HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
X-425-001
Topic:
PedAbdomen: Urinary Tract Infection (UTI)
Section:
Radiology
Effective Date:
January 1, 2019
Issued Date:
January 1, 2019
Last Revision Date:
October 2018
Annual Review:
October 2018
 
 

This policy describes the general guidelines for Pediatric Abdominal Imaging. 

Policy Position

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:

  • Differentiating a dilated non-obstructed urinary system from a true stenosis (e.g., UPJ obstruction; ureteral-vesical junction [UVJ] obstruction); or
  • Quantifying renal parenchymal function; or
  • Ultrasound findings that are compatible with a multicystic dysplastic kidney to evaluate function of the affected kidney or a ureteral-pelvic junction (UPJ) obstruction of the contralateral kidney; or
  • Diagnostic evaluation of upper tract dilatation when VCUG is negative; or
  • Renal function evaluation in patients with hydronephrosis.

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.

  • NOTE: MRU requires sedation in young children.
  • MRU can also quantitate renal function.

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:

  • DSMA is recommended for Detection of post-pyelonephritic renal scarring at least 6 months after the documented upper tract UTI in high risk patients with recurrent UTIs.

Radiopharmaceutical nuclear medicine imaging may be considered for ANY ONE of the following:

  • Suspected pyelonephritis; or
  • Diffuse interstitial nephritis

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:

  • Neonates; or
  • Young Children

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.

  • The current recommendation is to postpone the VCUG until the second febrile UTI UNLESS there are:

▪       Atypical or complex clinical circumstances; and

▪       Renal/bladder ultrasound reveals hydronephrosis, scarring, or obstructive uropathy.

Vesicoureteral Reflux (VUR)

  • Fluoroscopic VCUG is typically performed for diagnosis and grading of VUR, and should be the first modality used for diagnosis.
  • Ureteral Reflux Study (Radiopharmaceutical Voiding Cystogram), because of its lower radiation exposure and higher sensitivity for reflux greater than Grade I, is recommended for follow-up imaging of VUR, and investigation of VUR in siblings of affected patients.

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:

  • Ectopic distal ureteral insertion; or
  • Other complex lower urinary tract anatomy.

Ureteral Reflux Study (Radiopharmaceutical Voiding Cystogram) may be considered medically necessary in siblings of patients with known vesicoureteral reflux for ALL of the following:

  • If they have renal scarring on ultrasound or history of UTI; and
  • No prior evaluation for VUR

All other advanced imaging for lower urinary tract is considered not medically necessary.

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Place of Service: Outpatient



The policy position applies to all commercial lines of business



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