CurrentColorado Rocky Mountain Health PlansPolicy CSRAD017OH.D

Pediatric Chest Imaging Guidelines (For Ohio Only)

State-specific (Ohio) clinical guideline governing pediatric chest imaging utilization and medical necessity determination for Colorado Rocky Mountain Health Plans members in Ohio.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPediatric Chest Imaging Guidelines (For Ohio Only)

Policy CodePolicy CSRAD017OH.D

Change TypeNo material change

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionSubmit pertinent medical records and documentation of clinical evaluation to establish medical necessity when requesting advanced imaging.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

V1.0.2025guideline version

2025-11-01effective date

Ohio-onlyapplicability

Part 1document segment

23D rendering codes

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contrast caution GFR

Coverage criteria and clinical indications

General preface coverage criteria

Covered when ALL of the following are met

Clinical evaluation and documentation: Recent detailed history, physical examination since onset or change in symptoms, and/or relevant laboratory and prior imaging studies are submitted to establish medical necessity for advanced imaging or other designated procedures.

Telehealth or other meaningful technological contact may suffice if documented

Age-based guideline selection: Individuals 18 years old or younger should be imaged according to the Pediatric Chest Imaging Guidelines when addressed; individuals >18 years should follow General Chest Imaging Guidelines.<=18 years

Modality selection rationale: The chosen modality is appropriate for the clinical question (e.g., CT for pulmonary/trauma/vascular evaluation; MRI for advanced soft-tissue or spinal canal evaluation) and less invasive/lower-risk options have been considered prior to advanced imaging.

Condition-specific sections provide additional modality guidance

Billing and Appropriate Use Criteria

Coverage and appropriate use conditions described in these sections:

3D rendering billing conditions: Report CPT 76376 for 3D rendering not requiring an independent workstation and CPT 76377 for rendering requiring an independent workstation. Concurrent physician supervision/participation must be documented. 3D rendering codes must not be used for routine 2D reformatting and must not be billed with CAD, MRA, CTA, nuclear SPECT, PET/PET-CT, mammography, MRI breast, US breast, CT colonography, cardiac MRI/CT, or coronary CTA.

Chunks 43-45

Clinical scenarios appropriate for 3D rendering: Consider 3D rendering for complex bony conditions (congenital skull abnormalities, complex fractures, spine/pelvic/acetabulum fractures, complex facial fractures), pre-operative planning for complex surgical cases, cerebral angiography, and select pelvis/abdomen indications when conventional imaging is insufficient.

Chunk 45

Imaging guidance billing rules: Guidance codes (e.g., 75989, 76942, 77011-77013, 77021-77022) include the imaging necessary to guide percutaneous procedures and should be used instead of routinely billing a diagnostic procedure code with a guidance code. Use CPT 19085/19086 for MR-guided breast biopsy rather than CPT 77021. Only one unit of a guidance code should be reported per individual encounter (date of service).

PET‑MRI Appropriate Use

PET‑MRI may be appropriate when specific conditions are met

PET‑MRI allowance: PET‑MRI may be used when the individual meets guideline criteria for PET‑CT AND PET‑CT is not available at the treating institution AND the provider requests PET‑MRI in lieu of PET‑CT.

When allowed, report PET‑MRI using CPT 78813 (PET Whole‑Body) + CPT 76498 (MRI unlisted); other reporting methods are inappropriate.

Whole‑Body MRI Coverage

Whole‑body MRI is generally not supported except specific indications

WBMRI exceptions: Whole‑body MRI (WBMRI) may be approved for select cancer predisposition syndromes and for certain autoimmune conditions (for example, chronic recurrent multifocal osteomyelitis); otherwise WBMRI is generally not supported due to lack of standardization and outcome evidence.

When performed, WBMRI must be reported using CPT 76498 as no established CPT/HCPCS codes exist for WBMRI.

Unlisted CT/MR Procedures

Use of unlisted procedure codes is indicated when site-specific codes are unavailable

Unlisted code usage: Report CPT 76497 (unlisted CT) or CPT 76498 (unlisted MR) when an appropriate anatomic site‑specific CT or MR code is not available; report CPT 78999 for unlisted diagnostic nuclear medicine when no specific code exists. Prefer a Category III code if one accurately describes the procedure.

Typical scenarios include neurosurgical navigation, custom joint arthroplasty planning, or surgical planning requiring thinner cuts or different positional acquisition (e.g., navigational bronchoscopy).

Limited or Follow‑up CT (76380)

When to use CPT 76380

Limited CT appropriate use: Use CPT 76380 to report limited or follow‑up CT scans where the work of a full diagnostic CT code is not performed (examples: limited sinus CT, follow‑up slices through a known pulmonary nodule, limited slices to assess a non‑healing fracture).

Do not use CPT 76380 for treatment planning purposes or to cover routine 'extra slices' in diagnostic CT protocols; only one limited study per defined encounter as appropriate.

Quantitative MR Analysis (Investigational)

Quantitative MR Category III codes coverage stance

Quantitative mp‑MRI: Category III quantitative MRI/analysis codes (e.g., CPT 0648T/0649T, 0697T/0698T) and brain volumetric codes (0865T/0866T) are considered investigational/experimental and not medically necessary for routine clinical practice.

Most uses are limited to clinical trials; specific vendor-named applications (e.g., LiverMultiScan, CoverScan) are examples of investigational use.

General support for advanced imaging

Advanced chest imaging is supported only when the following conditions are met

Prerequisite clinical evaluation: A pertinent clinical evaluation since onset or change in symptoms (detailed history, physical exam, appropriate labs, and basic imaging such as plain radiography or ultrasound) or a documented meaningful technological contact must be performed prior to advanced imaging.

Documentation required for authorization and coverage determinations.

Symptomatic requirement: Individual must have documented active clinical signs or symptoms of chest disease; advanced imaging for asymptomatic screening is not supported unless a specific guideline section states otherwise.

Lack of documented symptoms may result in denial.

Pediatric applicability

Population applicability

Age: Individuals 18 years old or younger should be imaged according to the Pediatric Chest Imaging Guidelines; individuals older than 18 should follow the General Chest Imaging Guidelines unless directed otherwise by a specific section.<=18 years

Mediastinal mass

Mediastinal mass imaging recommendations

Initial imaging: Chest x-ray is indicated as the initial study for all individuals with suspected mediastinal mass.

CT for confirmed mass on x-ray: CT Chest with contrast (CPT 71260) is indicated for any pediatric individual with a mediastinal mass identified on chest x-ray.

When MRI is indicated: MRI Chest without and with contrast (CPT 71552) is indicated when a posterior (paravertebral) mediastinal mass on CT invades the spinal canal or when CT is inconclusive regarding specific anatomy; avoid MRI if a large anterior mass would require anesthesia to complete the study.

PET/CT and MIBG considerations: PET/CT (CPT 78815) is indicated prior to biopsy if lymphoma is known or strongly suspected or there is tracheal compression on CT; MIBG (CPT 78800/78802/78803/78804) is indicated prior to biopsy if neuroblastoma is known or strongly suspected.

Nuclear medicine and ultrasound indications

Nuclear medicine and ultrasound application

V/Q vs CTA/CT: Pulmonary ventilation‑perfusion imaging (CPT 78582) may be appropriate for suspected pulmonary embolism if CT is unavailable; CTA Chest (CPT 71275) or CT Chest with contrast (CPT 71260) have generally replaced V/Q for suspected PE.

Quantitative perfusion scans: Quantitative differential pulmonary perfusion scans (CPT 78597/78598) are indicated for preoperative planning of segmental or lobar lung resection and for postoperative transplant evaluation.

Mediastinal Mass

Mediastinal Mass — imaging is indicated as follows

Initial evaluation: Chest x-ray is indicated as an initial study for all individuals with suspected mediastinal mass.

CT indication: CT Chest with contrast (CPT 71260) is indicated for any pediatric individual with a mediastinal mass identified on chest x-ray.

MRI indications: MRI Chest without and with contrast (CPT 71552) is indicated for posterior mediastinal mass on CT that invades the spinal canal or when CT is inconclusive regarding anatomy.

MRI contraindication note: MRI should not be used for individuals with large anterior mediastinal masses if anesthesia is necessary to complete the study.

Hemoptysis

Hemoptysis — imaging indications

Initial assessment: A detailed history, physical examination, and appropriate laboratory studies should be performed prior to considering advanced imaging; chest x-ray is indicated as an initial study for stable individuals.

No advanced imaging: Advanced imaging is not indicated for individuals with epistaxis and a normal chest radiograph and no personal or family history of underlying lung disease or bleeding disorder.normal chest x-ray AND no relevant history

CT indications: CT Chest with contrast (CPT 71260) is indicated for pediatric individuals with hemoptysis except when contraindication to contrast exists; CT Chest without contrast (CPT 71250) is indicated for individuals with documented allergy to CT contrast or significant renal dysfunction.

MRI not indicated:

Cystic Fibrosis / Bronchiectasis

Cystic Fibrosis / Bronchiectasis imaging

Initial imaging in CF: Chest x-ray is the primary study for initial evaluation of acute clinical symptoms in individuals with cystic fibrosis.

CT indications in CF: CT Chest without contrast (CPT 71250) or with contrast (CPT 71260) is indicated for hemoptysis; pneumonia worsening despite antibiotics; pleural effusion or empyema; suspected fungal pneumonia; monitoring treatment changes in bronchiectasis; expiratory CT for small airways disease; and pre/post-lung transplant evaluation.

Surveillance frequency: Low-dose CT Chest without contrast (CPT 71250) is indicated every 2 years for monitoring bronchiectasis and small airways disease in individuals with cystic fibrosis.every 2 years

Bronchiolitis

Bronchiolitis — imaging guidance

When to image: Chest x-rays are indicated when there is clinical suspicion of pneumonia or other complications in bronchiolitis.clinical suspicion of pneumonia/complication

Advanced imaging limited use: Advanced imaging is not indicated for routine evaluation or monitoring of bronchiolitis; CT Chest with contrast (CPT 71260) is appropriate for pleural effusion or empyema on recent chest x-ray, immunocompromised individuals with acute pulmonary symptoms, or when recent chest x-ray suggests a condition other than bronchiolitis.one of listed conditions present

Pneumonia / COVID-19

Pneumonia / COVID-19 — pediatric imaging considerations

General pneumonia guidance: Chest x-ray and/or chest ultrasound (CPT 76604) is indicated when pediatric pneumonia does not respond to standard therapy.nonresponsive to standard therapy

CT in immunocompromised or recurrent infections: CT Chest with contrast (CPT 71260) is indicated for immunocompromised individuals with acute pulmonary symptoms; CT Chest without or with contrast (CPT 71250/71260) is appropriate for recurrent lower respiratory tract infections.immunocompromised OR recurrent infections

Ultrasound for complicated pneumonia: Ultrasound chest (CPT 76604) is appropriate for evaluation of complicated or recurrent childhood pneumonia.complicated or recurrent pneumonia

Solitary pulmonary nodule — initial and follow-up imaging

Initial evaluation: CT Chest with contrast (CPT 71260) as a one-time evaluation is indicated for any incidental pulmonary nodule discovered on other imaging in pediatric individuals.one-time

When follow-up imaging is indicated: Follow-up imaging is indicated for immunocompromised individuals; individuals with malignancy; invasive infection; or new or worsening pulmonary symptoms.

Individuals with malignant solid tumor should follow oncology-specific imaging guidelines.

When follow-up is not indicated: Routine follow-up imaging of incidental solitary pulmonary nodules in asymptomatic healthy pediatric individuals is not necessary.

Fleischner Society adult guidelines do not apply to pediatric individuals.

Tuberculosis imaging indications

Positive PPD or Tuberculosis

General: Imaging indications for positive PPD or tuberculosis in pediatric individuals are similar to adults; chest x-ray is useful as an initial imaging study when TB is suspected.

MRI spine with and without contrast is appropriate at symptomatic levels when spinal involvement is a concern.

Asthma — when imaging is appropriate

When chest x-ray/ultrasound indicated: Chest x-ray and/or chest ultrasound (CPT 76604) is indicated when the individual's asthma does not respond to standard therapy, to identify complications such as pneumonia, or to rule out other causes of respiratory distress.

Advanced imaging indications: CT Chest without (CPT 71250) or with (CPT 71260) contrast is appropriate for pleural effusion/empyema on recent x-ray; immunocompromised individuals with acute pulmonary symptoms; abnormality on recent x-ray suggesting a condition other than asthma; or poor response to therapy when other conditions may mimic asthma.

Advanced imaging is not indicated for routine evaluation or monitoring of asthma.

Pectus deformities — imaging indications

Indications for advanced imaging: CT Chest without contrast (CPT 71250), MRI Chest with and without contrast (CPT 71552), or MRI Chest without contrast (CPT 71550) is indicated for preoperative planning; significant cardiac displacement after chest x-ray and echocardiography (CPT 93306); or evidence of pulmonary impingement after chest x-ray and pulmonary function tests with increasing shortness of breath.

PFTs may be unobtainable in children younger than 9 years.

Associated conditions: Evaluate for associated congenital heart disease or connective tissue disorders (e.g., Marfan syndrome) when clinically suspected in individuals with pectus deformities.

Vascular ring — diagnostic pathway

Initial study by presentation: Chest x-ray is the recommended initial study for individuals with respiratory symptoms; barium esophagram is the recommended initial study for individuals with feeding difficulties.

Chest x-ray is not needed for individuals diagnosed prenatally.

Advanced imaging after initial evaluation: CT Chest with contrast (CPT 71260), CTA Chest (CPT 71275) or MRA Chest (CPT 71555) are appropriate in individuals with known or suspected vascular ring after initial studies. Echocardiography is appropriate to evaluate for associated congenital heart disease.

Specific echocardiography CPTs (e.g., 93303, 93306) are appropriate for initial evaluation if no prior echocardiogram exists.

Vascular ring imaging criteria

Imaging pathway for suspected or known vascular ring:

Initial evaluation: Chest x-ray is the recommended initial study in individuals with respiratory symptoms; barium esophagram is the recommended initial study in individuals with feeding difficulties.

Chest x-ray not needed for individuals diagnosed prenatally.

Advanced cross-sectional imaging: CT Chest with contrast (CPT 71260), CTA Chest (CPT 71275) or MRA Chest (CPT 71555) is appropriate to define anatomy in individuals with known or suspected vascular ring after prenatal imaging studies, chest x-ray, or barium esophagram.

Echocardiography appropriate to rule out associated congenital heart disease.

Congenital cystic lung disease imaging criteria

When a congenital cystic lung lesion is suspected:

Cross-sectional imaging: CT Chest with contrast (CPT 71260) is appropriate when a congenital cystic lung lesion is suspected. MRI Chest with and without contrast (CPT 71552) is appropriate if CT is inconclusive or if requested for pre-operative planning.

Pulmonary AVM imaging criteria

Pulmonary arteriovenous malformation imaging:

Initial imaging: Chest x-ray is indicated as an initial imaging modality for individuals with known pulmonary arteriovenous malformations (PAVMs) or individuals presenting with hypoxemia and/or hemoptysis.

Treatment planning: CTA or MRA is appropriate in individuals with known AVM or abnormal chest x-ray suggesting AVM for treatment planning.

Congenital diaphragmatic hernia imaging criteria

Congenital diaphragmatic hernia imaging pathway:

Initial imaging: If there is clinical concern for congenital diaphragmatic hernia (CDH), chest x-ray and/or chest ultrasound (CPT 76604) is indicated as the initial imaging study.

Most CDH are diagnosed prenatally or shortly after delivery.

Advanced imaging: CT Chest with contrast (CPT 71260) or MRI Chest with and without contrast (CPT 71552) is appropriate when chest x-ray and/or ultrasound are inconclusive or if requested for treatment planning.

Imaging studies requested solely for data collection or research purposes that are not intended to be used in the individual’s direct clinical management are not supported. Clinical trial imaging will be reviewed against these guidelines and may be denied if the study is inconsistent with established standards or lacks demonstrated clinical utility.

Pre-operative or pre-procedural imaging is only indicated when the planned procedure itself is indicated. If the procedure is not indicated, associated pre-procedural imaging should not be performed or billed. Likewise, orders for duplicate studies or repeat imaging without evidence of progression, recurrence, or documentation that the repeat exam will affect management are discouraged and may be considered overutilization.

CPT 76376 and 76377 (3D rendering) require documented concurrent physician supervision/participation and must not be billed for routine 2D reformatting. These codes must not be billed in conjunction with CAD, MRA, CTA, nuclear SPECT, PET, PET/CT, mammography, MRI breast, ultrasound breast, CT colonography, cardiac MRI/CT, or coronary CTA; prior authorization may also be required for 76376/76377 even when the underlying imaging procedure is not pre‑authorized.

Whole‑body CT or LifeScan performed for screening of asymptomatic individuals is not indicated. Such whole‑body CT screening lacks established validity and the radiation exposure is not justified for routine asymptomatic screening; limited exceptions (for example, oncologic staging in multiple myeloma) are described elsewhere.

Advanced imaging modalities should not be used for routine screening of asymptomatic individuals unless a specific guideline section explicitly allows it. Selection of CT versus MRI should be based on the clinical question and not used to substitute CT for MRI solely to avoid anesthesia or increase throughput; CT should not replace MRI for that reason alone.

For epistaxis presenting as apparent hemoptysis, advanced chest imaging is not indicated when the chest radiograph is normal and there is no personal or family history of lung disease or bleeding disorder. A detailed history and chest x‑ray should be obtained first; CT Chest with contrast (CPT 71260) is reserved for other pediatric patients with hemoptysis.

The adult Fleischner Society solitary pulmonary nodule guidelines do not apply to pediatric individuals. Management and follow‑up of pulmonary nodules in children differ from adults and are addressed in the pediatric-specific sections of this guideline.

When a vascular ring has been diagnosed on prenatal imaging, an immediate postnatal chest x‑ray is not required. Initial postnatal imaging decisions should be guided by clinical presentation (respiratory symptoms warrant chest x‑ray; feeding difficulties warrant barium esophagram).

Procedures, studies, or technologies considered investigational, experimental, or unproven—defined as lacking sufficient supporting evidence, clinical utility, or collective professional support—are subject to non‑coverage or denial. Requests for such studies will be evaluated against the guideline definitions and available evidence.

Repeat imaging performed without evidence of disease progression, recurrence, or documentation that the repeat exam will affect clinical management is generally not medically necessary. Prior relevant imaging and clinical history should be reviewed before ordering a repeat study.

Volumetric and quantitative MRI analysis Category III and specialty codes (including brain volumetric codes CPT 0865T/0866T) are considered investigational or not medically necessary for routine clinical practice. These software‑based quantitative analyses are generally limited to research contexts and lack sufficient evidence to support routine coverage.

Advanced imaging ordered for asymptomatic screening without documentation of active clinical signs or symptoms and without prior pertinent clinical evaluation is not supported. Documentation of a pertinent clinical evaluation (history, exam, labs, and prior basic imaging) is required to justify advanced studies.

Routine use of advanced imaging for evaluation or monitoring of bronchiolitis is not indicated. Chest x‑ray is reserved for suspected pneumonia or complications; CT Chest with contrast (CPT 71260) is appropriate only for specific situations such as pleural effusion/empyema, immunocompromised patients with acute pulmonary symptoms, or when chest x‑ray suggests an alternate diagnosis.

An incidental solitary pulmonary nodule in an otherwise asymptomatic, healthy pediatric individual generally does not require routine follow‑up imaging. CT Chest with contrast (CPT 71260) is appropriate as a one‑time evaluation when a nodule is identified, but ongoing surveillance is reserved for immunocompromised patients, those with known malignancy, invasive infection, or new/worsening pulmonary symptoms.

Billing codes and 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

Imaging guidance and biopsy/ablation CPT CodesCPTCovered

19085	Biopsy, breast, with placement of breast localization device(s), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including MR guidance
19086	Biopsy, breast, with placement of breast localization device(s), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including MR guidance
75989	Imaging guidance for percutaneous drainage with placement of catheter (all modalities)
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

Unlisted ProceduresCPT

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 related nuclear CPTCPTCovered

78830	SPECT/CT single area single day
78831	SPECT/CT two or more days
78832	SPECT/CT two areas one‑day and two‑day study
78072	SPECT/CT parathyroid nuclear imaging (effective 2013)

Quantitative MR Category III / T CodesCPTExperimental

0648T	Quantitative mp‑MRI analysis without diagnostic MRI
0649T	Quantitative mp‑MRI analysis with diagnostic MRI
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

HCPCS examples and guidanceHCPCS

C8931	MRA with dye, Spinal Canal (example HCPCS mentioned)
72159	MRA Spinal Canal (CPT example for comparison)
S8042	MRI, lowfield (non‐specific HCPCS example)

Interpretation CodesCPTCovered

76140

Interpretation of an outside study

PET codes referenced for PET‑MRICPTCovered

78813

PET Whole‑Body

Procedure Codes - MRI/CT/CTACPT

71550	MRI Chest without contrast
71551	MRI Chest with contrast
71552	MRI Chest without and with contrast
76498	Unlisted MRI procedure (for radiation planning or surgical software)
71555	MRA Chest (non-cardiac)
71250	CT Chest without contrast
71260	CT Chest with contrast
71270	CT Chest without and with contrast
77014	CT Guidance for Placement of Radiation Therapy Fields
76497	Unlisted CT procedure (for radiation planning or surgical software)

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Procedure Codes - PET/Nuclear/UltrasoundCPT

78811	PET Imaging; limited area
78812	PET Imaging: skull base to mid-thigh
78813	PET Imaging: whole body
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
78579	Pulmonary Ventilation Imaging
78580	Pulmonary Perfusion Imaging
78582	Pulmonary Ventilation and Perfusion Imaging
78597	Quantitative Differential Pulmonary Perfusion, Including Imaging When Performed

1–10 of 15

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Procedure Codes - Radiopharmaceutical NMCPT

78800	Radiopharmaceutical nuclear medicine imaging of an inflammatory process
78801	Radiopharmaceutical nuclear medicine imaging of an inflammatory process
78802	Radiopharmaceutical nuclear medicine imaging of an inflammatory process
78803	Radiopharmaceutical nuclear medicine imaging of an inflammatory process

Imaging recommended for specific pediatric indicationsCPTCovered

78815	PET/CT
76604	Ultrasound chest
71260	CT Chest with contrast
71552	MRI Chest without and with contrast

Cited imaging CPT CodesCPT

71260	CT Chest with contrast
71250	CT Chest without contrast
71552	MRI Chest without and with contrast
78815	PET/CT
78800	MIBG imaging (planar) / related MIBG CPTs
78802	MIBG imaging (SPECT) — cited as part of MIBG options
78803	MIBG imaging — cited
78804	MIBG imaging — cited
76604	Ultrasound chest

Referenced Imaging CPT CodesCPT

71260	CT Chest with contrast
71250	CT Chest without contrast
71275	CTA Chest
71555	MRA Chest
71552	MRI Chest with and without contrast
71550	MRI Chest without contrast
93306	Echocardiography (used in pectus/vascular ring evaluation)
93303	Transthoracic echo (additional echocardiography CPTs listed)
93320	Cardiac imaging CPT listed
93325	Cardiac imaging CPT listed

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Vascular ring and related cardiac imagingCPTCovered

71260	CT Chest with contrast
71275	CTA Chest
71555	MRA Chest
93303	Echocardiography, transthoracic, real-time with image documentation (initial codes referenced)
93306	Echocardiography, transthoracic, complete
93320	Doppler echocardiography, pulsed
93325	Doppler echocardiography, continuous

Congenital cystic lung diseases imagingCPTCovered

71260	CT Chest with contrast
71552	MRI Chest with and without contrast

Pulmonary AVM imaging (CTA/MRA referenced generally)CPTCovered

71260

CT Chest with contrast

Congenital diaphragmatic hernia imagingCPTCovered

76604	US Chest
71260	CT Chest with contrast
71552	MRI Chest with and without contrast

Renal function threshold for contrast — GFR <30 mL/min (increased risk for contrast-related complications)

Renal function thresholdGFR <30 mL/min — increased risk for contrast-related complications; both contrast CT and MRI share similar risk profile at this threshold

Clinical implicationExercise caution with iodinated contrast in renal impairment; consider non-contrast alternatives when feasible

Documentation

Indications and modality-specific appropriate uses

List of pediatric chest conditions covered by the full guideline

Covered pediatric chest conditions list: This guideline contains sections addressing multiple pediatric chest conditions including lymphadenopathy, mediastinal mass, hemoptysis, cystic fibrosis/bronchiectasis, bronchiolitis, pneumonia, solitary pulmonary nodule, tuberculosis, asthma, pectus deformities, breast masses, vascular malformations, and congenital chest diseases.

Referenced sections in full guideline

Modality-specific appropriate uses

CT appropriate uses: CT is appropriate for trauma screening, imaging pulmonary disease, imaging abdominal/pelvic viscera, complex fractures, when MRI is contraindicated, and to evaluate inconclusive ultrasound or MRI findings; selection of contrast (with/without) depends on clinical indication.

Chunk 25,28

MRI appropriate uses:

Prior authorization, documentation, and operational rules

Documentation Required

Prior authorization / medical necessity documentation

Prior authorization and medical necessity documentation: Advanced imaging and other designated procedures require submission of adequate, pertinent medical records to establish medical necessity. Documentation should include a recent detailed history and physical examination since onset or change in symptoms, relevant laboratory data, prior imaging reports, and any condition‑specific information requested in guideline sections. A meaningful technological contact (telehealth, phone, message) may substitute for an in‑person evaluation when applicable. Failure to submit adequate documentation can result in denial or delay.

Submit recent history, physical exam, labs, and prior imaging
Condition‑specific sections may require additional documentation
Technological contact may suffice when appropriate

Documentation Required

Reporting requirements for PET‑MRI and WBMRI

Reporting requirements for PET‑MRI and WBMRI: PET‑MRI is generally not supported except in select circumstances. When PET‑MRI is appropriate and PET‑CT criteria are met but PET‑CT is not available, report PET‑MRI as PET Whole‑Body (CPT 78813) plus MRI Unlisted (CPT 76498). Whole‑body MRI (WBMRI) lacks standardized technique and is reportable only with CPT 76498 except for select cancer predisposition syndromes and specified indications.

Prior authorization specifics

Prior Authorization

Submit pertinent medical records for prior authorization of advanced imaging

Advanced imaging modalities (CT, MRI, PET) and other designated procedures require submission of pertinent medical records to establish medical necessity prior to approval; do not order these studies before a clinical evaluation by the treating physician or consultant.

Include the recent history, physical exam, labs, and prior imaging when submitting authorization.
Clinical evaluation (including telehealth) may suffice if documented.

Prior Authorization

3D rendering (76376/76377) may require separate prior authorization

Prior authorization may be required for 3D rendering (CPT 76376/76377) even when the underlying imaging procedure is not pre‑authorized; verify payer policies before billing.

Prior Authorization

Contrast agent guidance and safety

Billing Rule

Contrast documentation and selection rules (renal, pregnancy, breastfeeding)

For contrast use, document renal function and pregnancy/breastfeeding status; use CT without contrast (CPT 71250) when contrast allergy or significant renal dysfunction (e.g., GFR <30 mL/min) is present and weigh benefits versus risks before using CT/MR contrast.

Document GFR, BUN/creatinine, pregnancy status, and breastfeeding plans when relevant.
If contrast is contraindicated, select appropriate non‑contrast CPT (e.g., 71250).

Billing Rule

Gadolinium safety — document rationale and limit repetitive exposure

Follow established GBCA safety guidance and document relevant follow‑up or mitigation when using gadolinium‑based contrast agents; assess necessity of repetitive GBCA exposure and record rationale.

Document reasons for GBCA use and efforts to limit repeat exposure.

Interval and repetition rules

MRI (with GBCA) — Assess necessity of repetitive GBCA use

Frequency principleAssess necessity of repetitive use of gadolinium-based contrast agents (GBCAs) for MRI; limit GBCA use to situations where additional diagnostic information is necessary

Safety noteMultiple studies show gadolinium deposition potential; FDA states no evidence of harm but recommends assessing necessity of repetitive GBCA exposure

DocumentationDocument clinical justification when repetitive GBCA-enhanced MRIs are requested

Low dose CT Chest (CPT 71250) — every 2 years

Surveillance intervalLow dose CT Chest (CPT 71250) indicated every 2 years for monitoring bronchiectasis and small airways disease in cystic fibrosis

Modality noteUse low-dose, non-contrast technique when appropriate to minimize radiation exposure in surveillance

Terms and definitions

Investigational/Experimental — definition and criteria

DefinitionInvestigational/Experimental: studies, treatments, procedures, or devices with paucity of supporting evidence, lack of demonstrated clinical utility, immature evidence for improved outcomes, or absence of collective opinion of support

Evidence requirementSupporting evidence includes credible scientific literature (e.g., RCTs, well-conducted cohort studies) or specialty society recommendations

Coverage implicationServices deemed investigational/experimental are subject to non-coverage or denial

Standard or conventional imaging — definition

DefinitionStandard or conventional imaging includes plain film (x-ray), CT, MRI, and ultrasound commonly used in initial and subsequent evaluations

Role

Background and scope

These guidelines are evidence‑based recommendations that evaluate advanced imaging modalities for a range of pediatric cardiothoracic and related conditions. They are intended to guide modality selection and imaging appropriateness for individuals 18 years and younger, while allowing clinician judgment and documentation to justify deviations when clearly necessary.

Services not supported

PET/MRI is generally not supported for most oncologic and neurologic indications; PET‑MRI may be allowed only when PET‑CT criteria are met and PET‑CT is unavailable and the provider requests PET‑MRI. Unbundling a PET/CT into separate PET and diagnostic CT components is not supported. Documentation and appropriate coding guidance apply when PET‑MRI or unlisted reporting is used (for example, CPT 78813 combined with CPT 76498 when permitted).

Document revision history

2025-11-01effective_dateLatest

Policy effective date for Pediatric Chest Imaging Guidelines (V1.0.2025).

2025-05-01revision

Annual evidence-based updates applied to the guideline (see Policy History).

2024-07-01revision

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPediatric Chest Imaging Guidelines (For Ohio Only)

Policy CodePolicy CSRAD017OH.D

Change TypeNo material change

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionSubmit pertinent medical records and documentation of clinical evaluation to establish medical necessity when requesting advanced imaging.

SourceLink

On This Page

Unlisted code use: Report CPT 76497/76498/78999 when no appropriate anatomic site-specific CT/MR/nuclear code exists. If a Category III code accurately describes the procedure, report that instead. Examples include neurosurgical navigation (Stealth/BrainLab), custom arthroplasty planning, or surgical planning requiring different acquisition parameters (e.g., navigational bronchoscopy).

Chunk 54

Ultrasound use in young children: Ultrasound chest (CPT 76604) is appropriate in individuals younger than 5 years to distinguish a prominent thymus from a true mediastinal mass.age <5 years

Single repeat CT acceptable: A single repeat CT Chest with contrast (CPT 71260) is appropriate to confirm stability and potentially avoid biopsy only if NONE of the following features are present: anterior mediastinal mass; enlarged lymph nodes anywhere in the imaging field; lymphopenia; pleural effusion.none of listed features present

Repeat CT allowed only when all exclusion features are absent

PET/CT indication: PET/CT (CPT 78815) is indicated prior to biopsy if lymphoma is known or strongly suspected or there is tracheal compression on CT.

MIBG indication: MIBG imaging (CPT 78800/78802/78803/78804) is indicated prior to biopsy if neuroblastoma is known or strongly suspected.

Ultrasound usage: Ultrasound chest (CPT 76604) is appropriate in individuals younger than 5 years to distinguish prominent thymus from true mediastinal mass.age < 5 years

Repeat CT to avoid biopsy: A single repeat CT Chest with contrast (CPT 71260) is appropriate to confirm stability and avoid biopsy for individuals with NONE of the following features: anterior mediastinal mass; enlarged lymph nodes anywhere in the imaging field; lymphopenia; pleural effusion.none of listed features present

MRI is not indicated in the evaluation of pediatric hemoptysis.

COVID-19 initial test: For pediatric individuals testing positive for COVID-19, chest x-ray is the initial imaging test.COVID-19 positive

MIS-C referral: Concerns for Multisystem Inflammatory Syndrome in Children (MIS-C) should follow the separate guideline (PEDCD-12).concern for MIS-C

Document renal function (GFR) prior to administering CT or MR contrast when clinically relevant

Number of slices/sequences for CT — No specific minimum or maximum defined in CPT

CPT guidanceThe AMA CPT manual does not define a minimum or maximum number of sequences or slices for any CT study

Operational noteA few additional slices or sequences are common and CT protocols vary by clinical situation

Coding cautionDo not inappropriately report CPT 76380 to cover 'extra slices' in diagnostic CT protocols

Anesthesia use for MRI — Usually required for almost all infants (except neonate) and children <7 years or older individuals with developmental delays

Typical anesthesia needAnesthesia is usually required for almost all infants (except neonates) and children <7 years, and for older individuals with developmental delays when undergoing MRI

Route considerationsAnesthesia may be administered orally or intravenously based on patient needs and local practice

Scheduling implicationPlan MRI sessions to minimize anesthesia exposure (obtain necessary body areas concurrently) when possible

MRI is appropriate for soft‑tissue characterization (brain, spinal cord, visceral and musculoskeletal masses), to evaluate inconclusive US/CT, and when avoiding ionizing radiation is desirable; MRI protocols and sequences should be tailored to the clinical question.

Ultrasound appropriate uses: Ultrasound is appropriate for evaluation of chest wall/pleural processes, adenopathy, procedural guidance, and initial evaluation of soft tissue masses; it is operator dependent.

Chunk 83

PET appropriate uses: PET, typically performed as PET/CT, is indicated for oncologic, cardiac, and brain metabolic evaluations and is not indicated for routine surveillance unless condition‑specific guidance states otherwise; PET/MRI generally not supported.

Chunks 33-34

Clinical scenarios appropriate for CPT 76376/76377

Clinical scenarios for 76376/76377: CPT 76376/76377 may be appropriate for evaluation of congenital skull abnormalities in newborns/infants/toddlers for pre‑operative planning; complex fractures/dislocations; spine, pelvic/acetabular, intra‑articular fractures when conventional imaging is insufficient; complex facial fractures; cerebral angiography; and select pelvis/abdomen conditions when initial ultrasound is indeterminate.

Chunk 45

MR-guided breast biopsy coding (contextual)

MR-guided breast biopsy coding: Use CPT 19085 for the first MR‑guided breast biopsy lesion and CPT 19086 for each additional lesion; CPT 77021 (MR guidance for needle placement) is not appropriate for breast biopsy coding.

Chunks 49,52

Whole‑body CT/MRI indications and restrictions

Whole‑body CT/MRI indications and restrictions: Whole‑body CT (LifeScan) is not indicated for screening asymptomatic individuals but whole‑body low‑dose CT is supported for oncologic staging in multiple myeloma. Whole‑body MRI is generally not supported except for select cancer predisposition syndromes and certain autoimmune conditions (e.g., chronic recurrent multifocal osteomyelitis); WBMRI must be reported with CPT 76498.

Chunks 63,65,66

SPECT/CT

SPECT/CT uses: SPECT/CT combines functional and anatomic information for improved localization and attenuation correction; common uses include MIBG and octreotide scintigraphy for neuroendocrine tumors and parathyroid imaging (CPT 78072); report hybrid studies using CPT 78830/78831/78832 as appropriate.

Chunk 57

Lymphadenopathy - supraclavicular

Supraclavicular lymphadenopathy imaging: For supraclavicular adenopathy in pediatric individuals (often pathologic), any of CT Chest with contrast (CPT 71260), MRI Chest without and with contrast (CPT 71552), or Ultrasound Chest (CPT 76604) are appropriate prior to excisional biopsy.

Chunk 88

Mediastinal mass

Mediastinal mass summary: Chest x‑ray initial; CT Chest with contrast (CPT 71260) for any mass identified on x‑ray; MRI (CPT 71552) for posterior masses invading the spinal canal or inconclusive CT; PET/CT (CPT 78815) if lymphoma suspected; MIBG for suspected neuroblastoma; ultrasound (CPT 76604) in children <5 years; a single repeat CT may be acceptable to confirm stability when specified adverse features are absent.

Chunk 91

Mediastinal mass workup (CT/MRI/PET/MIBG/US as specified)

Mediastinal mass workup: Workup options include CT, MRI, PET, MIBG, and ultrasound as specified by clinical presentation and age: CT Chest with contrast (CPT 71260) for masses seen on x‑ray; MRI (CPT 71552) for spinal canal invasion or inconclusive CT; PET/CT (CPT 78815) for suspected lymphoma; MIBG for suspected neuroblastoma; ultrasound (CPT 76604) in children <5 years.

Chunk 91

Hemoptysis evaluation (CT with contrast generally indicated)

Hemoptysis CT guidance: CT Chest with contrast (CPT 71260) is generally indicated for pediatric hemoptysis after appropriate initial assessment; CT without contrast (CPT 71250) when contrast contraindicated; MRI is not indicated.

Chunk 95

Cystic fibrosis advanced imaging

CF advanced imaging: Chest x‑ray for initial symptoms; CT Chest (71250/71260) for hemoptysis, worsening pneumonia, effusion/empyema, suspected fungal infection, monitoring bronchiectasis, expiratory CT for small airways disease, and pre/post‑transplant evaluation; low‑dose CT without contrast (71250) every 2 years for surveillance.

Chunk 98

Bronchiolitis — limited CT use

Bronchiolitis CT use limited: Advanced imaging (CT Chest with contrast CPT 71260) is limited to pleural effusion/empyema on recent x‑ray, immunocompromised patients with acute pulmonary symptoms, or when recent chest x‑ray suggests another condition; routine advanced imaging not indicated.

Chunk 102

Pneumonia / COVID-19 imaging

Pneumonia imaging: Chest x‑ray and/or ultrasound (CPT 76604) when not responding to standard therapy; CT Chest with contrast (71260) for immunocompromised individuals; CT (71250/71260) for recurrent infections; chest x‑ray initial for pediatric COVID‑19 positive individuals.

Chunks 105-106

Incidental solitary pulmonary nodule

Incidental solitary pulmonary nodule: CT Chest with contrast (CPT 71260) as a one‑time evaluation for incidental solitary pulmonary nodule; routine follow‑up not indicated for asymptomatic healthy pediatric individuals; follow‑up indicated for immunocompromised individuals, malignancy, invasive infection, or new/worsening symptoms.one-time

Chunk 110

Asthma not responding to standard therapy or suspected complications

Asthma complications imaging: Chest x‑ray and/or chest ultrasound (CPT 76604) when not responding to therapy or to identify complications; CT Chest (71250/71260) for pleural effusion/empyema, immunocompromised individuals with acute symptoms, abnormal recent x‑ray suggesting another condition, or poor response to therapy when other conditions may mimic asthma.

Chunk 118

Pectus deformity requiring surgical planning or evidence of cardiorespiratory compromise

Pectus preoperative imaging: CT or MRI chest (CPT 71250, 71550/71552) is indicated for preoperative planning, significant cardiac displacement after chest x‑ray and echocardiography, or evidence of pulmonary impingement with worsening symptoms; PFTs may be unobtainable in children <9 years.

Chunk 121

Suspected or known vascular ring

Suspected or known vascular ring: Initial evaluation: chest x‑ray for respiratory symptoms and barium esophagram for feeding difficulties; advanced imaging (CT 71260, CTA 71275, or MRA 71555) after initial studies to define anatomy; echocardiography to evaluate associated congenital heart disease.

Chunk 126

Suspected vascular ring with respiratory symptoms

Respiratory presentation: For suspected vascular ring presenting with stridor, wheezing, tachypnea, or cough, initial chest x‑ray is recommended.

Chunk 126

Suspected vascular ring with feeding difficulties

Feeding difficulties presentation: For suspected vascular ring presenting with dysphagia, slow feeding, hyperextension of the head while feeding, weight loss, or failure to thrive, barium esophagram is the recommended initial study.

Chunk 126

Known or suspected pulmonary arteriovenous malformation

Known or suspected PAVM: Chest x‑ray is indicated initially for individuals with known pulmonary arteriovenous malformation or those presenting with hypoxemia or hemoptysis; CTA or MRA is appropriate for treatment planning when AVM is suspected or confirmed.

Chunk 132

Clinical concern for congenital diaphragmatic hernia

Clinical concern for CDH: If there is clinical concern for congenital diaphragmatic hernia (CDH), chest x‑ray and/or chest ultrasound (CPT 76604) is indicated as the initial study; CT Chest with contrast (CPT 71260) or MRI Chest (CPT 71552) is appropriate when initial imaging is inconclusive or for treatment planning.

Chunk 133

PET‑MRI allowable when PET‑CT criteria met AND PET‑CT unavailable; use 78813 + 76498
WBMRI has no dedicated CPT codes; report with 76498 only
Diagnostic MRI codes may be used in addition when clinically appropriate

Prior Authorization

Prior authorization expectations for advanced imaging

Prior authorization expectations for advanced imaging: Advanced imaging should be justified by documented active clinical signs or symptoms and by prior evaluation (history, exam, and basic imaging such as radiograph or ultrasound) unless the request is for guideline‑supported scheduled surveillance. The selection of the imaging modality must be documented (why CT vs MRI vs ultrasound/PET is appropriate) and how the results will affect management.

Document active clinical signs/symptoms and prior pertinent evaluation
Explain modality selection and expected impact on clinical management
Scheduled surveillance per specific guideline sections may be exempt from new clinical exam documentation

Denial Risk

Denial risk for unproven or limit‑exceeding services

Denial risk for unproven or limit‑exceeding services: Services deemed investigational, experimental, or unproven due to insufficient evidence, lack of demonstrated clinical utility, or exceeding coverage/quantity limits will be evaluated against Ohio Administrative Code 5160‑1‑01 and may be denied. Provide robust supporting evidence or peer‑reviewed literature when requesting such services.

Requests lacking supporting evidence or collective professional endorsement risk denial
Services exceeding plan limits will be reviewed per OAC 5160‑1‑01

Billing Rule

Improper use of limited CT code

Improper use of limited CT code (CPT 76380): CPT 76380 describes a limited or follow‑up CT and should not be used to report extra slices added to a full diagnostic CT. It is inappropriate to bill 76380 in conjunction with diagnostic CT codes to cover additional sequences or slices; limited CT is not intended for treatment‑planning purposes.

Do not use 76380 to cover 'extra slices' for a diagnostic CT protocol
76380 is for limited or follow‑up CT work not requiring full diagnostic code-level work

Prior Authorization

Initial chest x‑ray required for suspected mediastinal mass

Initial chest x‑ray required for suspected mediastinal mass: For any individual with suspected mediastinal mass, obtain a chest radiograph as the initial study. CT Chest with contrast (CPT 71260) is indicated for any pediatric individual with a mediastinal mass identified on chest x‑ray. Ultrasound chest (CPT 76604) is appropriate in children <5 years to distinguish thymus from true mass.

Chest x‑ray is required as the initial study for suspected mediastinal mass
If mass seen on x‑ray, CT Chest with contrast (71260) is indicated
Ultrasound chest (76604) for children <5 to evaluate thymus

Prior Authorization

Chest x‑ray as initial study for stable hemoptysis

Chest x‑ray as initial study for stable hemoptysis: In stable individuals with hemoptysis, obtain a chest x‑ray as the initial imaging. Advanced imaging is not indicated if chest radiograph is normal and there is no personal or family history of lung disease or bleeding disorder. CT Chest with contrast (CPT 71260) is indicated for other pediatric individuals with hemoptysis; CT without contrast (CPT 71250) may be used for documented contrast allergy or severe renal dysfunction.

Chest x‑ray is the initial study for stable hemoptysis
If chest x‑ray normal and low risk, advanced imaging not indicated
CT Chest with contrast (71260) for other cases; 71250 if contrast contraindicated

Denial Risk

Ordering follow‑up imaging for incidental solitary pulmonary nodules

Follow‑up imaging for incidental solitary pulmonary nodules: Follow‑up imaging of incidental solitary pulmonary nodules in asymptomatic, otherwise healthy pediatric individuals is not indicated. CT Chest with contrast (CPT 71260) may be used as a one‑time evaluation of an incidentally discovered pulmonary nodule. Follow‑up imaging is indicated for immunocompromised individuals, known malignancy, invasive infection, or new/worsening pulmonary symptoms.

No routine follow‑up imaging for incidental solitary pulmonary nodules in healthy asymptomatic pediatric individuals
CT Chest with contrast (71260) as one‑time evaluation of incidental nodule
Follow‑up indicated for immunocompromise, malignancy, infection, or new symptoms

Documentation Required

Documentation of physician supervision

Documentation of physician supervision for 3D rendering (CPT 76376/76377): CPT 76376 and 76377 require concurrent physician supervision/participation in the post‑processing 3D reconstruction. Document the physician's active role (design of the anatomic region, tissue/structure selection, images archived, monitoring/adjustments) when billing these codes. Prior authorization may be required for the 3D codes even if the underlying imaging is not separately authorized.

Document active physician supervision/participation for CPT 76376 and 76377
Providers may need prior authorization for 3D rendering codes even when underlying study is authorized
76376 = no independent workstation; 76377 = requires independent workstation

Billing Rule

Interpretation of outside studies

Interpretation of outside studies: Use CPT 76140 for secondary interpretation of imaging studies performed at another facility. Do not use primary diagnostic imaging codes to report interpretation of outside exams. When an outside exam is compared with a current study, the diagnostic code for the current exam includes comparison to the prior study.

CPT 76140 is appropriate for interpretation of outside studies
Do not bill a diagnostic imaging code alone for a secondary interpretation of an outside exam

Documentation Required

Document clinical justification for advanced imaging; document respiratory or feeding symptoms

Document clinical justification for advanced imaging and respiratory/feeding symptoms: For chest and airway‑related conditions (e.g., mediastinal mass, vascular ring), document specific clinical findings that justify the choice of advanced imaging — for example, chest x‑ray showing a mass, signs of tracheal compression, stridor, wheeze, tachypnea, cough, or feeding difficulties (dysphagia, slow feeding, weight loss). When feeding symptoms predominate, consider barium esophagram per guideline. Documentation should explain how imaging will affect management and surgical or procedural planning.

Document chest x‑ray or other basic imaging findings that support advanced imaging
Record respiratory symptoms (stridor, wheeze, tachypnea, cough) or feeding symptoms (dysphagia, slow feeding, weight loss) when relevant
Explain how imaging results will influence management or operative planning

Note

Coverage governance; Step therapy (none specified)

Coverage governance and step therapy: Coverage decisions are governed by the member's benefit plan and applicable federal, state (Ohio Administrative Code), or contractual requirements. UnitedHealthcare uses InterQual for primary medical/surgical criteria and may use company policies when InterQual lacks applicable criteria. No specific step‑therapy sequence is specified in these guidelines for advanced imaging.

Reference federal, state (OAC), and contractual benefit requirements when determining coverage
InterQual is used as primary criteria; company policies used when InterQual is not applicable
No step therapy sequence specified in this guidance

Prior Authorization

Repeat CT to confirm stability prior to biopsy

Repeat CT to confirm stability prior to biopsy: For pediatric mediastinal masses without high‑risk features (no anterior mass, no enlarged nodes, no lymphopenia, no pleural effusion), a single repeat CT Chest with contrast (CPT 71260) is appropriate to confirm stability and potentially avoid biopsy. Document rationale and absence of exclusionary features when requesting repeat CT.

Single repeat CT Chest with contrast (71260) appropriate when no high‑risk features present
Document absence of anterior mass, enlarged nodes, lymphopenia, and pleural effusion to justify repeat CT

Prior Authorization

Obtain chest x‑ray or chest ultrasound prior to advanced imaging

Obtain chest x‑ray or chest ultrasound prior to advanced imaging in certain conditions: Prior to advanced imaging for asthma not responding to therapy, pneumonia evaluation when condition does not respond to therapy, or other chest conditions, obtain plain chest radiograph or chest ultrasound (CPT 76604) as indicated. Ultrasound chest is particularly useful in young children and for evaluation of complicated or recurrent pneumonia.

Chest x‑ray or ultrasound (76604) indicated when asthma or pneumonia fail to respond to standard therapy
Ultrasound chest appropriate for complicated/recurrent pneumonia and to evaluate thymus in young children

PET‑MRI and whole‑body MRI prior authorization and reporting rules

PET‑MRI may be allowed only when guideline criteria for PET‑CT are met and PET‑CT is unavailable at the treating institution; whole‑body MRI is reportable only with unlisted CPT 76498 and is generally limited to select indications (cancer predisposition syndromes, certain autoimmune conditions).

Report PET‑MRI as CPT 78813 + 76498 when permitted.
Report WBMRI using CPT 76498; WBMRI is generally not supported except select indications.

Prior Authorization

Document active signs/symptoms and anesthesia considerations for MRI/CT/PET prior authorization

Advanced imaging (MRI/CT/PET) must be supported by documented active clinical signs or symptoms and prior pertinent clinical evaluation; when MRI is requested for young children, document anesthesia/sedation resource considerations.

Provide documentation of symptoms and prior evaluation with authorization requests.
If anesthesia is required for MRI, include justification and plan.

Prior Authorization

Provide condition‑specific documentation when requesting prior authorization for advanced chest imaging

Prior authorization for CT, MRI, PET, MIBG, or ultrasound studies is subject to payer‑specific rules; when requesting authorization include condition‑specific documentation matching the guideline‑cited CPTs.

Cited CPTs include 71250, 71260, 71552, 78815, 78800 series, and 76604.
Attach guideline‑relevant clinical findings to support the requested modality.

Prior Authorization

Prior authorization may be required for cross‑sectional imaging used for surgical or complex vascular planning

Advanced cross‑sectional imaging (CT, CTA, MRI, MRA) for surgical planning or complex vascular evaluation (e.g., pectus deformity, vascular ring) may require prior authorization per plan rules; document the surgical planning need and prior studies such as echocardiography or chest x‑ray.

Include prior echocardiography, chest x‑ray, or barium esophagram results when applicable.
CPTs commonly used: 71260, 71275, 71555, 71552.

Note

Prior authorization governed by benefit plan and InterQual criteria

Prior authorization requirements for unspecified advanced imaging are governed by the member's benefit plan and may incorporate InterQual or other applicable policies; confirm plan‑specific rules before ordering.

Reference FDA/ACR guidance when applicable.

Billing Rule

Report whole‑body MRI with CPT 76498 (unlisted)

When whole‑body MRI is performed, report using unlisted MRI CPT 76498 because no established CPT codes exist for WBMRI.

Billing Rule

Modality‑specific contrast and CPT selection for chest MRI and CT

MRI chest is generally performed without and with contrast (CPT 71552); CT chest is generally performed with contrast (CPT 71260) unless contraindicated — when allergy or significant renal dysfunction is documented use CT without contrast (CPT 71250).

Select CPT 71552 for MRI without and with contrast when indicated.
Use CPT 71260 for contrast CT unless contraindications necessitate CPT 71250.

Indication contextApplies to monitoring of bronchiectasis and small airways disease in individuals with cystic fibrosis

CT Chest with contrast (CPT 71260) — single repeat CT

Repeat imaging allowanceA single repeat CT Chest with contrast (CPT 71260) is appropriate to confirm stability and potentially avoid biopsy in select mediastinal lesions

Exclusion criteriaRepeat CT to avoid biopsy is appropriate only when none of the following are present: anterior mediastinal mass, enlarged lymph nodes, lymphopenia, or pleural effusion

PurposeUsed to confirm stability of a lesion identified on prior imaging prior to invasive procedures

Often performed as the first-line imaging; advanced imaging used when standard imaging is indeterminate or insufficient

Contrast noteAppropriate use of contrast is determined by condition-specific guideline sections

Diagnostic ultrasound — definition and limitations

DefinitionDiagnostic ultrasound uses high-frequency sound waves with gray-scale and Doppler to evaluate soft tissues and vascular structures; it is operator-dependent and limited by bone/calcification

LimitationsLimited imaging window and reduced value for very large abnormalities or where bone obscures view

ApplicationsUseful for bedside dynamic imaging and initial evaluation of chest wall, mediastinum (in young children), and pleural processes

Concurrent supervision — definition for 3D reconstruction supervision

Concurrent supervision definitionConcurrent supervision is active physician participation and monitoring of 3D reconstruction, including design of the anatomic region to reconstruct, determination of tissue types/structures to display, selection of images/cine loops to archive, and monitoring/adjustment of the 3D work product

Documentation expectationACR recommends documenting the physician's supervision or participation when reporting CPT 76376/76377

Billing implicationConcurrent supervision is required for CPT 76376/76377 reporting

Unit of service for guidance codes — report per encounter, not per lesion

Unit of service ruleGuidance codes (CT/MR/US/fluoroscopy) should be reported as one unit per individual encounter (date of service), not per lesion or procedure

ExamplesCPT 77012/77021/76942 and related guidance codes include the imaging necessary to guide percutaneous procedures and are billed per encounter

Billing cautionDo not report multiple units of guidance codes for multiple lesions on the same date of service

SPECT/CT — definition

DefinitionSPECT/CT combines single photon emission computed tomography with CT to provide optimized localization, accuracy, and attenuation correction

Common usesUsed for MIBG and octreotide scintigraphy and parathyroid imaging; reported with CPT 78830/78831/78832 depending on study specifics

Hybrid advantageProvides both functional and anatomic information in a single exam

Quantitative mp‑MRI analysis (Category III codes) — definition and investigational status

DefinitionQuantitative mp‑MRI analysis (Category III codes) is software-based analysis of multiparametric MRI data for tissue physiology assessment

Coverage stanceThese Category III codes (e.g., 0648T/0649T/0697T/0698T and brain volumetric 0865T/0866T) are considered investigational/experimental for routine clinical practice

Typical usePrimarily used in clinical trials (examples include LiverMultiScan and CoverScan); not widely recommended in clinical practice

Pediatric population — Individuals 18 years old or younger should be imaged according to the Pediatric Chest Imaging Guidelines

Age-based ruleIndividuals 18 years old or younger should be imaged according to the Pediatric Chest Imaging Guidelines

ScopeConditions not specifically discussed in pediatric guidelines should follow the General Chest Imaging Guidelines

RationalePediatric diseases and management often differ from adults; imaging approach reflects those differences

Mediastinal mass — definition and pediatric considerations

DefinitionMediastinal mass: an abnormal mass in the mediastinum; in pediatrics causes and management differ from adults and have higher malignancy likelihood (up to ~50%)

Clinical noteInitial evaluation should include chest x-ray; CT with contrast is indicated when mass seen on x-ray

Pediatric considerationUltrasound helpful in children <5 to distinguish thymus from true mass; MRI indicated for posterior masses invading spinal canal

Bronchiolitis — definition

DefinitionBronchiolitis: a self-limiting viral infection causing inflammation of the small airways, most common in infants under 12 months

Imaging roleChest x-rays indicated when clinical suspicion for pneumonia or complications exists; advanced imaging not routine

When CT indicatedCT Chest with contrast is appropriate for pleural effusion/empyema, immunocompromised patients with acute symptoms, or abnormal chest x-ray suggesting other conditions

Pulmonary nodule — definition

DefinitionPulmonary nodule: a discrete, spherical pulmonary or pleural opacity 2-30 mm in diameter surrounded by normal lung tissue; larger lesions are masses

Clinical implicationCT Chest with contrast is used as one-time evaluation for incidental nodules; routine follow-up not needed in asymptomatic healthy pediatric individuals

DistinctionNon-spherical, linear, or scarring opacities are not considered nodules

Vascular ring — definition

DefinitionVascular ring: congenital vascular anomaly encircling the trachea and/or esophagus causing respiratory or feeding symptoms

PresentationCommonly presents with respiratory symptoms (stridor, wheeze, cough) or feeding difficulties (dysphagia, slow feeding); may be incidental on imaging

Evaluation noteChest x-ray is initial for respiratory presentation; barium esophagram for feeding issues; CT/CTA/MRA for anatomic definition

PAVM — definition

DefinitionPAVM (Pulmonary arteriovenous malformation): abnormal direct communication between pulmonary arteries and pulmonary veins

Initial imagingChest x-ray indicated initially for known AVMs or patients presenting with hypoxemia/hemoptysis

Treatment planningCTA or MRA appropriate for treatment planning when AVM suspected or seen on chest x-ray

CDH — definition

DefinitionCongenital diaphragmatic hernia (CDH): a diaphragmatic defect allowing abdominal organs into the chest cavity, potentially compromising pulmonary function

EpidemiologyOver 90% occur posterolaterally (Bochdalek) typically on the left; others are anterior (Morgagni)

Imaging pathwayIf clinical concern for CDH, initial study is chest x-ray and/or chest ultrasound (CPT 76604); CT with contrast or MRI with and without contrast appropriate when inconclusive or for treatment planning

Interim evidence-based updates applied to the guideline (see Policy History).

2024-02-01revision

Annual evidence-based updates applied to the guideline (see Policy History).