CurrentColorado Rocky Mountain Health PlansPolicy CSRAD017OH.E

UN-CSRAD017OH.E - Pediatric Chest Imaging Guidelinesopen_in_new

State-specific (Ohio) pediatric chest imaging clinical guidelines covering appropriate use of imaging modalities (US, CT, MRI, PET) for pediatric chest conditions, documentation requirements, investigational study criteria, and coding/billing guidance for imaging and related procedures. This part (1 of 3) includes preface, general principles, modality-specific guidance, and selected coding/billing rules (3D rendering, guidance codes, unlisted codes).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyUN-CSRAD017OH.E - Pediatric Chest Imaging Guidelinesopen_in_new

Policy CodePolicy CSRAD017OH.E

Change TypeNo material change

Effective DateFeb 3, 2026

Next Review Date

Key ActionProviders must submit detailed history, physical exam, relevant labs, and prior imaging to establish medical necessity for advanced imaging.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

V1.0.2026Guideline Version

Ohio-onlyGeographic Scope

2Low-dose CT interval (yrs)

Modality & codingContent Type

Multiple

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Procedure codes listed

Policy overview and scope

This document is an Ohio-specific pediatric chest imaging guideline (state = Ohio) — Part 1 of 3 — covering advanced imaging modalities including Nuclear Medicine (NM), Ultrasound (US), CT, MRI, and PET. The purpose is to optimize appropriate imaging, reduce overutilization, and ensure patient safety. These evidence-based guidelines are reviewed on an annual cadence and are based on national society guidance and peer-reviewed pediatric imaging literature. Policy number: CSRAD017OH.E. Guideline Version: V1.0.2026.

Document metadata

Policy NumberCSRAD017OH.E

VersionV1.0.2026

Geographic ScopeOhio-only

Effective DateFebruary 3, 2026

Content TypeIncludes modality guidance and coding

Pediatric sections represented11

High-level actionable guidance

Applicability and General Use

Applicability and General Use: This Medical Policy only applies to the state of Ohio. Any requests for services that are stated as unproven or services for which there is a coverage or quantity limit will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01.

This section applies only to individuals in Ohio. Evaluation of services described as investigational, unproven, or subject to coverage/quantity limits will follow Ohio Administrative Code 5160-1-01.

Clinical Documentation Requirements

Imaging is supported when ALL of the following are provided:

ALL of the following

Pertinent clinical evaluation since the onset or change in symptoms, including detailed history, physical examination, relevant laboratory studies, and prior imaging when applicable.
Clinical evaluation (which may include meaningful telehealth/telephone/video/electronic contact) must occur before ordering advanced imaging, except for guideline-supported scheduled surveillance follow-up studies.

Modality-specific general considerations

CT general considerations (pediatrics)

CT Chest generally performed either with contrast (CPT 71260) or without contrast (CPT 71250).

No generally accepted pediatric indications for CT Chest without and with contrast (CPT 71270).

CT should not be used to replace MRI solely to avoid sedation unless listed as recommended in a specific guideline.

Ultrasound and Nuclear Medicine general considerations (pediatrics)

ANY of the following

Ultrasound Chest (CPT 76604) medically necessary as initial study for evaluating adenopathy, palpable chest wall lesions, pleural effusion or thickening, patency of thoracic vasculature, and diaphragm motion abnormalities.

Selected pediatric condition-specific imaging indications

Lymphadenopathy (pediatric)

Axillary lymphadenopathy imaging indications identical to adult individuals; supraclavicular adenopathy is almost always pathologic.

Supraclavicular adenopathy in pediatrics is almost always pathologic; advanced imaging medically necessary prior to excisional biopsy.

Fine-needle aspiration is not medically necessary for evaluating lymphadenopathy in pediatric individuals.

ANY of the following

CT Chest with contrast (CPT 71260)
MRI Chest without and with contrast (CPT 71552)

CPT grouping and billing guidance

3D Rendering Codes (billing guidance)CPT

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

Imaging Guidance Procedure CodesCPT

19085	Biopsy, breast, with placement of breast localization device(s), first lesion, including MR guidance
19086	Biopsy, breast, additional lesion(s), 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 procedure, diagnostic nuclear medicine

MRI Xenon Contrast (Investigational)CPTExperimental

C9791

MRI utilizing Xenon Xe 129 for contrast (considered investigational)

MRI ChestCPTCovered

71550	MRI Chest without contrast
71551	MRI Chest with contrast
71552	MRI Chest without and with contrast (commonly used in pediatrics)
76498	Unlisted MRI procedure (for radiation planning or surgical software, WBMRI reporting, PET/MRI combination)

MRA / CTA / CT ChestCPTCovered

71555	MRA Chest (non-cardiac)
71250	CT Chest without contrast
71260	CT Chest with contrast
71270	CT Chest without and with contrast (no general pediatric indications)
77014	CT Guidance for Placement of Radiation Therapy Fields
76497	Unlisted CT procedure (for radiation planning or surgical software)
71275	CTA Chest (non-coronary)

PET / SPECT / Nuclear MedicineCPTCovered

78811	PET limited area (not used in pediatrics generally)
78812	PET skull base to mid-thigh (not used in pediatrics generally)
78813	PET whole body (not used in pediatrics generally)
78814	PET with concurrently acquired CT; limited area
78815	PET with concurrently acquired CT; skull base to mid-thigh
78816	PET with concurrently acquired CT; whole body
78830	SPECT/CT single area single day
78831	SPECT/CT 2 or more days
78832	SPECT/CT 2 areas with mixed days
78072	SPECT/CT parathyroid nuclear imaging (effective Jan 1, 2013)

1–10 of 15

1/2

Pulmonary Ventilation/Perfusion and Quantitative PerfusionCPTCovered

78579	Pulmonary Ventilation Imaging
78580	Pulmonary Perfusion Imaging
78582	Pulmonary Ventilation and Perfusion Imaging
78597	Quantitative Differential Pulmonary Perfusion, including imaging
78598	Quantitative Differential Pulmonary Perfusion and Ventilation, including imaging

Ultrasound / Breast / AxillaCPTCovered

76604	Ultrasound, chest (includes mediastinum, chest wall, and upper back)
76882	Ultrasound, axilla
76641	Ultrasound, breast; unilateral; complete, includes axilla when performed
76642	Ultrasound, breast; unilateral; limited, includes axilla when performed

Limited CT / Follow-up CTCPT

76380

Limited or follow-up CT (not medically necessary for treatment planning purposes)

Interpretation of Outside StudyCPTCovered

76140

Interpretation of an outside study (appropriate when secondary interpretation requested)

Quantitative MR Analysis (Category III codes)CPT

category_III

Category III CPT codes for quantitative analysis of mpMRI data (refer to condition-specific guidelines for criteria)

Chest x-ray / Ultrasound chest / CT / MRI / CTA / MRA / Echocardiography referenced CPT codesCPTCovered

76604	Ultrasound, chest (used as alternative or initial study in specified scenarios)
71260	CT, chest with contrast (multiple indications: pneumonia complications, recurrent infections, solitary pulmonary nodule one-time evaluation, cystic lung lesions, CDH when inconclusive, pulmonary sequestration alternative)
71250	CT, chest without contrast (indicated for recurrent lower respiratory tract infections; asthma indications; pectus evaluation alternative)
71275	CT angiography (CTA) chest (indicated for vascular ring, pulmonary sequestration gold standard, PAVM treatment planning)
71552	MR chest with and without contrast (radiation-free alternative; pectus deformity, congenital cystic lung disease if CT inconclusive; CDH treatment planning)
71550	MR chest without contrast (indicated for pectus deformity evaluation; pulmonary sequestration alternative; vascular ring)
71555	MR angiography (MRA) chest (indicated for vascular ring)
93303	Echocardiography, initial evaluation (vascular ring)
93306	Echocardiography, complete (noted in pectus evaluation and vascular ring)
93320	Doppler echo (noted for vascular ring evaluation)

1–10 of 11

1/2

Key coding rules: use unlisted procedure codes 76497 (CT), 76498 (MR), or 78999 (diagnostic nuclear medicine) only when no anatomic site–specific CPT exists and prefer a Category III code if one exists; CPT 76380 is restricted to limited or follow-up CT and must not be used to cover 'extra slices' or for treatment planning; PET/MRI performed in lieu of PET/CT should be reported using the convention 78813 + 76498 when PET/CT criteria are met but PET/CT is unavailable. Additionally, Category III quantitative MR analysis codes take precedence over unlisted codes when applicable.

Actionable documentation, prior auth and billing rules

Documentation Required

Submit Pertinent Clinical Evaluation

Submit a complete, pertinent clinical evaluation with all requests for pediatric chest imaging. This documentation is required to establish medical necessity and should accompany the request (electronic or prior authorization). Condition-specific guideline sections may require additional information.

Pertinent history/physical/labs/prior imaging; condition-specific sections may require additional documentation.

Prior Authorization

Prior Authorization May Be Required for 3D Rendering Codes

Prior authorization may be required for 3D post-processing/rendering codes when billed in addition to an imaging study. Authorization requirements may apply even when the base imaging procedure is separately covered.

Affected codes: 76376, 76377
PA may be required independently of the base imaging procedure.

Evidence base and references

Evidence and references: the guideline incorporates American College of Radiology (ACR) practice parameters and multiple society practice parameters, cites the FDA gadolinium safety communication (May 16, 2018), and references NCCN and peer‑reviewed pediatric imaging literature. The body of evidence includes ACR practice parameters for CT, MRI, PET, and US and other society guidelines and pediatric imaging studies used to support modality- and condition-specific recommendations.

Evidence sources

FDA safety communicationsSafety communications regarding gadolinium retention and class warnings cited (FDA May 16, 2018)

ACR Practice ParametersMultiple ACR practice parameters and society guidelines cited (CT, MRI, PET, US)

Version (as cited in evidence list)V1.0.2026

Referenced guidance examplesACR practice parameters, NCCN guidelines, peer-reviewed pediatric imaging literature cited

Terms used in this guideline

Term	Definition
Concurrent supervision (3D rendering)	Active physician participation in and monitoring of the reconstruction process including design of anatomic region, determination of tissue types to display, images to archive, and monitoring adjustment of the 3D work product.
Meaningful technological contact	Telehealth visit, telephone call, electronic mail or messaging since onset/change in symptoms that can serve as pertinent clinical evaluation.
Nodule	Any pulmonary or pleural lesion that is a discrete, spherical opacity 2-30 mm in diameter surrounded by normal lung tissue. A larger nodule is called a mass.

Document history and versioning

2026-02-03EffectiveLatest

Guideline effective date; Version V1.0.2026

02/01/2024Revision

Annual evidence-based updates (historical policy revision)

07/01/2024Revision

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyUN-CSRAD017OH.E - Pediatric Chest Imaging Guidelinesopen_in_new

Policy CodePolicy CSRAD017OH.E

Change TypeNo material change

Effective DateFeb 3, 2026

Next Review Date

Key ActionProviders must submit detailed history, physical exam, relevant labs, and prior imaging to establish medical necessity for advanced imaging.

SourceLink

On This Page

Submission of medical records pertinent to the requested imaging, including clinical notes, prior imaging reports and images, and any relevant laboratory or microbiology results.

Condition-specific guideline sections may require additional supporting clinical information; where specified, those requirements must be met.

Age Considerations for Pediatric Imaging

Age routing: determine whether pediatric-specific criteria apply.

ANY of the following

If age <= 18 years: Route to Pediatric Imaging Guidelines (PEDCH sections) for conditions discussed in pediatric-specific sections. Pediatric-specific recommendations, dosing, radiation-sparing protocols, and modality preferences apply.
If age > 18 years: Route to General Imaging Guidelines. Use adult sections unless a pediatric section explicitly specifies management for adults.

Investigational / Experimental Studies

Investigational / Experimental Studies: A study is considered investigational/experimental if ANY of the following apply:

ANY of the following

There is a paucity of supporting evidence in peer-reviewed medical literature for the study, procedure, or device.
Clinical utility has not been demonstrated for the indication in question.
Evidence has not matured to show improved health outcomes or meaningful clinical benefit.
There is no collective opinion of support from relevant physician specialty societies or expert clinicians.
Requested imaging is for data collection in a research context and is not being used to directly guide clinical management.

Clinical Trial Imaging

Clinical Trial Imaging: Clinical trial–related imaging may be supported when ALL of the following are met:

ALL of the following

Imaging is consistent with established clinical standards for the individual's condition and is used to guide direct clinical management of the participant.
The imaging request and protocol are necessary for the participant’s clinical care rather than solely for data collection or research endpoints.
Supporting documentation indicates the imaging is part of an approved clinical trial (e.g., trial protocol, IRB approval) and describes how results will be used in patient care.

General Pediatric Chest Imaging - Preconditions

General Pediatric Chest Imaging - Preconditions: Advanced imaging of the pediatric chest is supported only when ALL preconditions are met:

ALL of the following

A pertinent clinical evaluation has been performed since onset or change in symptoms; face-to-face or documented meaningful technological contact is required as specified by the condition-specific section.
Imaging is not being requested for asymptomatic screening without a guideline-supported surveillance indication.
Repeat advanced imaging is supported only for documented clinical progression, change in symptoms, or guideline-supported surveillance — not for routine repeated screening without change.
When MRI is considered for pediatric chest indications, MRI general considerations such as need for sedation/anesthesia planning, use of pediatric-specific protocols, and attention to radiation-free alternatives should be applied.
Limited/follow-up CT (CPT 76380) may be appropriate when targeted assessment of a known abnormality is required rather than a full diagnostic CT; documentation should describe prior imaging, the specific limited region/sequences requested, and the clinical rationale for a limited study.
Pediatric age routing: individuals ≤18 years should be imaged per Pediatric Chest Imaging Guidelines; individuals >18 years follow General Imaging Guidelines unless otherwise directed.

Condition-Specific Pediatric Chest Indications

Condition-specific pediatric indications (high-level): when pediatric imaging is supported the following condition-based considerations apply.

ANY of the following

Mediastinal Mass (pediatric): Cross-sectional imaging with contrast-enhanced CT or MRI is supported to characterize mediastinal masses, evaluate extent, airway/vascular compression, and plan management; MRI preferred when feasible to reduce radiation, with sedation and anesthesia considerations documented.
Hemoptysis (pediatric): CT angiography or contrast-enhanced CT may be supported for evaluation of significant or recurrent hemoptysis or when endobronchial or vascular sources are suspected; initial evaluation should include chest radiograph and otolaryngology/ENT assessment as clinically indicated.
Cystic Fibrosis (pediatric): Chest CT (low-dose, noncontrast or as specified) for baseline or surveillance of pulmonary disease and bronchiectasis may be supported per guideline intervals; MRI may be considered as radiation-free alternative when available and diagnostically adequate.
Bronchiectasis not associated with CF (pediatric): High-resolution chest CT is supported to confirm bronchiectasis, assess extent, and guide management; use pediatric dose-reduction protocols and consider MRI when appropriate.
Bronchiolitis (pediatric): Advanced imaging is generally not indicated for routine bronchiolitis; chest radiograph may be used for atypical presentations or concern for complications. CT/MRI reserved for persistent, complicated, or atypical courses with supporting clinical documentation.
Pneumonia (pediatric) - Medically Necessary Indications: Chest radiograph is first-line. Advanced imaging (CT) may be supported for complicated pneumonia, suspected empyema, necrotizing pneumonia, airway foreign body, or lack of expected clinical improvement; document clinical course and prior imaging. Routine CT for uncomplicated community-acquired pneumonia is not supported.
Coronavirus Disease 2019 (COVID-19) (pediatric): Imaging is reserved for pediatric patients with moderate to severe disease or when complications are suspected; chest radiograph or ultrasound may be first-line; CT only when results would change management or to evaluate complications.
Positive PPD or Tuberculosis (pediatric): Chest radiograph is standard initial imaging for evaluation of latent or active TB exposure. CT or MRI reserved for suspected complicated disease, dissemination, or when radiograph is inconclusive and clinical suspicion remains high.
Pectus Deformities (pediatric): Imaging (CT or MRI) may be supported for preoperative assessment or surgical planning to evaluate degree of deformity and cardiopulmonary impact; consider MRI to avoid radiation when diagnostic.
Vascular Ring and Other Vascular Malformations (pediatric): Contrast-enhanced CT angiography or MR angiography is supported to define vascular anatomy causing airway or esophageal compression; MRI/MRA preferred to minimize radiation when feasible and diagnostically adequate.
Congenital Cystic Lung Diseases (pediatric): Contrast-enhanced CT or MRI is supported to characterize congenital pulmonary airway malformations, bronchopulmonary sequestration, and other cystic lung lesions for diagnosis and surgical planning; prefer MRI to reduce radiation if adequate.
Pulmonary Arteriovenous Malformations (pediatric): CT angiography or MR angiography is supported for diagnosis, anatomical mapping, and pre-procedural planning; documentation should include history of hereditary hemorrhagic telangiectasia if present.
Congenital Diaphragmatic Hernia (pediatric): Cross-sectional imaging (CT or MRI) is supported for detailed anatomic assessment, extent of herniation, and operative planning; MRI is preferred when clinically feasible to avoid radiation exposure.

Pulmonary V/Q imaging (CPT 78582) is medically necessary for suspected pulmonary embolism if CT is unavailable.

Pulmonary Perfusion Imaging (CPT 78580) is medically necessary for follow-up of equivocal/positive V/Q (78582); not medically necessary in lieu of 78582 for initial evaluation.

Pulmonary Ventilation Imaging (CPT 78579) is not medically necessary in lieu of 78582 for PE evaluation but is medically necessary for additional evaluation of abnormal perfusion-only scan (78580).

Quantitative Differential Pulmonary Perfusion (CPT 78597/78598) medically necessary for preoperative planning of segmental/lobar/lung resection and post-lung transplant regional perfusion evaluation.

Radiopharmaceutical imaging of inflammatory process (CPT 78800–78803) medically necessary for sarcoidosis or drug toxicity evaluation.

SPECT/CT and PET/MRI; Whole-Body CT and Whole-Body MRI; Unlisted CT/MR codes usage

Unlisted CT/MR codes usage: Use CPT 76497 (unlisted CT), 76498 (unlisted MR), or 78999 (unlisted diagnostic nuclear medicine) when an anatomic site-specific code is not available. If a Category III code exists that describes the procedure, it must be reported rather than an unlisted code. CPT 76497/76498 medically necessary for neurosurgical navigation/Stealth or Brain Lab imaging, custom joint arthroplasty planning, or when thinner cuts or different positional acquisition than prior diagnostic study are needed (e.g., navigational bronchoscopy).

SPECT/CT and PET/MRI: SPECT/CT hybrid nuclear/CT reported as CPT 78830/78831/78832. PET/MRI generally not supported except when condition-specific criteria met OR when ALL of: meets PET/CT guideline criteria AND PET/CT unavailable at treating institution AND provider requests PET/MRI in lieu of PET/CT. When PET/MRI criteria met, report as PET Whole-Body CPT 78813 + MRI Unlisted CPT 76498; other reporting methods inappropriate. Diagnostic MRI codes can be medically necessary concurrently when appropriate.

Whole-Body CT and Whole-Body MRI: Whole-body CT for screening asymptomatic individuals is not a covered benefit. Whole-body low-dose skeletal CT supported for oncologic staging in multiple myeloma. Whole-body MRI generally not supported except for select cancer predisposition syndromes and some autoimmune conditions; no established CPT/HCPCS codes for WBMRI — reportable only using CPT 76498.

Cystic fibrosis monitoring threshold

Low dose CT interval for cystic fibrosis monitoringevery 2 years

Ultrasound Chest (CPT 76604)

title_line_error_fixing_placeholder": "Lymphadenopathy (pediatric)" } ,{

Billing Rule

Do Not Bill 3D Rendering with Specific Studies

Do not bill 3D rendering codes concurrently with certain anatomic imaging studies when coverage or bundling rules exclude separate reporting of 76376/76377. Review plan-specific coding guidance before billing.

Affected codes: 76376, 76377

Billing Rule

Single Unit for Guidance Codes per Encounter

Guidance/needle localization and similar guidance codes are limited to a single unit per encounter for the same targeted site. Bill one unit per encounter unless separate, distinct sites or separate encounters are documented.

Affected codes: 77012, 77021, 76942, 77002, 77003
Single unit per encounter unless documentation supports distinct separate sites or separate encounters.

Billing Rule

Breast Biopsy Coding

Breast biopsy and image guidance coding must reflect the procedure performed. Use the percutaneous biopsy codes appropriately with the.image-guidance code as indicated; do not duplicate billing for the same service.

Affected codes: 19085, 19086, 77021
Use 19085/19086 for percutaneous breast biopsy; report 77021 when separate image-guidance is performed and not included in the biopsy code.

Billing Rule

CPT 77013 Use Limitation

Do not substitute CPT 77013 when reporting services better described by other codes (for example, certain radiation oncology/planning codes such as 20982). Select the most specific code that describes the service.

Affected codes: 77013, 20982

Documentation Required

Anesthesia planning for MRI

For pediatric MRI requiring anesthesia, document the clinical rationale for anesthesia use (typically for children <7 years or when clinically necessary). Include a plan to minimize repeat anesthesia exposures and, when IV access is present, consider performing MRI without and with contrast in the same session to avoid repeat sedation.

Document need for anesthesia for children <7 years or when clinically necessary.
Document plan to minimize repeat anesthesia exposures.
Consider performing MRI with and without contrast in the same session if IV access is present.

Prior Authorization

One-time CT for solitary pulmonary nodule

One-time CT for evaluation of a solitary pulmonary nodule may require prior authorization when specified by the plan. Obtain prior authorization for CT chest nodule characterization when required by the member's plan.

Affected code: 71260
Obtain prior authorization for CPT 71260 when required by the plan.

Billing Rule

Unlisted code use

Unlisted or miscellaneous imaging codes should be used only when no anatomic-specific code exists. Use Category III temporary codes or the appropriate specific CPT code when available. Do not use unlisted codes to bypass established coding rules.

Report 76497/76498/78999 only when no anatomic-specific CPT code exists.
Prefer Category III codes when applicable.

Denial Risk

Whole-body CT screening

Whole-body CT screening (so-called screening WBC/LifeScan or similar) is not covered. Avoid ordering whole-body CT for screening purposes; such claims are at high risk for denial.

Screening whole-body CT is not covered and may be denied.

Documentation Required

Document therapeutic non-response for imaging escalation

When escalating imaging for therapeutic non-response (for example, worsening pneumonia or uncontrolled asthma symptoms), document failure or inadequate response to standard therapy prior to higher-level imaging or procedures.

Affected code: 76604
Document therapeutic non-response (e.g., failed standard antibiotic therapy for pneumonia or inadequate response to asthma therapy) when requesting escalated imaging.

Documentation Required

Indication documentation for CT/MRI in immunocompromised or complicated cases

For CT or MRI in immunocompromised, complicated, or rapidly progressive chest disease, document the specific clinical rationale supporting cross-sectional imaging. Examples of acceptable clinical rationale include new or worsening oxygen requirement, concern for invasive fungal or atypical infection, neutropenic fever with pulmonary findings, persistent fever despite appropriate therapy, or suspected malignancy recurrence.

Affected codes: 71250, 71260, 71275, 71550, 71552, 71555
Document examples of clinical rationale: new/worsening oxygen requirement, neutropenic fever with pulmonary findings, concern for invasive fungal infection, persistent fever despite therapy, suspected or known malignancy needing cross-sectional staging.

Billing Rule

CPT 76380 restrictions

CPT 76380 (computer-aided detection or reconstruction not otherwise specified) has specific restrictions. Do not use 76380 to report additional image slices, trivial post-processing, or routine treatment planning that is bundled into another primary procedural code.

Affected code: 76380
Do not use 76380 to cover extra slices or routine treatment planning; report only when true, distinct complex reconstruction/post-processing not included in the primary procedure.

Prior Authorization

PET/MRI reporting rules

When PET/MRI is used instead of PET/CT, reporting may require prior authorization and documentation for the combined modality and any unlisted component. Ensure appropriate prior authorization and report PET component and any unlisted MRI component appropriately.

Affected codes: 78813, 76498
Prior authorization/documentation may be required when PET/MRI (78813 + 76498) is used in lieu of PET/CT.

Billing Rule

CPT 77011 vs Diagnostic CT Codes

Use CPT 77011 (radiographic guidance for needle placement) only when the clinical situation specifically requires radiographic (fluoroscopic) guidance and when the service is distinct from diagnostic CT imaging. Do not substitute 77011 for diagnostic CT (71250/71260/71275) or use it to bypass CT-specific coding rules. When using CT to guide biopsy or intervention, select the appropriate diagnostic CT code and the guidance/intervention code(s) that accurately describe the performed services.

CPT 77011 is for radiographic guidance and should not replace diagnostic CT codes (e.g., 71250/71260/71275).
When CT is used to guide biopsy or intervention, report the diagnostic CT and the appropriate guidance/biopsy codes rather than using 77011 to describe diagnostic imaging.

Billing Rule

Limited CT restrictions and repeat CT to avoid biopsy

Limited CT protocols (and use of codes such as 76380 for post-processing) are restricted. Limited low-dose or targeted CT to minimize radiation is acceptable when clinically justified, but do not use limited CT or post-processing codes to evade complete diagnostic coding requirements. Repeat CT to avoid biopsy is permissible when documentation supports that CT changes will alter management and that less invasive options are inadequate.

Limited CT (including low-dose or targeted protocols) must be clinically justified and documented.
Do not use limited CT/post-processing to evade appropriate diagnostic coding requirements (see 76380 restrictions).
Repeat CT to avoid biopsy is allowed when documentation shows that the imaging result will directly alter management and biopsy is higher risk or not feasible.

Documentation Required

Use of MRI chest as radiation-free alternative

When MRI is an appropriate radiation-free alternative for pediatric chest imaging (e.g., to avoid ionizing radiation in surveillance or follow-up, or when MRI better answers the clinical question), document why MRI is preferred and follow pediatric MRI protocols. MRI may be the preferred modality for serial imaging in children when clinically appropriate.

Document rationale for choosing MRI as a radiation-free alternative.
Follow pediatric MRI protocols and anesthesia/documentation expectations when applicable.

Documentation Required

Follow pediatric oncology imaging guideline for malignancy

Follow the Pediatric Oncology Imaging Guidelines for children with known or suspected malignancy. Imaging for staging, surveillance, or treatment response should follow the pediatric oncology-specific protocols and documentation requirements.

Adhere to Pediatric and Special Populations Oncology Imaging Guidelines for malignancy.
Provide oncology treatment history and specific clinical questions being addressed.

Note

Summary

Provider actions summary: Submit a full clinical evaluation (history, physical, labs, prior imaging) with imaging requests; anticipate prior authorization triggers for specific codes (e.g., 71260, 76376/76377, 78813); adhere to single-unit guidance rules for image-guidance codes; document anesthesia needs for young children and clinical rationale for CT/MRI in immunocompromised or complicated cases; prefer MRI as a radiation-free alternative when appropriate; and follow pediatric oncology imaging guidance for malignancy-related imaging.

Interim evidence-based updates (historical policy revision)

05/01/2025Revision

Annual evidence-based updates (historical policy revision)

11/06/2025Revision

Annual evidence-based updates (historical policy revision)