CurrentUnitedHealthcarePolicy N/A

Cardiac Imaging Prior Authorization Form — Coverage Criteria

A UnitedHealthcare prior authorization form for ordering providers to request coverage for a range of cardiac imaging studies (MPI, stress echocardiogram, MUGA, TTE, TEE, fetal echo and related cardiac imaging) documenting patient, provider, facility, clinical indications, prior tests, and requested CPT/ICD codes.

Policy Summary

PayerUnitedHealthcare

PolicyCardiac Imaging Prior Authorization Form — Coverage Criteria (clinical/medical policy, cardiology)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form including CPT and ICD codes, clinical indication checkboxes, prior test dates/results, and required member/provider/facility information to enable review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9document chunks/pages

6distinct imaging modalities listed

multipleindication checkbox fields

3administrative sections

Coverage Criteria for Cardiac Imaging Prior Authorization

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Medical necessity documentation criteria

Authorization consideration is based on documentation that the requested study is for one or more listed clinical indications and, where relevant, supported by prior testing and risk factors.

Requested study selected: Provider checks the specific imaging study requested (MPI, Stress Echo, MUGA, Cardiac MRI, Coronary CTA, Preoperative/Postoperative evaluation, Evaluation during or prior to chemotherapy, Patient has physical limitation to exercise, TTE, TEE, Fetal Echo)>=1 study checked

See SECTION 4 and SECTION 5 study selection checkboxes

Clinical indication(s): One or more clinical reasons relevant to the requested study must be checked (examples: chest pain/suspected angina with specified features, associated conditions such as abnormal EKG, atrial fibrillation, cardiomyopathy, known CAD, new heart failure; other indications such as abnormal test results, anomalous coronaries, congenital heart disease, evaluation for myocardial viability, suspected constrictive pericarditis, quantification of intracardiac shunt or valvular regurgitation; TTE/TEE/fetal echo specific reasons as listed)>=1 indication checked

See SECTION 5 reason-for-study and indication lists

Chest pain features (when chest pain indication selected): Document checked characteristics: without other symptoms; exacerbated by exercise or relieved by rest; relieved with nitroglycerin; dyspnea; jaw pain; left arm/radiating pain; retrosternal locationdocument checked chest pain features when applicable

See chunk 5 chest pain checklist

Associated conditions and other indications: Document associated conditions checked (eg abnormal EKG, atrial fibrillation, cardiomyopathy, known CAD, new onset heart failure, prior transplant/aortic aneurysm/carotid stenosis) and other indications checked (eg abnormal test results with details, anomalous coronary artery, congenital heart disease, myocardial viability, pediatric acquired heart disease, suspected constrictive pericarditis, shunt or valvular regurgitation)document relevant associated conditions/other indications

See chunk 5 for full lists

Risk factors and symptoms: Document presence of CAD risk factors (age >40, family history of premature CAD, current smoker, diabetes, elevated cholesterol, hypertension, other) and symptoms with suspected cardiac etiology (chest pain, dyspnea, palpitations, syncope, ADL limitations) as applicabledocument relevant risk factors and symptoms

See chunks 5, 6, and 8 for risk-factor and symptom checklists

Prior testing documentation: Provide dates and results of prior cardiac testing when applicable (exercise stress test; MPI/PET/SPECT; stress echocardiogram; cardiac MRI; cardiac catheterization; coronary CTA; EKG; MUGA; TTE/TEE; other)provide dates/results when prior tests exist

See chunk 6 previous tests grid

TTE / TEE / Fetal Echo specific reasons: For TTE: document reasons such as abnormal test results, acquired pediatric heart disease, aortic disease, arrhythmias, congenital heart disease, device evaluation. For TEE: document reasons such as evaluation for cardiomyopathy, known or suspected fetal cardiac disorder, murmur or click, pericardial disease, pulmonary hypertension, pre-op/post-op, and symptoms assessing structural heart disease. For Fetal Echo: document reasons such as suspected cardiac mass, suspected or known endocarditis, valvular disease, ventricular function, suspected cardiac source of embolus, peripheral embolic event, TIA/stroke, and other relevant findings.document applicable echo-specific indications

See chunks 7, 8, and 9 for modality-specific indication lists

Supporting documentation and completeness: Attach any additional data relevant to medical necessity (detailed prior test results, dates, and clinical notes). Failure to provide completed clinical indication selections, prior test dates/results, requested CPT/ICD codes, and required administrative information may result in incomplete review or denial of the prior authorization request.attach supporting data and complete all required fields

See chunks 6 and 8–9 for prior tests and plan guidance

Providers must verify plan coverage and medical necessity rules when submitting this prior authorization form. The form requests clinical indications, prior test dates/results, and CPT/ICD codes to support review, but it does not replace the health plan's coverage policies — please consult the member's coverage policies, member benefits, and medical necessity guidelines for specific coverage rules and limits.

This authorization form does not list discrete exclusions or explicit 'not medically necessary' scenarios on the form itself. Determinations about whether a requested study is not medically necessary will be made using the health plan's medical necessity guidelines and coverage policies, and based on the completeness and clinical adequacy of the documentation provided.

Provider Responsibilities and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for all listed cardiac imaging studies (MPI, Stress Echocardiogram, MUGA, TTE, TEE, Cardiac MRI, Coronary CTA, Fetal Echo). Submit this completed Cardiac Imaging Prior Authorization Form with the requested CPT and ICD-10 codes and relevant clinical information to avoid delays.

Include specific CPT code(s) and ICD-10 diagnosis code(s) for each requested study.
Attach prior authorization form and any supporting clinical documentation when submitting the request.

Documentation Required

Required Administrative & Billing Information

Provide complete administrative and billing information on the form. Incomplete fields may delay processing.

Member demographics: patient name, DOB, health plan, member ID, group number.
Ordering provider: physician name, primary specialty, NPI, Tax ID, phone, fax, contact name.
Facility information: facility name, facility Tax ID, facility NPI, address, phone, fax, and date of service.
Specify CPT code(s) and description, and ICD diagnosis code(s) and description for the requested exam.

Documentation Required

Required Clinical Justification

Supply clear clinical justification for the requested study using the checkboxes and fields on the form. Document symptoms, relevant risk factors, associated conditions, and prior test results with dates and results.

Select the requested study(ies) and check all applicable indications/reasons.
List symptoms with suspected cardiac etiology (e.g., chest pain, dyspnea, palpitations, syncope) and associated conditions (e.g., known CAD, cardiomyopathy, arrhythmia).
Document coronary artery disease risk factors (age, family history, smoking, diabetes, hyperlipidemia, hypertension, etc.).
Provide prior noninvasive/invasive test details: exercise stress test (date/results), MPI/PET/SPECT (date/results), stress echocardiogram (date/results), cardiac MRI (date/results), cardiac catheterization (date/results), coronary CTA (date/results), EKG (date/results), and any other relevant prior tests.
Include dates of first and most recent office visits for this condition with any provider, and attach prior test reports when available.

Denial Risk

Incomplete Documentation May Trigger Denial or Delay

Incomplete or missing information on this form may result in denial or processing delay. Ensure all required checkboxes are marked and prior test dates/results, CPT/ICD codes, and provider/facility details are completed.

Missing CPT or ICD-10 codes can trigger denial.
Omitted prior test dates or results may delay authorization review.
Incomplete provider, facility, or member fields can cause processing delays or return of the request for completion.

OpenPayer

Cardiac Imaging Prior Authorization Form — Coverage Criteria

Coverage Criteria for Cardiac Imaging Prior Authorization

Requested Procedure and Diagnosis Codes

Provider Responsibilities and Submission Requirements

Background

Key Definitions of Cardiac Imaging Modalities