State-based medical necessity review (OAC 5160-1-01)

This policy applies to Ohio and medical necessity determinations (including for services stated as unproven or with coverage or quantity limits) will be evaluated using Ohio Administrative Code 5160-1-01.

CPT listing does not imply prior authorization

Inclusion of a CPT code in these clinical guidelines does not mean the code requires prior authorization; prior authorization requirements are determined separately by the plan.

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

Providers may be required to obtain prior authorization for 3D rendering CPT codes 76376 and 76377 even when the underlying imaging procedure is not subject to authorization; document physician concurrent supervision/participation when applicable.

• Codes: 76376, 76377
• Concurrent supervision must be documented as active physician participation in the reconstruction process.

SPECT/CT coding and authorization guidance

Hybrid nuclear/CT (SPECT/CT) studies should be reported using CPT 78830–78832 as appropriate; follow the applicable guideline section for management and payer authorization expectations.

• Report SPECT/CT with CPT 78830, 78831, or 78832 depending on area/days.

PET/MRI and WBMRI reporting and prior-authorization code combinations

When PET/MRI is approved, report the study using CPT 78813 (PET whole-body) in combination with CPT 76498 (MRI unlisted); WBMRI is reportable only using CPT 76498—use these code combinations when prior authorization is granted.

• PET/MRI reporting: CPT 78813 + CPT 76498
• WBMRI reporting: CPT 76498 only

Prior authorization / medical necessity overview for advanced imaging

Advanced imaging (CT, MRI, Nuclear Medicine) is subject to medical necessity review and generally requires documentation of active clinical signs/symptoms, prior clinical evaluation, and justification for modality choice; ultrasound is expected first-line for many neck indications.

• Document active symptoms and prior evaluation
• Justify choice of CT/MRI/Nuclear over ultrasound when applicable

Prior authorization expectation after initial ultrasound or other steps

Certain advanced imaging (specific CT/MRI CPTs listed in the guideline) is indicated only after specified clinical indications or an initial ultrasound per the guideline pathways; requests not meeting pathway requirements may require authorization.

• Ultrasound (CPT 76536) is the initial study for many pediatric neck masses
• Advanced CT/MRI follow only if ultrasound is inconclusive or clinical criteria met

Prior authorization expectation for specified advanced imaging CPTs

Providers should obtain prior authorization per payer rules when ordering identified advanced imaging tests that are medically necessary only in specific clinical scenarios (e.g., CT/MRI codes listed); verify authorization when studies are not emergent.

• Verify authorization for CPTs such as 70491, 72125, 72141, 70543, 70549, 76536, 76942, 78013/78014

CT and 3D rendering for complex congenital esophageal cases — authorization note

CT Neck with contrast (CPT 70491) and/or CT Chest with contrast (CPT 71260), and 3D rendering (CPT 76376 or 76377) are described as medically necessary for preoperative planning in complex congenital esophageal malformation cases; ensure prior authorization per plan rules.

• Codes: 70491, 71260, 76376, 76377
• Document complexity to support medical necessity for preoperative planning

Prior authorization and medical necessity reminder for CT and 3D rendering

CT Neck with contrast (70491), CT Chest with contrast (71260), CT Chest without contrast (71250), and 3D rendering (76376/76377) are described as medically necessary in specified pediatric indications—check plan/state/contractual prior authorization requirements before ordering.

• Verify plan/state/contractual rules for prior authorization
• Document clinical indication and need for 3D rendering

Clinician judgment may override guideline pathways

These guidelines state that clinician judgment may override the pathway when appropriate; however, deviations should be supported by clinical documentation explaining the rationale.

Perform clinical evaluation before ordering advanced imaging

A pertinent clinical evaluation (detailed history, physical exam since onset or change in symptoms, and appropriate labs) or a meaningful technological contact must be performed prior to advanced imaging unless guideline-supported scheduled follow-up imaging is planned.

• Acceptable technological contact includes telehealth, telephone, or electronic messaging
• Document the evaluation in the submitted clinical information

PET/MRI/WBMRI provider action reference

(Placeholder — references PET/MRI/WBMRI context but no specific provider action beyond coding guidance available in cited sections.)

Imaging escalation pathway for pediatric neck masses — ultrasound then MRI/CT

For neck masses, ultrasound (CPT 76536) is the initial imaging modality; escalate to MRI (70540/70543) or CT Neck with contrast (70491) when ultrasound is inconclusive or there is concern for malignancy.

• Initial: Ultrasound Neck (CPT 76536)
• If inconclusive or concern for malignancy: MRI 70540/70543 or CT 70491

Step‑up imaging pathway: ultrasound first for lymphadenopathy and torticollis

Ultrasound is the required initial study for persistent lymphadenopathy after conservative therapy (≥4 weeks) and for congenital torticollis in infants; proceed to CT or MRI only if ultrasound is inconclusive or negative as specified.

• Trial of conservative therapy ≥4 weeks for painful acute lymphadenopathy before advanced imaging
• Infants <12 months: start with ultrasound (76536)

Start thyroid evaluation with ultrasound before advanced imaging

Use ultrasound (CPT 76536) as the initial study for evaluation of thyroid masses or nodules; proceed to CT/MRI or nuclear uptake scans only when clinically appropriate and per the thyroid pathway.

• If low TSH or diagnosis unclear after ultrasound/labs → nuclear thyroid scintigraphy (CPT 78013/78014)
• FNA under ultrasound guidance CPT 76942 when indicated

Thyroid imaging sequence: ultrasound then nuclear uptake if unclear

Begin thyroid evaluation with ultrasound (CPT 76536). If diagnosis remains unclear after ultrasound and laboratory evaluation, proceed to thyroid uptake nuclear imaging (CPT 78012 or CPT 78014) as indicated.

• Ultrasound first-line (76536)
• If unclear after ultrasound/labs → CPT 78012 or 78014

Requests evaluated per Ohio Administrative Code 5160-1-01

Requests will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01; the guideline is evidence-based and intended to support appropriate imaging decisions but does not replace physician judgment—submit adequate supporting documentation.

Required clinical documentation: history, exam, labs, prior imaging

Submit adequate clinical information with authorization requests, including detailed history, physical examination since onset/change in symptoms, appropriate laboratory studies, and relevant prior imaging to establish medical necessity.

• Include prior imaging results and dates
• Describe onset/change of symptoms and prior treatments

Acceptable clinical evaluation may include telehealth/phone/electronic contact

Other meaningful technological contact (telehealth visit, telephone call, or electronic messaging) since symptom onset by an established provider can serve as an acceptable clinical evaluation when face-to-face is not required; document the contact.

• Document date and nature of telehealth/phone/electronic contact

Submit clinical history and prior studies with authorization requests

Clinical history submitted with requests should include the suspected or known abnormality for the imaged body part and all prior imaging/study reports; reviewers expect prior studies to be reviewed before ordering additional advanced imaging.

• Provide indication and prior study reports
• Explain why prior imaging is insufficient

Document concurrent supervision for 3D rendering

When billing 3D rendering (CPT 76376/76377), document physician concurrent supervision/participation (design of anatomic region, tissue determination, images archived, monitoring/adjustment) as recommended and potentially required.

• Document active physician participation during reconstruction
• Archive selected images/cine loops as part of documentation

Coding: use 77011 for technical-only stereotactic CT localization

Use CPT 77011 to report stereotactic CT localization when a pre‑operative CT dataset is obtained that does not require radiologist interpretation; if the CT is interpreted, report the diagnostic CT code instead (do not report both 70486 and 77011).

• Do not report CPT 70486 and CPT 77011 for the same session
• Use diagnostic CT code (e.g., 70486) if interpreted by a radiologist

Pertinent clinical evaluation required before advanced imaging

A pertinent clinical evaluation (history, physical exam, and appropriate labs) or meaningful technological contact should be performed prior to advanced imaging (CT/MRI/Nuclear) unless the request is for guideline-supported scheduled follow-up imaging.

Clinical evaluation or meaningful contact required prior to advanced imaging

A detailed history, focused physical exam since onset or change in symptoms, and appropriate laboratory studies — or a meaningful technological contact — must be documented prior to advanced imaging unless guideline-supported follow-up imaging is planned.

Document trial/response to conservative therapy (≥4 weeks) and infant age/US findings

Document trial and response to conservative therapy (at least 4 weeks) for painful lymphadenopathy; for infants with congenital torticollis document age and ultrasound findings when submitting requests.

• Conservative therapy ≥4 weeks before advanced imaging for painful lymphadenopathy
• For infants <12 months, include ultrasound results; positive ultrasound usually obviates further imaging

Documentation must support modality choice and image‑guided procedures (e.g., FNA)

Documentation should support the chosen imaging modality and, when applicable, justify procedures such as FNA performed under ultrasound guidance.

• If FNA performed, document ultrasound guidance indication (CPT 76942)
• Explain why modality chosen over alternatives

Document indication and prior ultrasound/labs for thyroid uptake nuclear imaging

When ordering nuclear thyroid uptake studies, document the clinical indication and prior ultrasound and laboratory evaluation demonstrating the need for uptake imaging.

• Provide ultrasound and lab results showing unclear diagnosis
• Order CPT 78012 or 78014 when indicated

Check federal/state/contractual requirements before applying this policy

Before using this guideline, check relevant federal, state (Ohio Administrative Code), or contractual benefit plan requirements because those may govern coverage in the event of a conflict with this policy.

Denial risk: requests inconsistent with standards or for data collection only

Requests inconsistent with established clinical standards, for data collection not used in direct clinical management, or for services described as unproven may be denied — ensure documentation demonstrates direct clinical utility and adherence to guideline criteria.

• Clinical trial/data-collection–only requests risk denial
• Services labeled investigational/unproven may be denied per OAC 5160-1-01

Denial risk: studies requested for research/data collection only

Imaging studies inconsistent with established clinical standards or requested solely for data collection and not used in direct clinical management are not medically necessary and may be denied.

Denial risk: CT without and with contrast flagged as overutilization

Requests for CT performed both without and with contrast (double contrast studies) have few indications and are identified as an overutilization risk that may lead to denial unless clearly justified.

• Provide clear clinical justification if requesting CT without and with contrast
• Examples of limited indications include mass characterization or recent inconclusive non-contrast CT

Denial risk: duplicate or repeat imaging without progression

Repeat imaging without evidence of disease progression, recurrence, or meaningful impact on management is considered unnecessary and may be denied; include prior imaging and rationale for repeat studies.

• Attach prior imaging and explain how repeat imaging will affect management

Denial risk: unbundling PET/CT into separate PET + diagnostic CT codes

Unbundling PET/CT into separate PET and diagnostic CT CPT codes is not medically necessary and may be denied; PET/CT is typically performed and billed as a combined study.

Denial risk: whole‑body CT screening not covered

Whole-body CT or LifeScan for screening of asymptomatic individuals is not a covered benefit and is a basis for denial—do not order whole-body CT screening for healthy individuals.