CurrentUnitedHealthcarePolicy BIP135.M

Diagnostic and Therapeutic Radiology Services

Defines UnitedHealthcare coverage stance for diagnostic and therapeutic radiological services (inpatient and outpatient) when medically necessary; applies to participating providers and enrollees under the plan.

Policy Summary

PayerUnitedHealthcare

PolicyDiagnostic and Therapeutic Radiology Services

Policy CodePolicy BIP135.M

Change TypeAdministrative / archival revisions

Effective DateNov 1, 2025

Next Review Date

Key ActionConfirm services are medically necessary and consistent with the member's Evidence of Coverage/Schedule of Benefits before providing or billing imaging services.

SourceLink

POLICY UPDATE CHANGES

Removed language pertaining to the California Health and Safety Code Section 123222.3.

Archived previous policy version BIP135.L.

1policy document

Numerouscovered modalities

Multiplenot-covered items

CAstate regulatory note

Coverage Criteria

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Covered services

Covered when services are medically necessary and consistent with the member's Evidence of Coverage/Schedule of Benefits.

General coverage: Diagnostic and therapeutic radiological services (inpatient or outpatient) used for screening, detection, or treatment of disease when determined to be medically necessary.medical necessity per EOC/SOB

Refer to member plan for specific provisions and applicable Federal/State mandated regulations.

Examples of covered modalities: Standard X-rays; bone mineral density studies (including ultrasound and DEXA); intravenous pyelogram (IVP); kidney, ureter, and bladder (KUB) x-ray; mammograms (see Breast Imaging policy); obstetrical ultrasound; oral and rectal contrast gastrointestinal studies (upper GI, barium enema, cholecystogram); plain film x-rays; ultrasonography; computed tomography (CT); invasive radiological procedures (myelogram, cystogram, angiogram, arthrogram); magnetic resonance angiogram (MRA); magnetic resonance imaging (MRI); nuclear scans; positron emission tomography (PET) when medical criteria are met; single photon emission computed tomography (SPECT).

Examples are not exhaustive; coverage is subject to member EOC/SOB.

Not medically necessary / Exclusions

Not covered / Considered not medically necessary:

Exclusions: Non-medically indicated or unnecessary radiological services (diagnostic and/or therapeutic).

These services include but are not limited to the items listed below and are subject to member EOC/SOB.

Examples: Experimental or unproven tests not medically indicated; radiology studies requested by an employer or school; radiological tests and procedures in preparation for or during a non-covered service; thermography.

This list is illustrative and not all-inclusive.

The following services are excluded from coverage when they are not medically necessary: experimental or unproven tests, radiology studies requested solely by an employer or school, radiological tests or procedures performed in preparation for or during a non‑covered service, and thermography. These items are considered not covered because they do not meet the plan’s medical‑necessity requirements.

Radiological services that are non‑medically indicated or otherwise unnecessary are treated as not medically necessary and are not covered. Examples include services performed for administrative reasons (such as employer/school requests), investigational procedures, or any imaging tied to a non‑covered benefit.

Coding and Billing

Covered modalities (no specific CPT/HCPCS codes listed)mixedCovered

Standard X-rays	Standard X-rays
Bone mineral density studies (including ultrasound and DEXA scans)	Bone mineral density studies (including ultrasound and DEXA scans)
Intravenous pyelogram (IVP)	Intravenous pyelogram (IVP)
Kidney, ureter, and bladder (KUB) x-ray	Kidney, ureter, and bladder (KUB) x-ray
Mammograms, including digital mammograms	Mammograms, including digital mammograms; refer to Breast Imaging policy
Obstetrical ultrasound	Obstetrical ultrasound
Oral and rectal contrast gastrointestinal studies	Oral and rectal contrast gastrointestinal studies (such as upper GIs, barium enemas, and oral cholecystograms)
Plain film x-rays	Plain film x-rays
Ultrasonography	Ultrasonography
Computed tomography (CT scan)	Computed tomography (CT scan)

1–10 of 16

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Not covered modalities/tests (no specific CPT/HCPCS codes listed)mixedNot Covered

Experimental or unproven tests	Experimental or unproven tests not medically indicated
Radiology studies requested by an employer or school	Radiology studies requested by an employer or school
Radiological tests/procedures for non-covered services	Radiological tests and procedures in preparation for or during a non-covered service
Thermography	Thermography

Medical necessity — must be medically necessary as defined by member EOC/SOB

Medical necessity requirementAll services must be medically necessary as defined by the member's Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If a discrepancy exists between this policy and the member's EOC/SOB, the EOC/SOB governs.

ScopeApplies to diagnostic and therapeutic radiological services (inpatient or outpatient) used for screening, detection, or treatment of disease when determined medically necessary.

Documentation implicationCoverage, limitations, and exclusions are defined by each benefit plan and must be confirmed in the member's EOC/SOB.

Prior authorization notePrior authorization requirements are not specified in this policy; follow member EOC/SOB and plan provisions.

Denial riskNon-medically indicated or unnecessary radiological services may be denied as not medically necessary per the member plan.

Provider Actions and Authorization

Prior Authorization

Prior Authorization Guidance

Prior authorization requirements are not detailed in this policy. Providers must verify and obtain any required prior authorization per the member's plan before performing services. All services must be medically necessary and documented in the medical record.

Obtain prior authorization when required by the member's plan.
Document medical necessity in the patient's medical record to support coverage.
Confirm plan-specific prior authorization processes and contact UnitedHealthcare if unclear.

Documentation Required

Medical Necessity and Member Plan Terms

Verify member coverage and benefit limitations prior to scheduling radiology services. Use the member's EOC/SOB to confirm coverage, limitations, and exclusions and resolve any discrepancies in favor of the EOC/SOB.

Check the member's Evidence of Coverage (EOC) / Schedule of Benefits (SOB) for plan-specific terms.
When EOC/SOB conflicts with this policy, follow the EOC/SOB.

Denial Risk

Denial Triggers

Services that are non‑medically indicated, unnecessary, experimental, or unproven may be denied. Examples include radiology studies requested by an employer or school, procedures performed in preparation for or during a non‑covered service, and thermography.

Denials may be issued for experimental or unproven tests not medically indicated.
Denials may be issued for radiology studies requested by an employer or school.
Denials may be issued for radiological tests performed in preparation for or during a non-covered service.
Thermography is considered not covered and may be denied.

Note

Provider action: verify benefits, obtain prior authorization if required, and ensure documentation supports medical necessity. Failure to follow plan prior authorization and medical necessity requirements may result in claim denial or member liability.

Confirm member eligibility and benefits before providing services.
Obtain and document prior authorization when required by the plan.
Include clinical documentation that supports the medical necessity of the requested radiology service on the claim.
Educate members if a service is non-covered to prevent unexpected liability.

Covered Indications

General diagnostic and therapeutic imaging indications when medically necessary

Imaging is indicated when ALL of the following are met:

Indication general: Imaging is indicated for diagnosis, screening, detection, or ongoing management of illness or injury when determined to be medically necessary per the member's Evidence of Coverage/Schedule of Benefits.medical necessity per EOC/SOB

Specific modality appropriateness and prior authorization requirements are governed by the member's plan and any applicable Federal/State mandated regulations; if conflict exists, the EOC/SOB governs.

Definitions

Radiological services — covered modalities

Standard X‑raysStandard X‑rays for diagnosis or screening of defined diseases are covered.

Ultrasound / Obstetrical ultrasoundUltrasonography including obstetrical ultrasound is listed as a covered modality.

Bone mineral density (DEXA)Bone mineral density studies, including ultrasound and DEXA scans, are covered.

Computed Tomography (CT)CT scans are included among specialized scanning and imaging covered when medically necessary.

Magnetic Resonance Imaging (MRI) / MRAMRI and magnetic resonance angiography (MRA) are covered; refer to related Breast Imaging policy for mammography‑related MRI guidance.

Nuclear Medicine / PET / SPECTNuclear scans, PET (when medical criteria are met), and SPECT are listed as covered modalities.

Invasive radiology (angiogram, myelogram, cystogram, arthrogram)Invasive radiological procedures including angiogram (including heart catheterization), myelogram, cystogram, and arthrogram are covered when medically necessary.

OpenPayer

Diagnostic and Therapeutic Radiology Services

Coverage Criteria

Coding and Billing

Provider Actions and Authorization

Covered Indications

Contrast Rules

Prior Authorization

Definitions

Background

Not Covered

Revision History