Ohio prior authorization / medical necessity evaluation

This policy applies to Ohio — services listed as unproven or subject to coverage/quantity limits will be evaluated for medical necessity under Ohio Administrative Code 5160-1-01; verify state-specific prior authorization processes when submitting requests.

• Requests for unproven services or those with coverage/quantity limits will be reviewed per OAC 5160-1-01.

CPT listing does not imply prior authorization

Inclusion of a CPT code in these guidelines does not by itself mean that prior authorization is required; providers must follow the payer’s prior authorization process to determine PA requirements for any given code.

Prior authorization for 3D rendering (76376/76377)

Prior authorization may be required specifically for 3D rendering CPT 76376 or 76377 even when the underlying imaging modality is not managed; obtain PA for the 3D code per payer rules.

• Document physician supervision/participation for 3D post-processing as recommended by ACR.

SPECT/CT coding and HCPCS handling

Hybrid SPECT/CT studies should be coded with CPT 78830–78832 as appropriate; HCPCS-coded requests (e.g., S‑codes) must be redirected to equivalent CPT codes and handled per PA rules.

• Report SPECT/CT using CPT 78830, 78831, or 78832 depending on area and days.
• Non-specific HCPCS (e.g., S8042) should be mapped to specific CPT codes for authorization.

PET/MRI and WBMRI reporting and authorization

PET/MRI is only authorized when condition-specific PET/MRI criteria are met or when the individual meets PET/CT criteria and PET/CT is unavailable; report PET/MRI as CPT 78813 + 76498 and treat WBMRI as CPT 76498 when requesting authorization.

• PET/MRI requires documented justification that PET/CT criteria are met and PET/CT is unavailable, or meet condition-specific PET/MRI criteria.
• Report PET/MRI as CPT 78813 + 76498; report WBMRI using CPT 76498 only.

Coordinate contrast use and anesthesia for pediatric MRI

When MRI with and without contrast is requested for pediatric patients, coordinate contrast use with anesthesia to avoid repeat sedation; document rationale for contrast and contraindications to gadolinium when contrast-enhanced MRI is not performed.

• If IV access and anesthesia will be used, consider obtaining both non-contrast and contrast sequences in the same session to avoid repeat sedation.
• Document any contraindication to gadolinium if contrast is omitted.

CT/CTA for syndromic PE evaluation (71260 / 71275)

CT Chest with PE protocol (CPT 71260) or CTA Chest (CPT 71275) is medically necessary to evaluate suspected pulmonary embolism in individuals with Klippel‑Trenaunay or CLOVES syndromes; include clinical justification when requesting authorization.

• Use CPT 71260 or 71275 for suspected PE in KT or CLOVES syndrome.
• Provide clinical signs/symptoms and rationale for modality choice.

Justify CT/CTA when MRI/MRA are unsuitable

Requests for CT/CTA must be justified when MRI/MRA are available — CT/CTA is medically necessary only when MRI/MRA are inconclusive or contraindicated; documentation should explain why MRI/MRA cannot be used.

• Document why MRI/MRA is inconclusive or contraindicated in the clinical record submitted with the request.
• CT/CTA may be used for lymphatic malformations, vascular abnormalities, pre-op planning, or post-op complications when indicated.

Prior authorization recommended for serial vascular surveillance

Serial MRA/CTA surveillance studies per the age- and interval-based schedules (e.g., familial aortopathy or other surveillance protocols) imply prior authorization — include the surveillance schedule and clinical justification when requesting serial studies.

• Document the surveillance interval and prior imaging results (age-based intervals described in guidance).
• Include justification that repeat imaging will affect management.

Prior authorization may be required for advanced imaging

Certain advanced cross-sectional and vascular imaging studies (CT/CTA, MRA, cardiac MRI, abdominal CT/MRA, ultrasound) may require prior authorization per payer rules; verify PA requirements for the specific CPT codes being requested.

• Check payer PA policies for codes such as 71260, 71275, 71555, 75557, 74175, 74160, 76700, 93975/93976/93978/93979 as applicable.

Syndrome-driven imaging requires documented clinical triggers (PHACE/LUMBAR)

Order advanced imaging for PHACE(S) or LUMBAR indications only when syndrome-specific clinical triggers are met and document the required findings; prior authorization is expected for syndrome-driven imaging.

• Provide documentation that clinical triggers for PHACE(S) or LUMBAR are present (e.g., hemangioma size/location, associated anomalies).
• Include images and prior studies when submitting PA for syndrome-driven imaging.

Expect InterQual and plan-level utilization review

UnitedHealthcare may use InterQual and plan-level medical policies for medical necessity determinations; expect utilization review processes at the plan level in addition to guideline criteria.

Perform clinical evaluation before ordering advanced imaging

Advanced imaging should follow a clinical evaluation by the treating physician or consultant and not be ordered prior to that evaluation unless guideline-supported scheduled imaging is indicated.

• Include documentation of history, physical exam, labs, and any prior imaging when submitting requests for advanced imaging.

Single-unit reporting for radiologic guidance codes

Only one unit of radiologic guidance codes (e.g., 77012, 77021, 77013, 77022, 76942, 77002-77003) should be reported per individual encounter/date of service; bill the unit as the encounter, not per lesion or biopsy.

• Ensure guidance codes are billed once per date of service regardless of number of lesions or repositionings.
• Use appropriate percutaneous procedure codes with guidance codes; do not bill guidance with open/excisional procedures.

Prefer MRI over CT; document modality choice

Prefer MRI over CT when feasible; CT should not be used solely to avoid sedation unless specifically recommended in a guideline section — document contraindications to MRI when CT is chosen.

• If MRI is contraindicated or inconclusive, document the rationale for selecting CT/CTA.
• When avoiding sedation is the reason for CT selection, reference guideline language if applicable.

Imaging modality escalation: US → MRI → CT/CTA/MRA

Use ultrasound as the initial exam for superficial lesions and MRI for extent/preoperative planning; escalate to CT/CTA or MRA only when MRI is contraindicated, inconclusive, or will not answer the clinical question.

• Include prior ultrasound findings and explain why cross-sectional imaging is needed.
• For surveillance, provide evidence that repeat imaging will affect management.

Obtain 3‑month interval imaging during active systemic therapy

For active systemic treatment of large-vessel vasculitis (e.g., Takayasu arteritis, polyarteritis nodosa), obtain imaging (MRA, CTA, or US) every 3 months to monitor response; document treatment status when requesting these interval studies.

• Attach evidence of active systemic therapy and prior imaging to support 3‑month interval imaging.
• Specify the modality requested and clinical goal (monitor response vs. complication detection).

Size-based surveillance escalation for visceral/splenic aneurysms

Surveillance intervals for aneurysms escalate with size (example for splenic artery aneurysm): <20 mm imaging every 3 years; 20–29 mm annually; ≥30 mm — refer for treatment; include aneurysm size in the request to justify surveillance interval.

• Provide current aneurysm measurements and prior imaging comparisons when requesting surveillance studies.
• Document planned management if size approaches treatment threshold (≥2 cm for visceral aneurysms generally).

Recommend hemangioma specialist consultation when imaging guides care

Consultation with a hemangioma specialist is recommended when imaging is used to guide treatment or follow-up of infantile hemangiomas; include specialist recommendations or consultation notes when available.

• Include hemangioma specialist recommendations to support advanced imaging requests.
• Specialist input is particularly useful for PHACE/LUMBAR or complex hepatic involvement.

Required clinical documentation to support imaging requests

Submit pertinent clinical documentation with imaging requests: history, physical exam, relevant labs, prior imaging, lesion size/location, family history/genetic testing status for aortopathy screening, and any contraindications to contrast or MRI.

• Clinical evaluation since symptom onset or change must be included unless guideline-supported scheduled imaging.
• For familial aortopathies include family history, genetic testing status, age, prior imaging results, and symptoms.

Include prior imaging and evaluation in submissions

Include prior imaging from the relevant episode (e.g., spine/musculoskeletal x‑rays) and explicitly state how the requested advanced imaging will affect management; review and reference prior studies in the request.

• Attach prior x‑rays or diagnostic tests from the time symptoms started or changed when applicable.
• Explain how the new imaging will change treatment or surgical planning.

Documentation requirements for unlisted and limited CT/MR codes

When billing unlisted CT/MR codes (76497/76498) provide documentation that no anatomic-specific CPT code exists and describe the specialized acquisition or planning purpose; limited CT (76380) is not appropriate for treatment planning or to cover 'extra slices'.

• Describe why a site‑specific code is unavailable and include clinical rationale (e.g., neurosurgical navigation, custom arthroplasty planning).
• Report a Category III code if one exists that describes the procedure instead of an unlisted code.

Outside study interpretation: document and use CPT 76140

For secondary interpretation of outside imaging studies, bill CPT 76140 and document that the images were completed elsewhere; do not use diagnostic imaging codes to report interpretation of outside exams.

• Document the origin of the outside images and reason for secondary interpretation.
• Do not bill diagnostic imaging codes for interpretation-only of external studies.

Clinical justification required — research/data-collection imaging denial risk

Provide clinical justification that advanced imaging is intended to directly affect patient management when ordering MRI/MRA/CT/CTA/PET; imaging performed solely for research or data collection not used in direct care risks denial.

• If imaging is part of a clinical trial, document how results will be used in direct clinical management.
• Avoid ordering studies solely for data collection without documented clinical intent.

Denial risk for overutilization and duplicate imaging

Requests representing duplicate or unnecessary imaging, double contrast CTs without supported indication, or routine combined MRI+MRA for surveillance when not clinically indicated risk denial for overutilization; include prior study comparisons and justification for repeat studies.

• Attach prior imaging and document evidence of progression or that repeat imaging will change management.
• Do not request routine MRI+MRA together for surveillance unless preoperative planning or other documented need.

Whole‑body CT screening and WBMRI exclusion

Whole‑body CT (LifeScan) for screening asymptomatic individuals is not a covered benefit and will be denied; whole‑body MRI is generally not medically necessary except for select cancer predisposition syndromes — authorization must cite the specific exception.

• Do not submit whole‑body CT screening requests for asymptomatic individuals.
• If requesting WBMRI, document the specific cancer predisposition syndrome or other guideline-supported indication.

WBMRI and PET/MRI coding and denial triggers

WBMRI should be reported only with CPT 76498; PET/MRI requests may be denied when criteria are not met — provide condition‑specific justification or PET/CT unavailability and document the necessity of PET/MRI.

• Report WBMRI as CPT 76498 only; other reporting methods (multiple body‑part MRI codes) are inappropriate.
• For PET/MRI include documentation that PET/CT criteria are met and PET/CT is unavailable, or that condition-specific PET/MRI criteria apply.

Liver ultrasound for multiple (≥5) hemangiomas — document indication

If ordering liver ultrasound (CPT 76700) for infants with multiple (≥5) cutaneous hemangiomas, document the number of lesions and rationale; absence of this indication for hepatic evaluation may lead to denial.

• Specify number of cutaneous hemangiomas (≥5) and clinical signs prompting hepatic evaluation.
• Include repeat Doppler ultrasound plans if monitoring hepatic hemangiomas.

Check governing federal/state/contractual benefit requirements

When coverage or guideline conflicts with federal, state (OAC), or contractual benefit plan requirements, those federal/state/contractual rules govern — check applicable benefit terms before relying on this policy as the sole authority.