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CurrentUnitedHealthcarePolicy MMP076.16

Radiologic Diagnostic Procedures

Medicare Advantage policy governing medical necessity, coverage, and billing reference for diagnostic radiology procedures (CT, CCTA, MRI/MRA, PET, SPECT, nuclear medicine, 3D rendering) including reliance on applicable Medicare NCDs/LCDs/LCAs and nationally recognized guidelines (InterQual) and UnitedHealthcare Radiology Prior Authorization Program where applicable.

Policy Summary

PayerUnitedHealthcare

PolicyRadiologic Diagnostic Procedures

Policy CodePolicy MMP076.16

Change TypeUpdates and code list revisions (material and non-material)

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionProviders must indicate the specific sign, symptom, or patient complaint that makes the diagnostic service reasonable and necessary and retain documentation to support coverage decisions.

SourceLink

POLICY UPDATE CHANGES

Removed content/language addressing computed tomographic colonography (CTC) for screening purposes.

Updates to Non-Covered Diagnosis Codes list effective 03/01/2026: Added Z40.81, Z40.82, Z40.89, Z59.861, Z59.868, Z59.869, Z84.11, Z84.19.

Z83.71 removed from Non-Covered Diagnosis Codes list.

Description updated in diagnosis code list: Revised description for Z83.718.

Administrative notation added indicating Z40.8, Z59.86, and Z84.1 were deleted Sep. 30, 2025.

Previous version archived as supporting information: Archived policy version MMP076.15.

MultipleModalities referenced (CT/MRI/PET/SPECT/Nuclear/3D)

8Non-covered diagnosis codes added

1Non-covered diagnosis codes removed

NCDs/LCDsExternal Medicare determinations required

Coverage Summary

Overview of scope: This policy governs Medicare Advantage coverage, medical necessity, and billing reference for Radiologic Diagnostic Procedures including CT, CCTA, MRI/MRA, PET, SPECT, nuclear medicine, and 3D rendering; it relies on applicable Medicare statutes, NCDs, and LCDs/LCAs and supplements Medicare guidance with nationally recognized criteria (e.g., InterQual) or internal criteria when Medicare is silent or flexible. Status: CURRENT. Subject: Radiologic Diagnostic Procedures. Effective date: March 1, 2026. Last review: January 14, 2026.

Policy metadata

PolicyRadiologic Diagnostic Procedures (MMP076.16)

PayerUnitedHealthcare

Effective Date2026-03-01

Last Review2026-01-14

StatusCURRENT

Policy Summary

PayerUnitedHealthcare

PolicyRadiologic Diagnostic Procedures

Policy CodePolicy MMP076.16

Change TypeUpdates and code list revisions (material and non-material)

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionProviders must indicate the specific sign, symptom, or patient complaint that makes the diagnostic service reasonable and necessary and retain documentation to support coverage decisions.

SourceLink

On This Page

Medical Necessity Criteria

General Coverage / Medical Necessity

Covered when ALL of the following are met:

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3D Rendering

Coverage depends on applicable LCDs/LCAs and Medicare/Plan requirements:

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Computed Tomography (CT, CCT, CCTA)

Coverage depends on applicable NCDs/LCDs/LCAs or nationally recognized guidelines:

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Magnetic Resonance Imaging (MRI) & Magnetic Resonance Angiography (MRA)

Coverage depends on NCD/LCD/InterQual:

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Positron Emission Tomography (PET)

Oncologic PET (FDG) coverage differentiated for initial vs subsequent scans:

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PET for Inflammation/Infection and Other Nuclear Medicine / SPECT

Coverage governed by LCDs/LCAs or InterQual and UnitedHealthcare program:

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Coding

3D Rendering CPTCPT

76376	3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation.
76377	3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation.

Other Nuclear Medicine CPTCPT

78012	Thyroid uptake, single or multiple quantitative measurement(s) (including stimulation, suppression, or discharge, when performed).
78013	Thyroid imaging (including vascular flow, when performed).
78014	Thyroid imaging; with single or multiple uptake(s) quantitative measurement(s).
78015	Thyroid carcinoma metastases imaging; limited area.
78016	Thyroid carcinoma metastases imaging; with additional studies.
78018	Thyroid carcinoma metastases imaging; whole body.
78070	Parathyroid planar imaging (including subtraction, when performed).
78075	Adrenal imaging, cortex and/or medulla.
78099	Unlisted endocrine procedure, diagnostic nuclear medicine.
78199	Unlisted hematopoietic, reticuloendothelial and lymphatic procedure, diagnostic nuclear medicine.

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Positron Emission Tomography (PET) CPTCPT

78608	Brain imaging, PET; metabolic evaluation.
78811	PET imaging; limited area.
78812	PET imaging; skull base to mid-thigh.
78813	PET imaging; whole body.
78814	PET with concurrently acquired CT for attenuation correction and anatomical localization; limited area.
78815	PET with concurrently acquired CT for attenuation correction and anatomical localization; skull base to mid-thigh.
78816	PET with concurrently acquired CT for attenuation correction and anatomical localization; whole body.

Single Photon Emission Computed Tomography (SPECT) CPTCPT

78071	Parathyroid planar imaging with tomographic (SPECT).
78072	Parathyroid planar imaging with tomographic (SPECT) and concurrently acquired CT for anatomical localization.
78803	Radiopharmaceutical localization; tomographic (SPECT), single area or acquisition, single day imaging.

Provider Actions & Documentation

Documentation Required

Document clinical indication

Providers must document the specific sign, symptom, or patient complaint that makes the requested diagnostic service reasonable and necessary. That clinical indication must be reported on the claim or request and retained in the patient record to support coverage decisions.

Prior Authorization

Follow applicable prior authorization program requirements

For regions/states/territories in the UnitedHealthcare Radiology Prior Authorization and Notification Program, follow the UnitedHealthcare Radiology and Cardiology Clinical Guidelines and program requirements. Where a delegate manages utilization management and prior authorization requirements for a member's plan, the delegate's requirements must be followed as applicable.

Denial Risk

Integrated Denial Notice for non-covered primary diagnoses

If a service is billed with a diagnosis that appears in the Non-Covered Diagnosis Codes List as the primary reason, call UnitedHealthcare so an Integrated Denial Notice (IDN) can be issued to the member and provider prior to rendering or referring for the non-covered service. Ensure the member has received the IDN before collecting payment.

Billing Rule

Codes provided for reference

The CPT and other procedure codes listed in this policy are provided for reference only. Inclusion of a code in this policy does not by itself determine coverage or guarantee payment; benefit coverage is determined by the member-specific plan document and applicable laws.

Medicare Determinations & Background

Background summary: UnitedHealthcare aligns diagnostic radiology coverage decisions with Medicare statutes, National Coverage Determinations (NCDs), and applicable Local Coverage Determinations/Articles (LCDs/LCAs). Where Medicare guidance is absent or allows flexibility, UnitedHealthcare supplements with internal criteria and nationally recognized guidelines such as InterQual. Regions participating in the UnitedHealthcare Radiology Prior Authorization and Notification Program must follow UnitedHealthcare Radiology and Cardiology Clinical Guidelines, and delegates' utilization management/prior authorization requirements are enforced where applicable.

Determination	Number / ID	Type
Computed Tomography	220.1	NCD
Magnetic Resonance Imaging	220.2	NCD
Positron Emission Tomography (FDG) for Oncologic Conditions	220.6.17	NCD
Single Photon Emission Computed Tomography (SPECT)	220.12	NCD
Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA)	L33947 / L33559 / L33423 / L35121 / L39521 (various)	LCD
Positron Emission Tomography (PET) for Inflammation and Infection	L39521	LCD

Evidence

NCD referencesCT (220.1), MRI (220.2), PET FDG oncologic (220.6.17), SPECT (220.12)

Guideline sourceInterQual CP: Imaging referenced for supplemental criteria

Definitions — Diagnostic Services: An examination or procedure performed on a patient (or materials derived from a hospital outpatient) to obtain information to aid in assessment of a medical condition or identification of a disease, including diagnostic x-rays, isotope studies, EKGs, pulmonary function, laboratory services, and other tests per Medicare Benefit Policy Manual Chapter 6.

Not Covered / Screening Exclusions

Screening exclusion: Screening radiological procedures as defined by Medicare are excluded. Diagnostic imaging for asymptomatic persons (screening radiological procedures) is not covered; radiology services that have no CMS screening benefit will be denied when billed as screening.

Changes to Non-Covered Diagnosis Codes: The policy notes updates effective 03/01/2026 that added diagnosis codes Z40.81, Z40.82, Z40.89, Z59.861, Z59.868, Z59.869, Z84.11, and Z84.19 and removed code Z83.71. Providers are advised to consult the Non-Covered Diagnosis Codes List for the complete and current set of codes and follow Integrated Denial Notice procedures when a non-covered primary diagnosis is used.

Revision History

2026-03-01material_revision

Removed content/language addressing computed tomographic colonography (CTC) for screening purposes (Coverage Rationale).

2026-03-01material_updateLatest

Updated Non-Covered Diagnosis Codes list — added Z40.81, Z40.82, Z40.89, Z59.861, Z59.868, Z59.869, Z84.11, and Z84.19 (material).

2026-03-01material_removal

Removed non-covered diagnosis code Z83.71 (material).

2026-03-01revision

Revised description for diagnosis code Z83.718 (non-material).

2026-03-01clarification

Added administrative notation that Z40.8, Z59.86, and Z84.1 were deleted Sep. 30, 2025 (non-material).

2026-03-01archival

Archived previous policy version MMP076.15 (supporting information, non-material).