Colorado Rocky Mountain Health Plans Neck Imaging Policy Update

Coverage Criteria and Indications

Indications for 3D rendering

Covered when ALL of the following are met:

ALL of the following

3D rendering (CPT 76376, 76377) is requested only as an add-on to an appropriate underlying advanced imaging study (for example CT or MRI) and is supported when it provides additional anatomic detail that directly impacts surgical planning or clinical management, and the requestor documents the specific clinical question that cannot be answered by the base imaging dataset alone.
3D rendering should NOT be billed in conjunction with CAD, MRA, CTA, nuclear medicine SPECT, PET, PET/CT, mammography, MRI breast, US breast, CT colonography (virtual colonoscopy), cardiac MRI, cardiac CT, or coronary CTA.
3D rendering (CPT 76376 or 76377) should not be reported with stereotactic localization scans (CPT 77011) or with diagnostic CT codes that already generate 3D datasets for the same session (e.g., do not report 76376/76377 with 70486/77011 when the procedure inherently produces a 3D dataset).
When 3D rendering is used for surgical navigation or operative planning, the imaging and rendering request must include documentation of the planned operative procedure and how the rendered dataset will alter or guide the operative approach.

Imaging guidance billing criteria and Use of unlisted procedure codes

Operational billing criteria — follow ALL of the following when reporting guidance or unlisted procedures:

ALL of the following

When performing stereotactic localization scans that do not require interpretation by a radiologist (commonly pre-operative CT localization for navigation), report CPT 77011. If the scan is a diagnostic CT interpreted by a radiologist, report the appropriate diagnostic CT code instead of 77011.
Do not report CPT 76376/76377 with CPT 77011 or with diagnostic CT codes that represent the interpreted diagnostic study for the same session (e.g., do not bill 70486 and 76376/76377 together for the same CT session).
Unlisted procedure codes (for example CPT 76498 for whole‑body MRI or other unlisted CT/MR procedures) may be used only when no appropriate specific CPT code exists; a complete clinical description, rationale for using an unlisted code, and supporting documentation (images, prior studies, operative plans) must be submitted with the claim or prior authorization request.
When an unlisted procedure code is submitted, submit the typically-billed CPT code(s) for the most analogous procedure(s), the clinical rationale for the selection, and any available comparable code(s) with supporting documentation to facilitate coverage determination and payment.

Limited or follow‑up CT

Covered when ALL of the following documentation and reporting requirements are met:

ALL of the following

Limited or follow-up CT: When a limited CT examination (e.g., single anatomic region or targeted limited study) is clinically indicated as follow-up to a prior diagnostic study, the request must reference the prior study, specify the focused clinical question, and indicate why full regional or multi‑phase imaging is unnecessary.
Limited (follow-up) CT or CT performed only without contrast is supported in specific clinical circumstances such as follow-up of known salivary stones, post-sialography imaging, or surveillance of a previously characterized focal abnormality where reduced field of view or single-phase technique sufficiently addresses the clinical question.
Dual-phase CT (without and with IV contrast) is generally not supported unless specifically indicated in the condition-specific guideline and explicitly justified in the clinical documentation due to the increased radiation exposure associated with double contrast studies.

Whole‑body CT/MR

Not supported or investigational when any of the following apply:

ANY of the following

Whole‑body CT or ‘LifeScan’ for screening of asymptomatic individuals is not indicated and is not supported due to lack of evidence of benefit versus radiation risk.
Whole‑body low‑dose CT is supported only for specific oncologic indications described in condition-specific guidelines (for example Multiple Myeloma staging) and otherwise is not routinely supported.
Whole‑body MRI (WBMRI) is generally not supported except for select cancer predisposition syndromes or autoimmune conditions where interval WBMRI is recommended; WBMRI should be reported using CPT 76498 when applicable, and other methods of reporting WBMRI (multiple individual MRI codes or MRI bone marrow supply CPT 77084) are inappropriate.

PET‑MRI coverage

PET‑MRI coverage considerations — follow ALL of the following:

ALL of the following

PET‑MRI (hybrid PET/MR) studies are considered only when the combined metabolic and high soft‑tissue contrast information is necessary to answer a specific clinical question that cannot be adequately addressed by separate PET/CT or MRI examinations, and when the requesting clinician documents the expected incremental benefit of PET‑MRI over alternative modalities.
When PET‑MRI is performed, billing must follow established coding guidance: report the applicable PET radiopharmaceutical and imaging code(s) (for example CPT 78815/78816 for PET/CT with appropriate radiotracer codes) and the appropriate MRI code(s). If no specific CPT exists for the combined PET‑MRI procedure, an unlisted PET/CT or PET/MR code may be required and must be accompanied by detailed documentation and comparison to analogous procedures.
PET‑MRI for whole‑body screening in asymptomatic individuals is not supported. PET‑MRI ordered for staging, restaging, or specific oncologic indications should align with the oncology imaging guidelines and associated coverage rules for the radiotracer and anatomic coverage required.

CPT / HCPCS / Coding Guidance

3D Rendering CPT CodesCPTCovered

76376	3D rendering; not requiring image post-processing on an independent workstation
76377	3D rendering; requiring image post-processing on an independent workstation

3D Rendering CPT CodesCPTCovered

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 Monitoring CodesCPTCovered

76942	Ultrasonic guidance for needle placement
75989	Imaging guidance for percutaneous drainage with placement of catheter
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

Referenced Diagnostic and Procedure CodesCPT

70486	Example diagnostic CT code (referenced)
19085	Biopsy, breast, with placement of breast localization device(s), first lesion, including MR guidance
19086	Biopsy, breast, with placement ... each additional lesion, including MR guidance

Unlisted procedure codesCPT

76497	Unlisted CT procedure (diagnostic or interventional)
76498	Unlisted MR procedure (diagnostic or interventional)
78999	Unlisted procedure, diagnostic nuclear medicine

Limited CTCPTCovered

76380

Limited or Follow-up CT

SPECT/CT and hybrid nuclear/CTCPT

78830	SPECT/CT single area single day
78831	SPECT/CT 2 or more days
78832	SPECT/CT 2 areas with one day and 2-day study
78072	SPECT/CT parathyroid nuclear imaging (effective Jan 1, 2013)

Quantitative MR Analysis (Category III / investigational)CPTExperimental

0648T	Quantitative mp-MRI analysis without diagnostic MRI (single organ)
0649T	Quantitative mp-MRI analysis with diagnostic MRI (single organ)
0697T	Quantitative MRI analysis without diagnostic MRI (multiple organs)
0698T	Quantitative MRI analysis with diagnostic MRI (multiple organs)
0865T	Volumetric/quantitative MRI analysis of the brain
0866T	Volumetric/quantitative MRI analysis of the brain (paired code)

PET‑MRI reporting combinationCPT

78813

PET Whole-Body

HCPCS examples and guidanceHCPCS

C8931	MRA with dye, Spinal Canal (example HCPCS analogous to CPT 72159)
S8042	MRI, lowfield (example non-specific HCPCS to be redirected)

Outside study interpretationCPTCovered

76140

Interpretation of an outside study

Referenced CPT codesCPT

76536	Ultrasound of neck soft tissues
70491	CT Neck with contrast
70492	CT Neck without and with contrast (dual-phase)
70490	CT Neck without contrast
70543	MRI Neck without and with contrast
76377	3-D reconstruction
76376	3-D reconstruction (alternate)
78264	Gastric emptying study
71260	CT Chest with contrast
74160	CT Abdomen with contrast

1–10 of 14

1/2

Referenced imaging CPT codesCPT

70491	CT Neck with contrast
71260	CT Chest with contrast
71275	CTA Chest
71555	MRA Chest
71550	MRI Chest without contrast
71552	MRI Chest without and with contrast
76536	Ultrasound Neck
70543	MRI Orbit/Face/Neck without and with contrast
70553	MRI Brain without and with contrast
70551	MRI Brain without contrast

Imaging for recurrent laryngeal nerve palsyCPTCovered

70553	MRI Brain without and with contrast
70551	MRI Brain without contrast
70543	MRI Orbit/Face/Neck with and without contrast
70491	CT Neck with contrast
71260	CT Chest with contrast

Thyroid nodule/disease imagingCPTCovered

76536	Ultrasound Neck
70491	CT Neck with contrast
70490	CT Neck without contrast
70540	MRI Orbit/Face/Neck without contrast
70543	MRI Orbit/Face/Neck without and with contrast
71250	CT Chest without contrast
71260	CT Chest with contrast

Thyroid nuclear imagingCPTCovered

78012	Thyroid uptake study
78013	Thyroid nuclear scan
78014	Thyroid nuclear scan

Parathyroid imagingCPT

78070	Parathyroid planar imaging
78071	Parathyroid planar imaging with SPECT
78072	Parathyroid planar imaging with SPECT/CT
70492	4D CT Neck without and with contrast
76376	3D imaging (indicated with 4D CT)
76377	3D imaging (indicated with 4D CT)
70543	MRI Neck without and with contrast
71260	CT Chest with contrast (ectopic mediastinal parathyroid)
78815	Choline PET/CT (considered experimental)
78816	Choline PET/CT (considered experimental)

Billing notes / unsupported combinationsCPTNot Covered

78800

Reporting/billing for intraoperative gamma probe (not supported if done with parathyroid nuclear scan)

Referenced imaging CPT codes and notesCPT

78070	Parathyroid Planar Imaging
78071	Parathyroid Planar Imaging with SPECT
78072	Parathyroid Planar Imaging with SPECT/CT
76536	Ultrasound, soft tissues of head and neck (e.g., parathyroid/thyroid)
70492	CT, neck, with and without contrast (4D CT Neck)
70543	MRI Neck without and with contrast
71260	CT Chest with contrast
78800	Radiopharmaceutical localization intraoperative (gamma probe) — usage not supported with concurrent parathyroid scan
78815	PET imaging, tumor, whole body, 18F-choline — considered experimental for parathyroid localization
78816	PET imaging, tumor, limited area, 18F-choline — considered experimental for parathyroid localization

1–10 of 12

1/2

Referenced imaging CPT codesCPT

70491	CT Neck with contrast
70490	CT Neck without contrast
71260	CT Chest with contrast
71250	CT Chest without contrast / Expiratory HRCT
72125	CT Cervical Spine without contrast
72141	MRI Cervical Spine without contrast
70553	MRI Brain without and with contrast
70487	CT Maxillofacial with contrast
70486	CT Maxillofacial without contrast
70498	Dynamic/Positional CTA

1–10 of 12

1/2

Salivary gland nuclear imaging CPTsCPTCovered

78230	Salivary gland, static imaging (CPT® referenced in document)
78231	Salivary gland, other (CPT® referenced in document)
78232	Salivary gland, other (CPT® referenced in document)

CT/MRI/US imaging CPTs referencedCPTCovered

70486	CT Maxillofacial without contrast
70490	CT Neck without contrast
70487	CT Maxillofacial with contrast
70491	CT Neck with contrast
70540	MRI Orbit/Face/Neck without contrast
70543	MRI Orbit/Face/Neck without and with contrast
76536	Ultrasound of salivary gland (CPT® 76536)

Neck mass size threshold — >= 1.5 cm

Neck mass size threshold>= 1.5 cm

ContextOne of multiple red-flag features that support initial CT Neck with contrast

ActionConsider ultrasound (76536) first for superficial masses unless red flags present; CT indicated when size ≥1.5 cm plus other criteria

Hoarseness duration for concern — > 3 weeks

Hoarseness duration for concern> 3 weeks

ContextPersistent hoarseness >3 weeks listed among red-flag features prompting CT Neck consideration for neck mass/adenopathy

Initial stepPerform laryngoscopy as primary diagnostic test; image if laryngoscopy abnormal or red flags present

TSH threshold for thyroid uptake — TSH low/subnormal (context specific)

TSH threshold for thyroid uptakeTSH below normal range or specific subclinical thresholds (e.g., <0.1 mU/L) depending on context

IndicationThyroid uptake study (78012/78014) indicated when TSH is low with elevated free T4/T3 or subclinical hyperthyroidism scenarios per guideline

Follow-upUse ultrasound (76536) for palpable nodules or when nuclear scan suggests nodular disease

PTH threshold for parathyroid variants — PTH ≥25 pg/mL

PTH threshold for parathyroid variantsPTH ≥25 pg/mL

Clinical meaningPTH ≥25 pg/mL is consistent with primary hyperparathyroidism in the context of appropriate calcium findings

Imaging intentImaging should be for preoperative localization and ordered by or after consultation with appropriate specialist

PTH threshold (duplicate) — PTH ≥25 pg/mL

PTH threshold (duplicate)PTH ≥25 pg/mL

Use-caseApplies to normocalcemic primary hyperparathyroidism variant after excluding secondary causes; consider imaging when requested by specialist

MonitoringIf normocalcemic, monitor annually; image if progression to hypercalcemia or clinical progression

PTH threshold for secondary renal hyperparathyroidism — PTH >9x ULN (~585 pg/mL)

PTH threshold for secondary renal hyperparathyroidismPTH >9x ULN (~585 pg/mL)

ContextConsider imaging for preoperative localization in individuals with stage 3a-5 CKD (GFR <60) when PTH remains >9x ULN despite medical therapy

OrderingShould be ordered by or after consultation with a specialist (endocrinologist or parathyroid surgeon)

Prior Authorization, Documentation, and Billing Actions

Prior Authorization

Prior authorization and medical necessity review

Prior authorization and medical necessity review: Imaging requests for Ohio members will be evaluated under Ohio Administrative Code 5160-1-01 and UnitedHealthcare/InterQual criteria. Requests described as unproven, experimental, exceeding plan limits, or otherwise outside OAC/contract terms may be denied. Submit adequate clinical records to establish medical necessity.

Apply Ohio OAC 5160-1-01 when making medical necessity determinations.
Use InterQual as primary clinical criteria; when InterQual is unavailable, apply UnitedHealthcare policies approved by Ohio Medicaid.

Prior Authorization

Authorization tied to pre-procedural imaging

Authorization tied to pre-procedural imaging: Pre-procedural, pre-operative or pre-surgical imaging is only indicated when the underlying procedure is authorized or when the procedure does not require prior authorization. If the procedure requires prior authorization, obtain or reference that approval before imaging is approved.

Pre-procedural imaging may be approved only after the associated procedure is approved or if the procedure does not require PA.
Imaging for surgical planning should be directly linked to the documented intent to operate.

Billing Rule

PET‑MRI coding expectation

PET‑MRI coding expectation: PET‑MRI is generally not supported except in select circumstances. When PET‑MRI is appropriate and PET‑CT is unavailable, report PET‑MRI as PET whole-body (CPT 78813) plus MRI unlisted (CPT 76498). Other reporting methods are inappropriate.

PET‑MRI supported only when PET‑CT criteria are met and PET‑CT is not available at the treating institution and provider requests PET‑MRI in lieu of PET‑CT.
When indicated, consider adding appropriate diagnostic MRI codes if clinically necessary.

Documentation Required

Advanced neck imaging documentation requirement

Advanced neck imaging documentation requirement: Prior to ordering advanced neck imaging (CT, MRI, Nuclear Medicine), document a pertinent clinical evaluation since onset or change in symptoms — recent history, focused physical exam, relevant labs, and prior imaging. A meaningful technological contact may suffice for evaluation in some cases.

Include date and findings of recent clinical evaluation, relevant labs, and prior imaging reports.
Face-to-face evaluation may be required for certain conditions per condition-specific sections.

Prior Authorization

Advanced imaging supported when clinical criteria met

Advanced imaging supported when clinical criteria met: Cross-sectional imaging (CT/MRI/Nuclear) is supported when condition-specific criteria are met and when results will affect management. Avoid high-level testing before less invasive modalities have been considered.

Ensure imaging is expected to impact management or treatment decisions.
Repeat imaging supported only for documented disease progression, recurrence, or when it will affect clinical management.

Prior Authorization

Preoperative parathyroid localization

Preoperative parathyroid localization: For classic primary hyperparathyroidism, parathyroid imaging (planar, SPECT, or SPECT/CT) and/or ultrasound and/or 4D CT Neck (CPT 70492) are appropriate only when PTH and calcium are elevated and the intention is preoperative localization.

Preferred: SPECT/CT parathyroid imaging (CPT 78072) when available; ultrasound (CPT 76536) and 4D CT (CPT 70492) are acceptable alternatives or complements.
Choline PET/CT (CPT 78815/78816) is experimental/investigational for preoperative localization and may be denied.
Billing CPT 78800 for intraoperative gamma probe localization is not supported when performed with parathyroid nuclear scan.

Prior Authorization

Prior auth/justification for 3‑D rendering add-on

Prior authorization and justification for 3‑D rendering add-on: CPT 76376/76377 (3‑D rendering) require physician concurrent supervision/participation documentation. Prior authorization may be required for these 3‑D codes even when the base study is pre-authorized.

Document active physician participation: design of anatomic region, tissue/structure selection, images/cine loops to archive, and monitoring/adjustment of renderings.
CPT 76376 = no independent workstation; CPT 76377 = requires independent workstation.
3‑D rendering may be supported as an add‑on for surgical planning (e.g., Eagle's syndrome) when requested and documented.

Note

Check plan/state prior authorization rules

Check plan/state prior authorization rules: Always reconcile coverage decisions with applicable federal, state (Ohio OAC), and contractual benefit plan rules. In case of conflict, federal/state/contractual requirements govern.

Verify state-specific (Ohio) rules before approving or ordering imaging.
UnitedHealthcare may modify policies; confirm current PA requirements with the payer.

Denial Risk

Denial triggers and overutilization risks

Denial triggers and overutilization risks: Requests may be denied for services stated as unproven, experimental, duplicative, or excessive. Common denial triggers include double-contrast CTs, duplicate studies, MRI substitutions without support, or imaging without appropriate prior basic evaluation.

Denial triggers: experimental services, requests exceeding plan limits, and services unsupported by OAC/contract terms.
Overutilization triggers: duplicate imaging, CT without and with contrast without indication, and MRI ordered solely to avoid radiation without clinical justification.

Billing Rule

Limited CT reporting misuse

Limited CT reporting misuse: CPT 76380 (limited or follow‑up CT) should not be used for treatment planning or to inappropriately bundle with full diagnostic CT codes to cover extra slices. Limited CT is for situations where full diagnostic CT work is not performed.

Do not report CPT 76380 in conjunction with diagnostic CT codes to cover 'extra slices' or for treatment planning.
There is no numeric slice threshold in CPT; document clinical rationale for a limited protocol.

Step Therapy

Ordering CT Neck without clear indication

Ordering CT Neck without clear indication and stepwise approach: CT Neck without and with contrast (double‑phase) is rarely indicated except for 4D CT Neck (CPT 70492) for parathyroid localization. For most neck complaints, begin with direct visualization, plain radiographs, ultrasound, VFSS, or barium studies as appropriate before CT/MRI.

Avoid routine dual‑phase CT Neck (70492) unless specifically for 4D parathyroid localization.
Preferred initial modalities: direct visualization/laryngoscopy, plain radiographs, ultrasound (CPT 76536), VFSS, or barium esophagram depending on presentation.
Document prior basic evaluation findings (e.g., abnormal radiograph/visualization) before proceeding to advanced imaging.

Prior Authorization

Ultrasound required before advanced thyroid imaging

Ultrasound required before advanced thyroid imaging: For evaluation of a palpable thyroid nodule or mass, ultrasound (CPT 76536) is required as the initial imaging study prior to advanced imaging. Nuclear scans are indicated only in specific TSH/clinical contexts.

Ultrasound also indicated for nodules incidentally found on CT, MRI, or PET.
Nuclear thyroid scan (CPT 78013/78014) indicated when TSH is subnormal and other listed criteria are present.

Billing Rule

Billing restriction for intraoperative localization

Billing restriction for intraoperative localization: Reporting CPT 78800 for intraoperative gamma probe localization is not supported when performed in conjunction with parathyroid nuclear scans (CPT 78070/78071/78072).

Do not bill CPT 78800 in addition to parathyroid nuclear scan codes when both are performed together.

Denial Risk

Unsupported advanced imaging without prior basic evaluation

Unsupported advanced imaging without prior basic evaluation: Advanced imaging beyond initial radiographs or direct visualization may be unsupported if there is no documented abnormality on basic evaluation. Document abnormal findings from initial evaluation to support escalation to CT/MRI.

Document direct visualization, plain radiograph, ultrasound, or endoscopy findings that justify advanced imaging.
For trauma, begin with plain radiographs; proceed to CT/MRI only if indicated by findings or high‑risk mechanism.

Note

State/contract conflict risk

State/contract conflict risk: In the event of conflicting guidance between this policy and federal, state (OAC), or contractual requirements, the federal/state/contractual requirements take precedence. Check applicable rules before applying policy.

When conflicts exist, follow the governing federal, state (Ohio OAC), or contractual benefit terms.
Policies may be updated; verify current requirements when making coverage decisions.

Documentation Required

Required clinical documentation and physician supervision

Required clinical documentation and physician supervision: For advanced imaging requests include recent history, exam, labs, prior imaging, conservative therapy trials (when applicable), and documentation of physician supervision for procedures requiring it (eg, 3‑D rendering). Record who supervised or interpreted outside studies.

Pertinent evaluation: recent detailed history and physical since onset/change of symptoms, relevant labs, and prior imaging.
Conservative therapy: document a 2‑week trial for acute painful lymphadenopathy before advanced imaging, when applicable.
Physician supervision: document concurrent supervision/participation for CPT 76376/76377 and include supervisory notes in the medical record.
Outside study interpretation: include the outside report and date; document if independent interpretation was performed locally.

Documentation Required

Conservative therapy and indication documentation

Conservative therapy and indication documentation: For conditions like acute cervical lymphadenitis, document a trial of conservative therapy (including antibiotics if indicated) for approximately 2 weeks and clinical response prior to advanced imaging unless other criteria are met.

If mass or adenopathy fails to improve after 2 weeks, document persistence and then consider ultrasound or CT per criteria.
Record specifics of conservative management, dates, and response.

Step Therapy

Preferred modality sequencing and stepwise imaging approach

Preferred modality sequencing and stepwise imaging approach: Follow a stepwise approach tailored to the clinical question — begin with the least invasive, lowest risk modality likely to answer the question (eg, direct visualization, radiographs, ultrasound, VFSS/barium) before CT or MRI unless specialist input justifies immediate advanced imaging.

Parathyroid sequencing: planar/SPECT/SPECT‑CT ± ultrasound preferred; SPECT/CT preferred when available; 4D CT (70492) or MRI in select cases per specialist order.
For dysphagia: VFSS or barium esophagram is generally first line; CT used when initial studies are inconclusive or to evaluate suspected post‑operative complications.
Document specialist ordering rationale if bypassing typical modality sequencing.

Prior Authorization Expectations

Prior Authorization

Advanced imaging reviewed per OAC and UnitedHealthcare criteria

Requests for advanced imaging (CT, MRI, PET, NM) will be reviewed for medical necessity under Ohio Administrative Code 5160‑1‑01 and UnitedHealthcare criteria; prior authorization is implied where the plan requires it.

Prior Authorization

Preprocedural imaging authorization when procedure requires authorization

Preprocedural imaging tied to a procedure that requires prior authorization may itself require authorization; imaging is not appropriate if the procedure is not indicated.

Prior Authorization

3‑D rendering codes may require separate prior authorization

Prior authorization may be required for 3‑D rendering CPT codes even if the underlying modality is pre‑authorized.

Prior Authorization

PET‑MRI allowed in lieu of PET‑CT when PET‑CT unavailable (report 78813+76498)

PET‑MRI is appropriate only when PET‑CT criteria are met and PET‑CT is unavailable; in such cases, PET‑MRI should be reported as CPT 78813 combined with CPT 76498 and must meet combined or condition‑specific criteria.

Documentation Required

Expect documented evaluation and preliminary tests before advanced neck imaging approval

Prior documentation of clinical evaluation and relevant preliminary testing is expected before approval of advanced neck imaging (CT, MRI, CTA, MRA, US); reviewers will check submitted clinical records.

Prior Authorization

Approve cross‑sectional imaging only with documented criteria or failed initial studies

Cross‑sectional advanced imaging (CT/CTA, MRI/MRA) is supported only when specific clinical criteria are documented or when initial preferred studies have failed to resolve the clinical question.

Prior Authorization

Authorize parathyroid nuclear imaging/4D CT only with elevated PTH/calcium and preoperative intent

Parathyroid nuclear imaging (78070–78072) and/or 4D CT Neck (70492) are indicated for preoperative localization when both PTH and calcium are elevated and the study intent is preoperative localization; ordering should be by or in consultation with appropriate specialists.

Prior Authorization

CT Chest indicated for ectopic parathyroid evaluation when specialist‑ordered

CT Chest with contrast (71260) is appropriate for evaluation of ectopic mediastinal parathyroid adenomas or reoperative localization in rare circumstances, when ordered by or after consultation with a specialist; prior authorization may be required per payer rules.

Prior Authorization

3‑D rendering supported as add‑on for surgical planning

3‑D rendering codes (CPT 76376/76377) are supported as an add‑on to CT Neck (70491/70490) for surgical planning when requested.

Note

Confirm plan/state rules for prior authorization and coverage

Confirm benefit plan and state rules because prior authorization requirements and coverage decisions may differ by plan or be governed by Ohio Administrative Code.

Definitions and Key Terms

Investigational/Experimental definition

Investigational/Experimental definitionStudies, treatments, procedures, or devices lacking sufficient supporting evidence, clinical utility, or collective opinion of support are considered investigational/experimental.

Evidence basisSupporting evidence includes peer-reviewed literature, randomized trials or broadly recognized specialty society recommendations; lacking these may render an intervention investigational.

Coverage implicationInvestigational/experimental items are not supported for coverage unless evidence changes

Standard or conventional imaging definition

Standard or conventional imaging definitionInitial and subsequent evaluations using plain film, CT, MRI, or ultrasound.

RoleUsed for initial diagnostic assessment; advanced imaging reserved when conventional imaging does not answer the clinical question

Contrast considerationAppropriate use of contrast (none, with, without and with) determined by condition-specific guidance

PET/CT definition and unbundling note

PET/CT definitionPositron emission tomography typically performed combined with CT to provide metabolic and anatomic information.

Billing noteUnbundling PET and diagnostic CT codes (separate billing) is not supported according to guideline

PET/MRIPET/MRI is generally not supported except in specific condition‑based situations

Concurrent supervision definition for 3D post-processing

Concurrent supervision definitionConcurrent supervision requires active physician participation and monitoring of 3D post‑processing, including design of the anatomic region, selection of tissue types/structures to display, and monitoring/adjustment of the 3D output.

DocumentationACR recommends documenting the physician's supervision or participation in the 3D reconstruction when reporting CPT 76376/76377.

Code distinction76376 = no independent workstation; 76377 = requires independent workstation post-processing

Imaging guidance procedure codes definition

Imaging guidance procedure codes definitionCodes that contain all imaging necessary to guide a needle or catheter; do not routinely bill a diagnostic procedure code in conjunction with a guidance code.

Billing ruleOnly one unit of any guidance code should be reported per encounter; guidance codes used for percutaneous procedures only, not open surgeries.

ExamplesIncludes CT, MR, and US guidance procedure codes per CPT guidance

SPECT/CT definition

SPECT/CT definitionHybrid SPECT combined with CT for anatomic localization and attenuation correction; combines functional and anatomic information.

ReportingReported using CPT 78830/78831/78832; CPT 78072 available for SPECT/CT parathyroid imaging.

Common usesIncludes MIBG and octreotide scintigraphy for neuroendocrine tumors and parathyroid localization.

Whole‑body MRI coding note (CPT 76498)

Whole‑body MRI coding note (CPT 76498)Whole‑body MRI lacks established CPT/HCPCS codes and is reportable using CPT 76498 (MRI unlisted).

LimitationsWBMRI techniques vary widely (sequences, contrast) and lack standardization; generally not supported except for select syndromes.

Reporting guidanceDo not report multiple separate diagnostic MRI codes for WBMRI; use 76498 when appropriate.

Advanced imaging of the neck definition (anatomic boundaries)

Advanced imaging of the neck definitionCT, MRI, and Nuclear Medicine studies covering skull base to head of clavicle, including parotid and supraclavicular regions.

Included areasSkull base, nasopharynx, upper oral cavity to head of clavicle, parotid glands, supraclavicular region; ultrasound coded separately (76536).

PrerequisitePertinent clinical evaluation and basic imaging (plain radiography or ultrasound) expected prior to advanced imaging unless guideline‑supported follow-up imaging.

VFSS definition — gold standard for oropharyngeal dysphagia

VFSS definitionVideofluoroscopic swallow study (modified barium swallow) performed with a speech therapist; gold standard first‑line test for oropharyngeal dysphagia.

RolePreferred initial modality for oropharyngeal dysphagia; CT generally not first‑line for motility or mucosal evaluation.

Postoperative sensitivityParticularly sensitive post‑anterior cervical spine surgery for detecting oropharyngeal dysfunction.

Dysphagia lusoria / vascular ring definition

Dysphagia lusoria / vascular ring definitionA rare condition (often an aberrant right subclavian artery) causing compression‑related dysphagia, typically suspected in consultation with cardiothoracic/cardiology/ENT specialists.

Preferred imagingCTA Chest (71275) or MRA Chest (71555) preferred; CT Chest with contrast (71260) or MRI Chest are acceptable alternatives.

Typical populationOften congenital, suspected earlier in life but may present in adults with progressive dysphagia due to calcification or atherosclerotic changes.

Idiopathic unilateral vocal fold paralysis definition

Idiopathic unilateral vocal fold paralysis definitionDiagnosis of exclusion: vocal fold immobility on laryngoscopy with no apparent cause on history/exam; requires imaging of the entire motor nerve pathway to seek etiology.

Imaging extentImaging should visualize from brain (vagus origin) through superior mediastinum to the neck to assess recurrent laryngeal nerve course.

Clinical prerequisiteDiagnosis must be newly identified on videostroboscopy or laryngoscopy by ENT or in consultation to support imaging.

Preoperative localization (parathyroid) definition

Preoperative localization (parathyroid) definitionImaging performed to localize abnormal parathyroid tissue prior to surgical exploration; supported when PTH and calcium are elevated or per variant criteria.

ModalitiesParathyroid planar (78070), SPECT (78071), SPECT/CT (78072 - preferred), ultrasound (76536), and/or 4D CT Neck (70492); MRI reserved for re-operation or contraindication to radiation.

OrderingShould be ordered by or after consultation with an endocrinologist, parathyroid surgeon, or radiologist when intent is preoperative localization.

Classic primary hyperparathyroidism definition

Classic primary hyperparathyroidism definitionElevated serum calcium and elevated PTH; imaging intended for preoperative localization when both are present.

Imaging indicationPerform parathyroid nuclear imaging and/or ultrasound and/or 4D CT when PTH and calcium are elevated and the intent is surgical localization.

Surgical criteriaRefer to specialty guidelines for parathyroidectomy candidacy; imaging supports operative planning.

Primary hyperparathyroidism variant - normocalcemic definition

Primary hyperparathyroidism variant - normocalcemic definitionNormal serum calcium with elevated PTH after exclusion of secondary causes; monitor annually and consider imaging if progression or specialist requests surgery.

Confirmatory testingExclude secondary causes (renal insufficiency, vitamin D deficiency, malabsorption) before labeling as normocalcemic variant.

Imaging triggerIf laboratory progression to hypercalcemia or clinical progression (fracture, stones), follow classic primary hyperparathyroidism imaging guidance.

Secondary renal hyperparathyroidism imaging threshold definition

Secondary renal hyperparathyroidism imaging threshold definitionConsider imaging for preoperative localization when individual has stage 3a-5 CKD (GFR<60) AND PTH >9x ULN (~585 pg/mL) despite medical therapy.

Clinical contextUsed for tertiary/secondary hyperparathyroidism evaluation prior to parathyroid surgery when medical management fails.

OrderingShould be requested by or after consultation with a specialist (endocrinologist or parathyroid surgeon).

Eagle's syndrome definition

Eagle's syndrome definitionRecurrent oropharyngeal and facial pain due to elongated styloid process or calcified stylohyoid ligament; may compress carotid arteries in stylocarotid syndrome.

Typical featuresIpsilateral persistent pharyngeal pain referred to ear, exacerbated by head rotation; may include dysphagia or foreign body sensation.

ImagingCT Maxillofacial (70486/70487) and/or CT Neck (70490/70491); dynamic/positional CTA (70498) supported for vascular compression assessment.

Subglottic stenosis (SGS) definition

Subglottic stenosis (SGS) definitionNarrowing of the subglottic airway; CT with multiplanar reformatting is highly sensitive and specific for detection and grading of stenosis.

EvaluationCT Neck with or without contrast (70491/70490) supported after specialist visualization; expiratory HRCT (71250) supported for tracheomalacia assessment.

Clinical prerequisiteSpecialist evaluation and direct visualization required prior to CT for SGS workup.

Hoarseness definition

Hoarseness definitionAltered voice quality reported by the individual.

Initial testLaryngoscopy is the primary diagnostic modality for hoarseness; imaging reserved for abnormal laryngoscopy or red flags.

Imaging triggersImmobility of a vocal cord, growth/asymmetry/ulceration, or other suspicious findings on laryngoscopy warrant advanced imaging.

Dysphagia definition

Dysphagia definitionDisordered or impaired swallowing (food impactions, globus sensation, choking/aspiration, regurgitation).

SubtypesIncludes oropharyngeal and esophageal (retrosternal) dysphagia; initial evaluation differs by subtype (VFSS for oropharyngeal, barium esophagram for esophageal).

Imaging roleImaging is complementary to endoscopy and manometry; CT reserved when initial studies are non‑diagnostic or suspicious findings present.

Odynophagia definition

Odynophagia definitionPainful swallowing.

Imaging indicationCT Neck with contrast (70491) supported for postoperative suspected complications or when laryngoscopy abnormal with red flags.

Initial managementUncomplicated pharyngitis does not require imaging; persistent symptoms >=2 weeks warrant laryngoscopy and directed imaging if indicated.

Condition-Specific Covered Indications

See condition-specific sections for modality and indication rules

See condition-specific sections: Refer to the condition-specific guideline sections (eg Dysphagia, Neck Mass, Thyroid, Larynx, Parathyroid, Salivary Gland) for modality-specific indications, required clinical details, and sequencing rules.

Condition-specific rules govern modality, contrast, and required documentation.

Supported imaging indications by modality

Ultrasound is appropriate for initial evaluation of soft tissue masses, differentiation of adenopathy from cyst/mass, and procedural guidance; it is operator dependent and useful to triage to advanced imaging.

Ultrasound coded as CPT 76536 for neck soft tissues.

CT is appropriate for trauma screening, osseous detail, suspected acute complications (eg leaks, abscess), and when CT better answers the clinical question or MRI is contraindicated; use contrast as indicated.

Avoid routine dual-phase CT Neck except for parathyroid 4D CT (70492).

MRI is appropriate for brain/spine imaging, characterizing soft tissue masses, infection, and when prior imaging is inconclusive; avoid gadolinium in pregnancy and consider renal function.

MRI Neck 70543 indicated for deep/complex lesions or perineural invasion.

PET/CT is primarily for oncologic metabolic evaluation; PET is rarely performed alone and PET/MRI is generally not supported except in select circumstances.

Unbundling PET and diagnostic CT is not supported.

Appropriate uses for 3D rendering

3D rendering (CPT 76376/76377) can be considered in the following clinical scenarios:

3D rendering clinical scenarios: Indications include complex bony conditions (congenital skull abnormalities, complex fractures/dislocations, spine/pelvic/acetabular/intra-articular fractures), complex facial fractures, pre-operative planning for complex surgical cases, cerebral angiography, and select pelvis/abdomen indications when initial imaging is equivocal.

Concurrent physician supervision/participation in post-processing should be documented when reporting CPT 76376/76377.

Appropriate uses for imaging guidance codes

Imaging guidance codes (CPT 76942, 77011–77022, 75989) — appropriate use rules:

Guidance billing rules: Guidance procedure codes contain all imaging necessary to guide a needle or catheter; do not routinely bill a diagnostic procedure code in conjunction with a guidance code. Only percutaneous surgical procedures should be billed with guidance codes. One unit of a guidance code should be reported per encounter.

Modality-specific exclusions apply (eg 77013 not for bone ablation).

Modality‑specific appropriate indications

Unlisted CT/MR/NM: Report CPT 76497/76498/78999 when a diagnostic or interventional CT, MR, or nuclear study lacks an appropriate anatomic site-specific code; prefer a Category III code if available.

Examples include neurosurgical navigation/planning and custom joint arthroplasty planning.

Limited CT: CPT 76380 may be used to report limited or follow-up CT when full diagnostic work is not performed; it is not appropriate for treatment planning or to cover extra slices alongside diagnostic CT codes.

SPECT/CT (CPT 78830/78831/78832) combines functional nuclear imaging with CT for localization and attenuation correction; CPT 78072 is available for parathyroid SPECT/CT.

PET‑MRI conditions: PET‑MRI may be appropriate only if condition-specific PET‑MRI criteria are met OR if the individual meets PET‑CT criteria, PET‑CT is unavailable, and provider requests PET‑MRI; report using CPT 78813 + 76498 when appropriate.

When MRI neck (70543) is appropriate

When MRI Neck (70543) is appropriate: MRI Neck (70543) is appropriate when CT suggests need for further imaging or when ultrasound/CT suggest neurogenic tumor, vascular malformation, deep neck mass, angiofibroma, cystic mass, concern for malignancy including perineural invasion, or when dental amalgam obscures CT anatomy.

Dysphagia/oropharyngeal/esophageal indications

Dysphagia imaging indications: For oropharyngeal dysphagia, initial evaluation includes laryngoscopy and VFSS/FEES; CT Neck with contrast (70491) is indicated for documented anatomic abnormalities on direct visualization. For esophageal dysphagia, initial evaluation is barium esophagram or endoscopy; advanced imaging supported for structural abnormalities on initial studies. For globus, perform direct visualization first; CT Neck (70491) indicated only with red-flag symptoms or concerning history/exam.

Dysphagia (oropharyngeal and retrosternal)

First-line for oropharyngeal dysphagia: Videofluoroscopic swallow study (modified barium swallow) is generally first-line for oropharyngeal dysphagia; CT is generally not first-line because it does not assess motility or mucosal detail.

Use water-soluble contrast first when evaluating suspected leaks or fistulas.

Suspected vascular ring (dysphagia lusoria)

Suspected vascular ring imaging: When vascular ring is suspected, obtain CTA Chest (71275) OR MRA Chest (71555) as preferred studies; CT Chest with contrast (71260) or MRI Chest (71550/71552) are acceptable alternatives.

Obtain in consultation with appropriate specialty.

Neck mass / adenopathy

Neck mass / adenopathy imaging: Ultrasound (76536) for superficial masses or after 2-week conservative therapy; CT Neck (70491) for listed red flags (size ≥1.5 cm, duration ≥2 weeks, firm/fixed, non-tender, persistent hoarseness >3 weeks, etc.); MRI (70543) for further characterization or skull base/perineural concerns.size >=1.5 cm; conservative therapy trial 2 weeks

ENT evaluation and ultrasound-guided biopsy are emphasized.

Recurrent laryngeal nerve palsy / vocal fold paralysis

Recurrent laryngeal nerve palsy imaging: For new idiopathic unilateral vocal fold paralysis confirmed by laryngoscopy/videostroboscopy, image the motor pathway: MRI Brain (70553 or 70551) AND MRI Orbit/Face/Neck (70543) OR CT Neck with contrast (70491); CT Chest with contrast (71260) is strongly recommended for left-sided paralysis and may be indicated for right-sided paralysis.

Imaging supported when diagnosis established by ENT or in consultation.

Recurrent laryngeal nerve palsy workup

Workup prerequisites: Newly identified idiopathic unilateral vocal fold paralysis/immobility must be documented on videostroboscopy or laryngoscopy by an Otolaryngologist (or clinician in consultation) prior to imaging the entire nerve pathway from brain to superior mediastinum.

Thyroid nodule evaluation

Thyroid nodule initial evaluation: Palpable thyroid nodule/mass/asymmetry/goiter — perform Ultrasound Neck (76536) as the initial study before any CT/MRI; ultrasound also indicated for incidentally found nodules on CT/MRI/PET.

Advanced imaging considered only after ultrasound for specific indications (eg substernal extension, airway compression, pathologic nodes).

Primary hyperparathyroidism localization

Parathyroid localization criteria: Biochemical evidence of primary hyperparathyroidism (elevated PTH and calcium) AND intention for preoperative localization; supported modalities include parathyroid planar/SPECT/SPECT-CT, ultrasound, and/or 4D CT (70492); MRI reserved for re-operation/difficult localization or contraindication to ionizing radiation.

SPECT/CT preferred; 3D rendering indicated with 4D CT.

Classic primary hyperparathyroidism — preoperative localization

Classic preoperative localization: Elevated PTH and calcium AND intention for preoperative localization — parathyroid imaging with 78070/78071/78072 (preferred SPECT/CT), 76536, and/or 70492 are appropriate; MRI 70543 for reoperation/difficult localization when ordered by or after consultation with specialist.

Secondary renal hyperparathyroidism - preoperative localization

Secondary renal hyperparathyroidism indication: Consider imaging for preoperative localization when: stage 3a–5 CKD (GFR <60) AND PTH >9× ULN (~585 pg/mL) despite medical therapy; ordering should be by or after consultation with a specialist.PTH >9x ULN (~585 pg/mL)

Parathyroid incidentaloma evaluation

Parathyroid incidentaloma evaluation: Incidentally discovered mass suspicious for parathyroid should prompt calcium and PTH testing; if abnormal, follow hyperparathyroidism imaging guidance; if normal, follow neck mass guidance. Preoperative localization prior to planned neck surgery may include 78070/78071/78072 and/or 76536 and/or 70492 when ordered by surgical team or in consultation.

Suspected laryngotracheal pathology

Initial laryngotracheal assessment: For suspected laryngotracheal pathology, perform direct visualization (laryngoscopy/bronchoscopy) and/or plain radiographs prior to advanced imaging.

Evaluation of suspected airway foreign body

Airway foreign body evaluation: CT is supported over radiographs when there is high clinical suspicion for an airway foreign body due to greater sensitivity and ability to detect radiolucent objects; select modality based on clinical scenario.

Neck trauma and cervical spine evaluation

Trauma / cervical spine: Plain radiographs are initial for trauma without high-risk mechanism; if inconclusive, CT Neck with contrast (70491) and/or CT Cervical Spine without contrast (72125) are appropriate; MRI cervical spine (72141) supported for neurologic deficit.

Imaging modality indications

Sore throat persistent >=2 weeks: For sore throat/odynophagia persistent ≥2 weeks, initial laryngoscopy is primary; if laryngoscopy abnormal or red flags present, CT Neck with contrast (70491) or MRI OFN (70543) are indicated.duration >=2 weeks

Hoarseness indications: Laryngoscopy is primary; advanced imaging (CT/MRI) indicated when laryngoscopy shows immobile/partially mobile vocal cord or suspected neoplasm.hoarseness >3 weeks may be relevant per neck mass criteria

Modality selection overall: Select modality (US, CT, MRI, NM, PET) based on the clinical question, contraindications, and prior imaging results; document required clinical evaluation and prior tests when ordering advanced imaging.

OpenPayer

Adult Neck Imaging Guidelines (For Ohio Only)

Coverage Criteria and Indications

CPT / HCPCS / Coding Guidance

Prior Authorization, Documentation, and Billing Actions

Prior Authorization Expectations

Contrast Use, Safety, and Special Considerations

Excluded / Not Supported Services

Definitions and Key Terms

Condition-Specific Covered Indications

Repeat Imaging and Frequency Guidance

Background and Evidence Basis

Contrast Considerations (Quick Reference)