CurrentUnitedHealthcarePolicy MMP076.16

Radiologic Diagnostic Procedures

Defines UnitedHealthcare Medicare Advantage policy regarding medical necessity, coverage, and applicable coding for diagnostic radiologic procedures (CT, CCTA, MRI/MRA, PET, SPECT, nuclear medicine, 3D rendering), including reliance on CMS NCDs/LCDs and InterQual criteria and exclusions for screening/asymptomatic imaging.

Policy Summary

PayerUnitedHealthcare

PolicyRadiologic Diagnostic Procedures

Policy CodePolicy MMP076.16

Change TypeCoverage and Code List Revisions

Effective Date03/01/2026

Next Review Date

Key ActionIndicate the specific sign, symptom, or patient complaint that makes the diagnostic imaging service reasonable and necessary and retain documentation to support coverage.

SourceLink

POLICY UPDATE CHANGES

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

Added non-covered diagnosis codes Z40.81, Z40.82, Z40.89, Z59.861, Z59.868, Z59.869, Z84.11, and Z84.19 to Non-Covered Diagnosis Codes list.

Archived previous policy version MMP076.15.

MultipleCovered Imaging Types (CT, MRI/MRA, PET, SPECT, Nuclear, 3D rendering)

ScreeningImaging Not Covered When Asymptomatic

NCDs/LCDs/InterQualExternal Guidance Sources Reliance

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Coverage Summary

Policy overview: UnitedHealthcare Medicare Advantage policy MMP076.16 (Effective 03/01/2026, Status: CURRENT) addresses Radiologic Diagnostic Procedures. The policy defines coverage for diagnostic imaging modalities including CT (including CCT/CCTA), MRI/MRA, PET (FDG), SPECT, other nuclear medicine procedures, and 3D rendering. Coverage decisions rely on Medicare statutes and National Coverage Determinations (NCDs), applicable Local Coverage Determinations/Articles (LCDs/LCAs), and, where Medicare guidance is absent or flexible, nationally recognized criteria such as InterQual CP: Imaging or UnitedHealthcare internal guidance. The policy emphasizes documentation of specific signs/symptoms to support medical necessity and explicitly excludes screening/asymptomatic imaging (radiologic procedures for asymptomatic persons and services billed as screening).

High-level Policy Facts

Policy numberMMP076.16

PayerUnitedHealthcare Medicare Advantage

Effective dateMarch 1, 2026

Last reviewJanuary 14, 2026

Coverage stanceMixed (coverage depends on medical necessity, NCDs/LCDs/LCAs, InterQual where applicable); screening/asymptomatic imaging not covered

Policy emphasisMedical necessity required with documentation of specific signs/symptoms; excludes screening/asymptomatic imaging

Medical Necessity Criteria

General Medical Necessity for Diagnostic Imaging

Covered when ALL of the following are met:

ref

Screening and Asymptomatic Imaging

Not covered when ANY of the following are true:

ref

Use of External/Local Criteria

Guidance for determining coverage when specific Medicare guidance absent or flexible:

ref

Positron Emission Tomography (PET) for Oncologic Conditions

Coding

3D Rendering CPT Codes (reference only)CPT

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 CPT Codes (reference only)CPT

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.

1–10 of 31

1/4

Positron Emission Tomography (PET) CPT Codes (reference only)CPT

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; limited area.
78815	PET with concurrently acquired CT; skull base to mid-thigh.
78816	PET with concurrently acquired CT; whole body.

SPECT CPT Codes (reference only)CPT

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

Provider Actions & Requirements

Documentation Required

Document specific sign/symptom for diagnostic imaging

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

Indicate sign/symptom on claim and retain documentation

Prior Authorization

Follow delegate prior authorization where applicable

For members in UnitedHealthcare Medicare Advantage plans where a delegate manages utilization management and prior authorization requirements, providers must follow the delegate's prior authorization and utilization management requirements.

Background

Background: UnitedHealthcare Medicare Advantage policies align with Medicare statutes, National Coverage Determinations (NCDs), and Local Coverage Determinations/Articles (LCDs/LCAs) where applicable, and supplement these with InterQual CP: Imaging or UnitedHealthcare internal criteria when Medicare guidance is absent or allows flexibility. Coverage is determined by medical necessity consistent with Medicare statute, regulations, and manuals; providers must document the specific sign, symptom, or patient complaint that makes the diagnostic service reasonable and necessary. The policy reiterates Medicare's exclusion of items or services that are not reasonable and necessary under SSA §1862(a)(1)(A). Screening and imaging for asymptomatic persons are excluded; radiology services that have no CMS screening benefit will be denied when billed as screening.

Diagnostic Services: A service is 'diagnostic' if it is an examination or procedure performed on a patient or on materials derived from a hospital outpatient to obtain information to aid in the assessment of a medical condition or identification of a disease. This includes diagnostic laboratory services, diagnostic x-rays, isotope studies, EKGs, pulmonary function studies, and other tests to determine the nature and severity of an ailment or injury (referencing Medicare Benefit Policy Manual, Chapter 6, §20.4.1).

Evidence references: Medicare National Coverage Determinations cited in this policy include NCD 220.1 (Computed Tomography), NCD 220.2 (Magnetic Resonance Imaging), NCD 220.12 (Single Photon Emission Computed Tomography, SPECT), and NCD 220.6.17 (Positron Emission Tomography [FDG] for Oncologic Conditions). The policy also references applicable Local Coverage Determinations/Articles (LCDs/LCAs) — for example, Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) LCD L33947 — and directs users to the Medicare Coverage Database and specific LCD/LCA tables where applicable.

Not Covered / Experimental

Primary not-covered rule: Diagnostic imaging performed for asymptomatic persons (screening radiological procedures as defined by Medicare) is not covered. Radiology services that have no CMS screening benefit will be denied when billed as screening. The policy's Screening and Asymptomatic Imaging criteria tree specifies that imaging for asymptomatic persons or services billed as screening meet the 'not covered' criteria. The Non-Covered Diagnosis Codes list has been updated per recent policy changes; providers should refer to the Non-Covered Diagnosis Codes (coding/appendix) and follow the Integrated Denial Notice process when a listed non-covered code is used as the primary reason for testing.

Revision History

2026-03-01effective_dateLatest

Policy effective date set to March 1, 2026.

2026-03-01revision

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

2026-03-01revision

Added non-covered diagnosis codes (Z40.81, Z40.82, Z40.89, Z59.861, Z59.868, Z59.869, Z84.11, Z84.19), removed Z83.71, revised description for Z83.718, and noted Z40.8, Z59.86, and Z84.1 were deleted Sep. 30, 2025 (material).