CurrentUnitedHealthcarePolicy CSRAD024OH.D

Pediatric Peripheral Vascular Disease (PVD) Imaging Guidelines (Ohio only)

Coverage and medical necessity guidance for imaging of pediatric peripheral vascular disease for UnitedHealthcare Community Plan members in Ohio; applies to providers requesting imaging services in Ohio.

Policy Summary

PayerUnitedHealthcare

PolicyPediatric Peripheral Vascular Disease (PVD) Imaging Guidelines (Ohio only)

Policy CodePolicy CSRAD024OH.D

Change TypeNo material changes

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionSubmit adequate clinical information (recent history, physical exam, relevant labs and prior imaging) to establish medical necessity for advanced pediatric PVD imaging; verify payer-specific prior authorization requirements for listed CPTs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-11-01effective date stated

Ohio-onlygeographic applicability

<=18 yrsage boundary

91document pages

V1.0.2025version

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Medical Necessity Criteria

General coverage criteria

Covered when imaging is supported by clinical evaluation and relevant prior studies and when modality-specific considerations are met.

General preconditions: Imaging is medically necessary when ALL of the following are met: (1) adequate clinical information is submitted (recent detailed history, physical exam since onset/change, appropriate labs and prior imaging); (2) results are expected to impact clinical management or treatment decisions; (3) the treating clinician has performed or arranged a pertinent clinical evaluation or documented a meaningful technological contact since onset/change in symptoms.

Condition-specific sections may list additional required documentation.

Age-based guideline selection: Use the Pediatric Peripheral Vascular Disease imaging guidelines for individuals <= 18 years when the condition is discussed in the pediatric sections; otherwise use the General Imaging Guidelines for individuals >18 years.<=18 years

Modality and contrast selection: Select imaging modality and contrast level based on the clinical question: MRI preferred for soft-tissue and neurologic indications; CT preferred for trauma, pulmonary evaluation, complex fractures, and when MRI is contraindicated; choose appropriate contrast level (none, with, or without and with) per condition-specific guidance.

Avoid gadolinium in pregnancy and use caution with renal impairment (GFR <30 mL/min).

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

Modality- and procedure-specific coverage criteria

Covered when usage meets these modality- and scenario-specific conditions

3D rendering (CPT 76376/76377): 3D rendering is supported when true 3D post-processing is required (not for 2D reformatting) such as complex pre-operative planning for congenital skull anomalies, complex fractures (spine, pelvis, facial), intra-articular injuries, select cerebral angiography, and other complex surgical planning scenarios.

Document concurrent physician supervision/participation as defined; CPT 76377 applies when independent workstation post-processing is used; CPT 76376 for rendering not requiring independent workstation. Do not bill 3D rendering in conjunction with enumerated incompatible studies.

Imaging guidance procedure codes: Use imaging guidance codes (CPT 77011–77022, 76942, 77002–77003, etc.) to report imaging guidance for percutaneous procedures; these codes include guidance, monitoring, and confirmation steps as specified.

Guidance codes are single-unit per individual encounter; report CPT 77011 when the scan is technical-only and use diagnostic CT code when interpreted. Do not routinely bill a diagnostic procedure code in conjunction with a guidance code for the same encounter.

Breast biopsy coding:

Whole-Body CT Imaging (Preface-5.1)

Whole-Body CT Imaging

Not indicated for screening in asymptomatic individuals: Whole-body CT (LifeScan: CT brain, chest, abdomen, pelvis) for screening of asymptomatic individuals is not indicated due to lack of validity and unfavorable benefit versus radiation risk.

Exception: low-dose whole-body CT is supported for oncologic staging in Multiple Myeloma per oncology guidelines.

Whole-Body MR Imaging (Preface-5.2)

Whole-Body MRI (WBMRI)

General stance: Whole-body MRI is generally not supported due to lack of standardization in technique and insufficient evidence of outcome benefit, except in select situations.

There are no established CPT/HCPCS codes for WBMRI other than CPT 76498 for reporting; other reporting methods are inappropriate.

Cancer predisposition exception: Interval WBMRI may be recommended for cancer screening in individuals with select cancer predisposition syndromes as specified in pediatric oncology guideline cross-references.

See pediatric oncology syndrome-specific sections for details.

Autoimmune/other exception: WBMRI may be approved in select autoimmune conditions (e.g., chronic recurrent multifocal osteomyelitis) when indicated by condition-specific guidance.

PET-MRI (Preface-5.3)

PET-MRI

When PET-MRI may be appropriate: PET-MRI may be appropriate only when the individual meets condition-specific PET-MRI criteria OR when ALL of the following are met: (1) the individual meets guideline criteria for PET-CT; (2) PET-CT is not available at the treating institution; and (3) the provider requests PET-MRI in lieu of PET-CT.

When approved, PET-MRI should be reported as CPT 78813 (PET whole-body) plus CPT 76498 (MRI unlisted); other reporting methods are inappropriate.

Quantitative MR Analysis (Preface-4.8)

Quantitative MR Analysis

Quantitative mp-MRI analysis status: Category III quantitative multiparametric MRI analyses are considered investigational/experimental for coverage purposes because they are primarily used in clinical trials and lack widely recommended clinical indications.

Specific Category III codes (e.g., 0648T/0649T/0697T/0698T) are listed; volumetric brain MRI analyses (0865T/0866T) are considered not medically necessary for routine clinical practice.

Coverage criteria for pediatric PVD imaging

Covered when clinical evaluation and indication justify advanced imaging for pediatric peripheral vascular disease as described below

Pre-imaging clinical evaluation: 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; a meaningful technological contact may serve as evaluation in some cases.

Symptomatic disease requirement: Advanced imaging of the peripheral vascular system is supported only for individuals with documented active clinical signs or symptoms; screening asymptomatic individuals is not supported unless a specific section states otherwise.

Repeat imaging: Repeat advanced imaging is supported only when there is evidence of disease progression, new disease, or documentation that the repeat study will affect management or treatment decisions.

Modality considerations:

Lymphatic Malformations — Imaging Criteria

Imaging for lymphatic malformations is indicated as follows

Lymphatic malformation imaging indications: Ultrasound is the initial exam for superficial lymphatic malformations. MRI (without contrast or without and with contrast) is indicated for deep tissue involvement, lesions too large for ultrasound, inconclusive ultrasound, preoperative planning, and post-treatment evaluation. CT is of limited value; CT with contrast is indicated for acute enlargement with compression concerns when MRI is contraindicated.

Venous Malformations — Imaging Criteria

Imaging for venous malformations is indicated as follows

Venous malformation imaging indications: Ultrasound with Doppler is the initial exam for superficial venous malformations. MRI (without and with contrast) is preferred for preoperative assessment and to define extent and relation to normal structures. MRA/CTA have limited roles and may be used when MRI/CT are equivocal and will impact acute management. CT with contrast is indicated when MRI is inconclusive or contraindicated. When pulmonary embolism is suspected in syndromic patients, CT chest with PE protocol (CPT 71260) or CTA chest (CPT 71275) is indicated.

Capillary Malformations — Imaging Criteria

Imaging for capillary malformations is indicated as follows

Capillary malformation imaging indications: MRI (without contrast or without and with contrast) is indicated to evaluate for occult underlying neurologic anomalies associated with encephalocele, spinal dysraphism, or Sturge-Weber syndrome when clinically suspected.

AVMs and Fistulas — Imaging Criteria

Imaging for AVMs and fistulas is indicated as follows

AVM/ Fistula imaging indications: Ultrasound with Doppler is the initial exam for superficial AVMs/fistulas. MRI (without and with contrast) evaluates extent and relation to normal structures; MRA (contrast as requested) is indicated for evaluation and surveillance. CT/CTA can characterize AVMs but are generally not superior to MRI and carry radiation risk; CT with contrast and/or CTA is indicated when MRI/MRA are inconclusive or contraindicated. Both MRI and MRA are rarely necessary for routine surveillance but may be needed for preoperative planning.

Vascular Tumors — Imaging Criteria

Imaging for vascular tumors is indicated as follows

Vascular tumor imaging indications: Ultrasound with Doppler is the initial exam for vascular tumors. MRI (without and with contrast) is indicated to evaluate extent and response to therapy; MRA is indicated for evaluation and surveillance. CT/CTA may be used but are generally inferior to MRI; CT with contrast and/or CTA is indicated when MRI/MRA are inconclusive or contraindicated. Both MRI and MRA are rarely necessary for routine surveillance but may be used for preoperative planning.

Large vessel vasculitis (Takayasu arteritis)

Imaging for Takayasu arteritis is covered when the following conditions are met:

Modalities indicated: Any of MRA, CTA, or Ultrasound with Doppler of the affected body area(s) may be indicated for diagnosis and monitoring (use contrast as requested by modality).

Monitoring intervals: Imaging may be performed every 3 months for treatment response during active systemic therapy and annually for surveillance of known involved body areas.

Medium vessel vasculitis (polyarteritis nodosa)

Imaging for polyarteritis nodosa is covered when the following conditions are met:

Indications and intervals: Any of MRA, CTA, or Ultrasound with Doppler of the affected body area(s) may be indicated for evaluation; imaging every 3 months during active systemic therapy for treatment response and annually for surveillance of known involved body areas.

Modality choice: MRA or CTA (contrast as requested) or Ultrasound with Doppler may be used based on clinical needs and modality considerations.

Small vessel vasculitis and end-organ imaging

Advanced imaging for small-vessel vasculitis:

Primary assessment not indicated: Advanced cross-sectional imaging is not sensitive enough for primary assessment of small-vessel vasculitis and is not indicated for that purpose.

HSP abdominal evaluation: Ultrasound abdomen (CPT 76700) is indicated to evaluate gastrointestinal complications in known or suspected Henoch-Schönlein Purpura and should be approved when requested for that indication.

GPA and EGPA thoracic/sinus imaging: CT Sinuses (CPT 70486) and/or CT Chest without or with contrast (CPT 71250/71260) are indicated for new or worsening symptoms, to assess response when a therapy change is contemplated, or annually to evaluate extent of disease.

Thoracic Aortic Disease: Initial and Surveillance Imaging

Covered when ALL of the following are met for familial aortopathies and surveillance:

Initial evaluation: Echocardiogram (transthoracic) should be obtained at time of evaluation for individuals with suspected aortopathy (gene positive, physical findings, or other concerning findings).

Additional initial imaging (Loeys-Dietz): For Loeys-Dietz syndrome, MRA or CTA of head, neck, chest, abdomen and pelvis may be indicated in addition to echocardiogram at initial workup.

Surveillance when imaging normal: For suspected or known disease but normal aortic imaging: echocardiogram at 6 months then annually; Loeys-Dietz patients may have additional cross-sectional imaging per guidance.

Surveillance after abnormal thoracic imaging: After abnormal thoracic imaging, both echocardiogram and CTA or MRA of chest/abdomen/pelvis/head/neck as indicated at diagnosis, at 6 months after diagnosis (if older than 2 years), then at intervals based on age and growth criteria (see thresholds).

Aortic Congenital Vascular Malformations: Modality Indications

Imaging modalities indicated for congenital aortic vascular malformations:

Modality selection: Cardiac MRI (without contrast CPT 75557 or without and with contrast CPT 75561), MRA chest (CPT 71555), CT chest with contrast (CPT 71260), or CTA chest (CPT 71275) may be indicated for evaluation of aortic congenital vascular malformations based on the clinical question.

Visceral Artery Aneurysms: Indications

Indication parity with adults: Imaging indications for visceral artery aneurysms in pediatric individuals follow the same indications as in adults; see adult peripheral vascular disease/aortic disorders guidance for specifics.

Infantile Hemangiomas: Imaging and Risk-Based Evaluation

Infantile Hemangiomas: imaging indications and high-risk features

When to image IH: Most infantile hemangiomas do not require imaging. Use ultrasound with Doppler when diagnosis is uncertain or when high-risk clinical considerations are present. MRI/MRA/CT/CTA considerations for other vascular neoplasms also apply.

High-risk features prompting further evaluation: Indications for additional evaluation include: multiple (≥5) cutaneous IHs (evaluate for hepatic hemangiomas); large cutaneous IHs causing high-output cardiac failure (obtain cardiac evaluation/echocardiography); beard-distribution or airway-associated IHs (assess for airway compromise); periocular IH >1 cm (evaluate for vision impairment); IH ≥2.5 cm over lumbar spine/sacrum in infants <6 months (spinal ultrasound and/or MRI lumbar spine); IH ≥5 cm (increased risk of extracutaneous structural abnormalities).>=5 hemangiomas; IH size >=2.5 cm; IH size >=5 cm

Consultation with a hemangioma specialist is recommended when these features are present.

Specialist involvement: Hemangioma specialist consultation may guide evaluation, treatment, and follow-up when imaging or high-risk features are present.

Multiple infantile hemangiomas

Covered when criteria met for multiple cutaneous hemangiomas

Liver ultrasound for multiple hemangiomas: When a child has multiple (5 or more) infantile hemangiomas, an ultrasound with Doppler of the liver (CPT 76700) is indicated for initial evaluation and for monitoring progression or response to treatment.>=5 hemangiomas

PHACE(S) evaluation

Covered when criteria met for suspected PHACE(S) syndrome

Clinical triggers for PHACE(S) imaging: Suspect PHACE(S) with a large (>=5 cm) infantile hemangioma of the face/scalp/neck; smaller facial/scalp/neck hemangioma with at least one major PHACE(S) anomaly; large (>=5 cm) hemangioma on upper chest/proximal upper extremity with major anomalies; or large intraorbital hemangioma.>=5 cm

Imaging for PHACE(S): Initial imaging for suspected PHACE(S) includes MRI brain (70551 or 70553), MRI orbits (70540 or 70543), MRA head (70544 or 70546) and MRA neck (70547/70548/70549), MRA chest (71555), and a screening transthoracic echocardiogram (93303 ± 93320/93325). If echocardiogram abnormal, cardiac MRI (75557 or 75561) is indicated; if aortic involvement suspected, MRI chest (71550 or 71552) is indicated.clinical suspicion per triggers above

LUMBAR and lower-extremity hemangioma evaluation

Covered when criteria met for suspected LUMBAR syndrome or lower-body large hemangiomas

Clinical triggers for LUMBAR imaging: LUMBAR is suspected with a large (>=5 cm) infantile hemangioma in the lumbosacral, perineal region, or lower extremity.>=5 cm

Initial and supplemental imaging for suspected LUMBAR: Indicated imaging includes spinal ultrasound (76800) in infants up to 6 months, abdominal (76700) and pelvic (76856) ultrasound with color Doppler; MRI lumbar spine without or without and with contrast (72148 or 72158) at 3–6 months or earlier if ultrasound inadequate or per hemangioma specialist; MRI pelvis/abdomen (72195/72197; 74181/74183) and MRA abdomen/pelvis (74185/72198) as indicated; MRI lower extremity (73718/73720/73721/73723) and MRA lower extremity reported per guidance (74185 + 73725) when extensive involvement is present.based on location/size and ultrasound adequacy

Proceed to MRI when ultrasound is inadequate or per specialist recommendation; report MRA abdomen and lower extremity per stated CPT combination guidance.

Follow-up / Surveillance

Surveillance/follow-up

Follow-up imaging indications: Follow-up or surveillance imaging is determined by initial clinical and imaging findings and any subsequent clinical change. Most frequent follow-up is for individuals at highest risk, including those with prior arterial stroke, arterial stenosis or occlusion (with or without moyamoya-like changes), structural brain abnormalities, or aortic arch/coarctation or congenital cardiac anomalies.clinical findings and changes

Pediatric cardiology or neurosurgical consultation may clarify surveillance frequency.

Imaging studies requested solely for data collection in clinical trials or those that are inconsistent with established clinical standards are not supported. Requests that lack sufficient supporting evidence, have not demonstrated clinical utility, or do not reflect a collective opinion of clinical support meet the definition of investigational/experimental and may be treated as not medically necessary.

Providers should submit adequate clinical documentation that demonstrates how the requested imaging will be used in direct clinical management; absent such documentation, these requests may be denied as not supported.

The guideline states that PET/MRI is generally not supported for most oncologic and neurologic indications. PET-MRI may be considered only when the individual meets the criteria for PET-CT, PET-CT is unavailable at the treating institution, and the provider specifically requests PET-MRI; when approved it should be reported as CPT 78813 + CPT 76498.

Additionally, MRI using Xenon Xe 129 (CPT C9791) is considered investigational/experimental and is not supported for routine clinical use.

CPT codes for 3D rendering (CPT 76376, 76377) are limited to true 3D post-processing and must not be used for routine 2D reformatting, since two-dimensional reconstructions are included in standard cross-sectional base codes.

These codes require documentation of concurrent physician supervision of the reconstruction process, and are not appropriate to bill in conjunction with the listed modalities (e.g., CAD, MRA, CTA, SPECT, PET/PET‑CT, mammography, breast MRI/US, CT colonography, cardiac CT/MRI, coronary CTA).

Imaging guidance codes (for example CPT 77012, 77021, 77013, 77022 and related modality guidance CPTs) are intended to report radiologic supervision and interpretation for percutaneous procedures. They are inappropriate to use with open, excisional, or incisional surgical codes.

The guidance codes include all elements required for image‑guided procedures; when used they should be billed as a single unit per individual encounter (date of service) per the unit‑of‑service definition and accompanied by documentation that the guidance was provided for a percutaneous procedure.

There are currently no established CPT or HCPCS codes for Whole‑Body MRI (WBMRI). When WBMRI is performed it should be reported using CPT 76498 (unlisted MR procedure); reporting WBMRI by billing multiple separate diagnostic MRI codes for individual body parts or alternative codes is inappropriate.

Separately, advanced quantitative MR analyses (Category III/other experimental codes) are primarily research‑oriented and should not be conflated with WBMRI coding; use the unlisted WBMRI code as directed when an institution requests WBMRI in an approved clinical context.

Use of advanced imaging to screen asymptomatic individuals for peripheral vascular disease is not supported. Advanced studies should be reserved for individuals with documented signs or symptoms or other guideline‑specified indications.

Several older nuclear medicine vascular flow and venous thrombosis studies (for example CPT 78445, 78456–78458) are obsolete and are no longer supported; modern alternatives (MRA, CTA, duplex ultrasound) are the preferred modalities.

For lymphatic and venous malformations, MRI is generally the preferred modality for deep or complex lesions because it better characterizes lesion extent and relationships to adjacent structures. CT is generally of limited value for lymphatic malformations and is less accurate than MRI for venous malformations.

CT and CTA may have a role when MRI is contraindicated, inconclusive, or when rapid assessment for acute enlargement or suspected pulmonary embolism (in syndromic patients) is required, but CT should not be used preferentially when MRI is the modality of choice due to radiation exposure.

Current evidence does not support routine use of PET/CT for management of pediatric vasculitis. PET/CT is identified in the guideline as not medically necessary for routine assessment or monitoring of pediatric vasculitis and may be denied when requested for this indication.

Most infantile hemangiomas (IH) do not require imaging. Routine imaging of uncomplicated, typical IHs is not indicated and is not supported by the guideline.

Ultrasound with Doppler is appropriate when the diagnosis is uncertain or when high‑risk clinical features are present; imaging is otherwise reserved for the subset of IHs that meet specific size, number, or location thresholds described in the guideline.

This guideline is intended to assist interpretation of UnitedHealthcare standard benefit plans for Ohio members and to inform medical necessity determinations; it does not override applicable federal, state (Ohio Administrative Code), or contractual coverage requirements. In the event of conflict, those governing rules prevail.

Services and procedures are treated as investigational or experimental when there is insufficient published evidence, lack of demonstrated clinical utility, or absence of broad professional support. Such services are not supported for coverage in routine clinical care.

Requests for investigational procedures should include supporting evidence demonstrating clinical utility and consensus support; absent that, the guideline indicates the service will be considered not medically necessary.

Repeat imaging without evidence of disease progression, new onset of disease, or documentation that the repeat will affect clinical management may be considered unnecessary and potentially denied. Prior adequate studies should be reviewed and included in the submission to justify any repeat study.

Preoperative imaging is appropriate only when the procedure itself is indicated; repeat or additional preprocedural imaging separate from an approved procedure may not be supported.

In general, repeat imaging is unnecessary unless there is documented evidence of progression, recurrence, or a clear expectation that the new imaging will change management. Imaging for treatment response during active systemic therapy may be approved at intervals (for example, every 3 months) when clinically indicated; routine repeat imaging outside these criteria is discouraged.

Providers requesting repeat studies should document the specific clinical change or management decision that justifies the repeat examination.

Category III and other quantitative MR analysis procedures (including multiparametric quantitative analyses) are primarily used in research and lack widely recommended clinical indications; accordingly they are considered investigational/experimental for coverage purposes.

Specifically, volumetric and quantitative brain MRI analyses (for example CPT 0865T/0866T) lack sufficient specificity and sensitivity to be clinically useful in routine practice and are considered not medically necessary.

Advanced imaging for asymptomatic screening of the peripheral vascular system is not supported and is considered not medically necessary. Outdated nuclear medicine vascular flow and venous thrombosis studies (e.g., CPT 78445, 78456–78458) are obsolete and not supported.

PET/MRI is generally not supported for most indications; PET/CT remains the standard PET modality when indicated and unbundling PET/CT into separate PET and diagnostic CT CPT codes is not supported.

The guideline specifically identifies PET/CT for pediatric vasculitis management as not medically necessary at this time; it is not recommended for routine assessment or monitoring of pediatric vasculitis.

Routine imaging for typical, uncomplicated infantile hemangiomas is not indicated. Most IHs can be managed clinically without imaging; ultrasound with Doppler should be reserved for diagnostic uncertainty or for those meeting high‑risk criteria described in the guideline.

Indications Where Imaging Is Covered

Modality-specific common indications

Ultrasound indications: Initial and bedside evaluation of soft-tissue, vascular structures (grey-scale and Doppler), procedural guidance, and characterization of superficial masses; limited by bone and lesion size.

Operator-dependent; may be first-line to avoid advanced imaging when appropriate.

CT indications: Rapid cross-sectional evaluation for trauma, pulmonary disease, complex fractures, characterization of masses, vascular anatomy evaluation, and when MRI contraindicated; CT may be performed without or with IV contrast depending on indication.

Consider radiation exposure and limit field of view when appropriate.

MRI indications: Preferred modality for advanced soft-tissue and neurologic imaging, characterization of visceral/musculoskeletal soft-tissue masses, evaluation of inconclusive ultrasound/CT findings, and in individuals with high radiation sensitivity or pregnancy considerations; perform without and with contrast per indication.

Procedure Codes and Coding Guidance

Experimental/Investigational CPTCPTExperimental

C9791

MRI utilizing Xenon Xe 129 (contrast) — considered investigational/experimental

3D Rendering CPT CodesCPT

76376	3D rendering not requiring image post-processing on an independent workstation
76377	3D rendering requiring image post-processing on an independent workstation

Imaging Guidance and Related CPT CodesCPT

19085	Biopsy, breast, with placement of breast localization device(s), first lesion, including MR guidance
19086	Biopsy, breast, 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
20982	CT guidance for bone tumor ablations

Breast biopsy and guidance codesCPT

77021	MR guidance for needle placement (not appropriate for breast biopsy)
19085	Breast biopsy, first site (MRI-guided)
19086	Breast biopsy, additional concurrent site

Guidance codes for ablation and proceduresCPT

77013	CT guidance for tumor ablation (non-bone) including monitoring and confirmation of coagulative necrosis
77022	MR guidance for tumor ablation including monitoring and confirmation of coagulative necrosis
20982	CT guidance for bone tumor ablations
77012	Radiologic guidance for needle placement (CT)
76942	Ultrasound guidance for needle placement
77002	Fluoroscopy guidance (lower range)
77003	Fluoroscopy guidance (upper range)

Unlisted procedure codesCPT

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

Limited CT codeCPT

76380

Limited or follow-up CT

SPECT/CT and hybrid nuclear/CT codesCPT

78830	Hybrid Nuclear/CT scan, single area, single day
78831	Hybrid Nuclear/CT scan, 2 or more days
78832	Hybrid Nuclear/CT scan, 2 areas with one day and 2-day study
78072	SPECT/CT parathyroid nuclear imaging

Quantitative MR analysis (Category III and others)CPTExperimental

0648T	Quantitative mp-MRI analysis without diagnostic MRI (single organ)
0649T	Quantitative mp-MRI analysis with diagnostic MRI (single organ)
0697T	Quantitative analysis without diagnostic MRI (multiple organs)
0698T	Quantitative analysis with diagnostic MRI (multiple organs)
0865T	Volumetric/quantitative MRI analysis of the brain (considered not medically necessary)
0866T	Volumetric/quantitative MRI analysis of the brain (considered not medically necessary)

PET-MRI reporting code combinationCPT

78813

PET Whole-Body (used in PET-MRI code combination)

HCPCS code examplesHCPCS

C8931	HCPCS example: MRA with dye, Spinal Canal
S8042	MRI, low-field (non-specific HCPCS example - redirect to specific CPT)

Outside study interpretationCPTCovered

76140

Interpretation of an outside study

MRA/CTA primary codesCPT

70546	MRA, head; without contrast followed by contrast and further sequence
70549	MRA, neck; without contrast followed by contrast and further sequences
71555	MRA, chest (excluding myocardium), with or without contrast
72198	MRA, pelvis, with or without contrast
73225	MRA, upper extremity, with or without contrast
73725	MRA, lower extremity, with or without contrast
74185	MRA, abdomen, with or without contrast
70496	CTA, head, with contrast, including noncontrast images and postprocessing
70498	CTA, neck, with contrast, including noncontrast images and postprocessing

CTA, PET, Ultrasound codesCPT

71275	Computed tomographic angiography, chest (noncoronary), with contrast, including noncontrast images and postprocessing
73206	Computed tomographic angiography, upper extremity, with contrast, including noncontrast images and postprocessing
73706	Computed tomographic angiography, lower extremity, with contrast, including noncontrast images and postprocessing
74174	Computed tomographic angiography, abdomen and pelvis, with contrast, including noncontrast images and postprocessing
74175	Computed tomographic angiography, abdomen, with contrast, including noncontrast images and postprocessing
75635	CTA Abdominal Aorta with Bilateral Iliofemoral Runoff
78811	PET Imaging; limited area (not used in pediatrics)
78812	PET Imaging: skull base to mid-thigh (not used in pediatrics)
78813	PET Imaging: whole body (not used in pediatrics)
78814	PET with concurrently acquired CT; limited area (rarely used in pediatrics)

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Ultrasound/Duplex and physiologic studiesCPT

93880	Duplex scan of extracranial arteries; complete bilateral study
93882	Duplex scan of extracranial arteries; unilateral or limited study
93875	Non-invasive physiologic studies of extracranial arteries, complete bilateral study
93922	Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries
93923	Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries
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

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Nuclear medicine codes (use cases and obsolete studies)CPT

78195	Lymphoscintigraphy
78445	Vascular flow imaging (not supported; obsolete)
78456	Venous thrombosis imaging (obsolete)
78457	Venous thrombosis imaging (obsolete)
78458	Venous thrombosis imaging (obsolete)
78800	Radiopharmaceutical nuclear medicine study (possible for infection/mycotic aneurysm)
78801	Radiopharmaceutical nuclear medicine study
78802	Radiopharmaceutical nuclear medicine study
78803	Radiopharmaceutical nuclear medicine study

Indicated CPT codes for suspected pulmonary embolism in syndromic patientsCPT

71260	CT Chest with contrast with PE protocol (CPT 71260)
71275	CTA Chest (CPT 71275)

Imaging referenced CPT codes for small vessel vasculitisCPT

76700

Ultrasound abdomen

CT imaging CPT codes for GPA/EGPACPT

70486	CT Sinuses
71250	CT Chest without contrast
71260	CT Chest with contrast

Referenced Imaging CPT CodesCPT

75557	Cardiac MRI without contrast
75561	Cardiac MRI without and with contrast
71555	MRA Chest
71260	CT Chest with contrast
71275	CTA Chest
93303	Echocardiography (used in cardiac evaluation for high-output failure)
93320	Doppler or additional echocardiography component (referenced with 93303)
93325	Add-on echocardiography component (referenced with 93303)
72148	MRI Lumbar Spine without contrast
72158	MRI Lumbar Spine without and with contrast

Indicated Ultrasound CPT (hepatic evaluation)CPTCovered

76700

Ultrasound, abdominal; complete (used here for liver ultrasound with Doppler)

Imaging CPT Codes for PHACE(S) evaluationCPTCovered

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

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Imaging CPT Codes for LUMBAR and related evaluationsCPTCovered

76800	Ultrasound, spinal (used here for infant spinal ultrasound)
76700	Ultrasound, abdominal; complete (abdomen)
76856	Ultrasound, pelvic (with Doppler)
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

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GFR threshold for renal risk (inv-64)

GFR renal risk thresholdGFR <30 mL/min

Clinical implicationExercise caution with iodinated contrast and gadolinium-based agents; consider alternative imaging or non-contrast studies

Prior Authorization, Documentation, and Billing Actions

Prior Authorization

Prior Authorization and Medical Necessity Evaluation

Prior authorization and medical necessity for pediatric PVD imaging will be evaluated per these guidelines and Ohio rules. Requests for services identified in the guideline as unproven, limited, or subject to coverage/quantity limits will be reviewed using Ohio Administrative Code 5160-1-01. Prior authorization requirements are governed by the member’s specific benefit plan; verify whether the requested service requires prior authorization under the applicable contract before submission.

Prior authorization and medical necessity decisions follow these guidelines and Ohio Administrative Code.
Verify benefit-plan specific prior authorization requirements before ordering.

Prior Authorization

PET‑MRI Reporting and Requirement

PET‑MRI may be considered only when PET‑CT criteria are met and PET‑CT is not available at the treating institution; when appropriate, report PET‑MRI using CPT 78813 (PET whole‑body) plus CPT 76498 (MRI unlisted). Other reporting methods are inappropriate. Diagnostic MRI codes may be used concurrently when clinically indicated.

Prior Authorization Specifics

Note

Contrast Use, Safety, and Special Considerations

Note

Imaging Frequency and Surveillance Intervals

Repeat imaging only when evidence of progression, recurrence, or when results will affect management (inv-151)

General repeat-imaging ruleRepeat imaging only when there is evidence of progression, recurrence, or when results are expected to affect clinical management

Prior imaging considerationReview and include prior imaging/procedural history to avoid duplicate studies; repeat studies without change are generally not necessary

Exception contextsImaging for treatment response during active systemic therapy or surveillance per condition-specific intervals (e.g., q3 months) may be approved

Repeat imaging only when it will affect management or there is evidence of progression/recurrence (inv-152)

Universal frequency principleRepeat imaging should only be performed if it will affect management or there is evidence of progression/recurrence

Services Generally Not Covered

PET/MRI remains generally not supported and MRI with Xenon Xe 129 (CPT C9791) is investigational. Additionally, the guideline does not support unbundling a combined PET/CT study into separate PET and diagnostic CT CPT codes; PET/CT is to be billed and considered as a combined single study.

Billing 3D rendering codes (CPT 76376/76377) in improper conjunctions with the specified modalities is not appropriate and may be denied.

3D rendering codes billed in conjunction with modalities expressly listed as incompatible (for example MRA, CTA, SPECT, PET/PET‑CT, mammography, breast MRI/US, CT colonography, cardiac CT/MRI, and coronary CTA) are not covered. Documentation should support true 3D post‑processing and concurrent physician participation per ACR recommendations when these codes are reported.

Screening asymptomatic individuals with advanced imaging and the obsolete nuclear medicine vascular flow and venous thrombosis studies (for example CPT 78445, 78456–78458) are not supported and are listed among not‑covered services.

Whole‑body CT for asymptomatic screening is likewise not supported given unfavorable benefit‑to‑radiation risk considerations.

Imaging of uncomplicated, typical infantile hemangiomas is not indicated; routine imaging is unnecessary for the majority of IHs. High‑risk features and specific thresholds (number, size, location) in the guideline identify the small subset that requires targeted imaging.

Terms and Definitions

Investigational/Experimental definition (inv-112)

Investigational/Experimental definitionStudies, treatments, procedures, or devices lacking sufficient supporting evidence, clinical utility, or collective professional support

Evidence requirementsSupporting evidence includes peer-reviewed literature, randomized trials, cohort studies, and specialty society recommendations

Coverage implicationSuch services may be considered not medically necessary or unsupported for coverage determinations

Standard imaging definition (inv-113)

Standard imaging definitionPlain film, CT, MRI, or ultrasound commonly used in initial evaluations

RoleOften the first-line or conventional studies before advanced imaging; may answer the initial clinical question

Background and Scope

These evidence‑based proprietary clinical guidelines evaluate a range of advanced imaging and procedures for cardiovascular and radiology applications and are intended to facilitate selection of the most appropriate imaging for an individual based on clinical condition.

The guideline is subject to state and plan‑specific application (this document applies to Ohio), is reviewed periodically, and supports that clinical judgment may appropriately vary from guideline recommendations when justified.

Document Changes and Revision History

2025-11-01policy_effectiveLatest

Policy version V1.0.2025 became effective for Ohio members (Pediatric Peripheral Vascular Disease Imaging Guidelines, CSRAD024OH.D).

Policy Summary

PayerUnitedHealthcare

PolicyPediatric Peripheral Vascular Disease (PVD) Imaging Guidelines (Ohio only)

Policy CodePolicy CSRAD024OH.D

Change TypeNo material changes

Effective DateNov 1, 2025

Next Review DateN/A

SourceLink

On This Page

For MRI-guided breast biopsy use CPT 19085 for the first lesion and CPT 19086 for additional concurrent lesions; CPT 77021 is not appropriate for breast biopsy coding.

MRI is generally performed without and with contrast unless contraindicated; CT/CTA may be indicated to further evaluate abnormalities suggested on prior US or MRI or for pre-operative planning; CT should not replace MRI solely to avoid sedation unless specifically recommended.

Nuclear medicine uses: Lymphoscintigraphy (CPT 78195) is indicated for lower-extremity lymphedema when a recent Doppler ultrasound is negative; radiopharmaceutical nuclear medicine studies (CPT 78800–78803) can be approved for mycotic aneurysm or suspected vascular graft/device infection; several older vascular nuclear studies (CPT 78445, 78456–78458) are obsolete and not supported.

Imaging for suspected dissection: For symptomatic suspected dissection obtain echocardiogram and CTA or MRA of chest/abdomen/pelvis as indicated; pediatric dissection imaging should involve vascular surgery/cardiology consultation and may be performed at any interval.

May require anesthesia in young children; coordinate body areas when multiple regions are indicated.

PET/CT indications: Oncologic metabolic imaging, select cardiac and brain metabolic evaluations; PET/CT is typically a combined study and PET/MRI is generally not supported except per PET-MRI criteria.

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

Clinical scenarios where 3D rendering (CPT 76376/76377) can be considered

Clinical scenarios where 3D rendering (CPT 76376/76377) can be considered.

3D rendering indications: Consider 3D rendering for evaluation of congenital skull abnormalities in infants for pre-operative planning; complex fractures/dislocations (spine, pelvis, intra-articular, facial) when conventional imaging is insufficient; selected pelvic/abdominal, cerebral angiography, and other complex surgical planning scenarios as referenced in condition-specific guidelines.

Document concurrent physician supervision/participation; do not use 3D rendering for simple 2D reformatting or in conjunction with incompatible modalities.

Whole-Body CT — Indications

WBC- screening not supported: Whole-body CT for asymptomatic screening is not supported; limited whole-body low-dose CT is supported for Multiple Myeloma staging only.

Whole-Body MRI — Indications

WBMRI appropriate uses: WBMRI may be appropriate for interval cancer screening in select cancer predisposition syndromes and in select autoimmune conditions (e.g., chronic recurrent multifocal osteomyelitis); otherwise WBMRI is generally not supported due to lack of standardization and outcome evidence.

Report WBMRI using CPT 76498 only.

PET-MRI — Indications

PET-MRI substitution criteria: PET-MRI may be used in lieu of PET-CT only when PET-CT criteria are met, PET-CT is unavailable at the treating institution, and the provider requests PET-MRI; when appropriate report as CPT 78813 + CPT 76498.

Lymphoscintigraphy for lymphedema — Indications

Lymphoscintigraphy indication: Lymphoscintigraphy (CPT 78195) is indicated for evaluation of lower-extremity lymphedema when a recent Doppler ultrasound is negative for valvular insufficiency.

Older vascular nuclear flow studies are obsolete and not supported.

CT/CTA specific uses — Indications and clinical contexts

CT/CTA clinical uses: CT/CTA may be indicated for further evaluation of abnormalities suggested on prior US or MRI, for lymphatic malformations, vascular abnormalities (vasculitis, thrombosis, aneurysm, dissection), pre-operative planning, or assessment of post-operative complications; limit exam region to reduce radiation when appropriate.

CT should not replace MRI solely to avoid sedation unless specifically recommended in condition-based guidance.

Lymphatic malformation — MRI preferred for deep or large lesions and pre/postoperative evaluation

Lymphatic MRI preference: Ultrasound is initial for superficial lesions; MRI (without or without and with contrast) is indicated for deep tissue involvement, lesions too large for ultrasound, inconclusive ultrasound, preoperative planning, and post-treatment evaluation; CT limited except for acute compression when MRI contraindicated.

Venous malformation — MRI preferred; CT/CTA reserved for specific circumstances including suspected PE

Venous modality guidance: Ultrasound with Doppler is initial; MRI (without and with contrast) is preferred for extent and preoperative planning; MRA/CTA limited but may be used when MRI/CT equivocal and will affect acute management; CT chest with PE protocol (71260) or CTA chest (71275) indicated when pulmonary embolism suspected in syndromic patients.

Capillary malformation — MRI indicated when associated occult neurologic anomalies suspected

Capillary malformation MRI triggers: MRI (without or without and with contrast) is indicated to evaluate occult underlying neurologic structures when encephalocele, spinal dysraphism, or Sturge-Weber syndrome is suspected.

AVMs, fistulas, and vascular tumors — MRI/MRA preferred; CT/CTA as secondary options

AVM/vascular tumor modality guidance: Ultrasound with Doppler is initial for superficial lesions; MRI (without and with contrast) is preferred to evaluate extent and relation to normal structures; MRA (contrast as requested) indicated for evaluation and surveillance; CT/CTA may be used when MRI/MRA inconclusive or contraindicated but carry radiation risk.

Both MRI and MRA are rarely necessary for routine surveillance but may be for preoperative planning.

Evaluation and monitoring of Takayasu arteritis — Indications for modality selection

Takayasu modality options: MRA, CTA, or Ultrasound with Doppler of affected body areas may be indicated; use contrast as requested per modality and clinical question.

Imaging intervals: every 3 months during active systemic therapy for treatment response and annually for surveillance.

Evaluation and monitoring of polyarteritis nodosa — Indications

Polyarteritis nodosa modality options: MRA, CTA, or Ultrasound with Doppler of affected body areas may be indicated; imaging every 3 months during active systemic therapy for treatment response and annually for surveillance.

Evaluation of gastrointestinal complications in Henoch-Schönlein Purpura — Indications

HSP abdominal imaging: Ultrasound abdomen (CPT 76700) is indicated to evaluate gastrointestinal complications of HSP and should be approved when requested for that indication.

Imaging for granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis — Indications

GPA/EGPA imaging indications: CT sinuses (70486) and/or CT chest (71250/71260) are indicated for new or worsening symptoms, to assess response when therapy changes are contemplated, or annually to evaluate disease extent.

Familial aortopathies — screening, initial workup, surveillance, and symptomatic evaluation (suspected dissection).

Screening and initial workup: Screening for individuals with family history may include echocardiogram; initial workup of suspected aortopathy includes echocardiogram and, for Loeys-Dietz, may include cross-sectional imaging (MRA/CTA) of head, neck, chest, abdomen and pelvis.

Surveillance intervals and growth-based follow-up described in condition-specific thresholds.

Symptomatic suspected dissection: Obtain echocardiogram and CTA or MRA of chest/abdomen/pelvis as indicated; involve vascular surgery/cardiology for pediatric dissection imaging planning.

Aortic congenital vascular malformations

Aortic congenital vascular malformations — Indications

Aortic congenital malformation imaging: Cardiac MRI (75557/75561), MRA chest (71555), CT chest with contrast (71260), or CTA chest (71275) may be indicated for evaluation of congenital aortic vascular malformations depending on the clinical question.

Infantile hemangiomas — Indications and risk-based imaging triggers

Imaging triggers for IH: Image when diagnosis is uncertain or when high-risk features are present (multiple lesions, large size, airway risk, high-output cardiac failure, periocular risk, lumbar/sacral location meeting size thresholds).

Most IHs do not require imaging.

High-risk thresholds: Number >=5 cutaneous hemangiomas or lesion size >=5 cm, IH >=2.5 cm over lumbar spine/sacrum in infants <6 months prompting spinal ultrasound and/or MRI lumbar spine, and periocular IH >1 cm prompting ophthalmologic evaluation and possible imaging.number >=5; size >=2.5 cm; size >=5 cm

Hepatic evaluation for multiple cutaneous hemangiomas

Hepatic evaluation for multiple cutaneous hemangiomas — Indications (e.g., 5 or more lesions).

Liver ultrasound indication: When a child has multiple (5 or more) infantile hemangiomas, perform abdominal ultrasound with Doppler (CPT 76700) to evaluate for hepatic hemangiomas and monitor progression or treatment response.>=5 hemangiomas

Suspected PHACE(S) syndrome — Indications for MRI and related imaging

Suspected PHACE(S) syndrome — Indications for MRI and related imaging.

PHACE(S) imaging triggers: Indications include large (>=5 cm) facial/scalp/neck hemangioma; smaller facial hemangioma with at least one major anomaly; large upper chest/proximal upper extremity hemangioma with major anomalies; or large intraorbital hemangioma.>=5 cm

When suspected, obtain MRI/MRA of brain, orbits, head/neck, chest and screening echocardiogram per guidance.

Suspected LUMBAR syndrome or lower body large hemangiomas — Indications for spinal/urogenital imaging

Suspected LUMBAR syndrome or lower body large hemangiomas — Indications for spinal/urogenital imaging.

LUMBAR imaging triggers: Suspect LUMBAR when a large (>=5 cm) infantile hemangioma is present in lumbosacral/perineal region or lower extremity; initial imaging includes spinal ultrasound (76800) in infants ≤6 months and abdominal/pelvic ultrasound with Doppler (76700/76856).>=5 cm

Proceed to MRI lumbar spine (72148/72158) at 3–6 months or earlier if ultrasound inadequate or per specialist; additional MRI/MRA abdomen/pelvis/lower extremity imaging indicated based on findings and specialist recommendation.

Relation to NSF/gadolinium

Low GFR increases risk of nephrogenic systemic fibrosis with GBCA exposure

Units of service for guidance codes — Only one unit per encounter (inv-65)

Guidance code unit ruleOnly one unit of any imaging guidance code should be reported per individual encounter (date of service)

Unit definitionUnit of service is the individual encounter, not the number of lesions, aspirations, biopsies, injections, or localizations

Applies to codesIncludes CPT 76942, 77002–77003, 77011–77022 and related guidance codes

Guidance unit reporting — Only one unit per date of service (inv-66)

Single-date reportingOnly one unit of a guidance code may be reported per date of service for an individual encounter

RationaleThe unit represents the encounter rather than the number of procedures or lesions performed during that encounter

Potential denial riskBilling more than one unit per date of service may be considered inappropriate and could be denied

Age threshold for pediatric guideline — <= 18 years (inv-67)

Pediatric age boundaryIndividuals 18 years old and younger (<=18 years)

ApplicationUse Pediatric PVD imaging guidelines for conditions discussed in the pediatric sections for <=18 years

AdultsIndividuals >18 years should follow general Peripheral Vascular Disease imaging guidelines unless otherwise specified

Multiple infantile hemangiomas threshold — 5 or more (inv-68)

Multiple IH threshold5 or more infantile hemangiomas

Action triggeredPerform liver ultrasound with Doppler (CPT 76700) to evaluate for hepatic hemangiomas

SurveillanceRepeat Doppler ultrasound to monitor progression and response to treatment when hepatic lesions identified

Surveillance intervals by age for aortopathy with prior abnormal imaging (inv-69)

Age-based surveillance schedule (prior abnormal thoracic aortic imaging)Age 0–2 years: every 3 months; Age 3–12 years: every 6 months; Age ≥13 years: annually if stable (<4.5 cm and <0.5 cm growth/year), or every 6 months if ≥4.5 cm or ≥0.5 cm growth/year

Initial post-diagnosis timingAt time of diagnosis and at 6 months after diagnosis (if older than 2 years)

Growth-triggered follow-upIf z-score increased or rapid growth detected, repeat imaging sooner than scheduled to assess rate of change

Infantile hemangioma size prompting spinal imaging — ≥2.5 cm over lumbar spine/sacrum (inv-70)

Spinal imaging size threshold for infantsInfantile hemangioma ≥2.5 cm overlying the lumbar spine or sacrum (in infants <6 months) should prompt spinal ultrasound and/or MRI lumbar spine

Preferred studiesSpinal ultrasound for infants <6 months; MRI Lumbar Spine without contrast (CPT 72148) or without and with contrast (CPT 72158) as indicated

Indication contextUsed to assess for underlying spinal dysraphism or other occult anomalies

High risk IH size — ≥5 cm (inv-71)

High-risk IH sizeInfantile hemangioma size ≥5 cm confers increased risk of extracutaneous structural abnormalities

Clinical consequencesLarge IHs (>5 cm) associated with higher disfigurement risk and possible functional impairment; consider specialist consult

Related syndromesLarge lesions may prompt evaluation for PHACE(S) or LUMBAR depending on location

Imaging triggers — Number ≥5 hemangiomas or lesion size ≥5 cm (inv-72)

Primary imaging triggersNumber of cutaneous hemangiomas ≥5 OR any lesion size ≥5 cm — either meets threshold to recommend further imaging

Resulting actionsFor ≥5 lesions: liver ultrasound with Doppler; for ≥5 cm lesions: targeted MRI/MRA and syndrome-specific imaging (PHACE(S)/LUMBAR) based on location

Clinical rationaleCount and size thresholds identify higher risk for extracutaneous involvement and organ dysfunction prompting imaging

PET‑MRI allowed only if guideline criteria for PET‑CT are met and PET‑CT is unavailable.

Report PET‑MRI as CPT 78813 + CPT 76498; do not use other reporting combinations.

Prior Authorization

Prior Authorization for Advanced Imaging and Modality Selection

Advanced imaging modality selection (MRI, CT/CTA, MRA, US, PET) for conditions such as Takayasu arteritis, polyarteritis nodosa, aortopathies, and other PVD indications should follow the condition‑specific sections. Some modalities or exams may require prior authorization; submit adequate clinical information to establish medical necessity.

Modality selection may require specialty input and prior authorization for certain conditions (e.g., vasculitis, aortopathy).
Use less invasive/lower‑cost imaging first when appropriate (e.g., ultrasound before advanced imaging).

Prior Authorization

Procedure Codes and Potential Prior Authorization Relevance

Procedure codes associated with PVD imaging (MRA, CTA, CT, PET, US, NM) are enumerated in the guideline and may be subject to payer‑specific prior authorization. Providers should verify prior authorization requirements for listed CPTs with UnitedHealthcare and the member’s benefit plan prior to scheduling.

Verify PA requirements for CPTs such as 70546, 71555, 72198, 73225, 73725, 74185, 70496, 71275, 73206, 73706, 74174, 74175, 75635, 78811‑78816, 76700.
Check payer portals or prior authorization resources for code‑level PA rules.

Note

Prior Authorization Governed by Benefit Plan

Prior authorization requirements and ultimate coverage decisions are governed by the member’s federal, state (Ohio Administrative Code), and contractual benefit rules. In the event of conflict between this guideline and a plan’s benefit terms or legal/regulatory requirements, the federal/state/contractual terms govern.

Always check federal, state (OAC), and contractual benefit requirements before using this guideline.
UnitedHealthcare may modify policies; benefit rules take precedence.

Denial Risk

Denial Risk for Unproven, Limited, or Overutilized Services

Requests for services described as unproven, experimental, or subject to coverage/quantity limits may be denied when evaluated under Ohio Administrative Code or the applicable benefit. Overutilization patterns (unnecessary imaging, duplicate studies, double contrast CT without indication, inappropriate MRI/CT combinations) are denial triggers.

Denial risk for unproven/limited services will be evaluated under OAC 5160‑1‑01.
Avoid ordering duplicate or low‑value imaging; document clinical necessity to reduce denial risk.

Billing Rule

Single‑Unit Reporting for Image Guidance per Encounter

Only one unit of radiologic guidance codes (CT, MR, US guidance such as CPT 77013, 77022, 77012, 77021, 76942, 77002‑77003) should be reported per individual encounter (date of service). The unit of service is the individual encounter, not the number of lesions or aspirations.

Report only one unit of guidance code per encounter; billing multiple units for the same date is inappropriate.
Do not bill a diagnostic imaging code in routine conjunction with a guidance procedure code for the same imaging performed for guidance.

Denial Risk

Screening and Repeat Imaging — Denial Risk and Surveillance Exceptions

Advanced imaging for screening asymptomatic individuals and repeat imaging without evidence that results will change management is not supported except where specific guideline sections allow surveillance (e.g., annual surveillance where growth may cause organ dysfunction). Prior authorization/medical necessity reviews will assess impact on management.

Do not use advanced imaging for routine screening of asymptomatic peripheral vascular disease unless specifically supported.
Repeat imaging requires documentation that results will affect management; surveillance intervals are specified in condition sections (e.g., every 3 months during active treatment; annual surveillance where indicated).

Denial Risk

PET/CT Not Medically Necessary for Pediatric Vasculitis

PET/CT is identified as not medically necessary for management of pediatric vasculitis and may be denied for that indication. Limited data exist supporting PET accuracy versus MRA for initial Takayasu arteritis diagnosis, but PET has not demonstrated benefit for treatment response or improved outcomes.

PET/CT not medically necessary for pediatric vasculitis management at this time.
Consider MRA/CTA/US for diagnosis and surveillance per condition‑specific guidance.

Documentation Required

Documentation Supporting Clinical Utility and Required Clinical Documentation

Clinical documentation must demonstrate clinical utility: submit a recent detailed history, focused physical exam since onset or change in symptoms, relevant laboratory and prior imaging results, and how the requested imaging will affect management. For scheduled, guideline‑supported surveillance imaging, document rationale per condition section.

Required documentation: recent history, exam, labs, prior imaging, and indication linking imaging to management.
Pertinent clinical evaluation may be in person or via meaningful technological contact; condition sections may require additional documentation.

Documentation Required

Stereotactic CT Documentation and Appropriate CPT Use

For stereotactic CT localization (CPT 77011), document whether the scan is technical‑only (no radiologist interpretation) or a diagnostic CT requiring interpretation. Do not report both CPT 77011 and a diagnostic CT code (e.g., CPT 70486) for the same stereotactic localization session. 3D rendering codes (CPT 76376/76377) should not be reported with CPT 77011.

Report CPT 77011 for technical‑only stereotactic localization scans; if interpreted, use the appropriate diagnostic CT code instead.
Do not report CPT 77011 and CPT 70486 for the same session; do not report 3D rendering codes with CPT 77011.

Billing Rule

Outside Study Interpretation Documentation and Coding

For interpretation of outside imaging studies, use CPT 76140 for secondary interpretation. It is inappropriate to bill a diagnostic imaging code when the service provided is only interpretation of a previously performed exam.

Use CPT 76140 for secondary/interpretive review of externally performed exams.
Do not bill diagnostic imaging CPTs for interpretation‑only services.

Note

Indications: Modality‑Specific Guidance and Imaging Intervals

Indications sections specify which modalities may be appropriate for particular diagnoses (e.g., Takayasu arteritis, polyarteritis nodosa, familial aortopathies, vascular rings). Follow the listed modality options (MRA, CTA, CT, US, echocardiography, cardiac MRI) and the imaging intervals outlined in condition sections.

Examples: Takayasu arteritis and polyarteritis nodosa — MRA, CTA, or Doppler US of affected areas; image every 3 months during active treatment and annually for surveillance.
Familial aortopathies and vascular rings — echocardiogram and MRA/CTA of specified body areas per the condition’s schedule.

Documentation Required

Imaging Interval Documentation and Documentation Expectations

Document imaging intervals and rationale when requesting follow‑up or surveillance imaging: imaging for treatment response during active systemic therapy may be approved every 3 months; annual surveillance may be approved for known lesions where growth could cause organ dysfunction. Include prior imaging, size/growth metrics, family history/genetic status (for aortopathies), and symptom changes to justify timing.

Treatment response imaging: every 3 months during active systemic therapy when supported by condition section.
Surveillance imaging: annually when growth may cause organ dysfunction or per condition‑specific schedules.
Provide prior imaging comparisons and objective measurements to support interval requests.

Note

Check Governing Federal, State (OAC), and Contractual Benefit Rules

Before using this guideline, check federal, state (OAC), and contractual benefit requirements as they may differ from the guideline. Coverage and prior authorization determinations must reference and defer to applicable legal and contractual rules when conflicts arise.

State and federal law or the member’s contract govern in case of conflict with this guideline.
Confirm plan‑specific prior authorization and coverage rules prior to ordering.

Documentation needSubmit clinical information demonstrating why repeat imaging is necessary and how it will impact treatment decisions

Denial riskRequests lacking documentation of clinical change or management impact may be denied as unnecessary

Any advanced imaging — Repeat only with evidence of progression, new disease, or documentation of impact on management (inv-153)

Advanced imaging repeat ruleRepeat advanced imaging is supported only with evidence of progression, new disease, or documentation that the repeat will change management

ApplicabilityApplies to CT, MRI, MRA, CTA, PET and other advanced modalities unless condition-specific guidelines state otherwise

Prior authorizationPrior authorization may be required to justify repeat advanced imaging based on documentation provided

Imaging for treatment response every 3 months (inv-154)

Treatment response intervalImaging for assessment of treatment response may be approved every 3 months during active systemic therapy

ScopeApplies to any indicated modality used to evaluate response (e.g., MRI, MRA, CTA, ultrasound) as described in condition sections

RequirementApproval typically requires documentation that imaging will influence continued management or therapy decisions

Annual surveillance (inv-155)

Annual surveillance allowanceAnnual surveillance imaging may be approved for areas where growth could cause significant organ dysfunction or functional impairment

Use case examplesAnnual surveillance commonly applied after active treatment or for stable lesions at risk for progression

DocumentationSurveillance imaging should be justified by initial findings and clinical context

MRA | CTA | Ultrasound with Doppler — Every 3 months during active systemic therapy; annually for surveillance (inv-156)

Interval for MRA/CTA/Ultrasound with Doppler during therapyEvery 3 months during active systemic therapy; annually for surveillance when stable

Applicable conditionsUsed for monitoring Takayasu arteritis, polyarteritis nodosa, and other vascular conditions per condition-specific guidance

Documentation/prior authorizationApproval for q3 month imaging during active therapy may require supporting documentation and adherence to plan rules

Echocardiogram +/- CTA or MRA — Age-based surveillance frequency and growth-based follow-up (inv-157)

Echocardiogram ± CTA/MRA surveillance principleAge-based surveillance frequency with growth-based follow-up for thoracic aortopathy: intervals set by age and size/growth criteria

Age examplesAge 0–2: q3 months; Age 3–12: q6 months; Age ≥13: annual if stable or q6 months if growth criteria met

Growth triggersIf diameter z-score increased or growth ≥0.5 cm/year (or diameter ≥4.5 cm), imaging frequency increases and earlier repeat studies are indicated

Relationship to advanced imagingAdvanced imaging used when standard studies are inconclusive or insufficient

PET/CT definition and unbundling guidance (inv-114)

PET/CT definitionCombined metabolic and anatomic imaging using PET with concurrently acquired CT; typically reported as a single PET/CT study

Unbundling guidanceUnbundling PET/CT into separate PET and diagnostic CT CPT codes is not supported

Common indicationsOncologic staging/restaging, cardiac metabolic evaluation, brain metabolic assessment when indicated

Concurrent supervision definition for 3D rendering (inv-115)

Concurrent supervision definition (3D rendering)Active physician participation and monitoring of the reconstruction process including anatomic region design, selection of tissue types/structures to display, determination of archived images/cine loops, and monitoring/adjustment of the 3D work product

Documentation recommendationACR recommends documenting physician supervision/participation for CPT 76376/76377

Code distinctionCPT 76376: does not require independent workstation; CPT 76377: requires independent workstation post-processing

Unit of service for guidance codes — Only one unit per encounter (inv-116)

Guidance code unit of serviceThe unit of service for guidance codes is the individual encounter (date of service); only one unit should be reported per encounter

ExamplesApplies to CPT 77012, 77021, 77013, 77022, 76942, 77002–77003 and similar guidance codes

ImplicationDo not report multiple units for multiple lesions during same encounter

SPECT/CT definition (inv-117)

SPECT/CT definitionHybrid imaging combining Single Photon Emission Computed Tomography (SPECT) with CT for localization, attenuation correction, and combined functional/anatomic information

Reporting optionsHybrid Nuclear/CT scans reported as CPT 78830/78831/78832 depending on schedule and areas imaged

Common usesExamples include parathyroid SPECT/CT and other functional imaging requiring anatomic localization

CPT 76497 / 76498 unlisted procedure codes definition (inv-118)

CPT 76497 / 76498 definitionUnlisted CT (76497) and unlisted MR (76498) procedure codes used when an appropriate anatomic site-specific code is not available

Use guidanceReport a Category III code when available; use unlisted codes for specialized navigation/planning studies or unique acquisitions

ExamplesStealth/BrainLab navigation CT/MR, custom joint arthroplasty planning, or other special technical acquisitions

Pediatric population definition — <=18 years (inv-119)

Pediatric population definitionIndividuals 18 years old and younger

Guideline applicationThese individuals should be imaged according to Pediatric PVD imaging guidelines when discussed in pediatric sections

Adult pathwayIndividuals >18 years follow general PVD imaging guidelines unless a pediatric section directs otherwise

Gadolinium-based contrast agents — Safety note and limited use (inv-120)

Gadolinium-based contrast agents (GBCAs) safety noteGBCAs have potential for tissue deposition; use should be limited to circumstances where additional information is necessary

Renal and pregnancy considerationsAvoid gadolinium in pregnancy and exercise caution in renal impairment (GFR <30 mL/min) due to NSF risk

Regulatory contextFDA notes gadolinium retention but currently no proven harm; limit repetitive dosing and justify necessity

Lymphatic malformations definition (inv-121)

Lymphatic malformations definitionComposed of dilated lymphatic channels filled with proteinaceous fluid that do not connect to normal lymphatic channels; typically soft, non-pulsatile masses

Clinical relevanceMRI preferred for deep or large lesions and for pre-/post-operative planning; ultrasound initial for superficial lesions

Imaging implicationCT of limited value except for acute compression when MRI contraindicated

Venous malformations definition (inv-122)

Venous malformations definitionSlow-flow lesions with dilated venous spaces, normal arterial component, soft compressible non-pulsatile lesions

Clinical associationsMay be isolated or part of syndromes (e.g., Klippel-Trénaunay, CLOVES) and can vary from small to infiltrating lesions

Imaging preferenceMRI without and with contrast preferred for extent and preoperative assessment; ultrasound with Doppler for initial evaluation

Arteriovenous malformations and fistulas definition (inv-123)

Arteriovenous malformations/fistulas definitionNetwork of abnormal vascular channels between feeding arteries and draining veins (AVM) or a single communication (fistula); lack a normal capillary bed

Clinical featuresOften pulsatile with possible thrill or bruit and may have aggressive clinical courses; can be congenital or present near adolescence

Imaging implicationMRI/MRA preferred; CT/CTA reserved when MRI inconclusive or contraindicated

Takayasu arteritis definition (inv-124)

Takayasu arteritis definitionPredominant large vessel vasculitis occurring in children; imaging used for diagnosis and monitoring

ModalitiesMRA, CTA, or ultrasound with Doppler may be indicated for affected body areas

Surveillance intervalsImaging q3 months during active systemic therapy; annually for surveillance

HSP (IgA vasculitis) definition (inv-125)

HSP (IgA vasculitis) definitionCommon small-vessel pediatric vasculitis; ultrasound abdomen commonly used to evaluate gastrointestinal complications

Imaging useDoppler ultrasound indicated for GI complications such as bowel wall edema, hemorrhage, or intussusception

Indication contextsUsed for new/worsening symptoms or to assess response when treatment changes are considered

Infantile Hemangioma (IH) definition and prevalence (inv-126)

Infantile Hemangioma (IH) definition & prevalenceCommon benign vascular tumor of infancy occurring in ~5% of infants; rapid early growth then gradual involution

Natural historyRapid growth typically 1–3 months; growth usually completed by 5 months; 90% involution by age 4 years

Risk stratificationRisk determined by number, size, location, and associated syndromes (PHACE(S), LUMBAR)

Aortopathy definition (genetic/syndromic predisposition) (inv-127)

Aortopathy definitionGenetic or syndromic conditions predisposing to thoracic aortic aneurysm/dissection (e.g., Marfan, Ehlers-Danlos, Loeys-Dietz, FBN1/TGFBR/ACTA2/MYH11 mutations)

Imaging roleEchocardiogram for screening/initial workup; MRA/CTA of head/neck/chest/abdomen/pelvis as indicated for Loeys-Dietz or abnormal findings

SurveillanceAge- and growth-based surveillance intervals apply after abnormal thoracic imaging

PHACE(S) syndrome definition (inv-128)

PHACE(S) definitionPosterior fossa malformations, Hemangiomas, Arterial anomalies, Coarctation of the aorta and Cardiac defects; S denotes sternal cleft/supraumbilical raphe

Clinical triggerFrequently suspected with large (≥5 cm) facial/scalp/neck infantile hemangioma; cerebrovascular anomalies common (>90%)

Imaging implicationsIf suspected, perform MRI/MRA of brain/orbits/head/neck/chest and screening echocardiogram

LUMBAR syndrome definition (inv-129)

LUMBAR definitionAssociation of Lower body infantile hemangiomas (>=5 cm) with Urogenital anomalies, Myelopathy, Bony deformities, Anorectal malformations, Renal anomalies and arterial anomalies

Clinical triggerSuspect when large (≥5 cm) lumbosacral/perineal or lower-extremity IH; prompts spinal ultrasound and abdominal/pelvic imaging

Imaging pathwayInfants <6 months: spinal US; MRI lumbar spine at 3–6 months or earlier if US inadequate; further MRI/MRA abdomen/pelvis/lower extremity as indicated