CurrentColorado Rocky Mountain Health PlansPolicy CSRAD006OH.D

UN-CSRAD006OH.D - Adult Head Imaging Guidelinesopen_in_new

State-specific (Ohio) UnitedHealthcare Community Plan clinical guideline V1.0.2025 governing advanced imaging of the head in adults, including modality-specific general guidance (US, CT, MRI, PET), documentation requirements, investigational criteria, coding/billing notes, and related prefatory material. Applies only to Ohio and references Ohio Administrative Code for evaluation of unproven/limited services.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyUN-CSRAD006OH.D - Adult Head Imaging Guidelinesopen_in_new

Policy CodePolicy CSRAD006OH.D

Change TypeAnnual evidence-based updates

Effective DateNov 1, 2025

Next Review Date

Key ActionProviders must submit recent history, physical exam, labs, and prior imaging pertinent to the requested advanced imaging to establish medical necessity.

SourceLink

POLICY UPDATE CHANGES

Annual evidence-based updates noted in policy history with entries 02/01/2024, 07/01/2024, and 05/01/2025.

v1.0.2025Guideline Version

MultipleCovered Modalities

Quant MRIInvestigational

LimitedWBMRI stance

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MultipleClinical sections

Coverage Summary & Scope

This guideline applies only to Ohio members and is an evidence‑based, proprietary clinical guideline for advanced head imaging in adults (CT, MRI, PET, NM, US) — Adult Head Imaging Guidelines, V1.0.2025. Its purpose is to guide appropriate modality selection for adult head imaging, reduce overutilization, and support patient safety. The document is versioned v1.0.2025 and the guideline undergoes a formal review with an annual evidence‑based update cadence (policy history notes interim and annual updates).

Key thresholds & quick facts

Donanemab — age59–86 years

Donanemab — MMSEMMSE 20–28

Lecanemab — age50–90 years

Lecanemab — MMSE/qualifiersMMSE ≥22; CDR global 0.5 or 1.0; CDR‑SB ≥0.5 and/or Memory Box ≥0.5

Dementia documentation before structural imagingEstablished dementia with documentation of 6 months cognitive decline (or appropriate neuro/bedside testing) required

Baseline MRI timing for amyloid therapiesBaseline MRI within 3 months prior to medication initiation (MRI 70551 or 70553) — amyloid PET (78811/78814) optional per pathway

MRI monitoring on donanemabMRI prior to 2nd, 3rd, 4th and 7th infusions; MRI for ARIA or neurologic symptoms; amyloid PET at 6,12,18 months

MRI monitoring on lecanemabMRI prior to 5th, 7th and 14th infusions; MRI for ARIA or neurologic symptoms; amyloid PET at 18 months

ARIA / neurologic symptom acute imagingIf neurologic signs/symptoms during therapy: CT head noncontrast (70450) OR MRI brain (70551/70553); follow-up MRI as indicated

Orbital metallic fragment screeningPlain x‑ray orbit films (2 views) generally sufficient; CT orbital rarely necessary; x‑ray detects ≥0.12 mm, CT ≥0.07 mm

CTA/MRA coding noteIf arterial and venous CT/MR performed same session, report single CTA/MRA CPT code; MRA/CTA head/neck codes listed for vascular evaluation

Medical-Necessity Criteria (Guiding Rules)

Application / Investigational Determination

Application / Investigational Determination: This policy applies to Ohio only. Services may be designated Investigational/Experimental when evidence is insufficient or clinical utility is unproven. Requests for services labeled unproven, investigational, or subject to quantity limits will be reviewed under Ohio Administrative Code 5160-1-01.

All requests must include relevant clinical documentation as described in General Clinical Documentation Requirements. Services considered investigational or experimental include, but are not limited to, quantitative MR analysis (including most Category III and volumetric codes), certain novel PET-MRI applications, and imaging requested solely for research or data collection without direct clinical impact.

General Clinical Documentation Requirements

General Clinical Documentation Requirements: Prior to authorization or determination, submitters must provide a recent clinical evaluation and supporting documentation.

Pertinent clinical evaluation within a recent timeframe (history and focused physical exam since onset or change of symptoms).

Condition-Specific Indications (selected topics)

MOG Antibody-Associated Disease (MOGAD)

MOG Antibody-Associated Disease (MOGAD) — diagnostic and follow-up imaging:

MOG Antibody-Associated Disease (MOGAD): Initial evaluation for suspected or antibody-positive MOGAD (ordered by neurologist or in consultation): MRI Brain without and with contrast (70553) or without (70551); MRI Orbit (70543/70540) for optic neuritis; MRI Cervical/Thoracic/Lumbar spine (72141/72156, 72146/72157, 72148/72158) for transverse myelitis and conus involvement. For established MOGAD, imaging is supported for optic neuritis, brain involvement, transverse myelitis, and repeat imaging to re-establish baseline after treatment (3-6 months), when changing therapy, or per specialist request. CT not recommended for routine MOGAD evaluation.

Document neurologist ordering or consultation for antibody-driven pathways.

Pituitary/sellar imaging

Pituitary / sellar imaging prerequisites and modality preferences:

Pituitary/sellar imaging: Endocrine laboratory studies should be performed prior to advanced imaging except for stable non-functioning microadenomas/macroadenomas, cysts, or incidental lesions. Primary pituitary imaging: MRI Brain without and with contrast (70553) with pituitary protocol (fine cuts through sella) or MRI Orbit/Face/Neck (70543). CT Head (70450/70470) or CT Maxillofacial (70486) may be used adjunctively for bony detail in preoperative planning. MRI 70553 covers both brain and dedicated pituitary if performed concurrently; no additional CPT needed. Imaging intervals: microadenoma follow-up at 12 months then every 1–2 years for 3 years if stable; macroadenoma every 6 months first year then annually for 3 years if stable. Post-op MRI generally at 3 months and per specialist discretion.

Not Medically Necessary / Experimental

Investigational / Not Medically Necessary Examples

Investigational / not medically necessary examples (quantitative MR, amyloid PET exclusions, PET for autism):

Investigational / Not Medically Necessary Examples: Quantitative mpMRI-category III codes (0648T/0649T/0697T/0698T) and volumetric brain MR codes (0865T/0866T) are investigational and not medically necessary for routine clinical practice. Amyloid PET (78811/78814) is NOT considered medically necessary for stroke evaluation. PET imaging is considered not medically necessary in evaluation of autism spectrum disorders. These investigational or not medically necessary stances apply unless otherwise specified (e.g., amyloid PET allowed when part of amyloid-reducing medication treatment pathway).

Preserve 'any/all' logic for separate investigational trees; cite prefatory investigational criteria.

Whole‑body MRI (WBMRI) is generally not supported because of lack of standardization and outcome evidence; when used it must be reported with CPT 76498 and is limited to select cancer predisposition syndromes or specific autoimmune indications. PET‑MRI is likewise generally restricted but may be authorized only if the individual meets PET‑CT criteria AND PET‑CT is unavailable at the treating institution AND the provider requests PET‑MRI in lieu of PET‑CT; when approved it is reported as CPT 78813 + CPT 76498.

Coding — CPT Code Groups

Coder note: When both arterial and venous CT or MR studies of the head are performed in the same session, report only a single CPT vascular study code for that session (do not report separate CPT codes for arterial and venous phases of the same modality/session).

Provider Actions & Billing Rules

Documentation Required

Submit Pertinent Clinical Evaluation

Provide recent, pertinent clinical information to support medical necessity: submit a history since onset or change in symptoms, focused neurological exam or full physical, relevant labs, and prior imaging reports. Telehealth or other meaningful contact since symptom onset is acceptable. For spine/MSK requests include prior x‑rays from the episode of symptom change. Ohio members: documentation is required to establish necessity per the guideline.

History and symptom onset/change
Focused neurologic exam (or full physical)
Relevant laboratory studies
Prior imaging reports (CT/MRI/ x‑rays as applicable)
Telehealth encounters acceptable
Applies to Ohio members — medical necessity evaluated per OAC 5160-1-01

Prior Authorization

Background & Evidence Highlights

Background: these guidelines are evidence‑based proprietary documents developed to support appropriate advanced imaging selection and patient safety. They are based on national society practice parameters, peer‑reviewed literature, and input from academic and community clinicians, and are reviewed and updated on a formal annual cycle.

Evidence	Value
FDG PET sensitivity for Alzheimer's disease
96% sensitivity; 100% specificity
FDG PET sensitivity for Frontotemporal dementia (FTD)
86% sensitivity; 97.6% specificity
DAT‑SPECT for probable Lewy Body Dementia (LBD)
Sensitivity 77.7%; Specificity 90.4%
CT head NPV for subarachnoid hemorrhage within 6 hours
Negative predictive value 99.9–100%
CTA sensitivity for aneurysm in SAH
>90% sensitivity
MRA sensitivity/specificity for aneurysm
~95% sensitivity; 89% specificity
MRA sensitivity for vertebral‑basilar insufficiency (contrast)
Up to 97% sensitivity with contrast enhancement
CTA sensitivity for vertebral artery dissection
100% (CTA) vs 77% (MRA) vs 71% (Doppler)

Definitions & Terms

Term	Definition
ARIA
Amyloid Related Imaging Abnormality; includes ARIA‑E (edema/effusion) and ARIA‑H (microhemorrhage/superficial siderosis).
MCI
Mild Cognitive Impairment due to Alzheimer's disease (clinical syndrome of cognitive decline not meeting dementia).
WBMRI reporting
Whole‑body MRI currently has no established CPT/HCPCS codes and should be reported using CPT 76498 if appropriate per criteria; generally not supported except select syndromes.
CIS
Clinically Isolated Syndrome: First episode of neurologic symptoms concerning for possible demyelinating disease lasting ≥24 hours without meeting MRI criteria for MS.
RIS
Radiologically Isolated Syndrome: Incidental brain MRI findings characteristic for demyelination in absence of clinical symptoms.
microadenoma/macroadenoma
Microadenoma = pituitary tumor <10 mm; Macroadenoma = pituitary tumor ≥10 mm (follow up intervals differ).
IAC
Internal Auditory Canals (IAC) — MRI sequences focused on these structures to detect small vestibular schwannomas; IAC views are additional sequences of brain MRI.
FIESTA
Fast Imaging Employing Steady State Acquisition sequences (3D‑FIESTA) — high spatial resolution steady‑state sequence useful for cranial nerve/CSF contrast and small IAC lesions.

Revision History

02/01/2024policy_update

Annual evidence-based updates noted in policy history with entries 02/01/2024, 07/01/2024, and 05/01/2025.

07/01/2024policy_update

Annual evidence-based updates noted in policy history with entries 02/01/2024, 07/01/2024, and 05/01/2025.

05/01/2025version_releaseLatest

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyUN-CSRAD006OH.D - Adult Head Imaging Guidelinesopen_in_new

Policy CodePolicy CSRAD006OH.D

Change TypeAnnual evidence-based updates

Effective DateNov 1, 2025

Next Review Date

Key ActionProviders must submit recent history, physical exam, labs, and prior imaging pertinent to the requested advanced imaging to establish medical necessity.

SourceLink

On This Page

Prior imaging and laboratory results relevant to the request.

Documentation of prior evaluation and conservative management when applicable (e.g., initial workup for headache, seizure, movement disorder).

For subspecialty imaging (e.g., epilepsy, pituitary, dementia workup for amyloid-directed therapies), include specialty consult notes and prior neuroimaging reports.

If the request is for follow-up surveillance, provide prior imaging dates and comparison findings.

When imaging is requested to support medication eligibility (e.g., amyloid-reducing agents), include the treating clinician’s treatment plan and rationale.

Imaging Modality Selection Principles

Imaging Modality Selection Principles: Choose the modality best suited to the clinical question; CT is preferred for acute hemorrhage/trauma/bony evaluation and MRI for most non-acute parenchymal, inflammatory, demyelinating, seizure, or neoplastic concerns.

Confirm modality selection is consistent with condition-specific sections before requesting advanced or contrast-enhanced studies.

Avoid advanced imaging when not indicated by condition-specific guidance (e.g., routine advanced imaging for uncomplicated primary headache).

When contrast is requested, document the specific diagnostic question that requires contrast and any contraindications to contrast.

For vascular concerns, select CTA or MRA per the CTA/MRA — Indications and Coding criteria below.

Investigational / Experimental Determination

Investigational / Experimental Determination: Certain procedures and codes are considered investigational (not medically necessary) when used outside recognized indications or for research.

Quantitative MR volumetric analyses and many Category III MR/CT codes (including, but not limited to, quantitative brain atrophy/volumetry not otherwise listed) are investigational.

Whole-body MRI, PET-MRI, and novel imaging sequences without established clinical utility are investigational unless covered by specific condition sections.

Magnetoencephalography (MEG)/Magnetic Source Imaging (MSI) and some advanced analytics are considered investigational except where explicitly supported in perioperative drug-resistant epilepsy pathways.

Clinical Situations Supporting 3D Rendering (CPT 76376/76377)

Clinical Situations Supporting 3D Rendering (CPT 76376/76377): 3D rendering may be supported when it adds distinct clinical value for preoperative planning or device sizing.

Use of 3D rendering must be directly tied to a specific clinical management decision (e.g., surgical approach, endovascular device planning).

Rendering should be performed only when source imaging (CT or MRI) of adequate quality is available and included in the request.

Billing: follow Radiologic Guidance Codes — Use Constraints and Guidance Imaging Codes and Billing Rules for unitization and when 76376/76377 are billable.

Guidance Imaging Codes and Billing Rules (Preface-4.2)

Guidance Imaging Codes and Billing Rules (Preface-4.2): Apply billing unit rules and constraints to image-guidance and related services.

Report guidance and planning codes only when performed and documented. Follow CPT guidance for separate reporting (e.g., when guidance is integral to the procedure versus separately reportable).

Do not bill guidance codes (including 77012/77021/77013/77022 patterns) in duplicate with included procedural imaging unless CPT allows separate reporting.

For unlisted CT/MR/nuclear services use appropriate unlisted codes (76497/76498/78999) when no specific CPT exists, and include documentation supporting medical necessity and technical details.

3D rendering and limited/follow-up CT (CPT 76380) have specific coding rules; ensure justification ties to management change.

When submitting codes that are time- or unit-based, include documentation to support the number of units billed.

77012/77021/77013/77022 Use

77012/77021/77013/77022 Use: These fluoroscopic and CT guidance/positioning codes have constrained use and should not be routinely billed for standard diagnostic head CT/MR imaging.

77012/77021/77013/77022 are only reportable when fluoroscopic or positioning guidance is separate from and not included in the primary diagnostic examination and when documentation details the distinct service provided.

Do not bill these codes when image guidance is an integral part of the diagnostic acquisition or when performed solely for routine positioning.

Unlisted CT/MR/Nuclear Codes

Unlisted CT/MR/Nuclear Codes: Use 76497/76498/78999 only when no specific CPT code accurately describes the service.

When using 76497/76498/78999 include detailed technical description, rationale, and how results will impact management.

Unlisted code use may trigger peer clinical review; provide comparators and prior imaging to support necessity.

CPT 76380 — Limited or Follow-up CT

CPT 76380 — Limited or Follow-up CT: CPT 76380 can be used for targeted or limited CTs when distinct from a full diagnostic study.

Use 76380 for limited follow-up CT examinations directed at a focused question (e.g., assessment of a known small lesion) when the limited nature is documented.

Do not use 76380 as a substitute for a complete diagnostic CT when a full study is clinically indicated.

Quantitative MR Analysis

Quantitative MR Analysis: Quantitative MR analyses and many Category III or volumetric codes are considered investigational unless specifically supported in condition-specific sections.

Most quantitative volumetric MR codes are not medically necessary for routine clinical care and are investigational outside of clearly defined surveillance programs.

If requested for clinical decision-making, provide evidence that the quantitative measure will change management and prior imaging for comparison.

SPECT/CT Imaging

SPECT/CT Imaging: SPECT/CT may be supported when SPECT has diagnostic utility and CT adds anatomic localization that alters management.

Provide documentation that the combined SPECT/CT will change patient management versus SPECT or CT alone.

Adhere to Guidance Imaging Codes and Billing Rules for combined modality billing.

Interpretation of Outside Studies (CPT 76140)

Interpretation of Outside Studies (CPT 76140): Interpretation of external imaging requires inclusion of the original study and report or documentation of clinical relevance.

CPT 76140 is reportable when interpreting prior external studies that materially affect interpretation of the current study and documentation demonstrates access to the outside images and reports.

If outside images are unavailable, document attempts to obtain them; lack of outside images may limit ability to bill 76140.

Whole-Body CT/MR and PET-MRI

Whole-Body CT/MR and PET-MRI: Whole-body imaging and PET-MRI have restricted indications; PET-MRI coding and use are limited.

Whole-body CT or MRI is supported only when specified by condition-specific guidelines (e.g., systemic staging when evidence supports whole-body assessment).

PET-MRI is considered investigational for many indications; document specific clinical rationale and evidence if requested.

Follow unlisted code guidance when PET-MRI lacks a precise CPT match.

General Head Imaging — Pre-evaluation and Modality Selection

General Head Imaging — Pre-evaluation and Modality Selection: Before advanced head imaging, ensure initial clinical evaluation and basic imaging/works-up as required by condition-specific sections.

Advanced imaging should not be ordered before appropriate clinical assessment by treating clinician or specialist and documentation of that assessment.

Basic studies (e.g., non-contrast head CT for acute trauma) should be obtained when indicated prior to advanced modalities per condition-specific guidance.

Specific Modality Indications — CT Head & MRI Brain

Specific Modality Indications — CT Head & MRI Brain: Use CT for acute hemorrhage, fractures, and urgent evaluation; MRI for parenchymal disease, demyelination, seizure focus, and most non-acute conditions. Contrast use guided by condition-specific sections.

CT head (non-contrast) is supported for acute head trauma, suspected acute hemorrhage, and bony injury.

MRI brain is preferred for subacute/chronic neurologic symptoms, seizure workup, demyelinating disease, tumor characterization, and suspected infection or inflammation.

When vascular assessment is needed, follow CTA/MRA — Indications and Coding for choice of CTA vs MRA and appropriate contrast/technique.

Orbital metallic foreign body screening: prior to MRI, obtain appropriate radiographs or CT to exclude metallic foreign bodies when there is history or suspicion of intraorbital or intraocular foreign body.

Microadenoma <10 mm; Macroadenoma >=10 mm

Document endocrine labs and specialist consultation as applicable.

Ohio-specific medical necessity evaluation for investigational/limited services

Ohio members only: services described as unproven or with coverage/quantity limits will be evaluated for medical necessity under Ohio Administrative Code 5160-1-01. This affects investigational or limited services and may require prior authorization and additional review.

Applies only to Ohio members
Unproven/limited services evaluated under OAC 5160-1-01
May require prior authorization

Billing Rule

Guidance procedure billing restriction

CT/MR/US guidance procedure codes include imaging necessary for needle/catheter guidance; do not routinely bill a diagnostic procedure code alongside guidance. Only one unit of imaging guidance (the encounter) should be reported per date of service.

Only one unit per encounter/date of service for guidance codes
Do not routinely bill diagnostic codes with guidance procedures
Guidance examples include CT/MR/US/fluoroscopy codes

Billing Rule

3D Rendering Supervision & Billing

3D rendering (CPT 76376/76377) requires active physician supervision/participation during post-processing; document supervision. Do not report 3D rendering separately for CBCT/navigation when the procedure inherently produces a 3D dataset.

Codes: 76376, 76377
Concurrent physician supervision/participation required
Do not bill 3D rendering separately for CBCT or when using 77011 navigation
Use 76377 when independent workstation post-processing required

Denial Risk

Quantitative MRI / Volumetric Analysis — Not Covered

Quantitative/volumetric MR analyses of the brain (Category III/other quantitative MRI codes) are investigational or not medically necessary for routine evaluation of MS, NMOSD, MOGAD and dementia; volumetric brain analysis (e.g., 0865T/0866T) lacks validated clinical utility and is limited to research.

Affected codes: 0648T, 0649T, 0697T, 0698T, 0865T, 0866T
Considered investigational/research — not medically necessary for routine MS/NMOSD/MOGAD or dementia

Documentation Required

Amyloid-Reduction Therapy Imaging Pathway

For amyloid-reducing therapies (donanemab, lecanemab) follow specified imaging and clinical prerequisites: document diagnosis of MCI or early AD and required cognitive testing; obtain baseline brain MRI within 3 months before initiation (MRI without contrast CPT 70551 or MRI without and with contrast CPT 70553) or amyloid PET (CPT 78811/78814) per pathway. During therapy obtain scheduled MRIs at specified infusions for ARIA monitoring and symptom-driven imaging; amyloid PET permitted at defined on‑treatment timepoints (6/12/18 months or 18 months post-treatment) per agent.

Baseline MRI Brain within 3 months (CPT 70551 or 70553) and/or Amyloid PET (CPT 78811 or 78814)
Donanemab: baseline MRI; MRIs prior to 2nd, 3rd, 4th and 7th infusions; amyloid PET at 6/12/18 months
Lecanemab: baseline MRI; MRIs prior to 5th, 7th and 14th infusions; amyloid PET at 18 months post-treatment
Document age and cognitive score eligibility and exclude hemorrhage/ARIA history
Obtain MRI for any neurologic signs/symptoms or radiographic ARIA — CT head acceptable acutely with MRI follow-up if needed

Billing Rule

CT/MR Venous+Arterial Same Session Coding

When arterial and venous CT or MR studies are performed in the same session report only one CPT code representing both arterial and venous components; do not report separate arterial and venous codes for the same encounter.

Use a single CPT when arterial and venous CT/MR both performed in same session
Document clinical rationale if both components are needed

Documentation Required

Ordering Provider / Specialist Requirements

Policy requires ordering or consultation by appropriate specialists for high‑impact imaging or specialist-driven pathways: examples include neurologist‑prescribed amyloid‑reducing medications with required baseline and on‑treatment imaging; PET‑MRI/PET studies require specialist criteria or institutional limitations; perioperative or neuronavigation imaging and epilepsy/pituitary/perioperative studies commonly requested by neurosurgery, ENT, neuro‑ophthalmology, or endocrinology—document specialist involvement.

Amyloid therapy imaging must be prescribed/coordinated by neurologist
PET‑MRI requires specialist criteria or PET‑CT unavailability (CPT 78813 + 76498)
Neuronavigation/unlisted CT/MR (76497/76498) for neurosurgical planning when requested by neurosurgeon
Epilepsy pre‑surgical imaging and PET/MRI typically ordered by neurosurgeon/neurologist
Pituitary and complex orbital/petroseal planning often require endocrinologist/neurosurgeon/ENT input

Annual evidence-based updates noted in policy history with entries 02/01/2024, 07/01/2024, and 05/01/2025.