CurrentColorado Rocky Mountain Health PlansPolicy CSRAD005OH.E
Adult Chest Imaging Guidelines (Ohio)
Clinical guidelines governing advanced and standard chest imaging modalities for adults in Ohio, including indications, documentation expectations, and applicability to Ohio Medicaid determinations.
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyAdult Chest Imaging Guidelines (Ohio)
Policy CodePolicy CSRAD005OH.E
Change TypeMinor / No material change
Effective DateFeb 3, 2026
Next Review DateN/A
Key ActionObtain and document a pertinent clinical evaluation (history, exam, labs, and prior imaging such as a chest x‑ray) before ordering advanced chest imaging.
No material clinical or coverage changes in this revision.
V1.0.2026guideline version
Ohio-onlyapplicability
Chest x-rayfirst-line imaging
≥8 mmPET/CT threshold
15 mmmediastinal node threshold
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Adults
population focus
Coverage Criteria
General medical necessity requirements
Covered when ALL of the following are met:
General requirements: Requests must be based on a pertinent clinical evaluation since onset or change in symptoms including detailed history, physical exam, appropriate labs, and prior imaging when available
Clinical judgment may override guideline when documented
Documentation: Submit supporting documentation that the imaging will affect management (e.g., prior chest x‑ray results, prior diagnostic tests, relevant specialist evaluations)
See condition-specific sections for additional documentation requirements
Regulatory review: Requests for services stated as investigational, experimental, or exceeding quantity limits will be reviewed for medical necessity under Ohio Administrative Code
May require prior authorization or be denied if investigational
Modality & contrast criteria
Modality and contrast choices are covered when clinical criteria and contraindications are considered as described below.
Modality selection: Select the imaging modality that best answers the clinical question; begin with standard/conventional imaging (plain film, US, CT, or MRI) and escalate to advanced modalities only when indicated
Use less invasive/lower-cost modalities first when appropriate
Contrast selection: Choose contrast level (none, with, without and with) based on the condition-specific guidance; non-contrast CT is appropriate for lung parenchyma and when contrast contraindicated
If an unexpected need for contrast arises during a non-contrast exam, its use is appropriate
Contrast safety and contraindications
Contrast use must consider allergy, renal function, pregnancy, and specific agent risks.
Renal function and GFR: Assess renal function prior to iodinated or gadolinium-based contrast; both CT and MRI contrast carry increased risk when GFR <30 mL/minGFR <30 mL/min
Use caution and consider alternatives; gadolinium risks (NSF, deposition) should be considered
Allergy considerations: Shellfish allergy does not predict iodinated contrast allergy; document known allergies and use non-contrast studies or MRI alternatives when iodinated contrast hypersensitivity is present
For breastfeeding, pumping and discarding milk 12–24 hours after iodinated contrast may be considered
Pregnancy and special populations: Avoid routine use of contrast in pregnancy when possible; use only if benefits outweigh fetal/thyroid risk and document justification
Gadolinium relatively contraindicated in pregnancy; limit repetitive GBCA exposure
Ultrasound indications
Covered when ANY of the following ultrasound indications apply:
Chest/axilla/soft tissue evaluation: Ultrasound (including chest 76604, axillary 76882, breast 76641/76642) is medically necessary for initial evaluation of palpable/suspected lymphadenopathy, characterization of superficial soft-tissue masses, and guidance for image-directed biopsy or drainage
Operator dependent; limited by bone and large body habitus
Pleural effusion assessment: Ultrasound is appropriate to detect and quantify pleural effusion and to guide thoracentesis or drainage
May substitute or complement decubitus radiographs
Dynamic evaluations: Dynamic chest ultrasound (CPT 76604) is medically necessary for slipping rib syndrome and for real-time procedural guidance when indicated
High diagnostic accuracy for slipping rib syndrome; CT/MRI reserved for surgical planning
PET/PET-CT criteria
PET/PET‑CT is covered for specified indications and limited otherwise.
Oncologic and select indications: PET/CT (CPT 78815) is medically necessary for oncologic staging, characterization of solid pulmonary nodules ≥8 mm, and other condition-specific oncologic indications≥8 mm for solitary solid lung nodule
Not effective for ground-glass nodules; repeat PET studies discouraged
Sarcoidosis-specific uses: PET/CT may be medically necessary to guide biopsy location, differentiate reversible granulomatous disease from irreversible fibrosis when it will change management, or identify treatment failure
Not for routine screening of all sarcoidosis patients
Prior CT requirement: If the CT that prompted PET/CT is >3 months old, obtain a repeat CT (CPT 71250 or 72160) prior to PET/CTCT >3 months old
3D Rendering Indications
3D rendering (CPT 76376/76377) may be considered when clinically necessary; report and documentation requirements apply.
Clinical scenarios: Consider 3D rendering for complex bony reconstructions (congenital skull anomalies, complex fractures, spine/pelvic/acetabular fractures), complex facial fractures, select pre-operative planning scenarios and cerebral angiography when conventional imaging is insufficient
Do not use for simple 2D reformatting; document concurrent physician supervision/participation
Billing and authorization: Document active physician participation (design of anatomic region, structures to display, archived images/cine loops) when reporting CPT 76376/76377 and obtain prior authorization if required by plan rules
3D rendering codes should not be billed with numerous other specified procedures (see guidance)
Imaging Guidance Criteria
Imaging guidance codes are appropriate when imaging is required to guide percutaneous procedures and include:
Guidance applicability: Use modality-specific guidance codes for procedures that require imaging to guide needle or catheter placement, drainage, biopsy, or ablation; report only the guidance code for the encounter (one unit per date of service)
Appropriate pairing: Do not routinely bill a diagnostic imaging code in conjunction with a guidance procedure code; imaging studies performed as part of guidance are included in the guidance code
If additional diagnostic imaging is clinically necessary and separate from guidance, document rationale
Unlisted Procedure Use Criteria
Unlisted CT/MR/nuclear codes should be used when no anatomic-specific code exists or for special planning:
Appropriate uses for unlisted codes: Use CPT 76497/76498/78999 when an anatomic site-specific code is not available or when thinner cuts/alternate positioning are required for navigation or surgical planning (e.g., navigational bronchoscopy, neurosurgical navigation, custom joint arthroplasty planning)
Report a Category III code if available; include justification and prior imaging dates when applicable
Navigational bronchoscopy specific: For navigational bronchoscopy planning, CPT 76497 may be used if a prior CT was performed <6 weeks and is not suitable for navigation; otherwise obtain CT Chest (71250) if prior CT ≥6 weeksprior CT <6 weeks
Thin-cut CT with specific reconstruction parameters is required for navigation
Limited/Follow-up CT (76380)
Limited CT (CPT 76380) usage rules:
Appropriate limited CT uses: CPT 76380 may be reported for CT examinations where the work of a full diagnostic CT is not performed (examples: limited sinus CT, limited slices for known pulmonary nodule follow-up, limited slices for non-healing fracture)
Do not use 76380 to report extra slices in conjunction with diagnostic CT codes or for treatment planning in oncology
Not medically necessary uses: CPT 76380 is not medically necessary for treatment planning purposes in oncology or to cover additional slices of a diagnostic CT protocol
If full diagnostic CT work is performed, report the appropriate full CT code instead
Limited CT (76380) Criteria
Limited CT (CPT 76380) usage guidance and limitations
Definition and examples: CPT 76380 represents targeted CT studies in which full diagnostic work is not performed; common examples include limited sinus protocol, follow-up slices for a known pulmonary nodule, or limited slices for a clavicle non-healing fracture
No specific minimum or maximum number of slices/sequences is defined in CPT
Reporting limitations: Do not report CPT 76380 in conjunction with diagnostic CT codes to cover additional slices; include clinical justification when limited protocol differs from prior diagnostic CT
Not appropriate for treatment planning in oncology
Whole-body CT Coverage
Whole-body CT is not a covered screening benefit for asymptomatic individuals.
Screening stance: Whole-body CT or LifeScan (CT brain, chest, abdomen, pelvis) for screening of asymptomatic individuals is not a covered benefit due to lack of demonstrated benefit versus radiation risk
Exception: whole-body low-dose skeletal CT supported for multiple myeloma staging per oncology guidance
Whole-body MRI Coverage
Whole-body MRI and PET/MRI have limited, specific uses and coding/reporting constraints.
WBMRI indications and coding: WBMRI is generally not supported except for select cancer predisposition syndromes and specific autoimmune conditions; when used, report only with CPT 76498
Do not report multiple diagnostic MRI codes in lieu of 76498
PET/MRI prerequisites: PET/MRI is generally not supported but may be medically necessary when either condition-specific PET/MRI criteria are met OR the individual meets PET/CT criteria, PET/CT is unavailable at the institution, and the provider requests PET/MRI; report PET/MRI using CPT 78813 + 76498
When clinically appropriate, include diagnostic MRI codes concurrently
PET/MRI Coverage
PET/MRI may be allowed only under narrow conditions and has specific reporting requirements.
When PET/MRI is medically necessary: PET/MRI may be used if the individual meets condition-specific PET/MRI guidelines OR meets PET/CT criteria and PET/CT is unavailable and provider requests PET/MRI
Report as CPT 78813 + 76498 when allowed; diagnostic MRI codes may be required when clinically appropriate
Comparison Exams and Clinical Evaluation
Outside exam interpretation and prerequisite clinical evaluation:
Outside exam interpretation: Do not use diagnostic imaging codes to report interpretation of an exam performed elsewhere; use CPT 76140 for secondary interpretation when requested
If outside exam used for comparison, include prior study date and facility
Prerequisite clinical evaluation: A pertinent clinical evaluation since onset or change in symptoms is required prior to advanced imaging and should include history, physical exam, appropriate labs, and basic imaging such as chest x‑ray over read by a radiologist
Meaningful technological contact may substitute for in-person evaluation for established patients
General prerequisites for advanced chest imaging
A chest x‑ray and clinical evaluation are required prior to most advanced chest imaging except for listed exceptions.
Pre-advanced imaging requirement: Obtain or document a chest x‑ray since onset/change in symptoms (over read by a radiologist when performed) and compare with prior films when available before ordering advanced imaging
Exceptions include supraclavicular/axillary lymphadenopathy, known CF, bronchiectasis, suspected ILD, positive PPD/TB evaluation, pulmonary nodules, mediastinal mass, pre/post transplant and select others
CT Chest indications and coding notes
CT chest selection and coding notes:
Choice of CT chest protocol: CT Chest with contrast (CPT 71260) is preferred to evaluate intrathoracic abnormalities; CT Chest without contrast (CPT 71250) is appropriate when contrast is contraindicated or for pulmonary nodule follow-up; CT without and with contrast (71270) has limited additional value
Match protocol on follow-up studies to initial protocol to avoid missing growth
Contrast considerations: Use CT without contrast for lung parenchyma evaluation or when renal insufficiency, elevated BUN/creatinine, or life‑threatening contrast allergy are present; consider MRI when iodinated contrast cannot be tolerated
Shellfish allergy is not a contraindication to iodinated contrast
CTA Chest (71275) medical necessity
CTA Chest (CPT 71275) is medically necessary for:
CTA chest indications: Non-cardiac chest pain, hemoptysis, pulmonary AVM, pulmonary embolism, pre-lung transplantation, and pre-minimally invasive/robotic thoracic surgery planning
CTA may be preferred over diagnostic CT when vascular evaluation is required
MRI Chest indications
MRI chest is appropriate when CT is contraindicated or for specific mediastinal/chest wall indications.
MRI chest indications: Clarification of equivocal prior imaging, mediastinal lymphadenopathy when contrast contraindicated, chest wall or mediastinal mass characterization, and select soft-tissue or brachial plexus indications
MRI is infrequently required and should be used when it will change management
Substitution when CT contrast contraindicated: When iodinated contrast cannot be tolerated (allergy/renal dysfunction), MRI chest without and with contrast (CPT 71552) or without contrast (71550) may be used
Document contraindication to iodinated contrast
Ultrasound and Nuclear Medicine indications
Ultrasound and nuclear medicine have defined roles in chest imaging.
Ultrasound role: Chest ultrasound (CPT 76604) is useful for pleural effusion detection and for initial evaluation of palpable/suspected lymphadenopathy; axillary ultrasound (76882) is first-line for axillary nodes
Ultrasound allows immediate image‑directed biopsy
Nuclear medicine role: Pulmonary perfusion (78580), ventilation–perfusion (78582), and quantitative perfusion/ventilation (78597/78598) are used for pulmonary embolism evaluation and pre‑operative functional assessment
SPECT/CT (78830) may be used for pre-operative split function assessment
Navigational bronchoscopy imaging criteria and evidence
Navigational bronchoscopy requires specific CT formatting and has defined diagnostic yield and safety considerations.
CT requirements for navigation: A thin-cut CT Chest with optimized reconstruction parameters formatted for navigation is required for navigational bronchoscopy; prior CT may be unusable if not formatted correctly; use CPT 76497 when prior CT <6 weeks and not suitable
Do not report 3D rendering codes (76376/76377) with navigational bronchoscopy
Evidence and safety: Navigational bronchoscopy diagnostic accuracy reported 70.9–79% with adverse event rate 3.3–5.6%; cone-beam CT may increase radiation exposure (example mean 48.4 Gy·cm2) and requires further study
Consider diagnostic yield versus radiation dose when selecting CBCT
Axillary lymphadenopathy initial evaluation and follow-up
Covered when ALL of the following apply for localized axillary lymphadenopathy:
Initial evaluation: Perform axillary ultrasound (CPT 76882) as the initial imaging test for any axillary mass or enlarged node
Observation intervals: If the clinical picture suggests benign reactive adenopathy, observe with ultrasound at 3–4 weeks; for ipsilateral COVID‑19 vaccine–related adenopathy, observe for ≥12 weeks before additional workup3-4 weeks; 12+ weeks for vaccine-related
Follow-up ultrasound is medically necessary if risk of metastatic disease is significant
Biopsy indications: Proceed to ultrasound‑directed core needle biopsy or surgical excision when adenopathy persists, if malignancy is suspected, or if core biopsy is non‑diagnostic
If biopsy is benign, further advanced imaging is not medically necessary
Mediastinal lymphadenopathy evaluation
Covered when ALL of the following are met or as specified:
Initial advanced imaging: CT Chest with contrast (CPT 71260) is medically necessary for mediastinal abnormalities identified on chest x‑ray or non‑dedicated imaging; if contrast is contraindicated, MRI chest (71552/71550) is appropriate
Document prior imaging and clinical context
Follow-up for nodes >=15 mm: Follow-up CT Chest is medically necessary at 3–6 months for enlarged mediastinal lymph nodes with short‑axis ≥15 mm and no other thoracic abnormalities; if stable or decreased, no further advanced imaging is necessary>=15 mm; 3-6 months
If increasing, PET/CT or biopsy is medically necessary
Further evaluation: Lymph node biopsy is medically necessary for persistent or increasing lymphadenopathy on follow-up CT or when malignancy is suspected; PET/CT (CPT 78815) is medically necessary for unexplained nodes ≥15 mm or increasing size
PET/CT may be false‑positive in inflammatory disease
Cough imaging pathway
Covered when ALL of the following are met for initial evaluation of cough:
Initial steps: Obtain a chest x‑ray performed after the current episode of cough started or changed and discontinue medications known to cause cough (e.g., ACE inhibitors)
If chest x‑ray abnormal, follow relevant condition‑specific imaging guidance
CT chest after conservative trial (non‑smokers): For non‑smokers with normal chest x‑ray, CT Chest (71250 or 71260) may be considered only after a cumulative 3‑week trial including antihistamine/decongestant or intranasal steroid, spirometry/PFTs, empiric corticosteroid and/or leukotriene antagonist, and GERD treatment3-week trial
CT may identify ILD or bronchiectasis not seen on x‑ray
Smokers or high suspicion: Current or former smokers with new cough >2 weeks, changed chronic cough, or high suspicion for lung cancer may proceed to CT without the 3‑week conservative trial>2 weeks for smokers
Non-Cardiac Chest Pain - Imaging
Covered when evaluation follows the guideline sequence and criteria:
Initial evaluation: Obtain a chest x‑ray as the first‑line imaging study for non‑cardiac chest pain
Perform cardiac and GI evaluation as indicated before advanced imaging for substernal pain
If chest x‑ray abnormal: CT Chest with contrast (CPT 71260) or CTA Chest (CPT 71275) is medically necessary when chest x‑ray is abnormal
Select CTA when vascular evaluation is required
Substernal chest pain with normal x‑ray: For substernal pain with normal x‑ray, perform cardiac evaluation and appropriate GI testing/trials; if pain persists despite evaluation, CT Chest with contrast (71260) is indicated
Initial evaluation: Obtain a chest x‑ray as the first imaging step for suspected costochondritis or other musculoskeletal chest wall pain
Most diagnoses are clinical and imaging is often non‑specific
CT chest after x‑ray: CT Chest (71250 or 71260) is medically necessary when chest x‑ray is inconclusive or nondiagnostic and there is concern for infection or neoplasm, symptoms persist >3 weeks despite treatment, or for pre‑surgical planning>3 weeks
For slipping rib syndrome, dynamic chest ultrasound (76604) is medically necessary
Slipping rib syndrome: Dynamic chest ultrasound (CPT 76604) is medically necessary for diagnosis; CT/MRI/bone scan may be used only for surgical planning or anatomy delineation
Dynamic chest ultrasound has high diagnostic accuracy
Dyspnea/Shortness of Breath Imaging Criteria
Covered when ALL of the following are met since onset or change in symptoms:
Initial step: Obtain a chest x‑ray as initial imaging for dyspnea/shortness of breath
Perform pulse oximetry, ECG, and PFTs as clinically indicated
CT after abnormal x‑ray: If chest x‑ray is abnormal, CT Chest without contrast (71250) or with contrast (71260) is medically necessary per the clinical context
If PE suspected, follow pulmonary embolism guidelines
When CT after indeterminate x‑ray: If initial chest x‑ray is indeterminate, CT chest (with or without contrast) is reasonable only after ECG/echocardiogram/stress test and pulse oximetry/PFTs have been performed and are indeterminate
Pre-operative functional assessment: Split function studies (CPT 78597/78598) or SPECT/CT (CPT 78830) are medically necessary for pre‑operative assessment prior to planned lobar/segmental resection or pre‑EBV assessment
Document surgical plan and how results will affect management
CT for EBV or resection planning: CT Chest (71250/71260/71270) is medically necessary for pre‑interventional planning for EBV placement or robotic lung resection; if prior diagnostic CT was ≥6 weeks prior, new CT is indicated; if prior CT <6 weeks, CPT 76497 may be used with justificationprior CT >= 6 weeks
Document prior imaging dates and rationale
Post-EBV imaging
Post endobronchial valve imaging:
Initial evaluation of suspected post‑EBV complication should include chest x‑ray
Chest x‑ray is first‑line to evaluate for pneumothorax and gross valve position
CT indications post‑EBV: CT Chest without contrast (71250) or with contrast (71260) is medically necessary for acute loss of benefit, increased dyspnea, sudden chest pain, increased cough, suspected valve malposition/migration, or to evaluate target lobe volume reduction
If chest x‑ray non‑diagnostic or no volume reduction at 1 month, CT is indicated; some centers perform routine CT at 6–8 weeks
Hemoptysis imaging
Hemoptysis evaluation:
Initial imaging after hemoptysis: Obtain a chest x‑ray after hemoptysis starts or worsens; if further evaluation needed, CT Chest with contrast (71260) or CTA Chest (71275) is medically necessary
CTA is preferred for pre‑embolization planning or recurrent hemoptysis
Contrast contraindication: CT Chest without contrast (71250) is only appropriate in individuals with poor renal function or life‑threatening iodinated contrast allergy; CT without and with contrast (71270) is not supported for hemoptysis
Document contraindication if non‑contrast CT used
Bronchiectasis imaging
Bronchiectasis imaging:
Initial and diagnostic imaging: High‑resolution CT Chest without contrast (CPT 71250) is medically necessary to confirm suspected bronchiectasis after an initial chest x‑ray, for known bronchiectasis with worsening symptoms or PFTs, and for hemoptysis with known or suspected bronchiectasis
CT with contrast may be used for suspected infectious complication; CTA for hemoptysis planning
Repeat imaging guidance: Repeat HRCT is indicated for clinical deterioration; routine serial imaging without change in clinical status is not routinely supported due to radiation riskclinical deterioration
Follow-up timing determined by treating provider
Adult Cystic Fibrosis — CT indications
CT Chest (71250/71260) is medically necessary for adult cystic fibrosis when ANY of the following are met:
CF CT indications: Suspected or initial diagnosis of cystic fibrosis; biennial surveillance (every 2 years); persistent respiratory symptoms with reduced lung function despite therapy; exacerbations with indeterminate chest x‑ray; hemoptysis; suspected fungal pneumonia; pre‑ or post‑lung transplant evaluationbiennial for routine surveillance
Consider low‑dose CT protocols when appropriate to minimize radiation
Bronchitis — initial imaging
Bronchitis imaging coverage:
Initial imaging: Chest x‑ray is medically necessary as initial imaging if symptoms persist or worsen for suspected bronchitis
Advanced imaging is not medically necessary unless directed by condition‑specific guidance
Asbestos exposure — chest imaging
Asbestos exposure imaging coverage:
Screening stance: Chest x‑ray is appropriate for radiographic screening of asbestos exposure; CT Chest is not medically necessary for population screening
HRCT (71250) is medically necessary for any change on chest x‑ray or progressive respiratory symptoms suggesting interstitial fibrosis
When HRCT indicated: Perform HRCT when chest x‑ray demonstrates change or when progressive symptoms suggest interstitial fibrosis
Document symptoms and x‑ray findings
COPD — CT indications
COPD imaging coverage:
Initial imaging step: Obtain a chest x‑ray initially for suspected COPD; CT Chest (71250/71260) is medically necessary for emphysema evaluation when pre‑operative LVRS assessment is requested, for persistent exacerbation, symptoms out of proportion to severity, or FEV1 <45% predictedFEV1 <45% of predicted
CT also indicated when PFTs and x‑ray do not reveal a definitive diagnosis and alternative diagnoses are suspected
Pre‑interventional assessment: CT/HRCT is appropriate for pre‑interventional assessment prior to endobronchial valve placement or lung volume reduction surgery
Include documentation of surgical intent and prior imaging
CT/HRCT for COPD
CT/HRCT for COPD — covered when ANY of the following are met:
Indications list: Emphysema known or suspected when pre‑operative LVRS study requested; OR known COPD with persistent exacerbation, symptoms out of proportion to disease severity, or FEV1 <45% predicted; OR when PFTs, labs, and chest x‑ray do not reveal a diagnosis and alternative diagnoses (eg bronchiectasis, sarcoidosis, alpha‑1 antitrypsin deficiency) are suspected; OR pre‑interventional assessment for EBV/LVRSFEV1 <45%
Choose HRCT when ILD/DLD is a concern
HRCT/CT for ILD/DLD (Diagnostic and Follow-up)
HRCT or CT chest is covered when ALL/ANY of the following ILD/DLD indications apply:
Diagnostic HRCT indications: HRCT without contrast (71250) (diagnostic modality of choice) OR CT Chest with contrast (71260) to evaluate interstitial or diffuse parenchymal changes identified on other imaging, for high clinical suspicion with abnormal PFTs and normal chest x‑ray, for connective tissue disease with pulmonary symptoms, or significant exposure linked to ILD/DLD
HRCT can guide biopsy site and subtype determination
Follow‑up/progression indications: Follow-up CT (71250/71260) for worsening symptoms or PFTs, to detect progressive pulmonary fibrosis (FVC decline ≥5% or DLCO decline ≥10% within past year), or annually in known pulmonary fibrosis when clinically indicatedFVC decline >=5%; DLCO decline >=10%
Routine IV contrast not supported for ILD evaluation unless alternate diagnoses require it
CT for EVALI
CT Chest (with or without contrast) coverage for EVALI:
EVALI indications: CT Chest (71250 or 71260) is medically necessary if chest x‑ray is negative but clinical suspicion for EVALI exists; to characterize extent of involvement seen on chest x‑ray; severe/worsening disease (eg tachycardia, tachypnea, hypoxia O2 ≤95%); to rule out other diagnoses or complications (pneumothorax/pneumomediastinum)
Document vaping history and clinical criteria
Pneumonia imaging — when CT chest is medically necessary
CT Chest (CPT 71250 or 71260) is medically necessary when ONE of the following applies:
Complication of pneumonia: Complication such as abscess, empyema, necrotizing pneumonia, or pneumothorax
CT helps define complications and guide intervention
Persistent radiographic abnormality: Possible lung mass associated with infiltrate or persistent abnormality on repeat chest x‑ray after 6–8 weeks6-8 weeks
Consider CT even when chest x‑ray negative if clinical status warrants
COVID-19 imaging — when CT chest is medically necessary
CT Chest (CPT 71250 or 71260) is medically necessary in the settings below:
High‑risk symptomatic COVID‑19: Symptomatic COVID‑19 positive individuals with underlying comorbidities or risk factors (eg age >65, chronic lung disease, immunocompromised state, BMI ≥30, transplant) when imaging will alter management
Chest radiography is typically first‑line; CT reserved for moderate/severe or worsening disease
Moderate to severe illness or complications: Moderate to severe symptomatic individuals with significant pulmonary dysfunction (eg hypoxemia, moderate‑to‑severe dyspnea), or suspected complications (eg PE) where imaging will change management
Follow condition‑specific protocols for suspected complications
Worsening or post‑recovery impairment: Significant worsening where imaging will modify management, or recovered individuals with persistent functional impairment or hypoxemia
Consider HRCT for suspected post‑COVID interstitial changes
General rules and preferences
First‑line imaging preference: Chest radiography is the appropriate first imaging modality for suspected pneumonia and typically first‑line for COVID‑19; routine CT screening is not recommended
MRI is not indicated for pneumonia imaging
Ultrasound and MRI roles: Chest ultrasound may be appropriate for parapneumonic effusion evaluation and procedure guidance; MRI is not medically necessary for routine pneumonia imaging
Use ultrasound to guide thoracentesis when applicable
Follow‑up imaging: Routine follow‑up imaging within 5–7 days is not recommended for adults improving clinically; follow‑up imaging at 6–12 weeks is medically necessary to confirm resolution in immunocompetent individuals when indicated5-7 days; 6-12 weeks
Select same modality used to detect the condition
PPD / TB / NTM-PD Imaging Criteria
CT Chest (with or without contrast) is indicated when any of the following TB/NTM‑PD criteria are met:
TB/NTM indications: Normal or equivocal chest x‑ray with positive PPD/IGRA OR suspected active/reactivated tuberculosis OR suspected NTM‑PD OR suspected complications/progression (eg pleural TB, empyema, mediastinitis)
Follow‑up CT for known TB limited to specialist discretion not to exceed 3 studies in 3 months
Fungal Infections Imaging Criteria
CT Chest (with contrast) or HRCT (without contrast) is indicated for suspected or known fungal infections when any of the following apply:
Fungal infection indications: Initial diagnosis of fungal pneumonia or chest infection; suspected complications or progression (eg worsening pneumonitis, pleural effusion, empyema, mediastinitis); suspected ABPA with atypical presentation or poor response to therapy; follow‑up at specialist discretion
For suspected fibrosing mediastinitis, CT chest with contrast preferred; MRI chest is an alternative
Suspected Sternal Dehiscence Imaging Criteria
Imaging pathway for suspected sternal wound dehiscence:
Initial step: Perform chest x‑ray prior to advanced imaging to assess sternal wire integrity and mid‑sternal stripe
If x‑ray equivocal or for preoperative planning, obtain CT Chest (71250 or 71260)
CT indications: CT chest without or with contrast is medically necessary to differentiate sternal wire migration from dehiscence and for surgical planning when clinical concern persists>3 months of pain/clicking/instability for non‑union evaluation
Consider infection workup when indicated
Wegener's / Granulomatosis with Polyangiitis
Cross‑reference guidance:
Vasculitis imaging: For imaging concerns related to Wegener's (Granulomatosis with Polyangiitis) and related entities, follow Small Vessel Vasculitis imaging guidance
Refer to peripheral vascular/specialty guideline sections for disease‑specific imaging
Sarcoidosis imaging coverage
CT chest and PET/CT coverage for sarcoidosis:
CT for suspected sarcoidosis: CT Chest with or without contrast (71260 or 71250) is medically necessary to establish or rule out sarcoidosis when suspected
If CT equivocal, tissue diagnosis may be required
CT for known sarcoidosis: Subsequent CT Chest is medically necessary for worsening symptoms, new symptoms after asymptomatic interval, or when a treatment change is being considered
Document how imaging will influence management
PET/CT in sarcoidosis: PET/CT (78815) is medically necessary only to guide biopsy location when CT lesion is difficult to access, to differentiate reversible granulomatous disease from irreversible fibrosis when it will affect treatment, or to identify treatment failure when the result will change therapy
PET/CT not for routine screening of all sarcoidosis patients
Solitary and incidental pulmonary nodule imaging
Imaging for solitary pulmonary nodules and incidental nodules:
Initial dedicated CT for nodules: Either CT Chest with contrast (71260) OR CT Chest without contrast (71250) is medically necessary initially for discrete nodules seen on non‑dedicated imaging (eg chest x‑ray, CT abdomen) to obtain accurate nodule size and characteristics
Use same CT protocol for follow‑up as initial study
Measurement and comparison: Measure nodules by averaging long‑ and short‑axis diameters and compare to prior studies (earliest and most recent) to assess stability or growthchange >=2 mm considered meaningful
Document measurement method and prior study dates
Size‑based follow‑up: Follow‑up intervals depend on size: <6 mm – optional CT at 12 months and no routine further if stable; 6–8 mm – CT at 6–12 months then 18–24 months if stable; ≥8 mm – CT at 3 months then 6–12 and 18–24 months or consider PET/CT or biopsysize‑based
Solid nodule surveillance
Follow-up for incidentally detected solid pulmonary nodules (time intervals from initial detection):
Solid <6 mm: No routine follow‑up in low‑risk individuals; optional CT at 12 months in select cases; if stable, no further advanced imaging is necessary<6 mm
High‑risk exceptions may warrant closer follow‑up
Solid 6–8 mm: CT at 6–12 months; if stable, consider repeat CT at 18–24 months (often one follow‑up is sufficient); consider PET/CT or biopsy for suspicious morphology or high‑risk individuals6-8 mm
Document risk factors and morphology
Solid >8 mm: CT surveillance at 3–6 months, 6–12 months, and 18–24 months, and consider PET/CT and/or tissue sampling; PET/CT is a reasonable consideration for nodules ≥8 mm>8 mm
Sub-solid nodule surveillance
Follow-up for incidentally detected sub‑solid pulmonary nodules (SSN):
Pure ground‑glass nodules <6 mm: No routine follow‑up; consider optional CT at 2 and 4 years in selected suspicious cases; if solid component or growth develops, consider resection<6 mm
Clinical judgment guides follow‑up
Pure GGN ≥6 mm: CT at 6–12 months to confirm persistence, then CT every 2 years until 5 years>=6 mm
Follow‑up beyond 5 years may be considered in select individuals
Part‑solid nodules (PSN): PSN ≥6 mm: CT at 3–6 months then annually for minimum 5 years if solid component <6 mm; if solid component ≥6 mm or growing, consider PET/CT or biopsysolid component size criteria
PET/CT utilization
When PET/CT is medically reasonable:
Primary PET/CT indication: PET/CT (CPT 78815) is medically necessary for characterization of a solitary solid lung nodule ≥8 mm on dedicated chest imaging; not indicated for pure ground‑glass nodules≥8 mm
Repeat PET studies are not medically necessary; PET/CT less reliable for nodules <8–10 mm
Follow‑up after negative PET: If PET/CT is negative for a lesion being surveilled, follow‑up CT at 3 months, 9 months, and 21–24 months may be used if clinically indicatedpost‑PET negative
In high pretest probability, negative PET does not exclude malignancy
Follow‑up after positive PET: If PET/CT is positive but biopsy is negative or not performed, follow‑up CT at 3 months, 9–12 months, and 24 months is reasonable if stable; tissue sampling should be considered when indicated
Not medically necessary - stability
When further advanced imaging is not necessary:
Stability criteria – solid nodules: No further advanced imaging if a nodule has been stable per defined intervals: solid nodules ≥6 mm stable on CT for 2 years; nodules <6 mm stable for 1 year; nodules stable on chest x‑raystability periods
Benign calcification patterns or decreasing size may also obviate further imaging
Pleural-based nodules and masses — initial imaging
Covered when ALL of the following are met:
Initial pleural nodule imaging: CT Chest with contrast (71260) or CT Chest without contrast (71250) is medically necessary for evaluation of pleural nodules; contrast‑enhanced CT is preferred for initial assessment
Compare with prior chest films and document largest measurement when multiple nodules
PET/CT for pleural disease
PET/CT is medically necessary when ALL of the following are met:
PET/CT pleural criteria: Pleural nodule/mass or defined pleural thickening ≥8 mm AND clinical likelihood of malignancy (eg current/prior malignancy, pleural effusion, bone erosion, chest pain) — PET/CT (CPT 78815) is medically necessary>=8 mm
Document clinical features increasing pretest probability
CT Chest for pleural effusion — indications
CT Chest with contrast (CPT 71260) is medically necessary after chest x‑ray when ONE of the following applies:
Indications after chest x‑ray: Thoracentesis performed or required; concern for loculated effusion, empyema, paramediastinal or subpleural collection; evaluation of chest tube/drain position; surgical planning; when ultrasound is inadequate or adjunctive imaging is needed
Ultrasound (76604) is an appropriate alternative or adjunct for effusion evaluation and procedural guidance
Studies, procedures, or devices that lack sufficient supporting evidence, demonstrated clinical utility, or a collective professional opinion of benefit are considered investigational/experimental and are excluded from coverage. Determinations of investigational status rely on peer‑reviewed literature, specialty society guidance, and consensus clinical practice; requests for such services will be reviewed for medical necessity and may be denied under the applicable Ohio administrative rules.
Certain advanced modalities are specifically identified as investigational or generally unsupported. MRI utilizing Xenon Xe‑129 (CPT C9791) is considered investigational/experimental. In addition, PET/MRI is generally not supported for routine use; PET remains primarily a PET/CT combined study, and unbundling PET/CT into separate PET and diagnostic CT components is not supported.
Billing and reporting rules for post‑processing and limited studies are strict. 3D rendering codes (CPT 76376, 76377) require physician concurrent supervision/participation and must not be reported for routine 2‑D reformatting or in conjunction with specified modalities (eg, CAD, PET/PET‑CT, CTA, stereotactic localization). Limited CT (CPT 76380) is intended for targeted follow‑up/limited protocols and is not appropriate for general treatment‑planning purposes or to report extra diagnostic slices.
Covered Indications by Condition and Modality
Coding / Billing Guidance
Experimental/Investigational codesCPTExperimental
C9791
MRI utilizing Xenon Xe 129 (listed as investigational/experimental)
3D Rendering CPT CodesCPT
76376
3D rendering; not requiring image post-processing on an independent workstation
76377
3D rendering; requiring image post-processing on an independent workstation
Imaging Guidance and Related Procedure CodesCPT
19085
Biopsy, breast, first lesion, including MR guidance
19086
Biopsy, breast, each additional lesion, including MR guidance
75989
Imaging guidance for percutaneous drainage with placement of catheter
76942
Ultrasonic guidance for needle placement
77011
CT guidance for stereotactic localization
77012
CT guidance for needle placement
77013
CT guidance for, and monitoring of parenchymal tissue ablation
77021
MR guidance for needle placement
77022
MR guidance for, and monitoring of parenchymal tissue ablation
Unlisted Procedure CodesCPT
76497
Unlisted CT procedure (diagnostic or interventional)
76498
Unlisted MR procedure (diagnostic or interventional)
78999
Unlisted diagnostic nuclear medicine procedure
Limited CT and SPECT/CT CodesCPT
76380
Limited or follow-up CT scan
78830
SPECT/CT imaging (single area, single day)
78831
SPECT/CT imaging (2 or more days)
78832
SPECT/CT imaging (2 areas with one day and 2-day study)
Quantitative differential pulmonary perfusion, including imaging
78598
Quantitative differential pulmonary perfusion and ventilation, including imaging
Biopsy CPT CodesCPTCovered
32408
Core needle biopsy of lung or mediastinum
Referenced imaging CPT codesCPT
76882
Axillary ultrasound
71260
CT Chest with contrast
71250
CT Chest without contrast
71552
MRI chest without and with contrast
71550
MRI chest without contrast
78815
PET/CT
70486
CT Maxillofacial without contrast
76380
CT Sinus, limited without contrast
Covered CPT Codes (mentioned)CPTCovered
CPT 71260
CT chest with contrast
CPT 71275
CTA Chest
CPT 71250
CT Chest without contrast
CPT 71552
MRI Chest without and with contrast
CPT 76604
Dynamic chest ultrasound
Referenced procedural CPT codesCPT
78597
Quantitative Differential Pulmonary Perfusion, Including Imaging When Performed
78598
Quantitative Differential Pulmonary Perfusion and Ventilation (e.g., Aerosol or Gas), Including Imaging When Performed
78830
SPECT/CT
71250
CT Chest without contrast
71260
CT Chest with contrast
71270
CT Chest without and with contrast
71275
CTA Chest
76497
Unlisted CT procedure
Covered CPT Codes (CT Chest)CPTCovered
71250
CT Chest without contrast / High resolution CT Chest (as listed)
71260
CT Chest with contrast
Referenced CT CPT CodesCPTCovered
71250
CT Chest without contrast
71260
CT Chest with contrast
Referenced CT codesCPT
71250
CT Chest without contrast
71260
CT Chest with contrast
Referenced imaging CPT codesCPTCovered
71260
CT Chest with contrast
71250
CT Chest without contrast
71275
CTA chest
71552
MRI Chest without and with contrast
Referenced imaging CPT codesCPT
71260
CT Chest with contrast
71250
CT Chest without contrast
71270
CT Chest without and with contrast
71275
CTA Chest
71550
MRI Chest without contrast
71552
MRI Chest without and with contrast
71555
MRA Chest without and with contrast
78815
PET/CT, whole body or limited
Referenced imaging CPT codesCPT
78815
PET/CT
71250
CT Chest without IV contrast
72160
CT Thorax/Chest with contrast? (as listed)
Covered CPT Codes (examples referenced in guidance)CPTCovered
71260
CT Chest with contrast
71250
CT Chest without contrast
71270
CT Chest without and with contrast
71275
CTA Chest
71550
MRI Chest without contrast
71552
MRI Chest without and with contrast
71555
MRA Chest without and with contrast
78815
PET/CT
76377
3D reconstruction (separate procedure)
76376
3D rendering with interpretation
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Frequency Limits and Surveillance Intervals
Repeat imaging general rule
General ruleRepeat imaging generally not necessary unless there is evidence of disease progression, recurrence, or the repeat will affect clinical management.
Documentation expectationReview prior imaging and clinical history before ordering repeat studies to avoid unnecessary radiation and cost.
Pre-procedural linkagePre‑operative or pre‑procedural imaging is not medically necessary if the underlying procedure is not medically necessary.
CT — navigational bronchoscopy reuse rules
Allowed reuse within 6 weeksA prior diagnostic CT Chest performed within 6 weeks may be reused for navigational bronchoscopy if it is thin‑cut and formatted correctly for navigation (otherwise a new CT is required).
Prior authorization and medical necessity review is required for many advanced imaging services. Provide adequate clinical documentation to establish medical necessity before ordering advanced imaging; lack of pertinent information may lead to denial or request for records.
Include detailed history, physical exam, pertinent labs, and prior imaging.
Face-to-face or meaningful technological contact since onset/change in symptoms is acceptable when noted.
Condition-specific guideline sections may require additional documentation.
Prior Authorization
Pre-procedural Imaging & Procedure Linkage
Pre-procedural imaging ordered for use during a procedure should be consistent with the timing requirements in the guideline (for example, navigational bronchoscopy and pre-interventional CT rules). Ensure the imaging requested is necessary for an approved procedure; pre-procedural imaging is not medically necessary if the procedure itself is not medically necessary.
Contrast Use and Safety
Billing Rule
Determination of contrast level (general)
Determination of contrast level (none, with, or without and with) must follow condition‑specific guidance; document contraindications (renal insufficiency, pregnancy, severe allergy) when requesting contrast-enhanced studies.
If unexpected need for contrast arises during a non‑contrast study, its use is appropriate and should be documented.
Billing Rule
Contraindications and renal/pregnancy/allergy considerations
When iodinated contrast is contraindicated (e.g., elevated BUN/creatinine, renal insufficiency, severe allergy), use non‑contrast CT or consider MRI alternatives; document renal function or allergy status when ordering.
Shellfish allergy does not predict iodinated contrast allergy; still document specific contrast contraindication.
GFR <30 mL/min increases risk for contrast-related complications; use gadolinium cautiously in MRI.
Not Covered / Investigational
PET/MRI as a modality is generally not supported and requires special justification when requested. MRI with Xenon Xe‑129 (CPT C9791) is explicitly listed as investigational. When PET/MRI is considered appropriate only under narrow circumstances (for example when PET/CT criteria are met and PET/CT is unavailable and the provider specifically requests PET/MRI), coding/reporting expectations require PET whole‑body reporting (CPT 78813) paired with the MRI unlisted code (CPT 76498). Requests for these services will be evaluated for medical necessity and prior authorization may be required.
Do not report 3D rendering codes for routine 2‑D reformatting or when the dataset or procedure inherently generates a 3‑D dataset (for example stereotactic localization CPT 77011/70486). Concurrent physician supervision and documentation are required when CPT 76376/76377 are billed. CPT 76380 (limited CT) should not be used to substitute for a full diagnostic CT or to cover additional diagnostic slices used for treatment planning.
Advanced cross‑sectional imaging prior to tissue diagnosis is not supported for clinically evident axillary lymphadenopathy. For localized axillary adenopathy the guideline specifies initial ultrasound (CPT 76882) with observation or ultrasound‑guided biopsy when indicated; ordering CT/MRI before biopsy for a clinically apparent axillary node is considered not medically necessary.
MRI of the chest is not medically necessary for the evaluation of suspected bronchiectasis because it is inferior to CT for assessment of lung parenchyma. High‑resolution CT without contrast is the preferred modality to confirm or evaluate bronchiectasis.
CT chest is not medically necessary for screening asymptomatic populations at risk for asbestos‑related disease. Chest radiography serves as the screening modality and HRCT is reserved for cases with radiographic change or progressive clinical symptoms.
Prior Authorization and Review Expectations
Prior Authorization
Requests for investigational/unproven services require review/prior auth
Requests for services stated as investigational/unproven (e.g., Xenon MRI) will be reviewed and may require prior authorization per Ohio rules before approval.
Prior Authorization
Pre-procedural imaging may require prior authorization linked to underlying procedure
Pre‑procedural imaging may require prior authorization linked to the underlying procedure; if the underlying surgery/procedure is not medically necessary, related imaging is not medically necessary.
Prior Authorization
3D rendering prior authorization may be required
Prior authorization may be required for 3D rendering codes (CPT 76376/76377) even if the base imaging is not pre‑authorized; obtain authorization where required.
Background
Background: These evidence‑based guidelines govern selection of chest imaging modalities, emphasizing a staged approach that begins with standard imaging (plain radiography, ultrasound, CT or MRI) and progresses to advanced modalities only when clinically indicated. The guidance highlights safe use of contrast agents, preference for less invasive or lower‑cost modalities where appropriate, and discourages investigational or unproven technologies (for example Xenon MRI or routine PET/MRI) unless justified by condition‑specific criteria. Clinical judgment may override the guideline when documented and supported by relevant clinical information.
Definitions
Standard or conventional imaging definition
DefinitionStandard or conventional imaging: plain film, CT, MRI, or ultrasound commonly used in initial and subsequent evaluations of chest conditions.
RoleThese modalities are typically first‑line; advanced imaging reserved for indeterminate or clinically warranted escalation.
Contrast selectionAppropriate level of contrast (none, with, or with and without) is determined by condition‑specific guidance.
Investigational/Experimental definition
DefinitionInvestigational/Experimental: studies, procedures, or devices lacking sufficient supporting evidence, clinical utility, or collective opinion of support; may be excluded from coverage.
ImplicationRequests for investigational services will be evaluated for medical necessity and may be denied if considered unproven.
Revision History
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyAdult Chest Imaging Guidelines (Ohio)
Policy CodePolicy CSRAD005OH.E
Change TypeMinor / No material change
Effective DateFeb 3, 2026
Next Review DateN/A
Key ActionObtain and document a pertinent clinical evaluation (history, exam, labs, and prior imaging such as a chest x‑ray) before ordering advanced chest imaging.
CT Chest with or without contrast (71260 or 71250) and/or bone scan may be medically necessary for suspected malignancy, infection, prior chest intervention, or other targeted indications
Choose modality based on suspected pathology
Immunocompromised individuals: High suspicion for pneumonia despite equivocal/negative chest x‑ray, persistent radiographic abnormalities after 6–12 weeks, or multiple/diffuse opacities/nodules6-12 weeks
CT may be necessary due to atypical presentations
Consider patient risk factors and morphology when escalating to PET/CT or tissue sampling
Management guided by pretest probability, PET/CT results, and biopsy findings
Persistent PSN with solid component ≥6 mm is highly suspicious
post‑PET positive
Integrate PET results with clinical risk and morphology
If a prior CT Chest was performed <6 weeks and a new navigation‑formatted study is required, report CPT 76497 (Unlisted CT procedure).
If prior CT ≥6 weeksIf prior diagnostic CT ≥6 weeks, obtain CT Chest without contrast (CPT 71250) formatted for navigation.
CT — follow-up interval for mediastinal nodes >=15 mm
Size threshold>= 15 mm short‑axis in mediastinum
Initial follow-up intervalFollow‑up CT Chest at 3–6 months for enlarged mediastinal lymph nodes ≥15 mm when no other thoracic abnormalities present.
Subsequent actionIf nodes are stable or decreasing after 3–6 months, further advanced imaging is not medically necessary; if increasing, PET/CT or biopsy indicated.
Initial imagingAxillary ultrasound (CPT 76882) is the preferred first‑line test for suspected or palpable axillary lymphadenopathy.
Short observationObservation with ultrasound at 3–4 weeks is appropriate for benign‑appearing axillary adenopathy.
Vaccine‑related axillary adenopathyFor ipsilateral COVID‑19 vaccine–related adenopathy, observe for ≥12 weeks before further workup.
CT — prior diagnostic CT reuse and CPT 76497 guidance
Prior CT >=6 weeksCT Chest (CPT 71250/71260) is appropriate when the prior diagnostic CT was performed ≥6 weeks before the planned study.
Prior CT <6 weeksIf a prior diagnostic CT Chest was performed <6 weeks and a new study is required for planning/navigation, consider CPT 76497 (Unlisted CT) with documentation and justification.
Formatting requirementA prior CT may be unusable for navigation if not formatted correctly; a thin‑cut CT with optimized reconstruction parameters is required for navigational planning.
CT Chest — CF surveillance interval
Surveillance intervalCT Chest (71250/71260) for adult cystic fibrosis: every 2 years (biennial) for routine surveillance.
Indications for earlier CTAlso medically necessary for suspected/initial diagnosis, persistent symptoms with reduced lung function despite therapy, indeterminate chest x‑ray during exacerbation, hemoptysis, suspected fungal pneumonia, and pre/post lung transplant evaluation.
Dose considerationUse low‑dose CT (LDCT) techniques where feasible to minimize cumulative radiation exposure in surveillance.
HRCT/CT Chest — surveillance frequency for pulmonary fibrosis
Routine surveillance frequencyAnnual HRCT or chest CT is indicated in individuals with known pulmonary fibrosis when needed for serial assessment, evaluation of progression, or treatment decisions.
Triggering events for CTObtain CT for new or worsening respiratory symptoms or worsening PFTs (e.g., FVC decline ≥5% or DLCO decline ≥10% within the past year).
Protocol noteHRCT (thin‑slice) is the diagnostic modality of choice and may be performed even if a regular CT was previously obtained.
CR or CT — pneumonia follow-up interval
Follow-up timingFollow‑up imaging within 5–7 days is not routinely recommended; follow‑up imaging at 6–12 weeks is medically necessary to confirm radiographic resolution in immunocompetent individuals.
Initial modalityChest radiography (CR) is the appropriate first imaging test for suspected pneumonia; CT reserved for complications, persistent abnormalities, or severe clinical status.
Indications for earlier CTCT may be medically necessary sooner for complications (abscess, empyema, necrotizing pneumonia), hypoxia/respiratory distress, or abnormal vital signs with negative/equivocal radiograph.
CT Chest (71250/71260) — follow-up limit for TB
Maximum frequencyFollow‑up CT Chest for known tuberculosis should not exceed 3 studies in 3 months (specialist discretion).
Initial indicationCT Chest (71250/71260) is indicated when chest x‑ray is normal/equivocal with positive TST/IGRA or suspected active or reactivated TB/NTM-PD.
Re‑evaluation noteRe‑evaluate individuals undergoing active treatment who had abnormalities seen only on CT Chest; further CT only if clinically indicated.
Follow‑up summary<6 mm: optional CT at 12 months and no routine further follow‑up if stable; 6–8 mm: CT at 6–12 months then at 18–24 months if stable; >8 mm: CT at 3–6 months, then 6–12 and 18–24 months if stable; consider PET/CT or biopsy for ≥8 mm or suspicious nodules.
Measurement conventionNodule measurements should be the average of maximal long‑ and short‑axis diameters, rounded to the nearest millimeter; a change ≥2 mm is meaningful.
CT — subsolid nodule follow-up schedule
Subsolid categoriesSub‑solid nodules include pure ground‑glass nodules (GGN) and part‑solid nodules (PSN); management depends on overall size and solid component.
Follow‑up intervalsPure GGN <6 mm: no routine follow‑up (optional CT at 2 and 4 years for selected cases); Pure GGN ≥6 mm: CT at 6–12 months to confirm persistence, then CT every 2 years until 5 years; PSN ≥6 mm: CT at 3–6 months then annual CT for minimum 5 years if solid component <6 mm; if solid component ≥6 mm consider PET/CT or biopsy.
High‑risk featuresPersistent part‑solid nodules with solid component ≥6 mm are highly suspicious and warrant more aggressive evaluation.
PET/CT — repeat discouraged
General stanceRepeat PET/CT studies are discouraged; serial PET studies are not medically necessary except for staging or when clearly clinically indicated.
Size threshold for PET/CTPET/CT may be considered for solid lung nodules or solid components of subsolid nodules ≥8 mm; PET/CT is unreliable for nodules <8–10 mm and for pure ground‑glass opacities.
Negative PET actionA negative PET/CT in a high pretest probability case does not exclude malignancy; continued surveillance for at least 2 years or tissue sampling is advised.
If a CT Chest has been performed <6 weeks and needed for navigational bronchoscopy, report CPT 76497 (Unlisted CT).
If previous diagnostic CT ≥6 weeks ago for navigational bronchoscopy, use CT Chest without contrast (CPT 71250).
For pre-interventional lung procedures (e.g., endobronchial valve), CT Chest may be required; if prior diagnostic scan ≥6 weeks old use standard CT codes; if <6 weeks, CPT 76497 may apply.
Prior Authorization
Prior Authorization for 3D Rendering
3D rendering codes (CPT 76376, 76377) require documentation of concurrent physician supervision/participation and may require separate prior authorization even when the base imaging does not. Do not report 3D rendering for routine 2D reformatting.
Document active physician participation in the reconstruction process per ACR guidance.
Use CPT 76376 for post-processing not requiring an independent workstation; CPT 76377 when an independent workstation is required.
Prior authorization may be required specifically for the 3D rendering code.
Prior Authorization
Prior Authorization / Coding for PET/MRI and WBMRI
Prior authorization and appropriate coding are required for PET/MRI and whole-body MRI; PET/MRI is only supported in select circumstances and must be reported using PET whole-body plus MRI unlisted code combination when allowed.
PET/MRI medically necessary only when guideline criteria for PET/CT are met and PET/CT unavailable at the treating institution and provider requests PET/MRI in lieu of PET/CT.
Report PET/MRI as CPT 78813 (PET Whole-Body) plus CPT 76498 (MRI Unlisted).
WBMRI generally not supported except in select cancer predisposition syndromes; report WBMRI using CPT 76498.
Billing Rule
Navigational Bronchoscopy CT Timing & Codes
For navigational bronchoscopy, ensure CT timing and codes align with guideline rules and avoid reporting 3D rendering codes in conjunction with bronchoscopy navigation.
Do not report bronchoscopy with computer-assisted navigation in conjunction with CPT 76376 or CPT 76377.
Use CPT 76497 if CT Chest performed within 6 weeks and a new unlisted CT is needed for navigation.
Use CPT 71250 for CT Chest without contrast if prior diagnostic scan ≥6 weeks.
Prior Authorization
Advanced Imaging for Mediastinal Lymphadenopathy
Advanced imaging for mediastinal lymphadenopathy requires prior clinical evaluation and specific size/timing criteria; biopsy considerations should be documented prior to PET/CT.
CT Chest with contrast (CPT 71260) indicated if mediastinal abnormalities detected on chest x-ray or non-dedicated imaging.
Follow-up CT Chest at 3-6 months for nodes ≥15 mm without other thoracic abnormalities; PET/CT (CPT 78815) is medically necessary for nodes ≥15 mm or increasing size.
Document less invasive biopsy plans (e.g., CT/US-guided, transbronchial with EBUS) or need for more invasive procedures when applicable.
Documentation Required
Prior Imaging & Clinical Evaluation Required
A recent clinical evaluation and relevant prior imaging are required before many advanced imaging studies. Provide dates and results of prior imaging and clinical encounters to support the request.
Pertinent clinical evaluation since onset/change in symptoms including detailed history, physical exam, labs, and prior imaging must be submitted.
For established individuals, meaningful technological contact (telehealth, phone, message) since onset/change may suffice—document date and content.
Condition-specific sections may exempt recent clinical evaluation for scheduled surveillance—cite the applicable guideline section when relevant.
Billing Rule
Unlisted CT When Prior CT <6 Weeks
If a dedicated CT was performed within 6 weeks and a new CT is requested for a related purpose, use the unlisted CT procedure code when appropriate and document timing/rationale.
CPT 76497 may be used when a CT Chest has been performed within the last 6 weeks and a new study is needed for procedures such as navigational bronchoscopy or robotic-assisted surgery planning.
Document reason prior CT is insufficient and why a new acquisition is required.
Include dates of prior CT and indications in the authorization request.
Prior Authorization
Chest CT Prior Authorization Expectations
Prior authorization and documentation expectations for chest CT requests: initial imaging, comparisons, and conservative management steps must be documented where required by condition-specific guidance.
Initial chest evaluation typically requires a chest x-ray prior to CT unless specified (e.g., cystic fibrosis initial diagnosis or certain acute scenarios).
Provide prior imaging comparison and measurement (largest measurement for nodules) when available; include dates and reports.
Document conservative management (e.g., trial of therapy) prior to CT when guideline specifies—e.g., non-smokers with low-risk presentations may require conservative management before advanced imaging.
Prior Authorization
CT Chest Prior Authorization Guidance & Timing
CT chest prior authorization should align with clinical indications; include timing/rationale and prior imaging to support need for CT when ordered for specific conditions like dyspnea, pneumonia, or pre-operative assessment.
For dyspnea/shortness of breath, initial chest x-ray is required; CT Chest is supported when x-ray abnormal or when additional evaluations (ECG, PFTs, oximetry) are indeterminate and documented.
For suspected pneumonia, initial chest x-ray is required; CT Chest indicated for complications or if chest x-ray is negative/equivocal with abnormal vitals or exam—document those findings.
For pre-operative or pre-interventional assessment, document prior scans, their dates, and rationale for repeat imaging per timing rules.
Prior Authorization
CT Chest Prior Authorization (TB/NTM)
CT chest for tuberculosis/NTM requires documentation of positive testing or strong clinical suspicion; follow specified follow-up frequency and limit repeat studies unless clinically justified.
CT Chest with or without contrast indicated for positive PPD/QuantiFERON or suspected active TB/NTM—include test results and dates.
For known TB, follow-up CT frequency is at the discretion of specialists but should not exceed 3 studies in 3 months without justification.
If initial CT unremarkable, document symptoms or new findings to support repeat CT.
Prior Authorization
Prior Auth for PET/CT and CT Chest
When requesting PET/CT, include recent CT timing and clinical rationale; a recent dedicated CT (within 3 months) is often required prior to PET/CT to ensure PET remains clinically necessary.
If the CT that led to the PET was >3 months ago, repeat CT (CPT 71250) is required prior to PET/CT.
Document that the PET/CT will affect management (biopsy guidance, staging, treatment change) and include prior imaging and dates.
Serial PET studies are not medically necessary unless clearly justified; document prior PET dates and rationale if requesting another PET.
Prior Authorization
PET/CT Prior Authorization Considerations
Considerations for PET/CT authorization include size thresholds and indication alignment; document indication, prior imaging, and why PET/CT will change management.
PET/CT generally for solid lung nodules ≥8 mm or when it will guide biopsy or change treatment.
Not medically necessary for infiltrate, ground glass opacity, or hilar enlargement without other supporting findings.
Include prior CT findings, dates, and measurement of the lesion when submitting a PET/CT request.
Note
Preference for Standard Imaging & Conservative Management
Prefer standard imaging first (plain radiography, ultrasound, CT, MRI) and document conservative management steps prior to advanced imaging when guidelines recommend a stepwise approach.
Obtain and document initial diagnostic tests and results prior to ordering higher-level advanced imaging.
Document trials of conservative management (e.g., antibiotics, anti-reflux therapy, PFTs) when required by condition-specific guidance before CT or MRI.
Avoid redundant imaging when prior adequate studies exist; include prior study dates and reports for comparison.
Denial Risk
Whole-Body CT/MRI Screening Restriction
When requesting whole-body CT or whole-body MRI, document the indication and note that whole-body CT screening of asymptomatic individuals is not covered; whole-body MRI is generally not supported except for select indications.
Whole-body CT (LifeScan) for screening asymptomatic individuals is not a covered benefit—do not submit for routine screening.
WBMRI is generally not supported due to lack of standardization; permitted for select cancer predisposition syndromes—cite the specific syndrome when applicable.
If requesting whole-body imaging for oncologic staging (e.g., multiple myeloma), reference the appropriate oncology guideline section.
Documentation Required
Required Documentation for Imaging Requests
Required documentation for imaging requests must include indication, timing, prior imaging comparisons, measurements, initial imaging results, and clinical justification showing how the study will impact management.
Indication documentation: clear reason for study tied to symptoms, suspected diagnosis, or management decision.
Timing and rationale: dates of symptom onset/change, dates of prior imaging, and why repeat/advanced imaging is needed now.
Imaging comparison and measurement: include prior imaging reports, dates, and measurements (use largest measurement for nodules).
Initial imaging documentation: prior chest x-ray or non-dedicated imaging and its interpretation (including radiologist over-read) when required by the guideline.
Clinical justification: describe how imaging results will change treatment, guide biopsy, or affect procedural planning.
Pre-advanced imaging steps must be completed and documented when specified: initial x-ray, conservative therapies, basic labs, and targeted noninvasive tests (e.g., PFTs, ECG) should be done and recorded prior to advanced imaging.
Initial imaging: chest x-ray is commonly required before CT; include date and report.
Conservative management: document trials such as anti-reflux therapy, GI evaluation, or respiratory therapy prior to CT for substernal chest pain when indicated.
Supporting evaluation: include ECG, echocardiogram, pulse oximetry, and PFTs when required by the condition-specific guidance.
Note
Imaging Stepwise Approach
Imaging step: follow a stepwise approach—start with standard imaging and progress to advanced studies only when prior tests are inconclusive and the results will influence management. Document each prior step and result.
Step 1: Initial evaluation with clinical exam and standard imaging (e.g., x-ray, ultrasound).
Step 2: If initial imaging indeterminate and conservative management tried when appropriate, proceed to dedicated CT or MRI per condition guidance.
Step 3: Consider PET/CT or biopsy only when advanced imaging will change management; document prior imaging age, findings, and impact on decision-making.
Note
Billing Rule
WBMRI technique and coding notes
WBMRI technique and sequences vary and are not standardized; whole‑body MRI is reportable only using CPT 76498 and generally not supported except for select indications — prior authorization or justification is required.
Billing Rule
When to use contrast (CT with vs without)
Choose CT chest with contrast (CPT 71260) for intrathoracic abnormalities or when vascular/soft tissue resolution is needed; use CT without contrast (CPT 71250) for nodule follow-up or when contrast is contraindicated.
CT without and with contrast (CPT 71270) generally has limited role; document specific rationale if requested.
Billing Rule
MRI alternatives when iodinated contrast not tolerated
If iodinated contrast cannot be tolerated, MRI chest (CPT 71552 or 71550) is an acceptable alternative; document reason for substituting MRI for CT.
Billing Rule
Vascular abnormality and x-ray abnormality contrast guidance
For suspected vascular abnormality or when chest x‑ray is abnormal, prefer CT chest with contrast (CPT 71260) or CTA chest (CPT 71275); document vascular concern when requesting contrast studies.
Billing Rule
Hemoptysis and suspected abscess contrast guidance
For hemoptysis or suspected abscess/complicated infection, use CT chest with contrast or CTA (CPT 71260/71275); reserve non‑contrast CT (CPT 71250) for patients with documented poor renal function or life‑threatening contrast allergy.
Billing Rule
CT with or without contrast — indication dependent
CT with or without contrast are both listed as medically necessary depending on indication; choose protocol consistent with the clinical question (e.g., HRCT without contrast for ILD).
Billing Rule
ILD contrast guidance
No literature supports routine IV contrast for initial or follow-up ILD imaging; avoid routine gadolinium unless evaluating other structures (pleura, mediastinum, vessels) and document rationale.
Billing Rule
Immunocompromised status and contrast guidance
In immunocompromised individuals with acute respiratory illness and equivocal/negative chest x‑ray, CT chest without contrast is medically necessary; CT with contrast may be necessary if it will affect management — document immunocompromised status and clinical signs.
Billing Rule
Preferred modality by indication (TB/NTM/fungal)
Preferred modality varies by indication: TB/NTM and fungal infections frequently require CT chest with or without contrast (CPT 71260/71250); MRI chest (CPT 71552) may be used for fibrosing mediastinitis or when CT contrast contraindicated.
Billing Rule
Nodule evaluation contrast rules
Intravenous contrast is not required to identify or characterize pulmonary nodules; CT with or without contrast (CPT 71260/71250) are both acceptable as specified — document the protocol used for baseline and follow-up studies.
For nodule follow-up, CT chest without IV contrast (CPT 71250) is generally sufficient unless contrast was requested.
Billing Rule
Nodule follow-up contrast guidance
For pulmonary nodule follow-up, use the same CT protocol as the initial study (CT without IV contrast, CPT 71250, is medically necessary for follow-up); if IV contrast was used initially and is requested, document rationale.
Billing Rule
Pleural nodule and pleural disease contrast guidance
For pleural nodules and pleural disease where parenchymal/pleural detail is required, CT chest with IV contrast (CPT 71260) is preferred for initial evaluation; document the pleural measurement and features when requesting PET/CT or further imaging.
PET/CT (CPT 78815) is medically necessary for pleural nodule/mass or pleural thickening ≥8 mm when malignancy is likely.
Routine surveillance CT for interstitial lung disease (ILD) without a clinical indication is not supported. The evidence does not support routine IV contrast for initial or follow‑up ILD imaging; contrast may be used selectively when alternative diagnoses involving pleura, mediastinum, or pulmonary vasculature are suspected.
CT chest is not indicated as a screening test for asymptomatic COVID‑19 or for individuals with mild disease in the absence of risk factors for progression. Chest radiography is the appropriate first‑line imaging modality; CT is reserved for individuals with worsening respiratory status or moderate‑to‑severe clinical features where imaging will change management.
CT is not medically necessary for routine evaluation of suspected asthma without a specific additional indication. CT may be considered when the chest radiograph is nondiagnostic and alternative diagnoses (for example allergic bronchopulmonary aspergillosis) are suspected.
Routine PET/CT is not supported as part of the standard work‑up or screening for all individuals with sarcoidosis. PET/CT (CPT 78815) is medically necessary only for narrowly defined indications such as biopsy guidance when CT lesions are inaccessible, differentiating reversible granulomatous inflammation from irreversible fibrosis when results will alter management, or assessing treatment failure where therapy will be changed.
PET/CT is not medically necessary for evaluation of non‑specific infiltrates, isolated ground‑glass opacity, or uncomplicated hilar enlargement. Serial PET/CT studies are discouraged and are considered not medically necessary unless part of an accepted staging or treatment response protocol; repeat PET/CT for routine surveillance or for lesions below characterization thresholds is not supported.
PET/CT has limited utility for small nodules. The guideline discourages routine PET/CT for solitary nodules <8–10 mm because of unreliable characterization and higher false negative rates. Repeat PET/CT without a new clinical indication is likewise discouraged; PET/CT is generally considered medically reasonable for solid nodules ≥8 mm or for pleural nodules/masses ≥8 mm when there is concern for malignancy.
Prior Authorization
PET/MRI / WBMRI prior auth and coding requirement
PET/MRI and whole‑body MRI use/reporting are limited to specific criteria; PET/MRI requires meeting PET/CT criteria or institutional unavailability of PET/CT and provider request, and is reported using CPT 78813 + 76498.
When prior CT was performed within 6 weeks and is needed for navigational bronchoscopy, document whether the prior CT is formatted for navigation; if prior CT <6 weeks but not properly formatted, CPT 76497 may be used and justification documented.
Prior Authorization
PET/CT prior auth for unexplained mediastinal nodes ≥15 mm
PET/CT (CPT 78815) is medically necessary for unexplained mediastinal nodes ≥15 mm or increasing size on follow‑up CT; prior authorization may be required and document prior CT comparisons.
Prior Authorization
Advanced imaging should be justified by prior x-ray and documented clinical evaluations
Advanced imaging should be justified by prior chest x‑ray results and documented clinical evaluations before authorization; include comparison with prior films and relevant clinical tests.
Billing Rule
Use CPT 76497 with justification when prior CT <6 weeks
When a prior diagnostic CT is <6 weeks old and a new study is requested for navigation/planning, use CPT 76497 with documented justification and prior imaging dates; otherwise, obtain CPT 71250 if prior CT ≥6 weeks.
Prior Authorization
CT prior authorization required for listed indications
CT chest (CPT 71250/71260) requires prior authorization when ordered for listed indications; include clinical documentation showing the indication (e.g., CF surveillance, COPD criteria, hemoptysis, pre/post transplant).
Prior Authorization
CT/HRCT prior auth for ILD/PPF indications
CT/HRCT ordered for ILD/PPF, diagnostic workup, or pre-procedure planning requires documentation of clinical suspicion (e.g., abnormal PFTs, exposures) and may require prior authorization.
Prior Authorization
CT prior auth expectations — support by clinical indications
CT chest (CPT 71250/71260) must document supporting clinical indications (complications, hypoxia, abnormal vitals, persistent radiographic abnormality after guideline intervals, or high‑risk COVID-19) to meet prior authorization requirements.
Prior Authorization
CT follow-up for known TB limited to ≤3 studies/3 months
Follow-up CT scanning for known TB is limited to specialist discretion and should not exceed three studies in three months without justification and prior authorization.
Prior Authorization
PET/CT prior auth for biopsy guidance or therapy assessment
PET/CT (CPT 78815) is considered/required when used to guide biopsy, assess reversible versus irreversible disease affecting treatment decisions, or evaluate treatment failure in sarcoidosis or other indicated conditions.
Prior Authorization
PET/CT recommended for solitary solid lung nodules ≥8 mm; repeat PET not covered
PET/CT is recommended for solitary solid lung nodules ≥8 mm; repeat PET is not covered — if prior CT is >3 months old obtain repeat CT (CPT 71250 or 72160) before PET/CT.
Prior Authorization
PET/CT generally required for pleural nodule/mass ≥8 mm
PET/CT is generally required for pleural nodule/mass ≥8 mm with likelihood of malignancy; include CT chest (with or without contrast) and documentation of features suggesting malignancy when requesting authorization.
Evidence standardSupporting evidence includes peer‑reviewed literature and specialty society recommendations.
GBCAs definition and note
DefinitionGadolinium‑based contrast agents (GBCAs) are MRI contrast agents that can cause T2 signal changes and are associated with tissue deposition; use should be limited to situations where additional information is necessary.
Safety noteGadolinium exposure should be minimized in individuals with low GFR due to risk of NSF; cumulative GBCA exposure should be assessed.
Pregnancy/renal ruleUse gadolinium cautiously in pregnancy and avoid in GFR <30 mL/min unless essential.
Concurrent supervision (3D rendering)
DefinitionConcurrent supervision for 3D rendering (CPT 76376/76377) requires active physician participation in and monitoring of the reconstruction process, including defining anatomy, structures to display, and images/cine loops to archive.
Coding note76376 is for rendering not requiring an independent workstation; 76377 requires an independent workstation; codes should not be used for 2D reformatting.
Prior authProviders may be required to obtain prior authorization for 3D rendering codes even if base imaging is not pre‑authorized.
Limited CT (CPT 76380) definition
DefinitionLimited CT (CPT 76380) describes a CT in which the work of a full diagnostic CT code is not performed; examples include limited sinus CT or limited slices for follow‑up of a known pulmonary nodule.
LimitationsDo not report CPT 76380 to cover extra slices of a diagnostic CT or for treatment planning purposes; it is inappropriate to report 76380 with other diagnostic CT codes to justify extra coverage.
Sequence noteThere is no specific minimum or maximum number of sequences or slices defined by CPT for CT studies.
SPECT/CT definition
DefinitionSPECT/CT is hybrid imaging that combines SPECT nuclear medicine with CT for anatomic localization and attenuation correction; reported with CPT 78830/78831/78832.
UsesCommonly used for targeted functional/anatomic studies such as parathyroid imaging and selected oncologic assessments.
CodingMultiple CPT options exist (78830–78832) depending on study timing and areas imaged.
WBMRI definition
DefinitionWhole‑Body MRI (WBMRI) — whole‑body MRI is currently reportable only using CPT 76498 and is generally not supported except for select cancer predisposition syndromes or specific autoimmune indications.
StandardizationTechnique, sequences, and reporting for WBMRI vary widely, limiting generalized support.
Coding implicationDo not report WBMRI using multiple anatomic MRI codes; use CPT 76498 when appropriate.
Chest ultrasound definition
DefinitionChest ultrasound (CPT 76604) includes transverse, longitudinal, and oblique imaging of the chest wall and mediastinum and can identify pleural effusions and guide interventions.
Axillary/breast codesBreast and axillary ultrasound CPTs include 76641/76642 (breast) and 76882 (axilla); ultrasound is useful for image‑directed biopsy.
AdvantagesNo ionizing radiation, immediate assessment, and ability to guide biopsy or drainage.
Navigational bronchoscopy definition
DefinitionNavigational bronchoscopy: guided bronchoscopy using internal sensors and a computer‑generated virtual bronchial tree requiring a thin‑cut CT with optimized reconstruction parameters for planning.
CT requirementsA thin‑cut, navigation‑formatted CT is required; prior CTs may be unusable if not properly formatted even if recently performed.
Procedure noteDo not report navigational bronchoscopy together with 3‑D rendering CPT codes 76376/76377.
Vaccine-related axillary adenopathy definition
DefinitionVaccine‑related axillary adenopathy: unilateral axillary lymph node enlargement following COVID‑19 vaccination; commonly develops within days and may persist >6 weeks; follow‑up recommendation often ≥12 weeks.
PET‑CT cautionPET/CT can be falsely positive up to 7–10 weeks post vaccination; consider vaccination timing when interpreting axillary uptake.
ManagementFor screening/surveillance exams, consider postponing non‑urgent imaging around vaccination or follow up at ≥12 weeks for ipsilateral adenopathy.
LDCT doseLow‑dose CT (LDCT) radiation dose approximately 1–2 mSv; useful for persistent symptoms and decreased lung function despite therapy (e.g., CF surveillance considerations).
Use caseLDCT techniques are recommended where feasible to reduce cumulative radiation in surveillance programs.
Contrast noteLDCT refers to dose/technique rather than a separate CPT code; use appropriate CT chest CPT when reporting.
ULDCT radiation dose note
ULDCT doseUltra‑low dose CT (ULDCT) radiation dose approximately 0.05–0.08 mSv; an emerging technique with promise for reduced ionizing radiation.
Current statusULDCT is investigational/emerging and may be used selectively; availability and protocols vary.
ReportingULDCT studies are reported using standard CT CPT codes (e.g., 71250) unless specific lung cancer screening codes apply.
COPD definition
COPD definitionCOPD: airflow reduction (FEV1/FVC <0.7 or FEV1 <80% predicted) with respiratory symptoms; exacerbation is acute worsening over <2 weeks.
Imaging roleChest x‑ray is initial imaging; CT/HRCT reserved for specific indications such as pre‑operative assessment, persistent exacerbation, or FEV1 <45% predicted.
FEV1 thresholdFEV1 <45% predicted is a documented threshold for considering CT in COPD evaluation.
ILD/DLD definition
DefinitionILD/DLD: interstitial or diffuse parenchymal lung diseases encompassing multiple pathologies affecting alveoli, airways, or interstitium; HRCT is preferred for evaluation.
Progression thresholdsProgressive pulmonary fibrosis (PPF) indicated by FVC decline ≥5% or DLCO decline ≥10% within the past year.
Contrast useNo evidence supports routine use of IV contrast for initial or follow‑up ILD imaging; contrast may be used to evaluate alternative diagnoses involving pleura/mediastinum or vessels.
EVALI definition
DefinitionEVALI: e‑cigarette or vaping product use–associated lung injury; diagnostic criteria include vaping within 90 days, bilateral pulmonary opacities on imaging, negative evaluation for infection, and no alternative diagnosis.
Imaging roleChest x‑ray first‑line; CT chest (71250/71260) indicated when x‑ray is negative but clinical suspicion persists or to evaluate severe/worsening disease.
Clinical contextConsider CT to identify extent of pulmonary involvement or rule out other diagnoses such as pneumothorax or pneumomediastinum.
NTM-PD definition
DefinitionNTM‑PD: nontuberculous mycobacterial pulmonary disease caused by organisms such as Mycobacterium avium complex, M. kansasii, M. xenopi, and M. abscessus.
Imaging roleCT chest is used to evaluate suspected NTM‑PD, monitor progression and response to therapy; chest x‑ray is initial imaging for suspected disease.
Follow‑upSerial CT imaging may be important for monitoring disease progression and response to therapy.
Pulmonary nodule definition
DefinitionPulmonary nodule: approximately rounded opacity up to 3 cm in diameter; lesions >3 cm are masses.
Measurement methodMeasure nodule size as the average of maximal long‑axis and perpendicular maximal short‑axis diameters, expressed to nearest millimeter.
Change definitionA meaningful change is an increase or decrease in average diameter of ≥2 mm.
Nodule measurement and change definition
Measurement conventionNodule size = average of maximal long‑axis and perpendicular maximal short‑axis diameters, rounded to nearest mm.
Meaningful change>=2 mm change in average diameter constitutes true size change rather than measurement variability.
Volumetry noteSemi‑automated volumetry is more sensitive for growth but requires dedicated software and is not universally available.