CurrentUnitedHealthcarePolicy BIP135.N

Diagnostic and Therapeutic Radiology Services

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Coverage of inpatient and outpatient diagnostic and therapeutic radiological services for UnitedHealthcare of California HMO and EPO/POS members, subject to medical necessity and the member's Evidence of Coverage or Schedule of Benefits.

Policy Summary

PayerUnitedHealthcare

PolicyDiagnostic and Therapeutic Radiology Services

Policy CodePolicy BIP135.N

Change TypeNo material clinical or coverage changes

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionEnsure covered diagnostic and therapeutic radiology services are medically necessary; PET scans require medical criteria to be met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Coverage sections used to determine benefits

8Standard X-ray and ultrasound examples

7Specialized imaging and procedure examples

4Non-covered radiology categories

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CurrentUnitedHealthcarePolicy BIP135.N

Diagnostic and Therapeutic Radiology Services

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Sign up for UnitedHealthcare Policy BIP135.N alerts

Get alerted when Policy BIP135.N changes without checking for updates manually.

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Policy Summary

PayerUnitedHealthcare

PolicyDiagnostic and Therapeutic Radiology Services

Policy CodePolicy BIP135.N

Change TypeNo material clinical or coverage changes

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionEnsure covered diagnostic and therapeutic radiology services are medically necessary; PET scans require medical criteria to be met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Coverage sections used to determine benefits

8Standard X-ray and ultrasound examples

7Specialized imaging and procedure examples

4Non-covered radiology categories

Covered and Non-Covered Radiology Services

General covered radiology services

Covered when all applicable requirements are met.

General coverage requirements

Covered clinical use: The service is used for screening, detection, or treatment of disease; or it is used for diagnosis and ongoing medical management of an illness or injury.

Covered modalities and procedures

Covered examples when the general medical-necessity requirements are met.

Covered modality or procedure categories

Standard X-ray and related studies: Bone mineral density studies, including ultrasound and DEXA; IVP; KUB X-ray; mammography; obstetrical ultrasound; oral and rectal contrast gastrointestinal studies; plain-film X-rays; and ultrasonography.
Breast imaging is subject to the related Breast Imaging for Screening and Diagnosing Cancer medical policy.
Specialized scanning and procedures: CT; invasive radiological procedures such as myelogram, cystogram, angiogram including heart catheterization, and arthrogram; MRA; MRI; nuclear scans; PET scans when medical criteria are met; and SPECT.
Breast MRI is subject to the related Breast Imaging for Screening and Diagnosing Cancer medical policy.

Experimental or unproven tests that are not medically indicated are not covered.

Radiology studies requested by an employer or school are not covered.

Radiological tests and procedures performed in preparation for or during a non-covered service are not covered.

Thermography is not covered.

Non-medically indicated or unnecessary diagnostic or therapeutic radiological services are not covered.

Medical Necessity and Denial Risks

Denial Risk

Non-Covered or Unnecessary Radiology

Radiological services are not covered when they are non-medically indicated or unnecessary. Apply these denial-risk conditions before ordering or billing diagnostic or therapeutic radiology.

Experimental or unproven tests that are not medically indicated.
Radiology studies requested by an employer or school.
Radiological tests and procedures performed in preparation for or during a non-covered service.
Thermography.
Non-medically indicated or otherwise unnecessary diagnostic or therapeutic radiological services.

Documentation Required

Medical Necessity and PET Criteria

Diagnostic and therapeutic radiological services, whether inpatient or outpatient, are covered for screening, detection, or treatment of disease only when medically necessary. Standard X-rays, specialized imaging, and specialized procedures—including PET scans—require the applicable medical-necessity criteria to be met.

Policy Scope and Clinical Context

This policy addresses inpatient and outpatient diagnostic and therapeutic radiological services used for screening, disease detection, treatment, diagnosis, and ongoing medical management of illness or injury. Coverage requires medical necessity and remains subject to the member’s Evidence of Coverage or Schedule of Benefits.

Covered Clinical Indications

Screening, detection, or treatment of disease

Covered when the following requirement is met.

General radiology indication: The radiological service is used for screening, detection, or treatment of disease and is medically necessary.

Applies to inpatient and outpatient diagnostic and therapeutic radiological services.

Diagnosis and ongoing medical management of illness or injury

Covered when the following requirement is met.

Illness or injury management: The imaging or procedure is medically necessary for diagnosis or ongoing medical management of an illness or injury.

Includes specialized scanning, imaging, and other specialized procedures.

Positron emission tomography

Covered when the following requirement is met.

Oral and Rectal Contrast Studies

Billing Rule

Use contrast gastrointestinal studies when medically necessary

Oral or rectal contrast gastrointestinal studies are covered examples when medically necessary. Examples include upper GI studies, barium enemas, and oral cholecystograms.

Upper GI studies
Barium enemas
Oral cholecystograms

Excluded Radiology Services

The following radiological services are not covered: thermography; experimental or unproven tests that are not medically indicated; radiology studies requested by an employer or school; and radiological tests and procedures performed in preparation for or during a non-covered service.