CurrentColorado Rocky Mountain Health PlansPolicy CSRAD013OH.D

UN-CSRAD013OH.D - Adult Peripheral Vascular Disease (PVD) Imaging Guidelines

State-specific (Ohio) UnitedHealthcare Community Plan guideline V1.0.2025 governing advanced imaging and procedure utilization for adult Peripheral Vascular Disease (PVD) and related cardiovascular/radiology imaging.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyUN-CSRAD013OH.D - Adult Peripheral Vascular Disease (PVD) Imaging Guidelines

Policy CodePolicy CSRAD013OH.D

Change TypeAnnual / Interim evidence-based updates

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionProviders must submit a recent detailed history and physical exam and any prior imaging or labs to establish medical necessity before ordering advanced imaging.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes noted in this update; policy history lists routine annual and interim evidence-based updates.

V1.0.2025Guideline Version

OhioGeographic Scope

Covered with criteriaCoverage Stance

3-24 moSurveillance Range

Several

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Investigational Codes

Genetic syndromesHigh-risk Populations

Coverage Summary

This policy is the Ohio-specific UnitedHealthcare Cardiovascular and Radiology Imaging Guideline V1.0.2025 (effective 2025-11-01) and applies only to the state of Ohio. It provides evidence-based coverage and utilization direction for advanced imaging and image-guidance procedures related to peripheral vascular and cardiovascular radiology. The guideline reflects a coverage stance: Covered with criteria (mixed) — imaging is covered when the condition- and modality-specific criteria and documentation requirements in the guideline are met.

Imaging authorization and use are governed by the guideline's condition- and modality-specific criteria; advanced studies must be justified by clinical presentation and required documentation, and physician judgment may override guideline recommendations in individual cases where supported by the clinical record.

Key actionable thresholds

ABI non-compressible>= 1.40

Recent clinical/ABI evaluation requiredClinical evaluation within 60 days / ABI within 60 days

Post-ablation ultrasound timingWithin 7 days post-procedure

Visceral artery aneurysm treatment threshold>= 2.0 cm

AAA surveillance bands>2.5–3.0 cm: 10 yrs; 3.0–3.9 cm: 3 yrs; 4.0–4.9 cm: 12 months; 5.0–5.4 cm: 6 months; >5.4 cm: refer/evaluate

EVAR sac growth trigger> 5 mm sac growth (trigger for CT)

Application / Scope

This policy applies only in Ohio. References: Ohio Administrative Code 5160-1-01 for review of services stated as unproven or subject to coverage/quantity limits.

All: The requested imaging/procedure must be for an Ohio-enrolled member and will be adjudicated per OAC 5160-1-01 when items are listed as unproven or limited.

General Imaging and Appropriateness

Required documentation and general appropriateness rules for vascular imaging.

All: A recent pertinent clinical evaluation (history and focused physical exam) documenting symptoms or change in status within 60 days of the requested advanced imaging unless the request is for routine scheduled surveillance per a condition-specific interval.

All: Indication documentation must include relevant prior noninvasive tests (e.g., ABI/segmental pressures within 30 days when applicable), prior imaging reports, current symptoms, prior interventions and dates, and relevant laboratory data when specified (e.g., renal function for contrast studies).

Coding (grouped by status)

Neutral / Unlisted Codesmixed

MRV_ABDOMEN_PELVIS	MR venography abdomen/pelvis — listed as MRV_ABDOMEN_PELVIS in source code groups
CTV_ABDOMEN_PELVIS	CT venography abdomen/pelvis — listed as CTV_ABDOMEN_PELVIS in source code groups

Experimental / Investigational CodesmixedExperimental

No codes listed

Not Covered / Obsolete CodesmixedNot Covered

No codes listed

Billing rulesmixed

BillingRule:UseAppropriateModifiers	Apply appropriate anatomic modifiers and laterality when billing duplex and MRA/MRV studies.
BillingRule:SeparateProcedures	When duplex or arterial studies are performed with therapeutic interventions, document medical necessity for both diagnostic and interventional procedures.

Provider Actions & Requirements

Documentation Required

Submit adequate clinical information

Providers must submit recent detailed history and physical exam since onset/change in symptoms and any prior imaging or laboratory studies necessary to establish medical necessity for advanced imaging or designated procedures. Include documentation of vascular history and physical (pulses, wound status, skin changes, bruits).

History and physical exam since onset/change in symptoms
Prior imaging (relevant prior studies)
Relevant laboratory studies as applicable

Prior Authorization

Prior authorization may be required for 3D rendering codes

CPT 76376 and 76377 (3D rendering) may require prior authorization even when the base imaging does not. These codes require physician concurrent supervision/participation of the 3D post-processing and have distinct definitions (76376: no independent workstation; 76377: requires independent workstation).

Background and Evidence

These UnitedHealthcare evidence-based proprietary clinical guidelines were developed to guide selection of appropriate advanced imaging and image-guided procedures (including NM, US, CT, MRI, PET) for cardiovascular and radiology indications, with the goals of reducing overutilization, aligning with specialty society guidance, and improving care quality and patient safety.

The guidance is intended to direct appropriate imaging selection while preserving clinician judgment: it supports use of lower-risk/less-resource-intensive modalities when appropriate, documents prerequisites and required clinical information, and allows physicians to override guideline recommendations in specific individual cases when the physician documents a clinically justified rationale.

Label	Value
Guideline version	V1.0.2025
Primary guideline sources cited	ACR Appropriateness Criteria; Society for Vascular Surgery; ACC/AHA aortic disease guidelines; AHA/ACC PAD guideline
Key references / reference examples	Multiple society guidelines and peer-reviewed studies (e.g., AHA/ACC 2016 PAD guideline; SVS 2015/2020; ACR appropriateness criteria; selected studies cited in references)

Definitions

Term	Definition
Concurrent supervision	Active physician participation in and monitoring of the reconstruction process including design of the anatomic region, determination of tissue types/structures to display, images archived, and monitoring/adjustment of the 3D work product.
ABI	Ankle-brachial index: noninvasive test for arterial insufficiency; can be performed after exercise if resting results normal; primary method for establishing PAD diagnosis.
CLI	Critical Limb Ischemia: rest pain and/or non-healing wound; associated with high limb loss and mortality risk.
WBMRI	Whole-body MRI — generally not supported except select cancer predisposition syndromes; reportable using CPT 76498 when appropriate.
Runoff study	Imaging from the umbilicus to the feet (CTA CPT 75635 or MRA combination CPT 74185/73725/73725).
DU	Duplex Ultrasound; initial imaging modality for many vascular indications.
TTE	Transthoracic Echocardiogram (CPT 93306/93307/93308).
TAA	Thoracic Aortic Aneurysm.
Endoleak type II	Persistent blood flow into aneurysm sac from branch vessels after EVAR; managed with surveillance unless sac expands.
Endoleak	Persistent blood flow outside the lumen of the endoluminal graft but within the aneurysm sac after endovascular aneurysm repair; may increase rupture risk.
CTV	Computed Tomography Venography.
MRV	Magnetic Resonance Venography.
DVT	Deep Venous Thrombosis.
VVI	Venous Valvular Insufficiency study — ultrasound assessment for venous reflux.
IVC	Inferior Vena Cava.
Venous reflux	Retrograde venous flow documented as >500 ms on venous valvular insufficiency study.
Varicose veins	Enlarged, tortuous veins visible under the skin; symptoms include achiness and heaviness.

Key Thresholds & Surveillance Intervals

Thresholds (quick reference)

ABI non-compressible threshold>= 1.40

Clinical evaluation recency requiredWithin 60 days (including ABI)

Ascending aortic surveillance<4.0 cm: annual; >=4.0 cm: every 6 months

Descending aortic surveillance3.5–4.4 cm: annual; >=4.5 cm: every 6 months; concern growth >=3.0 cm: one-time 3-month imaging

AAA diameter bands>2.5–3.0 cm: 10 years; 3.0–3.9 cm: 3 years; 4.0–4.9 cm: 12 months; 5.0–5.4 cm: 6 months; >5.4 cm or growth 0.5 cm/6mo or 1 cm/yr: vascular referral

Post-ablation ultrasound timingWithin 7 days post-procedure

EVAR sac growth threshold

Revision History

02/01/2024Annual evidence-based updates

Annual evidence-based updates documented in Policy History (Summary of Changes = Annual evidence-based updates).

07/01/2024Interim evidence-based updates

Interim evidence-based updates documented in Policy History (Summary of Changes = Interim evidence-based updates).

05/01/2025Annual evidence-based updatesLatest

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyUN-CSRAD013OH.D - Adult Peripheral Vascular Disease (PVD) Imaging Guidelines

Policy CodePolicy CSRAD013OH.D

Change TypeAnnual / Interim evidence-based updates

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionProviders must submit a recent detailed history and physical exam and any prior imaging or labs to establish medical necessity before ordering advanced imaging.

SourceLink

On This Page

All: Avoid duplicate imaging – advanced imaging is generally not indicated if an adequate, contemporaneous study of the same vascular territory with adequate technique and interpretation is available unless new/worsening symptoms or a clear clinical question remains.

All: Pre-operative imaging: advanced imaging for pre-op planning is allowed when the treating surgeon documents that imaging will change operative management; routine imaging solely for surgical convenience without documented impact on management is not supported.

Investigational / Experimental / Clinical Trials

Definitions and rules for investigational or clinical trial imaging.

Any: Imaging or procedures categorized as investigational/experimental (insufficient published evidence or lacking consensus support) are not supported unless the request is part of an approved clinical trial and the imaging is required for direct clinical management of the participant.

Any: Imaging requested solely for data collection, protocol endpoints not used in routine clinical care, or research purposes is not supported.

Any: Coverage of clinical trial-related imaging will follow statutory requirements and is considered when the imaging meets evidence-based clinical standards or is required for management of the trial participant per trial protocol and payer rules.

Modality-specific Guidance (Ultrasound, CT, MRI, PET)

Modality-specific operational considerations, contraindications, and billing guidance.

Any: Choose the least invasive modality expected to answer the clinical question (e.g., duplex ultrasound first-line for many peripheral and carotid evaluations).

All: MRI contraindications (implantable devices, severe claustrophobia, etc.) and CT contraindications (contrast allergy, eGFR considerations) must be documented when relevant.

Any: PET imaging: PET components that are bundled with CT or MR studies should not be billed separately when CPT descriptors indicate unbundling — follow CPT/NCCI guidance. PET-MRI and whole-body PET/MR require clinical justification beyond conventional PET/CT — scarce evidence for routine use in PVD.

All: SPECT/CT: when used, the CT portion must be reported and justified (interpretation and diagnostic contribution documented); use appropriate CPT codes and report CT dose/documentation per institutional requirements.

Any: Imaging Guidance/Procedures: CT/MR/US-guided vascular procedures require documentation of the guidance modality and physician-performed image interpretation; billable guidance codes (e.g., ultrasound guidance, CT guidance) must match the service performed.

Any: 3D Rendering (CPT 76376/76377): 3D reconstructions are allowable when necessary for preoperative planning or interpretation and when they add diagnostic value beyond standard multiplanar reformats; documentation must state why 3D rendering affected management.

Any: CPT 76380 (limited follow-up CT): Use when a limited, focused CT is performed to evaluate a known, previously imaged abnormality—documentation must reference the prior study and specify the limited nature.

Any: Unlisted Procedure Codes (76497/76498/78999) and use of unlisted CT/MR/Category III codes: Use only when no appropriate code exists; submit detailed documentation and imaging examples for review. Unlisted codes will be reviewed for medical necessity and appropriate coding.

Any: Interpretation of Outside Studies (CPT 76140): When only interpretation of outside imaging is requested, use CPT 76140 and provide the outside images/reports. Payment may be limited when no new imaging is performed.

Any: Whole-body CT/MR and PET-MRI: Generally not supported for routine PVD evaluation or surveillance without specific, documented clinical rationale.

Prerequisites before advanced imaging should be met

Prerequisites that should be met before ordering advanced vascular imaging.

All: A documented clinical evaluation within 60 days of the requested advanced imaging is required unless the imaging is part of a scheduled surveillance protocol.

Any: When peripheral arterial disease is suspected, an ABI (resting ankle–brachial index) should be performed and documented before advanced anatomic imaging unless ABI is unreliable (e.g., noncompressible vessels) or not feasible.

Any: Relevant laboratory testing supporting contrast use (e.g., recent eGFR within 30 days) must be documented for studies proposing iodinated or gadolinium-based contrast unless urgent/emergent indications justify proceeding without labs.

All: Initial testing expectations: duplex ultrasound is often first-line for carotid, extremity arterial and many venous conditions; CT angiography or MR angiography should be reserved for cases where ultrasound is inadequate or when cross-sectional anatomic mapping is required for intervention planning.

Repeat or Follow-up Imaging

Guidance on repeat or follow-up imaging and runoff reporting.

Any: Repeat imaging is supported for new or worsening symptoms, interval change on prior imaging, post-intervention surveillance per established intervals, or to evaluate complications.

All: Do not repeat an imaging study of the same vascular territory within a short interval unless there is documented clinical change or inadequate prior study quality.

Any: Runoff reporting: when performing aortic or peripheral arterial CTA/MRA for aneurysm or occlusive disease, include runoff to the calves/feet only when clinically indicated (e.g., planning revascularization) and document rationale.

Any: CPT 76380 may be used for limited follow-up CT examinations that target a previously imaged abnormality and document comparison to the prior study.

Cerebrovascular and Carotid Disease (PVD-3.1) — Initial Imaging

Initial imaging for cerebrovascular and carotid disease.

All: For symptomatic carotid disease (recent focal neurologic deficit, TIA localized to carotid distribution), noninvasive vascular imaging is indicated—duplex ultrasound is first-line for initial evaluation.

Any: When duplex ultrasound is nondiagnostic or discordant with clinical findings, CTA or MRA of the neck and head is appropriate for anatomic definition and surgical or endovascular planning.

Any: For acute stroke workup, follow institutional stroke pathways; vascular imaging choices (CTA head/neck, MRA) should align with emergent management needs.

Any: Cervical vessel repeat imaging for new or recurrent symptoms: Repeat duplex or CTA/MRA is supported when new focal neurologic symptoms occur or progressive carotid disease is suspected.

Carotid Surveillance (PVD-3.2/3.3) — No Prior Carotid Intervention

Carotid surveillance strategies when no prior carotid intervention/surgery.

All: Carotid duplex surveillance without prior carotid intervention is appropriate when there is documented asymptomatic carotid stenosis above a threshold consistent with guideline-based management (documentation of stenosis severity required).

Any: Asymptomatic individuals with <50% stenosis generally do not require routine duplex surveillance; monitor clinically and reimage only if symptoms develop or interval change is suspected.

Any: For 50–69% stenosis, follow-up imaging intervals should be individualized; typical surveillance intervals range 6–12 months initially then annually if stable per clinical judgment and specialty society guidance.

Any: For ≥70% stenosis in asymptomatic individuals, referral to vascular specialist for consideration of intervention is recommended; imaging surveillance frequency should be directed by the treating specialist.

Carotid Surveillance WITH History of Carotid Surgery or Intervention (PVD-3.3)

Carotid surveillance after carotid surgery or carotid artery intervention.

All: Postoperative surveillance imaging after carotid endarterectomy or carotid artery stenting requires documentation of the procedure date, clinical status, and surveillance interval.

Any: Duplex ultrasound is the preferred surveillance modality post-carotid intervention at standard intervals (commonly 1 month, 6 months, then annually if stable) unless clinical change dictates earlier evaluation.

Any: Additional CTA/MRA indicated when duplex is inconclusive, there is suspected restenosis, or pre-reintervention planning is required.

Billing Rule

Imaging guidance single unit per encounter and runoff reporting

Report only one unit of imaging guidance per encounter: imaging guidance procedure codes contain all imaging necessary to guide needle/catheter placement and are not routinely billed with diagnostic procedure codes. Do not bill multiple units for multiple lesions on the same date of service. Also, when performing runoff CTA/MRA, report as the single runoff codes rather than separate part codes.

Single-unit guidance codes per encounter: 76942, 77002-77013, 77021-77022, 75989
Runoff CTA/MRA reporting: 75635; 74185 + 73725 + 73725
Do not bill diagnostic imaging codes in conjunction with guidance procedure codes

Billing Rule

Use unlisted codes when no site-specific code exists (prefer Category III if available)

Use unlisted procedure codes when no appropriate anatomic site-specific CT/MR/nuclear code exists; if a Category III code exists, prefer it instead of an unlisted code. Unlisted codes are used for procedures such as WBMRI or PET-MRI pairing when no specific CPT applies.

76497 (unlisted CT)
76498 (unlisted MR)
78999 (unlisted diagnostic nuclear medicine)
Prefer Category III code when available

Documentation Required

Pertinent clinical evaluation and documentation required prior to advanced imaging

A current clinical evaluation (face-to-face or meaningful technological contact) within 60 days is required prior to advanced imaging. Document vascular history and physical (pulses, wound evaluation, skin changes, bruits), relevant labs, and a recent ABI (within 60 days) when applicable. If ABI is normal but clinical suspicion persists, document exercise ABI or Toe–Brachial Index as indicated.

Clinical evaluation within 60 days including history and focused physical exam
Recent ABI within 60 days when applicable; exercise ABI (CPT 93924) if resting ABI normal and suspicion remains
Relevant labs (e.g., CBC, CMP, ESR/CRP where indicated)

Denial Risk

Denial risk for imaging beyond recommended intervals or without indications

Imaging requests inconsistent with guideline timing or lacking clinical justification risk denial. Examples include routine surveillance or repeat imaging without new symptoms or growth, imaging beyond recommended intervals, and non‑indicated whole-body studies. Specific non-indicated examples: May-Thurner imaging or prophylactic imaging without acute/chronic DVT or sequelae; whole-body MRI generally not supported except select indications; PET-MRI only conditional. Routine or surveillance imaging without documented symptoms/justification may be denied.

Imaging beyond recommended intervals or without documentation may be denied
Routine surveillance without symptoms (e.g., prophylactic May-Thurner imaging) not supported
WBMRI generally not supported except select cancer predisposition syndromes; PET-MRI conditional

Billing Rule

Billing rules: runoff reporting, single-unit guidance, and secondary interpretation (76140)

Operational billing rules and coding guidance: runoff CTA/MRA should be reported as single runoff codes (CTA runoff = 75635; MRA runoff = 74185 + 73725 + 73725 — do not include 72198 with 74185/73725/73725). Only one unit of imaging guidance codes should be reported per encounter. For secondary interpretation of outside studies, use CPT 76140 rather than diagnostic imaging codes.

Runoff CTA: 75635
Runoff MRA: 74185 + 73725 + 73725 (do not add 72198)
Single-unit guidance codes per encounter (e.g., 76942, 77012, 77013, 77021, 77022)
Use CPT 76140 for secondary interpretation of outside studies

>5 mm sac growth — obtain CT

Visceral aneurysm treatment>= 2.0 cm (treat); Splenic artery: <20mm q3yrs; 20–29mm annual; >=30mm refer

Annual evidence-based updates documented in Policy History (Summary of Changes = Annual evidence-based updates).