Radiology Prior Authorization CPT Code List ...

1 1 Radiology | Prior AuthorizationPCA-1-22-01799-VC-WEB_05262 022-POCPT codeDescriptionModality70450CT HEAD/BRN C-MATRLCT70460CT HEAD/BRN C+ MATRLCT70470CT HEAD/BRN C-/C+CT70480CT ORBIT SELLA/POST FOSSA/EAR C-MATRLCT70481CT ORBIT SELLA/POST FOSSA/EAR C+ M AT RLCT70482CT ORBIT SELLA/POST FOSSA/EAR C-/C+CT70486CT MAXLFCL AREA C-MATRLCT70487CT MAXLFCL AREA C+ MATRLCT70488CT MAXLFCL AREA C-/C+CT70490CT SOFT TISS NCK C-MATRLCT70491CT SOFT TISS NCK C+ MATRLCT70492CT SOFT TISS NCK C-/C+CT70496CT ANGIOGRAPHY HEAD W/CONTRAST/ NONCONTRASTCT70498CT ANGIOGRAPHY NECK W/CONTRAST/ NONCONTRASTCT71250CT THORAX C-MATRLCT71260CT THORAX C+ MATRLCT71270CT THORAX C-/C+CT71275CT ANGIOGRAPHY CHEST W/CONTRAST/ NONCONTRASTCT72125CT CRV SPI C-MATRLCT72126CT CRV SPI C+ MATRLCT72127CT CRV SPI C-/C+CT72128CT THRC SPI C-MATRLCT72129CT THRC SPI C+ MATRLCT72130CT THRC SPI C-/C+CT72131CT LMBR SPI C-MATRLCT72132CT LMBR SPI C+ MATRLCT72133CT LMBR SPI C-/C+CTUnitedHealthcare Community Plan Radiology Prior Authorization CPT code listThe table below contains the CPT and Healthcare Common Procedure Coding System codes that apply to our UnitedHealthcare Community Plan Radiology Prior Authorization program.

2 Details regarding program effective dates by state are available at Click on Community Plan under Specific Radiology Programs. You can verify if Prior Authorization is required or initiate a request by calling 866-889-8054. CPT codeDescriptionModality72191CT ANGIOGRAPHY PELVIS W/CONTRAST/ NONCONTRASTCT72192CT PELVIS C-MATRLCT72193CT PELVIS C+ MATRLCT72194CT PELVIS C-/C+CT73200CT UXTR C-MATRLCT73201CT UXTR C+ MATRLCT73202CT UXTR C-/C+CT73206CT ANGIOGRAPHY UPPER EXTREMITYCT73700CT LXTR C-MATRLCT73701CT LXTR C+ MATRLCT73702CT LXTR C-/C+CT73706CT ANGIOGRAPHY LOWER EXTREMITYCT74150CT ABD C-MATRLCT74160CT ABD C+ MATRLCT74170CT ABD C-/C+CT74174CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMGESCT74175CT ANGIOGRAPHY ABDOMEN W/CONTRAST/ NONCONTRASTCT74176CT ABD & PELVIS W/O CONTRASTCT74177CT ABD & PELVIS W/CONTRASTCT74178CT ABD & PELVIS W/O CONTRST 1+ BODY REGNSCT74261CT COLONOGRPHY DX IMAGE POSTPROCESS NO CONTRASTCT74262CT COLONOGRPHY DX IMAGE POSTPROCESS W/ CONTRASTCT2 CPT

3 CodeDescriptionModality74263CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSINGCT75571CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUMCT75572CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPHCT75573CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT DXCT75574 CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POSTCT75635 CTA AA&BI ILIOFEM LXTR RS&I C-/C+ POST- PXESSINGCT76380CT LMTD/LOCLZD F-UP STDCT76497 UNLIS CT PXCT71271CT THORAX C-MATRL LOW DOSECTS8092 ELECTRON BEAM COMPUTED TOMOGRAPHY (ALSO KNOWN AS ULTRAFAST CT, CINET)CT0501 TFFR-CT (GLOBAL)CT0502 TFFR-CT (DATA PREP & TRANS)CT0503 TFFR-CT (VENDOR TECH COMPONENT)CT0504 TFFR-CT (INTER & REPORT MD)CT0633 TCT BREAST W/3D UNI C-CT0634 TCT BREAST W/3D UNI C+CT0635 TCT BREAST W/3D UNI C-/C+CT0636 TCT BREAST W/3D BI C-CT0637 TCT BREAST W/3D BI C+CT0638 TCT BREAST W/3D BI C-/C+CT0710T1,4N-INVAS ARTL PLAQ ALYS DATA PRP QUANREVIEW I&RCT0711T1,4N-INVAS ARTL PLAQ ALYS DATA PREP &TRANSMISSIONCT0712T1,4N-INVAS ARTL PLAQ ALYS QUANSTRUX&COMPOS VSL WALCT0713T1.

4 4N-INVAS ARTL PLAQ ALYS DATA REVIEW I&RCT70336 MRI TMPRMAND JTMR70540 MRI ORBIT FACE &/NECK W/O CONTRASTMR70542 MRI ORBIT FACE&NCK C+ MATRLMR70543 MRI ORBIT FACE&NCK C-/C+MR70544 MRA HEAD C-MATRLMR70545 MRA HEAD C+ MATRLMR70546 MRA HEAD C-/C+MR70547 MRA NCK C-MATRLMR70548 MRA NCK C+ MATRLMR70549 MRA NCK C-/C+MR70551 MRI BRN BRN STEM C-MATRLMR70552 MRI BRN BRN STEM C+ MATRLMR70553 MRI BRN BRN STEM C-/C+MR705541 MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATIONMR70555 MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATIONMR71550 MRI CH C-MATRLMRCPT codeDescriptionModality71551 MRI CH C+ MATRLMR71552 MRI CH C-/C+MR72141 MRI SPI CANAL&CNTS CRV C-MATRLMR72142 MRI SPI CANAL&CNTS CRV C+ MATRLMR72146 MRI SPI CANAL&CNTS THRC C-MATRLMR72147 MRI SPI CANAL&CNTS THRC C+ MATRLMR72148 MRI SPI CANAL&CNTS LMBR C-MATRLMR72149 MRI SPI CANAL&CNTS LMBR C+ MATRLMR72156 MRI SPI CANAL&CNTS C-/C+ CRVMR72157 MRI SPI CANAL&CNTS C-/C+MR72158 MRI SPI CANAL&CNTS C-/C+ LMBRMR72195 MRI PELVIS C-MATRLMR72196 MRI PELVIS C+ MATRLMR72197 MRI PELVIS C-/C+MR73218 MRI UXTR OTH/THN JT C-MATRLMR73219 MRI UXTR OTH/THN JT C+ MATRLMR73220 MRI UXTR OTH/THN JT C-/C+MR73221 MRI ANY JT UXTR C-MATRLMR73222 MRI ANY JT UXTR C+ MATRLMR73223 MRI ANY JT UXTR C-/C+MR73718 MRI LXTR OTH/THN JT C-MATRLMR73719 MRI IMG LXTR OTH/THN JT C+ MATRLMR73720 MRI LXTR OTH/THN JT C-/C+MR73721 MRI ANY JT LXTR C-MATRLMR73722 MRI ANY JT LXTR C+ MATRLMR73723 MRI ANY JT LXTR C-/C+MR74181 MRI ABD C-MATRLMR74182 MRI ABD C+ MATRLMR74712 MRI FETAL SNGL/1ST

5 GESTATIONMR74713 MRI FETAL EA ADDL GESTATIONMR75557 CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRASTMR75559 CARDIAC MRI W/O CONTRAST W STRESS IMAGINGMR75561 CARDIAC MRI W/W/O CONTRAST & FURTHER SEQMR75563 CARDIAC MRI W/W/O CONTRAST W STRESSMR76390 MRI SPECTROSCOPYMR76391 MRE (MAGNETIC RESONANCE ELASTOGRAPHY)MR76498 UNLIS MRI PX MR77021MR GUIDANCE NEEDLE PLACEMENTMR77084 BONE MARROW BLOOD SUPPLY MR71555 MRA CH C+-MATRLMRC8909 MRA CH C+-MATRL MRC8910 MRA CH C+-MATRLMRC8911 MRA CH C+-MATRLMR72159 MRA SPI CANAL&CNTS C+-MATRLMRC8931 MR ANGIOGRAPHY W/CONTRAST SPINAL CANAL CONTENTSMRPCA-1-22-01799-VC-WEB_05262022 -PO3 CPT codeDescriptionModalityC8932MR ANGIOGRAPHY W/O CONTRST SPINAL CANAL CONTENTSMRC8933MR ANGIO NO CONTRST FLW W/CONTRST SP CANAL CNTNMR72198 MRA PELVIS C+-MATRLMRC8918 MRA PELVIS C+-MATRLMRC8919 MRA PELVIS C+-MATRLMRC8920 MRA PELVIS C+-MATRL MR73225 MRA UXTR C+-MATRLMRC8934MR ANGIOGRAPHY WITH CONTRAST UPPER EXTREMITYMRC8935MR ANGIOGRAPHY WITHOUT CONTRAST UPPER EXTREMITYMRC8936 ANGIO W/O CONTRST FOLLOWED W/CONTRST UP EXTMR73725 MRA LXTR

6 C+-MATRLMRC8912 MRA LXTR C+-MATRLMRC8913 MRA LXTR C+-MATRLMRC8914 MRA LXTR C+-MATRLMR74183 MRI ABD C-/C+MRS8037 MRI ABD C-/C+MR74185 MRA ABD C+-MATRLMRC8900 MRA ABD C+-MATRLMRC8901 MRA ABD C+-MATRLMRC8902 MRA ABD C+-MATRLMR77046 MRI BREAST C- UNILATERALMR77047 MRI BREAST C- BILATERALMR77048 MRI BREAST C-+ W/CAD UNIMR77049 MRI BREAST C-+ W/CAD BIMRC8903 MRI BREAST UNILATERALMRC8905 MRI BREAST UNILATERALMRC8906 MRI BREAST BILATERALMRC8908 MRI BREAST BILATERALMRS8042 MRI, LOW FIELDMR0697T1,4 QUAN MR ALYS TIS COMPJ WO MRI SAME SESS MLT ORGNMR0698T1,4 QUAN MR ALYS TISS COMPOSITION W/MRI MLT ORGANSMR78012 THYROID UPTAKE MEASUREMENTNM78013 THYROID IMAGING W/BLOOD FLOWNM78014 THYROID IMG W/BF W/QUANT MEASNM78015 THYR CARC METASTASES IMG LMTD AREANM78016 THYR CARC METASTASES IMG ADDL STDNM78018 THYR CARC METASTASES IMG WHBDYNM78070 PARATHYR IMGNM78071 PARATHYRD PLANAR W/WO SUBTRJNM78072 PARATHYRD PLANAR W/SPECT&CTNM78075 ADRNL IMG CORTEX&/MEDULLANM78099 UNLIS ENDOC PX DX NUC MEDNM78102B1 MARROW IMG LMTD AREANMCPT codeDescriptionModality78103B1 MARROW IMG MLT AREASNM78104B1 MARROW IMG WHBDYNM78185 SPLEEN IMG ONLY +-VASC FLONM78195 LYMPHATICS&LYMPH NOD IMGNM78199 UNLIS HEMATOP RET/ENDO&LYMPHATIC DX NUC MEDNM78201 LVR IMG STATIC ONLYNM78202 LVR IMG VASC FLO NM78215 LVR&SPLEEN IMG STATIC

7 ONLYNM78216 LVR&SPLEEN IMG VASC FLONM78226 HEPATOBILIARY SYST IMAGING INCLUDING GALLBLADDERNM78227 HEPATOBIL SYST IMAG INC GB W/PHARMA INTERVENJNM78230 SALIVARY GLND IMGNM78231 SALIVARY GLND IMG SRL IMAGESNM782321 SALIVARY GLND FUNCJ STDNM782581 ESOPHGL MOTILITYNM782611 GSTR MUCOSA IMGNM782621 G-ESOP RFLX STDNM78264 GSTR EMPTYING STDNM78265 GASTRIC EMPTYING IMAG STUDYNM78266 GASTRIC EMPTYING IMAG STUDYNM78278 AQT GI BLD LOSS IMGNM782821 GI PROTEIN LOSSNM78290 INT IMGNM782911 PRTL-VEN SHUNT PATENCY TSTNM78299 UNLIS GI PX DX NUC MEDNM78300B1&/JT IMG LMTD AREANM78305B1&/JT IMG MLT AREASNM78306B1&/JT IMG WHBDYNM78315B1&/JT IMG 3 PHASE STDNM78399 UNLIS MUSCSKEL PX DX NUC MEDNM784281 CAR SHUNT DETCJNM78445 NON-CAR VASC FLO IMGNM78451 MYOCARDIAL SPECT MULTIPLE STUDIESNM78452 MYOCARDIAL SPECT MULTIPLE STUDIESNM78453 MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/ STRESSNM78454 MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIESNM78456 AQT VEN THROMBOSIS IMG PEPTIDENM784571 VEN THROMBOSIS IMG VENOGRAM UNINM784581 VEN THROMBOSIS IMG VENOGRAM BINM78466 MYOCRD IMG INFARCT AVID PLNR QUAL/QUANNM78468 MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQNM78469 MYOCRD IMG INFARCT AVID PLNR TOMOG SPECT +-QUANNM78472 CARD BPI GTD =BRM PLNR 1 STD REST/STRSNMPCA-1-22-01799-VC-WEB_0526202 2-POCPT codeDescriptionModality78473 CARD BPI GTD =BRM MLT STD WALL MOTION STDNM78481 CARD BL POOL PLANAR 1 STDY WAL MOTN EJECT FRACTNM78483 CARD BPI PLNR 1ST PS MLT STD PLUS EJEC FXJ NM78494 CARD BPI GTD =BRM SPECT REST WALL MOTIONNM78496

8 CARD BL POOL GATED 1 STDY REST RT VENT EJCT FRCTNM78499 UNLIS CV DX NUC MEDNM78579 PULMONARY VENTILATION IMAGINGNM78580 PULMONARY PERFUSION IMAGING PARTICULATENM78582 PULMONARY VENTILATION & PERFUSION IMAGINGNM78597 QUANT DIFFERENTIAL PULM PERFUSION W/WO IMAGINGNM78598 QUANT DIFF PULM PRFUSION & VENTLAJ W/WO IMAGINGNM78599 UNLIS RESPIR PX DX NUC MEDNM78600 BRAIN IMAGING <4 STATIC VIEWSNM78601 BRAIN IMAGING >4 STATIC VIEWS W VASCULAR FLOWNM78605 BRAIN IMAGING MIN 4 STATIC VIEWSNM78606 BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR FLOWNM78610 BRN IMG VASC FLO ONLYNM78630 CEREBSP FLU FLO IMG X INTRO MATRL CISTRNGNM78635 CEREBSP FLU FLO IMG X INTRO MATRL VENTRGNM78645 CEREBSP FLU FLO IMG X INTRO MATRL SHUNT EVALNM78650 CEREBSP FLU LEAKAGE DETCJ&LOCLZJNM78660RP DACRYOCSTOGRAPYNM78699 UNLIS NRVS SYS PX DX NUC MEDNM78700 KIDNEY IMAGING MORPHOLOGYNM78701 KDN IMG VASC FLONM78707 KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/O RXNM78708 KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W RXNM78709 KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLENM78740 URTRL RFLX STD RP VOIDING CSTOGRAMNM78761 TESTICULAR IMAGING WITH VASCULAR FLOWNM78799 UNLIS GENITOUR DX NUC MEDNM78800RP LOCLZJ TUM/DSTRBJ AGT LMTD AREANMCPT codeDescriptionModality78801RP LOCLZJ TUM/DSTRBJ AGT MLT AREASNM78802RP LOCLZJ TUM/DSTRBJ AGT WHBDY 1 D IMGNM78803RP LOCLZJ TUM/DSTRBJ AGT TOMOG SPECTNM78804RP LOCLZJ TUM/DSTRBJ AGT WHBDY REQ 2/> D IMGNM78830RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGINGNM78831RP LOCLZJ TUM SPECT 2 AREA 1D IMG/1 AREA

9 IMG>2+DNM78832RP LOCLZJ TUM SPECT CT 2 AREA 1D IMG/1 AR IMG>2+DNM78999 UNLIS MISC DX NUC MEDNM763763D RNDR I&R CT MRI US/OTH X REQ POSTPCXOTHER763773D RNDR I&R CT MRI US/OTH REQ POSTPCXOTHER784592,3 MYOCRD IMG PET METAB EVAL, SINGLE STUDY PET784912,3 MYOCRD IMG PET PRFUJ SINGLE STUDY REST/STRESSPET784922,3 MYOCRD IMG PET PRFUJ MULTIPLE STUDY REST & STRESSPET786082 BRN IMG P+ EMIJ TOMOG METAB EVALPET788112 PET IMAGING LIMITED AREA CHEST HEAD/ NECKPET788122 PET IMAGING SKULL BASE TO MID-THIGHPET788132 PET IMAGING WHOLE BODYPET788142 PET IMAGING CT FOR ATTENUATION LIMITED AREAPET788152 PET IMAGING CT ATTENUATION SKULL BASE MID- THIGHPET788162 PET IMAGING FOR CT ATTENUATION WHOLE BODYPET786092 BRN IMG P+ EMIJ TOMOG PRFUJ EVALPETG02352 PET IMAGING, ANY SITE NOT OTHERWISE SPECIFIEDPETG02522 PET, FULL AND PARTIAL RING, FOR INITIAL DX OF BREAST CANCERPETS8085 FLOURINE-18 IMAGINGPET784292,3 MYOCRD IMG PET METAB EVAL, SINGLE STUDY W/CTPET784302,3 MYOCRD IMG PET PRFUJ, SINGLE STUDY, REST/STRESS W/CTPET784312,3 MYOCRD IMG PET PRFUJ, MULTIPLE STUDIES, REST/STRESS W/CTPET784322,3 MYOCRD IMG PET PRFUJ + METAB EVAL STUDIES, W/DUAL RADIOTRACERPET784332,3 MYOCRD IMG PET PRFUJ + METAB EVAL STUDIES, W/DUAL RADIOTRACER W/CTPET1 Community Plan Non-covered for Louisiana2 UnitedHealthcare Community Plan Louisiana