UnitedHealthcare Pediatric Cardiac Imaging Prior Auth

Coverage Criteria and Clinical Indications

General medical necessity

Covered when ALL of the following are met

General medical necessity and documentation: Adequate clinical information is submitted to establish medical necessity (clinical presentation, recent detailed history and physical exam since onset/change in symptoms, relevant labs and prior imaging) and the requested advanced cardiac imaging or echocardiography is expected to affect patient management or treatment decisions

For individuals ≤18 years follow Pediatric Imaging Guidelines where applicable; see condition‑specific sections for additional documentation requirements

Modality substitution

Substitutions allowed when contraindications exist

CT in place of MRI: A CT study may be approved in lieu of an MRI when the clinical criteria for MRI are otherwise met AND there is a contraindication to MRI (e.g., pacemaker, ICD, neurostimulator, insulin pump, recent ferromagnetic implant)

When substituting, match contrast intent: MRI without contrast → CT without contrast; MRI with and without contrast → CT with contrast (or CT without and with contrast)

Appropriate use of 3D rendering codes

3D rendering CPT codes (76376, 76377) may be considered when specific clinical scenarios or technical conditions are met.

Selection of 3D rendering code: Select CPT 76376 for 3D rendering that does not require an independent workstation and CPT 76377 when post‑processing on an independent workstation is required; do not use these codes for 2‑D reformatting

Concurrent physician supervision/participation must be documented for 3D post‑processing

Clinical scenarios (examples): 3D rendering may be considered for complex pre‑operative planning (e.g., congenital skull abnormalities in newborns/infants/toddlers, complex fractures/dislocations, complex facial fractures, spine fractures, select pelvic/abdominal scenarios per site‑specific guidelines)

These are examples from the guideline; 3D codes should not be billed with modalities that inherently generate 3D datasets or for simple 2‑D reformatting

Image-guided procedure coding rules

Imaging guidance procedure codes include the imaging necessary to guide needles or catheters; diagnostic imaging should not routinely be billed in conjunction with guidance codes.

Guidance includes necessary imaging: Do not routinely bill a separate diagnostic imaging procedure in conjunction with an imaging guidance code; report the specific guidance CPT (eg, 77012 for CT needle placement, 76942 for ultrasound guidance) which includes the imaging required to guide the procedure

Only one unit of a guidance code should be reported per encounter regardless of number of lesions or attempts

Modality and procedure appropriateness: Use modality‑appropriate guidance codes only with percutaneous surgical procedures (not open/excisional/incisional surgeries); use breast biopsy codes 19085/19086 for MR‑guided breast biopsy rather than MR guidance code 77021

Guidance codes such as 77011, 77012, 77013, 77021, 77022 correspond to stereotactic localization, CT guidance, CT ablation monitoring, MR guidance for needle placement and MR ablation monitoring respectively

Stereotactic localization coding: Report 77011 for stereotactic CT localization scans that do not require radiologist interpretation; if a diagnostic CT is performed and interpreted, report the appropriate diagnostic CT code instead; do not report 3D rendering (76376/76377) with 77011 as the dataset is inherently 3D

Unlisted procedure reporting

When no anatomic site-specific CT/MR code exists, report unlisted CT/MR codes.

Use of unlisted codes: When a diagnostic or interventional CT/MR study lacks an appropriate anatomic site‑specific CPT code, report the unlisted CT (76497) or unlisted MR (76498) procedure; if a Category III code appropriately describes the procedure, report that instead of an unlisted code

Provide full documentation and rationale when using unlisted codes (examples: neurosurgical navigation, custom arthroplasty planning)

Limited CT (76380)

Limited or follow-up CT is used when full diagnostic work is not performed.

Appropriate use of limited CT (76380): Use CPT 76380 to report limited or follow‑up CT scans when the work of a full diagnostic CT is not performed (eg, limited slices through a known pulmonary nodule, limited sinus CT, limited slices for a non‑healing fracture)

Do not use 76380 for treatment planning and do not report it to cover 'extra slices' when a diagnostic CT code applies

Quantitative MR analysis stance

Category III quantitative mp‑MRI analyses are considered investigational or not medically necessary for routine clinical practice.

Quantitative MR code status: Category III quantitative mp‑MRI analytic codes (eg, 0648T/0649T, 0697T/0698T) are considered investigational; volumetric/quantitative brain MRI codes (0865T/0866T) lack sufficient clinical utility and are considered not medically necessary for routine practice

These procedures are primarily used in clinical trials and research settings

Appropriate evaluation and repeat imaging criteria

Advanced cardiac imaging and echocardiography are medically necessary when the following conditions are met:

Required pre‑imaging evaluation: A pertinent clinical evaluation (detailed history and physical exam or meaningful technological contact) AND review of appropriate diagnostic studies (laboratory tests, EKG, prior imaging) have been performed

Exceptions to the recent clinical evaluation requirement exist for first cardiology visit echos, guideline‑supported scheduled imaging, or individuals with documented active cardiac signs/symptoms

Exceptions to recent clinical evaluation: No recent clinical evaluation is required when: echocardiogram is being performed at the first cardiology visit for an appropriate indication; routine scheduled imaging is anticipated; or the individual has documented active clinical signs or symptoms of cardiac disease

See condition‑specific sections for examples

Permitted indications for advanced imaging or repeat imaging: Advanced imaging or repeat echocardiography is medically necessary as follow‑up for prior echo findings; when echocardiography is insufficient to define anatomy or function; when a specific guideline section indicates repeat imaging; or when there is new onset disease with documentation that repeat imaging will affect management

Whole-body imaging coverage stance

Stance on whole-body CT and MRI

Whole‑body CT screening: Whole‑body CT (LifeScan) for screening of asymptomatic healthy individuals is not indicated due to lack of demonstrated benefit and radiation exposure risk; limited exceptions exist (eg, oncologic staging in multiple myeloma)

Requests for whole‑body CT for screening may be denied

Whole‑body MRI general: Whole‑body MRI is generally not supported except for select cancer predisposition syndromes or specific autoimmune conditions; when reported, WBMRI should be reported using CPT 76498

WBMRI lacks standardization and established outcome benefit for most indications

PET-MRI criteria

PET‑MRI may be appropriate only when specific conditions are met

PET‑MRI appropriateness: PET‑MRI may be considered when the individual meets condition‑specific PET‑MRI guidelines OR meets PET‑CT criteria AND PET‑CT is not available at the treating institution; when allowed, report as PET Whole‑Body (78813) plus an unlisted MRI code

Other reporting methods for PET‑MRI are inappropriate

Medically necessary indications

Advanced imaging of the heart and echocardiogram are medically necessary when ANY of the following are met:

Medically necessary indications (any): As follow‑up for findings on prior echocardiograms; individuals with documented active clinical signs or symptoms of heart disease; when echocardiography is insufficient to evaluate the condition; guideline‑supported scheduled surveillance; or specific condition‑based indications (eg, anomalous coronaries, Kawasaki disease, MIS‑C)

Refer to condition‑specific sections for detail

Exceptions to pre-imaging clinical evaluation

Clinical evaluation is required prior to advanced imaging or echocardiogram unless ALL of the following exceptions apply:

Exceptions to pre‑imaging clinical evaluation: Echocardiogram is being performed at the first cardiology visit for an appropriate indication; routine scheduled imaging is anticipated at the next visit (eg, routine follow‑up interval); or the individual has documented active clinical signs or symptoms of cardiac disease

These exceptions permit imaging without a new recent clinical evaluation

Repeat imaging

Repeat imaging studies of the heart are indicated only when ONE or more of the following are present:

Repeat imaging allowed when: There is new onset of disease with documentation that repeat imaging will affect management; there is evidence of progression of disease; a specific guideline section indicates repeat imaging; or the study is follow‑up for findings on a prior echocardiogram

Absent these conditions, repeat imaging is not indicated and may be denied

Not indicated / screening

Advanced imaging and echocardiogram are not indicated in the absence of other appropriate indications when ANY of the following apply:

Not indicated/screening: Screening asymptomatic individuals for cardiac disorders; imaging solely because an individual is starting ADHD medications; or imaging asymptomatic individuals exposed to cardiotoxic drugs except per oncology cardiotoxicity guidance are not indicated

Such requests may be denied as not medically necessary

Use of advanced imaging when echocardiography inconclusive

Covered when ANY of the following are met:

Advanced imaging after inconclusive echo: Cardiac MRI (eg, CPT 75557/75561), MRA Chest (71555), Cardiac CT/CCTA (75572/75573/75574), or CTA Chest (71275) are indicated when a recent echocardiogram is inconclusive or does not completely define the disease

MRA Chest may be used alone if the patient cannot cooperate with a full cardiac MRI

Echocardiography frequency and indications

Covered when ANY of the following are present (routine and symptom-triggered imaging):

Routine and symptom‑triggered echocardiography: Echocardiography may be repeated per lesion‑ and age‑specific schedules; newborns/neonates may require more frequent imaging; additional echocardiography is indicated for documented change in clinical status or new concerning signs/symptoms (eg, shortness of breath, poor feeding, tachypnea, tachycardia, decreased ventricular function, increasing stenosis or regurgitation)

TTE is indicated within one month prior to heart surgery and within one month post‑operative in many conditions

PFO-specific coverage

Covered when specific conditions apply:

PFO — indications and timing: Follow‑up imaging for PFO is indicated for new cardiac symptoms, suspected paradoxical embolism, equivocal prior echocardiogram, prior echo that did not differentiate PFO from secundum ASD, preoperative evaluation for closure, intra‑procedural needs, or post‑procedure concerns (infection, malposition, embolization, persistent shunt). Post‑closure: TTE one time within 30 days and one time within 6 months; if persistent shunt, TTE every 3 months until stable or intervention

Routine surveillance for asymptomatic isolated PFO is not indicated

PFO imaging indications and schedule

Covered when ANY of the following indications or timing criteria apply:

PFO imaging indications and schedule: Indications include new cardiac symptoms, suspected paradoxical embolism, equivocal prior echo, preoperative evaluation for closure, and post‑procedure surveillance per defined intervals (eg, TTE within 30 days and at ~6 months after closure; repeat every 3 months if persistent shunt)

Routine surveillance of asymptomatic PFO is not supported

ASD and PAPVR imaging indications and surveillance

Covered when ALL/ANY as stated in schedule below (distinct rules for unrepaired, routine surveillance, and post-closure):

ASD/PAPVR — general indications: Imaging is indicated for change in clinical status or new concerning signs/symptoms and prior to planned cardiac intervention; advanced imaging (CMR/CT/CTA) is indicated if echo cannot assess the anomaly

Includes guidance for unrepaired defects, routine surveillance, and post‑closure follow‑up

Unrepaired small isolated ASD surveillance: Newborn: one repeat TTE within 2 months; Infant <6 months: TTE every 3 months; Child: TTE every 3 years (if small, asymptomatic, no pulmonary hypertension)

If echo inadequate or residual concerns, consider CMRI/CT/CTA

Post‑ASD device closure surveillance: Post‑device TTE: week, month, every 3 months, then year; may repeat every 3 months until stable if persistent shunt, valvular/ventricular dysfunction, arrhythmia, or pulmonary hypertension; long‑term every 2 years

Post‑surgical closure: within first month, within first year, then every 2 years

VSD imaging schedule

Covered when imaging per defect size and age-based frequency:

Small muscular VSD: Infancy: TTE every 6 months; Newborn: one repeat within 2 months; Childhood: TTE every 3 years

Small non‑muscular VSD: Newborn: repeat within 2 months; Infant: TTE every 6 months; Child: TTE yearly

Moderate or large VSD on medical management: Newborn: TTE every 2 weeks; Infant: monthly; Child <2 years: every 3 months; Child >2 years: yearly; Post‑op: one study within one month of surgery then every 2 years after first year; repeat every 3 months if significant residual issues

AVSD imaging

Covered when indicated for clinical change or pre-procedure and per repair status:

Unrepaired or partial/transitional AVSD: Newborn: one additional study within 2 months; Infancy: TTE every 3 months; Child: yearly; Child <2 years: every 6 months

Complete AVC: newborn repeat within first month; frequency increased for younger infants

Repaired AVSD surveillance: TTE within one month post‑op, within one year, then annually; may repeat every 3 months until stable if residual shunt, valve or LV dysfunction, LVOT obstruction, arrhythmia, pulmonary hypertension, or heart failure symptoms

PDA imaging

Covered when specific surveillance intervals or post-device follow-up apply:

Unrepaired PDA surveillance: No routine surveillance for trivial/silent PDA; Small PDA: TTE every 3 months in infancy then yearly in childhood; Moderate PDA: TTE monthly in infancy and every 6 months in childhood; adolescent intervals vary

Post‑PDA device follow‑up: Post‑procedure: TTE within first 30 days, then annually for first 2 years, then every 5 years after initial 2‑year period; consider MRA/CTA or lung perfusion if LPA stenosis or aortic obstruction suspected

TAPVR imaging

Covered for pre‑ and post‑operative surveillance and routine intervals after repair:

Indications for TAPVR imaging: TTE, TEE, CMRI/CT/CTA and lung perfusion scan indicated for change in clinical status, new concerning signs/symptoms, and prior to planned intervention

Post‑repair TAPVR surveillance: TTE every 3 months in infancy; TTE within first 30 days post‑procedure; Child: annually; Adolescent: every 2 years

Ebstein anomaly and tricuspid valve dysplasia

Covered when pre‑operative evaluation or symptomatic change present:

Ebstein anomaly and TV dysplasia indications: TTE, TEE, CMRI/CT/CTA indicated for change in clinical status, new concerning signs/symptoms, or prior to planned repair/intervention

Ebstein anomaly and tricuspid valve dysplasia surveillance

TTE/TEE/CMR/CT/CTA indicated for listed scenarios and surveillance intervals vary by repair status and severity.

Indications for imaging: TTE/TEE/CMR/CT/CTA are indicated prior to planned repair or intervention and for change in clinical status or new concerning signs/symptoms

Trivial tricuspid regurgitation is considered a normal finding

Unrepaired — infant/newborn surveillance: Newborn: repeat study within 30 days; Trivial TR: no additional surveillance; Moderate TR: TTE every 3 months; Mild TR: TTE yearly

Repaired surveillance: TTE once a year; post‑op within 30 days; every 6 months if valvular or ventricular dysfunction or arrhythmias; more frequent (eg every 3 months) for CHF or atrial arrhythmias

Pulmonary stenosis (PS) surveillance

TTE indicated prior to planned surgery and for initial evaluation of change in clinical status; surveillance intervals by age and post-procedure status.

Indications for PS imaging: TTE indicated prior to planned surgery and for initial evaluation of change in clinical status or new concerning signs/symptoms; consider MRA/CTA if pulmonary artery dilation or other thoracic issues are incompletely visualized on echo

Unrepaired — neonatal/infant/child/adolescent: Neonate/infant: repeat study within 30 days and TTE every 3 months during infancy; Child: TTE yearly; Adolescent: TTE every 2 years; MRA/CTA chest every 3 years if pulmonary artery dilation

Post‑procedure surveillance: Post‑procedure: TTE within 30 days; infant: TTE every 3 months; child: TTE yearly; moderate/severe sequelae: TTE every 6 months; heart failure: TTE every 3 months

Mitral valve disease surveillance

Surveillance intervals for unoperated and post‑procedure mitral stenosis/regurgitation and prosthetic mitral valves.

Unrepaired congenital mitral stenosis: Infant in first 3 months: weekly TTE for severe disease; every 3 months if mild MS; after 3 months monthly for moderate MS; child with moderate MS: every 3 months until intervention decision; mild symptoms annually

Unrepaired congenital mitral regurgitation: Infant: TTE every 6 months if asymptomatic mild MR; monthly for asymptomatic infant with moderate MR; Child: yearly for mild MR with normal LV size/function; every 6 months for moderate MR

Post‑procedure/surgical surveillance: TTE within 30 days post‑op; infant: TTE every 3 months for mild MS/MR with no LV dysfunction; child: monthly TTE for moderate MS/MR with dilated LV and no LV dysfunction; annual TTE for stable mild disease or normal prosthetic mitral valve

Special surveillance: TTE every 3 months for a child with prosthetic mitral valve or ventricular dysfunction and/or arrhythmias

Aortic valve disease and bicuspid aortic valve (BAV) surveillance

Imaging indications and frequency for unoperated and repaired aortic valve stenosis/regurgitation and BAV including aortic root Z‑score monitoring.

General indications for aortic valve/BAV imaging: Initial imaging for change in clinical status or new concerning signs/symptoms; TTE/TEE/Cardiac MRI/CT indicated pre‑operatively; surveillance intervals adjusted for aortic root Z‑score (eg stable vs increasing)

If unstable or increasing Z‑score, increase surveillance frequency

Unrepaired surveillance: Infant: frequent TTE for subvalvular AS; Child: TTE yearly if mild AS without AR; routine surveillance every 6–12 months for moderate AS/AR; TTE every 6 months for moderate subvalvular AS or mild AR

Repaired surveillance: Infant: TTE within 30 days post‑op; TTE every 3 months for mild disease in early period and more frequently for moderate disease; Child: yearly for mild disease, every 6 months for moderate disease, every 3 months if heart failure

Left ventricular outflow tract (LVOT) lesions surveillance

Surveillance imaging for LVOT lesions stratified by surgical status, age, lesion severity, and post‑procedural state.

Indications for LVOT imaging: TTE, TEE, Cardiac MRI/CT indicated for initial evaluation of change in clinical status or prior to surgery; use modality appropriate to the question (eg MRA/CTA for aortic root/ascending aorta)

Unrepaired — infant surveillance: Infant <3 months: TTE weekly; Infant >3 months: TTE every 3 months; escalate to monthly TTE if z‑moderate AS or AR; Child: yearly if mild disease and no aortic dilation; every 3 years if BAV trivial/mild dysfunction and no aortic root dilation; every 6 months with moderate AS/AR or aortic dilation

Post‑procedural surveillance: Infant: TTE within 30 days; monthly after neonatal intervention for z‑moderate AS/AR or LV dysfunction; Child: every 3 months for mild AS/AR with no LV dysfunction; every 6 months if z‑moderate disease; every 3 months if CHF or ventricular dysfunction

Covered surveillance criteria by condition and status

Imaging surveillance covered when matched to the condition, age group, and surgical status per the schedules below.

Unrepaired aortic valve/AS/AR surveillance (general): Infant <3 months: weekly TTE; Infant >3 months: TTE every 3 months; monthly TTE if z‑moderate AS/AR; Child: yearly TTE for mild disease without aortic dilation; TTE every 3 years for BAV with trivial/mild dysfunction and no aortic root dilation; escalate to every 6 months for moderate disease or increasing aortic root Z‑score

Follow lesion‑specific nodes for precise intervals

Post‑procedural aortic surveillance: Infant: TTE within 30 days and monthly after neonatal intervention if z‑moderate disease or LV dysfunction; Child: every 3 months for mild disease early post‑op; every 6 months for z‑moderate disease; yearly once stable; every 3 months if CHF or ventricular dysfunction

MRA/CTA chest every 3 years for coarctation surveillance as indicated

Aortic coarctation surveillance: Unrepaired newborn: TTE weekly if assessing ductal closure; Infant with mild coarctation: echo every 3 months; Child: echo yearly; MRA/CTA chest every 3 years; post‑procedure: TTE within 30 days, then frequent early intervals (eg every 3 months first year) with later yearly imaging as specified

DORV Imaging Indications

Imaging is indicated for any surgical status when there is a change in clinical status or new concerning signs/symptoms; preoperative evaluation also indicated.

DORV general indications: TTE and cross‑sectional imaging (CMR/CT/MRA/CTA) are indicated for initial evaluation of change in clinical status, new concerning signs or symptoms, and evaluation prior to repair or intervention

Follow lesion‑specific guidance for postoperative and surveillance intervals

D-Loop TGA Imaging Criteria

Imaging recommendations vary by surgical status with specified intervals.

D‑Loop TGA — any surgical status: TTE, CMRI/CT/MRA/CTA and stress imaging are indicated for changes in clinical status, new concerning signs/symptoms, and anytime after procedures involving the coronaries; routine cross‑sectional imaging (eg CMR/CT) is often scheduled every 3–5 years depending on repair type

Post‑procedure schedules vary by repair (arterial switch, Rastelli, atrial switch)

Post‑arterial switch surveillance: TTE within 30 days post‑repair; infant: monthly; child: every 3 months; routine CMR every 3 years; MRA/CTA chest annually if neo‑aortic insufficiency otherwise every 3 years; stress imaging annually if neo‑aortic insufficiency or aortic dilation

At least one routine test after arterial switch should be obtained

Post‑Rastelli and post‑atrial switch: Post‑Rastelli: TTE within 30 days, child every 6 months after first year if no/mild sequelae, every 3 months first year; adolescent annually; routine CMR/CT every 3 years. Post‑atrial switch: annual TTE if mild/no symptoms, routine CMR every 3 years; increase frequency for moderate systemic AV valve regurgitation, systemic RV dysfunction, LVOT obstruction, arrhythmias, or CHF

ccTGA Imaging Criteria

Imaging indicated preoperatively and for surveillance at intervals dependent on age, symptoms, and severity.

ccTGA — general: TTE, TEE, CMRI/CT/MRA/CTA indicated for preoperative evaluation (typically within one month) and for routine surveillance; cross‑sectional imaging (CMR/CT/MRA/CTA) often every 3 years

Frequency tailored by symptoms, degree of regurgitation, ventricular dysfunction

Unrepaired schedule: Newborn: weekly; Infant: every 3 months if no symptoms and only mild findings; Child: monthly if symptomatic with moderate findings; <2 years: every 3 months; >2 years: yearly; increase to every 3 months for CHF symptoms and every 6 months for moderate AV regurgitation

Postoperative anatomic repair: TTE within 30 days post‑op; annually after first year if asymptomatic with no/mild sequelae; within first year post‑op may be every 3 months for some; every 6 months if valvular/ventricular dysfunction or RV‑to‑PA conduit; every 3 months if CHF

CMR/CT/MRA/CTA every 3 years for routine surveillance

Truncus Arteriosus Imaging Criteria

Imaging indicated for change in clinical status, new concerning signs/symptoms, and prior to planned intervention; postoperative surveillance included.

Truncus arteriosus — preoperative/change in status: TTE and CMRI/CT/MRA/CTA indicated for initial evaluation of clinical status change, new concerning signs/symptoms, and prior to planned intervention or surgery

Truncus arteriosus — postoperative surveillance: TTE within 30 days post‑op; monthly in first year after surgery; after first year every 6 months; every 3 months for moderate truncal stenosis/regurgitation, residual VSD, RV‑to‑PA conduit or branch PA obstruction, or CHF symptoms; CMRI/CT annually if moderate disease

Single Ventricle imaging and surveillance

Covered when the following lesion-specific and timing-based criteria are met

Indication: Imaging (TTE, TEE, CMRI/CT/MRA/CTA, or cardiac catheterization) is indicated for change in clinical status, new concerning signs/symptoms, or preoperative evaluation (typically within one month)

Unrepaired single ventricle: TTE allowed one study per week1/week

Stage 1 palliation (Norwood/Sano/Hybrid): Routine weekly TTEweekly

Stage 2 palliation (Glenn): TTE within 30 days after surgical or catheter intervention; routine monthly imaging in infant/child as specified by provider

Eisenmenger / Pulmonary Hypertension (with CHD)

Covered when lesion-specific follow-up and therapy-related triggers are present

General indications for PHT/Eisenmenger with CHD: TTE and CMRI/CT/MRA/CTA indicated for preoperative evaluation, change in clinical status, or new concerning signs/symptoms

Initial evaluation: TTE before and after pulmonary hypertension therapy and with change in clinical status or new concerning signs/symptoms

Eisenmenger syndrome surveillance: TTE every 6 months for individuals with Eisenmenger Syndrome6 months

PHT associated with CHD: Unrepaired individuals with elevated pulmonary vascular resistance may have echocardiograms at provider‑requested frequency; postoperative stable child with PHT: TTE every 3 months; TTE/CMR/CT for changes in therapy

MIS-C: Initial and Repeat Cardiac Imaging

Covered when the following conditions apply to outpatient pediatric patients with suspected or confirmed MIS‑C:

Initial imaging indications: TTE (echocardiogram) can be approved when concern for MIS‑C exists; cardiac MRI can be approved at diagnosis if results will affect treatment decisions; cardiac CCTA if coronary arteries are incompletely visualized

Repeat/serial imaging triggers: Repeat/serial TTEs may be approved for new cardiac signs/symptoms, evidence of recurrent MIS‑C, changes in medication, or when treatment decisions depend on results; serial echos may be performed per cardiologist discretion when documented cardiac dysfunction exists

Post‑discharge routine schedule (when stable): For individuals discharged after MIS‑C with stable findings: TTE at 4 weeks post‑discharge, additional echos at 6 months and 1 year; routine cardiac MRI may be performed once ~3 months after diagnosis if there was cardiac involvement

Heart Murmur: Echocardiography Indications

Covered when evaluating a pediatric individual with a murmur if any of the following apply:

Indications for TTE in murmur: Pathologic murmur; any murmur with associated cardiac signs or symptoms; first evaluation when congenital heart disease status is unknown

Repeat echocardiography is not indicated if the initial study is normal and the murmur has not changed

Repeat echo rule: Repeat echocardiography is not indicated when the initial TTE is normal and there is no change in murmur quality or new concerning features

Chest Pain: Echocardiography and Advanced Imaging

Covered for pediatric chest pain when specific features suggesting cardiac pathology are present:

Indications for TTE in chest pain: Exertional chest pain; non‑exertional chest pain with abnormal EKG; chest pain with signs/symptoms of pericarditis; first‑degree relative with sudden unexplained death or cardiomyopathy; recent fever; recent illicit drug use

At least one high‑risk feature required

When to consider advanced imaging: Cardiac MRI or CT indicated if prior evaluation suggests cardiomyopathy, coronary artery abnormalities, or myocarditis; chest CTA/MRA if pulmonary embolism or aortic dissection suspected; stress imaging if ETT suggests ischemia or other imaging suggests coronary abnormality

TTE for chest pain

Covered when ONE of the listed TTE code combinations is selected and the patient has chest pain with at least one associated high‑risk feature:

Permitted TTE code combinations: One of these combinations: 93303 + 93306 + 93325; 93303 + 93320 + 93325; 93303 + 93306; or 93306 alone (note CPT 93320 and 93325 are included with CPT 93306 and should not be billed separately)

Billing/coding rules apply

Clinical indications for TTE in chest pain: Exertional chest pain; non‑exertional chest pain with abnormal EKG; chest pain with pericarditis features; first‑degree relative with sudden unexplained death or cardiomyopathy; recent fever; recent illicit drug use

At least one required

When repeat echo after normal initial study is indicated: Other signs or symptoms of cardiovascular disease; increased severity/change in chest pain quality; new abnormality on EKG; new signs/symptoms other than pain

Repeat echo not indicated if initial study normal unless one of these is present

Echocardiography for syncope

Echocardiography is indicated for syncope when the patient meets at least one higher‑risk feature:

Indications for echo in syncope: Exertional syncope; abnormal EKG; unexplained post‑exertional syncope; absence of prodromal symptoms; lack of prolonged upright posture; palpitations immediately before loss of consciousness; syncope in response to auditory/emotional stimulus; sudden cardiac arrest; first‑degree relative with pacemaker/ICD, known CHD, or cardiomyopathy; history of Kawasaki disease or coronary pathology

One or more required

When repeat echo after normal initial echo indicated: Pathologic murmur; irregular rhythm, gallop, or click on exam; increased severity/change in syncope quality; family history of sudden death or cardiomyopathy; new signs/symptoms of cardiovascular disease other than syncope; new abnormality on EKG

Repeat echo not routinely indicated if initial is normal unless criteria met

Advanced imaging and stress testing

Cardiac CT/MR or stress imaging are indicated in specific situations after initial evaluation suggests higher‑risk pathology:

Cardiac MR/CT for chest pain or cardiomyopathy: Indicated if prior evaluation suggests cardiomyopathy, coronary artery abnormalities, or myocarditis

Chest MRA/CTA: Indicated if pulmonary embolism or aortic dissection is suspected

Use CTA/MRA chest as clinically indicated

Stress imaging: Indicated when ETT suggests ischemia, other imaging suggests coronary abnormality, or EKG is uninterpretable; modalities include stress SPECT, stress echo, or stress MR

Pulmonary hypertension imaging surveillance: After comprehensive evaluation, echocardiography using PH‑specific protocols every 4–6 months is appropriate; CT/CTA/MRA may be indicated to evaluate pulmonary vascular/interstitial disease

Pericardial effusion/tamponade

Covered imaging for suspected pericardial effusion or tamponade:

Initial imaging for pericardial effusion/tamponade: Echocardiogram is the initial imaging study of choice to evaluate pericardial effusion or diagnose tamponade

When cardiac MRI is useful: Contrast‑enhanced cardiac MRI may be useful if a specific clinical question remains unanswered by recent imaging AND the answer will affect management (eg pericarditis, neoplastic effusion, myocardial infiltration, tamponade)

Kawasaki disease imaging

Imaging strategy for Kawasaki disease across initial, acute, and follow‑up phases:

Initial assessment: Echocardiography (CPT 93306) is indicated for initial assessment of suspected or known Kawasaki disease

Advanced imaging (CCTA 75574, cardiac MRI 75557/75561, MRA chest 71555) indicated when echocardiogram is inconclusive or for significant coronary abnormalities

Acute phase follow‑up frequency: Uncomplicated cases: repeat echo after treatment at 1–2 weeks and at 4–6 weeks; important/evolving coronary abnormalities (Z‑score >2.5) require more frequent echoes (eg at least twice per week while dimensions are expanding) until luminal dimensions stabilizeZ score >2.5

Advanced imaging reasonable when results will impact management in severe proximal coronary involvement

Use of invasive/advanced modalities: TEE, invasive angiography, CMRI, and CTA may be valuable in selected individuals but are not routinely indicated during acute illness; reserve advanced imaging for cases where results will affect management

Long-term routine surveillance in asymptomatic Kawasaki disease

Long‑term routine surveillance in asymptomatic Kawasaki disease is stratified by aneurysm size and history:

Risk‑based surveillance overview: Routine echo 4–6 weeks after acute illness for all risk levels; subsequent echo, stress, and coronary imaging frequency depends on largest historical and current aneurysm category (normal, dilation, small, medium, large/giant)

Refer to guideline tables for per‑category intervals (eg small: 6 months/12 months then yearly; medium: 3 months then every 6–12 months; large/giant: intensive early follow‑up at 1,3,6,9,12 months with coronary imaging at 2–6 months and periodic coronary imaging thereafter)

Indications for initial and repeat transthoracic echocardiography (TTE)

Initial TTE is indicated for many signs/symptoms, family history, and specific conditions; repeat TTE intervals depend on age, diagnosis, and clinical changes.

Initial TTE indications: Abnormal EKG or cardiac biomarkers; signs/symptoms possibly cardiac (central cyanosis, dyspnea, edema, poor feeding, desaturation); abnormal chest X‑ray; sudden cardiac arrest; first‑degree relative with early pacemaker/ICD or cardiomyopathy; known/suspected valvular dysfunction; arrhythmias (SVT, VT, PVCs); persistent systemic hypertension; planned cardiotoxic chemotherapy; suspected vascular ring; known or suspected pulmonary hypertension; many genetic syndromes and metabolic/storage disorders associated with cardiac disease

See full guideline lists for comprehensive indications

Repeat TTE indications general: Repeat TTE indicated for new/worsening cardiac symptoms, new EKG abnormalities, new murmur, new inheritable disease recognition in first‑degree relative, monitoring known cardiac disease; frequency individualized by age and condition (eg infants per cardiology request; children yearly for many surveillance scenarios)

Specific intervals and special populations (eg transplant, muscular dystrophy, chemotherapy) described in guideline

Specific repeat intervals:

Symptomatic individuals—when to escalate imaging

Imaging escalation for new or progressive symptoms.

Symptom‑driven imaging escalation: Perform stress imaging for new or progressing ischemic symptoms or ventricular dysfunction; echocardiogram may be done anytime with new/progressing cardiac symptoms; if noninvasive testing is positive, inconclusive, or suggests need for intervention, escalate to invasive or advanced coronary imaging (CT, MRI, invasive angiography)

Management decisions should drive the need for escalation

Fetal Echocardiography — Indications

Initial fetal echocardiography (CPT 76825) and/or Doppler (CPT 76827) with or without Doppler color flow mapping (CPT 93325) can be performed if ≥16 weeks for the following:

Fetal echocardiography indications: Known or suspected abnormal fetal cardiac evaluation on anatomic scan; fetal cardiac arrhythmia (persistent tachy/bradycardia); major fetal extra‑cardiac anomaly; CHD in a first‑degree relative; known fetal chromosomal abnormalities or suspicious ultrasound findings (excluding isolated soft markers); early onset fetal growth restriction; single umbilical artery; persistent right umbilical vein; chorioangioma or cord varix with concern for hydrops; fetal effusion or hydrops; monochorionic twins/TTTS; abnormal nuchal translucency (≥3.0 mm); abnormal ductus venosus waveform; severe or unexplained polyhydramnios with other suspicious findings≥16 weeks gestation

If 4‑chamber view is adequate and no other suspicion, fetal echo is not medically necessary; follow‑up ultrasound (76815/76816) is indicated for suboptimal visualization

Fetal Echocardiography — Exclusions / Not Indicated

When fetal echocardiography is not considered medically necessary

Fetal echo exclusions: Isolated soft ultrasound markers (echogenic intracardiac focus, choroid plexus cyst, thickened nuchal fold 6 mm, absent/hypoplastic nasal bone, shortened long bones, echogenic bowel, pyelectasis) are NOT indications for fetal echocardiography; if 4‑chamber view is adequate and no other suspicion, fetal echo is not medically necessary

A follow‑up detailed obstetric ultrasound is preferred for suboptimal visualization before fetal echo

Maternal-condition-based Indications

Fetal echocardiography can be performed for maternal conditions when ≥16 weeks

Maternal condition indications: Maternal pregestational diabetes or early GDM; maternal connective tissue disease with anti‑Ro/SSA or anti‑La/SSB antibodies; phenylketonuria; infections associated with cardiac anomalies (parvovirus, rubella, coxsackie); genetic conditions in a first‑degree relative associated with CHD (eg Marfan, 22q11.2 deletion, Noonan); pregnancy conceived by assisted reproductive technology; prior child with CHD in a parent≥16 weeks gestation

Some maternal conditions may require serial fetal echo scheduling (eg maternal diabetes)

Medication/Exposure-based Indications

Fetal echocardiography can be performed for medication or teratogen exposures when ≥16 weeks

Teratogen/medication exposure indications: Exposure to ACE inhibitors, excessive alcohol, folate antagonists (methotrexate), antiseizure medications (eg carbamazepine, hydantoin, valproate), lithium, NSAIDs in 2nd/3rd trimester, paroxetine, retinoids, thalidomide, venlafaxine, or other potential teratogens may indicate fetal echocardiography; detailed anatomy ultrasound (76811) may suffice in some cases≥16 weeks gestation

List is not exhaustive; use clinical judgment and refer to teratogen guidance

Indications for CCTA and Cardiac CT

CCTA (CPT 75574) or Cardiac CT (CPT 75572) is indicated when recent TTE and/or MRI is inconclusive and one or more of the following apply

CCTA/Cardiac CT indications: Full sibling(s) with history of sudden death before age 30 or documented anomalous coronary artery; unexplained new onset heart failure when CCTA will replace invasive coronary angiography; resuscitated sudden death with contraindication to invasive angiography; documented ventricular tachycardia when CCTA will replace invasive angiography; infants with otherwise unexplained dyspnea/tachypnea/wheezing/episodic pallor/irritability/poor feeding/failure to thrive; equivocal coronary anatomy after invasive cath; evaluation prior to coronary artery surgery in specific congenital lesions; evaluation of arterial supply/venous drainage in bronchopulmonary sequestration; cardiac or pericardial mass

Chest CTA (71275) may be added when chest vasculature evaluation is required

Imaging studies requested solely for data collection in research or clinical trials—when the images will not be used to directly inform the individual’s clinical management—are not supported for routine coverage. Such requests must meet the same evidence-based clinical guidelines as diagnostic imaging; if the imaging is inconsistent with established clinical standards or is intended only for data collection rather than to affect care, coverage is not provided.

Requests for duplicate, redundant, or questionably indicated examinations may be denied. Examples of misuse include ordering repeat advanced imaging when prior diagnostic studies already answer the clinical question, adult CT protocols applied to children, "double-contrast" CT studies without clear indication, or any imaging unlikely to change patient management. Providers should obtain and document prior test results and a focused clinical history demonstrating that the requested imaging will impact care before proceeding.

Do not report 3D rendering CPT codes (CPT 76376, 76377) for routine two-dimensional reformatting; 2D reformatting is included in cross-sectional imaging base codes. Also, 3D rendering should not be billed in conjunction with stereotactic localization CT (CPT 77011) or with diagnostic CT scans for which a radiologist interpretation code is used, since those procedures inherently generate a 3D dataset.

Advanced cardiac imaging (CT, MR, nuclear) and echocardiography are not indicated solely for population screening of asymptomatic individuals, for evaluation prior to initiating ADHD medications, or for incidental findings absent other clinical indications. Imaging should be performed only when a pertinent clinical evaluation and documentation show the study will influence management, or when a guideline-specified indication applies.

Advanced imaging and echocardiography are explicitly excluded when used only to screen asymptomatic individuals for cardiac disorders or when ordered solely because an individual is starting ADHD medications without other supporting clinical features. Such screening uses are not supported by these guidelines and may be denied.

CPT/HCPCS/Procedure Codes and Key Numeric Thresholds

3D rendering CPT codesCPT

76376	3D rendering without independent workstation (per document description)
76377	3D rendering with independent workstation (per document description)

3D Rendering CodesCPT

76376	3D rendering not requiring image post-processing on an independent workstation
76377	3D rendering requiring image post-processing on an independent workstation

3D Rendering CodesCPT

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 Procedure CodesCPTCovered

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
76942	Ultrasonic guidance for needle placement
75989	Imaging guidance for percutaneous drainage with placement of catheter (all modalities)

Breast biopsy codingCPTCovered

19085	Biopsy, breast, with placement of breast localization device(s), when performed, and imaging of the biopsy specimen; percutaneous; first lesion, including MR guidance
19086	Biopsy, breast ... each additional lesion, including MR guidance

Unlisted ProceduresCPT

76497	Unlisted CT procedure
76498	Unlisted MR procedure
78999	Unlisted procedure, diagnostic nuclear medicine

Limited CTCPT

76380

Limited or follow-up CT

Quantitative MR Analysis (Category III)CPTExperimental

0648T	Quantitative mp-MRI analysis without diagnostic MRI
0649T	Quantitative mp-MRI analysis with diagnostic MRI
0697T	Quantitative analysis without diagnostic MRI (multiple organs)
0698T	Quantitative analysis with diagnostic MRI (multiple organs)
0865T	Volumetric/quantitative MRI analysis of the brain (Category III)
0866T	Volumetric/quantitative MRI analysis of the brain (Category III)

Outside Study InterpretationCPTCovered

76140

Interpretation of an outside study

Whole-Body MRI reportingCPTCovered

76498

Unlisted magnetic resonance procedure (used for whole-body MRI reporting as per guideline)

PET-MRI coding combinationCPT | mixedCovered

78813	PET whole-body
unlisted MRI code	MRI unlisted (used in combination with PET Whole-Body to report PET-MRI)

Cardiac MRI codes (examples)CPT

75557	Cardiac magnetic resonance imaging for morphology and function without contrast material
75559	Cardiac MRI for morphology and function without contrast; with stress imaging
75561	Cardiac MRI for morphology and function without contrast followed by contrast and further sequences

CT/CTA and related codesCPT

75563	Cardiac MRI morphology and function with contrast and stress imaging
75565	Cardiac MRI velocity flow mapping (list separately)
75571	CT heart without contrast with coronary calcium
75572	CT heart with contrast for cardiac structure and morphology
75573	CT heart with contrast for congenital heart disease (including 3D postprocessing)
75574	CTA heart coronary arteries and bypass grafts with contrast including 3D postprocessing
75580	Noninvasive estimate of coronary fractional flow reserve (FFR) from CCTA

Nuclear medicine and PET/SPECT/MUGA codesCPT

78414	Determination of central cardiovascular hemodynamics (non-imaging)
78428	Cardiac shunt detection
78429	Myocardial PET metabolic evaluation with concurrently acquired CT
78430	Myocardial PET perfusion single study with concurrently acquired CT
78431	Myocardial PET perfusion multiple studies with concurrently acquired CT
78434	Absolute quantitation of myocardial blood flow (AQMBF), PET (list separately)
78451	Myocardial perfusion imaging, tomographic (SPECT), single study
78452	Myocardial perfusion imaging, tomographic (SPECT), multiple studies
78453	Myocardial perfusion imaging, planar, single study
78454	Myocardial perfusion imaging, planar, multiple studies

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Radiopharmaceutical localization codesCPT

78597	Quantitative differential pulmonary perfusion
78598	Quantitative differential pulmonary perfusion and ventilation
78800	Radiopharmaceutical localization imaging limited area
78801	Radiopharmaceutical localization imaging planar, 2 or more areas
78802	Radiopharmaceutical localization imaging planar, whole body, single day
78803	Radiopharmaceutical localization imaging, tomographic (SPECT), single area
78804	Radiopharmaceutical localization imaging planar; whole body, requiring 2+ days
78830	Radiopharmaceutical localization tomographic (SPECT) with concurrently acquired CT transmission scan

Echocardiography and related codes (includes add-ons and contrast)CPT | HCPCS

0331T	Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment
0332T	Myocardial sympathetic innervation imaging with tomographic SPECT
93303	Transthoracic echocardiography for congenital cardiac anomalies; complete
93304	Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study
93306	Echocardiography, transthoracic, 2D complete with spectral and color Doppler
93307	Echocardiography, transthoracic, spectral or color Doppler
93308	Echocardiography, transthoracic, follow-up or limited study
93312	Echocardiography, transesophageal, real-time with image documentation (2D) including probe placement
93313	TEE probe placement only
93314	TEE image acquisition, interpretation and report only

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Cardiac echocardiography (listed proprietary codes)CPT

C8926	TEE with or without contrast for congenital cardiac anomalies (probe placement; image acquisition, interpretation and report) (as listed)
C8928	Transthoracic echocardiography with contrast; real-time with image documentation (2D) including M-mode during rest and stress (as listed)
C8929	Transthoracic echocardiography with contrast; 2D complete with spectral and color flow doppler (as listed)
C8930	Transthoracic echocardiography with contrast during rest and stress with ECG monitoring and physician supervision (as listed)
+0439T	Myocardial contrast perfusion echocardiography (add-on)

Echocardiography CPT codesCPTCovered

93303	TTE for congenital cardiac anomalies; complete
93304	TTE for congenital cardiac anomalies; limited
93306	TTE (2D) m-mode complete with spectral and color flow doppler (non-congenital) — noted as not indicated in one bullet for known CHD
93308	TTE (2D) with/without m-mode; limited study (non-congenital)
93307	TTE (2D) with/without m-mode; complete (non-congenital)
93315	TEE for congenital cardiac anomalies; including probe placement; imaging, interpretation, and report
93312	TEE (2D) including probe placement; imaging, interpretation, and report

MRI / MRA codesCPTCovered

75561	Cardiac MRI morphology and function without and with contrast
75557	Cardiac MRI morphology and function without contrast
75565	Cardiac MRI velocity flow mapping (additionally list separately)
71550	MRI Chest without contrast
71552	MRI Chest with & without contrast
71551	MRI Chest with contrast
71555	MRA Chest (excluding myocardium) with or without contrast

CT / CTA codesCPTCovered

75573	CT, Heart; with contrast for evaluation of cardiac structure and morphology in CHD
75572	CT, Heart; with contrast material, for evaluation of cardiac structure and morphology
75574	CTA Heart; coronary arteries and bypass grafts, with contrast, including 3D post processing
71250	CT Thorax without contrast
71260	CT Thorax with contrast
71270	CT Thorax without & with contrast
71275	Determination of vascular extra-cardiac anatomy in complex CHD (CTA Chest)
71275	CTA Chest (listed again for specific indications)

Stress imaging and MPI codesCPTCovered

93350	TTE (2D) with or without m-mode during rest and cardiovascular stress, with interpretation and report
93351	TTE (2D) m-mode during rest and cardiovascular stress with interpretation
75559	Cardiac MRI morphology and function without contrast; with stress imaging
75563	Cardiac MRI without and with contrast with stress imaging
78451	MPI, tomographic (SPECT) single study at rest or stress (including attenuation correction etc.)
78452	MPI, tomographic (SPECT) multiple studies at rest and/or stress and/or redistribution/reinjection

Pulmonary perfusion imaging codesCPTCovered

78580	Pulmonary perfusion imaging (particulate)
78597	Quantitative differential pulmonary perfusion, including imaging
78582	Pulmonary ventilation and perfusion imaging (aerosol or gas)
78598	Quantitative differential pulmonary perfusion and ventilation including imaging

Referenced CPT examplesCPT

93306	TTE non-congenital echocardiogram (documented in text as CPT 93306 - non congenital echocardiogram)
93355	Intra-procedural TEE (not in scope for this program as noted)

Advanced imaging modalitiesmixed

CMR/CT/CTA/MRA	Cardiac MRI, Cardiac CT/CTA, MRA — advanced cross-sectional imaging modalities referenced for unresolved anatomy
lung perfusion scan	Lung perfusion scan — referenced for LPA stenosis follow-up

Referenced CPT Codes for Cardiac CT/CTACPT

75573	Cardiac CT for congenital heart disease (as listed)
75574	Cardiac CT for evaluating coronary artery anomalies (as listed)
71275	CTA Chest (as listed for great vessel evaluation)

Cardiac catheterization CPT codes mentionedCPT

93593	Cardiac catheterization (documented in policy text)
93594	Cardiac catheterization (documented in policy text)
93595	Cardiac catheterization (documented in policy text)
93597	Cardiac catheterization (documented in policy text)

Transthoracic echocardiography CPTs and related codesCPT

93303	Transthoracic echocardiography, complete (includes Doppler when performed)
93306	TTE, complete with spectral Doppler and color flow
93320	Doppler echocardiography, pulsed/continuous wave
93325	Doppler echocardiography, color flow

TTE related CPT codes and billing notesCPT

93303	Transthoracic echocardiography, complete (CPTC 93303 listed)
93306	Transthoracic echocardiography for congenital cardiac anomalies (CPTC 93306 listed)
93320	Doppler flow and/or cardiac output measurement included with some echocardiography codes (CPTC 93320 listed)
93325	Color flow Doppler echocardiography included with some codes (CPTC 93325 listed)

Advanced cardiac CT/MR/CTA/MRA codesCPT

75574	Coronary CTA (Coronary computed tomographic angiography)
75561	Cardiac MRI with and without contrast
75557	Cardiac MRI without contrast
71555	MRA chest
71250	CT chest (non-contrast) mentioned for pulmonary hypertension evaluation
71275	CTA chest (CT angiography)

Stress imaging (general)mixed

Stress imaging (SPECT/echo/MR)

Stress imaging modalities referenced (no specific CPT listed in this segment)

Referenced Echocardiography and related imaging CPT codesCPT

93303	Transthoracic echocardiography for congenital heart disease (2D and M-mode)
93304	Limited transthoracic echocardiogram for congenital heart disease
93306	Complete transthoracic echocardiogram with spectral and color flow Doppler
93307	2D transthoracic echocardiogram without Doppler
93308	Limited transthoracic echocardiogram (non-congenital)
93320	Doppler echocardiography, pulsed wave
93321	Doppler echocardiography, continuous wave
93325	Color flow Doppler mapping (add-on)
76825	Fetal echocardiography, initial
76826	Fetal echocardiography, follow-up

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Fetal echocardiography and related ultrasound codesCPT

76825	Initial fetal echocardiography
76827	Doppler fetal echocardiography (initial)
76826	Follow-up fetal echocardiography
76828	Follow-up Doppler fetal echocardiography
93325	Doppler color flow velocity mapping
76820	Obstetrical ultrasound, additional codes referenced as not supported to bill with Doppler
76821	Obstetrical ultrasound, additional codes referenced as not supported to bill with Doppler

Ejection fraction threshold for MUGA consideration

Ejection fraction thresholdConsider MUGA when recent echocardiogram shows left ventricular ejection fraction <50% and MUGA results will impact acute patient care decisions

Typical use caseQuantitation of LV function and wall motion when EF <50% on echo and decisions (eg. chemotherapy, acute management) depend on nuclear results

Relevant CPT examplesMUGA-related CPTs referenced in guideline include gated equilibrium and first-pass techniques (e.g., 78472, 78473, 78481, 78494, 78496)

RV end-diastolic volume index

RV end-diastolic volume index thresholdConsider moderate/progressive RV dilation when RV end-diastolic volume index approaches or exceeds thresholds in the 150–250 mL/m2 range; guideline cites 2150 mL/m2 as an example of a numeric threshold prompting concern

Associated triggersProgressive increase >25 mL/m2 or RVEF ≤48% or a 26% decrease in EF also prompt closer surveillance or consideration for PVR

Imaging implicationWhen thresholds met, escalate to cardiac MRI/CT for RV quantification and pre-procedural planning for pulmonary valve replacement (PVR)

Kawasaki coronary aneurysm Z-score threshold

Kawasaki Z-score alertZ-score >2.5 indicates important/evolving coronary abnormalities and requires more frequent echocardiography (eg. at least twice per week during acute expansion)

Acute phase monitoringPerform repeated echoes within 1–2 weeks and 4–6 weeks for uncomplicated cases; escalate to twice-weekly imaging when Z >2.5 until dimensions stabilize

Advanced imaging considerationUse coronary CTA, cardiac MRI, or invasive angiography when echo is inconclusive or when advanced imaging will affect management in severe proximal coronary involvement

Z-score aneurysm thresholds (Kawasaki coronary classification)

No involvementZ score <2 (No involvement)

DilationZ score 2 to <2.5 (Dilation only)

Small aneurysmZ score ≥2.5 to <5 (Small aneurysm)

Medium aneurysmZ score ≥5 to <10 and absolute dimension <8 mm (Medium aneurysm)

Large/Giant aneurysmZ score ≥10 OR absolute dimension ≥8 mm (Large/giant aneurysm)

Obesity threshold

Obesity definitionBody mass index (BMI) >30 classifies obesity for imaging considerations

Imaging relevanceObesity with additional cardiovascular risk factors is listed among indications for initial TTE to assess target organ damage

DocumentationInclude BMI and associated risk factors in clinical documentation supporting echocardiography orders

Fetal echocardiography timing

Minimum gestational ageInitial fetal echocardiography is usually not performed prior to 16 weeks gestation; indications listed apply when ≥16 weeks

Coding constraintInitial fetal echo CPT 76825 (with optional Doppler CPT 76827) is limited to one initial study per fetus per facility

Pre-imaging escalationIf routine 4‑chamber anatomic scan is adequate with no suspicion, fetal echo is not medically necessary; follow-up obstetric ultrasound (CPT 76815/76816) is recommended for suboptimal views

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization and Clinical Documentation Expectations

Advanced imaging and designated procedures will be reviewed for medical necessity using the UnitedHealthcare evidence-based guidelines and, for Ohio only, Ohio Administrative Code 5160-1-01 where applicable. Providers must submit adequate clinical documentation to establish medical necessity — include clinical presentation, recent detailed history and physical exam (or meaningful technological contact), relevant laboratory and prior imaging results, and age-specific rationale (individuals ≤18 years follow Pediatric Imaging Guidelines when applicable). A recent clinical evaluation is generally required before ordering advanced imaging unless the request is for a guideline-supported scheduled follow-up or explicit exception noted in condition-specific sections.

Ohio Administrative Code 5160-1-01 applies to services stated as unproven or with coverage/quantity limits (Ohio only).
For individuals ≤18 years, reference Pediatric Imaging Guidelines; >18 years reference General Imaging Guidelines unless otherwise specified.
Meaningful technological contact (telehealth/phone/video/message) may substitute for in-person evaluation when documented.
Include prior diagnostic test results to support need for advanced imaging; lack of prior studies may trigger denial.

Documentation Required

3D Rendering: Authorization and Supervision Documentation

Prior authorization may be required for 3D rendering (CPT 76376, 76377). When billed, document the physician's concurrent supervision and active participation in the reconstruction process (design of anatomic region, selection of tissue types/structures, selection/archiving of images or cine loops, monitoring/adjustment of 3D product). Billing these codes without adequate concurrent supervision documentation may lead to denial.

CPT 76376: 3D rendering without independent workstation.
CPT 76377: 3D rendering requiring independent workstation.
Do not report 3D rendering for 2D reformatting — 2D reformatting is included in cross-sectional base codes.
Payers may require prior authorization for the 3D code even if the underlying imaging study did not require authorization.

Billing Rule

Reporting and Coding: Whole‑Body MRI and PET‑MRI

Whole‑body MRI should be reported using CPT 76498. PET‑MRI is reportable as PET Whole‑Body (CPT 78813) plus an MRI unlisted code when clinically appropriate; other reporting methods are inappropriate. Whole‑body MRI and PET‑MRI are generally not supported except in select, guideline-specified situations (e.g., select cancer predisposition syndromes, select pediatric indications). PET‑MRI may be considered when PET‑CT is indicated but unavailable and condition-specific criteria are met.

WBMRI has no standardized CPTs other than CPT 76498 — do not split into multiple anatomic MRI codes.
PET‑MRI reporting: CPT 78813 + MRI unlisted code when PET‑CT is unavailable and clinical criteria met.
WBMRI and PET‑MRI require documentation of condition-specific justification; routine screening WBMRI for asymptomatic individuals is not supported.

Prior Authorization

Modality Sequencing and Advanced Cardiac CT/MR/CTA Codes

Echocardiography (TTE/TEE) is the primary cardiac imaging modality and is generally expected before advanced cross‑sectional imaging (Cardiac MRI, Cardiac CT/CCTA, MRA/CTA Chest) unless otherwise specified. Advanced cardiac CT/MR (CPT 75573, 75574, 75557, 75561) and Chest CTA (CPT 71275) are indicated when recent echocardiography is inconclusive, technically inadequate, or does not fully define the disease and when results will affect management. Document prior echo findings and explicit rationale for escalation.

Report CPT 75573 for congenital cardiac CT (CCT) evaluation and CPT 75574 for coronary CTA.
Cardiac MRI codes: CPT 75557 (without contrast) and CPT 75561 (without and with contrast).
CTA Chest code CPT 71275 may be used for extra-cardiac vascular anatomy assessment (pulmonary veins/arteries, great vessels) when echo is inconclusive.
Prior echocardiogram results must be submitted with the authorization request; if echo was equivocal due to poor acoustic windows, document that limitation.

Prior Authorization

Pre‑procedural and Preoperative Imaging Authorization

Pre-procedural and preoperative cardiac imaging (including TTE, TEE, Cardiac MRI/CT, MRA/CTA, and cardiac catheterization codes 93593, 93594, 93595, 93597) is indicated prior to planned cardiac intervention or surgery when required to inform procedural planning or when there has been a change in clinical status. Obtain prior authorization per payer workflows when the procedure or the imaging requires authorization.

TTE is often required within 1 month prior to planned cardiac surgery or intervention.
Document the planned procedure and how the imaging will inform surgical or interventional decision‑making.
Cardiac catheterization CPTs (93593–93597) may require authorization when used for preoperative evaluation.

Prior Authorization

Imaging Prior‑Authorization Considerations for MIS‑C

For MIS‑C, cardiac imaging authorization follows condition-specific guidance: an initial echocardiogram (TTE) can be approved at diagnosis when MIS‑C is suspected; cardiac MRI can be approved at diagnosis if results will affect management; routine cardiac MRI may be performed once about 3 months after acute illness in individuals with cardiac involvement. Repeat echos and coronary CCTA can be authorized when visualization is incomplete or when results will affect treatment decisions.

Echo at diagnosis for suspected MIS‑C or atypical/incomplete Kawasaki presentations.
Cardiac CCTA is appropriate if coronary arteries are incompletely visualized on echo.
Serial echos may be approved based on documented cardiac dysfunction; standard follow-up windows (e.g., within 1 week of discharge, 4 weeks, 3–6 months, 1 year) should be followed as indicated.

Billing Rule

Preauthorization and Coding Guidance: Echocardiography

Echocardiography coding guidance: providers may request multiple potential CPT codes for an initial pediatric echo because the final code depends on findings during the study. CPT 93306 (complete TTE) includes CPTs 93320 and 93325 and those add‑on codes should not be billed separately when 93306 is reported. Limited or congenital echos use CPTs 93308, 93304, or 93303 as appropriate; post‑service audits may verify correct final coding. For fetal echocardiography, initial fetal echo CPT 76825 and Doppler CPT 76827 are limited to one initial study per fetus per facility.

Acceptable initial echo code combinations to request: CPT 93303 +/- 93320/93325; CPT 93306 (which includes 93320/93325); CPT 93304 for congenital limited studies.
Do not approve CPT 93320 and CPT 93325 separately when CPT 93306 is submitted.
Fetal echo: CPT 76825/76827 performed once per fetus per facility; follow-up codes CPT 76826/76828 for subsequent studies.

Note

Stepwise Imaging and Escalation Criteria

Stepwise imaging consideration and escalation: obtain prior diagnostic test results and perform first‑line, less invasive testing (e.g., echocardiography) before escalating to higher‑level imaging. Escalation to advanced or invasive coronary imaging (CCTA, cardiac MRI, invasive angiography) is appropriate when noninvasive studies are positive, inconclusive, or when results will change management.

Document why prior studies were insufficient and how advanced imaging will alter management.
Avoid ordering duplicate or unnecessary advanced imaging without review of prior tests; requests lacking such review may be denied.

Documentation Required

Repeat Imaging, Surveillance, and Timing Documentation

Conditions for repeat imaging and routine surveillance: repeat cardiac imaging is indicated only when specified by guideline sections, for new onset or progression of disease with documentation that repeat imaging will change management, or for routine surveillance schedules defined per lesion, age, and repair status (for example, post‑op imaging commonly within 30 days and lesion‑specific surveillance intervals). Routine surveillance echocardiography for an asymptomatic individual with an isolated PFO is not indicated.

Document timing of post‑operative imaging (commonly within 30 days) and interval surveillance frequency based on age, lesion severity, and repair status.
Repeat echoes are allowed for increasing stenosis gradient, decreased ventricular function, new symptoms, or medication adjustments when management may change.
Routine surveillance schedules differ by lesion (see condition-specific sections).

Documentation Required

Clinical Justification and Documentation for Additional Imaging

Required clinical documentation for additional or advanced imaging must include the clinical change in status, specific findings on prior imaging that were equivocal or inadequate, and which management decisions will be affected by the requested study. For coronary CT (CCTA) requests, document prior imaging and specify which indication applies (e.g., no prior coronary imaging, need to map anatomy prior to invasive procedure, incomplete visualization on echo).

For ASD/PFO imaging, document new cardiac symptoms, suspected paradoxical embolism, or equivocal prior echo differentiating PFO from ASD.
When prior echo is equivocal due to poor acoustic windows, document that limitation and rationale for choosing MR/CT/CTA.
Include specific question to be answered (e.g., coronary origin, conduit patency, residual shunt) and relevant prior reports.

Billing Rule

Charge Submission, Code Bundling Risk, and Audit Triggers

Billing and coding integrity: submit charges only for the procedure actually performed. Do not bill add‑on or included codes separately when they are part of a primary code (e.g., CPTs 93320 and 93325 are included with CPT 93306). Incorrect code combinations, billing for unperformed procedures, or approving duplicate additive Doppler/color‑flow codes when included may trigger audits or denials.

Cardiologist must submit charges only for the procedure actually performed.
CPT 93306 includes CPT 93320 and CPT 93325 — these should not be billed separately.
Post‑service audits may be conducted to ensure correct claims submission; inaccurate submission may lead to denials and recoupment.

Billing Rule

Coding and Reimbursement Constraints

Coding and reimbursement constraints: follow inclusion rules for echocardiography code combinations and avoid billing additional ultrasound codes not supported by guidance (e.g., do not bill CPT 76820/76821 in addition to supported fetal Doppler codes). Minimal color Doppler alone (when included in a bundled service) is not separately reportable. Providers may request multiple possible CPTs on authorization but final claim coding must reflect the actual study performed.

Fetal Doppler codes CPT 76827/76828 include evaluation of veins/arteries/valves — do not bill CPT 76820/76821 in addition.
Limited TTE (CPT 93308) does not include certain Doppler codes; verify inclusion before billing.
If congenital heart disease is found on an initial echo, use congenital coding (CPT 93303 + appropriate Doppler/color codes) as described.

Key Definitions and Terms

Investigational / Experimental — definition

DefinitionInvestigational or experimental studies are those lacking sufficient evidence of improved health outcomes, clinical utility, or collective specialty support; considered unproven when evidence is sparse or not mature

Evidence expectationsSupporting evidence should include peer‑reviewed literature, well‑conducted trials or cohort studies, and specialty society recommendations when available

Clinical trial imagingImaging requested solely for data collection in trials and not used for direct clinical management may be considered investigational and unsupported

Clinical trial imaging — definition / handling

DefinitionClinical trial imaging refers to imaging performed in research settings; requests will be reviewed against guidelines to determine if they meet evidence-based clinical standards

Non-supported scenariosImaging inconsistent with established clinical standards or requested solely for data collection not used in direct care is not supported

Authorization noteClinical trial imaging may still require documentation showing clinical utility to be considered for coverage

Diagnostic ultrasound — definition

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

StrengthsProvides dynamic, bedside, real-time imaging useful for initial evaluation and procedural guidance

LimitationsLimited imaging window and reduced utility for large abnormalities or where bone obscures view; quality depends on operator skill

Computed Tomography (CT) — definition

DefinitionComputed tomography (CT) is cross-sectional imaging using ionizing radiation; can be performed with or without IV contrast depending on indication

Advantages/limitationsAdvantages: large field of view and fast imaging. Limitations: radiation exposure and less soft-tissue definition than MRI; protocol selection depends on clinical question

Dose guidancePerform CT only for valid medical indications and with minimum radiation exposure that provides diagnostic image quality (ACR guidance cited)

Magnetic Resonance Imaging (MRI) — definition

DefinitionMagnetic resonance imaging (MRI) uses magnetic fields and radiofrequency to image tissues without ionizing radiation; offers superior soft-tissue definition

Practical considerationsMRI exams are longer and more sensitive to motion; many infants and young children (age <7 years) require anesthesia or sedation—plan to avoid repeat short-interval anesthesia exposures

Clinical utilityFrequently used for congenital heart defects not well seen on echo, thoracic vessel evaluation, cardiomyopathies, and right ventricular disease

Positron Emission Tomography (PET) — definition

DefinitionPositron emission tomography (PET) is a nuclear medicine study using radiotracer to image tissue metabolism, frequently combined with CT (PET/CT)

Use casesIndications include oncologic staging, brain metabolic imaging, and selected cardiac metabolic evaluations; PET-MRI generally not supported except in limited circumstances

Reporting noteWhen PET-MRI is appropriate, report as PET Whole-Body (CPT 78813) plus an unlisted MRI code per guideline guidance

Concurrent supervision (3D rendering) — definition

DefinitionConcurrent supervision for 3D rendering means active physician participation in and monitoring of post-processing, including choosing anatomic region, tissue types, images/cine loops to archive, and adjusting the 3D work product

DocumentationPhysician supervision/participation should be documented to support billing of 3D rendering codes (76376/76377)

Coding implicationFailure to document concurrent supervision may trigger denial or audit

76376 vs 76377 — distinction

76376 vs 76377 distinctionUse 76376 for 3D rendering not requiring image post-processing on an independent workstation; use 76377 when post-processing on an independent workstation is required

Scope noteDo not use these codes for 2D reformatting, which is included in cross-sectional imaging base codes

Authorization noteProviders may need prior authorization specifically for 3D rendering codes even when the base imaging study does not require it

Pertinent clinical evaluation — definition

Pertinent clinical evaluationA pertinent clinical evaluation includes a detailed history, physical exam, or meaningful technological contact plus review of appropriate diagnostic studies (labs, EKG, prior imaging)

Pre-imaging requirementThis evaluation should occur prior to advanced imaging or echocardiogram except in listed exceptions (first cardiology visit, routine scheduled imaging, or active signs/symptoms)

DocumentationClinical findings and prior diagnostic results must be submitted to establish medical necessity

Advanced imaging — definition

Advanced imaging definitionAdvanced imaging refers to cardiac CT, cardiac MR, and nuclear medicine studies used when echocardiography is insufficient or for specified indications

Modality sequencingEchocardiography is generally primary and indicated before other advanced modalities unless specified otherwise

ExamplesIncludes CCTA (75574), Cardiac CT (75572), Cardiac MRI (75557/75561), and nuclear studies when indicated

Anesthesia considerations

Anesthesia noteMRI often requires anesthesia for infants and young children (age <7 years) or developmentally delayed children; plan sessions to avoid repeat short-interval anesthesia exposures

Operational guidanceIf multiple body areas are needed, obtain them in the same anesthesia session when clinically appropriate

Imaging planningConsider MRI length and motion sensitivity when selecting modality for pediatric patients

Neonate / newborn — age definition

Neonate/newborn ageNeonate/newborn defined as infant 0–28 days for purposes of these guidelines

Imaging frequency noteNewborns may require more frequent imaging due to rapidly changing physiology and pulmonary vascular resistance

Clinical implicationAllow flexibility in follow-up timing for neonates given physiologic changes

Child / Adolescent — age definitions used in the guideline

Child/adolescent agesChild 1–18 years; adolescent 11–18 years. 'Children' refers to ages 0–18 in these guidelines

ApplicabilityPediatric-specific schedules and imaging frequency use these age definitions

Documentation noteFor individuals ≤18 years follow Pediatric Imaging Guidelines; otherwise use General Imaging Guidelines

PFO — definition and surveillance guidance

PFO definitionPatent foramen ovale (PFO) is a normal variant; routine surveillance in asymptomatic individuals is not indicated

When to imageImaging indicated for new cardiac symptoms, suspected paradoxical embolism, equivocal prior echo, preoperative evaluation for closure, intra-procedural or post-procedural concerns

Post-closure surveillanceTTE one time within 30 days and one time within 6 months post-closure; repeat every 3 months if persistent shunt until stable or intervention

PAPVR — definition

PAPVR definitionPartial anomalous pulmonary venous return (PAPVR) is anomalous venous return of one or more pulmonary veins to the systemic venous circulation and may require CMR/CT/CTA if echo cannot assess anatomy

Imaging pathwayIf echo inadequate for anatomy, proceed to CMRI/CT/CTA for detailed anatomic definition prior to intervention or repair planning

Surveillance noteSurveillance intervals depend on lesion severity and surgical status as detailed in ASD/PAPVR sections

Severity qualifiers — trivial / mild / moderate / severe

Severity qualifiersSeverity descriptors used: trivial, mild, moderate, severe — applied across conditions to determine surveillance frequency (eg. trivial TR considered normal)

Operational useSurveillance intervals are stratified by these qualifiers; moderate/severe findings trigger more frequent imaging

DocumentationSpecify severity in clinical documentation to support imaging frequency and authorization

Congenital coronary anomalies — definition

DefinitionCongenital coronary anomalies include abnormal origin of a coronary artery (eg from pulmonary artery), anomalous aortic origin from a different sinus of Valsalva, coronary arteriovenous fistula, and ostial atresia

Clinical importanceThese anomalies are an important cause of sudden death in pediatric patients and may require stress testing, CMR/CT/CCTA, or catheterization depending on findings and symptoms

CCTA use limitsCCTA to evaluate coronary anomalies should be limited to individuals without prior clear imaging, those needing mapping before invasive procedure, or when history meets listed indications

Significant RV dilatation for PVR consideration — numeric thresholds

Significant RV dilatation criteriaModerate RV dilation examples include RV end-diastolic volume index ~2150 mL/m2 or progressive increase >25 mL/m2; RVEF ≤48% or a 26% decrease in EF also prompt evaluation for PVR

Action thresholdWhen these thresholds are met, consider referral for pulmonary valve replacement evaluation and advanced imaging (CMR/CT) for surgical planning

Surveillance implicationRoutine surveillance intervals shorten to 12 months or 36 months based on progressive RV dilation and dysfunction per TOF/PVR guidance

Single Ventricle (SV) — definition

Single Ventricle definitionSingle Ventricle (SV) refers to individuals not amenable to biventricular repair (eg hypoplastic left heart syndrome, tricuspid atresia, double inlet left ventricle)

Clinical implicationThese individuals require lesion-specific surveillance and often frequent TTE/advanced imaging per staged palliation status

Surveillance modalityImaging options include TTE, TEE, CMR/CT/MRA/CTA and cardiac catheterization as indicated

MIS-C — definition

MIS-C definitionMultisystem Inflammatory Syndrome in Children (MIS-C) is a severe inflammatory condition temporally associated with SARS‑CoV‑2 infection that can involve the heart and mimic Kawasaki disease

Initial imagingEchocardiography is approved when MIS-C suspected; cardiac MRI can be approved at diagnosis when results will affect management; CCTA if coronary arteries incompletely visualized

Follow-up schedulePost-discharge: routine echoes at ~4 weeks, 6 months, and 1 year when indicated; cardiac MRI may be performed once around 3 months if there was cardiac involvement

TTE — definition and CPT examples

TTE definitionTransthoracic echocardiogram (TTE) is the initial imaging modality for murmur and many pediatric cardiac evaluations; CPT examples include 93303, 93306, 93320, 93325

Coding/bundling noteCPT 93320 and 93325 are included with CPT 93306 and should not be billed/approved separately; submit charges only for the procedure actually performed

Use caseTTE is generally required before other advanced modalities unless specified otherwise; use congenital vs non-congenital TTE codes per findings

Z score classification (Kawasaki coronary artery)

Z-score classification rangesNo involvement: Z<2; Dilation: Z 2 to <2.5; Small aneurysm: Z ≥2.5 to <5; Medium: Z ≥5 to <10 and absolute <8 mm; Large/giant: Z ≥10 or absolute ≥8 mm

PurposeZ-score normalizes coronary dimensions to body surface area for risk stratification in Kawasaki disease

Surveillance tie-inRisk category determines echo frequency, stress imaging, and coronary imaging intervals per guideline

Z-score classification — further note

Z-score conceptCoronary artery Z-score expresses coronary dimension adjusted for body surface area; used to define categories (no involvement through large/giant aneurysm)

Clinical applicationCategories guide acute-phase monitoring frequency and long-term surveillance intervals

ReferenceClassification follows AHA-based recommendations cited in guideline background

Initial fetal echocardiography — CPT 76825 (with or without CPT 76827) usually after 16 weeks

CPT and timingInitial fetal echocardiography CPT 76825 (with optional Doppler CPT 76827) is usually performed after 16 weeks gestation

Coding constraintInitial fetal echo (76825/76827) is limited to one initial study per fetus per facility; follow-up fetal echo codes are CPT 76826/76828

Color flow mappingDoppler color flow mapping CPT 93325 may be used with fetal echo as applicable

CCTA / Cardiac CT — definition and CPT examples

CCTA / Cardiac CT definitionCCTA (CPT 75574) or Cardiac CT (CPT 75572) are CT angiography modalities for anatomic assessment of coronary arteries, chest vasculature, or intracardiac anatomy when other modalities are inconclusive

Typical indicationsIndicated when recent TTE/MRI is inconclusive and one or more listed indications apply (eg incomplete coronary visualization, mapping prior to invasive procedure, suspected anomalous coronary origin)

Coding examplesCPT 75572 (Cardiac CT) and 75574 (CCTA) referenced; CTA Chest CPT 71275 may be added for evaluation of great vessels

OpenPayer

Pediatric Cardiac Imaging Guidelines (Ohio)

Coverage Criteria and Clinical Indications

CPT/HCPCS/Procedure Codes and Key Numeric Thresholds

Prior Authorization, Documentation, and Billing Guidance

Background and Scope

Key Definitions and Terms