Pediatric Peripheral Vascular Disease (PVD) Imaging Guidelines

This policy covers pediatric peripheral vascular disorder (PVD) imaging modalities including MRA, CTA, ultrasound duplex and physiologic studies, and selected nuclear/PET exams for indications such as vascular anomalies, vasculitis, and disorders of the aorta and visceral arteries. It applies to pediatric patients (with patients ≥18 managed under adult PVD guidelines unless a pediatric section states otherwise) and specifically addresses imaging for vascular anomalies, vasculitis, and aortic/visceral arterial disorders. Major requirements/limitations include documented active clinical signs or symptoms and a recent (within 60 days) face-to-face evaluation prior to advanced imaging, avoidance of routine asymptomatic screening and unnecessary short-interval repeat studies, MRI contrast contraindications or implanted devices may preclude imaging, and certain PET codes are noted as not used or rarely used in pediatrics.

"Documentation of active clinical signs or symptoms of disease involving the peripheral vascular system to support approval of advanced imaging."