This policy describes the general guidelines for Pediatric Abdominal Imaging.
Upper Urinary Tract
All children with first time UTI should undergo ultrasound evaluation, as the initial imaging modality to diagnose hydronephrosis, pyelonephritis, or congenital renal anomaly.
If hydronephrosis is present, this should be further evaluated with voiding cystourethrography (VCUG), to evaluate for vesicoureteral reflux. In boys, this is generally accomplished using fluroroscopic imaging and iodinated contrast to exclude uretheral abnormalities. In girls, Ureteral Reflux Study (Radiopharmaceutical Voiding Cystogram) is commonly used as uretheral abnormalities are rare and this technique results in lower radiation exposure.
Diuretic renography using Tc-99m MAG 3 may be considered medically necessary for the following indications:
Post-contrast CT abdomen is sensitive in diagnosing pyelonephritis has a role in evaluation of renal abscess or unusual complications such as xanthogranulomatous pyelonephritis but has no role in the routine evaluation of UTI.
Magnetic resonance urography (MRU), is not a first line test for the routine evaluation of a UTI, but may be appropriate (where available) for investigation of a dilated upper urinary tract.
Technetium-99m-dimercaptosuccinic acid (Tc-99m DMSA) scintigraphy, is sensitive for the diagnosis of UTI but there is little benefit in using this after the first episode of a UTI:
Radiopharmaceutical nuclear medicine imaging may be considered for ANY ONE of the following:
Nuclear non-imaging renal function study may be considered medically necessary to evaluate renal function.
All other advanced imaging for upper urinary tract is considered not medically necessary.
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Lower Urinary Tract
Fluoroscopic Voiding cystourethrography (VCUG) for detection of possible vesico-ureteral reflux (VUR) may be considered medically necessary when hydronephrosis is seen on ultrasound in:
The American Academy of Pediatrics clinical practice guidelines no longer recommend routine VCUG for infants and young children from 2 to 24 months of age after the first febrile UTI.
▪ Atypical or complex clinical circumstances; and
▪ Renal/bladder ultrasound reveals hydronephrosis, scarring, or obstructive uropathy.
Vesicoureteral Reflux (VUR)
Male patients with first UTI should be evaluated with fluoroscopic VCUG studies rather than radionuclide cystography, to visualize the male urethra for possible abnormalities such as posterior urethral valves, strictures, or diverticula.
For female patients, radionuclide cystography may replace fluoroscopic VCUG as the initial study, since urethral anatomy is rarely abnormal except in complex malformations.
MR urography may be considered medically necessary for ANY ONE of the following:
Ureteral Reflux Study (Radiopharmaceutical Voiding Cystogram) may be considered medically necessary in siblings of patients with known vesicoureteral reflux for ALL of the following:
All other advanced imaging for lower urinary tract is considered not medically necessary.
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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
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The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
