State-specific medical necessity review (Ohio only)

This policy applies only to Ohio; services listed as unproven or with coverage/quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01. Verify Ohio OAC requirements when submitting requests.

CPT listing does not equal PA requirement

Inclusion of a CPT code in these guidelines does not itself mean the code requires prior authorization; however, some advanced imaging or designated procedures may require prior authorization per payer processes.

Prior authorization for 3D rendering

Prior authorization may be required for 3D rendering codes CPT 76376 and 76377 even if the underlying imaging procedure does not require authorization; document concurrent physician supervision/participation for these codes.

• CPT 76376/76377 require active physician participation and monitoring of the reconstruction process.

Prior authorization for hybrid nuclear/CT

Hybrid nuclear/CT studies (CPT 78830–78832) and SPECT/CT parathyroid imaging (CPT 78072) are established study types; prior authorization requirements should follow the applicable guideline sections and payer process.

• Report hybrid nuclear/CT per CPT 78830-78832 and CPT 78072 as appropriate.

PET/MRI prior authorization criteria

PET/MRI is medically necessary only when condition-specific PET/MRI criteria are met OR when the individual meets PET/CT guideline criteria, PET/CT is unavailable, and the provider requests PET/MRI in lieu of PET/CT; report PET/MRI as CPT 78813 + 76498 when allowed.

• When performed in lieu of PET/CT, report CPT 78813 + CPT 76498.

Advanced cross-sectional imaging for mediastinal mass

For any mediastinal mass identified on chest x‑ray, obtain cross-sectional imaging: CT Chest with contrast (CPT 71260) is medically necessary; MRI Chest without and with contrast (CPT 71552) or PET/CT (CPT 78815) may be required per the specific criteria outlined.

• CT Chest with contrast (CPT 71260) is medically necessary for any mediastinal mass seen on chest x‑ray.
• MRI 71552 indicated for posterior masses invading the spinal canal or inconclusive CT; PET/CT (78815) indicated prior to biopsy if lymphoma is suspected.

Prior authorization for CT chest studies

CT chest studies (CPT 71250/71260) are listed as medically necessary for specific scenarios (e.g., true hemoptysis, cystic fibrosis complications, pleural effusion/empyema); follow payer prior authorization processes for these indications.

• CPT 71250 and 71260 are medically necessary in the listed clinical scenarios; prior authorization applies per payer rules.

Prior authorization for advanced imaging

Requests for advanced imaging (CT chest CPT 71250/71260, chest ultrasound CPT 76604) must include documentation supporting the specific clinical indications (e.g., immunocompromise, pleural effusion, suspected abscess); prior authorization processes will confirm those indications.

• Ensure clinical documentation supports the requested advanced imaging indication.

Prior authorization expectation for advanced pediatric chest imaging

Prior authorization may be required per payer rules when CT or MRI are requested for pediatric chest imaging; imaging requests must meet the listed clinical indications (e.g., one-time CT for incidental nodule, MRI as CT alternative for TB, CT for asthma complications).

• Document which listed clinical indication the request meets to support authorization.

Prior authorization for advanced chest imaging

Advanced chest imaging codes require prior authorization when submitted for listed indications such as preoperative planning, suspected vascular ring, cardiac compression, or pulmonary impingement; include supporting initial imaging and clinical findings.

• Include chest x‑ray, barium esophagram, or prenatal imaging results when applicable.

Prior authorization expectation for advanced chest imaging (congenital/complex)

For complex congenital/complex chest conditions, prior authorization may be required for CT/CTA/MRI studies (e.g., CTA CPT 71275, MRI CPT 71550/71552); ensure documentation demonstrates initial imaging steps and clinical rationale per payer rules.

• Provide prior imaging or clinical suspicion to justify advanced cross-sectional studies.

Authorization criteria source

UnitedHealthcare uses InterQual for primary medical/surgical criteria; if InterQual lacks applicable criteria, UnitedHealthcare's Medical Policies, Coverage Determination Guidelines, and Utilization Review Guidelines approved by the Ohio Department for Medicaid Services may be used for authorization decisions.

No step therapy requirements specified

No formal step therapy requirements are specified in this guideline section.

Use lower-cost/less-invasive options first

Providers should consider less invasive or lower-cost imaging options first; unnecessary repeat or higher‑level studies may be considered overutilization and trigger review.

• Review prior diagnostic tests before ordering higher-level studies.

WBMRI step/conditional therapy

Whole-body MRI (WBMRI) is generally not medically necessary except for select cancer predisposition syndromes and some autoimmune conditions (e.g., chronic recurrent multifocal osteomyelitis); approvals are limited and WBMRI is reportable as CPT 76498.

• WBMRI is reportable using CPT 76498; separate diagnostic MRI codes for multiple body parts are inappropriate for WBMRI.

Ultrasound first-line recommendation for some lymphadenopathy/thymus evaluation

Use ultrasound (CPT 76604) as first-line for evaluation of axillary lymphadenopathy and to distinguish prominent thymus from mediastinal mass in children <5 years before proceeding to CT/MRI when appropriate.

• Supraclavicular adenopathy is almost always pathologic and advanced imaging is medically necessary prior to excisional biopsy; ultrasound may be initial in axillary cases.

Initial chest x-ray prior to advanced imaging in stable patients

In stable patients, obtain a chest x‑ray prior to advanced imaging unless specific indications (e.g., documented true hemoptysis, cystic fibrosis complications, or radiographic evidence of complication) justify immediate CT/CTA.

• Chest x‑ray is the initial study for mediastinal mass and hemoptysis; exceptions are defined in condition sections.

Imaging escalation pathway

Follow an escalation pathway: chest x‑ray or ultrasound are first‑line for suspected complications; CT is reserved for specified escalation indications such as pleural effusion/empyema, immunocompromise, inconclusive prior imaging, or worsening clinical course.

• Reserve CT for the listed escalation criteria within each condition-specific section.

Asthma imaging escalation criteria

For asthma, initial management should follow standard therapy before advanced imaging; CT chest is indicated only for poor response to bronchodilators/corticosteroids, suspected alternative diagnoses, or complications evident on chest x‑ray/ultrasound.

• Chest x‑ray or ultrasound is medically necessary when respiratory distress does not respond to standard therapy.

Initial imaging sequencing

Initial imaging sequencing: chest x‑ray is recommended first for individuals with respiratory symptoms; barium esophagram is the initial study for feeding difficulties prior to advanced imaging.

Initial imaging generally recommends chest x‑ray and/or chest ultrasound before advanced CT/MRI when clinically appropriate

Generally, obtain chest x‑ray and/or chest ultrasound before proceeding to advanced CT or MRI when clinically appropriate to limit radiation and guide need for escalation.

Documentation expectations (reminder of Ohio rules)

Providers must document clinical indications and supporting evidence consistent with guideline criteria and applicable Ohio Administrative Code when requesting imaging; physician judgment may override guidelines but requests will be reviewed against evidence-based standards.

Clinical documentation required (history, exam, labs, prior imaging)

Adequate clinical information must be submitted to establish medical necessity, including history since onset/change in symptoms, physical exam, relevant labs, prior imaging, and condition-specific required items; prior imaging should be available to avoid duplicate studies.

• Include prior imaging results and relevant labs when applicable.

3D reconstruction documentation requirement

For CPT 76376/76377 3D post-processing, document physician concurrent supervision/participation, design of the anatomic region reconstructed, tissue types/structures displayed, images/cine loops archived, and monitoring/adjustment of the 3D work product.

• Document the physician's role and the 3D reconstruction details to support billing.

Documentation for unlisted and limited CT procedures

When using unlisted CT/MR codes (CPT 76497/76498), document why no anatomic site-specific CPT exists and, for therapy planning, provide the specific indication (e.g., neurosurgical navigation, custom arthroplasty planning) and why a limited CT (CPT 76380) is not appropriate.

• If a Category III code exists, report that instead of an unlisted code.

Documentation for outside study interpretation (CPT 76140)

When performing a secondary interpretation of an outside study, document use of CPT 76140 and that the images were completed elsewhere rather than reporting diagnostic imaging codes for the study.

WBMRI reporting documentation (use CPT 76498)

When reporting Whole‑body MRI, use CPT 76498; reporting WBMRI using separate diagnostic MRI codes for multiple body parts is inappropriate.

• Do not report separate diagnostic MRI codes for multiple body parts to represent WBMRI.

PET/MRI reporting documentation (use 78813 + 76498)

When PET/MRI is performed in lieu of PET/CT, report with CPT 78813 (PET Whole-Body) and CPT 76498 (MRI Unlisted); diagnostic MRI codes may be medically necessary concurrently when appropriate.

• Ensure PET/CT criteria are met or PET/CT is unavailable if requesting PET/MRI substitution.

Documentation for oncology indications (age, suspected diagnosis, tracheal compression, lymphopenia)

For oncology-related imaging requests include patient age, suspected diagnosis (e.g., lymphoma, neuroblastoma), presence of tracheal compression, lymphopenia, pleural effusion, or enlarged nodes to support advanced imaging or PET/CT authorization.

Document initial chest x-ray findings and clinical history for hemoptysis/CF/immunocompromise

When ordering advanced imaging for hemoptysis, cystic fibrosis, or immunocompromise include the initial chest x‑ray findings and clinical history (e.g., true hemoptysis vs epistaxis, CF complications, immunocompromised status) to justify CT or CTA.

• Document whether hemoptysis is true hemoptysis versus aspirated blood from epistaxis or emesis.

Clinical justification for imaging (pneumonia complications, pleural effusion, immunocompromise)

Clinical documentation should support advanced imaging indications such as suspected pneumonia complications, pleural effusion/empyema on chest x‑ray or ultrasound, immunocompromised status with acute pulmonary symptoms, suspected abscess/necrotizing pneumonia, or new/worsening pulmonary symptoms.

Document clinical context and risk factors to justify advanced imaging

Document clinical context and risk factors (immunocompromise, malignancy, invasive infection, new/worsening pulmonary symptoms) when requesting follow-up or advanced imaging to justify medical necessity.

Required clinical documentation for preoperative/planning/cardiac indications

For preoperative, procedural planning, or cardiac indications include documented clinical indication such as preoperative planning, significant cardiac depression after chest x‑ray and echocardiography, pulmonary impingement with supporting chest x‑ray and PFTs, or feeding difficulties with barium esophagram.

• Provide PFTs when obtainable and prior imaging supporting the need for advanced imaging.

Document prior imaging or clinical suspicion to support advanced imaging requests

Include prior imaging or clinical suspicion demonstrating need (e.g., abnormal chest x‑ray, inconclusive ultrasound/CT) when requesting advanced imaging to avoid denials for lack of documented prior studies.

• Note if imaging is requested to avoid radiation (e.g., MRI as CT alternative) or for preoperative planning.

Check governing benefit requirements

Check federal, state (Ohio Administrative Code), or contractual benefit plan requirements before relying on this policy; coverage determinations must follow those governing rules where they differ.

Imaging requests inconsistent with established clinical standards (denial risk)

Imaging requests inconsistent with established clinical standards, requested for data collection rather than direct clinical management, or considered investigational/experimental due to insufficient evidence may be determined not medically necessary and denied.

• Clinical trial or research-only imaging that is not used for direct clinical management may be denied.

Clinical trial and research imaging denial risk

Imaging requested solely for clinical trial data collection or research that is inconsistent with established standards may be denied as not medically necessary.

Ordering duplicate or questionably necessary imaging (denial risk)

Ordering duplicate or questionably necessary imaging, or imaging performed without prior diagnostic results or clinical history demonstrating need, may trigger denial as overutilization.

• Obtain prior diagnostic test results before ordering further imaging to reduce denial risk.

Whole-body CT screening denial risk

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

Inappropriate use of guidance codes

Inappropriate use of radiologic guidance codes (e.g., CPT 77012, 77013, 77021, 77022) with open/excisional/incisional surgical codes or for non‑percutaneous procedures may trigger claim denial; only one unit of guidance code should be reported per encounter.

• Guidance codes are for percutaneous procedures only; CPT guidance units limited to one per date of service.

Whole-body CT screening denial risk (duplicate)

Whole‑body CT or LifeScan screening exams performed in asymptomatic individuals are explicitly not a covered benefit and risk denial.

CT chest required for mediastinal mass identified on chest x-ray (denial risk if omitted)

If a mediastinal mass is identified on chest x‑ray, CT chest (CPT 71260) is medically necessary; failing to obtain indicated cross‑sectional imaging when a mass is seen could lead to denial of less appropriate studies.

• Chest x‑ray is the initial study; CT with contrast is required when a mass is identified.

Advanced imaging not necessary for epistaxis with normal chest x-ray

Advanced imaging is not medically necessary for evaluation of epistaxis when chest radiograph is normal and there is no history of lung disease or bleeding disorder; requesting MRI for pediatric hemoptysis is not medically necessary.

Advanced imaging (CT Chest) not necessary for routine bronchiolitis

CT Chest is not medically necessary for routine bronchiolitis management; CT is only indicated for specified complications (e.g., pleural effusion/empyema, immunocompromised status, or chest x‑ray abnormalities). Requests outside these indications risk denial.

Follow-up imaging exclusion for incidental solitary pulmonary nodule in asymptomatic healthy children

Follow‑up imaging of an incidental solitary pulmonary nodule in an asymptomatic healthy pediatric individual is not medically necessary; requests for routine follow-up in such cases risk denial.

Advanced imaging for routine cases may be denied (bronchiolitis/pneumonia)

Advanced imaging requests for routine evaluations or monitoring of bronchiolitis or uncomplicated pneumonia without specified indications are not medically necessary and may be denied.

Follow-up imaging exclusion for incidental solitary pulmonary nodule (duplicate)

Follow‑up imaging for an incidental solitary pulmonary nodule in an asymptomatic healthy pediatric individual is not medically necessary; routine/advanced imaging for asthma without criteria is also not medically necessary.

Lack of documented initial imaging or indications

Advanced imaging is medically necessary only after appropriate initial studies (prenatal imaging, chest x‑ray, or barium esophagram) where specified; failure to document these preceding studies or clinical indications may risk denial.

Requests should align with stated medically necessary indications

Requests for advanced imaging should align with the medically necessary indications listed (e.g., CT Chest with contrast CPT 71260; CTA Chest CPT 71275; MRI Chest CPT 71550/71552); lack of documentation demonstrating the specific indication may risk denial.

Follow governing coverage rules

Coverage determinations must reference federal, state (Ohio Administrative Code), or contractual requirements; failure to follow applicable governing coverage rules may result in denial.