Pediatric Peripheral Nerve Disorders PND Imaging Guidelines

This policy covers diagnostic imaging for pediatric peripheral nerve disorders (PND) via the eviCore Clinical Decision Support Tool, primarily addressing MRI studies (e.g., neck, cervical, brachial plexus, chest and related CPT codes) for evaluation and follow-up. It applies to patients under 18 with conditions such as neurofibromatosis, brachial plexus injury and Gaucher disease, and requires documented active clinical signs (no screening of asymptomatic patients), a recent evaluation (generally within 60 days), physician review for atypical presentations, preference for MRI with and without contrast unless contraindicated, and minimization of anesthesia exposure in young or developmentally delayed children.

"This tool addresses common symptoms and symptom complexes."

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