Which advanced outpatient imaging procedures require notification/prior authorization?
Radiology services not covered by listed Procedure-4 procedure codes should be billed with the appropriate unlisted Procedure-4 code. The following Procedure-4 unlisted codes require authorization on a Treatment Authorization Request (TAR):
Procedure-4 Code Description
76496 Unlisted fluoroscopic procedure (eg, diagnostic, interventional)
76497 Unlisted computed tomography procedure (eg, diagnostic, interventional)
76498 Unlisted magnetic resonance procedure (eg, diagnostic, interventional)
76499 Unlisted diagnostic radiographic procedure
Include a comprehensive report of the service billed in the Remarks field (Box 80)/Reserved for Local Use field (Box 19) of the claim or as an attachment to the claim.
Notification/prior authorization is required for certain instances of the following advanced outpatient imaging procedures:
• Computerized tomography (CT)
• Magnetic resonance imaging (MRI)
• Magnetic resonance angiography (MRA)
• Positron-emission tomography (PET)
• Nuclear medicine
• Nuclear cardiology
For the most current listing of CPT® codes for which notification/prior authorization is required pursuant to the protocol, refer to UHCprovider.com/radiology.
If you don’t request notification/prior authorization or verify that one has been obtained before rendering an advanced outpatient imaging procedure, it may result in an administrative claim denial. You cannot bill members for the services.
UnitedHealthcare Medicare Advantage Radiology Prior Authorization CPT® Code List
The table belowcontains theCPT® andHCPCS codes that apply to ourUnitedHealthcare Medicare Advantage Radiology Prior Authorization program. Details regarding this rogram are available at UHCprovider.com > Prior Authorization and Notification Resources > Radiology. Click on Medicare Advantage under Specific Radiology Programs. You can verify if prior authorization is required or initiate a request by calling 866-889-8054.
RADIOLOGY CPT CODE REQUIRE Authorization
78012 THYROID UPTAKE MEASUREMENT NM 78231 SALIVARY GLND IMG SRL IMAGE NM
78013 THYROID IMAGING W/BLOOD FLOW NM 78232 SALIVARY GLND FUNCJ STD NM
78014 THYROID IMG W/BF W/QUANT MEAS NM 78258 ESOPHGL MOTILITY NM
78015 THYR CARC METASTASES IMG LMTD AREA NM 78261 GSTR MUCOSA IMG NM
78016 THYR CARC METASTASES IMG ADDL STD NM 78262 G-ESOP RFLX STD NM
78018 THYR CARC METASTASES IMG WHBDY NM 78264 GSTR EMPTYING STD NM
78070 PARATHYR IMG NM 78265 GASTRIC EMPTYING IMAG STUDY NM
78071 PARATHYRD PLANAR W/WO SUBTRJ NM 78266 GASTRIC EMPTYING IMAG STUDY NM
78072 PARATHYRD PLANAR W/SPECT&CT NM 78278 AQT GI BLD LOSS IMG NM
78075 ADRNL IMG CORTEX&/MEDULLA NM 78282 GI PROTEIN LOSS NM
78099 UNLIS ENDOC PX DX NUC MED NM 78290 INT IMG NM
78102 B1 MARROW IMG LMTD AREA NM 78291 PRTL-VEN SHUNT PATENCY TST NM
78103 B1 MARROW IMG MLT AREAS NM 78299 UNLIS GI PX DX NUC MED NM
78104 B1 MARROW IMG WHBDY NM 78300 B1&/JT IMG LMTD AREA NM
78185 SPLEEN IMG ONLY +-VASC FLO NM 78305 B1&/JT IMG MLT AREAS NM
78195 LYMPHATICS&LYMPH NOD IMG NM 78306 B1&/JT IMG WHBDY NM
78199 UNLIS HEMATOP RET/ENDO&LYMPHATIC DX NUC MED NM
78315 B1&/JT IMG 3 PHASE STD NM
78201 LVR IMG STATIC ONLY NM 78399 UNLIS MUSCSKEL PX DX NUC MED NM
78202 LVR IMG VASC FLO NM 78428 CAR SHUNT DETCJ NM
78215 LVR&SPLEEN IMG STATIC ONLY NM 78445 NON-CAR VASC FLO IMG NM
78216 LVR&SPLEEN IMG VASC FLO NM 78451 MYOCARDIAL SPECT MULTIPLE STUDIES NM
78226 HEPATOBILIARY SYST IMAGING INCLUDING GALLBLADDER NM
78452 MYOCARDIAL SPECT MULTIPLE STUDIES NM
78227 HEPATOBIL SYST IMAG INC GB W/PHARMA INTERVENJ NM
78453 MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/ NM
78230 SALIVARY GLND IMG NM 78454 MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES NM
78456 AQT VEN THROMBOSIS IMG PEPTIDE NM
What information may be requested for a notification/prior authorization request to be reviewed?
The following information may be requested:
• Member’s name, address, phone number and date of birth, member identification (ID) and group number
• Ordering care provider’s name, tax (ID) number (TIN)/ National Provider Identifier (NPI) number
• Ordering care provider’s mailing address, phone and fax number and email address
• Rendering care provider’s name, mailing address, phone number and TIN/NPI number (if different than the ordering provider)
• The imaging procedure(s) being requested, with the CPT code(s)
• The working diagnosis with the appropriate ICD code(s)
• The member’s clinical condition including any symptoms, listed in detail, with severity and duration
• Treatments that have been received, including dosage and duration for drugs; and dates for other therapies.
• Any other information that will help in evaluating whether the service ordered meets current evidence-based clinical guidelines, including but not limited to, prior diagnostic tests and consultation reports.
To help ensure proper payment, the ordering care provider must communicate the notification/authorization number to the rendering care provider.
Does the notification/prior authorization process have to be completed for each advanced outpatient imaging procedure ordered?
Yes. The notification/prior authorization process must be completed for each individual CPT code. Each notification/authorization number is CPT code-specific. Notification/authorization numbers are not required to be included on the claim form.