2011 Master Radiology CPT Code List
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2011 Radiology Prior Notification/ Authorization CPT Code List
The table below contains the CPT and HCPCS codes that apply to our radiology prior notification and prior authorization programs. Details regarding each individual program and program effective dates by state are available at www.UnitedHealthcareOnline.com. To verify specific notification/authorization requirements by member, please contact 866-889-8054.
Procedure Code Description Procedure Code Description
Modality CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT
Modality CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT
70450 70460 70470 70480 70481 70482 70486 70487 70488 70490 70491 70492 70496 70498 71250 71260 71270 71275 72125 72126 72127 72128 72129 72130 72131 72132 72133 72191 72192 72193
CT HEAD/BRN C-MATRL CT HEAD/BRN C+ MATRL CT HEAD/BRN C-/C+ CT ORBIT SELLA/POST FOSSA/EAR C-MATRL CT ORBIT SELLA/POST FOSSA/EAR C+ MATRL CT ORBIT SELLA/POST FOSSA/EAR C-/C+ CT MAXLFCL AREA C-MATRL CT MAXLFCL AREA C+ MATRL CT MAXLFCL AREA C-/C+ CT SOFT TISS NCK C-MATRL CT SOFT TISS NCK C+ MATRL CT SOFT TISS NCK C-/C+ CT ANGIOGRAPHY HEAD W/CONTRAST/ NONCONTRAST CT ANGIOGRAPHY NECK W/CONTRAST/ NONCONTRAST CT THORAX C-MATRL CT THORAX C+ MATRL CT THORAX C-/C+ CT ANGIOGRAPHY CHEST W/CONTRAST/ NONCONTRAST CT CRV SPI C-MATRL CT CRV SPI C+ MATRL CT CRV SPI C-/C+ CT THRC SPI C-MATRL CT THRC SPI C+ MATRL CT THRC SPI C-/C+ CT LMBR SPI C-MATRL CT LMBR SPI C+ MATRL CT LMBR SPI C-/C+ CT ANGIOGRAPHY PELVIS W/CONTRAST/ NONCONTRAST CT PELVIS C-MATRL CT PELVIS C+ MATRL
72194 73200 73201 73202 73206 73700 73701 73702 73706 74150 74160 74170 74175 74176 74177 74178 74261 74262 74263* 75571 75572 75573 75574 75635
CT PELVIS C-/C+ CT UXTR C-MATRL CT UXTR C+ MATRL CT UXTR C-/C+ CT ANGIOGRAPHY UPPER EXTREMITY CT LXTR C-MATRL CT LXTR C+ MATRL CT LXTR C-/C+ CT ANGIOGRAPHY LOWER EXTREMITY CT ABD C-MATRL CT ABD C+ MATRL CT ABD C-/C+ CT ANGIOGRAPHY ABDOMEN W/ CONTRAST/NONCONTRAST CT ABD & PELVIS W/O CONTRAST CT ABD & PELVIS W/CONTRAST CT ABD & PELVIS W/O CONTRST 1+ BODY REGNS CT COLONOGRPHY DX IMAGE POSTPROCESS NO CONTRAST CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSING CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT DX CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST CTA AA&BI ILIOFEM LXTR RS&I C-/C+ POSTPXESSING
* Medicare Non-covered ^ UnitedHealthcare Non-covered
Page 1 of 4
Procedure Code Description
Modality CT CT CT CT
Procedure Code Description
Modality MR MR MR MR MR MR MR MR MR MR MR MR
76380 76497 0159T^ S8092*
CT LMTD/LOCLZD F-UP STD UNLIS CT PX CPTR AID DETCJ BREAST MRI ELECTRON BEAM COMPUTED TOMOGRAPHY (ALSO KNOWN AS ULTRAFAST CT, CINET) MRI TMPRMAND JT MRI ORBIT FACE &/NECK W/O CONTRAST MRI ORBIT FACE&NCK C+ MATRL MRI ORBIT FACE&NCK C-/C+ MRA HEAD C-MATRL MRA HEAD C+ MATRL MRA HEAD C-/C+ MRA NCK C-MATRL MRA NCK C+ MATRL MRA NCK C-/C+ MRI BRN BRN STEM C-MATRL MRI BRN BRN STEM C+ MATRL MRI BRN BRN STEM C-/C+ MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION MRI CH C-MATRL MRI CH C+ MATRL MRI CH C-/C+ MRI SPI CANAL&CNTS CRV C-MATRL MRI SPI CANAL&CNTS CRV C+ MATRL MRI SPI CANAL&CNTS THRC C-MATRL MRI SPI CANAL&CNTS THRC C+ MATRL MRI SPI CANAL&CNTS LMBR C-MATRL MRI SPI CANAL&CNTS LMBR C+ MATRL MRI SPI CANAL&CNTS C-/C+ CRV MRI SPI CANAL&CNTS C-/C+ MRI SPI CANAL&CNTS C-/C+ LMBR MRI PELVIS C-MATRL MRI PELVIS C+ MATRL MRI PELVIS C-/C+ MRI UXTR OTH/THN JT C-MATRL MRI UXTR OTH/THN JT C+ MATRL MRI UXTR OTH/THN JT C-/C+ MRI ANY JT UXTR C-MATRL MRI ANY JT UXTR C+ MATRL MRI ANY JT UXTR C-/C+ MRI LXTR OTH/THN JT C-MATRL MRI IMG LXTR OTH/THN JT C+ MATRL MRI LXTR OTH/THN JT C-/C+ MRI ANY JT LXTR C-MATRL
73722 73723 74181 74182 75557
MRI ANY JT LXTR C+ MATRL MRI ANY JT LXTR C-/C+ MRI ABD C-MATRL MRI ABD C+ MATRL CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST CARDIAC MRI W/O CONTRAST W STRESS IMAGING CARDIAC MRI W/W/O CONTRAST & FURTHER SEQ CARDIAC MRI W/W/O CONTRAST W STRESS UNLIS MRI PX MR GUIDANCE NEEDLE PLACEMENT BONE MARROW BLOOD SUPPLY MRA CH C+-MATRL
70336 70540 70542 70543 70544 70545 70546 70547 70548 70549 70551 70552 70553 70554 70555 71550 71551 71552 72141 72142 72146 72147 72148 72149 72156 72157 72158 72195 72196 72197 73218 73219 73220 73221 73222 73223 73718 73719 73720 73721
MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR
75559 75561 75563 76498 77021 77084 71555/ C8909C8911 72159/ C8931C8933* 72198/ C8918C8920 73225/ C8934C8936* 73725/ C8912C8914 74183/ S8037* 74185/ C8900C8902 76390*^ 77058/ C8903C8905 77059/ C8906C8908 S8042* 78000 78001 78003 78006 78007 78010 78011 78015 78016 78018
MRA SPI CANAL&CNTS C+-MATRL
MR
MRA PELVIS C+-MATRL
MR
MRA UXTR C+-MATRL
MR
MRA LXTR C+-MATRL
MR
MRI ABD C-/C+ MRA ABD C+-MATRL
MR MR
MRI SPECTROSCOPY MRI BREAST UNILATERAL
MR MR
MRI BREAST BILATERAL
MR
MRI, LOW FIELD THYR UPTK 1 DETER THYR UPTK MLT DETERS THYR UPTK STIMJ SUPRJ/DSCHRG X 1ST UPTK STD THYR IMG UPTK 1 DETER THYR IMG UPTK MLT DETERS THYR IMG ONLY THYR IMG VASC FLO THYR CARC METASTASES IMG LMTD AREA THYR CARC METASTASES IMG ADDL STD THYR CARC METASTASES IMG WHBDY
MR NM NM NM NM NM NM NM NM NM NM
* Medicare Non-covered ^ UnitedHealthcare Non-covered
Page 2 of 4
Procedure Code Description
Modality NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM
Procedure Code Description
Modality NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM
78070 78075 78099 78102 78103 78104 78185 78195 78199 78201 78202 78205 78206 78215 78216 78220 78223 78230 78231 78232 78258 78261 78262 78264 78278 78282 78290 78291 78299 78300 78305 78306 78315 78320 78399 78428 78445 78451 78452 78453 78454 78456 78457 78458
PARATHYR IMG ADRNL IMG CORTEX&/MEDULLA UNLIS ENDOC PX DX NUC MED B1 MARROW IMG LMTD AREA B1 MARROW IMG MLT AREAS B1 MARROW IMG WHBDY SPLEEN IMG ONLY +-VASC FLO LYMPHATICS&LYMPH NOD IMG UNLIS HEMATOP RET/ENDO&LYMPHATIC DX NUC MED LVR IMG STATIC ONLY LVR IMG VASC FLO LVR IMG SPECT LVR IMG SPECT VASC FLO LVR&SPLEEN IMG STATIC ONLY LVR&SPLEEN IMG VASC FLO LVR FUNCJ STD HEPATBL AGT SRL IMAGES HEPATBL DUX SYS IMG GLBLDR SALIVARY GLND IMG SALIVARY GLND IMG SRL IMAGES SALIVARY GLND FUNCJ STD ESOPHGL MOTILITY GSTR MUCOSA IMG G-ESOP RFLX STD GSTR EMPTYING STD AQT GI BLD LOSS IMG GI PROTEIN LOSS INT IMG PRTL-VEN SHUNT PATENCY TST UNLIS GI PX DX NUC MED B1&/JT IMG LMTD AREA B1&/JT IMG MLT AREAS B1&/JT IMG WHBDY B1&/JT IMG 3 PHASE STD B1&/JT IMG TOMOG SPECT UNLIS MUSCSKEL PX DX NUC MED CAR SHUNT DETCJ NON-CAR VASC FLO IMG MYOCARDIAL SPECT MULTIPLE STUDIES MYOCARDIAL SPECT MULTIPLE STUDIES MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES AQT VEN THROMBOSIS IMG PEPTIDE VEN THROMBOSIS IMG VENOGRAM UNI VEN THROMBOSIS IMG VENOGRAM BI
78466 78468 78469 78472 78473 78483 78494 78499 78580 78584 78585 78586 78587 78588 78591 78593 78594 78596 78599 78600 78601 78605 78606 78607 78610 78630 78635 78645 78647 78650 78660 78699 78700 78701 78707 78708
MYOCRD IMG INFARCT AVID PLNR QUAL/ QUAN MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ MYOCRD IMG INFARCT AVID PLNR TOMOG SPECT +-QUAN CARD BPI GTD =BRM PLNR 1 STD REST/ STRS CARD BPI GTD =BRM MLT STD WALL MOTION STD CARD BPI PLNR 1ST PS MLT STD PLUS EJEC FXJ CARD BPI GTD =BRM SPECT REST WALL MOTION UNLIS CV DX NUC MED PULM PI PART PULM PI PART VNTJ 1 BRTH PULM PI PART VNTJ RBRTHING&WSHOT +-1 BRTH PULM VI AERSL 1 PROJECTION PULM VI AERSL MLT PRJCJ PULM PI PART VNTJ IMG AERSL 1/MLT PRJCJ PULM VI GASEOUS 1 PRJCJ PULM VI GASEOUS RBRTHING&WSHOT 1 PRJCJ PULM VI GASEOUS RBRTHING&WSHOT MLT PRJCJ PULM QUAN DIFFIAL FUNCJ VNTJ/PRFUJ STD UNLIS RESPIR PX DX NUC MED BRAIN IMAGING <4 STATIC VIEWS BRAIN IMAGING >4 STATIC VIEWS W VASCULAR FLOW BRAIN IMAGING MIN 4 STATIC VIEWS BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR FLOW BRAIN IMAGING TOMOGRAPHIC SPECT BRN IMG VASC FLO ONLY CEREBSP FLU FLO IMG X INTRO MATRL CISTRNG CEREBSP FLU FLO IMG X INTRO MATRL VENTRG CEREBSP FLU FLO IMG X INTRO MATRL SHUNT EVAL CEREBSP FLU FLO IMG X INTRO MATRL TOMOG SPECT CEREBSP FLU LEAKAGE DETCJ&LOCLZJ RP DACRYOCSTOGRAPY UNLIS NRVS SYS PX DX NUC MED KIDNEY IMAGING MORPHOLOGY KDN IMG VASC FLO KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/O RX KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W RX
* Medicare Non-covered ^ UnitedHealthcare Non-covered
Page 3 of 4
Procedure Code Description
Modality NM NM NM NM NM NM NM NM NM NM NM NM NM
Procedure Code Description
Modality NM
OTHER OTHER
78709 78710 78740 78761 78799 78800 78801 78802 78803 78804 78805 78806 78807
KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC URTRL RFLX STD RP VOIDING CSTOGRAM TESTICULAR IMAGING WITH VASCULAR FLOW UNLIS GENITOUR DX NUC MED RP LOCLZJ TUM/DSTRBJ AGT LMTD AREA RP LOCLZJ TUM/DSTRBJ AGT MLT AREAS RP LOCLZJ TUM/DSTRBJ AGT WHBDY 1 D IMG RP LOCLZJ TUM/DSTRBJ AGT TOMOG SPECT RP LOCLZJ TUM/DSTRBJ AGT WHBDY REQ 2/> D IMG RP LOCLZJ INFLAMMATORY PROCESS LMTD AREA RP LOCLZJ INFLAMMATORY PROCESS WHBDY RP LOCLZJ INFLAMMATORY PROCESS TOMOG SPECT
78999 76376 76377 78459 78491 78492 78608 78811 78812 78813 78814 78815 78816 78609* G0235* G0252* S8085*
UNLIS MISC DX NUC MED 3D RNDR I&R CT MRI US/OTH X REQ POSTPCX 3D RNDR I&R CT MRI US/OTH REQ POSTPCX MYOCRD IMG P+ EMIJ TOMOG METAB EVAL MYOCRD IMG P+ EMIJ TOMOG PRFUJ 1 STD MYOCRD IMG P+ EMIJ TOMOG PRFUJ MLT STD BRN IMG P+ EMIJ TOMOG METAB EVAL PET IMAGING LIMITED AREA CHEST HEAD/ NECK PET IMAGING SKULL BASE TO MID-THIGH PET IMAGING WHOLE BODY PET IMAGING CT FOR ATTENUATION LIMITED AREA PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH PET IMAGING FOR CT ATTENUATION WHOLE BODY BRN IMG P+ EMIJ TOMOG PRFUJ EVAL PET IMAGING, ANY SITE NOT OTHERWISE SPECIFIED PET, FULL AND PARTIAL RING, FOR INITIAL DX OF BREAST CANCER FLOURINE-18 IMAGING
PET PET PET PET PET PET PET PET PET PET PET PET PET PET PET
G0219*^ PET IMAGING WHOLE BODY
M47147 12/10 © 2010 United HealthCare Services, Inc. * Medicare Non-covered ^ UnitedHealthcare Non-covered
Page 4 of 4
The table below contains the CPT and HCPCS codes that apply to our radiology prior notification and prior authorization programs. Details regarding each individual program and program effective dates by state are available at www.UnitedHealthcareOnline.com. To verify specific notification/authorization requirements by member, please contact 866-889-8054.
Procedure Code Description Procedure Code Description
Modality CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT
Modality CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT
70450 70460 70470 70480 70481 70482 70486 70487 70488 70490 70491 70492 70496 70498 71250 71260 71270 71275 72125 72126 72127 72128 72129 72130 72131 72132 72133 72191 72192 72193
CT HEAD/BRN C-MATRL CT HEAD/BRN C+ MATRL CT HEAD/BRN C-/C+ CT ORBIT SELLA/POST FOSSA/EAR C-MATRL CT ORBIT SELLA/POST FOSSA/EAR C+ MATRL CT ORBIT SELLA/POST FOSSA/EAR C-/C+ CT MAXLFCL AREA C-MATRL CT MAXLFCL AREA C+ MATRL CT MAXLFCL AREA C-/C+ CT SOFT TISS NCK C-MATRL CT SOFT TISS NCK C+ MATRL CT SOFT TISS NCK C-/C+ CT ANGIOGRAPHY HEAD W/CONTRAST/ NONCONTRAST CT ANGIOGRAPHY NECK W/CONTRAST/ NONCONTRAST CT THORAX C-MATRL CT THORAX C+ MATRL CT THORAX C-/C+ CT ANGIOGRAPHY CHEST W/CONTRAST/ NONCONTRAST CT CRV SPI C-MATRL CT CRV SPI C+ MATRL CT CRV SPI C-/C+ CT THRC SPI C-MATRL CT THRC SPI C+ MATRL CT THRC SPI C-/C+ CT LMBR SPI C-MATRL CT LMBR SPI C+ MATRL CT LMBR SPI C-/C+ CT ANGIOGRAPHY PELVIS W/CONTRAST/ NONCONTRAST CT PELVIS C-MATRL CT PELVIS C+ MATRL
72194 73200 73201 73202 73206 73700 73701 73702 73706 74150 74160 74170 74175 74176 74177 74178 74261 74262 74263* 75571 75572 75573 75574 75635
CT PELVIS C-/C+ CT UXTR C-MATRL CT UXTR C+ MATRL CT UXTR C-/C+ CT ANGIOGRAPHY UPPER EXTREMITY CT LXTR C-MATRL CT LXTR C+ MATRL CT LXTR C-/C+ CT ANGIOGRAPHY LOWER EXTREMITY CT ABD C-MATRL CT ABD C+ MATRL CT ABD C-/C+ CT ANGIOGRAPHY ABDOMEN W/ CONTRAST/NONCONTRAST CT ABD & PELVIS W/O CONTRAST CT ABD & PELVIS W/CONTRAST CT ABD & PELVIS W/O CONTRST 1+ BODY REGNS CT COLONOGRPHY DX IMAGE POSTPROCESS NO CONTRAST CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSING CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT DX CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST CTA AA&BI ILIOFEM LXTR RS&I C-/C+ POSTPXESSING
* Medicare Non-covered ^ UnitedHealthcare Non-covered
Page 1 of 4
Procedure Code Description
Modality CT CT CT CT
Procedure Code Description
Modality MR MR MR MR MR MR MR MR MR MR MR MR
76380 76497 0159T^ S8092*
CT LMTD/LOCLZD F-UP STD UNLIS CT PX CPTR AID DETCJ BREAST MRI ELECTRON BEAM COMPUTED TOMOGRAPHY (ALSO KNOWN AS ULTRAFAST CT, CINET) MRI TMPRMAND JT MRI ORBIT FACE &/NECK W/O CONTRAST MRI ORBIT FACE&NCK C+ MATRL MRI ORBIT FACE&NCK C-/C+ MRA HEAD C-MATRL MRA HEAD C+ MATRL MRA HEAD C-/C+ MRA NCK C-MATRL MRA NCK C+ MATRL MRA NCK C-/C+ MRI BRN BRN STEM C-MATRL MRI BRN BRN STEM C+ MATRL MRI BRN BRN STEM C-/C+ MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION MRI CH C-MATRL MRI CH C+ MATRL MRI CH C-/C+ MRI SPI CANAL&CNTS CRV C-MATRL MRI SPI CANAL&CNTS CRV C+ MATRL MRI SPI CANAL&CNTS THRC C-MATRL MRI SPI CANAL&CNTS THRC C+ MATRL MRI SPI CANAL&CNTS LMBR C-MATRL MRI SPI CANAL&CNTS LMBR C+ MATRL MRI SPI CANAL&CNTS C-/C+ CRV MRI SPI CANAL&CNTS C-/C+ MRI SPI CANAL&CNTS C-/C+ LMBR MRI PELVIS C-MATRL MRI PELVIS C+ MATRL MRI PELVIS C-/C+ MRI UXTR OTH/THN JT C-MATRL MRI UXTR OTH/THN JT C+ MATRL MRI UXTR OTH/THN JT C-/C+ MRI ANY JT UXTR C-MATRL MRI ANY JT UXTR C+ MATRL MRI ANY JT UXTR C-/C+ MRI LXTR OTH/THN JT C-MATRL MRI IMG LXTR OTH/THN JT C+ MATRL MRI LXTR OTH/THN JT C-/C+ MRI ANY JT LXTR C-MATRL
73722 73723 74181 74182 75557
MRI ANY JT LXTR C+ MATRL MRI ANY JT LXTR C-/C+ MRI ABD C-MATRL MRI ABD C+ MATRL CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST CARDIAC MRI W/O CONTRAST W STRESS IMAGING CARDIAC MRI W/W/O CONTRAST & FURTHER SEQ CARDIAC MRI W/W/O CONTRAST W STRESS UNLIS MRI PX MR GUIDANCE NEEDLE PLACEMENT BONE MARROW BLOOD SUPPLY MRA CH C+-MATRL
70336 70540 70542 70543 70544 70545 70546 70547 70548 70549 70551 70552 70553 70554 70555 71550 71551 71552 72141 72142 72146 72147 72148 72149 72156 72157 72158 72195 72196 72197 73218 73219 73220 73221 73222 73223 73718 73719 73720 73721
MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR
75559 75561 75563 76498 77021 77084 71555/ C8909C8911 72159/ C8931C8933* 72198/ C8918C8920 73225/ C8934C8936* 73725/ C8912C8914 74183/ S8037* 74185/ C8900C8902 76390*^ 77058/ C8903C8905 77059/ C8906C8908 S8042* 78000 78001 78003 78006 78007 78010 78011 78015 78016 78018
MRA SPI CANAL&CNTS C+-MATRL
MR
MRA PELVIS C+-MATRL
MR
MRA UXTR C+-MATRL
MR
MRA LXTR C+-MATRL
MR
MRI ABD C-/C+ MRA ABD C+-MATRL
MR MR
MRI SPECTROSCOPY MRI BREAST UNILATERAL
MR MR
MRI BREAST BILATERAL
MR
MRI, LOW FIELD THYR UPTK 1 DETER THYR UPTK MLT DETERS THYR UPTK STIMJ SUPRJ/DSCHRG X 1ST UPTK STD THYR IMG UPTK 1 DETER THYR IMG UPTK MLT DETERS THYR IMG ONLY THYR IMG VASC FLO THYR CARC METASTASES IMG LMTD AREA THYR CARC METASTASES IMG ADDL STD THYR CARC METASTASES IMG WHBDY
MR NM NM NM NM NM NM NM NM NM NM
* Medicare Non-covered ^ UnitedHealthcare Non-covered
Page 2 of 4
Procedure Code Description
Modality NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM
Procedure Code Description
Modality NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM
78070 78075 78099 78102 78103 78104 78185 78195 78199 78201 78202 78205 78206 78215 78216 78220 78223 78230 78231 78232 78258 78261 78262 78264 78278 78282 78290 78291 78299 78300 78305 78306 78315 78320 78399 78428 78445 78451 78452 78453 78454 78456 78457 78458
PARATHYR IMG ADRNL IMG CORTEX&/MEDULLA UNLIS ENDOC PX DX NUC MED B1 MARROW IMG LMTD AREA B1 MARROW IMG MLT AREAS B1 MARROW IMG WHBDY SPLEEN IMG ONLY +-VASC FLO LYMPHATICS&LYMPH NOD IMG UNLIS HEMATOP RET/ENDO&LYMPHATIC DX NUC MED LVR IMG STATIC ONLY LVR IMG VASC FLO LVR IMG SPECT LVR IMG SPECT VASC FLO LVR&SPLEEN IMG STATIC ONLY LVR&SPLEEN IMG VASC FLO LVR FUNCJ STD HEPATBL AGT SRL IMAGES HEPATBL DUX SYS IMG GLBLDR SALIVARY GLND IMG SALIVARY GLND IMG SRL IMAGES SALIVARY GLND FUNCJ STD ESOPHGL MOTILITY GSTR MUCOSA IMG G-ESOP RFLX STD GSTR EMPTYING STD AQT GI BLD LOSS IMG GI PROTEIN LOSS INT IMG PRTL-VEN SHUNT PATENCY TST UNLIS GI PX DX NUC MED B1&/JT IMG LMTD AREA B1&/JT IMG MLT AREAS B1&/JT IMG WHBDY B1&/JT IMG 3 PHASE STD B1&/JT IMG TOMOG SPECT UNLIS MUSCSKEL PX DX NUC MED CAR SHUNT DETCJ NON-CAR VASC FLO IMG MYOCARDIAL SPECT MULTIPLE STUDIES MYOCARDIAL SPECT MULTIPLE STUDIES MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES AQT VEN THROMBOSIS IMG PEPTIDE VEN THROMBOSIS IMG VENOGRAM UNI VEN THROMBOSIS IMG VENOGRAM BI
78466 78468 78469 78472 78473 78483 78494 78499 78580 78584 78585 78586 78587 78588 78591 78593 78594 78596 78599 78600 78601 78605 78606 78607 78610 78630 78635 78645 78647 78650 78660 78699 78700 78701 78707 78708
MYOCRD IMG INFARCT AVID PLNR QUAL/ QUAN MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ MYOCRD IMG INFARCT AVID PLNR TOMOG SPECT +-QUAN CARD BPI GTD =BRM PLNR 1 STD REST/ STRS CARD BPI GTD =BRM MLT STD WALL MOTION STD CARD BPI PLNR 1ST PS MLT STD PLUS EJEC FXJ CARD BPI GTD =BRM SPECT REST WALL MOTION UNLIS CV DX NUC MED PULM PI PART PULM PI PART VNTJ 1 BRTH PULM PI PART VNTJ RBRTHING&WSHOT +-1 BRTH PULM VI AERSL 1 PROJECTION PULM VI AERSL MLT PRJCJ PULM PI PART VNTJ IMG AERSL 1/MLT PRJCJ PULM VI GASEOUS 1 PRJCJ PULM VI GASEOUS RBRTHING&WSHOT 1 PRJCJ PULM VI GASEOUS RBRTHING&WSHOT MLT PRJCJ PULM QUAN DIFFIAL FUNCJ VNTJ/PRFUJ STD UNLIS RESPIR PX DX NUC MED BRAIN IMAGING <4 STATIC VIEWS BRAIN IMAGING >4 STATIC VIEWS W VASCULAR FLOW BRAIN IMAGING MIN 4 STATIC VIEWS BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR FLOW BRAIN IMAGING TOMOGRAPHIC SPECT BRN IMG VASC FLO ONLY CEREBSP FLU FLO IMG X INTRO MATRL CISTRNG CEREBSP FLU FLO IMG X INTRO MATRL VENTRG CEREBSP FLU FLO IMG X INTRO MATRL SHUNT EVAL CEREBSP FLU FLO IMG X INTRO MATRL TOMOG SPECT CEREBSP FLU LEAKAGE DETCJ&LOCLZJ RP DACRYOCSTOGRAPY UNLIS NRVS SYS PX DX NUC MED KIDNEY IMAGING MORPHOLOGY KDN IMG VASC FLO KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/O RX KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W RX
* Medicare Non-covered ^ UnitedHealthcare Non-covered
Page 3 of 4
Procedure Code Description
Modality NM NM NM NM NM NM NM NM NM NM NM NM NM
Procedure Code Description
Modality NM
OTHER OTHER
78709 78710 78740 78761 78799 78800 78801 78802 78803 78804 78805 78806 78807
KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC URTRL RFLX STD RP VOIDING CSTOGRAM TESTICULAR IMAGING WITH VASCULAR FLOW UNLIS GENITOUR DX NUC MED RP LOCLZJ TUM/DSTRBJ AGT LMTD AREA RP LOCLZJ TUM/DSTRBJ AGT MLT AREAS RP LOCLZJ TUM/DSTRBJ AGT WHBDY 1 D IMG RP LOCLZJ TUM/DSTRBJ AGT TOMOG SPECT RP LOCLZJ TUM/DSTRBJ AGT WHBDY REQ 2/> D IMG RP LOCLZJ INFLAMMATORY PROCESS LMTD AREA RP LOCLZJ INFLAMMATORY PROCESS WHBDY RP LOCLZJ INFLAMMATORY PROCESS TOMOG SPECT
78999 76376 76377 78459 78491 78492 78608 78811 78812 78813 78814 78815 78816 78609* G0235* G0252* S8085*
UNLIS MISC DX NUC MED 3D RNDR I&R CT MRI US/OTH X REQ POSTPCX 3D RNDR I&R CT MRI US/OTH REQ POSTPCX MYOCRD IMG P+ EMIJ TOMOG METAB EVAL MYOCRD IMG P+ EMIJ TOMOG PRFUJ 1 STD MYOCRD IMG P+ EMIJ TOMOG PRFUJ MLT STD BRN IMG P+ EMIJ TOMOG METAB EVAL PET IMAGING LIMITED AREA CHEST HEAD/ NECK PET IMAGING SKULL BASE TO MID-THIGH PET IMAGING WHOLE BODY PET IMAGING CT FOR ATTENUATION LIMITED AREA PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH PET IMAGING FOR CT ATTENUATION WHOLE BODY BRN IMG P+ EMIJ TOMOG PRFUJ EVAL PET IMAGING, ANY SITE NOT OTHERWISE SPECIFIED PET, FULL AND PARTIAL RING, FOR INITIAL DX OF BREAST CANCER FLOURINE-18 IMAGING
PET PET PET PET PET PET PET PET PET PET PET PET PET PET PET
G0219*^ PET IMAGING WHOLE BODY
M47147 12/10 © 2010 United HealthCare Services, Inc. * Medicare Non-covered ^ UnitedHealthcare Non-covered
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