ Proptosis (forward displacement of the eyeball)
○○ Strabismus (inability of one eye to accomplish binocular vision with the other, due to extra-ocular muscle
imbalance)
○○ Thyroid ophthalmopathy
○○ Visual loss unexplained by ophthalmic evaluation
Orbital pseudotumor
Osseous lesion evaluation
Note: Such as fibrous dysplasia, Paget’s disease, and otosclerosis
Pain, localized facial
●● When persistent and unexplained
Tinnitus, pulsatile
Skull base evaluation
●● For suspected or known tumors

Trauma
●● Soft tissue injury
●● Fracture
References
1. Huang BY. Zdanski C, Castillow M. Pediatric sensorineural hearing loss, part 1: Practical aspects for neuroradiologists.
AJNR Am J Neuroradiol. 2012;33(2):211-217
Am J Neuroradiol. 2012;33(3):399-406.
3. Morzaria S, Wasterberg BD, Kozak FK. Evidence-based algorithm for the evaluation of a child with bilateral
sensorineural hearing loss. J Otolaryngol. 2005;34(5):297-303.

♦ List may not be exclusive | MRI of Orbit, Face, Neck | Copyright © 2015. AIM Specialty Health. All Rights Reserved. 35
CPT Codes
70540 �� MRI orbit, face and neck, without contrast
70542 �� MRI orbit, face and neck, with contrast
70543 �� MRI orbit, face and neck, without contrast, followed by re-imaging with contrast
●● Scan coverage is dependent on the specific anatomic area of clinical interest. Exams usually include multi-planar
imaging, using different pulse sequences
●● MRI is usually preferred over CT for evaluation of the sella turcica and visual pathways, unless contraindicated
●● CT is generally the modality of choice for traumatic injury, calcified lesions, localized infection (for example, orbital
extension of an adjacent complicated sinusitis), and foreign body evaluation, after initial radiographic evaluation for a
radiopaque foreign body
●● CT of the neck is an alternative exam in patients who cannot undergo MRI
inappropriate
●● MRI of the orbit, face and neck is not allowed for imaging the IACs. See MRI of the brain (CPT codes 70551 –
70553)
The following diagnostic indications for MRI of the orbit, face and neck (soft tissues) are accompanied by pre-test
considerations as well as supporting clinical data and prerequisite information
treatment
Glottic lesion
●● Assessment following endoscopic detection
Hoarseness
●● Unexplained, following direct visualization or prior non-diagnostic imaging of neck/upper chest (extending along the
course of the recurrent laryngeal nerves)1,2
(Any one♦ of the following)
●● Abscess
●● Cellulitis (including orbital cellulitis)
●● Osteomyelitis
MRI Orbit, Face & Neck (Soft Tissues) –
Pediatrics

Lymphadenopathy
●● Following non-diagnostic ultrasound (any one of the following)
○○ Failed to resolve after a six (6) week course of therapy3,4
○○ Red flag sign6
(any one of the following):
■■ Constitutional symptom
■■ Firm/immobile and larger than 3 cm in diameter3
■■ Painless
■■ Persistent enlargement on exam for more than 2 weeks
■■ Supraclavicular or posterior triangle
■■ Ulceration
○○ Sonographic features suggestive of nodal malignancy3,5
Note: In the presence of red flag signs, biopsy may be more appropriate than advanced imaging
Neck mass, malignant (biopsy proven)
●● Management and surveillance (any one♦ of the following)
○○ Lymphoma, Hodgkin’s or non-Hodgkin’s
○○ Neuroblastoma
○○ Rhabdomyosarcoma
Neck mass, diagnosis and evaluation
●● Following non-diagnostic ultrasound3,4,6,7
○○ Diagnosis when ultrasound demonstrates a solid neck mass other than lymph node
○○ Evaluation of complication (including hemorrhage, infection, mass effect of the airway)
Note: For lymph nodes, see Lymphadenopathy
Neck mass, cystic
●● Following non-diagnostic ultrasound
●● Pre-operative evaluation to define the extent of disease
Note: This includes brachial cleft cyst, capillary hemangioma, thyroglossal duct cyst, and venolymphatic malformation.
Nasal indications, not otherwise listed
●● Anosmia
●● Nasal airway obstruction or polyposis refractory to medical therapy
●● Recurrent epistaxis
Obstructive thyroid nodule or thyromegaly (goiter)
●● Associated with mass effect on the upper airway or esophagus
●● Following non-diagnostic thyroid ultrasound or thyroid scintigraphy
●● Pre-operative evaluation

Orbital indications, not otherwise listed
●● Absence of a red reflex on exam (concern for retinoblastoma or rhabdomyosarcoma)
●● Extraocular myopathy
●● Extraocular weakness or nonconjugate eye movements
●● Nystagmus
●● Orbital pseudotumor
●● Optic neuritis
●● Papilledema (swelling and elevation of optic disc)
●● Proptosis
●● Strabismus
●● Thyroid ophthalmopathy
●● Visual loss unexplained by ophthalmic evaluation
Stridor
●● Following non-diagnostic soft tissue neck radiograph and ENT evaluation
Note: This applies to subacute and chronic presentations of stridor. Soft tissue radiographs are generally sufficient to
diagnose the common causes such as croup and foreign bodies (latter is often a medical emergency). In the
pediatric population, common causes of stridor include vascular ring, laryngotracheomalacia, subglottic stenosis
Torticollis (twisted or rotated neck)
●● Childhood (acquired) torticollis with clinical findings that suggest another cause (such as infection, neoplasm,
trauma)
●● Congenital muscular torticollis (fibromatosis colli)8-13
in newborns age 8 months or less11,12
○○ Following non-diagnostic cervical spine radiograph
○○ Following non-diagnostic ultrasound
○○ Unresponsive to four (4) weeks of conservative therapy
Note: Childhood torticollis is typically associated with myositis of the sternocleidomastoid/trapezius14
, and advanced
imaging is generally not indicated unless there are additional signs/symptoms to suggest another cause. For
congenital muscular torticollis, typical cases do not generally require imaging and atypical cases can be confirmed
by ultrasound
Trauma to the orbit and face
Note: CT preferable for bony assessment
Trauma to the soft tissues of the neck
●● Evaluation of anatomic structures when not otherwise specified in this guideline (any one♦ of the following)
○○ Facial structures
○○ Larynx and subglottic regions
○○ Nasopharynx, oropharynx and hypopharynx
○○ Neck soft tissues, surrounding the airway and glands
○○ Optic nerve
○○ Orbit
○○ Salivary glands
○○ Sella turcica (pituitary tumors including macroadenoma and microadenoma)
○○ Sinuses
○○ Thyroid and parathyroid glands

Upper airway obstruction
Note: This includes tracheal stenosis
Wegener’s granulomatosis, suspected or known
Note: Presentation includes recurrent epistaxis and stridor
References
1. American Academy of Otolaryngology — Head and Neck Surgery Foundation. Choosing Wisely: Five Things Physicians
and Patients Should Question. ABIM Foundation; February 21, 2013. www.choosingwisely.org.Accessed September 10,
2014.
2. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck
Surg. 2009;141(3 Suppl 2):S1-S31.
3. Meier JD, Grimmer JF. Evaluation and management of neck masses in children. Am Fam Physician. 2014;89(5):353-
358.
4. Rozovsky K, Hiller N, Koplewitz BZ, Simanovsky N. Does CT have an additional diagnostic value over ultrasound in the
evaluation of acute inflammatory neck masses in children? Eur Radiol. 2010;20(2):484-490.
5. Ludwig BJ, Wang J, Nadgir RN, Saito N, Castro-Aragon I, Sakai O. Imaging of cervical lymphadenopathy in children and
young adults. AJR Am J Roentgenol. 2012;199(5):1105-1113.
6. Rosenberg HK. Sonography of pediatric neck masses. Ultrasound Q. 2009;25(3):111-127.
7. Lloyd C, McHugh K. The role of radiology in head and neck tumours in children. Cancer Imaging. 2010;10:49-61.
8. Snyder EM, Coley BD. Limited value of plain radiographs in infant torticollis. Pediatrics. 2006;118(6):e1779-1784.
9. Wei JL, Schwartz KM, Weaver AL, Orvidas LJ. Pseudotumor of infancy and congenital muscular torticollis: 170 cases.
Laryngoscope. 2001;111(4 Pt 1):688-695.
10. Ballock RT, Song KM. The prevalence of nonmuscular causes of torticollis in children. J Pediatr Orthop. 1996;16(4):500-
504.
11. Haque S, Bilal Shafi BB, Kaleem M. Imaging of torticollis in children. Radiographics. 2012;32(2):557-571.
12. Morrison DL, MacEwen GD. Congenital muscular torticollis: observations regarding clinical findings, associated
conditions, and results of treatment. J Pediatr Orthop. 1982;2(5):500-505.
13. Do TT. Congenital muscular torticollis: current concepts and review of treatment. Curr Opin Pediatr. 2006;18(1):26-29.
14. Pharisa C, Lutz N, Roback MG, Gehri M. Neck complaints in the pediatric emergency department: a consecutive case
series of 170 children. Pediatr Emerg Care. 2009 Dec;25(12):823-826.

♦ List may not be exclusive | CT Paranasal Sinus & Maxillofacial Area | Copyright © 2015. AIM Specialty Health. All Rights Reserved. 39
CPT Codes
70486 �� CT of maxillofacial area, without contrast
70487 �� CT of maxillofacial area, with contrast
70488 �� CT of maxillofacial area, without contrast, followed by re-imaging with contrast
●● Includes the sinuses, facial structures and maxillary regions. Individual scan coverage depends on the specific
clinical request, but generally includes images through the entire frontal, ethmoid, maxillary and sphenoid sinuses.
Coverage may be extended to include the mandible and temporomandibular joint (TMJ) in select cases and
depending on the clinical indication. CT sections may be obtained in one or two (usually coronal and axial) planes
●● The prevalence of sinus inflammatory disease is high. The disease is estimated to affect approximately 33 million
US citizens
●● This guideline includes reference to rhinosinusitis in the evaluation of sinus inflammatory disease, since sinusitis
usually involves the nasal passage as well as the paranasal sinuses
●● Clinicians should distinguish presumed acute bacterial rhinosinusitis from acute rhinosinusitis due to viral upper
respiratory infections and non-infectious conditions
●● Acute sinusitis is considered a self-limiting disease, since most patients improve within 2 weeks, despite the etiology
and treatment option used
●● Sinus CT is not usually performed at the time of initial clinical presentation with acute uncomplicated sinusitis
●● Sinus CT is often reserved for difficult cases or delineation of anatomy prior to planned sinus surgery, as follows:
○○ Limited (coronal) Sinus CT – typically used for recurrent or refractory sinus inflammatory disease, or if the
diagnosis is in doubt
○○ Full Sinus CT – generally performed for surgical planning to interrogate for osteomeatal obstruction, fungal
sinusitis, facial or orbital cellulitis complicating sinusitis and suspected malignancy
●● CT of the paranasal sinuses is appropriately coded to CPT 70486. There are no required number of slices or phases
for contrast-enhanced exams that constitute a paranasal sinus and maxillofacial CT study. This code may be used to
describe limited or complete imaging of the sinuses
●● CT of the maxillofacial area is a bilateral study. Separate requests to image the right and left facial area are not
allowed
●● For temporomandibular joints, CT may be used after MRI if diagnosis still in doubt or when MRI cannot be done
The following diagnostic indications for sinus CT are accompanied by pre-test considerations as well as supporting clinical
treatment
Anosmia
Congenital anomaly
Foreign body in the maxillofacial region
Fungal or other complex sinus infection
CT Paranasal Sinus & Maxillofacial
Area – Pediatrics

Mucocele of paranasal sinuses
Nasal airway obstruction refractory to medical therapy
Osteomyelitis of the facial bones
Polyposis
Pre-operative or pre-procedure evaluation
Recurrent epistaxis
Sinusitis, acute and subacute
●● Screening of immunocompromised patient or a patient who is likely to become immunocompromised by therapy (for
example, prior to chemotherapy or transplant1
)
●● Management of complications of acute sinusitis1,2
○○ Abscess, intracranial or orbital
○○ Encephalitis or cerebritis
○○ Meningitis
○○ Sinus thrombosis
○○ Invasive fungal sinusitis in immunocompromised patients
Note: Any episode of sinusitis with duration of less than 30 (acute) or 31-90 (subacute) days1
. Sinusitis is generally rare in
patients under 3 years of age
Sinusitis, chronic or recurrent
●● Corroborate diagnosis of chronic sinusitis prior to a prolonged course of antibiotics
●● Diagnose underlying medical condition (any one of the following)
○○ Chronic allergies or asthma
○○ Ciliary motility disorder
○○ Craniofacial abnormality
○○ Cystic fibrosis
○○ Immunodeficiency
●● Diagnose unilateral sinusitis
●● Post-operative management of complications
●● Pre-operative evaluation to determine whether the patient is a surgical candidate
●● Pre-operative image guidance study
Note: Any episode of sinusitis that persists beyond ninety (90) days1
. Indication includes recurrent acute bacterial sinusitis
(RABS), defined as episodes of sinusitis lasting less than 30 days with at least 10 symptom-free days in-between. At
least three (3) such episodes within six (6) months or four (4) episodes within a year are required to qualify1
.

Temporomandibular disease (TMD), diagnosis3
●● Panorex has abnormal findings requiring further characterization (any one of the following):
○○ Arthritis (infectious or inflammatory – particularly rheumatoid)
○○ Bone infarct
○○ Bone neoplasm
○○ Osteolysis
○○ Trauma
●● Panorex is inconclusive or not available
●● Panorex is normal with high clinical suspicion for TMJ pathology when the results will change management (for
example, headache of oromaxillofacial origin5
)
Note: Temporomandibular disease (TMD) is a collective term, which includes disorders of both the masticatory muscles
and the temporomandibular joint3,4
. CT is not generally indicated when a muscular etiology for TMD is suspected.
Most temporomandibular joint (TMJ) pathology can be evaluated with a panorex radiograph3
.
Trauma to the facial bones
●● Significant injury
Tumor or mass lesion in the sinonasal region
Wegener’s granulomatosis, suspected or known
Note: Presentation includes recurrent epistaxis and stridor
References
1. Wald ER, Applegate KE, Bordley C, et al; American Academy of Pediatrics. Clinical practice guideline for the diagnosis
and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-e280.
2. Setzen G, Ferguson BJ, Han JK, et al. Clinical consensus statement: appropriate use of computed tomography for
paranasal sinus disease. Otolaryngol Head Neck Surg. 2012;147(5):808-816.
3. American Academy of Orofacial Pain. Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management. De
Leeuw R, Klasser GD, eds. Chicago: Quintessence Publishing Co., Inc.; 2013.
4. American Association of Oral and Maxillofacial Surgeons (AAOMS). Clinical Paper: Temporomandibular Disorders.
Rosemont, IL: AAOMS; 2013.
5. Scrivani SJ, Keith DA, Kaban LB. Temporomandibular disorders. N Engl J Med. 2008;359(25):2693-2705.

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