CurrentUnitedHealthcarePolicy CSRADOO6OH.D

Adult Head Imaging Guidelines (For Ohio Only)

Clinical coverage and appropriateness criteria for advanced head imaging modalities for adult members in Ohio under UnitedHealthcare Community Plan; governs medical necessity determinations and requests for services in Ohio.

Policy Summary

PayerUnitedHealthcare

PolicyAdult Head Imaging Guidelines (For Ohio Only)

Policy CodePolicy CSRADOO6OH.D

Change TypeNo material changes

Effective DateNov 1, 2025

Next Review Date

Key ActionSubmit adequate clinical information and relevant prior imaging when requesting advanced head imaging; prior authorization may be required for designated advanced procedures such as amyloid PET and 3D rendering.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-11-01effective date

V1.0.2025document version

381pages

70551/70553primary MRI CPTs

76498WBMRI report code

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.

multiplekey codes referenced

Coverage and Appropriateness Criteria

Covered Imaging Criteria

Covered imaging criteria describe common supported studies and clinical scenarios where advanced imaging is appropriate. These criteria consolidate modality-specific guidance and condition-specific indications to help determine the most appropriate study for the clinical question. Studies should be expected to impact patient management and be supported by a pertinent clinical evaluation (history, exam, and relevant prior studies).

ALL of the following

A pertinent clinical evaluation (history and physical exam, including neurologic exam when applicable) or documented meaningful technological contact (telehealth, telephone, electronic messaging) since onset or change in symptoms is present.
Clinical documentation includes the presenting signs/symptoms, duration and time course, prior relevant imaging or laboratory results, and how the requested imaging will affect management or treatment decisions.
For individuals ≤18 years, follow Pediatric Imaging Guidelines when specified; otherwise, follow General Imaging Guidelines for adults (>18 years).
Advanced imaging should not be ordered for routine surveillance or data collection alone; it is supported when the result is expected to change clinical management or is required for pre-procedural/surgical planning as described in condition-specific sections.
When two studies using the same modality both cover the anatomic region of clinical interest, only one is generally supported unless specific exceptions apply (for example dedicated pituitary protocol after a routine brain MRI, or simultaneous evaluation of anatomically distinct regions as described in anatomic guidance).
Selection of modality (MRI vs CT vs Ultrasound vs Nuclear) should follow modality-specific advantages, contraindications, and the guidance in condition-specific sections (e.g., MRI preferred for soft tissue evaluation; CT preferred when MRI contraindicated or for acute trauma).

Modality-specific Appropriate Uses

Codes and Reporting Guidance

Experimental/Investigational CPTCPTExperimental

C9791

MRI utilizing Xenon Xe 129 (listed as CPT C9791) considered investigational

3D Rendering CPT CodesCPT

76376	3D rendering (not requiring independent workstation)
76377	3D rendering (requiring independent workstation)

Guidance and breast biopsy codesCPT

19085	Biopsy, breast; with placement of breast localization device(s), percutaneous; first lesion, including MR guidance
19086	Biopsy, breast; with placement of breast localization device(s), percutaneous; each additional lesion, including MR guidance
77021	MR guidance for needle placement
77012	CT guidance for needle placement

Imaging guidance procedure codesCPT

75989	Imaging guidance for percutaneous drainage with placement of catheter
76942	Ultrasonic guidance for needle placement
77011	CT guidance for stereotactic localization
77013	CT guidance and monitoring of parenchymal tissue ablation
77022	MR guidance for and monitoring of parenchymal tissue ablation
77002	Fluoroscopy guidance (one of codes referenced)
77003	Fluoroscopy guidance (one of codes referenced)

Unlisted procedure codesCPT

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

Limited CT codeCPT

76380

Limited or follow-up CT

SPECT/CT and hybrid nuclear/CT codesCPT

78072	SPECT/CT parathyroid nuclear imaging (effective Jan 1, 2013)
78830	Hybrid Nuclear/CT scan (single area single day)
78831	Hybrid Nuclear/CT scan (2 or more days)
78832	Hybrid Nuclear/CT scan (2 areas with one day and 2-day study)

Outside study interpretationCPT

76140

Interpretation of an outside study

Quantitative MR analysis (Category III) codesCPTExperimental

0648T	Quantitative mp-MRI analysis without diagnostic MRI (single organ)
0649T	Quantitative mp-MRI analysis with diagnostic MRI (single organ)
0697T	Quantitative mp-MRI analysis without diagnostic MRI (multiple organs)
0698T	Quantitative mp-MRI analysis with diagnostic MRI (multiple organs)
0865T	Volumetric/quantitative MRI analysis of the brain (Category III)
0866T	Volumetric/quantitative MRI analysis of the brain (Category III)

Interpretation of Outside StudyCPTCovered

76140

Interpretation of an Outside Study

Whole-Body MRI reportingCPT

76498

Whole-body MRI

HCPCS examplesHCPCS

S8042	MRI; low field (example of non-specific HCPCS code)
C8931	MRA with dye, Spinal Canal (example HCPCS)

Covered CPT Codes (examples referenced in text)CPTCovered

70551	MRI Brain without contrast
70552	MRI Brain with contrast
70553	MRI Brain without and with contrast
70450	CT Head without contrast
70460	CT Head with contrast
70470	CT Head without and with contrast
70540	MRI Orbit/Face/Neck (IAC views / limited sets referenced)
70486	CT Maxillofacial
70544	MRA Head without contrast
70545	MRA Head with contrast

1–10 of 21

1/3

Covered CPT Codes and 3D renderingCPTCovered

76376	3D rendering not requiring image post-processing on an independent workstation
76377	3D rendering requiring image post-processing on an independent workstation
70551	MRI Brain without contrast
70553	MRI Brain without and with contrast
70540	MRI Orbit/Face/Neck without contrast
70543	MRI Orbit/Face/Neck without and with contrast
70486	CT Maxillofacial (specific CPT series: 70486)
70487	CT Maxillofacial (specific CPT series: 70487)
70488	CT Maxillofacial (specific CPT series: 70488)
70450	CT Head without contrast

1–10 of 17

1/2

Supported MRI Brain CodesCPTCovered

70553	MRI Brain without and with contrast
70551	MRI Brain without contrast

Supported CT Head Codes (acute/trauma/mental status change)CPTCovered

70450

CT Head without contrast

Supported MRI Spine CodesCPTCovered

72141	MRI Cervical Spine without contrast
72156	MRI Cervical Spine without and with contrast
72146	MRI Thoracic Spine without contrast
72157	MRI Thoracic Spine without and with contrast
72148	MRI Lumbar Spine without contrast
72158	MRI Lumbar Spine without and with contrast

Unlisted CTCPT

76497

unlisted CT procedure code

PET imagingmixedNot Covered

PET	Positron emission tomography (modalities abbreviated)

Imaging codes cited for basilar impression/invaginationCPT

70551	MRI Brain without contrast
72141	MRI Cervical Spine without contrast
70450	CT Head without contrast
72125	CT Cervical Spine without contrast
70544	MRA Head without contrast
70546	MRA Head without and with contrast
70496	CTA Head
70547	MRA Neck without contrast
70548	MRA Neck with contrast
70549	MRA Neck without and with contrast

1–10 of 11

1/2

Imaging codes cited for platybasiaCPT

70551	MRI Brain without contrast
70450	CT Head without contrast
70496	CTA Head
72125	CT Cervical Spine without contrast
70498	CTA Neck
70544	MRA Head without contrast
70545	MRA Head with contrast
70546	MRA Head without and with contrast
70548	MRA Neck with contrast
70549	MRA Neck without and with contrast

Supported cross-sectional imaging (CT/MRI)CPTCovered

70551	MRI Brain without contrast
70553	MRI Brain without and with contrast
70450	CT Head without contrast

PET procedure codesCPT

78608	FDG PET metabolic brain studies
78609	PET Brain perfusion studies (non-FDG)
78811	Amyloid Brain PET (limited PET)
78814	Amyloid Brain PET (limited PET/CT)

inv-125: GFR — high risk threshold for contrast

High-risk renal threshold for contrastGFR <30 mL/min (considered high risk for contrast-related issues)

Contrast risk noteGadolinium and iodinated contrast carry increased risk in low GFR; consider non-contrast studies or alternative modality

Prior Authorization, Documentation, and Billing Actions

Denial Risk

Ohio Medical Necessity Evaluation and Denial Risks

This Medical Policy applies to Ohio. Requests for services that are unproven or subject to coverage/quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01. Requests may be denied for lack of adequate clinical information, duplicate exams, or if the study is questionably indicated. Review prior imaging and procedural history before ordering advanced studies; duplicate studies covering the same anatomic region are generally not supported.

Application (Ohio only): Evaluate unproven services per Ohio Administrative Code 5160-1-01.
Denial triggers: Inadequate documentation, duplicate exams, or non‑indicated studies.

Prior Authorization

Prior Authorization and History Review

Prior authorization may be required for specific procedures. Preauthorization is expected when the procedure is designated by the plan. Even when the underlying modality does not require prior authorization, CPT 76376 and 76377 (3D rendering) may require prior authorization. Requests for PET brain imaging (including Amyloid PET CPT 78811/78814) require prior authorization and must include required clinical documentation.

Prior Authorization Expectations

Note

Surveillance and Repeat Imaging Intervals

inv-269: MRI/CT — Repeat imaging is individualized

Repeat imaging policyRepeat imaging is individualized; decisions based on clinical context and specialist input

Documentation expectationPertinent clinical evaluation and documentation required prior to repeat advanced imaging except in specified follow-up scenarios

Avoid duplicate modalitiesOrdering two studies using same modality that cover same anatomic region is generally not needed

inv-270: MRI, Amyloid PET — Imaging prior to specified infusions and periodic monitoring (e.g., donanemab/lecanemab schedules)

Pre-therapy baseline imagingBaseline MRI Brain (within 3 months) and/or Amyloid PET (CPT 78811/78814) are required prior to initiating amyloid‑reducing therapy

On‑therapy MRI schedule (donanemab)

Contrast Use and Safety Considerations

Note

Not Medically Necessary / Exclusions

The following modalities and procedures are generally not supported: PET‑MRI for routine oncologic or neurologic indications except in narrowly specified circumstances when PET‑CT is unavailable and condition‑specific criteria are met; MRI using Xenon Xe 129 (CPT C9791) is considered investigational; and quantitative/volumetric brain MRI analyses (Category III CPTs such as 0865T/0866T) are not medically necessary for routine clinical practice and are limited to research use.

Routine CT of the orbit performed solely to screen for metallic fragments prior to MRI is rarely necessary and is not supported as standard practice. Initial screening should be performed with plain X‑ray (two views), which is generally sufficient; CT increases radiation exposure and is reserved for specific clinical indications.

Quantitative volumetric MRI analyses (e.g., CPT 0865T/0866T) and similar Category III quantitative MR procedures are considered investigational or not medically necessary for routine clinical use due to insufficient specificity and sensitivity. Likewise, routine use of Amyloid PET for diagnosis or screening is not medically necessary except when explicitly required as part of evaluation for amyloid‑reducing therapy per the policy criteria.

Abdominal surveillance imaging for ventriculoperitoneal (VP) shunts in asymptomatic individuals is not indicated. Abdominal complications of VP shunts are typically symptomatic; imaging of the abdomen (e.g., ultrasound) should be reserved for clinical signs or specialist‑directed evaluation.

Advanced imaging is not indicated for newly diagnosed migraine or tension‑type headache when the neurologic examination is normal, nor for chronic stable migraine without red flags. Imaging should be reserved for patients with atypical features or specified 'red flag' signs that suggest secondary pathology.

Scope, Evidence, and Guideline Context

These evidence‑based clinical guidelines evaluate a broad range of advanced imaging modalities and procedures across adult head imaging indications, including nuclear medicine (PET, SPECT), ultrasound, CT, and MRI. The guidance is intended to support selection of the most appropriate imaging test for a given clinical scenario and to promote patient safety and quality of care.

Key Terms and Definitions

inv-197: Investigational/Experimental — defined examples and usage

Investigational/Experimental definitionCertain studies, procedures, or devices are investigational/experimental when evidence is insufficient, clinical utility not demonstrated, or lacking collective professional support

ExamplesMRI utilizing Xenon Xe 129 (CPT C9791) and Category III quantitative mp‑MRI codes are listed as investigational/experimental

Implication for coverageInvestigational/experimental services are not supported for routine clinical management and may be excluded from coverage

inv-203: WBMRI definition

WBMRI definitionWhole‑Body MRI (WBMRI) is a comprehensive MRI covering multiple body regions and is reportable only with CPT 76498

Evidence limitation

Document Version and Effective Dates

2025-11-01policy_effective_dateLatest

Policy version V1.0.2025 becomes effective for Ohio; Effective: November 1, 2025 is stated repeatedly throughout the document.

V1.0.2025version_release

Document/version identifier published as V1.0.2025 and referenced throughout the guideline metadata and preface.

Policy Summary

PayerUnitedHealthcare

PolicyAdult Head Imaging Guidelines (For Ohio Only)

Policy CodePolicy CSRADOO6OH.D

Change TypeNo material changes

Effective DateNov 1, 2025

Next Review Date

SourceLink

On This Page

NSF riskGadolinium exposure in low GFR increases risk of Nephrogenic Systemic Fibrosis

Modality substitutionCT may be approved in place of MRI when MRI contraindicated; match contrast level when substituting (e.g., MRI without contrast -> CT without contrast)

inv-126: WBMRI reporting — report with CPT 76498

WBMRI reporting codeWhole‑Body MRI must be reported using CPT 76498 only

Standardization limitationWBMRI currently lacks standardized technique and broad outcome evidence; generally not supported except select indications

ExceptionsInterval WBMRI may be recommended for select cancer predisposition syndromes (e.g., Li‑Fraumeni, NF, HPP)

inv-127: TMJ MRI reporting — CPT 70336 bilateral rule

TMJ MRI billing ruleCPT 70336 (TMJ MRI) is inherently bilateral and should not be reported twice on the same date of service

Use guidanceReport TMJ studies with single CPT 70336 even when both joints imaged

Avoid duplicate codesDo not pair IAC/brain MRI codes with TMJ code when TMJ views are part of another brain study unless separate clinical indication

inv-128: Fragment detection size (X-ray vs CT)

Plain X‑ray detection thresholdPlain X‑ray detects metallic fragments ≥0.12 mm

CT detection thresholdCT detects metallic fragments ≥0.07 mm

Pre‑MRI screening recommendationInitial screening for orbital metallic fragments should be with plain X‑ray (2 views); CT orbital rarely necessary

inv-129: Duration of cognitive decline for established dementia (>= 6 months)

Required duration for established dementiaDocumented cognitive decline ≥ 6 months is required to establish dementia for imaging consideration

Alternate evidenceAbnormal bedside or neuropsychological testing (eg, MMSE<26 or MoCA<26) may substitute when history/exam insufficient

Documentation componentsRecords must include date of onset, detailed history, and exclusion of alternative causes

inv-130: Baseline MRI timing (within 3 months of medication initiation)

Baseline MRI timing for amyloid therapyBaseline MRI Brain must be obtained within 3 months of medication initiation

Acceptable MRI codesMRI Brain without contrast (CPT 70551) OR MRI Brain without and with contrast (CPT 70553) are supported as baseline studies

Amyloid PET roleAmyloid PET (CPT 78811/78814) may be used in conjunction with baseline MRI to confirm amyloid when indicated for therapy consideration

Prior authorization may be required for CPT 76376/76377 even if base modality is not preauthorized.
Amyloid Brain PET (CPT 78811/78814) requires prior authorization with supporting clinical documentation.

Documentation Required

Documentation for 3D Rendering and Outside Study Interpretation

Document the physician's active, concurrent participation when supervising 3D post‑processing (CPT 76376/76377). Include the design of the anatomic region reconstructed, determination of tissue types/structures to display, images/cine loops archived, and monitoring/adjustment of the 3D work product. Use CPT 76140 for secondary interpretation of outside studies and document that CPT 76140 was used. Do not bill diagnostic imaging CPTs to interpret studies performed elsewhere.

Physician documentation for 3D rendering: describe concurrent supervision/participation and workstation use (if applicable).
Use CPT 76140 when interpreting outside exams; document usage in the medical record.

Documentation Required

Required Clinical Evaluation Prior to Imaging

A pertinent clinical evaluation (detailed history, neurological exam since onset/change in symptoms, and appropriate labs) should be performed prior to ordering advanced imaging except for guideline‑supported scheduled follow‑up imaging. Telehealth or other meaningful contact since symptom onset can substitute when allowed. Failure to perform or document a detailed clinical evaluation may lead to denial.

Required clinical evaluation: detailed history, neurologic exam, and relevant labs prior to advanced imaging.
Exceptions: scheduled guideline-supported surveillance or when a specialist has already evaluated the patient.
Telehealth/other meaningful contact is acceptable in many scenarios.

Prior Authorization

Provider Action When Surgery Is Being Considered for Basilar Conditions

When surgery is being considered for basilar impression, basilar invagination, or platybasia, additional imaging beyond MRI Brain and MRI Cervical may be required for surgical planning: CT Head and CT Cervical Spine (without contrast) and vascular imaging (MRA or CTA Head and Neck) are indicated. Document that surgery is being considered and include the requested pre‑surgical imaging in the request.

If surgery is being considered: include CT Head (CPT 70450) and CT Cervical Spine (CPT 72125) without contrast and vascular imaging (MRA Head CPT 70544/70545/70546 or CTA Head CPT 70496; MRA Neck CPT 70547/70548/70549 or CTA Neck CPT 70498).
One-time screening of first‑degree relatives with MRI Brain without contrast is supported for basilar conditions.

Documentation Required

Documentation for Amyloid‑Reduction Therapy Imaging

For consideration of amyloid‑reducing therapy, provide medical records supporting a diagnosis of MCI due to Alzheimer's disease or early Alzheimer's dementia, including detailed history, date of onset, cognitive decline documentation (6 months), bedside or neuropsychological testing results, and exclusion of alternative causes (DLB, FTD, vascular dementia, B12 deficiency, untreated thyroid disease, TBI, encephalopathy, mood disorder). Baseline MRI brain within 3 months of medication initiation (MRI Brain CPT 70551 or 70553) and/or Amyloid PET Brain (CPT 78811 or 78814) are required as supported imaging. During therapy, follow-up MRI schedules and imaging for ARIA should be performed per treating neurologist and documented.

Required documentation: date of onset, 6 months of documented cognitive decline, detailed history, mental status testing, and exclusion of alternative diagnoses.
Supported baseline imaging for amyloid‑reduction therapy: MRI Brain (CPT 70551 or 70553) within 3 months of initiation and/or Amyloid PET (CPT 78811/78814).
On-treatment imaging: MRI monitoring for ARIA per treating neurologist; follow MRI timeframes and document neurologic signs/symptoms during treatment.

Documentation Required

Documentation for Dissection and Vascular Imaging

For suspected arterial dissection or vascular causes of headache, include detailed vascular imaging indications and relevant clinical documentation. For carotid or vertebral artery dissection suspicion, order CTA Head (CPT 70496) or MRA Head (CPT 70544/70545/70546) and CTA/MRA Neck as indicated; document sudden unilateral headache, Horner syndrome, high‑risk scenarios, or traumatic mechanism. For dissection imaging requests, include symptom onset, focal findings, and any high‑risk history.

Dissection imaging documentation: sudden onset unilateral headache, ipsilateral Horner's, high‑risk history (FMD, Marfan, trauma, chiropractic manipulation), and indication for CTA/MRA Head and Neck.
If both arterial and venous studies are performed in one session, report only one CPT code.

Documentation Required

Documentation for CSF Leak Evaluation and Shunt Imaging

For evaluation of suspected CSF leak or shunt malfunction, document the clinical indication and ordering consultant. Repeat or post‑operative shunt imaging should be ordered by or in consultation with a neurologist, neurosurgeon, or other appropriate specialist. For suspected CSF pseudocyst or distal shunt outlet obstruction, abdominal ultrasound (CPT 76700) may be indicated. Include symptoms (e.g., altered consciousness, vomiting, visual/neurologic decline) and prior shunt details in the request.

CSF leak/shunt documentation: ordering/coordination by neurologist, neurosurgeon, or provider in consultation with them.
Post‑operative and repeat shunt imaging: MRI Brain without contrast (CPT 70551) or CT Head without contrast (CPT 70450); follow-up imaging 6–12 months after procedure and then annually if stable.
Abdominal ultrasound (CPT 76700) for suspected distal shunt complications.

Documentation Required

Clinical Indication and Consultant Request

Clinical indication and consultant request must be clearly documented on imaging requests. When a specialist (neurologist, neurosurgeon, neuro‑ophthalmologist, endocrinologist, ENT, ophthalmologist, or other listed specialist) has evaluated the individual since symptom onset, that may satisfy the requirement for a detailed neurological exam. Requests lacking consultant involvement or clear clinical indication risk denial.

Document the clinical indication (symptoms, onset, prior treatment) and any consultant specialist who has evaluated the patient.
Specialist evaluation since symptom onset can substitute for a new detailed neurologic exam in many scenarios.

Billing Rule

Whole‑Body CT/MRI Use and Coding

Whole‑body CT for asymptomatic screening is not supported. Whole‑body low‑dose CT is supported only for oncologic staging in Multiple Myeloma per the Oncology Imaging Guidelines. Whole‑body MRI is generally not supported except in select cancer predisposition syndromes or specific autoimmune conditions; when WBMRI is used, CPT 76498 is the appropriate code.

Whole‑body CT: not indicated for asymptomatic screening; supported low‑dose whole‑body CT only for Multiple Myeloma staging.
Whole‑body MRI: generally not supported; report using CPT 76498 when appropriate.
Do not use non‑specific HCPCS codes (e.g., S8042) in place of specific CPT codes.

MRI brain prior to 2nd, 3rd, 4th, and 7th infusions; follow-up amyloid PET at 6, 12, and 18 months as specified

On‑therapy MRI schedule (lecanemab)MRI brain prior to 5th, 7th, and 14th infusions; post‑treatment amyloid PET at 18 months as specified

Symptom-driven imagingNeurologic signs or symptoms on therapy: CT Head without contrast (CPT 70450) OR MRI Brain (CPT 70551/70553)

inv-271: MRI Brain or CT Head — Post-operative follow-up at 6-12 months after shunt placement then every 12 months for stable clinical findings

Post‑op shunt follow-up intervalInitial post‑operative imaging after shunt placement or ETV, then follow‑up at 6–12 months and annually thereafter for stable clinical findings

Preferred modalitiesMRI Brain without contrast (CPT 70551) or CT Head without contrast (CPT 70450) for post‑operative and surveillance imaging

Specialist orderingRepeat imaging requests should be ordered by or in consultation with neurologist/neurosurgeon where applicable

inv-272: CTA Head or MRA Head — Screening every 5 years for high-risk individuals

Screening interval for high‑risk individualsScreening every 5 years for high‑risk populations (eg, ≥2 first‑degree relatives with cerebral aneurysm/SAH; ADPKD screening age 20–65 every 5 years)

Supported imaging modalitiesCTA Head (CPT 70496) OR MRA Head (CPT 70544/70545/70546) are supported for screening and surveillance

Initiation ageScreening usually begins at age 20 unless unusual circumstances

inv-273: MRI Brain — Annual (where specified)

Annual imaging for select syndromesAnnual MRI Brain surveillance is supported for certain conditions (eg, MOPD II) where specified

Supported MRI codesMRI Brain without contrast (CPT 70551) OR MRI Brain without and with contrast (CPT 70553)

Specialist requestImaging often performed at diagnosis and repeated annually when confirmed by genetic testing or specialist request

inv-274: CT or MRI — Repeat imaging considered on a case-by-case basis for change in neurologic symptoms or when requested by specialist

Repeat imaging case‑by‑caseRepeat CT or MRI is considered on a case‑by‑case basis for changes in neurologic symptoms or when requested by a specialist

Specialist coordinationRepeat imaging should be requested/coordinated by or approved by an infectious disease specialist, neurologist, neurosurgeon, or radiologist when applicable

Scope of repeat imagingRepeat imaging may refer to any of the CPT codes listed for initial imaging depending on clinical question

Routine imaging in low‑risk individuals without listed indications or red flags is not supported because the low diagnostic yield and the risk of incidental findings outweigh benefits. Imaging and surveillance should be limited to the specified high‑risk conditions or when clinical features indicate further evaluation.

Advanced or investigational functional and physiologic imaging modalities — including SPECT, FDG‑PET/CT brain, CT/MR perfusion, MR spectroscopy (MRS), functional MRI (fMRI), and diffusion tensor imaging (DTI) — are considered research tools and are not supported for routine evaluation of head trauma. These techniques lack sufficient evidence to change standard clinical management in the typical head‑injury population.

WBMRI lacks standardized technique and broad outcome evidence and is generally not supported except for select cancer predisposition syndromes

Reporting restrictionOther methods of reporting WBMRI (multiple individual MRI codes) are inappropriate

inv-205: PET coding (78608, 78811, 78814)

PET coding examplesMetabolic Brain PET = CPT 78608; Amyloid Brain PET = CPT 78811 (limited PET) or CPT 78814 (limited PET/CT)

PET use noteAmyloid PET is limited to evaluation when used for amyloid‑reducing medication treatment decisions; other PET types (eg, FDG PET 78608) have specific diagnostic roles

Reporting guidanceUse appropriate PET CPT codes for metabolic vs amyloid PET studies as specified

inv-206: Imaging preference — MRI preferred over CT except in acute trauma

Modality preferenceMRI is preferred over CT for most indications due to superior visualization of posterior fossa and cerebellum; CT preferred in acute trauma or when MRI contraindicated

Exception examplesCT Head without contrast (CPT 70450) is preferred for acute head trauma per decision rules

Modality substitution guidanceWhen MRI contraindicated, CT may be used and contrast level should be matched appropriately

inv-215: ARIA — Amyloid Related Imaging Abnormality definition

ARIA definitionAmyloid Related Imaging Abnormality (ARIA) includes ARIA‑E (edema/sulcal effusion) and ARIA‑H (microhemorrhage/superficial siderosis)

Clinical relevanceARIA may be asymptomatic or cause headache, confusion, focal deficits, seizures; relates to amyloid‑reducing therapies

Management implicationIf moderate‑severe ARIA detected, treatment may be suspended and follow‑up MRI indicated per treating physician

inv-214: NPH definition

NPH definitionNormal Pressure Hydrocephalus (NPH): clinical triad of cognitive dysfunction, urinary incontinence, and gait disturbance with ventriculomegaly on imaging

Imaging noteInitial single‑modality imaging (CT head or MRI brain) is indicated; MRI preferred for pre‑surgical planning

Cine MRI roleCine MRI can demonstrate aqueductal CSF flow dynamics to help identify shunt‑responsive patients