Colorado Rocky Mountain Health Plans PNND Coverage Update

Coverage Criteria and Clinical Indications

General medical necessity and documentation — Covered when ALL of the following are met

Covered when ALL of the following are met

Clinical evaluation: Recent detailed history and physical exam since onset or change in symptoms (or documented meaningful technological contact) must be submitted

Condition-specific sections may add requirements.

Prior studies: Relevant laboratory and prior imaging studies must be provided; spine and musculoskeletal guidelines require x-rays from current episode start/change

Impact on management: Requested imaging is expected to affect individual management or treatment decisions

Repeat imaging generally requires evidence of progression or will affect management.

Age-based imaging routing

Apply the following routing rules

Pediatric routing: Individuals 18 years old or younger should be imaged according to Pediatric Imaging Guidelines when specified; otherwise follow General Imaging Guidelines

Adult routing: Individuals older than 18 years should be imaged according to General Imaging Guidelines unless directed otherwise by a specific guideline section

Contrast and modality selection considerations

Use modality/contrast appropriate to clinical indication

CT contrast selection: CT may be performed without, with, or without and with IV contrast depending on indication; CT without and with contrast has limited indications (e.g., mass characterization, arterial/venous anatomy); CT with contrast may be used to better characterize findings on a very recent inconclusive non-contrast CT

Consider risks of ionizing radiation and contrast-induced nephropathy; both CT and MRI contrast share increased risk when GFR <30 mL/min

MRI contrast caution: Gadolinium use should be limited to when additional information is necessary; use caution in renal failure and contraindicated in pregnancy unless benefit outweighs riskGFR <30 mL/min

Gadolinium can deposit in tissues and may pose risk in renal impairment

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

Limited CT (CPT 76380)

Guidance on appropriate use of limited CT (CPT 76380):

Use constraints for CPT 76380: CPT 76380 is for limited or follow-up CT where full diagnostic CT work is not performed; it is not indicated for treatment planning and must not be used to report 'extra slices' in conjunction with other diagnostic CT codes

Examples include limited sinus CT, limited slices for known pulmonary nodule, limited slices for non-healing fracture.

Quantitative MR Analysis

Stance on quantitative MR analysis:

Investigational status: Category III CPT codes for quantitative mp‑MRI (e.g., 0648T, 0649T, 0697T, 0698T, 0865T, 0866T) are considered investigational/experimental and not standard for routine clinical practice

Primarily used in clinical trials; volumetric brain MRI analysis lacks sufficient specificity and sensitivity for routine use.

Whole-Body CT and MRI

Whole-body imaging coverage stance:

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

Whole‑body CT screening lacks benefit versus radiation risk

Whole‑body MRI is generally not supported due to lack of standardization and evidence of outcome improvement, except for select cancer predisposition syndromes and some autoimmune conditions; WBMRI should be reported using CPT 76498

Do not report WBMRI using multiple separate diagnostic MRI codes.

PET-MRI

PET-MRI conditional use:

When PET‑MRI may be appropriate: PET‑MRI may be appropriate when the individual meets condition‑specific PET‑MRI guidelines OR when the individual meets PET‑CT guideline criteria and PET‑CT is unavailable and the provider requests PET‑MRI in lieu of PET‑CT

When appropriate, report PET‑MRI using CPT 78813 plus CPT 76498; other reporting methods are inappropriate.

General PNND imaging coverage criteria — Covered when ALL of the following are met

Covered when ALL of the following are met

General prerequisite: A pertinent clinical evaluation (history, neurologic exam, relevant labs/ non‑advanced imaging) documenting onset or change in symptoms is present

Other meaningful contact (telehealth, telephone, messaging) since symptom change by an established clinician can serve as evaluation.

Electrodiagnostic testing: EMG/NCV studies are required initially for many neuropathies unless a section explicitly states otherwise

Nerve conduction studies may be normal early; timing considerations (1–4 weeks) apply.

Modality selection: Ultrasound preferred for superficial peripheral nerves; MRI indicated for deep nerves, nerves obscured by bone, or surgical planning; CT reserved only when MRI contraindicated

MRI provides superior soft tissue contrast; ultrasound provides higher spatial resolution for superficial nerves.

Carpal Tunnel Syndrome

Carpal tunnel

Carpal tunnel imaging: EMG/NCV and clinical findings are equivocal AND MRI wrist without contrast (CPT 73221) is requested for pre‑operative planning

MRI wrist indicated only in that specific scenario.

Ulnar and Radial Neuropathy

Ulnar and radial neuropathies

Ulnar neuropathy imaging: After EMG/NCV, ONE of: MRI elbow/wrist without contrast (CPT 73221) OR MRI forearm/hand without contrast (CPT 73218) when requested for surgical consideration

Radial neuropathy imaging: MRI arm/forearm without contrast (CPT 73218) when surgery considered; MRI arm/forearm without and with contrast (CPT 73220) if suspicion for nerve tumor

Pudendal Neuropathy

Pudendal neuropathy

Pudendal imaging: Documented concern for pudendal neuropathy/entrapment: MRI pelvis without contrast (CPT 72195) OR MRI pelvis without and with contrast (CPT 72197); if MRI contraindicated, ONE of CT pelvis CPT 72192/72193/72194

Specific documented concern required.

Sciatic Neuropathy

Sciatic neuropathy

Sciatic imaging: EMG/NCV initially required; MRI pelvis without contrast (CPT 72195) indicated; CT pelvis without contrast (CPT 72192) NOT routinely indicated (only for MRI contraindication)

Imaging for piriformis syndrome follows sciatic neuropathy criteria.

Femoral Neuropathy

Femoral neuropathy

Femoral imaging: EMG/NCV initially not required; MRI pelvis without contrast (CPT 72195) indicated when imaging is needed

Occurs with pelvic surgery complications or retroperitoneal bleeding.

Meralgia Paresthetica and Peroneal Neuropathy

Meralgia paresthetica and peroneal neuropathy

Meralgia imaging: MRI pelvis without contrast (CPT 72195) indicated for diagnostic uncertainty or pre‑operative planning; CT pelvis not routinely indicated except when MRI contraindicated

Meralgia usually diagnosed clinically.

Peroneal imaging: EMG/NCV initially required; if surgery considered or surgeon‑ordered, MRI knee without contrast (CPT 73721) OR MRI lower extremity other than joint without contrast (CPT 73718) is indicated

Meralgia paresthetica imaging

Advanced imaging recommendations for focal lower‑extremity neuropathies

Meralgia paresthetica MRI pelvis without contrast: 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; only if MRI contraindicated or contrast allergy.

Peroneal neuropathy imaging

Peroneal neuropathy imaging when surgery considered or surgical consultation

Peroneal neuropathy MRI knee or other lower extremity: 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 or in consultation with a surgeon.

Polyneuropathy with CNS involvement

Polyneuropathies with possible CNS involvement — brain/spine MRI indicated when clinical findings suggest CNS pathology

CNS imaging for polyneuropathy: If clinical findings point to abnormalities in brain or spinal cord, then ANY of MRI Brain (70553), MRI Cervical Spine (72156), MRI Thoracic Spine (72157), MRI Lumbar Spine (72158) are indicatedclinical findings suggest CNS involvement

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

Brachial plexus imaging

Brachial plexus imaging criteria and modality selection

EMG/NCV requirement: EMG/NCV examination is required prior to advanced imaging of the brachial plexus unless malignant infiltration or radiation plexitis is suspected (in which case EMG is not required)

Imaging for malignant infiltration or radiation plexitis: Any ONE of: MRI Upper Extremity other than joint without contrast (73218) OR MRI Upper Extremity without and with contrast (73220) OR MRI Chest without contrast (71550) OR MRI Chest without and with contrast (71552) OR MRI Neck without or with contrast per indicationsmalignant infiltration or radiation plexitis

MRI Chest/Neck are bilateral; MRI Upper Extremity is unilateral.

Neurogenic thoracic outlet syndrome: MRI Chest without and with contrast (71552) OR MRI Neck without contrast (70540) are indicated

Magnetic Resonance Neurography (MRN) coverage criteria

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

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

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

Lumbar and Lumbosacral Plexus imaging criteria

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

Imaging options: MRI Pelvis without contrast (CPT 72195) with fat suppression OR MRI Pelvis without and with contrast (CPT 72197) with fat suppression OR MRI Abdomen without contrast (CPT 74181) plus MRI Pelvis without contrast (CPT 72195) with fat suppression OR MRI Abdomen without and with contrast (CPT 74183) plus MRI Pelvis without and with contrast (CPT 72197) with fat suppression; if traumatic, also MRI Lumbar Spine without contrast (CPT 72148); if MRI unavailable, CT Pelvis with contrast (72193) OR CT Abdomen and Pelvis with contrast (74177) are alternatives

EMG/NCV required prior to advanced imaging unless malignant infiltration suspected.

Motor Neuron Disease/ALS imaging criteria

For initial evaluation of suspected MND/ALS, ANY of the following are indicated:

Brain/Spine MRI options: MRI Brain (70551 or 70553) AND/OR Cervical Spine MRI (72141 or 72156) AND/OR Thoracic Spine MRI (72146 or 72157) AND/OR Lumbar Spine MRI (72148 or 72158)

Neurological exam not required for individuals with established diagnosis or when suspected by certain specialists.

Motor Neuron Disease / ALS Imaging (PN-8.1)

MRI indications for motor neuron disease/ALS

ALS and mimics: MRI of the brain and/or spine is indicated to evaluate for ALS‑associated changes and disorders that may mimic ALS

Spinal Muscular Atrophy (PN-8.2)

Spinal Muscular Atrophy (SMA) imaging stance

SMA diagnosis: Molecular genetic testing is the standard for diagnosis; MRI is NOT supported for diagnosis in children unless other diseases are being considered

Adult‑onset SMA: In adult‑onset disease, advanced imaging is indicated when upper and lower motor neuron findings are present; see Motor Neuron Disease/ALS (PN‑8.1)

Fasciculations (PN-8.3)

Fasciculations — prerequisites and imaging indications

Prerequisites: All of the following evaluations are required prior to advanced imaging: documented history and physical (time course, areas involved, weakness, associated symptoms), EMG/NCV evaluation, and laboratory evaluation (examples provided)

When upper motor neuron signs present: With upper motor neuron signs (increased tone; hyperreflexia; Babinski or Hoffman signs) and concern for motor neuron disease, ANY of MRI Brain (70551 or 70553), AND/OR MRI Cervical Spine (72141 or 72156), AND/OR MRI Thoracic Spine (72146 or 72157) are indicated

Lumbar imaging: Lumbar spine imaging is NOT indicated unless there is sphincter involvement or need to rule out lower motor neuron etiologies in the lower extremities

Neuromuscular Junction Disorders (PN-8.4)

Neuromuscular junction disorders imaging

Myasthenia gravis thymic evaluation: After established diagnosis of MG 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 indicated in specific scenarios

LEMS cancer evaluation: For suspected LEMS, ANY of CT Chest with contrast (71260) AND/OR CT Abdomen and Pelvis with contrast (74177) are indicated; if initial CT negative and suspicion persists, repeat every 6 months for 2 years

Stiff-Person Syndrome

Stiff‑Person Syndrome and paraneoplastic evaluation

Initial evaluation for suspected stiff‑person syndrome: If suspected, ANY of CT Abdomen and Pelvis with contrast (74177) or CT Abdomen and Pelvis without and with contrast (74178); OR MRI Abdomen without and with contrast (74183) and MRI Pelvis without and with contrast (72197); OR CT Chest with contrast (71260) or CT Chest without contrast (71250); OR CT or MRI of any other symptomatic body areas are indicated

Muscle Diseases (PN-8.5)

Muscle diseases — MRI indications

Imaging to plan biopsy or evaluate muscle disease: MRI of the affected muscle is supported to demonstrate abnormalities, help distinguish types of muscle disease, select biopsy sites, evaluate differential diagnosis, monitor progression or treatment response, and detect occult malignancy; typical studies include MRI upper extremity other than joint (73218/73220) and MRI lower extremity other than joint (73718/73720); bilateral studies supported when criteria met

Gaucher Disease (PN-8.6)

Gaucher disease imaging schedule

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

Surveillance every 12 months: For individuals on enzyme replacement therapy or in surveillance, repeat annually: MRI Lumbar Spine without contrast (72148), bilateral femurs MRI (73718), MRI Abdomen without contrast (74181); CT Chest without contrast (71250) for documented pulmonary involvementEvery 12 months

Pulmonary symptoms: New or worsening pulmonary symptoms warrant CT Chest without contrast (71250)

Gaucher disease imaging — surveillance and indications

Covered when imaging is used for surveillance or to assess treatment response or disease progression:

Gaucher surveillance imaging: Periodic imaging every 12 months when used to assess treatment response for individuals on enzyme replacement therapy or to assess disease progression for individuals under surveillanceEvery 12 months

Studies listed include MRI lumbar spine without contrast (72148); MRI bilateral femurs without contrast (73718); MRI abdomen without contrast (74181); CT chest without contrast (71250) for documented pulmonary involvement.

New or worsening pulmonary symptoms in Gaucher disease

Covered when:

Pulmonary symptoms: New or worsening pulmonary symptoms in an individual with Gaucher diseaseN/A

CT Chest without contrast (71250) is supported.

PET/CT in Gaucher disease

Not supported except when malignancy is suspected:

PET/CT not routinely covered: PET/CT imaging is considered not medically necessary in the evaluation of Gaucher disease in the absence of suspected malignancyN/A

18F‑FDG does not reliably detect Gaucher disease in marrow; other isotopes not FDA‑approved for clinical use.

Peripheral Nerve Sheath Tumors (PNST) imaging

Covered when evaluating suspected or known PNST:

PNST initial evaluation: When PNST is suspected, MRI of the relevant body region without and with contrast is supported (brain for vestibular schwannoma 70553; spine levels 72156/72157/72158 for paraspinal neurofibroma; MRI of limb/torso with/without contrast after x‑ray for non‑paraspinal lesions)N/A

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

PNST follow‑up: Routine follow‑up imaging is not indicated except for new symptoms/neurologic findings or specific post‑operative scenarios; then MRI without and with contrast of the known body area is supportedN/A

Post‑op imaging may be at surgeon discretion or to establish baseline if tumor not completely removed.

Metastatic work‑up for suspected malignant transformation: When malignant transformation is known or suspected, CT chest with contrast (71260) and/or CT abdomen with contrast (74160) are supported for work‑up

Imaging modality selection and exclusions

Covered when ALL of the following are met (implicit):

Primary imaging modality: MRI is the preferred imaging modality for evaluation of known or suspected peripheral nerve sheath tumors and soft tissue PNSTs

MRI preferred due to soft tissue contrast and lack of ionizing radiation

Nuclear/PET stance: Nuclear medicine studies are NOT indicated for evaluation of peripheral nerve disorders; PET imaging role in PNSTs is not well established and generally would not add clinical value; PET/MRI is considered not medically necessary for peripheral nerve disease

Imaging requests may be considered investigational/experimental and therefore not supported when the procedure lacks sufficient supporting evidence, clinical utility, demonstrated improvement in health outcomes, or collective professional opinion of support. Supporting evidence is defined as credible, peer‑reviewed literature or established specialty society recommendations.

The use of gadolinium MRI contrast in pregnancy is contraindicated unless the specific need outweighs risk to the fetus. Exercise caution with gadolinium in individuals with renal failure (notably GFR <30 mL/min per related guidance) and consider alternative imaging or non‑contrast protocols when appropriate.

CPT codes for 3D rendering (CPT 76376, 76377) require documented concurrent physician supervision/participation in the reconstruction process and should not be billed in combination with CAD, MRA/CTA, PET/SPECT/PET‑CT, mammography/MRI breast/US breast, CT colonography, cardiac CT/MRI, or coronary CTA. Document the supervising physician’s role per ACR recommendations and obtain prior authorization when required.

Whole‑body MRI is generally not supported due to lack of standardization and limited evidence of improved outcomes; when performed, WBMRI must be reported using CPT 76498. PET‑MRI may be considered only when PET‑CT criteria are met but PET‑CT is unavailable; report PET‑MRI using CPT 78813 plus CPT 76498 where applicable and with appropriate justification.

CT pelvis is not routinely indicated for evaluation of sciatic neuropathy or meralgia paresthetica because CT lacks the soft‑tissue contrast needed to assess peripheral nerves. Reserve pelvic CT only for rare circumstances such as MRI contraindication or contrast allergy.

CT pelvis without contrast (CPT 72192) is not routinely indicated for meralgia paresthetica due to inadequate soft‑tissue contrast; use MRI pelvis (CPT 72195) for diagnostic uncertainty or pre‑operative planning and use CT only if MRI is contraindicated.

Magnetic resonance neurography (MRN) is supported only for evaluation of traumatic or compressive focal neuropathies and brachial plexus injuries when all listed criteria are met (including in‑person specialist evaluation, EMG/NCV performed, and consideration of surgery). MRN for lumbosacral plexopathy, neuromuscular disease, polyneuropathy, or other indications is considered not medically necessary at this time.

Fluorine‑18 FDG PET/CT is not supported for evaluation of brachial or lumbosacral plexopathy in the absence of a known malignancy; current literature does not demonstrate clinical utility for plexopathy assessment without suspected cancer.

MRI is not supported as a diagnostic tool for Spinal Muscular Atrophy (SMA) in children; molecular genetic testing is the diagnostic standard. MRI may be considered only when alternative diagnoses are being evaluated or when adult‑onset differential considerations require neuroimaging.

PET/CT is not medically necessary for routine evaluation or surveillance of Gaucher disease in the absence of suspected malignancy, and the role of PET in peripheral nerve sheath tumor (PNST) evaluation is not established. Routine PET exposes patients to radiation without demonstrated benefit in these contexts.

Nuclear medicine studies, including PET and PET/MRI, are not indicated for routine evaluation of peripheral nerve disorders. PET/MRI's role in peripheral nerve disease is currently undefined and is considered not medically necessary for these indications.

Services deemed investigational or experimental because of insufficient evidence, lack of proven clinical utility, immature outcome data, or absent collective professional support are not supported for coverage. Such determinations are based on peer‑reviewed literature and specialty society guidance where available.

Pre‑operative or pre‑procedural imaging is not indicated when the associated surgery or procedure itself is not clinically indicated. Avoid repeat imaging unless there is documentation that results will change management (e.g., interval clinical change or new findings). Prior authorization for the procedure may affect approval of related preoperative imaging.

Quantitative or volumetric MRI analyses (Category III CPT codes such as CPT 0648T, 0649T, 0697T, 0698T, and brain volumetric codes 0865T/0866T) are considered investigational/not medically necessary for routine clinical practice. Whole‑body MRI is likewise generally not supported except in select, guideline‑specified cancer predisposition syndromes.

Advanced imaging requests without documentation of a prior pertinent clinical evaluation (history, neurologic exam) or without required EMG/NCV testing when indicated are not supported. EMG/NCV is required initially for many neuropathies and results should be provided unless an exception (e.g., suspected malignant infiltration) applies.

Covered Indications and Modality-Specific Uses

CPT/HCPCS Codes and Billing Guidance

Not supported / investigational CPTCPTNot Covered

C9791

MRI utilizing Xenon Xe 129 (listed as investigational/experimental in this document)

3D Rendering CodesCPT

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

Imaging Guidance and Related CodesCPT

19085	Biopsy, breast, with placement of breast localization device(s), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including MR guidance
19086	Biopsy, breast, with placement of breast localization device(s), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including MR guidance
75989	Imaging guidance for percutaneous drainage with placement of catheter (all modalities)
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

Unlisted Procedure CodesCPT

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

Limited/Follow-up CTCPT

76380

Limited or follow-up CT

Limited CTCPT

76380

Limited or follow-up CT

SPECT/CT and related nuclear medicineCPT

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

Outside study interpretationCPT

76140

Interpretation of an outside study

Quantitative MR Category III codesCPTExperimental

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

HCPCS example codes and guidancemixed

C8931	MRA with dye, Spinal Canal (HCPCS example)
72159	MRA Spinal Canal (CPT example for comparison)
S8042	MRI, lowfield (non-specific HCPCS example)

Whole-body MRI and PET-MRI reportingCPT

76498	MRI unlisted procedure (used for whole-body MRI reporting)
78813	PET whole-body

Carpal tunnel / upper extremity joint MRICPTCovered

73221

MRI Upper Extremity Joint (Wrist) without contrast

Radial neuropathy MRICPTCovered

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

Pelvic imaging (pudendal, sciatic, femoral, meralgia)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

Peroneal neuropathy / lower extremity MRICPTCovered

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

Pelvis and Lower Extremity Imaging (selected)CPT

72195	MRI Pelvis without contrast
72192	CT Pelvis without contrast
73721	MRI Lower Extremity Joint (Knee) without contrast
73718	MRI Lower Extremity Other Than Joint without contrast

Brain/Spine, Brachial Plexus, Chest/Neck ImagingCPT

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

1–10 of 19

1/2

MRN reported as unlisted MRICPTCovered

76498

Unlisted MRI procedure code (used for MRN)

MRN reported as 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

Lumbar/lumbosacral plexus 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 Motor Neuron Disease/ALS evaluationCPTCovered

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
72148	MRI Lumbar Spine without contrast
72158	MRI Lumbar Spine without and with contrast

Motor neuron disease CNS imagingCPTCovered

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 and paraneoplastic syndromesCPTCovered

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

Muscle disease and Gaucher disease imagingCPTCovered

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
72148	MRI Lumbar Spine without contrast
74181	MRI Abdomen without contrast
71250	CT Chest without contrast

Imaging CPT codes referencedCPT

72148	MRI Lumbar Spine without contrast
73718	MRI Lower Extremity, other than joint, without contrast (bilateral femurs)
74181	MRI Abdomen without contrast
71250	CT Chest without contrast
70553	MRI Brain without and with contrast (vestibular schwannoma workup reference)
72156	MRI Cervical Spine without and with contrast
72157	MRI Thoracic Spine without and with contrast
72158	MRI Lumbar Spine without and with contrast (for paraspinal PNST)
71260	CT Chest with contrast (metastatic work-up for PNST malignant transformation)
74160	CT Abdomen with contrast (metastatic work-up for PNST malignant transformation)

inv-80: GFR threshold for increased risk

GFR thresholdGFR <30 mL/min

Clinical implicationExercise caution with gadolinium-based contrast agents when GFR <30 mL/min due to increased risk

Provider Requirements, Prior Authorization, and Documentation

Documentation Required

State-specific medical necessity evaluation

This policy applies only to Ohio. Requests for services identified as unproven or subject to coverage/quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01.

Prior Authorization

Prior authorization and pre-procedural imaging guidance

Prior authorization may be required for advanced imaging and certain post-processing/3D rendering codes. Advanced imaging or designated procedures should not be ordered prior to a pertinent clinical evaluation by the treating physician (in-person or acceptable technological contact) since onset or change in symptoms; condition-specific sections may require face-to-face evaluation. Submit recent detailed history, physical exam, relevant labs, prior imaging and EMG/NCV results (where required) to establish medical necessity. Requests lacking adequate clinical information may be denied or require additional documentation.

Pertinent clinical evaluation: recent history, physical exam, neurologic exam, labs, prior imaging.

Imaging Frequency and Surveillance Intervals

inv-172: any — Repeat imaging not generally necessary

General frequency guidanceRepeat imaging is not generally necessary unless there is evidence of progression, recurrence, or the repeat will affect management

Pre-procedural imaging notePre-operative imaging is not indicated if the associated surgery/procedure is not indicated

Review prior studiesObtain results of prior diagnostic tests before performing further imaging to avoid unnecessary duplication

inv-173: CT Chest and/or CT Abdomen and Pelvis — Repeat every 6 months

Repeat intervalRepeat CT Chest and/or CT Abdomen and Pelvis every 6 months when indicated (e.g., if initial CT negative but suspicion persists)

Duration for LEMS surveillance

Prior Authorization Expectations

Prior Authorization

Advanced imaging may require medical necessity review

Advanced imaging modalities (NM, US, CT, MRI, PET) are evaluated per the guideline and may require medical necessity review annually or per payer rules; verify authorization processes with the plan.

Prior Authorization

Prior authorization for pre-procedural imaging tied to procedure authorization

Prior authorization may be required when pre-procedural imaging is requested in relation to a procedure that itself requires prior authorization; ensure the procedure authorization status is clear when submitting imaging requests.

Prior Authorization

3D rendering may require separate prior authorization

Prior authorization may be required for 3D rendering even if the parent imaging modality is not separately authorized; document supervision and clinical rationale when submitting.

Definitions and Terminology

inv-128: Investigational/Experimental definition

DefinitionInvestigational/Experimental: studies, treatments, procedures, or devices lacking sufficient supporting evidence, demonstrated clinical utility, improved health outcomes, or collective opinion of support

Evidence criteriaSupporting evidence includes peer-reviewed literature, randomized trials, or recognized specialty society recommendations

Coverage implicationServices meeting investigational criteria may be considered not supported for coverage

inv-129: Standard or conventional imaging

DefinitionStandard or conventional imaging: imaging typically performed in initial evaluations including plain film, CT, MRI, or ultrasound

RoleUsed as first-line studies; further advanced imaging considered when initial studies are inconclusive

Services Not Covered / Considered Investigational

MRI utilizing inhaled Xenon Xe‑129 reported with CPT C9791 is considered investigational/experimental and not supported for coverage at this time.

Unbundling PET/CT into separate PET and diagnostic CT CPT codes is not supported; PET/CT is performed and reported as a single combined study and should be billed accordingly.

CPT 77021 is not an appropriate code to report for breast biopsy guidance in the contexts described; use the appropriate image‑guidance and biopsy procedure codes instead.

Routine CT pelvis for evaluation of sciatic neuropathy or meralgia paresthetica is not indicated because CT provides insufficient soft‑tissue contrast to evaluate peripheral nerves; reserve CT only when MRI is contraindicated.

FDG‑PET/CT is not supported for evaluation of brachial plexopathy when there is no known malignancy, as current literature does not demonstrate diagnostic utility in this setting.

MRN is considered not medically necessary for evaluation of lumbosacral plexopathy, generalized neuromuscular disease, or polyneuropathy; its supported indications are limited to traumatic or compressive focal neuropathies and brachial plexus injuries meeting specific criteria.

FDG‑PET/CT for plexopathy evaluation is unsupported in the absence of known malignancy and may be denied; MRI remains the preferred modality for brachial and lumbosacral plexus assessment.

Background and Scope

These evidence‑based guidelines evaluate advanced imaging modalities (NM, US, CT, MRI, PET) and related procedures for peripheral nerve and neuromuscular disorders. They align imaging choice with clinical presentation and the best available evidence; investigational technologies (e.g., quantitative mp‑MRI, Xenon MRI) and non‑standard reporting (e.g., unbundled PET/CT) are generally not supported. The guidance emphasizes prior clinical evaluation, appropriate use of EMG/NCV when required, and using modality‑appropriate imaging (for example, ultrasound for superficial nerves and MRI for deep or surgically relevant nerves).

Policy Revision History

2025-11-01policy_effectiveLatest

New/updated PNND imaging guideline (v1.0.2025) became effective for Ohio members

OpenPayer

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

Coverage Criteria and Clinical Indications

Covered Indications and Modality-Specific Uses

CPT/HCPCS Codes and Billing Guidance

Provider Requirements, Prior Authorization, and Documentation

Imaging Frequency and Surveillance Intervals

Prior Authorization Expectations

Definitions and Terminology

Services Not Covered / Considered Investigational

Background and Scope

Policy Revision History