CurrentUnitedHealthcarePolicy MMPO76.14

Radiologic Diagnostic Procedures

Defines Medicare Advantage coverage guidance for diagnostic radiology services (CT, CCTA, CT colonography, MRI/MRA, PET, SPECT, nuclear medicine, 3D rendering) including reliance on CMS NCDs/LCDs/LCAs and nationally recognized guidelines (InterQual) and policies for screening vs diagnostic designation.

Policy Summary

PayerUnitedHealthcare

PolicyRadiologic Diagnostic Procedures

Policy CodePolicy MMPO76.14

Change TypeCoverage & Criteria Updates

Effective DateOct 1, 2025

Next Review Date

Key ActionFor every diagnostic service billed, include the specific sign, symptom, or patient complaint that makes the service reasonable and necessary and retain documentation to support coverage decisions when requested.

POLICY UPDATE CHANGES

Added language that radiology services that have no CMS screening benefit will be denied when billed as a screening.

Updated Coverage Rationale and Overview sections and CT scan determinations to reference InterQual criteria and clarify use where no LCDs/LCAs exist.

2025-10-01Policy Effective Date

MultipleModalities Covered

MMPO76.14Policy Number

Coverage Summary

Policy purpose: to determine medical necessity for diagnostic imaging by relying on CMS National Coverage Determinations (NCDs), Local Coverage Determinations/Articles (LCDs/LCAs) where applicable and on nationally recognized guidelines (e.g., InterQual) in states/regions or situations where LCDs/LCAs do not apply; and to clarify that services without a CMS screening benefit will be denied if billed as screening and that diagnostic claims must document relevant signs/symptoms.

Coding

Referenced Procedure Codes (diagnostic radiology and nuclear medicine) - informational list (not exhaustive)CPT

76376	3D rendering with interpretation and reporting; not requiring image postprocessing on an independent workstation
76377	3D rendering with interpretation and reporting; requiring image postprocessing on an independent workstation
78012	Thyroid uptake, single or multiple quantitative measurement(s)
78013	Thyroid imaging (including vascular flow, when performed)
78014	Thyroid imaging with uptake 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)
78071	Parathyroid planar imaging; with tomographic (SPECT)

1–10 of 42

1/5

Non-Covered Diagnosis Codes (never covered as primary reason)ICD-10Not Covered

Z00.5

Encounter for examination of potential donor

Non-covered CPT/HCPCS when billed as screening (examples cited)CPT|HCPCSNot Covered

72198	Unlisted - Abdomen and Pelvis related code referenced as non-covered when screening
74185	CT Abdomen and Pelvis; coding clarification referenced as non-covered when screening
C8900	HCPCS referenced in coding clarification (non-covered when screening)
C8901	HCPCS referenced in coding clarification (non-covered when screening)
C8902	HCPCS referenced in coding clarification (non-covered when screening)
C8918	HCPCS referenced in coding clarification (non-covered when screening)
C8919	HCPCS referenced in coding clarification (non-covered when screening)
C8920	HCPCS referenced in coding clarification (non-covered when screening)

Provider Actions

Documentation Required

Document signs/symptoms for diagnostic imaging

For every diagnostic service billed, include the specific sign, symptom, or patient complaint that makes the service reasonable and necessary; retain documentation to support coverage decisions when requested.

Prior Authorization

Follow prior authorization/notification requirements where delegated or in program

For members in UnitedHealthcare Medicare Advantage plans where a delegate manages utilization management and authorization requirements, follow the delegate's requirements; for regions in the UnitedHealthcare Radiology Prior Authorization and Notification Program refer to UnitedHealthcare Radiology and Cardiology Clinical Guidelines for prior authorization/notification.

Refer to UnitedHealthcare Radiology and Cardiology Clinical Guidelines (UnitedHealthcare Radiology Prior Authorization and Notification Program) where applicable.

Billing Rule

Do not bill screening when no CMS screening benefit

Radiology services that have no CMS screening benefit will be denied when billed as screening; if a non-covered diagnosis code is the primary reason, obtain an Integrated Denial Notice (IDN) to inform the member of liability prior to rendering service.

Z00.5
72198
74185
C8900
C8901
C8902
C8918
C8919
C8920

Documentation Required

Retain documentation for medical necessity review

Providers are expected to retain or have access to appropriate documentation when requested to support coverage; UnitedHealthcare may request documentation to support coverage decisions.

Background

UnitedHealthcare Medicare Advantage policy follows Medicare statutes, NCDs, and applicable LCDs/LCAs to determine medical necessity for diagnostic radiology; where LCDs/LCAs do not apply or for plans not in the Radiology Prior Authorization and Notification Program, the policy relies on nationally recognized guidelines (e.g., InterQual) to supplement Medicare criteria.

screening services that have no CMS screening benefit will be denied when billed as screening, and diagnostic imaging for asymptomatic persons is not covered. Providers must indicate the specific sign, symptom, or patient complaint on every diagnostic claim and retain documentation to support coverage decisions when requested.

Diagnostic Services: A service performed to obtain information to aid in the assessment of a medical condition or identification of a disease (examples include diagnostic laboratory services, diagnostic X-rays, isotope studies, EKGs, pulmonary function studies, thyroid function tests, psychological tests, and similar examinations/tests).

Name	Number	Type
Computed Tomography	220.1	NCD
Magnetic Resonance Imaging	220.2	NCD
Single Photon Emission Computed Tomography	220.12	NCD

Revision History

10/01/2025added