CurrentUnitedHealthcarePolicy CSRAD016OH.E

UN-CSRAD016OH.E - Pediatric Cardiac Imaging Guidelinesopen_in_new

UnitedHealthcare Community Plan clinical guideline for pediatric cardiac and cardiovascular imaging in Ohio, describing modality-specific guidance (US, CT, MRI, PET), general application, documentation requirements, investigational definitions, and CPT/HCPCS coding and billing guidance for imaging procedures.

Policy Summary

PayerUnitedHealthcare

PolicyUN-CSRAD016OH.E - Pediatric Cardiac Imaging Guidelinesopen_in_new

Policy CodePolicy CSRAD016OH.E

Change TypeAnnual and interim evidence-based updates

Effective DateFeb 3, 2026

Next Review Date

Key ActionProviders must submit detailed history, physical exam, appropriate labs, and prior imaging to establish medical necessity for advanced imaging.

SourceLink

POLICY UPDATE CHANGES

Annual and interim evidence-based updates recorded on 02/01/2024, 07/01/2024, 05/01/2025, and 11/06/2025.

1State-specific Policy (Ohio only)

V1.0.2026Guideline Version

3Primary Modalities Covered (US, CT, MRI)

1Single unit guidance code rule

Whole-body CT screening coverage (asymptomatic)

detailedMIS-C surveillance complexity

Coverage Summary & Scope

This UnitedHealthcare Community Plan coverage guideline applies specifically to the state of Ohio and provides pediatric cardiac and cardiovascular imaging policy (Guideline Number CSRAD016OH.E, V1.0.2026, Effective Date February 3, 2026). The scope covers primary imaging modalities including ultrasound (echocardiography), computed tomography (CT/CCTA/CTA), magnetic resonance imaging (MRI/CMR/MRA), and positron emission tomography (PET) (among other nuclear modalities). The guideline includes modality-specific appropriateness, documentation requirements, CPT/HCPCS coding and billing guidance, lesion-specific surveillance schedules, and state-specific applicability (Ohio Administrative Code 5160-1-01 will be used for items stated as unproven or with coverage/quantity limits). Overall coverage stance is mixed (condition- and modality-dependent), with many procedures covered when specified clinical criteria or surveillance intervals are met.

Medical Necessity Criteria (General and Modality-Specific)

Application / General Coverage Rule

Policy applies only to Ohio. Use Ohio Administrative Code 5160-1-01 for evaluation of services listed as unproven or subject to coverage/quantity limits.

This Medical Policy only applies to the state of Ohio. Any requests for services that are stated as unproven or services for which there is a coverage or quantity limit will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01.

Clinical Documentation Requirements

Required clinical documentation to establish medical necessity for pediatric cardiac imaging.

Pertinent clinical evaluation since onset or change in symptoms, including detailed history and targeted physical examination.

Relevant laboratory studies when applicable (e.g., troponin, BNP, inflammatory markers for MIS-C or Kawasaki disease).

Prior imaging and reports relevant to the request (e.g., prior echocardiograms, chest x-rays, prior CT/MRI) must be provided; when available, prior images should be obtained and reviewed to avoid unnecessary repeat imaging.

For scheduled surveillance or routine follow-up exams where prior clinical evaluation was previously documented, submit documentation of the indication and the prior imaging schedule.

Documentation of any contraindications or precautions to contrast administration (e.g., prior contrast reaction, known severe renal dysfunction) and pregnancy/breastfeeding status where relevant.

Age Considerations

Age-based application of pediatric versus adult imaging guidance.

Individuals 18 years old or younger should be imaged according to the Pediatric Imaging Guidelines when the condition is discussed in the pediatric-specific sections.

Conditions not specifically discussed in the Pediatric Imaging Guidelines should follow the General Imaging Guidelines.

Individuals older than 18 years should be imaged according to the General Imaging Guidelines unless a specific guideline directs otherwise.

Investigational / Experimental Determination

Definition and determination of investigational/experimental (unproven) services.

A study, treatment, procedure, or device is considered experimental, investigational, or unproven if: there is a paucity of supporting evidence; evidence does not demonstrate improved health outcomes; clinical utility has not been demonstrated; or there is no collective opinion of support from relevant clinical communities.

Clinical trial imaging requests are reviewed against these guidelines; imaging requested primarily for data collection and not used in direct clinical management is not supported.

When a service is deemed unproven for Ohio, the Ohio Administrative Code 5160-1-01 will be used to evaluate medical necessity or coverage limits.

Modality-Specific Appropriateness (General Guidance)

Modality selection guidance (general). Prefer modalities that answer the clinical question with the least risk—consider radiation, need for sedation, and diagnostic yield.

Echocardiography (TTE/TEE) is the preferred initial cardiac imaging modality for most pediatric cardiac indications because it is noninvasive, radiation-free, and readily available.

Cardiac MRI (CMR) is preferred for detailed anatomic delineation, ventricular function, tissue characterization (including myocarditis, cardiomyopathy), and when echocardiography is nondiagnostic or limited by acoustic windows.

Cardiac CT/Coronary CTA is preferred for rapid high-resolution anatomic evaluation of coronary artery origins and course, complex vascular anatomy, and when MRI is contraindicated or unavailable. Use tailored low-dose pediatric protocols.

Nuclear techniques (including Xenon ventilation in pediatrics) are considered investigational/unproven when not supported by condition-specific evidence; Xenon ventilation studies are generally considered investigational in children in this guideline unless supported by specific indications.

Contrast and Renal Function

Contrast use and renal function considerations for pediatric cardiac imaging.

Gadolinium-based contrast agents for MRI: weigh risks of nephrogenic systemic fibrosis in severe renal impairment and consider macrocyclic agents and the lowest effective dose; document renal function when indicated.

Iodinated contrast for CT: assess renal function and prior contrast reactions; use weight-based dosing and consider hydration protocols when appropriate.

Pregnancy and breastfeeding: avoid ionizing radiation and iodinated or gadolinium contrast unless urgent and justified. If contrast is administered during pregnancy, document informed consent and consideration of alternatives; for breastfeeding, discuss risk — iodinated contrast generally does not require pumping/withholding; small amounts of gadolinium excreted in breast milk may lead to recommendations for a brief interruption in breastfeeding per institutional protocols.

Overutilization / Repeat Imaging

Rules to minimize overutilization and unnecessary repeat imaging.

Avoid repeat advanced imaging unless there is a clear change in clinical status, new/worsening signs or symptoms, preoperative planning changes, inconclusive prior study, or elapsed surveillance interval per guideline.

Obtain and review prior imaging and reports before authorizing repeat imaging; if prior images are unavailable, thoughtful repetition may be permitted but expect documentation of attempts to obtain prior studies.

Pre-operative imaging is appropriate when the result will change surgical or interventional management; routine pre-op imaging without change in status is generally not supported.

General modality and indication rules; Echocardiography coding and baseline rules

Top-level rules for when advanced imaging beyond echocardiography is covered.

Advanced cardiac imaging (CT, CMR, coronary CTA, cardiac catheterization) is supported when ALL of the following are met: (1) change in clinical status or new/worsening signs or symptoms that cannot be answered by prior echocardiography; OR (2) pre-operative or pre-intervention planning that will change management; OR (3) echocardiography is inconclusive, nondiagnostic, or technically limited due to body habitus, acoustic windows, or patient cooperation.

Baseline or routine surveillance echocardiography is supported per specific lesion or disease section criteria; advanced imaging for baseline anatomic definition may be supported when required for definitive anatomic mapping not provided by echocardiography.

When transthoracic echocardiography is technically limited, consider transesophageal echocardiography, cardiac MRI, or cardiac CT depending on the clinical question and patient safety considerations.

Modality considerations for advanced imaging

When echocardiography is nondiagnostic, modality considerations for selection of CT vs MRI vs other imaging.

If echocardiography is inconclusive for intracardiac anatomy, ventricular size/function, or valvular pathology and sedation is acceptable, CMR is preferred for comprehensive assessment including flow quantification, ventricular volumes, and tissue characterization.

For evaluation of coronary artery origins, course, and suspected coronary anomalies (including post-Kawasaki disease coronary aneurysm assessment when high-resolution coronary imaging is needed), coronary CTA/CT heart is preferred when rapid assessment is required or when MRI coronary imaging is inadequate.

CT is preferred for high-resolution assessment of extracardiac vascular anatomy (aortic arch, pulmonary arteries, venous anomalies) especially when metal devices or motion limit MRI; use pediatric low-dose protocols.

Use of nuclear perfusion studies is limited in pediatrics and should be reserved for specific indications when other modalities cannot answer myocardial perfusion questions; discuss radiation implications.

3D Rendering, Imaging Guidance, and Billing Guidance

3D rendering, imaging guidance, specific billing and unlisted procedure guidance relevant to advanced cardiac imaging.

3D rendering (CPT 76376/76377): Report 76376 for 3D rendering with interpretation of CT/MR data when performed and medically necessary for surgical or procedural planning; report 76377 for additional rendering work when applicable. Documentation must support the clinical necessity and how the rendering impacted management.

Imaging guidance codes (CT/MR/US guidance preface): When image-guided interventions are performed, report the appropriate modality-specific guidance code (e.g., CT guidance, MR guidance, US guidance) consistent with AMA CPT coding guidance and payer billing rules. Guidance codes should reflect the imaging modality used for real-time or intermittent guidance and be supported by operative reports or procedural documentation.

Use of guidance and imaging guidance codes: Guidance codes are billed in addition to the primary interventional procedure when imaging guidance was clinically required and documented. Do not report guidance codes when imaging was purely diagnostic or for planning only and no real-time imaging guidance was used during the procedure.

Specific CPT billing guidance (selected examples): Examples include reporting CT or MR guidance codes with percutaneous cardiac or vascular access procedures when image guidance is directly used; when both CT and US guidance are used, report the guidance code that represents the primary modality of guidance per CPT rules and local payer guidance.

Lesion-specific surveillance and Selected Condition Imaging Rules

Lesion- and diagnosis-specific surveillance and surveillance interval principles (examples).

Atrial Septal Defect (ASD)/Patent Foramen Ovale (PFO)/Ventricular Septal Defect (VSD)/Atrioventricular Septal Defect (AVSD): Initial echocardiographic diagnosis at presentation. Post-repair surveillance imaging schedule depends on lesion, repair type, and symptoms — typically baseline post-op echo, then interval imaging at 1 year and at clinician discretion thereafter; advanced imaging reserved for suspected residual shunt, pulmonary hypertension, or anatomy not well defined by echo.

Tetralogy of Fallot (TOF): Post-operative and surveillance imaging includes routine echocardiographic evaluation for RV size/function and PR. CMR is preferred for serial quantification of RV volumes and pulmonary regurgitation when echo is inconclusive or at set surveillance intervals (e.g., adolescence and pre-repair or re-intervention planning). CT/CTA used when metal artifacts limit MRI or to define pulmonary artery/conduit anatomy.

Double Outlet Right Ventricle (DORV): Use echocardiography for initial assessment. Advanced imaging (CMR or CT) is indicated for complex anatomy delineation, conduit assessment, ventricular volume quantification, and preoperative planning.

D-Loop Transposition of the Great Arteries (D-Loop TGA): Echocardiography for baseline and post-operative assessment; advanced imaging (CT or CMR) for coronary anatomy delineation, systemic/pulmonary venous anomalies, or when echo windows are inadequate.

Lesion-Specific Indications & Surveillance Schedules

Condition-Specific Imaging (Acute & Special Conditions)

Coding Guidance and Modality-Specific Billing Rules

Imaging Guidance and Billing Rules

Imaging guidance and specific CPT billing rules. These criteria capture single-unit-per-encounter rules and examples of billing guidance for CT/MR/US guidance and unlisted procedures.

ALL of the following

Imaging guidance codes (CT/MR/US) are limited to a single billable unit per encounter when used for guidance/targeting rather than full diagnostic imaging. Guidance codes should be reported only when image guidance is specifically performed and documented.
When guidance is performed as part of an otherwise reportable diagnostic study, do not separately bill guidance codes unless the guidance represents a distinct, incremental service beyond the diagnostic acquisition and is documented as such.
Unlisted procedure codes (eg, 76498, 76999) require submission of supporting documentation including a narrative description of the service performed, images if applicable, and a justification for use instead of a listed CPT code.

Provider Actions — Prior Authorization, Documentation & Billing Rules

Documentation Required

Submit Pertinent Clinical Evaluation

Submit a detailed, pertinent clinical evaluation when requesting advanced cardiac imaging. Include the history and physical exam since onset or change in symptoms, relevant laboratory studies, and all prior imaging (echocardiograms, CT, MRI, nuclear studies). Condition-specific guideline sections may list additional required clinical information; follow those requirements when present. If the request is for scheduled guideline-supported surveillance imaging, document the rationale per the applicable lesion-specific schedule.

History and physical exam since onset or change in symptoms
Appropriate laboratory studies
Prior imaging studies (echo, CT, MRI, nuclear)
Condition‑specific required information when listed

Prior Authorization

Background, Evidence & Definitions

These are UnitedHealthcare's proprietary, evidence-based pediatric clinical guidelines for cardiac and cardiovascular imaging. They evaluate use of NM, US, CT, MRI, PET and related procedures and are developed from specialty society guidance, peer-reviewed literature, and input from practicing physicians. The guidelines undergo a formal annual review with interim updates as needed and include instructions for documentation, age-based pediatric considerations, investigational determinations, and coding/billing guidance to support medical necessity determinations.

Source	Note
FDA Gadolinium Warning	FDA required new class warnings re: gadolinium retention (May 16, 2018).
AHA Kawasaki 2017	AHA scientific statement: Diagnosis, treatment, and long-term management of Kawasaki disease (McCrindle et al. 2017) — used for KD imaging timing, z-score risk stratification, and surveillance intervals.
ESC/ERS Pulmonary Hypertension 2015	2015 ESC/ERS Guidelines for diagnosis and treatment of pulmonary hypertension cited as supporting evidence for pediatric PHT imaging recommendations.
ACR Practice Parameters	ACR practice parameters for imaging modalities (CT, MRI, US) and pediatric CT/MR practice guidelines referenced to support modality and radiation/contrast guidance.
Guideline version V1.0.2026	Document version identifier for these UnitedHealthcare Pediatric Cardiac Imaging Guidelines (effective Feb 3, 2026) — lists references and guideline provenance.

Definitions List

When PET/MRI is medically necessary and reporting instructions

Alternate criteria when condition-specific PET/MRI criteria not met: Individual meets guideline criteria for PET/CT, PET/CT unavailable, and provider requests PET/MRI in lieu of PET/CT.

ref":"b4_2","title":"PET/MRI Reporting Criteria"},{

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Revision History

02/01/2024policy_update

Annual evidence-based update recorded; no specific clinical policy statement changes (non-material).

07/01/2024policy_update

Interim evidence-based update recorded; no specific clinical policy statement changes (non-material).

05/01/2025policy_update

Annual evidence-based update recorded; no specific clinical policy statement changes (non-material).

Policy Summary

PayerUnitedHealthcare

PolicyUN-CSRAD016OH.E - Pediatric Cardiac Imaging Guidelinesopen_in_new

Policy CodePolicy CSRAD016OH.E

Change TypeAnnual and interim evidence-based updates

Effective DateFeb 3, 2026

Next Review Date

Key ActionProviders must submit detailed history, physical exam, appropriate labs, and prior imaging to establish medical necessity for advanced imaging.

SourceLink

On This Page

Unlisted procedures (CT/MR/Nuclear) and when to use: Use unlisted procedure codes when no specific CPT code describes a novel or highly individualized CT, MR, or nuclear procedure. When billing unlisted codes, submit detailed operative/technical documentation, indication, imaging protocols, time, and justification of medical necessity to support reimbursement.

Whole-Body CT and Whole-Body MRI (WBMRI) coverage: Whole-body CT or MRI exams intended for general screening in asymptomatic individuals are not routinely supported. WBMRI/Whole-body CT for surveillance may be considered when specifically indicated by a documented high-risk condition and when supported in the condition-specific section; otherwise, deny as screening.

Congenitally Corrected TGA (ccTGA/L-TGA): Use echocardiography for serial functional assessment; CMR for detailed systemic/pulmonary ventricular function assessment and tricuspid valve evaluation when echo is limited.

Truncus Arteriosus: Echocardiography for initial diagnosis and early post-op surveillance; CT or CMR for coronary and arch anatomy, conduit assessment, and when echo is insufficient.

Single Ventricle (including HLHS and variants): High-level longitudinal surveillance requires multimodality imaging. Echocardiography for routine follow-up; CMR for ventricular volumes, flow quantification, valve regurgitation, and conduit/pulmonary artery assessment when feasible. CT may be used for rapid anatomic definition or when CMR contraindicated.

Eisenmenger and Pulmonary Hypertension with CHD: Echocardiography for initial assessment including estimation of pulmonary pressures; cardiac catheterization is required when precise hemodynamics are needed for treatment decisions. CMR/CT for structural assessment as adjuncts.

Multisystem Inflammatory Syndrome in Children (MIS-C): Initial imaging: TTE is indicated for all suspected MIS-C to assess ventricular function, coronary arteries, and pericardial effusion. Repeat imaging: follow-up TTE at intervals per clinical course (commonly 1-2 weeks and again at 4-6 weeks) and consider CMR for persistent myocardial dysfunction or unclear etiology.

Heart Murmur (initial evaluation): Innocent murmurs with normal exam and no other findings generally do not require echocardiography. Echocardiography is indicated for murmur with abnormal cardiac exam, cyanosis, failure to thrive, abnormal ECG, or other concerning signs.

Chest Pain (pediatric): Initial evaluation includes history, exam, ECG, and troponin where indicated. Echocardiography is indicated if abnormal ECG, elevated biomarkers, persistent concerning symptoms, or clinical signs suggest cardiac etiology. Advanced imaging (CMR/CT) for suspected myocarditis, coronary anomaly, or when echo is nondiagnostic.

Syncope (pediatric): Echocardiography indicated when there are abnormal cardiac examination findings, abnormal ECG, exertional syncope, or other red flags. Routine echocardiography for isolated vasovagal syncope without concerning features is not supported.

Pediatric Pulmonary Hypertension - General: Use echocardiography for screening and serial noninvasive assessment. Right heart catheterization is required for definitive hemodynamic diagnosis and therapy initiation. CMR/CT may be used to further delineate pulmonary vascular and cardiac anatomy.

Pulmonary Hypertension Imaging: Echocardiography for serial assessment; CT pulmonary angiography for suspected thromboembolic disease or anatomic evaluation; V/Q scan for thromboembolic PH when applicable.

Pericardial Effusion / Tamponade Imaging: Echocardiography is the initial and primary modality for diagnosis and guidance for pericardiocentesis. CT/MRI used when echocardiography is nondiagnostic or to evaluate extracardiac thoracic pathology.

Kawasaki Disease - Initial Imaging: Echocardiography at diagnosis to evaluate for coronary artery dilation/aneurysm and ventricular function. If echocardiography is limited, coronary CTA can be used for more detailed coronary assessment, recognizing radiation exposure.

Kawasaki Disease - Chronic Phase and Long-Term Surveillance: Surveillance imaging frequency guided by maximum coronary artery z-score and presence of aneurysm; coronary CTA or CMR may be used for detailed anatomic assessment when indicated.

Transthoracic Echocardiography (TTE) Coding and Indications: Initial TTE (comprehensive) is indicated per condition-specific initial indications (see PEDCD-8.2). Repeat or limited TTE codes are supported when there is documented clinical change, comparison to prior study, or focused question (see PEDCD-8.3).

Initial TTE Indications (PEDCD-8.2): Indications include suspected congenital heart disease, abnormal cardiac exam, murmur with concerning features, suspected myocarditis or cardiomyopathy, Kawasaki disease at diagnosis, MIS-C evaluation, unexplained syncope with cardiac red flags, and preoperative cardiac assessment when clinically indicated.

Repeat TTE Indications (PEDCD-8.3): Repeat TTE is supported for new or worsening symptoms, interval change in clinical status, assessment after therapy/intervention, surveillance of known lesions per recommended intervals, or when prior study was inadequate.

CT Heart / Coronary CTA / Cardiac CT Indications: Indicated for evaluation of coronary artery origins/anomalies, suspected coronary complications of Kawasaki disease when high-resolution imaging required, preoperative 3D anatomic mapping when CT is superior or MRI contraindicated, and evaluation of stents/conduits when MRI limited by artifact.

Radiation and Modality Considerations for CCTA/Cardiac CT: Use pediatric-tailored low-dose protocols, ECG-gating when needed, weight-based contrast dosing, heart-rate control strategies if necessary, and document justification of radiation exposure versus diagnostic yield.

Cardiac MRI — Iron overload and surveillance frequency: CMR with T2* or other validated iron quantification sequences is indicated for surveillance of myocardial iron overload in at-risk patients (e.g., transfusion-dependent anemias). Frequency depends on clinical risk and prior results; typically every 6-12 months in those at higher risk or per hematology guidance.

Chest MRA/MRI for Congenital Heart Disease: Chest MRA/MRI is indicated for assessment of complex vascular anatomy, pulmonary arteries, aortic arch anomalies, and extracardiac vasculature when echocardiography is inadequate; consider need for sedation and use of contrast-enhanced angiographic sequences when appropriate.

Cardiac Catheterization — General and diagnostic indications: Cardiac catheterization is indicated when invasive hemodynamic assessment is necessary to guide therapy (e.g., suspected pulmonary hypertension needing vasoreactivity testing), when interventional catheter-based therapy is planned, or when noninvasive imaging cannot define anatomy/physiology for management.

Cardiac Catheterization — Applicability: Diagnostic catheterization is reserved for conditions where precise pressure measurements, oxygen saturations, or opportunity for intervention during the same procedure are required; routine diagnostic catheterization solely for imaging when noninvasive options suffice is not supported.

CPT 76380 (limited or follow-up CT for limited area) is restricted and should only be reported when a limited CT of a specific region is performed for follow-up or focused evaluation; documentation must support why a full diagnostic study was not appropriate.

3D rendering codes (C8922–C8930) are subject to billing guidance and exclusions: when 3D rendering is included as part of the interpretation of the primary diagnostic study, payers may consider it bundled; separate reporting requires documentation of distinct, added work and commercially available rendering software or services used; check payer-specific coverage for professional vs technical component reporting.

Specific CPT billing examples: Selected diagnostic catheterization and cardiac imaging codes (93451–93461, +93462; 93593–93597) represent comprehensive cardiac catheterization and intraprocedural imaging services. These codes often include hemodynamic measurements, imaging, and interpretation; separate reporting of overlapping services is limited and must meet CPT bundling rules and medical necessity.

SPECT/CT, Hybrid Nuclear/CT and PET/MRI Reporting Criteria

SPECT/CT, hybrid nuclear/CT coding and PET/MRI reporting guidance. Diagnostic MRI codes may be reported when clinically indicated alongside PET/MRI; PET/MRI reporting combinations require appropriate unlisted or combination coding as described below.

ALL of the following

SPECT/CT and hybrid nuclear/CT: When a nuclear medicine study (eg, SPECT) and a CT for attenuation correction/anatomic localization are performed as a combined hybrid exam, report the appropriate nuclear medicine CPT code(s) (eg, 78800 series) and the CT code(s) only when the CT provides diagnostic information beyond attenuation correction. If CT is non-diagnostic or solely for attenuation correction, CT may be considered bundled and not separately payable.
Document the purpose of the CT (attenuation correction vs diagnostic localization) in the report.
PET/MRI reporting: The PET radiopharmaceutical imaging component (eg, 78813 series) may be reported in combination with an unlisted CT/MR add-on when a specific CPT combination is not available; for example, when PET/MRI reporting requires an unlisted code, report the PET code (eg, 78813 where appropriate) plus CPT 76498 (unlisted imaging procedure) to represent the MRI component if no specific PET/MRI CPT exists. Provide detailed documentation and images to support the combined service.
When diagnostic MRI sequences are performed concurrently with PET/MRI and meet clinical indications for a diagnostic MRI, the appropriate MRI diagnostic CPT codes may be reported in addition to the PET code if documentation supports distinct diagnostic interpretation and if payer policy permits concurrent payment.
Operational note: For PET/MRI reporting where a specific billing pathway exists (eg, payer-specific pairings), follow payer rules. When using CPT 76498 with PET codes, include sufficient documentation to allow coding review and medical necessity determination.

Prior Authorization May Be Required for 3D Rendering Codes

CPT 76376 and 76377 (3D rendering) may require prior authorization even when the base echocardiography or ultrasound does not. These codes require concurrent physician supervision/participation of the 3D post-processing and differ by whether an independent workstation is required (76377 requires one; 76376 does not).

Affected codes: 76376, 76377

Billing Rule

One Unit Per Encounter for Guidance Codes

Guidance procedure codes represent the imaging necessary to guide needles or catheters and should be reported as a single unit per individual encounter (the unit is the encounter/date of service, not number of lesions). Only one unit of any guidance code should be reported per date of service.

77012
77021
76942
77002
77003

Billing Rule

Do Not Bill Diagnostic Codes with Guidance Codes

Do not routinely bill a diagnostic procedure code in conjunction with CT/MR/US guidance procedure codes because guidance codes contain all imaging necessary to perform the guided procedure. Diagnostic procedure codes are inappropriate to add routinely unless a separate percutaneous surgical procedure (not just guidance) is performed.

Billing Rule

Do Not Bill 3D Rendering with Specific Modalities

Do not report 3D rendering CPT 76376/76377 together with certain diagnostic/stereotactic/localization modalities. Examples of modalities and codes that should not be billed with 3D rendering include stereotactic localization and related CT interpretation codes and cardiac CT/MRI/CTA modalities. When excluding billing, also consider modality examples such as CTA/CTA coronary, cardiac MRI, PET/SPECT, mammography, and stereotactic localization.

76376
76377
77011
70486

Billing Rule

Unlisted code reporting and documentation

Report unlisted CT (76497), unlisted MR (76498), or unlisted diagnostic nuclear medicine (78999) only when no appropriate anatomic site-specific CPT code or Category III code exists. Provide documentation justifying the unlisted code: clear clinical justification, description of the procedure/anatomic site, and why a standard code is not applicable (for example, neurosurgical navigation planning, custom arthroplasty planning, or thin-cut/acquisition positioning different from completed diagnostic study). If a relevant Category III code exists, it must be used instead of an unlisted code.

76497
76498
78999
Documentation: clinical justification and reason no site-specific or Category III code applies

Billing Rule

Echocardiography code usage; Do not approve redundant add-on codes with 93306; Pre-authorization code selection and documentation

Echocardiography coding rules: use congenital codes (93303, 93304 with appropriate add-ons) for congenital heart disease and non‑congenital codes (93306, 93307, 93308) for acquired/normal anatomy as specified. CPT 93306 includes +93320 and +93325 and those add-ons should not be billed separately. Avoid approving redundant add-on codes when 93306 is reported. For pre-authorization, providers may request multiple echo codes because the final code depends on intra-procedure findings; documentation must support the final code selection. When billing or requesting authorization, reference the appropriate codes for congenital and non-congenital studies and include necessary supporting documentation.

Primary codes: 93303, 93304, 93306, 93307, 93308
Add-on codes: 93320, 93321, 93325 (do not bill add-ons separately when 93306 is used)
Related codes for advanced documentation: 93307, 93308

Documentation Required

MIS-C discharge surveillance schedule

For individuals discharged after MIS-C, document and schedule outpatient transthoracic echocardiograms at key time points: within 1 week of discharge, at 4 weeks post-discharge, at 6 months, and at 1 year. Cardiac MRI may be performed approximately 3 months after illness for individuals with evidence of cardiac involvement when results will affect management (a routine cardiac MRI once after ~3 months is supported for those with cardiac involvement). Coronary CT angiography can be used if coronary visualization is incomplete on echocardiography.

TTE at: within 1 week post-discharge; 4 weeks; 6 months; 1 year
Cardiac MRI: routine once after ~3 months when cardiac involvement documented
CCTA: if echocardiogram does not adequately visualize coronaries

Denial Risk

Whole-body CT for asymptomatic screening not covered

Whole‑body CT (LifeScan) or whole‑body CT screening of asymptomatic individuals is not a covered benefit and may be denied when billed for screening purposes. Whole‑body low‑dose skeletal CT is supported only for specific oncologic staging (e.g., multiple myeloma); whole‑body MRI is generally not supported except for select cancer predisposition syndromes and limited indications.

11/06/2025policy_updateLatest

Annual evidence-based update recorded; no specific clinical policy statement changes (non-material).