ModifiedColorado Rocky Mountain Health PlansPolicy RADIOLOGY 034.24

Radiopharmaceuticals and Contrast Media

Policy governing reimbursement and billing rules for radiopharmaceuticals and contrast media billed with radiology, nuclear medicine, PET, CT, and MRI procedures for Colorado Rocky Mountain Health Plans/Oxford administered claims (EviCore may administer). Affects providers submitting claims for these services.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyRadiopharmaceuticals and Contrast Media

Policy CodePolicy RADIOLOGY 034.24

Change TypeAdded and revised code/administrative references

Effective DateDec 1, 2025

Next Review Date

Key ActionBill HCPCS A9616 with a qualifying PET procedure code, appropriate diagnosis, and include an invoice to support reimbursement.

SourceLink

POLICY UPDATE CHANGES

Added HCPCS code A9616 to Applicable Codes.

Replaced references to 'eviCore healthcare' with 'Oxford and EviCore' and clarified that Oxford and EviCore may administer claims on behalf of Oxford.

Changed policy type classification from 'Clinical Policy' to 'Administrative Policy'.

Updated related policy references for outpatient cardiology and radiology procedures for EviCore arrangement (Oxford only).

Archived previous policy version RADIOLOGY 034.23.

96 hoursadministration window (before procedure)

A9616HCPCS added

A9587/A9616/A9588PET exceptions

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

A9584Investigational code

~20+distinct A-codes listed

Coverage and Reimbursement Criteria

Coverage criteria summary

Coverage stance varies by code and context. Radiopharmaceuticals and contrast media are generally considered part of the primary imaging procedure and not separately reimbursable except as specifically noted below.

ALL of the following

Radiopharmaceuticals and contrast agents are considered part of the underlying imaging examination and will be denied as 'included in the primary procedure' unless a specific HCPCS code is listed as reimbursable or an exception applies.
Applies to MRI contrast, PET-associated radiopharmaceuticals (general rule), CT and other radiographic studies when not paired with an allowed procedure code.
Exceptions for PET scans: HCPCS codes A9587, A9616, and A9588 may be reimbursed when billed with an appropriate PET procedure code, an appropriate diagnosis (per the policy), and accompanied by an invoice for the radiopharmaceutical. The radiopharmaceutical may be administered up to 96 hours before the primary procedure.
See PET-specific code list and diagnosis requirements.
Certain radiopharmaceutical HCPCS codes are specifically listed as reimbursable when billed in conjunction with allowed nuclear medicine procedure codes (see radiopharmaceutical/procedure pairings). These services may be processed if billed with the permitted procedure code(s) and within the allowed timing (up to 96 hours before the procedure).
Refer to the radiopharmaceutical pairing lists for code-specific allowances.
Contrast material cost is considered part of the underlying examination and is non-reimbursable separately, except where a specific HCPCS entry in the policy indicates a payable circumstance (for example, select PET radiopharmaceuticals when meeting PET criteria).
Contrast injections (A9576–A9579, A9581, A9583, etc.) are listed as non-reimbursable in general.

Coverage criteria for radiopharmaceuticals and contrast media

Radiopharmaceuticals listed below are payable only when billed in conjunction with the specified nuclear medicine or PET procedure codes, with appropriate diagnosis when required, and when supported by documentation (invoice). Radiopharmaceuticals may be administered up to 96 hours before the primary procedure.

ANY of the following

A9587 (Gallium ga-68 dotatate, diagnostic, 0.1 millicurie) — Allow with PET procedure codes 78812, 78813, 78814, 78815, 78816 when used for Somatostatin Receptor–Positive Neuroendocrine Tumor(s); invoice required.
Reimbursable when diagnosis matches policy list and invoice provided; up to 96 hours prior.
A9616 (Gallium Ga-68 gozetotide, diagnostic, 1 millicurie) — Allow with PET procedure codes 78812–78816 when used for Prostate Cancer (ICD-10 C61, R97.21, Z85.46); invoice required.
Added to applicable codes; see policy history for effective date.
A9588 (Fluciclovine F-18, diagnostic, 1 millicurie) — Allow with PET procedure codes 78812–78816 when used for Prostate Cancer; invoice required.
Diagnosis requirement applies; invoice required.

Code Listings, Dose Limits, and Administration Rules

Radiopharmaceuticals allowed with listed nuclear medicine procedure codes (example)HCPCSCovered

A9500

Technetium Tc-99m, Sestamibi, diagnostic, per study dose

Radiopharmaceuticals allowed with listed nuclear medicine procedure codes (example)HCPCSCovered

A9502

Technetium Tc-99m tetrofosmin, diagnostic, per study dose

Additional radiopharmaceutical HCPCS examplesHCPCSCovered

A9503	Technetium Tc-99m, Medronate (MDP), diagnostic, per study dose, up to 30 mCi
A9507	Indium IN 111 Capromab Pendetide (ProstaScint) per study dose, up to 10 mCi
A9510	Technetium Tc-99 Disofenin (Hepatolite DISIDA), per study dose, up to 15 mCi

Radiopharmaceutical HCPCS examples and associated allowed procedure codesHCPCSCovered

A9520	Technetium TC-99m, tilmanocept, diagnostic, up to 0.5 millicurie
A9521	Technetium Tc-99m Exametazine (Ceretec), diagnostic, per study dose, up to 25 mCi
A9524	Iodinated I-131-Serum Albumin, diagnostic, per 5 microcuries

Radiopharmaceutical HCPCS A-codesHCPCSCovered

A9537	Technetium Tc-99m Mebrofenin (Choletec) Diagnostic, per study dose, up to 15 mCi's.
A9538	Technetium Tc-99m Pyrophosphate (PYP) (Pyrolite) Diagnostic, per study dose, up to 25 mCi's.
A9540	Technetium Tc-99m Macroaggregated Albumin (MAA), Diagnostic, per study dose, up to 10 mCi's.
A9548	Indium IN-111 Pentetate (MyoScint) Diagnostic, per 0.5 mCi.
A9551	Technetium Tc-99m Succimer (DMSA), Diagnostic, per study dose, up to 10 mCi's.
A9554	Iodine-125 Sodium Iothalamate (Glofil-125), Diagnostic, per study dose, up to 10 microcuries.
A9556	Gallium Ga-67 Citrate, Diagnostic, per mCi.
A9557	Technetium Tc-99m Bicisate (Neurolite), Diagnostic, per study dose, up to 25 mCi's.
A9558	Xenon Xe-133 Gas, Diagnostic, per 10 mCi's.
A9560	Technetium Tc-99m Labeled Red Blood Cells (RBCs), Diagnostic, per study dose, up to 30 mCi's.

Reimbursable radiopharmaceuticals (examples)HCPCSCovered

A9560	Technetium Tc-99m Labeled Red Blood Cells, diagnostic, per study dose, up to 30 mCi
A9561	Technetium Tc-99m Oxidronate, diagnostic, per study dose, up to 30 mCi
A9562	Technetium Tc-99m Mertiatide (MAG-3), diagnostic, per study dose, up to 15 mCi
A9570	Indium-111 labeled autologous white blood cells, diagnostic, per study dose
A9571	Indium-111 labeled autologous platelets, diagnostic, per study dose
A9572	Iodine I-123 Iobenguane (AdreView), diagnostic, per study dose, up to 15 mCi

Non-reimbursable or investigational codesHCPCSNot Covered

A9584	Iodine I-123 ioflupane, diagnostic, per study dose, up to 5 millicuries (investigational with SPECT brain)
A9552	Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries (listed non-reimbursable in this section)

PET radiopharmaceuticals payable with PETHCPCSCovered

A9587	Gallium Ga-68 dotatate, diagnostic, 0.1 millicurie (reimbursable with PET when requirements met)
A9616	Gallium Ga-68 gozetotide (Gozellix), diagnostic, 1 millicurie (reimbursable with PET when requirements met)
A9588	Fluciclovine F-18, diagnostic, 1 millicurie (reimbursable with PET when requirements met)

Applicable HCPCS codes referencedHCPCSCovered

A9616	Radiopharmaceutical, diagnostic, per study dose, not otherwise classified (added to Applicable Codes)
78812-78816	PET scan HCPCS codes referenced as qualifying procedures

inv-14: administration timeframe

Administration timeframeRadiopharmaceutical may be administered up to 96 hours before the primary procedure.

ScopeApplies to radiopharmaceuticals billed in conjunction with nuclear medicine procedures; covered services processed per policy chart.

Claim processingCovered services will be processed according to the chart provided in the policy.

inv-15: A9503 dosage limit

HCPCS code

Provider Responsibilities, Billing Conditions, and Denials

Note

Cross-reference to EviCore outpatient procedure policies

Oxford, a UnitedHealthcare Company and EviCore may administer claims on behalf of Oxford for services billed in conjunction with radiopharmaceuticals and/or contrast media. Refer to the Medical Policies titled: Outpatient Radiology Procedures for EviCore Arrangement (for Oxford Only) and Outpatient Cardiology Procedures for EviCore Arrangement (for Oxford Only) for additional information.

Billing Rule

Allowed radiopharmaceutical–procedure pairings (partial)

Allowed radiopharmaceutical-procedure pairings (partial). When billing radiopharmaceuticals, ensure the HCPCS radiopharmaceutical code is billed only with the allowed nuclear medicine or PET procedure codes listed and with appropriate diagnosis documentation where specified.

A9537 (Technetium Tc-99m Mebrofenin, per study dose, up to 15 mCi) — Allow with procedure codes: 78215, 78216, 78226, 78227.
Radiopharmaceuticals billed in conjunction with nuclear medicine procedures: example pairing includes HCPCS 78121 billed with 78122, 78130, 78140, 78185, 78191, 78195, 78199 (partial list).

Definitions and Policy Terms

inv-26: Included in the primary procedure

Included-in-primary rule (MRI)Contrast agents billed with MRI will be denied as included in the primary procedure.

Included-in-primary rule (PET)Radiopharmaceuticals billed with PET will be denied as included in the primary procedure unless an exception applies (see PET exceptions).

CT/other studiesAny code not on the covered list or billed without an allowed primary procedure code will deny as included in the primary procedure.

inv-27: Administration timeframe

Administration timeframeRadiopharmaceuticals may be administered up to 96 hours before the primary nuclear medicine procedure.

Reimbursement conditionOxford and EviCore will reimburse covered radioisotopes when used with a listed nuclear medicine procedure.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyRadiopharmaceuticals and Contrast Media

Policy CodePolicy RADIOLOGY 034.24

Change TypeAdded and revised code/administrative references

Effective DateDec 1, 2025

Next Review Date

Key ActionBill HCPCS A9616 with a qualifying PET procedure code, appropriate diagnosis, and include an invoice to support reimbursement.

SourceLink

On This Page

A9500 (Technetium Tc-99m Sestamibi) — Allow with specified procedure codes including 78012–78016, 78018, 78020, 78070–78072, 78075, 78099, 78428, 78445, 78451–78454, 78456–78458, 78466–78483, 78494–78496, 78499, 78605–78606, 78800–78804, 78830–78832, 78999, etc., when billed with the listed nuclear medicine procedure code.

Refer to full pairing list in policy for exact allowed procedure codes.

A9537 (Technetium Tc-99m Mebrofenin, Choletec, up to 15 mCi) — Allow with procedure codes 78215, 78216, 78226, 78227 when billed with those procedures.

Per radiopharmaceutical pairing list.

A9540 (Technetium Tc-99m Macroaggregated Albumin, MAA, up to 10 mCi) — Allow with procedure codes 78291, 78428, 78579–78580, 78582, 78597–78599, 78800–78801–78803, 78102–78104 when billed with those procedures.

See policy for full enumerate of allowed pairings.

A9541 (Technetium Tc-99m Sulfur Colloid, up to 20 mCi) — Allow with procedure codes 78110, 78111, 78120, 78121, 78122, 78130, 78140, 78185, 78191 when billed with those procedures.

Refer to pairing list.

A9560 (Technetium Tc-99m Labeled Red Blood Cells, up to 30 mCi) — Allow with procedure codes 78226, 78227, 78230–78232, 78258, 78261, 78262, 78264 when billed with those procedures.

Refer to pairing list.

Other radiopharmaceuticals listed in the policy (see Applicable Codes section) may be non-reimbursable or reimbursable only under specific conditions; consult the Applicable Codes and pairing lists for each HCPCS code before billing.

Examples of non-reimbursable entries include many contrast agents and certain radiopharmaceuticals noted as non-reimbursable in the policy.

DescriptionTechnetium Tc-99m, Medronate (MDP), diagnostic, per study dose.

Dosage limitUp to 30 mCi per study.

Allowable procedure codes78300-78315, 78399, 78803 (per policy).

inv-16: A9510 dosage limit

HCPCS codeA9510

DescriptionTechnetium Tc-99 Disofenin (Hepatolite DISIDA), diagnostic, per study dose.

Dosage limitUp to 15 mCi per study.

Allowable procedure codes78012-78016, 78018, 78020 (per policy).

inv-17: A9521 dosage limit

HCPCS codeA9521

DescriptionTechnetium Tc-99m Exametazine (Ceretec), diagnostic, per study dose.

Dosage limitUp to 25 mCi per study.

Allowable procedure codes78630, 78635, 78645, 78650, 78660, 78699, 78803, 78102-78104 (per policy).

inv-18: per-study dose limits

Per-study dose limits (examples)A9537: up to 15 mCi; A9538: up to 25 mCi; A9540: up to 10 mCi.

Per-mCi billingSome agents (e.g., A9556 Gallium Ga-67 Citrate) are billed per mCi as specified in the policy.

Microcurie limitsCertain codes specify microcurie limits (e.g., A9554 up to 10 microcuries).

Study-specific limitsMultiple listed A‑codes include explicit per‑study maximum mCi values; refer to the chart for each code.

inv-19: Administration window before PET

Administration window before PETRadiopharmaceutical may be administered up to 96 hours before the primary PET procedure.

ApplicabilityApplies to PET‑specific reimbursable HCPCS codes (e.g., A9587, A9616, A9588) when PET reimbursement conditions are met.

ProcessingCovered PET services will be processed according to the PET section chart in the policy.

inv-20: Documentation requirement

When requiredAn invoice for the radiopharmaceutical is required when billing A9616 in conjunction with qualifying PET codes and an appropriate diagnosis.

Qualifying PET procedure codes78812, 78813, 78814, 78815, 78816 (per policy).

Qualifying diagnoses for A9616Appropriate diagnosis examples noted in policy (e.g., Prostate Cancer for certain PET agents).

Billing Rule

PET radiopharmaceutical reimbursement conditions

Oxford and EviCore will reimburse HCPCS codes A9587, A9616, and A9588 only when all of the following are met: they are used in conjunction with an appropriate PET procedure (e.g., 78812–78816), an appropriate diagnosis (as specified below), and an invoice for the radiopharmaceutical is provided. The radiopharmaceutical may be administered up to 96 hours before the primary PET procedure.

A9587 (Gallium Ga-68, dotatate, diagnostic, 0.1 millicurie) — Allow with PET procedure codes 78812, 78813, 78814, 78815, 78816. Diagnosis: Somatostatin receptor–positive neuroendocrine tumor(s).
A9616 (Gallium Ga-68 gozetotide, diagnostic, 1 millicurie) — Allow with PET procedure codes 78812–78816. Diagnosis: Prostate cancer (e.g., ICD-10 C61, R97.21, Z85.46).
A9588 (Fluciclovine F-18, diagnostic, 1 millicurie) — Allow with PET procedure codes 78812–78816. Diagnosis: Prostate cancer.

Denial Risk

Investigational denial rule

HCPCS code A9584 when used in conjunction with SPECT brain imaging is considered investigational and will be denied.

Note

Claims administration and reimbursement conditions

Claims administration note: Oxford and EviCore may administer claims for the services described. For reimbursement of PET radiopharmaceuticals (A9587, A9616, A9588), ensure the PET procedure code (78812–78816), appropriate diagnosis, and an invoice for the radiopharmaceutical accompany the claim.

Radiopharmaceutical may be administered up to 96 hours before the primary procedure.
A9616 is reimbursable only when billed with PET procedure codes 78812–78816, an appropriate diagnosis (e.g., C61, R97.21, Z85.46), and an invoice.

ProcessingCovered services processed per the policy's provided chart.

inv-28: Radiopharmaceutical A-codes

Radiopharmaceutical A-codes (summary)HCPCS A-codes represent diagnostic radiopharmaceutical agents billed per study or per mCi with specified dose rules (examples include A9537, A9540, A9556, A9560).

Billing unitsSome codes billed per study dose with max mCi; others billed per mCi or per microcurie as specified.

Refer to chartEach A‑code's allowable procedure codes and dose limits are listed in the policy chart and must be followed.

inv-29: Radiopharmaceutical Material

DefinitionRadiopharmaceutical Material: A radioactive pharmaceutical, nuclide, or other chemical used for diagnostic or therapeutic purposes.

UsageApplies to agents billed as diagnostic or therapeutic radiopharmaceuticals under HCPCS A‑codes.

Policy contextDefinition used to clarify which substances are subject to the radiopharmaceutical reimbursement rules.

inv-30: Oxford

OxfordRefers to Oxford Health Plans, LLC and subsidiaries; Oxford and EviCore may administer claims on behalf of Oxford.

Related policiesSee Outpatient Radiology Procedures and Outpatient Cardiology Procedures for EviCore arrangement (for Oxford only) as referenced in the policy history.

Administrative notePolicy classification updated to Administrative Policy in the revision history.