CPT code inclusion ≠ automatic prior authorization

The guideline states that listing a CPT code in the document does not mean the code requires prior authorization; providers must follow payer prior authorization policies and processes when submitting requests.

Inclusion of codes does not equal PA requirement

Inclusion of CPT codes in the guideline does not imply they are subject to management or prior authorization; providers must follow UnitedHealthcare prior authorization processes and submit required clinical documentation when applicable.

Prior authorization may be required for 3D rendering (CPT 76376/76377)

CPT 76376 and CPT 76377 require documentation of active physician supervision for 3D post-processing and providers may be required to obtain prior authorization for these 3D rendering codes even when the underlying base imaging does not require authorization.

• Document physician's concurrent supervision/participation in the reconstruction process (design of anatomic region, tissue types/structures to display, images/cine loops archived, monitoring/adjustment of 3D work product).
• Obtain prior authorization for CPT 76376/76377 when payer policy requires it even if base study (e.g., ultrasound) was not preauthorized.

Use unlisted CT/MR (76497/76498) and guidance codes per guidance

When no anatomic site–specific CT or MR code exists, report the procedure with CPT 76497 (CT) or CPT 76498 (MR); for CT/MR guidance for percutaneous tumor ablation use CPT 77013 (CT) or CPT 77022 (MR) and remember guidance codes are limited to one unit per encounter.

• Report WBMRI using CPT 76498 (other methods such as multiple separate MRI body-part codes or CPT 77084 are inappropriate).
• Use CPT 77013/77022 for percutaneous tumor ablation guidance and limit to one unit per date of service/encounter.

PET/MRI allowed only with specific criteria or guideline support

PET/MRI is generally not medically necessary except when condition‑specific guidelines allow or when all substitution criteria are met; providers seeking PET/MRI in lieu of PET/CT must document that PET/CT criteria are met, PET/CT is unavailable at the treating institution, and the provider requests PET/MRI.

• If approved, report PET/MRI as CPT 78813 + 76498.
• Submit condition-specific guideline justification or documentation that PET/CT criteria were met and PET/CT was unavailable.

Report WBMRI with CPT 76498; other methods inappropriate

Whole-body MRI (WBMRI) must be reported using CPT 76498; alternative reporting methods (multiple separate MRI body‑part codes, CPT 77084, etc.) are inappropriate and may be denied.

• Provide clinical justification referencing condition‑specific guideline support when requesting WBMRI (e.g., listed cancer predisposition syndromes).

Submit adequate documentation when requesting advanced imaging

Advanced cross‑sectional imaging (CT/CTA/MRA/MRI) is medically necessary only for the specific scenarios listed in the guideline; providers must submit adequate clinical documentation demonstrating the indication (e.g., radiographic or direct‑visualization findings) to establish medical necessity.

• When the indication is not clearly documented (for example GERD without exceptions), prior authorization may be required by the payer.
• Include pertinent history, exam, labs, prior imaging, and specialist consultation notes when applicable.

No explicit PA rules in these sections — follow clinical criteria and payer rules

The guideline excerpts do not specify payer prior authorization processes for every modality; clinical criteria are provided for when ultrasound, CT with contrast, or MRI are medically necessary and providers should follow payer rules for prior authorization.

• Ensure clinical criteria from the applicable condition section are documented when submitting requests.

Advanced imaging appropriate after initial evaluation — document prior steps

Advanced imaging (CT/MRI/CT Chest) is appropriate only after initial evaluation steps—e.g., ultrasound for thyroid nodules or specialist‑identified vocal fold paralysis—and providers should document that these initial evaluations were completed or justify exceptions.

• For thyroid nodules, document prior ultrasound or cite an exception (e.g., substernal goiter, preoperative planning).
• For idiopathic unilateral vocal fold paralysis, document specialist identification by laryngoscopy/videostroboscopy.

Parathyroid nuclear imaging requires appropriate labs and specialist indication; Choline PET/CT is investigational

Parathyroid nuclear imaging and experimental modalities must be ordered with appropriate clinical indications and specialist involvement; Choline PET/CT (CPT 78815/78816) is considered experimental and investigational and would risk denial.

• Parathyroid planar (78070), SPECT (78071), SPECT/CT (78072), ultrasound (76536), and/or 4D CT (70492) are medically necessary for preoperative localization when calcium and PTH are elevated and the intent is surgical localization.
• Choline PET/CT is investigational for preoperative localization and likely requires prior authorization or will be denied.

Document labs and ultrasound findings for thyroid uptake/ultrasound requests

Thyroid uptake studies (CPT 78012/78013/78014) and ultrasound (CPT 76536) require documentation of the biochemical or clinical indications (e.g., TSH and free T4/free T3 status, palpable nodule, or exception reasons) to justify imaging.

• Document TSH and free T4/free T3 status when requesting thyroid uptake studies per the listed biochemical criteria.
• Perform and document thyroid ultrasound prior to CT/MRI for routine nodule evaluation unless an exception applies.

Parathyroid preoperative localization must be ordered by/with surgical team and include labs

Parathyroid localization studies (planar/SPECT/SPECT‑CT, ultrasound, and/or 4D CT) are medically necessary when ordered by the surgical team or after consultation with the surgical team for preoperative localization; documentation must show elevated PTH and calcium and the intent for surgery.

• Include laboratory calcium and PTH results and a statement that imaging is for preoperative localization or that the order is placed by/with the surgical team.
• If MRI neck is requested, document re‑operation, difficult localization, or contraindication to ionizing radiation and that it was ordered by or after consultation with a parathyroid specialist.

Order specified CT/CTA/MRI/MRA only for listed neck indications and document justification

The document specifies particular CT/CTA/MRI/MRA studies as medically necessary for listed neck indications; although prior authorization specifics are not stated here, providers must document the indication and follow payer prior authorization requirements where applicable.

• When ordering CT Neck (70491) or MRI Orbit/Face/Neck (70543), include documentation of abnormal laryngoscopy, red flags, symptom duration ≥2 weeks, or suspected postoperative complication as appropriate.

Document history/exam for salivary gland imaging; ultrasound as initial study

For salivary gland imaging, providers must document a current history and comprehensive head & neck exam prior to advanced imaging; ultrasound is medically necessary as initial or additional imaging for parotid or salivary gland masses.

• Ultrasound (76536) may be ordered as initial imaging and does not have to be completed before advanced imaging when clinically appropriate.
• For CT of salivary glands, document need for IV contrast and avoid billing dual‑phase (without and with contrast) which is not medically necessary.

PA required for CT Neck (70491) or MRI 70543 unless guideline criteria documented

Prior authorization is required by the payer when ordering advanced neck imaging (CT Neck with contrast CPT 70491 or MRI Orbit/Face/Neck CPT 70543) unless documentation clearly shows abnormal laryngoscopy, red flag symptoms, persistent/progressive symptoms ≥2 weeks, or a suspected postoperative complication.

• Include results of laryngoscopy and presence/absence of red flag symptoms (weight loss, referred otalgia, hoarseness, hemoptysis, unilateral symptoms) with the request.
• If symptoms are persistent ≥2 weeks, document prior conservative therapy and findings to support advanced imaging.

Obtain clinical evaluation before ordering advanced imaging

Advanced imaging should follow a clinical evaluation by the treating provider or consultant; imaging should not be ordered prior to this clinical evaluation except for guideline‑supported scheduled follow‑up.

• Ensure medical records show a recent pertinent clinical evaluation (history, exam, labs, prior imaging) when submitting imaging requests.

Do not use CPT 76380 for treatment planning

CPT 76380 (limited or follow‑up CT) is not medically necessary for treatment planning and should not be used as a substitute for appropriate diagnostic CT codes for planning purposes.

• Do not bill CPT 76380 to cover 'extra slices' or as a treatment‑planning substitute; use unlisted CT or appropriate diagnostic CT codes if needed.

Step therapy: prefer PET/CT first; PET/MRI only if PET/CT criteria met and unavailable

For PET/MRI requests providers must first consider PET/CT per guideline criteria; PET/MRI may be used only when PET/CT criteria are met and PET/CT is not available at the treating institution.

• When requesting PET/MRI as a substitute, document that PET/CT criteria were met and PET/CT was unavailable; if approved report as CPT 78813 + 76498.

Perform targeted GI or swallow studies before advanced imaging for dysphagia

Initial imaging for esophageal dysphagia should be barium esophagram or upper GI endoscopy prior to advanced imaging; for oropharyngeal dysphagia, VFSS (MBSS) and direct visualization are first‑line before CT unless a documented anatomic abnormality exists.

• If direct visualization shows an anatomic abnormality, CT Neck with contrast (70491) is medically necessary without requiring a radiographic swallow study.
• If laryngoscopy is normal but red flag symptoms exist or symptoms persist, barium esophagram or endoscopy should precede CT/MRI as specified.

Require 2‑week conservative therapy trial before advanced imaging for acute lymphadenitis

A 2‑week trial of conservative therapy (including antibiotics if appropriate) is recommended before ordering advanced imaging for painful acute cervical lymphadenitis; if nodes improve, advanced imaging is not medically necessary.

• Document the trial of conservative therapy and its duration when submitting imaging requests for persistent lymphadenopathy.

Ultrasound‑first pathway for thyroid nodule evaluation

For routine thyroid nodule evaluation, perform and document ultrasound (CPT 76536) prior to CT or MRI except in defined exceptions (e.g., substernal goiter, preoperative planning); CT/MRI are not first‑line.

• If ultrasound was not performed, document the clinical exception that justifies proceeding directly to CT/MRI.

Follow recommended sequencing for parathyroid localization and document surgical intent

When preoperative parathyroid localization is intended, select modalities in sequence per guideline — nuclear scan ± ultrasound ± 4D CT — and document specialist consultation and the surgical intent.

• Include lab evidence (elevated PTH and calcium) and a statement that imaging is for preoperative localization.
• 3‑D imaging (76376/76377) is medically necessary with 4D CT neck when requested for surgical planning.

Annual ultrasound surveillance for unresected parathyroid incidentaloma when labs normal

For unresected incidental parathyroid masses with normal labs, annual surveillance with neck ultrasound (CPT 76536) is medically necessary; document lab results and surveillance plan when ordering imaging.

• If imaging is requested for localization in the setting of planned surgery, include laboratory calcium and PTH and surgical team consultation documentation.

Ultrasound is acceptable initial imaging for salivary gland masses; document exam

Ultrasound (CPT 76536) is medically necessary as initial or additional imaging for parotid or other salivary gland masses and does not need to be completed prior to advanced imaging when clinically appropriate; document history and head & neck exam.

• Submit current history and comprehensive head & neck exam to support any advanced imaging request for salivary gland pathology.

Obtain targeted GI evaluation (barium esophagram or endoscopy) before advanced neck imaging when laryngoscopy normal

For persistent throat symptoms with dysphagia/odynophagia and normal laryngoscopy (no red flags), obtain barium esophagram or GI upper endoscopy before advanced neck imaging as required by the guideline.

• If laryngoscopy is abnormal or red flags are present, document those findings to justify CT Neck (70491) or MRI (70543) without prior barium/endoscopy.

CPT code listing does not imply PA requirement (reminder)

Reminder: inclusion of CPT codes in the guideline does not mean they require prior authorization — follow payer prior authorization policies and processes.

Submit adequate clinical documentation to establish medical necessity

Providers must submit adequate clinical information to establish medical necessity for advanced imaging, including history, physical exam, relevant labs, prior imaging, and any specialist consultation as specified in condition‑specific sections.

• Condition‑specific sections may require additional documentation (e.g., prior x‑rays for spine/MSK, laryngoscopy results for hoarseness/dysphagia).

Document active physician supervision for 3‑D reconstruction

For 3‑D reconstruction (CPT 76376/76377), document the physician's active supervision or participation in the reconstruction process, including the anatomic region selected, tissue/structure determinations, archived images/cine loops, and monitoring/adjustment of the 3‑D work product.

• Include evidence of concurrent supervision in the medical record to support billing for CPT 76376/76377.

Use CPT 76497/76498 when anatomic site‑specific codes are unavailable

When anatomic site‑specific CT or MR codes are unavailable, report the study using unlisted CT (CPT 76497) or unlisted MR (CPT 76498) and follow Management of Unlisted Codes guidance.

• For WBMRI specifically, report with CPT 76498; do not report WBMRI using multiple separate MRI body‑part codes or CPT 77084.

Provide condition‑specific justification for WBMRI or PET/MRI exceptions

When requesting WBMRI or PET/MRI exceptions, provide clinical justification referencing condition‑specific guideline support (e.g., designated cancer predisposition syndromes) or document that PET/CT criteria are met and PET/CT is unavailable.

• Include specialist consultation notes and explicit mention of the syndrome or condition that supports WBMRI or PET/MRI coverage.

Document anatomic abnormalities on direct visualization for CT Neck in oropharyngeal dysphagia

CT Neck with contrast (70491) for oropharyngeal dysphagia requires documented anatomic abnormalities on direct visualization (flexible laryngoscopy, rigid video stroboscopy, or FEES) to justify the study.

• Include the direct visualization report or images when submitting requests for CT Neck for oropharyngeal dysphagia.

Document timing relative to surgery for post‑operative dysphagia imaging

For post‑operative dysphagia imaging, document the timing relative to surgery (immediate within 3 months versus delayed ≥3 months) as this determines whether CT Neck/Chest with contrast is justified immediately or whether endoscopy/esophagram/VFSS should guide further imaging.

• State surgery date and relationship of symptoms to the operation in the imaging request documentation.

Provide prior ultrasound results when proceeding to CT/MRI

Prior ultrasound results should be available when listed as a reason to proceed to CT; document prior ultrasound findings, duration, size, texture, associated symptoms, and history of malignancy when relevant to justify CT or MRI.

• Attach prior ultrasound reports/images or summarize key findings when submitting advanced imaging requests.

Specialist identification required for vocal fold paralysis imaging

For new idiopathic unilateral vocal fold paralysis, the diagnosis must be identified on videostroboscopy or laryngoscopy by an Otolaryngologist‑Head and Neck surgeon (or clinician in consultation with such a specialist) to support advanced imaging.

• Include the specialist's laryngoscopy/videostroboscopy report in the imaging request for MRI brain, MRI neck, or CT neck/chest imaging.

Include calcium and PTH labs and surgical intent for parathyroid imaging requests

For parathyroid imaging requests (including incidentaloma), include laboratory calcium and PTH results and the clinical rationale (e.g., planned surgery or surgical team consultation) to justify imaging.

• If ordering preoperative localization, state that the order is by or in consultation with the surgical team and include relevant lab values.

Document TSH and thyroid hormone levels for thyroid uptake studies

For hyperthyroidism workup and requests for thyroid uptake studies (CPT 78012/78013/78014), document TSH and free T4/free T3 status to show the biochemical indications listed in the guideline are met.

• Attach recent thyroid function tests to the imaging request when applicable.

Document labs and clinical rationale for parathyroid incidentaloma imaging

When requesting parathyroid imaging for an incidentaloma, include laboratory calcium and PTH results and clinical indication such as planned neck surgery or surgical team consultation to support medical necessity.

• If labs are normal, note that parathyroid nuclear scans are likely low‑yield and explain the clinical rationale for imaging.

3‑D rendering is medically necessary as add‑on for surgical planning when requested

3‑D rendering (CPT 76376 or CPT 76377) is medically necessary as an add‑on to CT Neck (CPT 70491 or 70490) when requested for surgical planning (e.g., Eagle syndrome); document the surgical planning need.

• Include statement that 3‑D rendering is requested for surgical planning and document the expected incremental benefit over standard reconstructions.

Provide current history and comprehensive head & neck exam for salivary gland imaging

Current history and a comprehensive head & neck exam are required prior to any advanced imaging for suspected salivary gland pathology; include those findings when submitting imaging requests.

• Document relevant symptoms, physical exam findings, and prior interventions or surgeries in the request.

Document laryngoscopy findings and red flags for hoarseness imaging requests

When requesting advanced imaging for hoarseness, document laryngoscopy results and presence or absence of red flag symptoms (weight loss, referred otalgia, hoarseness duration, hemoptysis, unilateral findings) to justify CT/MRI.

• If laryngoscopy is abnormal (e.g., immobile vocal cord), include the laryngoscopy report to support advanced imaging.

Risk of denial for imaging requested solely for data collection or inconsistent with standards

Imaging requests inconsistent with established clinical standards or requested for data collection not used in direct clinical management may be considered not medically necessary and are subject to denial.

Denial risk for duplicate or unsupported repeat imaging

Repeat imaging or pre‑operative imaging may be denied if not supported by evidence of disease progression/recurrence or if the underlying surgery/procedure is not medically necessary; review prior studies before ordering repeats.

• Attach prior imaging reports and document clinical change or rationale that justifies repeat imaging.

Denial risk if PA not obtained for 3‑D rendering

Failure to obtain prior authorization when required for 3‑D rendering (CPT 76376/76377) may trigger denial even if the base imaging study did not require authorization.

• Check payer prior authorization rules for 3‑D rendering codes and obtain PA when required.

Whole‑body CT/LifeScan screening is not covered

Whole‑body CT or LifeScan for screening of asymptomatic individuals is not a covered benefit and will be denied.

WBMRI generally noncovered — provide syndrome‑specific justification if requested

WBMRI is generally not medically necessary except for select cancer predisposition syndromes and certain autoimmune conditions; lack of standardization and outcome evidence may lead to denial for other uses.

• If requesting WBMRI outside listed syndromes, include strong condition‑specific justification and specialist input.

PET/MRI generally noncovered — risk of denial without meeting criteria

PET/MRI is generally not medically necessary for most oncologic and neurologic conditions; coverage is allowed only when specific criteria are met and lack of such justification may lead to denial.

• Document condition‑specific criteria or PET/CT unavailability and provider request for substitution to support PET/MRI.

Denial risk for advanced imaging for GERD without documented exception

Advanced imaging for GERD is not medically necessary except in defined exceptions; requests lacking documented exceptions may be denied.

• Provide documentation of exceptional indications (e.g., refractory symptoms with consideration of gastroparesis and gastric emptying study) when ordering advanced imaging for GERD.

Denial risk if imaging ordered before a 2‑week conservative therapy trial for acute lymphadenitis

Imaging after only a brief (<2 weeks) trial of conservative therapy for presumed infectious/inflammatory cervical lymphadenitis may be denied; ultrasound is indicated only after failure of a 2‑week trial unless other criteria apply.

• Document the trial of conservative therapy and its duration when submitting imaging for persistent lymphadenopathy.

Denial risk for CT/MRI for thyroid nodule evaluation without prior ultrasound

MRI and CT are not medically necessary for routine thyroid nodule evaluation and should only be considered after ultrasound has been performed; failure to follow the ultrasound‑first pathway may risk denial.

• If requesting CT/MRI without prior ultrasound, document the clinical exception (e.g., substernal extension, preoperative planning) to justify the request.

18FDG‑PET for thyroid nodule evaluation not covered

18FDG‑PET imaging and routine preoperative 18FDG‑PET scanning for thyroid nodules (including indeterminate cytology) are not medically necessary and would risk denial.

Choline PET/CT considered experimental — risk of denial

Choline PET/CT (CPT 78815/78816) is considered experimental/investigational for preoperative parathyroid localization and is likely to be denied; obtain prior authorization only with strong investigational justification and payer approval.

Risk of low‑yield parathyroid scans when calcium and PTH normal

Parathyroid nuclear scans have a low likelihood of positive results when calcium and PTH are normal; ordering these scans in that setting is unlikely to be useful and may risk noncoverage.

• Document lab abnormalities (elevated calcium and PTH) when requesting parathyroid nuclear imaging for localization.

Further advanced imaging not necessary when CT/MRI identified local cause

If CT Neck or CT/MRI Cervical Spine has identified a local cause for symptoms, further advanced imaging is not medically necessary.

• Include prior CT/MRI findings showing the identified local cause when requesting additional imaging to justify necessity.

Dual‑phase CT (without and with contrast) not medically necessary

Dual‑phase CT imaging (without and with IV contrast) is not medically necessary and could be denied if billed as dual‑phase.

• Do not bill both non‑contrast and contrast CT phases routinely; provide clinical justification for multiphasic imaging if claimed.

Risk of denial for routine imaging in uncomplicated pharyngitis or hoarseness without abnormal laryngoscopy

Imaging requests for uncomplicated viral or streptococcal pharyngitis or for most cases of hoarseness without abnormal laryngoscopy findings are not medically necessary and may be denied.

• Ensure laryngoscopy findings or red flag signs are documented when advanced imaging is requested for hoarseness or persistent throat pain.