CurrentColorado Rocky Mountain Health PlansPolicy N/A

Radiology prior authorization crosswalk table (commercial & Individual Exchange)

Crosswalk table mapping prior-authorization CPT codes to submitted/claim CPT codes for outpatient radiology services for commercial and Individual Exchange (UnitedHealthcare Individual & Family ACA Marketplace) plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyRadiology prior authorization crosswalk table (commercial & Individual Exchange)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionUse the crosswalk table to determine which CPT code a prior authorization was given for versus which CPT code was submitted on the claim.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+document chunks in this partial extract (0-19)

20+ CPT mappings shownnumber of CPT code crosswalk entries in this segment

0501T-0504TFFR-CT codes mapped and present

FFR-CT & PETnotable procedure groups present

legal footerpayer and trademark notices present

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.

Crosswalk Coverage Criteria

inv-01: Crosswalk mapping (partial)

Mapping of the CPT code for which prior authorization was issued to the CPT code(s) that may be submitted on the claim (examples from head/brain series).

ALL of the following

Claim submitted with 70460 (CT HEAD/BRN C+ MATRL).
Claim submitted with 70470 (CT HEAD/BRN C-/C+).
Claim submitted with 76380 (related CT post-processing).
Claim submitted with CT LMTD/LOCLZD F-UP STD (limited/localized follow-up standard).

ALL of the following

Claim submitted with 70450 (CT HEAD/BRN C-MATRL).
Claim submitted with 70470 (CT HEAD/BRN C-/C+).
Claim submitted with 76380 (related CT post-processing).
Claim submitted with CT LMTD/LOCLZD F-UP STD (limited/localized follow-up standard).

ALL of the following

Claim submitted with 70450 (CT HEAD/BRN C-MATRL).
Claim submitted with 70460 (CT HEAD/BRN C+ MATRL).

inv-02: Crosswalk mappings (examples)

Representative prior-authorization CPTs and the claim CPTs they map to, including modality and contrast/material variants (spine, upper and lower extremity examples).

ALL of the following

Claim submitted with 72131 or 72133 or 76380.
Claim submitted with CT LMBR SPI C-MATRL (CT LMBR SPI C-/C+).

ALL of the following

Claim submitted with 72131 or 72132 or 76380 or CT LMTD/LOCLZD F-UP STD.

ALL of the following

Claim submitted with 73201 or 73202 or 76380 or CT LMTD/LOCLZD F-UP STD.

inv-03: Sample crosswalk criteria nodes

Sample mapping nodes showing modality crosswalks, joint/extremity MRI equivalence, cardiac MRI claim variants, and FFR-CT component mappings.

ALL of the following

Claim submitted with 73701 = 73720 or 73721 or 73723 (MRI joint/lower extremity variants).
Claim submitted with MRI ANY JT LXTR C+ MATRL or MRI ANY JT LXTR C-MATRL or MRI ANY JT LXTR C-/C+.

ALL of the following

Claim submitted with 75557 (cardiac MRI morphology & function w/o contrast).
Claim submitted with 75559 or 75561 as alternate cardiac MRI submission codes depending on sequence/contrast/stress.

ALL of the following

inv-04: Observed CPT mapping entries

Observed claim-submitted codes mapped back to the prior-authorization codes in this segment (claim => prior-auth).

ALL of the following

Prior authorization given with 78816 (PET imaging for CT attenuation whole body).

ALL of the following

Prior authorization given with 71271 (CT thorax C-MATRL low dose for lung cancer screening).

ALL of the following

Prior authorization given with 0501T (FFR-CT GLOBAL).
Prior authorization given with 0503T/0504T per component cross-mapping.

CPT / HCPCS Code Tables

Sample CPT crosswalk groupCPT

70450	CT HEAD/BRN C-MATRL (prior auth) - mapped to claim codes including 70460, 70470, 76380, CT LMTD/LOCLZD F-UP STD
71250	CT THORAX C-MATRL (prior auth) - mapped to claim codes including 71260, 71270, 71271, 76380
70542	MRI ORBIT FACE & NECK mappings (examples shown)

Spine CT prior‑auth codesCPT

72132	CT LMBR SPI C+ MATRL (prior authorization given with this CPT code)
72133	CT LMBR SPI C-/C+ (prior authorization given with this CPT code)

Upper extremity CT/MRA codesCPT

73200	CT UXTR C-MATRL (prior authorization given with this CPT code)
73225	MRA upper extremity (represented in upper extremity crosswalks)

Lower extremity CT/MRA codesCPT

73700	CT LXTR C-MATRL (prior authorization given with this CPT code)
73725	MRA lower extremity (represented in lower extremity crosswalks)

Representative CPT crosswalk groupsCPT

73722	Prior authorization given with this CPT code; mappings to MRI joint lower extremity and related submitted codes
74150-74187	Abdomen/pelvis CT/MRI/MRA crosswalk entries (multiple abdominal/pelvis CT/MRI codes represented)
75559-75563	Cardiac MRI CPT crosswalk entries (examples shown for 75559, 75561, 75563)

PET imaging codesCPT

78811-78816

PET imaging series crosswalks (limited area, skull base–mid-thigh, whole body, and CT attenuation components)

FFR-CT codesCPT

0501T-0504T

FFR-CT global and component codes crosswalked among prior authorization and claim submission (0501T Global; 0502T Data Prep & Trans; 0503T Vendor Tech Component; 0504T Interpret & Report - MD)

Prior authorization target CPTs in this segmentCPTCovered

78816	PET IMAGING FOR CT ATTENUATION WHOLE BODY (prior authorization target)
0501T	FFR-CT (GLOBAL) (prior authorization target)
0502T	FFR-CT (DATA PREP & TRANS) (prior authorization target)
0503T	FFR-CT (VENDOR TECH COMPONENT) (prior authorization target)
0504T	FFR-CT (INTER & REPORT - MD) (prior authorization target)
71271	CT THORAX C-MATRL (Low Dose for Lung Cancer Screening) (prior authorization target)
78429	MYOCRD IMG PET METABOLIC, SINGLE STUDY W/CT (prior authorization target)

Provider Billing & Submission Guidance

Note

Crosswalk usage summary

Use this crosswalk to match the CPT code that was approved at prior authorization with the CPT(s) actually billed on the claim. The crosswalk lists the CPT submitted on the prior-authorization record ("Prior authorization given with this CPT code") and one or more CPTs that may be billed on the claim ("Claim is submitted with this CPT code"). When a prior-auth label and billed code differ, the crosswalk documents acceptable claim substitutions so claims are processed without additional review when medically appropriate.

Crosswalk entries are directional: the left side is the CPT associated with the prior authorization; the right side lists CPT(s) that may appear on the submitted claim.
When multiple claim CPTs are listed for a single prior-auth CPT, any one of the listed claim CPTs may be submitted and will be treated as covered if the original prior authorization criteria were met.
If you receive a denial for a billed CPT that is listed as an allowable claim match for the prior-auth CPT, include the prior-authorization reference number with your appeal and point to the crosswalk entry.
For differences in contrast/material variants (for example C-MATRL, C+ MATRL, C-/C+), confirm the imaging procedure’s contrast usage on the claim matches clinical documentation; the crosswalk indicates which billed variant corresponds to which prior-auth label.

Note

Example CPT crosswalk entries

Terminology & Table Keys

Mapping of prior-authorization CPT to claim CPT (definition)

DefinitionMapping of the CPT code for which prior authorization was issued to the CPT code(s) submitted on the claim

PurposeUsed to determine which CPT code was authorized versus which CPT code a provider should submit on the claim for outpatient radiology prior authorization

ScopeApplies to commercial and Individual Exchange (UnitedHealthcare Individual & Family ACA Marketplace) plans as shown in the crosswalk table

Descriptor: CT lumbar spine with contrast/material

Table descriptorCT LMBR SPI C+ MATRL — CT lumbar spine with contrast/material

Alternate notationCT LMBR SPI C-MATRL — CT lumbar spine without/with alternate material notation

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyRadiology prior authorization crosswalk table (commercial & Individual Exchange)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionUse the crosswalk table to determine which CPT code a prior authorization was given for versus which CPT code was submitted on the claim.

SourceLink

On This Page

ALL of the following

Claim submitted with 73200 or 73201 or 73202 or 76380.

ALL of the following

Claim submitted with 73701 or 73702 or 76380 or CT LMTD/LOCLZD F-UP STD.

0501T (FFR-CT GLOBAL) may be submitted as 0502T (DATA PREP & TRANS), 0503T (VENDOR TECH COMPONENT), or 0504T (INTER & REPORT - MD).
0502T/0503T/0504T submission variants likewise map across 0501T–0504T as shown in the table.

ALL of the following

Prior authorization given with 78429 (MYOCRD IMG PET METABOLIC, SINGLE STUDY W/CT).

Examples show how a single prior-authorization CPT maps to claim-submitted CPTs in common studies.

70450 (CT head/brain without contrast) — claim may be submitted as 70460 (CT head/brain with contrast), 70470 (CT head/brain without and with contrast), or 76380 (limited follow-up/targeted CT) depending on what was performed and documented.
72132–72133 (CT lumbar spine contrast variants) — prior auth for a CT lumbar spine with contrast (C+ MATRL) may correspond to billed CPTs 72131, 72132, 72133 or 76380 depending on how the study is reported.
73200–73202 (CT upper extremity variants) — prior authorization for CT upper extremity without contrast (C-MATRL) may be billed as 73201 or 73202 where appropriate; contrast and limited/localized follow-up variants are listed separately.
73700–73702 (CT lower extremity variants) — mappings show which billed codes correspond to prior-auth labels for CT lower extremity without/with contrast and localized follow-up.
74150 (CT abdomen variants) — prior authorization labels for CT abdomen without contrast map to billed CPTs 74160 or 74170 when the claim reflects a different reporting variant.

Billing Rule

Crosswalk mapping: prior authorization given vs claim submitted

This crosswalk identifies prior-auth CPT labels and the acceptable CPT(s) that may be submitted on the claim; the prior authorization remains valid for a billed CPT listed as an allowable match. Use the prior-authorization CPT label to locate the corresponding allowable billed CPT(s).

If the claim CPT is listed as a matching code for the prior-auth CPT, the claim should adjudicate using the prior authorization.
If the claim CPT is NOT listed as a match, the claim may be denied; submit a corrected claim or an appeal with clinical documentation and the original prior-authorization number.
Maintain documentation showing that the performed procedure matches the clinical indication approved at authorization, especially when billing a different contrast/material variant than the prior-auth label.
For bundled or composite services (e.g., global vs component reporting), consult the crosswalk entries that show which components (or global codes) were authorized vs which component codes may be submitted.

Note

FFR-CT crosswalk

FFR-CT entries show how the global and component CPTs relate between authorization and claim submission. The crosswalk supports interchangeable submission of global vs component codes when supported by documentation and vendor reporting.

0501T (FFR-CT global) — prior authorization for 0501T may result in claims submitted as 0502T (data prep & transfer), 0503T (vendor technical component), or 0504T (interpretation & report – MD) depending on how the service was billed.
0502T (data prep & transfer) — prior authorization for 0502T may correspond to billed 0501T (global), 0503T, or 0504T.
0503T (vendor tech component) — prior authorization for 0503T may correspond to billed 0501T, 0502T, or 0504T.
0504T (interpretation & report – MD) — prior authorization for 0504T may correspond to billed 0501T, 0502T, or 0503T.

Note

CPT crosswalk — PET and CT attenuation mappings

PET and CT-attenuation crosswalk entries indicate which PET imaging and CT attenuation CPTs were authorized versus which CPTs may appear on the claim.

78816 (Prior authorization label: PET imaging for CT attenuation — whole body) — claim may be submitted as 78813 (PET skull base to mid‑thigh), 78814 (PET whole body), 78815 (PET CT attenuation limited area), or 78812/78816 depending on reporting.
71271 (CT thorax, low dose for lung cancer screening) — may be billed as 71250 or other CT thorax CPTs shown in the crosswalk when the performed study differs in reporting variant.
For myocardial PET with CT attenuation, see the myocardial PET crosswalk entries for allowable billed CPT substitutions.

Documentation Required

CPT crosswalk — FFR-CT components (detailed)

Detailed FFR-CT component mappings are provided so claims billed using global or component codes will align with the prior authorization. Submit the combination of component codes that reflects how the service was rendered and documented.

When prior authorization was issued for the global FFR-CT code (0501T), claims billed as the global code or as component codes (0502T, 0503T, 0504T) are acceptable if documentation supports that reporting method.
If prior authorization was issued for a component (0502T, 0503T, or 0504T), claims billed as the global code (0501T) or other components listed as matches are treated per the crosswalk entries.
Ensure the medical record and vendor reporting show which component(s) were actually performed so the billed component set accurately reflects the service.

Note

CPT crosswalk — myocardial PET

Myocardial PET crosswalk entries map prior-authorization myocardial PET labels to the CPT(s) that may be billed on the claim. Use these mappings when the PET study includes CT attenuation or when stress/rest protocols are billed as alternative CPTs.

78429 (Myocardial PET metabolic, single study with CT) — may be billed as 78459 (single study metabolic PET) or other myocardial PET report variants listed.
78430 (Myocardial PET perfusion, single study rest/stress with CT) — claim may be submitted as 78491 or other CPTs depending on how the procedure is reported.
78431–78433 (Multiple study or dual radiotracer myocardial PET variants) — crosswalk lists the allowable billed CPTs such as 78430, 78491, 78492, and 78459 depending on study complexity and reporting.
When the prior authorization includes CT attenuation for PET studies, confirm the CT attenuation CPT billed corresponds to the body area and extent of attenuation imaging performed as listed in the PET/CT crosswalk.

Usage exampleAppears alongside CPT entries such as 72132 and 72133 to indicate contrast/material variant in crosswalk mappings

Descriptors: CT upper extremity without/with contrast or material

Without contrastCT UXTR C-MATRL — CT upper extremity (contrast/material variant)

With contrastCT UXTR C+ MATRL — CT upper extremity with contrast/material

Table roleThese shorthand descriptors are used in crosswalk rows for CPTs such as 73200–73202 to indicate submitted/authorized contrast variants

Prior authorization / Claim submission crosswalk — column descriptors

Column: Prior authorization given with this CPT codeIndicates the CPT code for which prior authorization was issued (the authorized procedure)

Column: Claim is submitted with this CPT codeLists the CPT code(s) a provider may submit on the claim that correspond to the authorized procedure

How to useMatch the 'prior authorization' CPT to the 'claim submitted' CPT(s) to confirm correct billing when filing claims under the outpatient radiology prior authorization program

CPT trademark notice

Trademark noticeCPT® is a registered trademark of the American Medical Association.

Legal footer contextAppears in the document footer alongside insurance and administrative service provider notices

Usage noteRetain the CPT® trademark symbol when reproducing CPT terminology as required by AMA trademark policy