CurrentUnitedHealthcarePolicy CSRAD003OH.E

Adult Cardiac Imaging Guidelines (For Ohio Only)

Evidence-based clinical guideline governing advanced adult cardiac imaging (NM, US, CT, MRI, PET, etc.) for UnitedHealthcare Community Plan members in Ohio; describes medical necessity, documentation, and investigational criteria for services. Affects providers requesting cardiac imaging for Ohio members.

Policy Summary

PayerUnitedHealthcare

PolicyAdult Cardiac Imaging Guidelines (For Ohio Only)

Policy CodePolicy CSRAD003OH.E

Change TypeNo material change

Effective DateFeb 3, 2026

Next Review DateN/A

Key ActionSubmit pertinent clinical evaluation and prior imaging documentation to support medical necessity before ordering advanced cardiac imaging.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

291total pages

V1.0.2026guideline version

Ohio-onlygeographic applicability

3examples of modality groups

≥100CAC threshold

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Advanced Cardiac Imaging

CT Heart / CT Cardiac (structure/morphology)

CT Heart / CT Cardiac (structure/morphology) — CT Heart (CPT 75572) is considered medically necessary for the following indications when documentation supports the clinical question and the results will affect management:

Cardiac vein identification for lead placement in left ventricular pacing

To evaluate the anatomy of the pulmonary veins prior to a pulmonary vein isolation (ablation) procedure for atrial fibrillation

Post-procedure evaluation between 3-6 months after ablation

When echocardiogram is inconclusive for: cardiac or pericardial tumor or mass; cardiac thrombus; pericarditis/constrictive pericarditis; complications of cardiac surgery

In place of MRI when there is clinical suspicion of arrhythmogenic right ventricular dysplasia or arrhythmogenic cardiomyopathy (ARVD/ARVC) if clinical suspicion is supported by established criteria

Recurrent laryngeal nerve palsy due to cardiac chamber enlargement

Prior to planned valvular interventions (TAVR, TMVR and TTVR) in individuals with radiation-induced valve disease

CT Cardiac (CPT 75572) can be performed instead of TEE for assessment of left atrial appendage (LAA) occlusion device or to assess for thrombus

CT Heart for Congenital Heart Disease

CT Heart for Congenital Heart Disease — CT Heart for congenital heart disease (CPT 75573) is considered medically necessary in the following situations:

Evaluation of coronary artery anomaly

When a cardiac catheterization was performed and not all coronary arteries were identified

Thoracic arteriovenous anomaly evaluation

After MRI Cardiac or CT angiogram Chest suggests congenital heart disease to further delineate anatomy

Complex adult congenital heart disease evaluation when detailed anatomic definition is required

When no CT Cardiac or MRI Cardiac has been performed and there is a contraindication to MRI Cardiac

Appropriate Modalities and Indications

Procedure and Billing Codes

Experimental / Investigational CPTCPTExperimental

C9791

MRI utilizing Xenon Xe 129 (listed as investigational/experimental)

3D Rendering CPT CodesCPTCovered

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

Imaging guidance and related CPT CodesCPTCovered

19085	Biopsy, breast, with placement of breast localization device(s), including MR guidance (first lesion)
19086	Biopsy, breast, with placement of breast localization device(s), including MR guidance (each additional lesion)
75989	Imaging guidance for percutaneous drainage with placement of catheter
76942	Ultrasonic guidance for needle placement
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
70486	Example diagnostic CT code referenced (not exhaustively listed in window)

Unlisted Procedure CodesCPT

76497	Unlisted CT procedure (diagnostic or interventional)
76498	Unlisted MR procedure (diagnostic or interventional)
78999	Unlisted procedure, diagnostic nuclear medicine

Unlisted CPT CodesCPT

76497	Unlisted CT procedure (diagnostic or interventional)
76498	Unlisted MR procedure (diagnostic or interventional)
78999	Unlisted procedure, diagnostic nuclear medicine

Limited CTCPT

76380

Limited or follow-up CT

SPECT/CT CodesCPT

78830	SPECT/CT single area single day
78831	SPECT/CT 2 or more days
78832	SPECT/CT 2 areas with one day and 2-day study
78072	SPECT/CT parathyroid nuclear imaging (effective 2013-01-01)

Outside Study InterpretationCPTCovered

76140

Interpretation of an outside study

PET/MRI reporting combinationCPTCovered

78813	PET Whole-Body
76498	MRI unlisted (used in PET/MRI combination)

HCPCS examples and mappingHCPCS

C8931	MRA with dye, Spinal Canal (example HCPCS)
S8042	Magnetic resonance imaging [MRI], lowfield (example HCPCS to redirect)
72159	MRA Spinal Canal (CPT example for mapping)

Stress echo, SPECT MPI or stress MRICPTCovered

75559	Cardiac MRI for morphology and function without contrast, with stress imaging
75563	Cardiac MRI for morphology and function without and with contrast, with stress imaging
78451	MPI, tomographic (SPECT), single study, at rest or stress
78452	MPI, tomographic (SPECT), multiple studies, rest and/or stress

Additional stress echo and planar MPI CPTsCPTCovered

78453	Myocardial perfusion imaging, planar, single study, at rest or stress
78454	Myocardial perfusion imaging, planar, multiple studies, rest and/or stress
93350	Echocardiography (TTE), (2D), with or without m-mode, during rest and cardiovascular stress, with interpretation and report
93351	Echocardiography (TTE), (2D), m-mode, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation

Cardiac perfusion PETCPTCovered

78430	Myocardial imaging, PET, perfusion study; single study, at rest or stress, with concurrently acquired CT transmission scan
78431	Myocardial imaging, PET, perfusion study; multiple studies at rest and stress, with concurrently acquired CT transmission scan
78491	Myocardial imaging, PET, perfusion study; single study at rest or stress
78492	Myocardial imaging, PET, perfusion study; multiple studies at rest and stress

Related internal referencesmixed

CD-6.4

Cardiac PET Metabolic - Indications (reference to another section)

Transthoracic Echocardiography CPT codesCPTCovered

93303	TTE for congenital cardiac anomalies, complete
93304	TTE for congenital cardiac anomalies, follow-up or limited
93306	TTE with 2-D, M-mode, Doppler and color flow, complete
93307	TTE with 2-D, M-mode, without Doppler or color flow
93308	TTE with 2-D, M-mode, follow-up or limited

3D Echocardiography and post-processingCPTCovered

76376	3D rendering with interpretation and reporting without requiring independent workstation post-processing
76377	3D rendering with interpretation and reporting requiring image post-processing on an independent workstation
93319	3D echocardiographic imaging and post-processing during TEE or TTE for congenital cardiac anomalies (add-on)

Doppler and advanced echocardiography add-on codesCPTCovered

+93320	Doppler echo, pulsed wave and/or spectral display
93321	Doppler echo, pulsed wave and/or spectral display, follow-up or limited study
+93325	Doppler echo, color flow velocity mapping
+93356	Myocardial strain imaging (speckle tracking-derived) (list separately)

CMS C-codes for contrast echocardiographyHCPCS

C8921	Transthoracic Echocardiography = TTE for congenital cardiac anomalies, complete (maps to CPT 93303)
C8922	Transthoracic Echocardiography = TTE for congenital cardiac anomalies, follow-up or limited (maps to CPT 93304)
C8929	Transthoracic Echocardiography = TTE with 2-D, M-mode, Doppler and color flow, complete (maps to CPT 93306)
C8923	Transthoracic Echocardiography = TTE with 2-D, M-mode, without Doppler or color flow (maps to CPT 93307)
C8924	Transthoracic Echocardiography = TTE with 2-D, M-mode, follow-up or limited (maps to CPT 93308)

Investigational codesCPTExperimental

0439T	Myocardial contrast perfusion echocardiography (investigational)
0932T	Noninvasive detection of heart failure derived from augmentative analysis of an echocardiogram (investigational)

Referenced CPT CodesCPT

93306

TTE post-procedure (referenced for Transcatheter Tricuspid Valve Replacement)

TEE CPT CodesCPTCovered

93312	TEE with 2-D, M-mode, probe placement, image acquisition, interpretation and report
93313	TEE probe placement only
93314	TEE image acquisition, interpretation, and report only
93315	TEE for congenital anomalies with 2-D, M-mode, probe placement, image acquisition, interpretation and report
93316	TEE for congenital anomalies, probe placement only
93317	TEE for congenital anomalies, image acquisition, interpretation and report only

Stress Echo and Doppler CodesCPTCovered

93350	Echo, transthoracic, with (2D), during rest and exercise stress test, with report
93351	Echo, transthoracic, with (2D), during rest and exercise stress test including continuous ECG monitoring and physician supervision
+93320	Doppler echo, pulsed wave and/or spectral display (add-on)
+93321	Doppler echo, pulsed wave and/or spectral display, follow-up/limited study (add-on)
+93325	Doppler echo, color flow velocity mapping (add-on)

3D Echocardiography CodesCPTCovered

76376	3D rendering with interpretation and reporting under concurrent supervision; not requiring independent workstation
76377	3D rendering with interpretation and reporting requiring independent workstation post-processing
+93319	3D echocardiographic imaging and post-processing during TEE or TTE for congenital anomalies (add-on)

Associated HCPCS/C codesHCPCS

C8925	HCPCS code mapping to CPT 93312
C8926	HCPCS code mapping to CPT 93315
C8928	HCPCS mapping for CPT 93350
C8930	HCPCS mapping for CPT 93351

3D Echocardiography / 3D renderingCPTCovered

76376	3D rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality with image post-processing under concurrent supervision; not requiring image post-processing on an independent workstation
76377	3D rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality with image post-processing under concurrent supervision; requiring image post-processing on an independent workstation
+93319	3D echocardiographic imaging and post-processing during TEE or TTE for congenital cardiac anomalies (list separately in addition to code for echocardiographic imaging)

Myocardial Strain ImagingCPTCovered

93356

Myocardial strain imaging (speckle tracking longitudinal strain)

Nuclear Cardiac Imaging Procedure Codes (MPI)CPT

78451	MPI tomographic (SPECT), single study, at rest or stress
78452	MPI tomographic (SPECT), multiple studies, rest and/or stress
78453	Myocardial perfusion imaging, planar, single study, at rest or stress
78454	Myocardial perfusion imaging, planar, multiple studies, rest and/or stress
+0742T	Absolute quantitation of myocardial blood flow (AQMBF), SPECT (list separately)

MPI CPT CodesCPTCovered

78451	MPI, tomographic (SPECT); single study, at rest or stress
78452	MPI, tomographic (SPECT); multiple studies, rest and/or stress
78453	Myocardial perfusion imaging, planar; single study, at rest or stress
78454	Myocardial perfusion imaging, planar; multiple studies, rest and/or stress
+0742T	Absolute quantitation of myocardial blood flow (AQMBF), SPECT, add-on

MUGA / Blood Pool / First Pass CodesCPTCovered

78472	Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress
78473	Cardiac blood pool imaging, gated equilibrium; planar, multiple studies
78494	Cardiac blood pool imaging, gated equilibrium, SPECT, at rest
78481	Cardiac blood pool imaging (planar), first pass technique; single study
78483	Cardiac blood pool imaging (planar), first pass technique; multiple studies
+78496	Right ventricular ejection fraction by first pass technique (add-on to 78472)

Myocardial sympathetic innervation (Category III)CPTExperimental

0331T	Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment (Category III)
0332T	Myocardial sympathetic innervation imaging, planar; with tomographic SPECT (Category III)

Obsolete Non-imaging Heart Function / Shunt CodesCPTNot Covered

78414	Non-imaging heart function (obsolete)
78428	Cardiac shunt imaging (obsolete)

Prior Authorization, Documentation, and Billing Actions

Prior Authorization

Prior authorization and clinical evaluation requirement

Prior authorization and adequate clinical evaluation are required for advanced cardiac imaging and selected procedures. Submit a pertinent clinical evaluation since onset or change in symptoms (history, physical exam, relevant labs, prior imaging) and objective data that demonstrate the imaging will affect management. Advanced imaging or designated procedures should not be ordered prior to clinical evaluation by the treating physician or consultant; meaningful technological contact (telehealth, phone, secure message) may substitute when appropriate. Exceptions exist for guideline-supported scheduled surveillance as described in condition-specific sections.

Include vital signs, height/weight or BMI, and statement of the clinical question to be answered.
Provide recent prior imaging and most recent stress test or ECG when relevant.
Document onset or change in symptoms and any objective findings (e.g., murmur, BNP, troponin).

Denial Risk

Overutilization triggers for denial

Frequency and Interval Guidance

Stress imaging — frequency

Stress imaging repeat intervalEvery 2 years

Applies toHistory of silent ischemia or asymptomatic ischemic ECG response when indicated

Modalities includedStress echocardiography, SPECT MPI, stress perfusion MRI, PET perfusion

Preoperative imaging stress test — timing

Preoperative stress imaging intervalWithin 1 year

When requiredHigh-risk surgery if no imaging within 1 year; intermediate-risk with risk factors if unable to perform ETT and no imaging within 1 year

Services Not Covered or Considered Investigational

MRI using Xenon Xe 129 (CPT C9791) is considered investigational/experimental and is not supported for coverage. In addition, PET/MRI is generally not supported as a routine modality; PET is typically performed as combined PET/CT and the unbundling of PET/CT into separate PET and diagnostic CT CPT codes is not supported. When PET/MRI is authorized as a substitute for PET/CT (rare), document that PET/CT criteria are met and PET/CT is unavailable at the treating institution.

Providers should follow standard PET and MRI guidance in the document for contrast, modality selection, and prior authorization expectations; requests for investigational imaging are subject to review and may be denied if not meeting evidentiary standards.

Coronary artery calcium scoring (CPT 75571) is not supported for evaluation of symptomatic coronary artery disease and is considered not appropriate when the individual has known CAD. CPT 75571 is intended for asymptomatic risk-stratification under narrowly defined eligibility criteria (see calcium scoring indications) and should not be used to evaluate or triage symptomatic patients.

Use of CPT 75571 for symptomatic CAD evaluation may trigger non-coverage and should be avoided; select an appropriate diagnostic pathway (for example CCTA or stress imaging) per the guideline when evaluating symptomatic individuals.

Transthoracic echocardiography (TTE) performed solely for population screening of asymptomatic individuals without a pertinent family history of cardiac, vascular, or related connective tissue disorders is not covered. TTE is the preferred initial modality when clinically indicated, but routine screening of the general asymptomatic public is not medically necessary.

Coronary CT plaque quantification (CPT 75577) is not medically necessary for screening or disease surveillance and is explicitly not indicated in unstable coronary syndromes, when performed in conjunction with invasive coronary catheterization, within 30 days of myocardial infarction, or when a completed CCTA documents Normal (CAD‑RADS‑0), CAD‑RADS 4 or 5, or high‑grade stenosis (>70%).

Contrast and Safety Considerations

Note

Background and Scope

These evidence‑based proprietary clinical guidelines evaluate advanced imaging modalities for cardiovascular conditions and are reviewed annually. They are based on national and international society guidance, peer‑reviewed literature, and expert input and are intended to guide—but not replace—physician judgment.

The guideline highlights modality‑specific coverage stances, definitions of investigational procedures, documentation and prior‑authorization expectations, and coding/cobundling rules to support consistent utilization management decisions.

Scope of guidelines

Scope of guidelinesEvidence-based clinical guidelines reviewing advanced imaging and procedures including NM, US, CT, MRI, PET, Radiation Oncology and selected interventions

PurposeGuide appropriate imaging selection and document-based medical necessity; not a substitute for clinical judgment

VersioningGuidelines reviewed annually as noted in document metadata

Investigational / Experimental

Definitions and Clinical Terms

Concurrent supervision (3D rendering)

Concurrent supervision definitionActive physician participation and monitoring of 3D reconstruction process including anatomic design, tissue/structure selection, image/cine loop archiving, and adjustment of the 3D work product

Applies to codesCPT 76376 and 76377 require documented concurrent supervision

Documentation expectationDocument physician's supervision or participation per ACR recommendation

Imaging guidance — billing and usage

Imaging guidance billing ruleGuidance procedure codes include all imaging necessary to guide a needle or catheter and should not routinely be billed with diagnostic procedure codes

Unit reporting

Policy Summary

PayerUnitedHealthcare

PolicyAdult Cardiac Imaging Guidelines (For Ohio Only)

Policy CodePolicy CSRAD003OH.E

Change TypeNo material change

Effective DateFeb 3, 2026

Next Review DateN/A

Key ActionSubmit pertinent clinical evaluation and prior imaging documentation to support medical necessity before ordering advanced cardiac imaging.

SourceLink

On This Page

When a prior CT Cardiac or MRI Cardiac was performed ≥1 year ago and updated anatomic assessment is needed

Use in accordance with Adult Congenital Heart Disease guidance (See Adult Congenital Heart Disease CD-11)

Requests may be denied for overutilization when less invasive or lower-cost alternatives were not considered, when duplicate or unnecessary studies are requested, or when imaging will not change clinical management. Review prior studies and use conventional imaging first when appropriate.

High-level testing without prior consideration of plain film, CT, MRI, or ultrasound.
Duplicate imaging when adequate recent studies exist.
CT "double contrast" studies and MRI ordered to avoid radiation without considering indication.

Denial Risk

Whole-body CT screening exclusion

Whole-body CT screening (LifeScan: brain, chest, abdomen, pelvis) for asymptomatic individuals is excluded from coverage and will be denied.

Exception: whole-body low-dose skeletal CT supported for oncologic staging in multiple myeloma per Oncology guidelines.

Documentation Required

Medical necessity tied to listed indications

Procedures must meet the listed medical-necessity indications in this guideline to be covered. Cardiac imaging is not medically necessary if results will not alter management (for example, when catheterization has already been planned). Follow condition-specific indication sections (e.g., heart failure/viability, stress testing, CCTA).

Heart failure/viability: new or worsening HF, LVEF <50% or decline ≥10%, or suspected ischemic ventricular dysfunction when revascularization is considered.
Stress testing: symptomatic patients who cannot undergo interpretable ETT or meet listed ECG/exercise exclusions.
CCTA: indicated per CCTA section (e.g., new cardiomyopathy with no prior invasive or alternative imaging).

Prior Authorization

Preoperative imaging requirement

Preoperative imaging for stable patients follows a two-step process: determine if the individual would qualify for imaging independent of surgery; if not, use surgical risk stratification to decide need. High-risk surgery generally requires imaging if no imaging within 1 year; intermediate-risk requires risk factors and inability to perform ETT.

If the individual qualifies for imaging independent of planned surgery, follow standard stress testing indications.
Low-risk surgery: pre-operative imaging is not medically necessary.
Document surgical risk category and prior imaging timing.

Prior Authorization

Pre-authorization and coding cautions

Pre-authorization requests may include multiple potential CPT codes when the final reported code is uncertain (for example congenital vs non-congenital echocardiography). Providers may be required to obtain prior authorization for specific add-on or 3D codes even when the base procedure does not require it.

It is acceptable to list multiple possible echocardiography codes (e.g., 93303, 93320, 93325, 93306) on pre-authorization when uncertainty exists.
3D rendering codes (76376/76377) may require separate prior authorization.

Denial Risk

Denial risk for unsupported repeat TTE

Repeat transthoracic echocardiography (TTE) requests that do not meet interval-based criteria or documented clinical change are at risk for denial. Routine surveillance outside specified intervals or without new/worsening signs or symptoms is not supported.

Examples of supported repeat timing: specific valve disease surveillance intervals (e.g., every 3 years for certain mild valve disease) or anytime with change in clinical status (e.g., new murmur, MI, new/worsening HF).
One repeat echo allowed for agitated saline/contrast if not given initially and initial results warrant it.

Denial Risk

Screening exclusions

Screening imaging in asymptomatic individuals is generally not covered unless specific guideline-supported indications or family history exist. Imaging for general population screening will be denied.

TTE is not medically necessary for screening asymptomatic individuals without family history of cardiac, vascular, or connective tissue disorders.
Coronary CTA plaque quantification is not medically necessary for screening or surveillance.

Billing Rule

Incorrect code combinations / hospital billing

Incorrect code combinations and hospital billing errors can trigger denials. Use CPT 93312 when both probe placement and image acquisition/interpretation are performed; do not report CPT 93313 and 93314 together. Do not bill attenuation correction separately with MPI; do not bill MUGA/first pass studies with MPI.

Hospitals should report TEE using CPT 93312 for the complete service.
Do not report CPT 75571 together with CPT 75572-75574.
First pass (78481/78483), MUGA (78472/78473), and SPECT MUGA (78494) should not be reported in conjunction with MPI codes (78451–78454).

Documentation Required

Use of 3D echocardiography (CPT 76376/76377)

3D rendering/echocardiography (CPT 76376, 76377) requires documented physician supervision or participation per ACR definitions. Concurrent supervision must be documented and include active physician involvement in reconstruction design, tissue selection, archived images, and monitoring/adjustment of the 3D work product.

76376: procedures not requiring an independent workstation. 76377: require independent workstation.
3D echo (76376/76377) may be medically necessary for LV volume/LVEF assessment affecting treatment decisions, mitral valve anatomy for stenosis, pre-procedural LAA occlusion planning, LVAD planning, and guidance for transcatheter procedures.
Documentation of physician supervision or participation is recommended.

Billing Rule

Bundling and mutually exclusive reporting

Bundling and mutually exclusive reporting rules apply: do not report MUGA/first pass studies with MPI; do not separately bill attenuation correction with MPI; only one cardiac CT code (75572–75574) may be reported per encounter; CPT 75571 (calcium scoring) is a stand-alone code and not to be reported with contrast CTA codes.

Only one code from CPT 75572–75574 per encounter.
CPT 75571 should not be reported with CPT 75572–75574.
Attenuation correction is included in MPI definitions; no additional code should be assigned.

Billing Rule

Use of unlisted procedure codes

When anatomic site–specific CPT codes are not available, report the appropriate unlisted CT/MR/nuclear unlisted code (76497, 76498, 78999) and include a full description. Use a Category III code if one exists instead of an unlisted code. Certain unlisted CT/MR codes are medically necessary for navigation, custom surgical planning, or when different acquisition parameters are required.

Report CPT 76497 for unlisted CT; CPT 76498 for unlisted MR; CPT 78999 for unlisted diagnostic nuclear medicine.
Provide detailed documentation describing why anatomic site-specific codes are unavailable and include a Category III code if applicable.

Documentation Required

Limited CT documentation expectations

Limited CT (CPT 76380) is intended for targeted or follow-up slices where full diagnostic CT work is not performed. Do not use CPT 76380 for treatment planning purposes or to report 'extra slices' in protocols; documentation must justify the limited/follow-up nature.

Examples: limited sinus protocol, follow-up slices through a known pulmonary nodule, limited slices for non-healing fracture.
Do not report 76380 in conjunction with full diagnostic CT codes to circumvent proper coding.

Documentation Required

Required patient data

Required patient data and clinical question must accompany imaging requests: include vital signs, height/weight/BMI or habitus, and a clear statement of the clinical question that the imaging will answer and how results will affect management.

Attach recent relevant laboratory data and prior imaging reports when available.
State whether results will change therapy, prompt invasive testing, or alter surgical planning.

Documentation Required

Heart failure / viability documentation

Documentation for heart failure or myocardial viability studies must support the indication: new or worsening heart failure; new LVEF <50% or decline ≥10%; or suspected ischemic ventricular dysfunction when revascularization is being considered. Specify modality chosen (MRI, PET, SPECT, dobutamine echo) and rationale.

For viability assessment, document symptoms, prior coronary anatomy/testing, and how results will influence revascularization decisions.
Include LVEF values, BNP or other relevant labs when available.

Billing Rule

Required coding documentation

Follow coding rules for complete vs limited studies and additive components. For example, CPT 93306 is a complete TTE including Doppler; do not separately report Doppler codes (93320–93325) with 93306. Use limited TTE codes when the study does not evaluate all required structures.

93306 includes Doppler and color flow mapping; use 93307 for 2D without Doppler and 93308 for limited TTE.
When congenital study is done, use congenital-specific codes (e.g., 93303, 93304) per guidance.

Documentation Required

Clinical status and timing documentation

Clinical status and timing must be documented for all repeat or surveillance imaging requests. Specify prior imaging dates, interval since prior study, changes in symptoms or exam, and any intervening therapies that would impact interpretation or management.

Indicate prior test type, date, and key findings that prompt the current request.
For surveillance, reference the guideline-supported interval or explain clinical rationale for deviation.

Documentation Required

Supporting clinical documentation for medical necessity

Supporting clinical documentation must demonstrate how the requested imaging will affect patient care decisions. Include prior diagnostics, how results will change therapy or procedural planning, and any contraindications to alternative modalities.

For CCTA in newly diagnosed cardiomyopathy: document no prior invasive angiography or alternative imaging (SPECT, PET, stress echo) since diagnosis, EF <50%, and absence of known CAD.
For MUGA: If used because echocardiography is limited or discrepant, provide documentation of technical limitation or discordant results and explain how quantitative LVEF will impact management (e.g., ICD candidacy, chemotherapy decisions).

Documentation Required

Clinical justification for MUGA

Clinical justification for MUGA studies must show why echocardiography is inadequate or discrepant and how the quantitative LVEF measurement will affect management decisions (e.g., device implantation, chemotherapy dosing). MUGA is not appropriate solely to repeat a prior MUGA.

Document prior ECHO limitations (technical or interpretive) or discrepant LVEF results.
Explain specific management decisions contingent on MUGA-derived LVEF.

Step 1: if patient qualifies independent of surgery follow standard indications; Step 2: determine surgical risk

TTE — repeat interval if negative

TTE negative repeat allowanceMay repeat every 2 years if negative (e.g., familial aortic disease screening when prior imaging negative)

ContextApplies to screening in certain connective tissue/genetic aortic disease contexts

ModalityTransthoracic echocardiogram (TTE, CPT 93306/93308)

TTE — interval for valvular disease and familial aortic disease

Valvular disease surveillance intervalEvery 3 years for specified valvular disease

Familial aortic disease screening intervalEvery 2 years for first-degree relatives with thoracic aortic aneurysm/dissection when prior imaging negative

Examples includedBicuspid aortic valve, mild aortic stenosis/sclerosis, mild mitral regurgitation, non-severe mitral stenosis

TTE — post-procedure and surveillance intervals

Post-procedure and surveillance intervalsSpecified per condition: surgical valve repair/mechanical valve replacement baseline at 6 weeks then every 3 years; bioprosthetic valve surveillance 6 weeks → every 3 years until 10 years → then annually; TAVR: 1 week, 1 month, 1 year, then annually; mitral clip: 1 month, 6 months, 1 year, then annually; LVAD and device-specific schedules as listed

Pulmonary hypertension surveillanceEvery 6 months for stable moderate/severe PH (PASP ≥50 mm Hg); 3 months after PH therapy change

Anytime repeatRepeat TTE anytime for new/worsening clinical signs or symptoms as documented

Stress Echocardiography — repeat timing

Repeat stress echo interval when prior provocable gradient <30 mm HgRepeat in 1–2 years

Earlier testing triggersWorsening symptoms or therapeutic change warrant earlier repeat testing

ModalitiesStress echocardiography (CPT 93350/93351) with spectral/color Doppler as needed

TEE / Echocardiography — LAA closure follow-up

LAA closure post-procedure imagingRoutine repeat imaging at 45 days post-procedure

Additional imaging before 1-year surveillanceIf 45-day study shows peri-device gap ≥5 mm or device-related thrombus, additional imaging (often at 3–6 months) is required before 1-year surveillance

Follow-up scheduleThen typically at 1 year post-procedure

CT (non-contrast calcium scoring) — frequency and radiation history

Initial asymptomatic CAC screening intervalNo prior calcium score performed in previous 5 years for initial asymptomatic screening

Radiation history ruleFor individuals with prior chest radiation, initial study should be ≥5 years since last RT; subsequent testing ≥5 years since last CT calcium scoring

Standalone codeUse CPT 75571 for non-contrast calcium scoring as a standalone study

CCTA — liver transplant pre-transplant repeat

Liver transplant pre-transplant CCTA repeat intervalMay be repeated once in 3 years

Indication contextCCTA used for pre-transplant coronary assessment per listed clinical scenarios

CodingCCTA reported with CPT 75574; only one of CPT 75572-75574 reported per encounter

CT Cardiac / TEE — post-ablation and device follow-up

Post-ablation CT timingPost-ablation CT between 3–6 months

Additional early follow-upIf 45-day imaging (TEE) shows peri-device gap ≥5 mm or device-related thrombus, obtain additional follow-up before 1 year

Relation to TEETEE findings at 45 days may prompt earlier CT or additional imaging as clinically indicated

Plaque quantification should be reserved for the limited, clinically defined situations described in the guideline where it will affect management; use outside those scenarios risks denial.

3D rendering post-processing codes (e.g., CPT 76376, 76377) should not be billed in conjunction with procedures that inherently produce or include 3D datasets or when explicitly disallowed by the guideline. Examples include imaging modalities and procedures such as CTA/CCTA, MRA, nuclear medicine SPECT/PET (including PET/CT), and stereotactic localization studies (e.g., CPT 77011 or CPT 70486) where the base study already provides volumetric/3D data or where 3D rendering is defined as not separately billable.

Physician documentation of concurrent supervision or participation is required when 3D rendering codes are used, but billing these codes where the dataset is inherently 3D or where the guideline disallows additional 3D charges is considered not covered.

Do not bill 3D rendering (CPT 76376, 76377) together with myocardial perfusion imaging (MPI) codes because attenuation correction and other required processing are included in MPI code definitions. 3D rendering is not a separately billable add-on with MPI and such billing may be denied as unbundled or duplicative.

When post-processing is clinically necessary for procedures that do not inherently include 3D datasets, document the clinical scenario and physician participation per the guideline; otherwise 3D rendering charges are not supported.

3D rendering should not be billed with stereotactic localization procedures (for example CPT 77011 or CPT 70486) because such procedures inherently generate a 3D dataset used for navigation and planning. Reporting 3D rendering codes in these contexts is considered duplicative and is not covered.

Ensure coding reflects whether the post-processing represents distinct additional work beyond the dataset generated by the billed procedure; when it does not, do not report separate 3D rendering CPTs.

3D rendering codes are not appropriate when billed with CTA/MRA studies where the primary reportable code already includes post-processing and 3D reconstructions. Billing 3D rendering in these scenarios is considered an unbundled charge and is not covered under the guideline.

When 3D processing is essential for surgical planning and is not included in the primary procedure definition, document the necessity and physician participation; otherwise separate 3D charges will be disallowed.

3D rendering billed together with PET, PET/CT, or PET/MRI studies is generally not supported because the combined modality reporting and required corrections are included in the nuclear medicine procedure definitions. Separate 3D rendering charges in these contexts are considered not covered.

If a provider believes an exception applies, prior authorization and explicit documentation of clinical need and physician involvement in the reconstruction process are required.

3D rendering codes should not be billed with breast MRI, breast ultrasound, CT colonography, or other imaging studies where the primary procedure inherently includes the reconstructions or where specific guidance disallows additional 3D billing. Such billing is considered duplicative and will not be supported.

Follow the guideline’s coding examples and physician documentation requirements for any allowed 3D rendering use to avoid denials for unbundled services.

3D rendering should not be reported in conjunction with MUGA/first‑pass studies or when attenuation correction is included in the primary nuclear code; reporting separate 3D or attenuation correction charges with MPI or blood pool studies is not appropriate and may be denied.

When post-processing beyond the routine scope of the billed nuclear procedure is required, obtain prior authorization and provide documentation of the additional work performed and physician oversight.

Other investigational items noted in the guideline include MRI using Xenon Xe 129 (CPT C9791) and certain Category III investigational echocardiography codes; these items are considered experimental/investigational and are not supported for coverage. Providers submitting requests for such services should expect medical‑necessity review and likely denial unless compelling evidence and prior authorization criteria are met.

Requests for services stated as investigational or unproven will be evaluated per Ohio administrative rules and the guideline’s investigational policy language; include supporting evidence when requesting review.

Investigational/Experimental definitionStudies, treatments, procedures, or devices considered investigational when supporting evidence is lacking, clinical utility not demonstrated, or collective opinion of support absent

Examples notedPET/MRI generally not supported for many oncologic/neurologic conditions unless criteria met; certain CPT Category III codes listed as investigational

ImplicationInvestigational status may trigger medical necessity review or non-coverage per plan rules

Pediatric imaging routing

Pediatric routingIndividuals ≤18 years follow Pediatric Imaging Guidelines when addressed; otherwise follow General Imaging Guidelines

Adult routingIndividuals >18 years follow General Imaging Guidelines unless a condition-specific section directs otherwise

DocumentationPediatric-specific condition differences may require different imaging or documentation as noted in pediatric sections

Only one unit of a guidance code should be reported per encounter

Appropriate useGuidance codes intended for percutaneous procedures and inappropriate with open/excisional surgical codes

Quantitative multiparametric MRI (mp-MRI)

mp-MRI mentionQuantitative multiparametric MRI (mp-MRI) methods and Category III codes referenced for quantitative analysis

Use contextSee condition-specific guidelines for criteria associated with quantitative mp-MRI

Coding noteCategory III CPT codes exist for quantitative mp-MRI analysis

WBMRI — coding availability

WBMRI codingWhole-body MRI currently reportable only using CPT 76498

Evidence stanceWBMRI generally not supported except select cancer predisposition syndromes and limited conditions

Technique variabilitySubstantial variation exists in sequences, image number, and contrast use

Acute chest pain

Acute chest pain definitionNew onset (<2 months) or change in pattern, intensity, or duration compared with previous episodes

Associated termsIncludes angina pectoris, anginal equivalents, and ACS considerations

RelevanceUsed to determine need for urgent or advanced cardiac imaging

CAD-RADS

CAD-RADS categoriesCAD-RADS 0 = 0%; 1 = 1–24%; 2 = 25–49%; 3 = 50–69%; 4 = 70–99% or ≥50% left main; 5 = 100% total occlusion

UseStandardized reporting framework for CCTA to inform management

Related thresholdModerate stenosis (CAD-RADS 3) defined as 50–69%

Abnormal ETT and target heart rate

Abnormal ETT criteriaST depression ≥1.0 mm (horizontal/downsloping), development of chest pain, drop in systolic BP >10 mmHg, non-sustained VT ≥3 beats >100 bpm, or sustained VT

Target heart rate for adequate ETT85% of age-predicted maximum heart rate (MPHR = 220 - age)

Functional capacity threshold>=5 METs considered adequate functional capacity

Imaging Stress Tests

Imaging stress tests includedStress echocardiography, SPECT MPI, stress perfusion MRI, PET perfusion

Stress methodsExercise or pharmacologic stress are acceptable; CPT codes unchanged by stress type

Representative CPTsStress echo CPTs 93350/93351; SPECT MPI 78451-78454; PET MPI 78430/78431/78491/78492

Moderate coronary stenosis (CAD-RADS 3)

Moderate coronary stenosis definitionCAD-RADS 3: 50–69% coronary stenosis

Clinical implicationFunctional assessment (stress imaging or FFR-CT) may be indicated for intermediate lesions

ReferenceGeneral Guidelines CD-1.0 definitions applied

ETT adequate target

ETT target heart rate85% of maximum age-predicted heart rate (220 - age)

Alternate adequacyAchieving ≥5 METs is considered adequate functional capacity

When ETT preferredIf patient can perform and ECG interpretable, ETT without imaging is preferred

Complete and Limited TTE — coding

Complete TTE (CPT 93306)TTE with 2-D, M-mode, Doppler and color flow; includes Doppler exams so CPT 93320-93325 should not be assigned together with 93306

Limited TTE (CPT 93308)Reported when study does not evaluate or document attempted evaluation of all required structures; may be used with certain add-on Doppler codes

Coding cautionUse appropriate CPT based on completeness and components performed

Limited TTE (CPT 93308) — definition

Limited TTE definition (CPT 93308)Limited transthoracic echocardiogram reported when the study does not evaluate or document attempted evaluation of all required structures

Use with DopplerCPT 93325 can be reported with 93308 if color flow Doppler included; CPT 93321 not used with 93308 if Doppler included

Coding implicationSelect limited vs complete code based on documented components

Frequent ventricular premature complexes / PVC burden

Frequent VPCs/PVCs thresholdMore frequent than 30 times per hour (diagnostic); surveillance thresholds may use >10,000 PVCs/24 hours or >10% PVC burden

Clinical useTriggers evaluation including TTE for LV dysfunction or arrhythmia assessment

Related surveillanceHigh PVC burden used in surveillance criteria for repeat imaging

TTE — definition

TTE definitionTransthoracic echocardiogram: ultrasonic examination of the heart through the chest wall using sonography

Radiation/contrast noteTTE uses ultrasound — no ionizing radiation and no contrast-induced nephropathy concern

Primary rolePrimary imaging tool for initial cardiac evaluation and family screening for thoracic aortic disease

TEE — definition and uses

TEE definitionTransesophageal echocardiography: semi-invasive ultrasonic exam via the esophagus providing improved visualization of cardiac structures compared with TTE

UsesUsed for endocarditis, intracardiac masses, LAA thrombus evaluation prior to cardioversion/ablation, pre-procedural planning

ContrastTEE does not require IV contrast; relative/absolute contraindications (esophageal pathology, coagulopathy) should be considered

3D echocardiography — description

3D echocardiography descriptionEchocardiography with three-dimensional rendering and post-processing used for detailed assessment of cardiac structures and pre-procedural planning in select cases

CodesCPT 76376/76377 for rendering; +93319 for 3D echo add-on during TTE/TEE in congenital cases

Utility note3DE utility remains limited per literature and should be reserved for listed indications

Myocardial strain imaging

Myocardial strain imaging (CPT 93356)Adjunct ultrasound technique measuring myocardial deformation (longitudinal strain) to detect subclinical LV dysfunction and assess myocardial mechanics

IndicationsInitial LVH evaluation when etiology unclear and concern for infiltrative cardiomyopathy; transplant surveillance; cardiotoxic therapy monitoring

Radiation/contrastUltrasound-based — no ionizing radiation or contrast nephropathy risk

MPI and MUGA — codes and notes

MPI (SPECT/planar) codesSPECT MPI CPTs 78451-78454; planar 78453-78454; includes attenuation correction

MUGA codesGated equilibrium and first pass CPTs 78472-78473, 78481-78483, 78494; do not report MUGA with MPI codes

AQMBF statusAbsolute quantitation of myocardial blood flow (AQMBF) CPT +0742T considered experimental/investigational