Prior authorization guided by clinical guideline

These evidence-based guidelines are used to evaluate appropriateness of advanced imaging and procedures; prior authorization requirements follow plan rules and the guideline when applicable.

CPT inclusion does not imply prior authorization

The presence of a CPT code in these guidelines does not automatically mean the code requires prior authorization; providers must consult plan management/authorization tools to determine PA requirements.

Prior authorization for 3D rendering codes (76376/76377)

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

• Report CPT 76376 for 3D rendering not requiring an independent workstation and CPT 76377 when an independent workstation is required.
• Document physician participation/ supervision of the reconstruction process as recommended.

SPECT/CT reporting and management

Hybrid SPECT/CT studies must be reported with the appropriate nuclear/CT CPT (78830–78832) or CPT 78072 for parathyroid SPECT/CT and follow the applicable guideline management which may include payer authorization processes.

• Report hybrid nuclear/CT as CPT 78830, 78831, or 78832 as appropriate.
• Use CPT 78072 for SPECT/CT parathyroid imaging.

PET/MRI prior authorization and reporting

PET/MRI is generally not medically necessary but may be approved when condition‑specific PET/MRI criteria are met or when all of the following apply: meets PET/CT criteria, PET/CT is unavailable, and the provider requests PET/MRI; when approved report CPT 78813 + 76498.

• When approved, report PET Whole-Body CPT 78813 plus MRI unlisted CPT 76498.
• Documentation must show PET/CT criteria met and PET/CT not available if PET/MRI requested in lieu of PET/CT.

Prior authorization and coding note for cardiac/nuclear CPTs

Certain cardiac and nuclear medicine CPT codes are enumerated in the guideline (e.g., cardiac CT/MR and myocardial PET/SPECT codes); providers should follow payer prior authorization processes where required for these procedures.

• Examples include CT/MR cardiac codes (75557–75574) and nuclear cardiology codes (78429–78454, 78800, 78803, 78830).
• Check plan-specific prior authorization requirements for listed advanced imaging CPTs.

Follow payer prior authorization processes when not specified

When the guideline text does not explicitly state prior authorization requirements for a given study, providers must follow the payer's standard prior authorization processes for that plan and procedure.

Advanced cardiac CT/MR/CTA prior authorization

For advanced cardiac CT/MR/CTA modalities enumerated (e.g., CPT 75572–75574, 71275), providers should follow payer-specific prior authorization processes when required by the plan.

• Use CPT 75574 for CTA heart (coronary arteries/bypass grafts) and CPT 75573 for congenital heart disease CT when indicated.
• Authorization expectations align with lesion‑specific indications (e.g., preoperative mapping or inconclusive echocardiography).

Prior authorization and codes (unspecified in excerpt)

Some sections reference imaging timing and codes without specifying prior authorization; when PA applicability is unclear, follow the payer's authorization process for the specific code and clinical indication.

Follow standard prior authorization processes when applicable

Follow the payer's standard prior authorization process when the guideline indicates prior authorization may apply; documentation of clinical status and indication is typically required.

• Prior authorization is implied for preoperative imaging or routine surveillance beyond standard intervals — supply clinical justification.

Advanced cardiac CT/MR usage and prior authorization expectations

Advanced cardiac CT/MR modalities (e.g., CPT 75574, 75573) and CTA Chest (CPT 71275) are identified as appropriate for mapping complex anatomy or preoperative planning and may require prior authorization per plan rules.

• Report CPT 75574 for evaluating coronary artery anomalies; CPT 75573 for congenital heart disease.
• Include documentation supporting need for advanced cross‑sectional imaging (preoperative mapping, inconclusive echo).

Prior authorization — document clinical indication for preoperative/surveillance imaging

When imaging is requested for preoperative evaluation or routine surveillance per the guideline intervals, prior authorization is typically implied and the provider must document clinical status, the indication, and timing relative to planned procedures.

• Preoperative imaging is typically performed within one month of planned procedure; include documentation to support timing.

Prior authorization for cardiac catheterization codes

Cardiac catheterization CPTs (e.g., 93593–93597) are listed as medically necessary for single ventricle patients when indicated (change in clinical status or preoperative evaluation); follow payer PA and coding rules when requesting these procedures.

• Cardiac catheterization may be authorized for SV surveillance or when clinically indicated; confirm plan PA requirements.

Frequency-based authorization should match guideline intervals

Prior authorization for serial or frequency‑based imaging should reflect the guideline-recommended intervals (for example, TTE every 3 months for a postoperative stable child with PHT and serial TTEs for MIS‑C until stabilization); provide documentation supporting the requested frequency.

• MIS‑C post-discharge scheduled TTEs: within 1 week, at 4 weeks, at 6 months, and at 1 year — document clinical rationale for each.
• Postoperative PHT surveillance intervals should be supported by clinical notes and prior imaging.

Echocardiography coding and billing accuracy

When billing echocardiography, submit charges only for the procedure actually performed and note that CPT 93320 and 93325 are included with CPT 93306 and should not be billed separately if 93306 is reported.

• Use the listed pediatric TTE code combinations (e.g., 93303 ± add‑ons or 93304 combinations) appropriate to the study performed.

Obtain and review prior imaging before ordering advanced studies

Obtain and review prior imaging and less invasive/standard studies before ordering advanced imaging; repeat imaging requires evidence of progression, recurrence, or that the repeat study will affect clinical management.

• Expect reviewers to request prior study results and clinical notes demonstrating that advanced imaging will change management.
• Avoid ordering advanced imaging as a duplicate of a recent adequate study.

Repeat imaging requires clinical justification

Repeat imaging is generally not allowed unless there is evidence of disease progression, recurrence, or the repeat imaging will affect clinical management.

Echocardiography is primary—escalate to advanced imaging if echo equivocal

Echocardiography is the primary imaging modality for many surveillance needs; if a transthoracic echo is equivocal due to persistent technical limitations (e.g., poor acoustic windows), proceed to cardiac MR/CT or MRA/CTA Chest as indicated.

• Cardiac MR/CT may be used with the same frequency as echoes if substituting for repeat echo when echo is technically inadequate.

Limit CCTA for anomalous coronary artery to defined scenarios

Cardiac CT (CCTA) to rule out an anomalous coronary artery should be limited to defined clinical situations such as mapping prior to an invasive procedure or when no prior definitive imaging demonstrating the anomaly exists.

• Use CPT 75574 for evaluating coronary artery anomalies and include documentation supporting need for CCTA (pre‑procedural mapping or lack of prior definitive imaging).

Escalate imaging from noninvasive to invasive only as indicated

For symptomatic patients, perform noninvasive imaging (TTE, stress imaging) before invasive coronary imaging; invasive or coronary imaging (CT, MRI, invasive angiography) is reserved for studies that are positive, inconclusive, or indicate the need for intervention.

• Stress imaging is indicated for new/progressing ischemia or ventricular dysfunction.
• Reserve invasive coronary angiography for cases where noninvasive studies are positive, inconclusive, or direct intervention.

Submit required clinical documentation with PA requests

When requesting prior authorization, submit adequate clinical documentation including a detailed history, physical exam, relevant labs, prior imaging, and condition‑specific information to support medical necessity.

• Include documentation of change in clinical status, reasons prior imaging was equivocal (e.g., poor acoustic windows), medication adjustments, and timing relative to planned procedures.
• For unlisted CT/MR (76497/76498) include a description of the specific procedure and provide a Category III code if available.

Documentation required for unlisted CT/MR procedures (76497/76498)

When reporting an unlisted CT or MR procedure (CPT 76497 or 76498), document the specific procedure and clinical scenario and provide a Category III code if available to describe the work performed.

• Use 76497/76498 for navigation/planning (e.g., neurosurgical navigation, custom joint arthroplasty) when no anatomic site-specific code exists.

Document clinical justification and context for imaging

Document clinical status changes, reasons prior imaging was equivocal (for example, persistent poor acoustic windows), medication adjustments, and timing relative to planned surgery to support imaging beyond routine surveillance.

Support post-procedure TTE timing with documentation

Post‑procedure transthoracic echocardiography schedules (for example, one TTE within 30 days and one within 6 months after PFO closure) must be supported by documentation indicating the timing and clinical indication.

• For PFO post‑closure: TTE one time within 30 days and one time within 6 months; additional imaging for concerns (infection, malposition, embolization, persistent shunt) should be documented.

Required clinical justification for MIS‑C imaging and repeats

Documentation should show clinical concern for MIS‑C or cardiac involvement when requesting initial or repeat imaging; repeat studies must state how results will affect treatment or show new signs/symptoms.

• Serial TTEs during MIS‑C are approved if results will affect treatment (e.g., IVIg) or if there are new signs/symptoms.
• Post‑discharge MIS‑C TTE schedule (1 week, 4 weeks, 6 months, 1 year) should be justified in the record.

Billing accuracy — submit charges only for procedure performed (echo codes)

Billing must accurately reflect the echocardiography procedure actually performed; CPT 93320 and 93325 are included with CPT 93306 and should not be billed separately when 93306 is reported.

• Submit charges only for the procedure actually performed and use the appropriate pediatric TTE code combinations listed in the guideline.

Denial risk for research‑only or nonstandard imaging

Imaging studies performed solely for research, data collection, or otherwise inconsistent with established clinical standards are not medically necessary and may be denied.

Research/clinical trial and non‑clinical imaging requests risk denial

Requests for imaging that are inconsistent with established clinical standards or requested for data collection in clinical trials (when not used in direct clinical management) may be denied.

PET/CT unbundling and PET/MRI denial risk

Unbundling PET/CT into separate PET and diagnostic CT CPT codes is not medically necessary and PET/MRI is generally not medically necessary; such requests or billing may be denied unless condition‑specific guidance allows them.

• PET/CT should be billed as a single combined study; separate PET + diagnostic CT codes are not appropriate.

Whole‑body CT/LifeScan screening will be denied

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

Unsupported echocardiography code (CPT 93306) — denial risk

CPT 93306 is not medically necessary for the evaluation of known congenital heart disease; claims using CPT 93306 for this purpose may be denied.

Echocardiography required before other modalities in most cases

Echocardiography is generally the required primary modality; other imaging modalities are usually considered medically necessary only after an appropriate echocardiogram unless otherwise specified.

Document change in status or planned intervention to avoid denial

Requests lacking documentation of a change in clinical status, absence of planned cardiac procedure, or no new concerning signs/symptoms may not meet the guideline's medically necessary triggers and could be denied.

• Ensure records demonstrate new/worsening signs or that imaging is requested prior to a planned intervention.

Denial risk for surveillance without documented indications

Lack of documented change in clinical status or absence of planned procedure or concerning signs/symptoms may render surveillance imaging requests inconsistent with the guideline and subject to denial.

Potential basis for denial: imaging not tied to management decisions

Requests for imaging without documentation that results would affect treatment decisions — or without new/worsening signs or symptoms — may be considered unsupported by the guideline and could be denied.

Contrast selection: avoid contrast in renal failure/allergy/pregnancy when indicated

When contrast use is a concern (renal insufficiency, allergy, pregnancy, urgent/emergent scenarios), select noncontrast studies or avoid contrast-enhanced CT/MRI as indicated; both CT and MRI carry similar risk in renal failure (GFR <30 mL/min).

• GFR <30 mL/min is cited as a threshold for heightened risk with contrast.
• MRI contrast is relatively contraindicated in pregnancy.

Follow established contrast safety guidance (ACR referenced)

General contrast and safety considerations reference ACR guidance; select contrast level (none/with/without and with) per condition‑specific recommendations.

Pediatric cardiac MRI contrast and anesthesia considerations

For pediatric cardiac MRI, imaging is typically performed without and with contrast when appropriate; plan sessions to obtain all needed body areas concurrently in children requiring anesthesia.

• Avoid repeat anesthesia sessions by obtaining all indicated MRI regions during the same session when clinically appropriate.

Select CPT by contrast usage; use CTA (75574) for coronary/bypass evaluation

Select the CPT code corresponding to whether contrast is used (many CT/MR codes distinguish contrast vs noncontrast); for coronary anomalies or bypass graft evaluation use CTA Heart with contrast (CPT 75574) including 3D post‑processing.

• Use CPT 75574 for CTA heart (coronary anatomy) when contrast and 3D postprocessing are required.
• Choose contrast-specific CPTs (e.g., 71550/71551/71552 for MRI chest; 71250/71260/71270 for CT chest).

Use MRA Chest (71555) when full cardiac MRI not feasible

If the patient cannot cooperate with a full cardiac MRI exam, perform MRA Chest alone (CPT 71555) as an alternative to visualize great vessels or when isolated vascular assessment is needed.

• MRA Chest (71555) is appropriate when the aorta or pulmonary arteries/veins need visualization beyond echocardiography or when full CMR is not feasible.