Pediatric Peripheral Nerve Disorders (PND) Imaging Guidelines

This policy covers pediatric advanced imaging—primarily MRI (multiple CPT codes for neck, spine, brachial plexus, chest, abdomen, pelvis, extremities) and select PET—ordered for common pediatric symptoms and symptom complexes as addressed by the Clinical Decision Support diagnostic tool. It applies to patients <18 with typical presentations that match the tool; imaging for atypical presentations or without a recent (≤60 days) documented history, physical including a thorough neurologic exam and appropriate labs requires physician review/consultation, and screening asymptomatic patients or routine repeat imaging are not supported.

"Documentation of evidence for progression of disease."

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