Pediatric Peripheral Nerve Disorders (PND) Imaging Guidelines

This policy covers advanced imaging of the peripheral nervous system in pediatric patients — primarily MRI with and without contrast (and when appropriate CT, PET, or unlisted MRI procedures) — for conditions such as general pediatric peripheral nerve disorders, neurofibromatosis-related nerve lesions, brachial plexus disorders, and Gaucher disease. Imaging is limited to patients under 18 with documented active signs or symptoms and generally requires a recent (≤60 days) detailed history, neurologic exam, and appropriate labs (unless scheduled follow-up); screening asymptomatic patients is not covered and repeat imaging is permitted only for progression, new onset, or when it will affect management, while patients ≥18 are directed to adult guidelines.

"History and physical findings to support the decision to obtain testing such as imaging studies."

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