UnitedHealthcare MRI/CT Site-of-Service Coverage

Coverage Criteria — Hospital Outpatient MRI/CT

Not Medically Necessary — Hospital outpatient MRI/CT

Not medically necessary

General exclusions: All other MRI/CT imaging procedures at a hospital-based imaging department or facility are considered not medically necessary

Examples include cancer screening; initial diagnosis and/or initial staging for suspected or known cancer; non-cancerous musculoskeletal conditions; surveillance of cancer in remission with no clinical suspicion for change in disease status.

This policy explains when an MRI or CT performed in a hospital outpatient department is considered medically necessary. Covered situations include, but are not limited to, when the member is participating in a clinical trial that requires specific imaging equipment or protocol not available in freestanding facilities; when the imaging is scheduled within 24 hours of a hospital specialist appointment at the same hospital-based facility; when the member has a known allergy to a contrast agent; when direct comparison to prior studies requires the same protocol or equipment (for chronic disease or systemic cancer on active treatment); when pre-procedure imaging is performed within 24 hours and is integral to a planned interventional or surgical procedure; when obstetrical or perinatology services or observation are required; when the patient is under 18 years of age; when there are no geographically accessible appropriate alternative sites (including need for moderate/deep sedation, general anesthesia, equipment sized for the patient, or open MRI for documented claustrophobia/severe anxiety); or when imaging at a physician office or freestanding center would reasonably be expected to delay care and adversely impact health outcome.

This Medical Policy does not apply to the state of Massachusetts.

All other MRI/CT imaging procedures performed in a hospital-based imaging department or facility that do not meet the listed medical necessity criteria are considered not medically necessary. Examples explicitly cited include imaging for cancer screening, initial diagnosis or initial staging for suspected or known cancer, non-cancerous musculoskeletal conditions, and surveillance of cancer in remission with no clinical suspicion for change in disease status.

Appropriate Use and Covered Indications

Imaging during pregnancy and lactation

Preferred modalities in pregnancy: Ultrasonography and magnetic resonance imaging (MRI) are the imaging techniques of choice for the pregnant patient and should be used prudently only when expected to answer a relevant clinical question.

ACOG guidance

Ionizing radiation considerations: Radiography, computed tomography (CT), or nuclear medicine imaging techniques expose the fetus to doses much lower than exposures associated with fetal harm but should be used prudently.

ACOG guidance

MRI patient safety considerations: Assess age-related and health-related risks (including need for intensive or critical care, impaired respiratory function, changes in sedation or ventilation, hemodynamic instability, comorbidities) and the presence of foreign bodies or implanted ferromagnetic items prior to MRI; limit gadolinium use in pregnancy and use only if it significantly improves diagnostic performance and is expected to improve fetal or maternal outcome.

Applicable CPT/HCPCS Codes

Computed Tomography (partial list)CPT

70450	Computed tomography, head or brain; without contrast material.
70460	Computed tomography, head or brain; with contrast material(s).
70470	Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections.
70480	Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material.
70481	Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s).
70482	Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections.
70486	Computed tomography, maxillofacial area; without contrast material.
70487	Computed tomography, maxillofacial area; with contrast material(s).
70488	Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections.
70490	Computed tomography, soft tissue neck; without contrast material.

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Computed Tomography (continued)CPT

70498	Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing.
71250	Computed tomography, thorax, diagnostic; without contrast material.
71260	Computed tomography, thorax, diagnostic; with contrast material(s).
71270	Computed tomography, thorax, diagnostic; without contrast material, followed by contrast material(s) and further sections.
71271	Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s).
71275	Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing.
72125	Computed tomography, cervical spine; without contrast material.
72126	Computed tomography, cervical spine; with contrast material.

Magnetic Resonance Imaging (partial list)CPT | HCPCS

70336	Magnetic resonance (e.g., proton) imaging, temporomandibular joint(s).
70540	Magnetic resonance imaging, orbit, face, and/or neck; without contrast material(s).
70542	Magnetic resonance imaging, orbit, face, and/or neck; with contrast material(s).
70543	Magnetic resonance imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences.
70544	Magnetic resonance angiography, head; without contrast material(s).
70545	Magnetic resonance angiography, head; with contrast material(s).
70546	Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences.
70551	Magnetic resonance imaging, brain; without contrast material.
70552	Magnetic resonance imaging, brain; with contrast material(s).
70553	Magnetic resonance imaging, brain; without contrast material, followed by contrast material(s) and further sequences.

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Applicable CPT Codes (edits noted)CPT

0042T

Removed from applicable CPT list

Time window for scheduling adjacency

Scheduling adjacency windowImaging scheduled within 24 hours of a hospital specialist appointment at the same hospital-based facility is considered medically necessary.

Pre-procedure imaging timingPre-procedure imaging done within 24 hours of the interventional or surgical procedure and integral to the planned procedure qualifies.

Clinical-trial scheduling relevanceImaging required by a clinical trial that mandates specific protocols or equipment not available at freestanding facilities may require hospital scheduling within the same facility.

N/A

N/A placeholderNo threshold or additional information provided.

Provider Actions and Authorization Notes

Prior Authorization

Prior Authorization Note

Authorization is not required for procedures performed in an emergency room, observation unit, urgent care center, or during an inpatient stay.

Applicable when imaging is performed in these settings; prior authorization rules for outpatient settings still apply as noted below.

Prior Authorization

Check Prior Authorization Per Member Plan

Before requesting imaging, check the member-specific benefit plan for prior authorization requirements and applicable CPT codes; Oxford plan members may be subject to this shared policy version and state-specific exclusions (for example, this policy does not apply to Massachusetts).

Verify applicable CPT codes against the member plan — annual code updates may have changed covered codes.
Confirm any Oxford plan-specific instructions or exclusions in the member's benefit document.

Contrast Use and Pregnancy Considerations

Billing Rule

Document known contrast allergy when ordering hospital outpatient imaging

Known allergy to a contrast agent is a listed reason supporting hospital outpatient imaging; ensure allergy history is documented and consider alternative imaging or premedication per clinical protocols for hospital outpatient settings.

Billing Rule

Limit gadolinium use in pregnancy; document justification

Limit use of gadolinium contrast in pregnancy; gadolinium may be used only if it significantly improves diagnostic performance and is expected to improve fetal or maternal outcome—document pregnancy considerations when ordering contrast-enhanced MRI.

Definitions and Risk Considerations

Medically necessary hospital outpatient MRI/CT — summary

Clinical trial requirementsMedically necessary when the individual is participating in a clinical trial that requires a specific imaging protocol or equipment not available in a freestanding facility.

Scheduling adjacencyMedically necessary when scheduled within 24 hours of a hospital specialist appointment at the same hospital-based facility.

Contrast allergyMedically necessary for individuals with a known allergy to a contrast agent used for the procedure.

Continuity of protocol/equipmentMedically necessary when direct comparison to prior studies requires the same imaging protocol or equipment obtained at the same hospital-based facility (chronic disease or systemic cancer on active treatment).

Pre-procedure imagingMedically necessary when performed within 24 hours of an interventional or surgical procedure and is integral to the planned procedure.

Prior Authorization Details

Prior Authorization

No prior authorization required for ER/observation/urgent care/inpatient MRI/CT

Authorization is not required for MRI/CT procedures performed in the emergency room, observation unit, urgent care center, or during an inpatient stay.

Prior Authorization

Verify member-specific prior auth requirements and CPT code edits

Check the member specific benefit plan for prior authorization requirements and applicable CPT code edits before requesting MRI/CT services, as requirements and code applicability may vary.

Background

Magnetic resonance imaging (MRI) and computed tomography (CT) are widely used diagnostic modalities across many clinical settings. This policy focuses on the site of service, specifying when hospital outpatient department performance of MRI/CT is appropriate—principally when clinical, logistical, or safety considerations (for example, need for anesthesia, complex protocols or equipment, pediatric care, obstetrical/perinatology services, or continuity with prior studies) make a hospital setting necessary. Professional guidance on imaging in pregnancy and anesthetic considerations for MRI are referenced to support clinical considerations and safety assessments.

Not Covered

Hospital outpatient MRI/CT is not covered when performed in a hospital-based imaging department and the procedure is for cancer screening, for initial diagnosis or initial staging of suspected or known cancer, for evaluation of non-cancerous musculoskeletal conditions, or for routine surveillance of cancer in remission when there is no clinical suspicion for change in disease status. Imaging that does not meet the policy's listed medical necessity criteria may be denied. Note that authorization is not required for procedures performed in an emergency room, observation unit, urgent care center, or during an inpatient stay; other prior authorization rules should be checked per the member-specific plan.

Revision History

2026-01-01template_update_and_code_editsLatest

Created shared policy version to support application to Oxford plan membership; added language that the policy does not apply to Massachusetts; updated applicable CPT codes (removed 0042T); archived prior versions MP.13.18 and RADIOLOGY 041.12.

OpenPayer

Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scan - Site of Service

Coverage Criteria — Hospital Outpatient MRI/CT

Appropriate Use and Covered Indications

Applicable CPT/HCPCS Codes

Provider Actions and Authorization Notes

Contrast Use and Pregnancy Considerations

Definitions and Risk Considerations

Prior Authorization Details

Background

Not Covered

Revision History