Preauthorization Requirements –
Effective Jan. 1, 2026

0439T

Myocardial contrast perfusion echocardiography, at rest or with stress, for assessment of myocardial ischemia or viability (List separately in addition to code for primary procedure)

76801

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation

76802

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)

76805

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation

76810

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)

76811

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation

76812

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)

76813

Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation

76814

Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation (List separately in addition to code for primary procedure)

76815

Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., fetal heartbeat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses

76816

Ultrasound, pregnant uterus, real time with image documentation, follow-up (e.g., re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus

76817

Ultrasound, pregnant uterus, real time with image documentation, transvaginal

76818

Fetal biophysical profile; with non-stress testing

76819

Fetal biophysical profile; without non-stress testing

76820

Doppler velocimetry, fetal; umbilical artery

76821

Doppler velocimetry, fetal; middle cerebral artery

76825

Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording;

76826

Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording; follow-up or repeat study

76827

Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete

76828

Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study

77750

Infusion or instillation of radioelement solution (includes 3-month follow-up care)

78012

Thyroid uptake, single or multiple quantitative measurement(s) (including stimulation, suppression, or discharge, when performed)

78013

Thyroid imaging (including vascular flow, when performed);

78014

Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) quantitative measurement(s) (including stimulation, suppression, or discharge, when performed)

78015

Thyroid carcinoma metastases imaging; limited area (eg, neck and chest only)

78016

Thyroid carcinoma metastases imaging; with additional studies (eg, urinary recovery)

78018

Thyroid carcinoma metastases imaging; whole body

78020

Thyroid carcinoma metastases uptake (List separately in addition to code for primary procedure)

78070

Parathyroid planar imaging (including subtraction, when performed)

78071

Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT)

78072

Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization

78075

Adrenal imaging, cortex and/or medulla

78102

Bone marrow imaging; limited area

78103

Bone marrow imaging; multiple areas

78104

Bone marrow imaging; whole body

78185

Spleen imaging only, with or without vascular flow

78195

Lymphatics and lymph nodes imaging

78201

Liver imaging; static only

78202

Liver imaging; with vascular flow

78215

Liver and spleen imaging; static only

78216

Liver and spleen imaging; with vascular flow

78226

Hepatobiliary system imaging, including gallbladder when present

78227

Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed

78230

Salivary gland imaging

78231

Salivary gland imaging; with serial images

78232

Salivary gland function study

78258

Esophageal motility

78261

Gastric mucosa imaging

78262

Gastroesophageal reflux study

78264

Gastric emptying imaging study (eg, solid, liquid, or both)

78265

Intravenous infusion for therapy/diagnosis; initiation of prolonged infusion (more than 8 hours), requiring use of portable or implantable pump

78266

Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel and colon transit, multiple days

78278

Acute gastrointestinal blood loss imaging

78282

Gastrointestinal protein loss

78290

Intestine imaging (eg, ectopic gastric mucosa, Meckel's localization, volvulus)

78291

Peritoneal-venous shunt patency test (eg, for LeVeen, Denver shunt)

78300

Bone and/or joint imaging; limited area

78305

Bone and/or joint imaging; multiple areas

78306

Bone and/or joint imaging; whole body

78315

Bone and/or joint imaging; 3 phase study

78445

Non-cardiac vascular flow imaging (ie, angiography, venography)

78456

Acute venous thrombosis imaging, peptide

78457

Venous thrombosis imaging, venogram; unilateral

78458

Venous thrombosis imaging, venogram; bilateral

78579

Pulmonary ventilation imaging (eg, aerosol or gas)

78580

Pulmonary perfusion imaging (eg, particulate)

78582

Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging

78597

Quantitative differential pulmonary perfusion, including imaging when performed

78598

Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed

78600

Brain imaging, less than 4 static views

78601

Brain imaging, less than 4 static views; with vascular flow

78605

Brain imaging, minimum 4 static views

78606

Brain imaging, minimum 4 static views; with vascular flow

78610

Brain imaging, vascular flow only

78630

Cerebrospinal fluid flow, imaging (not including introduction of material); cisternography

78635

Cerebrospinal fluid flow, imaging (not including introduction of material); ventriculography

78645

Cerebrospinal fluid flow, imaging (not including introduction of material); shunt evaluation

78650

Cerebrospinal fluid leakage detection and localization

78660

Radiopharmaceutical dacryocystography

78700

Kidney imaging morphology

78701

Kidney imaging morphology; with vascular flow

78707

Kidney imaging morphology; with vascular flow and function, single study without pharmacological intervention

78708

Kidney imaging morphology; with vascular flow and function, single study, with pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic)

78709

Kidney imaging morphology; with vascular flow and function, multiple studies, with and without pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic)

78725

Kidney function study, non-imaging radioisotopic study

78730

Urinary bladder residual study (List separately in addition to code for primary procedure)

78740

Ureteral reflux study (radiopharmaceutical voiding cystogram)

78761

Testicular imaging with vascular flow

78800

Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); limited area

78801

Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); multiple areas

78802

Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); whole body, single day imaging

78804

Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); whole body, requiring 2 or more days imaging

78831

Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT), minimum 2 areas (eg, pelvis and knees, chest and abdomen) or separate acquisitions (eg, lung ventilation and perfusion), single day imaging, or single area or acquisition over 2 or more days

78832

Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT), minimum 2 areas (eg, pelvis and knees, chest and abdomen) or separate acquisitions (eg, lung ventilation and perfusion), single day imaging, or single area or acquisition over 2 or more days

79403

Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion

93303

Transthoracic echocardiography for congenital cardiac anomalies; complete

93304

Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study

93306

Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography

93307

Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography

93308

Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study

93312

TEE 2D; Including probe placement, imaging, interpretation, and reporting

93313

Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only

93314

Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); image acquisition, interpretation and report only

93315

Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report

93319

3D echocardiographic imaging and postprocessing during transesophageal echocardiography, or during transthoracic echocardiography for congenital cardiac anomalies, for the assessment of cardiac structure(s) (eg, cardiac chambers and valves, left atrial appendage, interatrial septum, interventricular septum) and function, when performed (List separately in addition to code for echocardiographic imaging)

C8921

Transthoracic echocardiography with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; complete

C8922

Transthoracic echocardiography with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; follow-up or limited study

C8923

Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color doppler echocardiography

C8924

Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording when performed, follow-up or limited study

C8928

Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report

C8929

Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography

C8930

Transthoracic echocardiography, with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with physician supervision