UnitedHealthcare Pediatric Chest Imaging Coverage Update

General coverage criteria

Covered when ALL of the following are met

Clinical documentation and relevance: Adequate clinical information is submitted including clinical presentation, time since onset/change, relevant laboratory and prior imaging studies, and how the imaging result will affect management.

See Clinical Documentation and Age Considerations.

Age-based guideline assignment: Individuals <=18 years are imaged per Pediatric Imaging Guidelines; individuals >18 years follow General Imaging Guidelines unless a specific section directs otherwise.

Avoidance of duplicate testing: Prior imaging and procedural history have been reviewed and repeat advanced imaging is performed only if there is evidence of progression, new disease, or documentation that repeat imaging will affect management.

Overutilization precautions apply.

Modality/contrast coverage criteria

Modality and contrast selection covered when ALL of the following are met

Modality selection: Modality is chosen based on the condition-specific guideline and clinical question (e.g., ultrasound for soft tissue/vascular bedside assessment; CT for pulmonary parenchyma, trauma, and bony detail; MRI for soft tissue characterization and neurologic/spinal evaluation; PET for metabolic activity when indicated).

Consider radiation risk in pediatrics.

Contrast use justification: The level of IV contrast (none / with / without and with) is determined by condition-specific guidance; non-contrast studies are acceptable when contraindications to contrast exist or when appropriate for the clinical question.

CT with contrast may be used to clarify an inconclusive non-contrast CT performed within two weeks.

Renal and pregnancy considerations: Use caution with iodinated contrast and gadolinium in individuals with renal insufficiency (notably GFR <30 mL/min) and in pregnancy; breastfeeding individuals may pump and discard for 12–24 hours after iodinated contrast.GFR <30 mL/min

Gadolinium contraindicated in pregnancy unless benefit outweighs risk; limit GBCA use to when additional information is necessary.

3D Rendering — Coverage Criteria

Covered when billing reflects actual procedure and documentation meets requirements:

3D rendering billing: Report CPT 76376 or 76377 only when 3D rendering/post-processing as defined is performed; document concurrent physician supervision/participation in the reconstruction process; do not use these codes for routine 2D reformatting.

Concurrent supervision must be documented per guideline.

Imaging Guidance — Coverage Criteria

Guidance procedure billing rules:

Guidance vs diagnostic codes: Do not routinely bill a diagnostic procedure code in conjunction with CT/MR/US guidance procedure codes because guidance codes include the imaging necessary for the guidance procedure; report the appropriate guidance CPT code per the procedure table.

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

Appropriate pairing: Only percutaneous surgical procedures should be billed with guidance codes (e.g., CT/MR guidance for needle placement or ablation); guidance codes are inappropriate with open, excisional, or incisional surgical codes.

Unit of service is per encounter, not per lesion.

Unlisted Procedure Codes — Coverage Criteria

Use of unlisted codes:

When to use unlisted CT/MR codes: Report CPT 76497, 76498, or 78999 when no anatomic site–specific code exists; prefer a Category III code if one appropriately describes the procedure; unlisted codes may be used for custom surgical/navigation planning or when site-specific codes are unavailable.

Provide documentation supporting why no listed code applies.

Limited CT — Coverage Criteria

Limited CT (CPT 76380):

Use of 76380: Use CPT 76380 for limited or follow-up CT studies in which the work of a full diagnostic CT is not performed (e.g., limited slices through a known pulmonary nodule); 76380 is not indicated for treatment planning or to cover 'extra slices'.

No specific slice or sequence counts are defined in CPT.

SPECT/CT — Coverage Criteria

SPECT/CT and Hybrid Nuclear/CT:

SPECT/CT coding: Report hybrid nuclear/CT studies using CPT 78830, 78831, or 78832 as appropriate; CPT 78072 is used for SPECT/CT parathyroid imaging. These studies combine functional and anatomic information and may include attenuation correction.

Select code based on single- or multi-day and number of areas per CPT guidance.

Outside Study Interpretation — Coverage Criteria

Interpretation of outside studies:

Outside exam interpretation: Use CPT 76140 for secondary interpretation of an imaging exam performed at another facility; do not report standard diagnostic imaging codes for an interpretation-only service.

Document that the exam was completed elsewhere and the nature of the review.

Whole‑Body CT Screening

Not covered for screening

Whole‑body CT screening: Whole‑body CT (LifeScan) for screening of asymptomatic healthy individuals is not indicated and is not covered.

Whole‑body CT screening does not meet validity criteria and poses radiation risk without demonstrated benefit.

Whole‑Body MRI (WBMRI) — Coverage Criteria

Restricted/conditional coverage for Whole‑Body MRI

WBMRI permissible scenarios: WBMRI (reportable only with CPT 76498) may be approved for select cancer predisposition syndromes and certain autoimmune conditions (e.g., chronic recurrent multifocal osteomyelitis); otherwise WBMRI is generally not supported due to lack of standardization and outcome evidence.

Do not report WBMRI by splitting into diagnostic MRI codes for multiple body parts.

PET‑MRI — Coverage Criteria

Conditional use of PET‑MRI

PET‑MRI conditional criteria: PET‑MRI may be appropriate only when the individual meets condition‑specific PET imaging criteria or PET‑CT criteria AND PET‑CT is not available at the treating institution; when appropriate, PET‑MRI may be reported using designated PET and diagnostic MRI codes per guideline instructions.

Other methods of reporting PET‑MRI are inappropriate.

Quantitative MR Analysis — Coverage Criteria

Quantitative MR analysis stance

Quantitative mp‑MRI: Quantitative multiparametric MRI analyses (Category III CPT codes such as 0648T, 0649T, 0697T, 0698T, 0865T, 0866T) are considered investigational/experimental and are not medically necessary for routine clinical practice outside of research contexts.

Volumetric/quantitative MRI analysis lacks sufficient evidence for routine use.

Supported use of advanced imaging

Advanced chest imaging is supported only when ALL of the following are met:

General prerequisite: A pertinent clinical evaluation since onset or change in symptoms (detailed history, physical exam, appropriate laboratory testing, and basic imaging such as radiography or ultrasound) or meaningful technological contact has been performed prior to advanced imaging, unless guideline-supported scheduled follow-up is specified.

Supports decision for advanced imaging; exceptions noted in condition sections.

Symptom/Sign requirement: Documented active clinical signs or symptoms of disease involving the chest are present; screening of asymptomatic individuals with advanced imaging is not supported.

Repeat imaging: Repeat advanced imaging is supported only when there is evidence of progression, new disease, or documentation that repeat imaging will affect clinical management.

Avoid unnecessary repeat studies.

Mediastinal mass — Coverage Criteria

Mediastinal mass initial workup: Chest X‑ray is indicated as the initial study for suspected mediastinal mass; CT Chest with contrast (CPT 71260) is indicated for any pediatric individual with a mediastinal mass identified on chest X‑ray.

MRI indications for mediastinal mass: MRI Chest without and with contrast (CPT 71552) is indicated for posterior mediastinal masses invading the spinal canal or when CT findings are inconclusive; avoid MRI if anesthesia is required for large anterior masses.

PET/CT and MIBG indications: PET/CT (CPT 78815) is indicated prior to biopsy when lymphoma is suspected or when tracheal compression is present on CT; MIBG studies (CPT 78800/78802/78803/78804) are indicated prior to biopsy when neuroblastoma is suspected.

Refer to pediatric oncology guidelines for disease‑specific imaging.

Lymphadenopathy — Coverage Criteria

Supraclavicular adenopathy: Advanced imaging is indicated prior to excisional biopsy for supraclavicular adenopathy; ultrasound (CPT 76604), CT Chest with contrast (CPT 71260), or MRI Chest without and with contrast (CPT 71552) are appropriate options.

Fine needle aspiration is inappropriate for pediatric lymphadenopathy.

Hemoptysis imaging — Coverage Criteria

Hemoptysis initial evaluation: Perform a detailed history, physical examination, and appropriate laboratory studies prior to advanced imaging; chest X‑ray is the initial study for stable individuals to help differentiate true hemoptysis from aspirated blood due to epistaxis or emesis.

Hemoptysis advanced imaging: CT Chest with contrast (CPT 71260) is indicated for pediatric individuals with hemoptysis except when epistaxis with a normal chest radiograph and no underlying lung or bleeding disorder is documented; CT without contrast (CPT 71250) is appropriate for documented contrast allergy or significant renal dysfunction; MRI is not indicated.

Hemoptysis — Coverage Criteria (Modality selection guidance)

Hemoptysis imaging — Covered when the following conditions guide modality selection

Initial evaluation: Detailed history, physical exam, and appropriate laboratory studies are performed prior to advanced imaging; true hemoptysis is rare in pediatrics.

When chest X‑ray indicated: Chest X‑ray is indicated as the initial study for stable individuals with hemoptysis.

When CT with contrast indicated: CT Chest with contrast (CPT 71260) is indicated for pediatric individuals with hemoptysis except when epistaxis with normal CXR and no underlying lung or bleeding history is documented; CT Chest without contrast (CPT 71250) may be used for documented CT contrast allergy or significant renal dysfunction; MRI is not indicated.

Cystic fibrosis and bronchiectasis — Coverage Criteria

Cystic fibrosis imaging — Covered when ALL of the following or specific indications are present

Initial acute evaluation: Chest X‑ray is the primary study for initial evaluation of acute clinical symptoms in individuals with cystic fibrosis.

CT without initial CXR indications: CT Chest without contrast (CPT 71250) or with contrast (CPT 71260) may be performed without an initial chest X‑ray for: pneumonia worsening despite antibiotics; suspected fungal pneumonia; pleural effusion or empyema; monitoring treatment changes in bronchiectasis; expiratory CT for small airways disease; and pre‑ or post‑lung transplant evaluation.

Monitoring interval: Low‑dose CT Chest without contrast (CPT 71250) is indicated every 2 years for monitoring bronchiectasis and small airways disease in cystic fibrosis.every 2 years

Periodic monitoring may require prior authorization per payer rules.

Bronchiolitis — Coverage Criteria

Bronchiolitis imaging — Covered when specific complications or risk factors present

General: Bronchiolitis is usually self‑limiting; chest X‑rays are indicated when there is clinical suspicion of pneumonia or other complications (e.g., pleural effusion or empyema).

CT with contrast for exceptions: CT Chest with contrast (CPT 71260) is appropriate for immunocompromised individuals with acute pulmonary symptoms or when a recent chest X‑ray suggests a condition other than bronchiolitis.

Advanced imaging not indicated routinely.

Pneumonia and COVID-19 — Coverage Criteria

Pneumonia and COVID-19 imaging — Covered with pediatric-specific considerations

Initial imaging: Chest X‑ray and/or chest ultrasound (CPT 76604) is indicated when the condition does not respond to standard therapy; chest X‑ray is the initial imaging test for pediatric COVID‑19 positive individuals.

CT for immunocompromised or recurrent infections: CT Chest with contrast (CPT 71260) is indicated for immunocompromised individuals with acute pulmonary symptoms; CT Chest without contrast (CPT 71250) or with contrast (CPT 71260) may be used for recurrent lower respiratory tract infections.

Solitary pulmonary nodule — Coverage Criteria

Solitary pulmonary nodule — Coverage stance

One-time CT evaluation: CT Chest with contrast (CPT 71260) is appropriate as a one‑time evaluation for any individual with an incidentally discovered pulmonary nodule on other imaging; follow‑up imaging of incidental solitary nodules in asymptomatic healthy pediatric individuals is not necessary.

Fleischner Society adult guidelines do not apply to pediatric individuals.

Follow-up indicated: Follow‑up imaging is indicated for immunocompromised individuals, individuals with known malignancy, invasive infection, or new/worsening pulmonary symptoms.

Tuberculosis / Positive PPD imaging — Coverage Criteria

Imaging approach for pediatric patients with positive PPD or suspected tuberculosis:

TB imaging recommendations: Chest X‑ray is useful as the initial imaging study when tuberculosis is suspected; MRI spine with and without contrast is appropriate at symptomatic levels when spinal involvement is a concern.

Refer to chest TB guideline sections for further detail.

Asthma imaging — Coverage Criteria

Imaging indications in pediatric asthma:

Initial and advanced imaging: Chest X‑ray or chest ultrasound (CPT 76604) is indicated when the patient's condition does not respond to standard therapy or to identify complications such as pneumonia or suspected foreign body; advanced imaging (CT Chest without or with contrast) is not routine but is appropriate for immunocompromised patients, poor response to therapy with concern for alternative diagnoses, or abnormal chest X‑ray suggesting other conditions.

Pectus deformities imaging — Coverage Criteria

When to use cross-sectional imaging for pectus deformities:

Indications for CT/MRI: CT Chest without contrast (CPT 71250), MRI Chest with and without contrast (CPT 71552), or MRI Chest without contrast (CPT 71550) are indicated for significant cardiac displacement after chest X‑ray and echocardiography, for preoperative planning, for evidence of pulmonary impingement after chest X‑ray and PFTs with increasing dyspnea, and when congenital heart disease or connective tissue disorder (e.g., Marfan syndrome) is suspected.

PFTs may be unobtainable in children younger than ~9 years.

Vascular ring and other vascular malformations — Coverage Criteria

Imaging pathway based on presenting symptoms:

Respiratory symptoms: Chest X‑ray is the recommended initial study in individuals with respiratory symptoms suggestive of a vascular ring; if prenatally diagnosed, chest X‑ray is not required.

Feeding difficulties: Barium esophagram is the recommended initial study in individuals with feeding difficulties; after initial studies or prenatal imaging, CT Chest with contrast (CPT 71260), CTA Chest (CPT 71275), or MRA Chest (CPT 71555) are appropriate to define anatomy.

Cardiac evaluation: Echocardiography is appropriate to rule out associated congenital heart disease; selected echocardiography CPT codes are referenced when no prior echocardiogram exists.

Congenital cystic lung disease — Coverage Criteria

Evaluation of suspected congenital cystic lung lesions:

Modality choice: CT Chest with contrast (CPT 71260) is appropriate when a congenital cystic lung lesion is suspected; MRI Chest with and without contrast (CPT 71552) is appropriate if CT is inconclusive or if requested for preoperative planning.

Lesions may be identified prenatally or incidentally on chest X‑ray.

Congenital Cystic Lung Diseases - Imaging Appropriateness

Imaging is appropriate as follows:

Cystic lung lesions imaging: CT Chest with contrast (CPT 71260) is appropriate when a lung lesion is suspected; MRI Chest with and without contrast (CPT 71552) is appropriate if CT is inconclusive or if requested for pre‑operative planning.

Pulmonary Arteriovenous Malformations - Imaging Appropriateness

Imaging is appropriate as follows:

PAVM initial and advanced imaging: Chest X‑ray is an initial imaging modality for individuals with known PAVMs or presenting with hypoxemia or hemoptysis; CTA or MRA is appropriate for treatment planning in individuals with known AVM or abnormal chest X‑ray suggesting AVM.

Congenital Diaphragmatic Hernia - Imaging Appropriateness

Imaging is appropriate as follows:

CDH initial imaging: If there is clinical concern for congenital diaphragmatic hernia, chest X‑ray and/or chest ultrasound (CPT 76604) is indicated as the initial imaging study.

CDH secondary imaging: CT Chest with contrast (CPT 71260) or MRI Chest with and without contrast (CPT 71552) is appropriate when chest X‑ray and/or ultrasound are inconclusive or when requested for treatment planning.

Imaging requests that are inconsistent with established clinical standards, those requested solely for data collection rather than direct clinical management, and procedures meeting the guideline definition of investigational/experimental are not supported. Investigational/experimental status is applied when peer‑reviewed evidence demonstrating clinical utility and improved health outcomes is lacking or when a procedure lacks collective specialty support. Review the individual's prior studies and clinical record—advanced imaging should be ordered only when results are expected to affect management and are consistent with these standards.

MRI using inhaled Xenon Xe‑129 (CPT C9791) is considered investigational/experimental and not supported for routine clinical use due to limited evidence of clinical utility. Quantitative MR applications remain investigational in many contexts; procedures lacking sufficient supporting data should be treated per investigational criteria.

Combined PET‑MRI is generally not supported for routine clinical use. PET imaging should only be used for surveillance when explicitly permitted in condition‑specific guideline sections. When PET‑MRI is requested, it may be considered only if the individual meets the condition‑specific PET/PET‑CT criteria and PET‑CT is unavailable at the treating institution; otherwise PET‑CT remains the standard hybrid PET reporting approach.

Billing and reporting must reflect the actual service performed. CPT 76376/76377 (3D rendering) require documented concurrent physician supervision and must not be used for routine 2‑D reformatting, since two‑dimensional reconstructions are included in base cross‑sectional imaging codes. For MRI‑guided breast biopsy, use CPT 19085/19086; CPT 77021 is not appropriate for breast biopsy. Do not routinely bill diagnostic imaging procedure codes in conjunction with CT/MR/US guidance codes when the guidance code already contains the necessary imaging element.

Whole‑body CT examinations performed for screening of healthy, asymptomatic individuals (so‑called LifeScan/whole‑body CT screening) are excluded/not covered. These studies do not meet validity criteria for screening and expose individuals to unnecessary radiation without proven benefit.

Advanced imaging is not supported for routine screening of asymptomatic individuals or for routine health surveillance. Pulmonary ventilation imaging alone (CPT 78579) is not appropriate as a substitute for combined ventilation‑perfusion imaging (CPT 78582) when evaluating suspected pulmonary embolism; CTA or CT chest with contrast are preferable when available. PET surveillance without a condition‑specific allowance is also discouraged.

MRI is not indicated for evaluation of pediatric hemoptysis. Management of pediatric pulmonary nodules differs from adult practice: the Fleischner Society adult solitary pulmonary nodule guidelines do not apply to pediatric patients, and follow‑up imaging for incidental solitary nodules in otherwise healthy, asymptomatic pediatric individuals is generally not necessary unless specific risk factors are present.

Advanced imaging is not indicated for routine monitoring of asthma. Chest radiography or chest ultrasound (CPT 76604) is recommended when the patient does not respond to standard therapy or when complications are suspected; CT chest (with or without contrast) is reserved for immunocompromised patients, poor therapeutic response with concern for alternative diagnoses, or abnormal chest X‑ray findings suggesting other pathology.

This policy provides informational guidance only. Coverage and prior authorization requirements are governed by the member's applicable federal, state (Ohio Administrative Code), or contractual benefit plan. Verify plan‑specific requirements and document clinical justification according to the governing benefit terms before ordering advanced imaging.

Routine surveillance PET imaging is not indicated unless explicitly permitted in a condition‑specific section. Double‑contrast CT (both non‑contrast and contrast on the same encounter) has limited indications and may be subject to denial. Avoid routine simultaneous billing of diagnostic imaging codes together with guidance codes; limited CT (CPT 76380) should not be used to inappropriately cover extra slices or for treatment planning.

Do not routinely bill diagnostic imaging procedure codes in addition to imaging guidance codes when guidance CPTs already include the necessary imaging. One unit of a guidance code is appropriate per encounter. Limited CT (CPT 76380) is intended for targeted follow‑up slices and not for treatment planning or to justify additional diagnostic work; misuse may be denied.

Quantitative multiparametric MRI analyses using Category III CPT codes (e.g., 0648T, 0649T, 0697T, 0698T, 0865T, 0866T) are considered investigational/experimental and not medically necessary for routine clinical practice outside of research contexts.

Repeat advanced imaging should only be performed when there is documented evidence of disease progression, new disease, or when repeat imaging will clearly affect clinical management. Repeat imaging without progression or documentation of impact on management is not supported and may be denied.

Follow‑up imaging of incidental solitary pulmonary nodules in otherwise healthy, asymptomatic pediatric individuals is generally not necessary. A one‑time CT Chest with contrast (CPT 71260) may be used for initial evaluation of an incidentally discovered nodule, but ongoing surveillance is reserved for specified risk groups (eg, immunocompromised individuals, known malignancy, invasive infection, or new/worsening symptoms).

Covered Indications and Appropriate Use

List of pediatric chest-specific indications addressed in the guideline

Pediatric chest indications list: Guideline addresses pediatric chest topics including mediastinal mass, lymphadenopathy, hemoptysis, bronchiolitis, cystic fibrosis and bronchiectasis, pneumonia/COVID‑19, tuberculosis/positive PPD, solitary pulmonary nodule, asthma, pectus deformities, vascular malformations, breast masses, and congenital chest diseases.

Modality-specific common indications

Ultrasound indications: Ultrasound is indicated for soft tissue and visceral chest imaging, vascular assessment when not obscured by bone, initial evaluation of ill‑defined soft tissue masses, and procedural guidance; it is operator dependent and useful as an initial modality (CPT 76604, 76882).

CT indications: CT is appropriate for evaluation of pulmonary parenchymal disease, trauma, bony detail, and to further evaluate inconclusive ultrasound or MRI findings; CT may be performed without, with, or without and with IV contrast depending on indication.

Consider radiation risks in pediatrics.

MRI indications: MRI is superior for soft tissue definition, characterization of masses, and evaluation of the brain/spine or when CT is contraindicated; MRI protocols vary and may require sedation in children.

Limit GBCA use to when additional information is necessary.

PET indications: PET is used for oncologic staging/restaging and selected metabolic assessments and is not typically used for routine surveillance unless specified in condition‑specific guideline sections; PET‑MRI is generally not supported except in select circumstances.

PET is usually combined with CT; PET‑MRI generally not supported.

Clinical scenarios appropriate for 3D rendering

3D rendering indications: Consider CPT 76376/76377 for complex anatomic evaluations and preoperative planning such as congenital skull abnormalities in infants, complex fractures, spine/pelvic fractures, complex facial fractures, cerebral angiography, and other cases where conventional imaging is insufficient for operative planning.

Document concurrent physician supervision of the reconstruction.

When to use unlisted CT/MR procedure codes

When to use unlisted CT/MR procedure codes: Use unlisted CT/MR procedure codes (CPT 76497/76498/78999) when an appropriate anatomic site–specific code does not exist (e.g., custom joint arthroplasty planning, neurosurgical navigation/planning); prefer an applicable Category III code if available.

Provide documentation explaining use of unlisted code.

WBMRI for cancer predisposition syndromes and select autoimmune conditions

WBMRI indications: Interval WBMRI may be recommended for select cancer predisposition syndromes and can be approved for select autoimmune conditions such as chronic recurrent multifocal osteomyelitis; WBMRI must be reported using CPT 76498 and is otherwise generally not supported due to lack of standardization and outcome data.

Refer to pediatric oncology sections for specific syndromes.

PET‑MRI when PET‑CT not available and condition-specific criteria met

PET‑MRI when PET‑CT unavailable: PET‑MRI may be appropriate when PET‑CT is unavailable at the treating institution and the individual meets condition‑specific PET or PET‑CT criteria; the provider should request PET‑MRI in lieu of PET‑CT only when PET‑CT is not available.

When appropriate, report PET‑MRI using designated PET and diagnostic MRI codes per guidance.

Ultrasound as initial study for specified chest conditions

Ultrasound as initial study: Ultrasound chest (CPT 76604) or axilla (CPT 76882) is indicated as an initial study for adenopathy, palpable chest wall lesions, pleural effusion or thickening, thoracic vascular patency, and diaphragm motion abnormalities.

Ultrasound is operator dependent but useful at bedside.

Evaluation of suspected mediastinal mass — appropriate imaging pathways

Mediastinal mass evaluation pathway: Start with chest X‑ray for suspected mediastinal mass; proceed to CT Chest with contrast (CPT 71260) when mass is identified on X‑ray; reserve MRI (CPT 71552) for posterior masses invading the spinal canal or when CT is inconclusive; use PET/CT or MIBG when lymphoma or neuroblastoma is suspected prior to biopsy.

Ultrasound chest is helpful in children <5 years to distinguish thymus from mass.

Evaluation of pediatric hemoptysis — appropriate imaging pathway

Hemoptysis pathway: Initial evaluation for pediatric hemoptysis includes detailed history, physical exam, and labs with chest X‑ray as the first imaging step for stable patients; CT Chest with contrast (CPT 71260) is indicated for other presentations; MRI is not indicated.

Differentiate aspirated blood from epistaxis or emesis; CT without contrast (CPT 71250) for contrast allergy/renal dysfunction.

Hemoptysis — covered indications

Hemoptysis covered indications: Chest X‑ray for stable individuals; CT Chest with contrast (CPT 71260) for other pediatric individuals with hemoptysis; CT without contrast (CPT 71250) when contrast allergy or significant renal dysfunction is documented.

MRI is not indicated.

Cystic fibrosis / Bronchiectasis — monitoring and acute indications

CF monitoring and acute indications: Chest X‑ray is the primary initial study for acute symptoms in cystic fibrosis; CT Chest (71250/71260) may be performed without initial chest X‑ray for specified acute or pre/post‑transplant scenarios; low‑dose CT (CPT 71250) is indicated every 2 years for monitoring bronchiectasis and small airways disease.every 2 years

Periodic monitoring may require prior authorization.

Bronchiolitis — condition-specific covered indication

Bronchiolitis covered indication: Chest X‑ray is indicated when clinical concern for pneumonia or complications exists; CT Chest with contrast (CPT 71260) is appropriate for immunocompromised individuals or when recent chest X‑ray suggests an alternative diagnosis.

Advanced imaging not routinely indicated.

Pneumonia / COVID-19 — condition-specific covered indication

Pneumonia/COVID covered indication: Chest X‑ray and/or chest ultrasound (CPT 76604) is indicated when the condition does not respond to standard therapy; CT (CPT 71250/71260) is reserved for immunocompromised individuals with acute pulmonary symptoms or for recurrent lower respiratory tract infections.

Solitary pulmonary nodule — covered indication

SPN covered indication: CT Chest with contrast (CPT 71260) as a one‑time evaluation is appropriate for any incidentally discovered pulmonary nodule; follow‑up imaging only for immunocompromised patients, known malignancy, invasive infection, or new/worsening pulmonary symptoms.

Fleischner adult guidelines do not apply to pediatric individuals.

Active or suspected tuberculosis / positive PPD — covered indication

TB covered indication: Positive PPD or clinical suspicion of tuberculosis warrants chest X‑ray as an initial imaging study; MRI spine with and without contrast is appropriate at symptomatic levels if spinal involvement is suspected.

Asthma with poor response or complication — covered indication

Asthma with poor response: Chest X‑ray or chest ultrasound (CPT 76604) is indicated when asthma patients do not respond to standard therapy or to evaluate complications; CT Chest (71250/71260) is reserved for immunocompromised patients, poor response with concern for alternative diagnoses, or abnormal chest X‑ray findings.

Advanced imaging is not routine for asthma.

Suspected vascular ring or vascular malformation — covered indication

Vascular ring - respiratory: For respiratory presentations (stridor, wheeze, cough), start with chest X‑ray; proceed to CT Chest with contrast (CPT 71260), CTA (CPT 71275), or MRA (CPT 71555) after initial studies to define anatomy.

If prenatally diagnosed, chest X‑ray is not required.

Vascular ring - feeding: For feeding difficulties suggestive of vascular ring, start with barium esophagram; use CT/CTA/MRA for anatomic definition after initial studies.

Pectus deformity requiring advanced imaging — covered indication

Pectus deformity indications: Indications for CT or MRI in pectus deformity include significant cardiac displacement after chest X‑ray and echocardiography, preoperative planning, evidence of pulmonary impingement with worsening dyspnea, or suspected congenital heart disease/Marfan syndrome.

PFTs may be unobtainable in young children.

Congenital cystic lung disease — covered indication

Congenital cystic lung disease indication: Suspected congenital cystic lung lesion identified prenatally or on chest X‑ray warrants CT Chest with contrast (CPT 71260); MRI Chest with and without contrast (CPT 71552) is appropriate if CT is inconclusive or for preoperative planning.

Congenital cystic lung lesions — covered indication

Congenital cystic lung lesions indication: When a lung lesion is suspected or preoperative planning is needed, CT Chest with contrast (CPT 71260) is appropriate; MRI Chest with and without contrast (CPT 71552) may be used if CT is inconclusive or for surgical planning.

Pulmonary arteriovenous malformations (PAVMs) — covered indication

PAVM indications: Known or suspected pulmonary arteriovenous malformation (PAVM) with abnormal chest X‑ray, hypoxemia, or hemoptysis: start with chest X‑ray and proceed to CTA or MRA for treatment planning as indicated.

Congenital diaphragmatic hernia (CDH) — covered indication

CDH indications: Clinical concern for congenital diaphragmatic hernia warrants initial chest X‑ray and/or chest ultrasound (CPT 76604); CT Chest with contrast (CPT 71260) or MRI Chest with and without contrast (CPT 71552) is appropriate if initial imaging is inconclusive or for treatment planning.

Most CDH are diagnosed prenatally.

Coding and Billing Guidance

Experimental/InvestigationalCPTExperimental

C9791

MRI Xenon Xe 129 (noted investigational)

3D Rendering CPT CodesCPT

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

Imaging guidance and related CPT CodesCPT

19085	Biopsy, breast, with placement of breast localization device(s), when performed, and imaging of the biopsy specimen, percutaneous; first lesion, including MR guidance
19086	Biopsy, breast; each additional lesion, including MR guidance
75989	Imaging guidance for percutaneous drainage with placement of catheter (all modalities)
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

Unlisted Procedure 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 and Hybrid Nuclear/CT CodesCPT

78830	Hybrid Nuclear/CT single area single day
78831	Hybrid Nuclear/CT 2 or more days
78832	Hybrid Nuclear/CT 2 areas one day and 2-day study
78072	SPECT/CT parathyroid nuclear imaging

Outside Study InterpretationCPT

76140

Interpretation of an outside study

SPECT‑CT / Hybrid nuclear imaging CPT codesCPT

78830	Hybrid nuclear SPECT/CT scan - single area, single day (parathyroid nuclear imaging)
78831	Hybrid nuclear SPECT/CT scan - two or more days
78832	Hybrid nuclear SPECT/CT scan - two areas with one day and two‑day study

Category III quantitative MRI codesCPTExperimental

0648T	Quantitative mp‑MRI data analysis without diagnostic MRI (single organ)
0649T	Quantitative mp‑MRI data analysis with diagnostic MRI (single organ)
0697T	Quantitative mp‑MRI data analysis without diagnostic MRI (multiple organs)
0698T	Quantitative mp‑MRI data analysis with diagnostic MRI (multiple organs)
0865T	Volumetric and quantitative MRI analysis of the brain (category III)
0866T	Volumetric and quantitative MRI analysis of the brain (category III)

Outside study interpretationCPTCovered

76140

Interpretation of an outside study

Whole‑body MRI reportingCPT

76498

Whole‑body MRI (single code for reporting WBMRI)

Chest MRI/CT/CTA and related unlisted codesCPT

71550	MRI Chest without contrast
71551	MRI Chest with contrast
71552	MRI Chest without and with contrast
76498	Unlisted MRI procedure (for radiation planning or surgical software)
71250	CT Chest without contrast
71260	CT Chest with contrast
71270	CT Chest without and with contrast
77014	CT Guidance for Placement of Radiation Therapy Fields
76497	Unlisted CT procedure (for radiation planning or surgical software)
71275	CTA Chest (non-coronary)

PET and Pulmonary Nuclear MedicineCPT

78811	PET Imaging; limited area
78812	PET Imaging: skull base to mid-thigh
78813	PET Imaging: whole body
78814	PET with concurrently acquired CT; limited area
78815	PET with concurrently acquired CT; skull base to mid-thigh
78816	PET with concurrently acquired CT; whole body
78579	Pulmonary Ventilation Imaging
78580	Pulmonary Perfusion Imaging
78582	Pulmonary Ventilation and Perfusion Imaging
78597	Quantitative Differential Pulmonary Perfusion, Including Imaging

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Ultrasound and other nuclear medicineCPT

76604	Ultrasound, chest (includes mediastinum, chest wall, and upper back)
76882	Ultrasound, axilla
76641	Ultrasound, breast; unilateral, complete
76642	Ultrasound, breast; unilateral, limited
78800	Radiopharmaceutical nuclear medicine imaging (specific codes vary)
78801	Radiopharmaceutical nuclear medicine imaging
78802	Radiopharmaceutical nuclear medicine imaging
78803	Radiopharmaceutical nuclear medicine imaging
78804	MIBG (listed variant)

Condition-specific procedure codesCPT

78815	PET/CT (skull base to mid-thigh) indicated for lymphoma prior to biopsy or when tracheal compression present
78582	V/Q imaging — may be appropriate if CT unavailable for suspected PE

Referenced imaging CPT codesCPT

71260	CT Chest with contrast (CPT 71260)
71250	CT Chest without contrast (CPT 71250)
76604	Ultrasound chest (CPT 76604)

Referenced imaging CPT codesCPT

CPT 76604	Ultrasound chest
CPT 71250	CT Chest without contrast
CPT 71260	CT Chest with contrast
CPT 71275	CTA Chest
CPT 71550	MRI Chest without contrast
CPT 71552	MRI Chest with and without contrast
CPT 71555	MRA Chest
CPT 93306	Echocardiography (referenced for evaluation)
CPT 93303	Echocardiography, transthoracic, limited
CPT 93320	Doppler flow

1–10 of 11

1/2

Appropriate MRI CPTCPTCovered

71552

MRI Chest with and without contrast (CPTC 71552)

Appropriate CT CPTCPTCovered

71260

CT Chest with contrast (CPTC 71260)

UltrasoundCPTCovered

76604

Ultrasound Chest (CPTe 76604)

Renal function threshold — GFR <30 mL/min

Renal function thresholdGFR <30 mL/min

Contrast risk noteIndividuals with GFR <30 mL/min have increased risk for contrast-induced nephropathy and gadolinium-related complications; use non-contrast alternatives when appropriate

CT/MRI parityBoth contrast CT and MRI have similar risk profiles in the setting of renal failure (GFR <30 mL/min)

Age for anesthesia consideration — anesthesia usually required for most infants and children <7 years or those with delays

Age guideline for anesthesiaAnesthesia usually required for almost all infants (except neonates) and children <7 years

ExceptionsNeonates may not require anesthesia; older children with developmental delays may also need anesthesia

Anesthesia planningWhen anesthesia is anticipated, consider performing non-contrast and contrast sequences in the same session to avoid repeat anesthesia exposure

Provider Actions and Authorization

Prior Authorization

Prior authorization and guideline review — advanced imaging

Advanced imaging requests are reviewed against UnitedHealthcare guidelines and may require prior authorization. Requests for CT with and without contrast (so-called "double contrast" studies) have few indications and may be denied as overutilization; include the clinical rationale if both phases are requested.

CT without and with contrast (double contrast) — few indications; justify necessity or consider single-phase imaging
Prior authorization may be required for advanced imaging modalities per plan procedures

Prior Authorization

Clinical evaluation and prior authorization

Submit adequate, recent clinical information to establish medical necessity. A pertinent clinical evaluation (history, exam, relevant labs, basic imaging such as chest X‑ray or ultrasound) since the onset or change in symptoms or documented meaningful technological contact (telehealth, telephone/video call, secure messaging) is expected prior to authorization of advanced imaging unless guideline-supported surveillance is being requested.

Document date of last clinical evaluation or meaningful contact
Include relevant prior imaging and laboratory results in the request

Documentation Required

Prior authorization for 3D rendering and documentation

3D rendering (CPT 76376, CPT 76377) requires documented physician supervision/participation in the post‑processing and may itself require prior authorization even when the base imaging did not. Do not use 3D rendering codes for routine 2D reformatting; document workstation use and the specific 3D reconstructions produced.

Document active physician participation in reconstruction (design of anatomy, tissue types to display, images/cine loops archived)
CPT 76376 — procedures not requiring independent workstation; CPT 76377 — requires independent workstation
3D rendering may require separate prior authorization even if base study did not

Denial Risk

Whole‑body CT and advanced imaging for asymptomatic screening

Whole‑body CT screening for asymptomatic individuals is not indicated and may be denied. Advanced imaging should not be used to screen asymptomatic people for chest disorders; imaging is supported only when there are documented active clinical signs or symptoms or guideline‑specified indications.

Whole‑body low‑dose CT supported only for select oncologic indications (e.g., multiple myeloma) per oncology guidelines
Requests for screening in asymptomatic individuals will be evaluated as not supported

Prior Authorization

PET‑MRI use in lieu of PET‑CT — documentation and criteria

PET‑MRI may be appropriate only when PET‑CT is unavailable and guideline criteria are otherwise met. If PET‑MRI is requested in lieu of PET‑CT, document why PET‑CT cannot be obtained; use the approved code combinations and include diagnostic MRI codes where clinically appropriate.

PET‑MRI only when PET‑CT is not available and condition‑specific criteria met
Document unavailability of PET‑CT at treating institution
Use appropriate PET and MRI code combinations; other reporting methods are inappropriate

Note

Ultrasound as initial study and imaging sequencing

Ultrasound is indicated as the initial imaging study for several chest indications (adenopathy, palpable chest wall lesion, pleural effusion/thickening, thoracic vascular patency, diaphragm motion abnormalities) and can guide selection of the optimal advanced modality; obtain ultrasound or chest X‑ray when recommended before advanced imaging to support authorization.

CPT 76604 (chest ultrasound) and CPT 76882 (axilla ultrasound) as initial studies when applicable
Obtain and document initial imaging (CXR or US) per condition-specific sequencing prior to advanced imaging unless guidelines allow direct CT/MRI

Documentation Required

Review of prior imaging, sequencing, and required documentation

Review prior imaging and procedural history to avoid duplicate exams. The results of initial diagnostic tests or radiologic studies should be obtained prior to further testing; failure to document prior imaging or to follow recommended stepwise sequencing (for example, chest X‑ray as the initial study for stable pediatric hemoptysis, CF acute symptoms, bronchiolitis, suspected vascular ring, or other conditions) may affect authorization.

Document prior studies and dates; include prior reports or secondary interpretation (use CPT 76140 for outside study interpretation)
Chest X‑ray is the recommended initial study in many pediatric chest presentations; obtain and document as indicated

Billing Rule

Limited CT (CPT 76380) — appropriate use and misuse

Limited or follow‑up CT (CPT 76380) describes targeted CT work where a full diagnostic CT is not performed. Do not bill CPT 76380 for treatment‑planning CTs, 'extra slices', or to supplement other diagnostic CT codes. Inappropriate use may be denied.

Common uses: limited slices for known pulmonary nodule, limited sinus protocol, limited slices for non‑healing fracture
Do not report CPT 76380 in conjunction with full diagnostic CT codes to bypass full CT reporting

Documentation Required

Verify applicable benefit requirements

Verify applicable benefit, federal, state (OAC), and contractual plan requirements before requesting authorization. This policy is informational; coverage and prior authorization requirements may vary by member plan, and state or contractual rules govern in case of conflict.

Check member's federal, state (OAC) or contractual benefit plan for prior authorization and coverage specifics
This guideline does not replace plan‑level benefit determinations

Definitions

Investigational and Experimental Studies — definition and criteria

DefinitionInvestigational/experimental studies are those lacking sufficient peer-reviewed evidence of clinical utility, improved health outcomes, or collective specialty support

Evidence requirementsSupport requires credible scientific evidence such as well-conducted randomized trials, cohort studies of sufficient power, or recognized specialty society recommendations

Coverage implicationProcedures deemed investigational/experimental are not supported for routine coverage (may be limited to research contexts)

Pediatric Imaging Guidelines applicability — individuals <=18 years

Applicability agePediatric Imaging Guidelines apply to individuals 18 years old or younger

Older individualsIndividuals >18 years follow the General Imaging Guidelines unless a pediatric section specifically directs otherwise

Use instructionWhen a condition is not listed in the Pediatric Imaging Guidelines, follow the General Imaging Guidelines

Standard/conventional imaging — plain film, CT, MRI, or ultrasound used in initial and subsequent evaluations

Standard imaging definitionStandard/conventional imaging includes plain film (X-ray), CT, MRI, or ultrasound used in initial and subsequent evaluations

Role in evaluationStandard imaging is most often performed in initial and subsequent evaluations; advanced modalities used when conventional imaging is inconclusive or inadequate

Contrast selectionAppropriate contrast level is determined by condition-specific guideline sections

Concurrent supervision — active physician participation definition

DefinitionConcurrent supervision is active physician participation in and monitoring of reconstruction/post-processing (design of region, tissue/structure selection, image selection for archive, monitoring/adjustment)

Documentation expectationPhysician supervision/participation should be documented when billing 3D rendering codes (CPT 76376/76377)

Billing consequenceLack of documented concurrent supervision may trigger claim denial for 3D rendering codes

Limited CT (CPT 76380) — definition

DefinitionLimited CT (CPT 76380) describes a CT scan where the work of a full diagnostic code is not performed, used for targeted follow-up slices (e.g., limited slices through a known pulmonary nodule)

Not for treatment planningCPT 76380 is not indicated for treatment planning and should not be used to cover 'extra slices' inappropriately

Reporting guidanceNo specific slice or sequence counts are defined in CPT definitions; use only when full diagnostic work is not performed

SPECT‑CT — hybrid imaging definition

DefinitionSPECT‑CT is hybrid imaging combining SPECT nuclear medicine and CT to provide combined functional and anatomic information and attenuation correction

Common usesCommon SPECT‑CT studies include MIBG and octreotide scintigraphy; CPT 78072 applies to SPECT‑CT parathyroid imaging

Coding optionsHybrid Nuclear/CT scans can be reported as CPT 78830 (single area, single day), 78831 (2+ days), or 78832 (2 areas with one- and two-day study)

Quantitative mp‑MRI — definition and investigational status

DefinitionQuantitative multiparametric MRI (mp‑MRI) is software-based analysis of MR data to assess tissue physiology

Coverage stanceCategory III quantitative mp‑MRI CPT codes are considered investigational and experimental and not medically necessary for routine clinical practice

Common examplesCategory III codes include 0648T, 0649T, 0697T, 0698T, 0865T, and 0866T used for various organ analyses

Pediatric population — individuals <=18 years note

DefinitionPediatric population = individuals who are 18 years old or younger

Imaging assignmentThose <=18 years should be imaged per Pediatric Chest Imaging Guidelines; >18 follow General Chest Imaging Guidelines unless directed otherwise

Clinical implicationPediatric disease presentations and imaging needs may differ from adults; follow pediatric-specific recommendations when available

MRI Chest without and with contrast — CPT 71552 note

CPT referenceMRI Chest without and with contrast is reported using CPT 71552

Usage noteMRI chest is generally performed without and with contrast unless there is a documented contraindication to gadolinium

Anesthesia coordinationConsider combining without and with contrast sequences in same MRI session to avoid repeat anesthesia exposure in children

nodule — definition

DefinitionNodule: a pulmonary or pleural lesion that is a discrete, spherical opacity 2–30 mm in diameter surrounded by normal lung tissue

DistinctionLesions larger than 30 mm are considered masses; linear or scarring opacities are not nodules

Clinical relevanceNodule characterization guides use of CT Chest with contrast (71260) for one-time evaluation

Congenital cystic lung disease — definition and examples

DefinitionCongenital cystic lung disease includes congenital pulmonary airway malformation, bronchogenic cyst, and congenital lobar overinflation

DetectionMay be identified prenatally or incidentally on chest radiograph

Imaging approachCT Chest with contrast (71260) is appropriate when a lung lesion is suspected; MRI (71552) if CT is inconclusive or for pre-operative planning

Vascular ring — definition

DefinitionVascular ring: a congenital vascular anomaly that can present with respiratory symptoms (stridor, wheeze, cough) or feeding difficulties

Clinical presentationMay present with respiratory symptoms or feeding problems; imaging pathway includes chest X‑ray, barium esophagram, then cross‑sectional vascular imaging

Imaging stepsCT Chest with contrast (71260), CTA (71275), or MRA (71555) used to define anatomy after initial studies

Congenital cystic lung lesions — definition

DefinitionCongenital cystic lung lesions: includes congenital pulmonary airway malformation (congenital cystic adenomatoid malformation), bronchogenic cyst, and congenital lobar overinflation

Clinical noteMay be identified prenatally or on chest X‑ray and evaluated with CT or MRI as indicated

Imaging preferenceCT with contrast (71260) appropriate when lesion suspected; MRI (71552) for inconclusive CT or preoperative planning

Pulmonary arteriovenous malformations (PAVMs) — definition

DefinitionPulmonary arteriovenous malformations (PAVMs) are abnormal communications between pulmonary arteries and pulmonary veins

PresentationMay present with hypoxemia or hemoptysis

Imaging approachChest X‑ray indicated as initial imaging; CTA or MRA appropriate for treatment planning when AVM known or suspected

Congenital diaphragmatic hernia (CDH) — definition and note

DefinitionCongenital diaphragmatic hernia (CDH) is a diaphragmatic defect allowing abdominal organs into the chest cavity, potentially compromising pulmonary function

EpidemiologyMost CDH are diagnosed prenatally or shortly after delivery; majority are posterolateral (Bochdalek) hernias

Imaging stepsChest X‑ray and/or ultrasound chest (76604) indicated initially; CT chest with contrast (71260) or MRI chest (71552) appropriate when inconclusive or for treatment planning

OpenPayer

Pediatric Chest Imaging Guidelines (Ohio)

Coverage Criteria

Covered Indications and Appropriate Use

Coding and Billing Guidance

Provider Actions and Authorization

Contrast and Safety Rules

Frequency Limits and Monitoring Intervals

Prior Authorization Specifics

Definitions

Not Covered / Investigational

Background and Scope

Revision History