CurrentUnitedHealthcarePolicy 2026R0104B

Contrast and Radiopharmaceutical Materials reimbursement

This UnitedHealthcare reimbursement policy governs when physicians and other qualified health care professionals will be reimbursed separately for high/low osmolar contrast materials and radiopharmaceutical materials for imaging and therapeutic procedures, and applies to UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

PayerUnitedHealthcare

PolicyContrast and Radiopharmaceutical Materials reimbursement

Policy CodePolicy 2026R0104B

Change TypeLists and verbiage updated

Effective Date

Next Review Date

Key ActionDo not separately reimburse contrast or radiopharmaceutical materials when billed with a facility place of service for procedures included in the facility case rate; allow separate reimbursement in non‑facility settings and in ASC (POS 24) when eligible.

SourceLink

POLICY UPDATE CHANGES

Policy lists (Contrast and Radiopharmaceutical Materials Code List and Eligible Imaging and Therapeutic Procedures Code List) were updated multiple times across 2024-2026.

Policy verbiage updated to reflect 'Qualified' Health Care Professional.

Transferred content to shared policy template that applies to both UnitedHealthcare Commercial and Individual Exchange benefit plans.

CMS 1500claim form this policy applies to

ASC (POS 24)facility setting where separate reimbursement allowed for certain codes

Up to 2 daysprior-day reporting window

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.

Coverage Criteria for Separate Reimbursement

Coverage criteria

Conditions under which separate reimbursement for contrast and radiopharmaceutical materials is allowed or disallowed:

ALL of the following

No separate reimbursement to physicians or other qualified health care professionals for High Osmolar Contrast Materials (HOCM), Low Osmolar Contrast Materials (LOCM) or Radiopharmaceutical Materials when submitted with a facility Place of Service (POS 19, 21, 22, 23, 24, 26, 34, 51, 52, 56, or 61).
Materials submitted with HCPCS codes A4641, A4642, A9500–A9700, J1245, Q3001, Q9951, Q9953, Q9954, Q9956, Q9957 and Q9958–Q9968 are not separately reimbursable with a facility POS because they are needed to perform the technical component or global service of the procedure.
Exception: Separate reimbursement to a physician for HOCM, LOCM or Radiopharmaceutical Materials will be allowed in an Ambulatory Surgical Center (ASC) (POS 24) when provided in conjunction with eligible imaging procedures that are not included on the CMS ASCFS Addendum BB. Procedures listed on the ASCFS Addendum BB include materials in the facility case rate and are not separately reimbursable.

ALL of the following

Separate reimbursement allowed to the Same Group Physician or Other Qualified Health Care Professional for HOCM, LOCM or Radiopharmaceutical Materials when reported on the same date of service with a procedure code that requires contrast or radiopharmaceutical materials.
Separate reimbursement is allowed for contrast and radiopharmaceutical materials reported with a date of service up to two days prior to a nuclear medicine imaging scan (CPT 78012–79999).
In accordance with CMS coding guidelines, A9512 will not be separately reimbursed when submitted with A9538 or A9560 on the same day by the Same Group Physician or Other Qualified Health Care Professional.

ALL of the following

Contrast and radiopharmaceutical materials will not be separately reimbursed if the associated imaging or nuclear medicine procedure is denied under another UnitedHealthcare reimbursement policy; the associated procedure must be eligible for reimbursement.

ALL of the following

Eligible Imaging and Therapeutic Procedures Code List includes codes whose descriptors indicate 'with contrast', 'with imaging guidance', or 'including radiologic localization', and additional codes determined by clinical review to require contrast or radiopharmaceutical materials.
Separate reimbursement up to two days prior applies only to nuclear medicine imaging scans (CPT 78012–79999), not to all eligible imaging or therapeutic procedures.

Referenced Codes, Mappings, and Timing

Referenced HCPCS codes and ASCFS mappingsHCPCSCovered

A4641	Contrast and radiopharmaceutical materials (ASCFS mappings to multiple nuclear medicine procedure codes)
A4642	ASCFS Contrast and Radiopharmaceutical Materials Code (mapped to specific ASCFS nuclear medicine codes)
A9500	Radiopharmaceutical/material code referenced in policy list
A9700	Radiopharmaceutical/material code referenced in policy list
J1245	Radiopharmaceutical/material code referenced in policy list
Q3001	Radiopharmaceutical/material code referenced in policy list
Q9951	Radiopharmaceutical/material code referenced in policy list
Q9953	Radiopharmaceutical/material code referenced in policy list
Q9954	Radiopharmaceutical/material code referenced in policy list
Q9956	Radiopharmaceutical/material code referenced in policy list

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Prior-day reporting window

AllowanceSeparate reimbursement allowed for contrast and radiopharmaceutical materials reported with a date of service up to 2 days prior to a nuclear medicine imaging scan (CPT 78012-79999).

Applicable procedure typeNuclear medicine imaging scans (CPT codes 78012-79999).

Timing restrictionUp to two days prior to the date of the nuclear medicine imaging scan.

LimitationPrior-day allowance applies only to nuclear medicine imaging scans, not to all eligible imaging or therapeutic procedures.

Provider Billing and Reimbursement Rules

Billing Rule

Provider billing rules and denial risks for contrast and radiopharmaceutical materials

Do not bill contrast or radiopharmaceutical materials separately when the imaging or nuclear medicine procedure is performed in a facility Place of Service and the materials are part of the facility technical component or facility case rate; separate reimbursement is allowed only in non‑facility settings and in ASC (POS 24) for eligible procedures. A9512 is not separately reimbursed when submitted the same day with A9538 or A9560 by the same group. Separate reimbursement in non‑facility settings is allowed when reported same date as the procedure, and contrast/radiopharmaceutical materials reported up to two days prior to a nuclear medicine imaging scan may be reimbursed separately.

Do not separately reimburse HOCM, LOCM or Radiopharmaceutical Materials when submitted with a facility POS (19, 21, 22, 23, 24, 26, 34, 51, 52, 56, or 61) because they are needed for the technical component or included in the facility case rate; procedures listed on the CMS ASCFS Addendum BB include materials in the facility case rate and are not separately reimbursable. [[see cited chunks]]
Separate reimbursement allowed in Ambulatory Surgical Center (POS 24) only when provided with eligible imaging procedures that are not included on the CMS ASCFS Addendum BB.
When performed in a non‑facility setting, separate reimbursement is allowed to the Same Group Physician or Other Qualified Health Care Professional when materials are reported the same date as a procedure code that requires them.

Definitions

Osmolar Contrast Materials

DefinitionAn iodine-based substance administered intravascularly, intra-articularly or intrathecally to enhance visibility of structures or fluids during imaging procedures (e.g., X-ray, MRI, CT) and diagnostic/interventional cardiovascular procedures.

Primary useEnhance visualization of anatomy or fluids during diagnostic and interventional imaging.

Administration routesIntravascular, intra-articular, intrathecal.

Radiopharmaceutical Materials

DefinitionRadioactive chemical or pharmaceutical preparations used as diagnostic or therapeutic agents.

PurposeUsed to perform diagnostic imaging or deliver targeted therapeutic radiation.