CurrentColorado Rocky Mountain Health PlansPolicy CSRAD012OH.D

Adult Peripheral Nerve and Neuromuscular Disorders (PNND) Imaging Guidelines (For Ohio Only)

Clinical imaging guideline governing advanced imaging and related procedures for adult peripheral nerve and neuromuscular disorders in Ohio; applies to requests evaluated for medical necessity under Ohio rules and affects providers and reviewers of imaging services in Ohio.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAdult Peripheral Nerve and Neuromuscular Disorders (PNND) Imaging Guidelines (For Ohio Only)

Policy CodePolicy CSRAD012OH.D

Change TypeNo material clinical or coverage changes

Effective DateNovember 1, 2025

Next Review DateN/A

Key ActionSubmit adequate clinical documentation including recent history, physical exam, EMG/NCV when indicated, and prior imaging to support medical necessity and prior authorization requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

V1.0.2025guideline version

Ohiostate

105pages

<=18pediatric age threshold

<30

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Coverage Criteria and Indications

inv-01: General coverage criteria

Imaging is covered when based on clinical presentation and adequate documentation; modality selection guided by condition-specific guidelines and contraindications.

General requirements: Recent pertinent clinical evaluation (history, physical exam since onset/change, labs, prior imaging) submitted; modality selection appropriate to clinical question; results expected to impact management.

Spine and musculoskeletal guidelines require current-episode x-rays.

inv-02: Contrast and modality-specific rules

Modality substitution and contrast guidance

CT vs MRI substitution: CT may be approved in place of MRI when MRI criteria are met but MRI contraindicated (e.g., pacemaker, ICD, neurostimulator); when substituting, match contrast level per guidance.

MRI without contrast -> CT without contrast; MRI without and with contrast -> CT with contrast or CT without and with contrast.

Contrast precautions: Use gadolinium cautiously in renal failure; both CT and MRI contrast share similar risk profile at GFR <30 mL/min; MRI contrast contraindicated in pregnancy unless benefits outweigh risks.GFR <30 mL/min

Gadolinium retention and NSF risks noted.

inv-03: Nuclear medicine (PET) criteria

PET/CT usage

PET/CT coverage: PET is typically used with CT (PET/CT) for metabolic imaging in oncology, cardiac, and brain indications; PET is not indicated for routine surveillance unless specified in condition-specific sections; PET/MRI generally not supported.

Unbundling PET/CT into separate PET and CT codes is not supported.

inv-04: Indications for 3D rendering

3D rendering (CPT 76376/76377) may be considered in the following clinical scenarios when conventional imaging is insufficient:

3D rendering appropriate scenarios: Evaluation of congenital skull abnormalities in newborns/infants/toddlers for pre-operative planning; complex fractures/dislocations (comminuted or displaced) for preoperative planning when conventional imaging is insufficient; spine fractures, pelvic/acetabulum fractures, intra-articular fractures for preoperative planning when conventional imaging is insufficient; complex facial fractures; cerebral angiography; select pelvis and abdomen indications such as uterine intracavitary lesions when ultrasound equivocal, hydrosalpinx when ultrasound indeterminate, lost IUD when ultrasound unable to locate, and infertility evaluation; pre-operative planning for other complex surgical cases.

Do not use 76376/76377 for routine 2D reformatting; document concurrent physician supervision when required.

inv-05: Imaging guidance billing rules

Imaging guidance codes (77011–77022, 76942) are appropriate when the imaging is used to guide percutaneous procedures; only one unit should be billed per encounter.

Guidance code use rules: Guidance codes contain the imaging necessary to guide a needle or catheter and should not routinely be billed together with a diagnostic procedure code; only one unit of guidance code should be reported per encounter; codes are modality-specific and inappropriate for open surgical procedures.

77013 is for non-bone ablation; 20982 covers CT guidance for bone tumor ablations.

inv-06: Limited/Follow-up CT (76380)

Limited CT (CPT 76380) usage guidance:

Limited CT use rules: CPT 76380 reports limited or follow-up CT when full diagnostic work is not performed (examples: limited sinus CT, follow-up slices for pulmonary nodule, limited slices for non-healing fracture); it is not indicated for treatment planning and should not be used to cover 'extra slices' in diagnostic CTs.

No specific slice/sequence counts defined by AMA.

inv-07: Unlisted procedure use

Unlisted CT/MR/nuclear medicine codes (76497/76498/78999):

When to use unlisted codes: Report unlisted codes when an appropriate site-specific code is not available; prefer a Category III code if one exists; examples include studies for neurosurgical navigation/Stealth imaging and custom joint arthroplasty planning; include detailed documentation to justify use.

Use Category III code instead of unlisted when available.

inv-08: Whole-body CT screening (Not indicated)

Not covered when used for screening in asymptomatic individuals

Whole-body CT screening exclusion: Whole-body CT (LifeScan) for screening of asymptomatic individuals is not indicated and should not be performed due to unclear benefit versus radiation risk.

Exception: low-dose whole-body CT supported for multiple myeloma staging per oncology guideline.

inv-09: Whole-body MRI (WBMRI)

Generally not supported except for specific indications

Appropriate uses of WBMRI: Whole-body MRI (WBMRI) may be appropriate for select cancer predisposition syndromes and certain autoimmune conditions; otherwise generally not supported due to lack of standardization and evidence of outcome benefit.

Report WBMRI using CPT 76498; other reporting methods are inappropriate.

inv-10: PET-MRI

PET-MRI may be appropriate in select circumstances when specific conditions are met

PET-MRI appropriateness: PET-MRI may be used when the individual meets condition-specific guidelines for PET-MRI OR when ALL of: the individual meets guideline criteria for PET-CT; PET-CT is not available at the treating institution; and the provider requests PET-MRI in lieu of PET-CT.

Report using CPT 78813 plus CPT 76498 when criteria met; other reporting methods inappropriate.

inv-11: Quantitative MR analysis

Quantitative multiparametric MRI procedures

Quantitative mpMRI and volumetric MRI of brain: Category III quantitative mp-MRI procedures (e.g., CPT 0648T, 0649T, 0697T, 0698T) are considered investigational and experimental; volumetric/quantitative brain MRI (CPT 0865T/0866T) is not medically necessary for routine clinical practice.

Most uses limited to clinical trials.

inv-12: Carpal Tunnel

Advanced imaging is indicated for the following focal neuropathies when ALL specified conditions are met:

Carpal Tunnel: EMG/NCV required initially; MRI wrist without contrast (CPT 73221) indicated only when EMG/NCV and clinical findings are equivocal and only when requested for pre-operative planning.

inv-13: Ulnar Neuropathy

Ulnar Neuropathy: EMG/NCV required initially; after EMG/NCV, ONE of MRI elbow or MRI forearm/wrist without contrast (upper extremity codes) is indicated if requested for surgical consideration.

inv-14: Radial Neuropathy

Radial Neuropathy: EMG/NCV required initially; MRI upper extremity other than joint without contrast (CPT 73218) when surgery is being considered; MRI with and without contrast (CPT 73220) if a nerve tumor is suspected.

inv-15: Pudendal Neuropathy

Pudendal Neuropathy: EMG/NCV not required initially; documented concern for pudendal neuropathy, pudendal neuralgia, or pudendal entrapment supports MRI pelvis without contrast (CPT 72195) or MRI pelvis without and with contrast (CPT 72197); if MRI contraindicated, CT pelvis options (72192/72193/72194) are alternatives.

inv-16: Sciatic Neuropathy

Sciatic Neuropathy: EMG/NCV required initially; MRI pelvis without contrast (CPT 72195) indicated; CT pelvis without contrast (CPT 72192) is not routinely indicated and only for rare contraindication to MRI (e.g., pacemaker or contrast allergy).

inv-17: Femoral Neuropathy

Femoral Neuropathy: EMG/NCV not required initially; MRI pelvis without contrast (CPT 72195) indicated.

inv-18: Meralgia Paresthetica

Meralgia Paresthetica: EMG/NCV not required initially; MRI pelvis without contrast (CPT 72195) indicated for diagnostic uncertainty or pre-operative planning; CT pelvis without contrast (CPT 72192) is not routinely indicated except for rare contraindication to MRI.

inv-19: Peroneal Neuropathy

Peroneal Neuropathy: EMG/NCV required initially; MRI lower extremity joint (knee) without contrast (CPT 73721) OR MRI lower extremity other than joint without contrast (CPT 73718) when surgery is considered or when ordered by/with a surgeon.

inv-20: Tarsal Tunnel Syndrome

Tarsal Tunnel Syndrome: Refer to Foot (Tarsal Tunnel Syndrome) in the Musculoskeletal Imaging Guidelines for advanced imaging guidance.

inv-21: Meralgia paresthetica — imaging indications

Imaging for meralgia paresthetica

Meralgia paresthetica MRI indications: MRI Pelvis without contrast (CPT 72195) is indicated for ANY of: cases of diagnostic uncertainty; pre-operative planning.

CT pelvis without contrast (CPT 72192) is NOT routinely indicated except rare contraindication to MRI (e.g., pacemaker or contrast allergy).

inv-22: Peroneal neuropathy

Peroneal neuropathy imaging

Peroneal neuropathy MRI indications: MRI Lower Extremity Joint (Knee) without contrast (CPT 73721) OR MRI Lower Extremity Other Than Joint without contrast (CPT 73718) when surgery is considered or when ordered by/with a surgeon.

inv-23: Polyneuropathy with possible CNS involvement

Polyneuropathy with CNS involvement

CNS imaging for polyneuropathy: If clinical findings point to abnormalities in brain/spinal cord, ANY of: MRI Brain without and with contrast (70553), MRI Cervical Spine without and with contrast (72156), MRI Thoracic Spine without and with contrast (72157), MRI Lumbar Spine without and with contrast (72158) are indicated.

CNS imaging not required for polyneuropathy without CNS signs/symptoms.

inv-24: Brachial plexus — covered indications and modality preferences

Brachial plexus imaging criteria

General rule: EMG/NCV examination is required prior to advanced imaging except in cases of malignant infiltration or radiation plexitis.

Malignant infiltration or radiation plexitis: Any ONE of: MRI Upper Extremity other than joint without contrast (73218); MRI Upper Extremity other than joint without and with contrast (73220); MRI Chest without contrast (71550); MRI Chest without and with contrast (71552); MRI Neck without contrast (70540) — imaging may be done without prior EMG in this scenario.

Traumatic or preoperative evaluation: Any ONE of the above MRI studies; if concern for radiculopathy also obtain MRI Cervical Spine (72141). If MRI unavailable/contraindicated, one CT neck/upper extremity/chest study is acceptable (see CT alternatives).

MRI preferred; PET not supported without known malignancy.

inv-25: Magnetic Resonance Neurography (MRN) coverage

MRN is supported when ALL of the following criteria are met:

MRN coverage criteria: 1) The study is to evaluate a traumatic or compressive focal neuropathy or a brachial plexus injury; 2) Requested by a neurosurgeon, orthopedic surgeon, neurologist, or podiatrist after an in-person clinical evaluation AND when surgery is being considered; 3) EMG/NCV has been performed and results provided; 4) The diagnosis remains unclear following prior imaging of the region with x-ray, ultrasound, or conventional imaging (CT or MRI).

MRN reported as CPT 76498 or listed extremity MR codes; MRN for other indications is NOT medically necessary.

inv-26: Lumbar and lumbosacral plexus imaging

For suspected lumbar and/or lumbosacral plexopathy, ONE of the following is indicated:

Lumbar/lumbosacral plexus MRI options: MRI Pelvis without contrast (72195) with fat suppression OR MRI Pelvis without and with contrast (72197) with fat suppression OR MRI Abdomen without contrast (74181) plus MRI Pelvis without contrast (72195) with fat suppression OR MRI Abdomen without and with contrast (74183) plus MRI Pelvis without and with contrast (72197) with fat suppression.

If suspected plexopathy due to traumatic injury, MRI Lumbar Spine without contrast (72148) is ALSO indicated; if MRI contraindicated, CT pelvis/abdomen options with contrast are alternatives.

inv-27: Motor Neuron Disease / ALS (PN-8.1)

MRI is indicated in motor neuron disease evaluation when imaging is needed to evaluate for ALS-associated changes or mimic disorders.

Motor Neuron Disease / ALS imaging: MRI of the Brain and/or Spine is indicated to evaluate for amyotrophic lateral sclerosis (ALS)-associated changes and to assess for disorders that may mimic ALS.

inv-28: Spinal Muscular Atrophy (PN-8.2)

Spinal Muscular Atrophy (SMA) imaging stance and when imaging is used.

SMA diagnostic approach: Molecular genetic testing is the standard for diagnosis; MRI is not supported for diagnosis in children unless other diseases are being considered; in adult-onset cases, advanced imaging is indicated when upper and lower motor neuron findings are present.

See Motor Neuron Disease/ALS for imaging specifics.

inv-29: Fasciculations (PN-8.3)

Imaging indications for fasciculations and required pre-imaging evaluations.

Pre-imaging requirements for fasciculations: History and physical documentation, EMG/NCV evaluation, and laboratory evaluation are required prior to advanced imaging.

If upper motor neuron signs present, CNS MRI studies are indicated.

When upper motor neuron signs present: If upper motor neuron signs (increased tone, hyperreflexia, Babinski or Hoffman signs) raise concern for motor neuron disease, any of MRI Brain (70551/70553), MRI Cervical Spine (72141/72156), MRI Thoracic Spine (72146/72157) are indicated.

Lumbar spine imaging not indicated unless sphincter involvement or need to rule out lower motor neuron etiologies.

inv-30: Neuromuscular Junction Disorders (PN-8.4)

Imaging for neuromuscular junction disorders (MG, LEMS) and related malignancy evaluation.

Myasthenia Gravis chest imaging: After established diagnosis or when suspected by a specialist, one of CT Chest with contrast (71260), CT Chest without contrast (71250), MRI Chest without and with contrast (71552), or MRI Chest without contrast (71550) is indicated to assess for thymic disease; repeat imaging is indicated for chest mass symptoms, rising antibody titers, or pre-operative evaluation.

Lambert-Eaton Myasthenic Syndrome (LEMS): For suspected LEMS, CT Chest with contrast (71260) and/or CT Abdomen and Pelvis with contrast (74177) are indicated; if initial CT negative and suspicion persists, repeat any of these studies every 6 months for 2 years.Every 6 months x 2 years when initial imaging negative and suspicion persists

Associated with malignancy, notably small cell lung cancer.

inv-31: Muscle Diseases (PN-8.5)

Imaging in known or suspected muscle disease to guide biopsy, diagnosis, and monitoring.

Imaging to plan muscle biopsy or evaluate myopathy: MRI of affected muscle (upper extremity CPT 73218/73220; lower extremity CPT 73718/73720) is supported to demonstrate abnormalities, select biopsy sites, and evaluate progression or treatment response; bilateral studies supported when criteria met.

MRI helps avoid false-negative biopsies and evaluates inflammatory myopathies.

Inflammatory muscle disease additional imaging: For inflammatory myopathies with concern for occult neoplasm, initial and repeat imaging with CT Chest and/or Abdomen and Pelvis are supported to evaluate for associated cancers.

inv-32: Gaucher Disease (PN-8.6)

Imaging recommendations for Gaucher disease (storage disorder).

Initial imaging for Gaucher disease: Initial imaging may include MRI Lumbar Spine without contrast (72148), bilateral femurs MRI Lower Extremity without contrast (73718), MRI Abdomen without contrast (74181), DEXA scan, and CT Chest without contrast (71250) for new or worsening pulmonary symptoms.

Surveillance imaging for Gaucher disease: Every 12 months: MRI Lumbar Spine (72148), bilateral femurs MRI (73718), MRI Abdomen (74181); CT Chest without contrast (71250) for documented pulmonary involvement.Every 12 months

To assess treatment response or disease progression in individuals on enzyme replacement therapy or surveillance.

Pulmonary symptom-driven imaging: New or worsening pulmonary symptoms: CT Chest without contrast (71250).

inv-33: Gaucher disease surveillance imaging

Covered when criteria below are met for routine monitoring or specific clinical indications

Routine surveillance every 12 months: Every 12 months to assess treatment response for individuals on enzyme replacement therapy or assess disease progression for individuals in surveillance; includes MRI lumbar spine (72148), MRI bilateral femurs (73718), MRI abdomen (74181), and CT chest without contrast (71250) for documented pulmonary involvement.Every 12 months

DEXA interval guidance: every 12-24 months until normal, then every 3 years.

Pulmonary symptoms: New or worsening pulmonary symptoms

CT Chest without contrast (CPT 71250)

DXA timing: DEXA scans every 12-24 months until normal, or every 3 years, or following enzyme replacement therapy dose change

Used to evaluate bone disease/osteoporosis risk

inv-34: Peripheral Nerve Sheath Tumors (PNST) imaging

Imaging supported for suspected or known PNST when specific conditions are met

Initial evaluation by location: MRI of the affected body region without and with contrast is supported for PNST (e.g., MRI brain without and with contrast CPT 70553 for vestibular schwannoma; paraspinal: MRI cervical/thoracic/lumbar spine without and with contrast CPT 72156/72157/72158; limb/torso: MRI after plain x-ray).

Plain x-ray not required for individuals with cancer predisposition syndromes.

Follow-up imaging triggers: Routine follow-up imaging is NOT indicated except for new symptoms/neurological findings, post-operative scenarios (surgeon discretion or to establish baseline after incomplete resection), or when malignant transformation/metastatic work-up is known or suspected; metastatic work-up may include CT chest with contrast (71260) and/or CT abdomen with contrast (74160).

inv-35: Imaging modality coverage guidance

Coverage stance for imaging in peripheral nerve sheath tumors and peripheral nerve disorders

Preferred modality: MRI of the known or suspected body region is supported for evaluation of PNSTs and is the preferred imaging modality due to superior soft tissue resolution and lack of radiation exposure.

PET/Nuclear imaging role: PET imaging's role in PNSTs and peripheral nerve disorders is not well established and generally does not add clinical value; nuclear medicine studies are NOT indicated for routine evaluation of peripheral nerve disorders.

PET/MRI for peripheral nerve disease is considered not medically necessary.

Approved Indications and Modality-Specific Guidance

inv-157: Modality-specific indications

Modality-specific indications

Ultrasound indications: Obstetric/gynecologic imaging; soft tissue and visceral imaging; vascular imaging when not obscured by bone; procedural guidance; initial evaluation of soft tissue masses or adenopathy.

Operator dependent; limited by bone and large abnormalities.

CT indications: Trauma screening; pulmonary disease; abdominal/pelvic viscera; complex fractures; inconclusive US/MRI findings or MRI contraindication.

CT chosen per indication; avoid double contrast studies except specific exceptions.

MRI indications: Imaging brain/spinal cord; characterizing visceral and musculoskeletal soft tissue masses; evaluating ligaments/tendons; infections; when superior soft-tissue definition needed.

MRI may require sedation; contraindicated with some implants; contrast considerations apply.

CPT/HCPCS Codes and Coding Guidance

Experimental/Investigational CPTCPTExperimental

C9791

MRI utilizing Xenon Xe 129 (investigational)

3D Rendering and Limited CTCPT

76376	3D rendering; without image post-processing on an independent workstation
76377	3D rendering; requiring image post-processing on an independent workstation
76380	Limited or follow-up CT

Imaging Guidance CodesCPT

76942	Ultrasonic guidance for needle placement
77011	CT guidance for stereotactic localization
77012	CT guidance for needle placement
77013	CT guidance for, and monitoring of parenchymal tissue ablation
77021	MR guidance for needle placement
77022	MR guidance for, and monitoring of parenchymal tissue ablation

Breast Biopsy CodesCPT

19085	Biopsy, breast, with placement of breast localization device(s), percutaneous; first lesion, including MR guidance
19086	Biopsy, breast, with placement of breast localization device(s), percutaneous; each additional lesion, including MR guidance

Unlisted Procedure CodesCPT

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

Percutaneous Drainage GuidanceCPT

75989

Imaging guidance for percutaneous drainage with placement of catheter

CT codes and notesCPT

76380

Limited or Follow-up CT

SPECT/CT and nuclear medicine codesCPT

78830	SPECT/CT single area and single day
78831	SPECT/CT 2 or more days
78832	SPECT/CT 2 areas with one day and 2-day study
78072	SPECT/CT parathyroid nuclear imaging (effective 2013-01-01)

Interpretation codesCPT

76140

Interpretation of an outside study

Quantitative MR Category III and related codesCPTNot Covered

0648T	Quantitative mpMRI data analysis without diagnostic MRI (single organ)
0649T	Quantitative mpMRI data analysis with diagnostic MRI (single organ)
0697T	Quantitative MRI analysis without diagnostic MRI (multiple organs)
0698T	Quantitative MRI analysis with diagnostic MRI (multiple organs)
0865T	Volumetric/quantitative MRI analysis of the brain
0866T	Volumetric/quantitative MRI analysis of the brain

Whole-body MRI and PET-MRI codingCPT

76498	Unlisted MRI procedure (used to report WBMRI or MRI component of PET-MRI)
78813	PET whole-body

HCPCS examples and guidancemixed

C8931	MRA with dye, Spinal Canal (example HCPCS)
72159	MRA Spinal Canal (CPT example for comparison)
S8042	MRI, low-field (non-specific HCPCS example noted as discouraged)

Covered CPT Codes (upper extremity wrist)CPTCovered

73221

MRI Upper Extremity Joint (Wrist) without contrast

Covered CPT Codes (upper extremity other)CPTCovered

73218	MRI Upper Extremity Other Than Joint (Arm or Forearm) without contrast
73220	MRI Upper Extremity Other Than Joint (Arm or Forearm) without and with contrast

Covered CPT Codes (pelvis)CPTCovered

72195	MRI Pelvis without contrast
72197	MRI Pelvis without and with contrast
72192	CT Pelvis without contrast
72193	CT Pelvis with contrast
72194	CT Pelvis without and with contrast

Covered CPT Codes (lower extremity)CPTCovered

73721	MRI Lower Extremity Joint (Knee) without contrast
73718	MRI Lower Extremity Other Than Joint without contrast

Meralgia / Pelvic imagingCPTCovered

72195	MRI Pelvis without contrast
72192	CT Pelvis without contrast

Peroneal neuropathy / lower extremity MRICPTCovered

73721	MRI Lower Extremity Joint (Knee) without contrast
73718	MRI Lower Extremity Other Than Joint without contrast

CNS/spine imaging for polyneuropathy with CNS involvementCPTCovered

70553	MRI Brain without and with contrast
72156	MRI Cervical Spine without and with contrast
72157	MRI Thoracic Spine without and with contrast
72158	MRI Lumbar Spine without and with contrast

Brachial plexus and chest/neck imagingCPTCovered

73220	MRI Upper Extremity other than joint without and with contrast
73218	MRI Upper Extremity other than joint without contrast
71552	MRI Chest without and with contrast
70540	MRI Neck without contrast
71550	MRI Chest without contrast
70543	MRI Neck without and with contrast

CT alternatives when MRI contraindicatedCPTCovered

70490	CT Neck without contrast
70491	CT Neck with contrast
70492	CT Neck without and with contrast
73200	CT Upper Extremity without contrast
73201	CT Upper Extremity with contrast
73202	CT Upper Extremity without and with contrast
71250	CT Chest without contrast
71260	CT Chest with contrast
71270	CT Chest without and with contrast

MRN reporting codesCPTCovered

76498

Unlisted MRI procedure code (MRN)

MRN extremity MRI codesCPTCovered

73218	MRI Upper Extremity, other than joint, without contrast
73220	MRI Upper Extremity, other than joint, without and with contrast
73718	MRI Lower Extremity, other than joint, without contrast
73720	MRI Lower Extremity, other than joint, without and with contrast

Plexus/spine/abdomen/pelvis imaging codesCPTCovered

72195	MRI Pelvis without contrast
72197	MRI Pelvis without and with contrast
74181	MRI Abdomen without contrast
74183	MRI Abdomen without and with contrast
72148	MRI Lumbar Spine without contrast
72193	CT Pelvis with contrast
74177	CT Abdomen and Pelvis with contrast

Imaging for suspected motor neuron disease / ALSCPTCovered

70551	MRI Brain without contrast
70553	MRI Brain without and with contrast
72141	MRI Cervical Spine without contrast
72156	MRI Cervical Spine without and with contrast
72146	MRI Thoracic Spine without contrast
72157	MRI Thoracic Spine without and with contrast

Chest/Abdomen/Pelvis imaging for neuromuscular junction disorders and paraneoplastic evaluationCPTCovered

71260	CT Chest with contrast
71250	CT Chest without contrast
71552	MRI Chest without and with contrast
71550	MRI Chest without contrast
74177	CT Abdomen and Pelvis with contrast
74178	CT Abdomen and Pelvis without and with contrast

MRI for muscle disease / biopsy planningCPTCovered

73218	MRI Upper Extremity other than joint without contrast
73220	MRI Upper Extremity other than joint without and with contrast
73718	MRI Lower Extremity other than joint without contrast
73720	MRI Lower Extremity other than joint without and with contrast

Imaging for Gaucher disease (initial and surveillance)CPTCovered

72148	MRI Lumbar Spine without contrast
74181	MRI Abdomen without contrast
71250	CT Chest without contrast
73718	MRI Bilateral femurs (Lower Extremity other than joint) without contrast

Imaging for Gaucher disease surveillanceCPTCovered

72148	MRI Lumbar Spine without contrast
73718	MRI Lower Extremity, other than joint, bilateral femurs, without contrast
74181	MRI Abdomen without contrast
71250	CT Chest without contrast

CT for new or worsening pulmonary symptomsCPTCovered

71250

CT Chest without contrast

DXA scansmixedCovered

DEXA	Dual-energy X-ray Absorptiometry (bone density) scanning

Imaging for PNST and related workupCPTCovered

70553	MRI Brain without and with contrast
72156	MRI Cervical Spine without and with contrast
72157	MRI Thoracic Spine without and with contrast
72158	MRI Lumbar Spine without and with contrast
74160	CT Abdomen with contrast
71260	CT Chest with contrast

Contrast renal function threshold

GFR threshold for contrast

Prior Authorization, Documentation, and Billing Actions

Prior Authorization

Preprocedural imaging and prior auth

Pre-procedural imaging is not indicated if the procedure itself is not indicated. If a procedure requires prior authorization, tie approval of any preprocedural imaging to the procedure approval; when the procedure is approved (or the procedure does not require prior authorization), appropriate preprocedural imaging may be approved.

Preprocedural imaging should only be requested after clinical justification for the procedure has been established.

Prior Authorization

Prior authorization for 3D rendering codes

CPT 76376 and 76377 require documented concurrent physician supervision and active participation in the 3D post-processing and rendering. Providers may need to obtain prior authorization for these 3D rendering codes even when the parent imaging study does not require prior authorization.

Document physician oversight per ACR recommendations (design of region, tissue types displayed, archived cine loops, monitoring/adjustments).
76376 = no independent workstation; 76377 = requires independent workstation.

Contrast Use and Safety Guidance

Note

Imaging Frequency and Surveillance Intervals

Gaucher and LEMS imaging frequency summary

Gaucher surveillance (MRI) frequencyEvery 12 months: MRI lumbar spine, bilateral femurs, MRI abdomen; CT chest without contrast when pulmonary involvement documented

LEMS follow-up (CT) frequencyIf initial CT negative and suspicion persists, repeat CT chest ± abdomen/pelvis every 6 months for 2 years

Prior authorization notePrior authorization may be required for routine surveillance studies; provide clinical justification (enzyme replacement therapy monitoring, pulmonary involvement)

Routine interval guidance for MRI/CT anatomic studies

Routine MRI/CT interval guidanceFrequency guidance for listed anatomic MRI/CT surveillance is every 12 months when specified (e.g., Gaucher disease surveillance studies)

Use-case

Prior Authorization Expectations

Note

Background and Scope

These guidelines provide an evidence-based scope for advanced imaging and related procedures used in the evaluation of peripheral nerve and neuromuscular disorders. They address modality selection across nuclear medicine, ultrasound, CT, MRI (including Magnetic Resonance Neurography), and PET techniques, and emphasize that imaging is appropriate when it is based on the clinical presentation and supported by adequate documentation (history, focused neurologic exam, prior imaging and, when indicated, electrodiagnostic testing). The guidance prioritizes MRI for deep or complex nerve assessments and surgical planning and recognizes ultrasound as preferred for many superficial peripheral nerve evaluations due to higher spatial resolution, while also noting pediatric considerations and the need to follow age-specific imaging pathways.

Definitions and Terminology

Description of guideline

Guideline descriptionEvidence-based, proprietary clinical guidelines based on peer-reviewed literature, specialty society guidance, and expert input; formally reviewed annually

ScopeEvaluates advanced imaging and procedures including NM, US, CT, MRI, PET across multiple specialties

PurposeFacilitate appropriate imaging selection while allowing physician judgment; support quality and patient safety

Standard or conventional imaging definition

Standard/conventional imagingPlain film, CT, MRI, or ultrasound used in initial and subsequent evaluations (e.g., malignancy); modality selection depends on clinical question

RoleConventional imaging often drives need for further advanced imaging when studies are inconclusive or indeterminate

Services Not Supported / Investigational

The following procedures are identified as not covered or investigational: PET/MRI is generally not supported for routine evaluation of peripheral nerve and neuromuscular disorders except in narrowly defined circumstances where PET‑CT criteria are met and PET‑CT is unavailable; reporting guidance (CPT 78813 + 76498) applies when that rare exception is used. MRI utilizing Xenon Xe‑129 (CPT C9791) is considered investigational/experimental and not supported. 3D rendering (CPT 76376/76377) should not be billed when the requested service is routine 2‑D reformatting or otherwise duplicative of standard cross‑sectional imaging, and separate reimbursement for routine 3D reformats is not appropriate.

Whole‑body CT performed as a screening study in asymptomatic individuals is not covered because it does not meet established validity criteria for screening and exposes individuals to unnecessary radiation. Quantitative multiparametric MRI procedures and volumetric/quantitative brain MRI (Category III CPT codes such as 0648T/0649T/0697T/0698T and CPT 0865T/0866T) are considered investigational or not medically necessary for routine clinical practice and therefore are not supported.

CT Pelvis without contrast (CPT 72192) is not routinely indicated for evaluation of sciatic neuropathy or meralgia paresthetica because of limited soft‑tissue contrast relative to MRI. CT pelvis without contrast should be reserved for rare circumstances when MRI is contraindicated (for example, non‑MRI‑conditional implanted devices or severe contrast/allergy issues) and the provider documents the specific contraindication to MRI.

Fluorine‑18 FDG PET/CT is not supported for evaluation of traumatic or nontraumatic brachial plexopathy in the absence of a known malignancy. The guideline notes there is no literature supporting FDG‑PET/CT for routine plexopathy assessment without established malignancy, and MRI remains the preferred modality for brachial plexus evaluation.

Policy Revision History

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAdult Peripheral Nerve and Neuromuscular Disorders (PNND) Imaging Guidelines (For Ohio Only)

Policy CodePolicy CSRAD012OH.D

Change TypeNo material clinical or coverage changes

Effective DateNovember 1, 2025

Next Review DateN/A

Key ActionSubmit adequate clinical documentation including recent history, physical exam, EMG/NCV when indicated, and prior imaging to support medical necessity and prior authorization requests.

SourceLink

On This Page

PET indications: Oncologic tumor metabolic activity evaluation; cardiac myocardial metabolic activity; brain metabolic activity for procedural planning; typically performed as PET/CT.

PET not for routine surveillance unless specified.

inv-158: Appropriate clinical scenarios for 3D rendering and limited CT

Appropriate clinical scenarios for 3D rendering and limited CT

3D rendering and limited CT indications: 3D rendering (76376/76377) appropriate for complex bony and surgical planning cases as listed; limited CT (76380) appropriate for limited or follow-up imaging when full diagnostic CT is not performed (e.g., limited sinus CT, follow-up pulmonary nodule slices, limited slices for non-healing fracture).

Do not bill 76376/76377 for 2D reformatting; 76380 not for treatment planning.

inv-159: Appropriate use of imaging guidance codes

Appropriate use of imaging guidance codes

Imaging guidance appropriate use: Use modality-specific guidance codes (US 76942, CT 77011/77012/77013, MR 77021/77022) for percutaneous procedures and ablations; one unit per encounter; not appropriate for open surgical procedures or routine diagnostic reporting.

77013 for non-bone ablation; 20982 covers CT guidance for bone tumor ablations.

inv-160: Appropriateness of whole-body CT, whole-body MRI, and PET-MRI

Appropriateness of whole-body CT, whole-body MRI, and PET-MRI

Whole-body CT screening: Whole-body CT for screening asymptomatic individuals is not indicated; exception: low-dose CT supported for multiple myeloma staging.

WBMRI appropriateness: WBMRI may be appropriate for select cancer predisposition syndromes and certain autoimmune conditions; otherwise generally not supported due to lack of standardization and outcome data.

Report WBMRI using CPT 76498.

PET-MRI conditional use: PET-MRI may be appropriate only when PET-CT criteria are met and PET-CT is unavailable and the provider requests PET-MRI in lieu of PET-CT; report using CPT 78813 plus CPT 76498 when appropriate.

inv-161: Specific neuropathy-related imaging indications

Specific neuropathy-related imaging indications

Neuropathy imaging indications: Indications include pre-operative planning, diagnostic uncertainty after EMG/NCV and clinical exam, documented concern for specific neuropathies (pudendal, sciatic, femoral, peroneal, meralgia paresthetica), and suspicion for nerve tumor.

EMG/NCV required for many neuropathies as specified per entry.

inv-162: Meralgia paresthetica specific criteria

Meralgia paresthetica specific: MRI Pelvis without contrast (72195) indicated for diagnostic uncertainty or pre-operative planning; CT pelvis without contrast (72192) is not routinely indicated except when MRI contraindicated.

EMG/NCV not required initially.

inv-163: Peroneal neuropathy criteria

Peroneal neuropathy criteria: EMG/NCV required initially; MRI lower extremity (73721 or 73718) when surgery being considered or when ordered by/with a surgeon.

inv-164: Brachial plexus disorders — covered scenarios

Brachial plexus covered scenarios: Covered scenarios include malignant infiltration, radiation plexitis (EMG not required), neurogenic thoracic outlet syndrome, traumatic injury, brachial plexitis, and preoperative evaluation; EMG/NCV generally required except for malignant infiltration or radiation plexitis.

MRI preferred; CT alternative when MRI contraindicated.

inv-165: Brachial plexus imaging

Brachial plexus imaging prerequisites and modalities: EMG/NCV required prior to advanced imaging except malignant infiltration or radiation plexitis; MRI Chest/Neck/Upper Extremity (listed CPTs) are preferred; if MRI unavailable/contraindicated, one CT neck/upper extremity/chest study may be used.

FDG-PET/CT not supported in absence of known malignancy.

inv-166: Magnetic Resonance Neurography (MRN)

MRN coverage summary: MRN is indicated to evaluate traumatic or compressive focal neuropathy or brachial plexus injury when requested by a specialist after in-person evaluation, EMG/NCV performed, and prior imaging inconclusive; report as CPT 76498 or specified extremity MR codes.

MRN for other indications (lumbosacral plexopathy, neuromuscular disease, polyneuropathy) is not medically necessary.

inv-167: Motor neuron disease / fasciculations with UMN signs

Motor neuron disease / fasciculations with UMN signs: When upper motor neuron signs are present or concern for ALS exists, MRI Brain and/or Spine studies are indicated to evaluate for ALS-associated changes or mimic disorders (see ALS imaging CPT codes).

Pre-imaging EMG/NCV and lab evaluation generally required as specified in fasciculations section.

inv-168: Known or suspected muscle disease

Known or suspected muscle disease: MRI of the affected muscle (upper extremity CPT 73218/73220; lower extremity CPT 73718/73720) is supported to plan biopsy, evaluate myopathy, assess progression, and monitor treatment response; bilateral studies supported when criteria met.

Consider chest/abdomen/pelvis imaging for paraneoplastic evaluation when indicated.

inv-169: Suspected paraneoplastic neuromuscular syndromes

Paraneoplastic evaluation indications: For suspected paraneoplastic neuromuscular syndromes (e.g., MG, LEMS, stiff-person), chest CT/MRI and CT abdomen/pelvis (or MRI alternatives) are indicated; repeat imaging per defined intervals if initial imaging negative and suspicion persists.

LEMS follow-up interval: every 6 months for 2 years if initial CT negative and suspicion persists.

inv-170: Monitoring and assessment of Gaucher disease progression or treatment response; evaluation of new/worsening pulmonary symptoms

Gaucher monitoring and pulmonary evaluation: For Gaucher disease surveillance or treatment monitoring, annual imaging includes MRI lumbar spine (72148), bilateral femurs MRI (73718), MRI abdomen (74181); CT chest without contrast (71250) for new or worsening pulmonary symptoms.Every 12 months

DEXA scans every 12-24 months until normal, then every 3 years.

inv-171: Initial evaluation of suspected PNST or targeted follow-up when clinically indicated

Initial evaluation of suspected PNST: For suspected PNST, MRI without and with contrast of the affected body region is supported as initial evaluation; plain x-ray often precedes soft-tissue MRI except in cancer predisposition syndromes.

Routine follow-up imaging not indicated except for specific triggers.

inv-172: Evaluation of peripheral nerve sheath tumors and peripheral nerve disorders

Evaluation of PNST and peripheral nerve disorders: MRI of the known or suspected body region is the preferred imaging modality for PNST and peripheral nerve disorders; nuclear medicine studies are not indicated for routine evaluation as they do not add clinical value.

PET/MRI for peripheral nerve disease is considered not medically necessary.

GFR <30 mL/min — both iodinated CT contrast and gadolinium-based MRI contrast share increased risk at GFR <30 mL/min

Clinical implicationUse caution or avoid contrast in individuals with GFR <30 mL/min due to risk of CIN and NSF

Reference practiceWhen renal impairment present, select non-contrast imaging when feasible or justify contrast use based on clinical need

CT slice/sequence and coding note

CT slices/sequences guidanceNo specific minimum or maximum number of CT slices or sequences is defined by AMA CPT; protocols vary by clinical indication

Billing implicationDo not use limited CT (CPT 76380) to report 'extra slices' on a diagnostic CT; 76380 is for limited/follow-up studies when full diagnostic CT work is not performed

Protocol noteCT protocols should be tailored to the clinical question; additional sequences are common when clinically indicated

EMG/NCV prerequisite — brachial plexus

EMG/NCV prerequisite (brachial plexus)EMG/NCV examination is required prior to advanced imaging of the brachial plexus except in cases of malignant infiltration or radiation plexitis

RationaleElectrodiagnostic testing establishes origin of pathology and helps target imaging; MRI is reserved when EMG/NCV and exam are inconclusive

ExceptionIf malignant infiltration or radiation plexitis is suspected, advanced imaging may proceed without prior EMG/NCV

EMG/NCV prerequisite — plexus imaging

EMG/NCV prerequisite (lumbar/lumbosacral plexus)EMG/NCV should be performed prior to advanced imaging for suspected lumbar/lumbosacral plexopathy unless concern for malignant infiltration

Imaging alternativesIf malignant infiltration is suspected, imaging may be obtained without prior EMG/NCV; MRI pelvis options listed in guideline

DocumentationProvide EMG/NCV results with imaging request unless exception applies

Gaucher disease surveillance interval

Gaucher surveillance intervalEvery 12 months: MRI lumbar spine (CPT 72148), bilateral femurs MRI (CPT 73718), MRI abdomen (CPT 74181); CT chest (CPT 71250) if documented pulmonary involvement

PurposeAssess treatment response for individuals on enzyme replacement therapy or monitor disease progression

Additional testingDEXA and CT chest included as clinically indicated per guideline

LEMS follow-up imaging frequency

LEMS follow-up imaging frequencyIf initial CT is negative and clinical suspicion for malignancy persists, repeat CT Chest ± CT Abdomen/Pelvis every 6 months for 2 years

Modality specifiedCT Chest with contrast (CPT 71260) and/or CT Abdomen and Pelvis with contrast (CPT 74177) are indicated for LEMS evaluation

RationaleLEMS is associated with malignancy (notably small cell lung cancer) — serial imaging targets occult malignancy

Documentation Required

Modality selection and justification

Select the imaging modality that best answers the clinical question and justify modality choices in the clinical documentation. MRI is preferred prior to PET when both are under consideration; CT is an acceptable alternative when MRI is contraindicated or unavailable.

When peripheral nerve imaging is indicated, ultrasound is preferred for superficial nerves; MRI for deep nerves or surgical planning; CT only if MRI contraindicated.
MRI should be performed prior to consideration of PET imaging.

Prior Authorization

Prior authorization and coding headline

Magnetic Resonance Neurography (MRN) is supported only when ALL specific criteria are met (traumatic/compressive focal neuropathy or brachial plexus injury; requested by appropriate specialist after in-person evaluation when surgery is being considered; EMG/NCV performed; prior imaging inconclusive). MRN for other indications is considered not medically necessary and may be denied. Report MRN using CPT 76498 or the supported extremity MRI CPTs when applicable.

Report MRN as CPT 76498 OR an appropriate extremity MRI CPT (73218/73220/73718/73720).
MRN for indications such as lumbosacral plexopathy, neuromuscular disease, or polyneuropathy is NOT supported.

Prior Authorization

Extremity MRI for muscle disease

Extremity MRI is indicated to plan muscle biopsy or to evaluate known or suspected muscle disease (including myopathy/myositis and inflammatory muscle diseases). When criteria are met, bilateral extremity MRI may be supported.

Typical CPTs: Upper extremity other than joint 73218 or 73220; Lower extremity other than joint 73718 or 73720.
Imaging may be used for selection of biopsy site, differential diagnosis, progression assessment, treatment monitoring, or occult malignancy detection.

Prior Authorization

Thoracic/abdominopelvic imaging for neuromuscular junction disorders

Chest and abdomen/pelvis imaging are indicated when evaluating myasthenia gravis (MG) or suspected thymic disease and for evaluation of Lambert-Eaton Myasthenic Syndrome (LEMS) given its paraneoplastic associations. Document specialist involvement before ordering thoracic/abdominopelvic imaging for MG/LEMS.

For MG: one of CT chest with or without contrast (71260/71250) or MRI chest (71552/71550).
For LEMS: CT chest with contrast (71260) and/or CT abdomen and pelvis with contrast (74177); if initial imaging negative, repeat imaging every 6 months for 2 years when suspicion persists.

Denial Risk

Denial risk for unproven or limited services

Services stated as unproven or subject to limits (including certain uses of PET, PET/MRI, MRN for unsupported indications, and nuclear medicine for peripheral nerve disorders) will be evaluated per Ohio Administrative Code and may be denied.

Requests for PET/CT, PET/MRI, or nuclear medicine for peripheral nerve disease without clear supporting criteria may be denied as not medically necessary.
Follow OAC 5160-1-01 when services are described as unproven or limited.

Billing Rule

Inappropriate use of CPT 76380

CPT 76380 (limited or follow-up CT) is not indicated for treatment planning and should not be used to cover 'extra slices' or to substitute for an appropriate diagnostic CT code. Do not report 76380 in conjunction with full diagnostic CT codes to justify additional sequences.

Use 76380 only when the work of a full diagnostic code is not performed (limited or follow-up CT).
There is no CPT-defined minimum/maximum number of slices for CT; billing 76380 to cover extra sequences is inappropriate.

Denial Risk

MRN denial risks

MRN requests that do not meet the listed MRN criteria (see MRN coding headline) are considered not medically necessary and subject to denial.

MRN requires in-person clinical evaluation by an appropriate specialist, EMG/NCV results, and prior imaging that fails to clarify the diagnosis.
MRN for indications other than traumatic/compressive focal neuropathies or brachial plexus injuries is NOT supported.

Documentation Required

Pre-imaging workup required for fasciculations

Before ordering advanced imaging for fasciculations, complete the required pre-imaging workup: focused history and physical, EMG/NCV, and laboratory testing. Requests lacking these elements may be denied.

Required: history (time course, areas, weakness, associated symptoms), EMG/NCV evaluation, and labs (CBC, CMP, thyroid, B12, ESR, autoimmune panels, SPEP/UPEP, infectious testing as indicated, heavy metal testing).
If concern for radiculopathy, neuromuscular, or muscle disorders, follow the applicable imaging guideline sections.

Denial Risk

Denial risk for nuclear imaging in peripheral nerve disorders

Nuclear medicine studies, including PET and PET/MRI, are not indicated for routine evaluation of peripheral nerve disorders and are considered not medically necessary in most peripheral nerve scenarios. Requests for nuclear imaging for peripheral nerve disease may be denied.

PET/MRI may be appropriate only when PET-CT criteria are met and PET-CT is unavailable and when reported as CPT 78813 + CPT 76498 per policy.
PET imaging is not generally useful for peripheral nerve disorders due to limited spatial resolution.

Documentation Required

Age-based imaging guidance

Age-based imaging guidance: individuals ≤18 years should follow Pediatric Imaging Guidelines when addressed in condition-specific sections; otherwise use General Imaging Guidelines. Individuals >18 years follow the General Imaging Guidelines unless otherwise specified.

Apply pediatric-specific recommendations for minors where present; account for age-related differences in disease and management.

Billing Rule

Documentation for stereotactic CT localization

When CPT 77011 stereotactic CT localization is performed as a technical-only preoperative dataset without radiologist interpretation, report CPT 77011. If a diagnostic CT is interpreted, use the appropriate diagnostic CT code instead. Do not report 77011 and a diagnostic CT code for the same session; do not report 3D rendering (76376/76377) with 77011.

If no radiologist interpretation is provided, bill CPT 77011 for stereotactic localization.
If interpreted, bill an appropriate diagnostic CT code (e.g., 70486) and do not also bill 77011 for the same imaging session.

Billing Rule

Reporting secondary interpretation of outside studies

Use CPT 76140 for secondary interpretation of outside imaging studies. Do not use diagnostic imaging procedure codes to report interpretation of a study performed elsewhere; the diagnostic code for a current exam already includes comparison to prior studies when applicable.

When a secondary interpretation of an outside exam is requested, report CPT 76140.
Do not bill a full diagnostic imaging code solely to interpret an external study.

Documentation Required

Clinical and electrodiagnostic documentation

Clinical history and electrodiagnostic studies (EMG/NCV) are primary diagnostic tools and must be documented in the record. A pertinent neurologic exam, relevant laboratories, and non-advanced imaging results should accompany requests for advanced imaging.

EMG/NCV is frequently required prior to advanced imaging; document timing relative to symptom onset and provide results.
Include recent history, focused neurologic exam, labs, and prior imaging when submitting imaging requests.

Documentation Required

Required documentation for MRN

Required documentation for MRN: an in-person clinical evaluation by a neurosurgeon, orthopedic surgeon, neurologist, or podiatrist when surgery is being considered; EMG/NCV results; prior imaging that fails to answer the clinical question; and clear indication that MRN will impact surgical planning or management.

Include the specialist's in-person evaluation note, EMG/NCV reports, and prior imaging reports/images when requesting MRN.
Without this documentation, MRN requests are likely to be denied.

Documentation Required

Required clinical documentation for fasciculations

For fasciculations, required clinical documentation must include the time course of symptoms, areas involved, presence or absence of weakness, and associated symptoms (pain, sensory changes, bowel/bladder dysfunction). Laboratory and EMG/NCV data must be submitted prior to advanced imaging.

Document detailed symptom chronology and distribution, weakness, and any bulbar or autonomic symptoms.
Provide EMG/NCV report and specified laboratory evaluations with the imaging request.

Documentation Required

Clinical documentation for MG chest imaging

When ordering chest imaging for myasthenia gravis evaluation, ensure the diagnosis is established or strongly suspected by a specialist (neurologist, rheumatologist, or ophthalmologist) and include relevant clinical, electrodiagnostic, and antibody data. Repeat imaging is indicated for new chest mass symptoms, rising antibody titers, or pre-operative planning.

Supported chest studies: CT chest with or without contrast (71260/71250) or MRI chest (71552/71550).
Repeat imaging indicated when symptoms of chest mass, rising anti-striated muscle antibody titers, or need for pre-operative assessment occur.

Documentation Required

Clinical indication documentation

Document the specific clinical indication for imaging (e.g., surveillance, new pulmonary symptoms, pre-operative planning) and how the requested study will affect management. For surveillance imaging (e.g., Gaucher disease), include interval and treatment status.

Surveillance imaging example: Gaucher disease annual imaging for those on enzyme replacement (lumbar spine MRI, bilateral femurs MRI, abdominal MRI, CT chest for documented pulmonary involvement).
Requests must state how results will influence care to avoid denials for overutilization or duplicative studies.

Note

Plan and regulatory precedence

Federal, state (Ohio Administrative Code), or contractual requirements govern in the event of conflict with this Medical Policy. Providers must check applicable rules and ensure requests comply with those requirements.

In event of conflict, federal/state/contractual terms take precedence over this policy.
Follow OAC 5160-1-01 for evaluation of unproven or limited services.

Denial Risk

Avoidance of duplicate imaging

Review prior imaging to avoid duplication. Repeat studies are only generally supported when there is evidence of progression, recurrent disease, incomplete prior study, or when repeat imaging will change management.

Document prior studies and reason for repeat imaging (e.g., progression, new symptoms, postoperative baseline, incomplete prior study).
Prevention of unnecessary repeat imaging protects patients from excess radiation and cost.

Documentation Required

EMG prerequisite

EMG/NCV is required prior to advanced imaging for most peripheral neuropathies; exceptions include malignant infiltration or radiation plexitis and other condition-specific exceptions noted in the guideline sections.

Document EMG/NCV timing and results when submitting imaging requests.
Exceptions to EMG/NCV prerequisites should be clearly documented and justified (e.g., malignant infiltration).

Prior Authorization

Annual surveillance for Gaucher disease

Annual surveillance imaging for Gaucher disease may be indicated for individuals on enzyme replacement therapy or for disease progression monitoring. Typical surveillance elements include MRI lumbar spine, bilateral femurs MRI, abdominal MRI, and CT chest if pulmonary involvement is documented.

Frequency: Every 12 months when indicated for treatment response or progression assessment.
Imaging modalities: MRI lumbar spine (72148), MRI bilateral femurs (73718), MRI abdomen (74181), CT chest without contrast (71250) when pulmonary disease documented.

Prior Authorization

PNST follow-up imaging triggers

Routine follow-up imaging for Peripheral Nerve Sheath Tumors (PNST) is not indicated except for new symptoms, postoperative scenarios, incomplete resections needing baseline imaging, or when malignant transformation is suspected. When follow-up is indicated, MRI of the known region with and without contrast is preferred; metastatic workup uses CT chest/abdomen as appropriate.

Indications for follow-up: new neurological findings, post-operative baseline/re-evaluation, incomplete resection, or suspected malignant transformation.
Preferred follow-up study: MRI with and without contrast of the region; CT chest with contrast (71260) and CT abdomen with contrast (74160) for metastatic work-up when transformation is suspected.

Apply annual interval to the specific anatomic studies named in condition sections (lumbar spine, bilateral femurs, abdomen, etc.)

AuthorizationProviders should supply clinical indication and justification when requesting routine annual surveillance imaging

DEXA frequency guidance

DEXA frequency guidanceEvery 12–24 months until results are normal or following enzyme replacement therapy dose change; once normal, interval may be every 3 years

IndicationUsed to assess bone disease/osteoporosis risk in conditions such as Gaucher disease

Trigger for earlier repeatRepeat DEXA after enzyme replacement therapy dose change or if clinical concerns arise

Contrast selectionAppropriate contrast level (none/with/without and with) is determined by condition-specific guidance

PET/CT unbundling definition

PET/CT unbundlingUnbundling PET/CT into separate PET and diagnostic CT CPT codes is not supported because PET/CT is performed as a single study

Reporting practiceReport PET/CT as the combined study rather than separate PET and diagnostic CT codes

PET-MRI notePET/MRI is generally not supported except in specific conditional circumstances

Concurrent supervision (3D rendering) definition

Concurrent supervision (3D rendering)Active physician participation and monitoring of the reconstruction process (design of anatomic region, selection of tissues/structures, archived images, and adjustment of 3D work product); document supervision

Coding distinctionCPT 76376 (no independent workstation) vs 76377 (requires independent workstation); do not use for routine 2D reformatting

Prior authorizationProviders may be required to obtain prior authorization for 3D rendering codes even if base imaging is authorized

Imaging guidance for percutaneous drainage

Imaging guidance for percutaneous drainageUse CPT 75989 to report imaging guidance when a catheter is placed and left in situ; applicable across fluoroscopy, ultrasound, CT, or MR guidance

General ruleGuidance codes are modality-specific and appropriate when imaging is used to guide percutaneous procedures

Unit reportingOnly one unit of guidance code should be reported per encounter unless otherwise specified

Hybrid SPECT/CT definition

Hybrid SPECT/CTSPECT/CT combines functional nuclear imaging with CT for localization and attenuation correction; report using CPT 78830–78832 depending on study timing/areas

Use casesCommon studies include MIBG and octreotide scintigraphy; CPT 78072 available for parathyroid SPECT/CT

Nuclear roleSPECT/CT provides combined anatomic and functional information when indicated clinically

Quantitative mp-MRI definition

Quantitative mp-MRI definitionSoftware-based analysis of multiparametric MRI data using Category III CPT codes (e.g., 0648T, 0649T, 0697T, 0698T, 0865T, 0866T) — considered investigational/experimental for routine practice

Clinical statusPrimarily used in clinical trials; not widely recommended for routine clinical use

Coding implicationCategory III codes exist for single- and multi-organ analyses; volumetric brain MRI codes (0865T/0866T) considered not medically necessary

Ultrasound vs MRI preference and performance

Ultrasound vs MRI for peripheral nervesUltrasound is preferred for superficial peripheral nerves due to higher spatial resolution and advantages in cost, speed, and side-to-side comparison; MRI preferred for deep nerves or when bone obscures the nerve

Performance noteUltrasound may detect multifocal and subtle caliber changes better than MRI; MRI may miss multifocal pathologies

Modality selectionChoose ultrasound for superficial nerves; use MRI for deep plexus, surgical planning, or when ultrasound is inadequate

EMG/NCV timing

EMG/NCV timingNerve conduction studies often are normal early; changes commonly occur 1–4 weeks after symptom onset, with optimal time to detect denervation changes ~10–14 days after injury

Implication for imagingPerform EMG/NCV at appropriate interval to guide need for advanced imaging; early normal studies may require repeat testing

Clinical utilityEMG/NCV results help localize pathology and inform imaging selection

Meralgia paresthetica definition and imaging role

Meralgia paresthetica definitionPathology of the lateral femoral cutaneous nerve causing sensory loss in the lateral thigh; primarily diagnosed clinically; imaging (MRI pelvis without contrast) reserved for diagnostic uncertainty or preoperative planning

Imaging roleMRI pelvis without contrast (CPT 72195) indicated when exam/EMG inconclusive or for pre-op planning; CT pelvis without contrast not routinely indicated

Clinical noteEMG/NCV is not required initially for meralgia paresthetica

Brachial plexitis (Parsonage-Turner) definition

Brachial plexitis (Parsonage-Turner) definitionA self-limited syndrome with initial shoulder pain followed by weakness in a non-root distribution; imaging and EMG used when diagnosis is uncertain

Imaging roleEMG and MRI may assist when clinical/exam findings are unclear; MRI is preferred for brachial plexus evaluation

Typical courseOften self-limited but imaging considered for atypical presentation or surgical planning

Brachial plexitis — brief definition

Brachial plexitis concise noteSelf-limited syndrome with shoulder pain followed by weakness not conforming to a single root; consider imaging and EMG when diagnosis uncertain

When to imageImaging reserved for atypical or persistent cases or when alternative diagnoses are suspected

EMG roleEMG can help define extent and timeline of denervation

MRN definition

Magnetic Resonance Neurography (MRN)MRN uses MRI sequences optimized to increase contrast between nerve and surrounding soft tissue to view nerve layers in detail; used for detailed nerve assessment

CapabilityProvides enhanced visualization of nerve anatomy and pathology compared with conventional MRI sequences

Coding noteMRN is reported using unlisted MRI CPT 76498 or specified extremity MRI codes when indicated

Spinal Muscular Atrophy (SMA) definition

Spinal Muscular Atrophy (SMA)Genetic disorder diagnosed primarily by molecular genetic testing; MRI is not supported for diagnosis in children unless other diseases are being considered

Adult-onsetIn adult-onset cases, advanced imaging is indicated when both upper and lower motor neuron findings are present

Diagnostic standardMolecular genetic testing remains the diagnostic standard

Fasciculations definition and imaging role

Fasciculations definitionInvoluntary, irregular muscle movements from activation of a single motor unit; often benign but more likely pathologic if multiple muscles involved or associated with weakness/atrophy/hyperreflexia

Imaging considerationsAdvanced imaging requires prior history/physical, EMG/NCV, and laboratory evaluation; CNS MRI indicated if UMN signs are present

EMG roleEMG/NCV helps differentiate benign from pathologic fasciculations

Gaucher disease definition

Gaucher disease definitionAutosomal recessive storage disorders caused by acid β-glucuronidase deficiency leading to visceral and bone involvement; treatable with enzyme replacement therapy

Major organ involvementLiver, spleen, bone marrow/bones commonly affected; pulmonary involvement may occur and prompt CT chest evaluation

Imaging roleImaging assesses visceral and bone disease and monitors treatment response

PNST definition

Peripheral Nerve Sheath Tumors (PNST)Tumors such as schwannomas or neurofibromas arising from Schwann cells or nerve connective tissue; may occur anywhere and carry ~5% malignant transformation risk

Clinical impactPNSTs can require region-specific imaging to evaluate for malignant transformation or surgical planning

Preferred modalityMRI is preferred for PNST evaluation; PET/nuclear imaging role is not established

PNST and peripheral nerve disorders — imaging stance

PNST/peripheral nerve disorders summaryMRI of the known or suspected body region is the preferred modality for evaluation of PNSTs and peripheral nerve disorders; nuclear medicine studies are not indicated for routine evaluation

Role of nuclear imagingPET imaging's role is not well established for PNST and generally will not add clinical value

Follow-up guidanceRoutine follow-up imaging not indicated unless new symptoms, post-op scenarios, incomplete resection, or suspected malignant transformation

PET/CT imaging is considered not medically necessary for routine evaluation of Gaucher disease when no malignancy is present. The guidance states 18F‑FDG does not reliably detect Gaucher disease in marrow and that other radiotracers are not FDA‑approved for clinical use; thus PET/CT is not supported for routine Gaucher disease assessment. Similarly, PET/CT (and other nuclear medicine studies) is not generally supported for peripheral nerve sheath tumor evaluation absent specific, documented indications.