Pediatric Peripheral Vascular Disease (PVD) Imaging Guidelines
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Imaging coverage guidelines for evaluation of pediatric peripheral vascular disease (individuals ≤18 years) governing advanced imaging modality selection, appropriateness, and prior authorization requirements for services managed by eviCore for Cigna.
No material clinical or coverage changes in this revision.
Coverage Criteria and Medical Necessity
Medical Necessity Criteria - Advanced Imaging
Advanced imaging is considered medically necessary when ALL of the following are met:
Meaningful technological contact (telehealth, telephone, electronic messaging) may substitute.
CT/CTA Indications
CT/CTA specific considerations — covered when any of the following apply:
Not an exhaustive list.
Modality Considerations
MRI/Ultrasound modality guidance:
Consider need to limit gadolinium use and avoid repetitive GBCA exposures.
Avoid repeated anesthesia sessions.
Start with ultrasound for superficial lesions and escalate to MRI or CT when indicated.
Initial imaging — Lymphatic malformations
Covered when ANY of the following are met
Treatment monitoring and surveillance — Lymphatic malformations
Covered when ALL of the following are met
Initial imaging — Venous malformations
Covered when ANY of the following are met
Monitoring and acute evaluation — Venous malformations
Covered when ALL of the following are met
Imaging — Capillary malformations
Covered when ANY of the following are met
Additional imaging is not considered medically necessary in the absence of complex associated clinical findings such as Sturge‑Weber syndrome or Klippel‑Trenaunay syndrome.
MRI for suspected underlying neurologic involvement
MRI for occult neurologic associations
Initial, treatment monitoring, and surveillance imaging for AVMs/fistulas
Imaging for AVMs and Fistulas
Initial, monitoring, preoperative planning, and surveillance for vascular tumors
Imaging for Vascular Tumors
Initial Evaluation — Takayasu arteritis
Initial imaging for Takayasu arteritis
Monitoring During Active Treatment
Clinical changes and monitoring treatment for large vessel vasculitis
Modality may be MRA, CTA, or ultrasound with Doppler.
Surveillance
Surveillance for large vessel vasculitis
Initial Evaluation — Polyarteritis nodosa
Initial imaging for medium vessel vasculitis (including polyarteritis nodosa)
Monitoring and Surveillance — Polyarteritis nodosa
Monitoring and surveillance for polyarteritis nodosa
Small Vessel Vasculitis — Imaging Indications
Small vessel vasculitis imaging guidance
Thoracic Aortic Disease — Familial Aortopathies
Imaging for familial aortopathies and surveillance is considered medically necessary as described below when individuals are gene‑positive, have physical exam findings, or definite disease:
Aortic Congenital Vascular Malformations
Imaging for initial diagnosis and surgical planning for congenital aortic vascular malformations is medically necessary as follows:
Visceral Artery Aneurysms
Imaging of visceral artery aneurysms in pediatric individuals follows adult indications; imaging is medically necessary for initial evaluation:
General Imaging Indications for Infantile Hemangiomas
Imaging is indicated in infantile hemangiomas when specific diagnostic uncertainty or high‑risk clinical features are present.
Refer to specific syndrome sections for additional criteria.
Multiple Infantile Hemangiomas
Covered when ALL of the following are met:
Order ultrasound with Doppler of the liver (CPT 76700) for initial evaluation and repeat exams to monitor progression or response to treatment.
PHACE(S) Syndrome Initial Imaging
Initial diagnostic imaging is medically necessary when PHACE(S) is suspected by clinical findings including any of the following:
If suspected, obtain brain MRI/MRA, orbit MRI, neck/chest MRA, transthoracic echocardiogram; cardiac MRI and chest MRI as indicated by findings.
PHACE(S) Surveillance
Repeat imaging is medically necessary when results will impact clinical management or when high‑risk findings identified
Follow pediatric cardiology/neurosurgery recommendations.
LUMBAR Syndrome Imaging
Imaging is medically necessary when LUMBAR syndrome is reasonably suspected:
Obtain spinal ultrasound in infants ≤6 months, abdominal and pelvic ultrasound with color Doppler; MRI lumbar spine at 3–6 months or earlier if ultrasound inadequate or per specialist; other regional MRI/MRA as indicated.
Imaging criteria for suspected LUMBAR syndrome
Covered when a child has an infantile hemangioma meeting location and size criteria and imaging is indicated per specialist recommendation
This is the trigger for imaging recommendations.
Ultrasound is first‑line in early infancy.
Report as CPT 74185 and CPT 73725; exclude CPT 72198 in this circumstance.
The use of advanced imaging to screen asymptomatic individuals for peripheral vascular disorders is not considered medically necessary unless a specific guideline section explicitly allows screening. A pertinent clinical evaluation (history, physical exam, appropriate labs, and basic imaging such as radiography or ultrasound) should be performed prior to advanced imaging except for guideline‑supported scheduled evaluations. Repeat imaging is limited and is not considered medically necessary unless there is documented progression, new disease, or documentation that repeat imaging will affect management.
Capillary malformations (eg, nevus simplex, port‑wine birthmarks) are usually diagnosed clinically and do not require additional advanced imaging unless there are complex associated findings. Advanced imaging is not considered medically necessary in the absence of syndromic or other complex associated clinical findings such as Sturge‑Weber syndrome or Klippel‑Trenaunay syndrome; a prior pertinent clinical evaluation should support any imaging request.
Additional advanced imaging for isolated capillary malformations is not considered medically necessary unless clinical findings suggest an associated complex disorder (for example, Sturge‑Weber syndrome or Klippel‑Trenaunay syndrome). Clinical documentation demonstrating those associated findings is required to justify imaging beyond routine clinical assessment.
For vascular tumors, MRA (contrast as requested) of the affected body part is considered medically necessary for surveillance of known lesions. However, routine use of both MRI and MRA together for treatment response or surveillance is not considered medically necessary. CT/CTA with contrast is reserved for situations when MRI/MRA are inconclusive or contraindicated.
Advanced imaging is not considered medically necessary for the primary assessment of small‑vessel vasculitis because these modalities are not sufficiently sensitive to detect small‑vessel changes. Imaging may still be appropriate for evaluating end‑organ complications where indicated (eg, ultrasound abdomen for HSP or CT chest/sinuses for GPA) but not for primary small‑vessel assessment.
Most infantile hemangiomas do not require imaging. Ultrasound with Doppler is appropriate when the diagnosis is uncertain or when high‑risk clinical features are present, but routine imaging of uncomplicated infantile hemangiomas is not supported.
Repeat advanced imaging studies are not considered medically necessary unless there is documented progression of disease, new onset of disease, or documentation that repeat imaging will affect management or treatment decisions. Exceptions are those specifically stated elsewhere in the guideline (for example, scheduled surveillance intervals for particular conditions).
For capillary malformations, additional imaging beyond clinical evaluation is not medically necessary unless complex associated findings are present (eg, Sturge‑Weber syndrome, Klippel‑Trenaunay syndrome). Documentation of lesion characteristics and any syndromic features should accompany imaging requests when such associations are suspected.
Advanced imaging for simple capillary malformations is not medically necessary. Similarly, routine combined MRI plus MRA for surveillance or routine treatment‑response imaging of vascular tumors is not considered medically necessary; MRA alone (contrast as requested) suffices for surveillance and MRI or MRA is used for treatment response as clinically indicated.
Imaging studies that are not listed as medically necessary for the described indications in this guideline are not supported. Selection of studies should follow the stated modality guidance (eg, begin with ultrasound for superficial lesions, escalate to MRI/MRA or CT/CTA when indicated by lesion depth, size, inconclusive ultrasound, or need for preoperative planning) and must be supported by clinical documentation.
Covered Indications and Appropriate Uses
Appropriate uses and modality selection
Appropriate uses and modality selection
Lymphatic malformations — initial evaluation
Lymphatic malformations — initial evaluation
Venous malformations — initial evaluation
Venous malformations — initial evaluation
Capillary malformations — when to use MRI
Capillary malformations — when to use MRI
Occult neurologic involvement associated with cutaneous vascular lesions
Occult neurologic involvement associated with cutaneous vascular lesions
Arteriovenous malformations and fistulas
Arteriovenous malformations and fistulas
Both MRI and MRA may be necessary for preoperative planning.
Vascular tumors initial assessment, monitoring, and surveillance
Vascular tumors initial assessment, monitoring, and surveillance
Routine combined MRI+MRA for surveillance/treatment response is not medically necessary.
Initial evaluation of Takayasu arteritis
Initial evaluation of Takayasu arteritis
Initial evaluation of polyarteritis nodosa
Initial evaluation of polyarteritis nodosa
Evaluation and monitoring of GPA and EGPA
Evaluation and monitoring of GPA and EGPA
Evaluation of gastrointestinal complications in HSP
Evaluation of gastrointestinal complications in HSP
Familial aortopathies (Marfan, EDS, Loeys-Dietz, familial thoracic aneurysm/dissection)
Familial aortopathies (Marfan, EDS, Loeys‑Dietz, familial thoracic aneurysm/dissection)
Surveillance intervals and age‑based schedules apply as described.
Aortic congenital vascular malformations / vascular rings
Aortic congenital vascular malformations / vascular rings
Visceral artery aneurysms
Visceral artery aneurysms
Surveillance intervals and post‑stent imaging schedules are specified.
Evaluation for hepatic hemangiomas in infants with multiple (5 or more) cutaneous hemangiomas
Evaluation for hepatic hemangiomas in infants with multiple (5 or more) cutaneous hemangiomas
Initial imaging for suspected PHACE(S) syndrome
Initial imaging for suspected PHACE(S) syndrome
Imaging for suspected LUMBAR syndrome
Imaging for suspected LUMBAR syndrome
Suspected LUMBAR syndrome in children with large lower-body infantile hemangiomas
Suspected LUMBAR syndrome in children with large lower-body infantile hemangiomas
Imaging Frequency and Surveillance Intervals
Coding and Procedure Lists
| 70546 | Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequence |
| 70549 | Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences |
| 71555 | Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s) |
| 72198 | Magnetic resonance angiography, pelvis, with or without contrast material(s) |
| 73225 | Magnetic resonance angiography, upper extremity, with or without contrast material(s) |
| 73725 | Magnetic resonance angiography, lower extremity, with or without contrast material(s) |
| 74185 | Magnetic resonance angiography, abdomen, with or without contrast material(s) |
| 70496 | Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing |
| 70498 | Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing |
| 71275 | Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing |
| 73206 | Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing |
| 73706 | Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing |
| 74174 | Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing |
| 74175 | Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing |
| 75635 | CTA Abdominal Aorta with Bilateral Iliofemoral Runoff |
| 93880 | Duplex scan of extracranial arteries; complete bilateral study |
| 93882 | Duplex scan of extracranial arteries; unilateral or limited study |
| 93875 | Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries |
| 93922 | Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries |
| 93923 | Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries (alternate code listed) |
| 93930 | Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral |
| 93931 | Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited |
| 93965 | Non-invasive physiologic studies of extremity veins, complete bilateral study |
| 93970 | Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study |
| 93971 | Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study |
| 76700 | US abdomen complete (example listed) |
| 76705 | US abdomen limited (example listed) |
| 93975 | Duplex scan abdomen (example listed) |
| 93976 | Duplex scan abdomen follow-up (example listed) |
| 93978 | Duplex scan other (example listed) |
| 93979 | Duplex scan other follow-up (example listed) |
| 74175 | CTA Abdomen |
| 74160 | CT Abdomen with contrast |
| 74185 | MRA Abdomen |
| 70551 | MRI Brain without contrast |
| 70553 | MRI Brain without and with contrast |
| 70540 | MRI Orbits without contrast |
| 70543 | MRI Orbits without and with contrast |
| 70544 | MRA Head without contrast |
| 70546 | MRA Head without and with contrast |
| 70547 | MRA Neck without contrast |
| 70548 | MRA Neck with contrast |
| 70549 | MRA Neck without and with contrast |
| 71555 | MRA Chest |
| 76700 | Ultrasound, abdominal, real time with image documentation; complete |
| 76800 | Ultrasound, spinal, real time with image documentation |
| 76856 | Ultrasound, pelvic (nonobstetric), real time with image documentation; complete |
| 72148 | MRI Lumbar Spine without contrast |
| 72158 | MRI Lumbar Spine without and with contrast |
| 72195 | MRI Pelvis without contrast |
| 72197 | MRI Pelvis without and with contrast |
| 74181 | MRI Abdomen without contrast |
| 74183 | MRI Abdomen without and with contrast |
| 74185 | MRA Abdomen |
| 76800 | Ultrasound spine |
| 76700 | Ultrasound abdomen complete |
| 76856 | Ultrasound pelvic transabdominal, limited |
| 72148 | MRI lumbar spine without contrast |
| 72158 | MRI lumbar spine without and with contrast |
| 72195 | MRI pelvis without contrast (note: sometimes listed as pelvis without contrast) |
| 72197 | MRI pelvis without and with contrast |
| 74181 | MRI abdomen without contrast |
| 74183 | MRI abdomen without and with contrast |
| 74185 | MRA abdomen (with or without contrast) — arterial and/or venous |
Provider Actions, Prior Authorization, and Documentation
eviCore review required for listed CPTs
The advanced imaging procedures and CPT codes listed in this guideline apply to services managed by eviCore for Cigna and are subject to eviCore review per the Cigna CPT list.
Surveillance MRI/MRA requires prior authorization
Annual surveillance MRI or MRA (contrast as requested) is considered medically necessary for known AVMs or vascular tumors located in body areas where growth could cause significant organ dysfunction or functional impairment; preauthorization may be required per payer processes.
Initial imaging modalities permitted (MRA/CTA/Ultrasound)
For initial evaluation of Takayasu arteritis and polyarteritis nodosa, any of the following modalities is considered medically necessary for the affected body area(s): MRA (contrast as requested), CTA (contrast as requested), or Doppler ultrasound.
Prior authorization guidance for listed imaging CPTs
The document identifies specific imaging modalities and CPT codes (CT/CTA, MRA, cardiac MRI, abdominal imaging, and specified ultrasound/duplex CPTs) as medically necessary for defined indications; listing of these CPTs implies prior authorization expectations per payer policy.
Prior authorization required for specified CPT codes
Certain imaging procedures (e.g., MRI/MRA, echocardiography, abdominal ultrasound, spine MRI, and other CPTs listed for PHACE(S), LUMBAR and related indications) are specified as medically necessary for defined indications and require prior authorization per payer rules when submitted for those indications.
Prior authorization for CPTs used in suspected LUMBAR syndrome
Prior authorization is required per payer policy for the referenced imaging CPT codes when used to evaluate suspected LUMBAR syndrome (e.g., spine ultrasound, MRI lumbar spine, MRI pelvis/abdomen, MRA abdomen/pelvis, lower extremity MRI/MRA) as described in the LUMBAR section.
Start with ultrasound and escalate to MRI/CT when indicated
Begin imaging with ultrasound for superficial lesions; use Doppler ultrasound for venous lesions. Escalate to MRI or CT when indicated by depth, size, inconclusive ultrasound, preoperative planning needs, or contraindication/inconclusiveness of MRI.
- Ultrasound (with Doppler for venous lesions) is the initial examination for superficial lesions.
- Escalate to MRI (without or without and with contrast) for deep, large, or inconclusive lesions; CT with contrast when MRI is contraindicated or inconclusive.
Preferred initial imaging modality: ultrasound with Doppler
For superficial lesions, perform ultrasound with Doppler as the preferred initial modality and escalate to MRI/MRA as clinically indicated for extent assessment, preoperative planning, or when ultrasound is inadequate.
Step therapy requirements
No specific step therapy requirements are specified in this excerpt.
Repeat imaging only when it will change management
Repeat imaging is considered medically necessary only when results will impact clinical management or when high‑risk findings or clinical changes are present.
- Repeat imaging is not medically necessary without evidence of progression, new disease, or documentation that repeat imaging will affect management.
Required clinical evaluation before advanced imaging
A pertinent clinical evaluation since onset or change in symptoms (detailed history, physical exam, appropriate labs, and basic imaging such as radiography or ultrasound) should be performed prior to advanced imaging unless guideline-supported scheduled imaging evaluation; meaningful technological contact can substitute.
Document lesion depth and superficial vs deep status
Document lesion depth and whether the lesion is superficial versus deep, and record clinical suspicion (for example, concern for airway or organ compression or inconclusive ultrasound) to support modality selection and authorization.
Document clinical indication and rationale
Clinical documentation must support the indication for imaging (for example: suspected AVM, treatment response assessment, preoperative planning, surveillance in high‑risk growth areas, or superficial lesion inadequately characterized by ultrasound).
Document family history and aortopathy evaluation
For suspected familial aortopathies, document family history, genetic or clinical suspicion of an aortopathy, and imaging findings; perform an initial transthoracic echocardiogram (TTE) at the time of evaluation as recommended.
Document hemangioma size, location, number, and high‑risk signs
Document hemangioma size, location, number, and presence of high‑risk clinical signs (for example, high‑output cardiac failure, airway compromise, functional impairment or ulceration) to support imaging requests.
Document clinical rationale and lesion size for LUMBAR imaging
When requesting imaging for suspected LUMBAR syndrome, document clinical rationale and that the child has an infantile hemangioma meeting the size/location threshold (≥5 cm in lumbosacral, perineal region, or lower extremity), or state why ultrasound is inadequate or that a hemangioma specialist recommended MRI/MRA.
- Spine ultrasound is indicated for infants up to 6 months; MRI lumbar spine at 3–6 months or earlier if ultrasound inadequate or per specialist.
Denial risk: imaging used for screening asymptomatic individuals
Use of advanced imaging to screen asymptomatic individuals for peripheral vascular disorders is considered not medically necessary and may trigger denial unless a guideline section explicitly allows screening.
Denial risk: additional imaging without complex associated findings
Additional imaging is not considered medically necessary in the absence of complex associated clinical findings (for example Sturge‑Weber or Klippel‑Trenaunay); ordering advanced imaging without those findings may not be supported.
Denial risk: imaging not necessary for isolated capillary malformations
Advanced imaging is not considered medically necessary for isolated capillary malformations when there are no complex associated clinical findings (such as Sturge‑Weber or Klippel‑Trenaunay), and may be denied if ordered without those indications.
Denial risk: imaging not indicated for small‑vessel vasculitis primary assessment
Advanced cross‑sectional imaging is not sufficiently sensitive for primary assessment of small‑vessel vasculitis and is not considered medically necessary for that purpose.
Denial risk: PHACE(S) imaging requires specified clinical findings
Imaging for PHACE(S) is medically necessary only when clinical findings meet specified size/location thresholds or associated major anomalies; lack of these documented clinical triggers may risk denial.
- Examples of triggers include facial/scalp/neck hemangioma ≥5 cm or hemangioma with associated major anomalies.
Denial risk: imaging beyond specified indications
Imaging studies beyond the specified indications (for example, studies not listed as medically necessary for suspected LUMBAR syndrome) may not meet the policy's medically necessary indications and could be denied.
Document ultrasound inadequacy or specialist recommendation to escalate imaging
When ultrasound is the initial exam but is inadequate, document that ultrasound was inadequate or that a hemangioma specialist recommended further imaging (MRI/MRA) to justify escalation.
Prior Authorization Expectations
Contrast and Modality Substitution Guidance
Not Medically Necessary / Not Covered
Additional imaging for isolated capillary malformations without complex associated clinical findings is not covered and is considered not medically necessary.
Routine combined MRI and MRA for surveillance or routine treatment‑response imaging of vascular tumors is not covered as medically necessary. Advanced imaging without a specific clinical indication for these purposes is not supported.
Advanced imaging for the primary assessment of small‑vessel vasculitis is not covered because these modalities are not sensitive enough to evaluate small‑vessel disease.
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Definitions and Background
Pediatric peripheral vascular conditions often differ from adult diseases in presentation, natural history, and management; these guidelines apply to individuals aged 18 years and younger. Advanced imaging in the pediatric population should be reserved for situations with documented clinical indications, and modality selection should favor ultrasound for superficial lesions with escalation to MRI/MRA or CT/CTA when lesion characteristics, depth, size, or preoperative planning dictate. Repeat imaging and surveillance intervals are limited and specified in condition‑specific sections to minimize unnecessary testing and exposures in children.
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