Which payers have published criteria for Functional MRI brain (CPT 70554)?

The imaging guidelines used by Aetna, Anthem BCBS, Cigna, Medicare, UnitedHealthcare include criteria that apply to this study. Whether a specific patient's plan requires prior authorization depends on the plan, so confirm on the payer's portal or by phone before scheduling.

Who reviews prior authorization requests for Functional MRI brain (CPT 70554)?

Most commercial payers hand imaging reviews to a radiology benefit manager. For the payers tracked here, requests are reviewed using guidelines from eviCore, Carelon, CMS, UnitedHealthcare / eviCore. The request is submitted through that organization's portal rather than the health plan's general line.

What should be in the clinical notes before requesting Functional MRI brain (CPT 70554)?

Reviewers look for a recent office visit that documents the symptoms and how long they have lasted, exam findings, results of any earlier imaging, treatments already tried and how the patient responded, and the specific question the study is expected to answer. The diagnosis code on the request should match what the notes describe.

How much does Functional MRI brain (CPT 70554) cost?

Across 565 hospitals that publish their negotiated rates, the median commercial insurance rate is $691, with the middle half of rates between $367 and $1,381. A patient's own cost depends on their plan, deductible and where the study is done.

What can be done if Functional MRI brain (CPT 70554) is denied?

Read the denial letter for the stated reason, then request a peer-to-peer conversation between the ordering clinician and the reviewing physician, which often resolves missing-information denials. If that fails, file a written appeal that answers the stated reason directly and attach the supporting notes. The denial letter lists the deadline and where to send the appeal.

CPT 70554: Functional MRI brain - Prior Authorization and Price

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CPT 70554

MRI imaging of the brain is performed functionally.

MRI Head & Neck

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Payer guidelines that apply

Payer	Reviewed using	Guideline	Sections
Aetna	eviCore	Pediatric and Special Populations Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Head Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pediatric Head Imaging Guidelines 2.0.2026, effective Sep 1, 2026	16 that name this code
Anthem BCBS	Carelon	Imaging of the brain effective Sep 19, 2026 Oncologic imaging effective Apr 4, 2026	36 that name this code
Cigna	eviCore	Pediatric and Special Populations Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Head Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pediatric Head Imaging Guidelines 2.0.2026, effective Sep 1, 2026	16 that name this code
Medicare	CMS	NCD 220.2: Magnetic Resonance Imaging effective Apr 10, 2018 L37373: MRI and CT Scans of the Head and Neck (Noridian Healthcare Solutions) effective Oct 23, 2025 L34425: Magnetic Resonance Imaging of the Head and Neck (Palmetto GBA) effective Mar 27, 2025	3 that name this code
Original Medicare does not run a prior authorization program for outpatient imaging; claims are judged against the coverage policies above. Medicare Advantage plans set their own prior authorization rules.
UnitedHealthcare	UnitedHealthcare / eviCore	Commercial and Exchange Cardiovascular and Radiology Imaging Guidelines 09.2026, effective Sep 1, 2026	16 that name this code

Guidelines collected from the payers' published documents on September 29, 2026. Payers revise these documents during the year. Open the guideline link to confirm the current version before you submit.

Conditions the guidelines address for this study

These are the clinical situations where payer guidelines discuss Functional MRI brain. Each has its own criteria for when the study is considered appropriate.

Abnormality on neurologic exam Anthem BCBS
Acoustic neuroma Anthem BCBS
Ataxia Anthem BCBS
Bell’s palsy (peripheral facial nerve palsy) Anthem BCBS
Brain and Spinal Cord Malignancy Anthem BCBS
Cancer screening, not otherwise specified Anthem BCBS
Congenital anomalies Anthem BCBS
Developmental delay (Pediatric only) Anthem BCBS
Dizziness or vertigo Anthem BCBS
Headache Anthem BCBS
Hearing loss Anthem BCBS
Hematoma or hemorrhage – intracranial or extracranial Anthem BCBS
Histiocytic Neoplasms Anthem BCBS
Horner’s syndrome Anthem BCBS
Hydrocephalus/ventricular assessment Anthem BCBS
Infectious conditions – not otherwise specified Anthem BCBS
Inflammatory conditions – not otherwise specified Anthem BCBS
Magnetoencephalography and magnetic source imaging Anthem BCBS
Meningioma Anthem BCBS
Movement disorders (Adult only) Anthem BCBS
Multiple sclerosis (MS) and other white matter disease s Anthem BCBS
Neurocognitive disorders (Adult only) Anthem BCBS
Neurocutaneous disorders Anthem BCBS
Neuroendocrine Tumors Anthem BCBS
Papilledema Anthem BCBS
Pituitary mass (including pituitary adenoma, incidentaloma) Anthem BCBS
Sickle cell disease (Pediatric only) Anthem BCBS
Spontaneous intracranial hypotension (SIH) Anthem BCBS
Stroke or transient ischemic attack (TIA) Anthem BCBS
Suspected or Known Metastases Anthem BCBS
Syncope Anthem BCBS
Tinnitus Anthem BCBS
Trauma Anthem BCBS
Trigeminal neuralgia and persistent idiopathic facial pain (Adult only) Anthem BCBS
Tumor – not otherwise specified Anthem BCBS
Visual disturbance Anthem BCBS
CNS Tumors Aetna · Cigna · UnitedHealthcare
Cerebral Aneurysm and AVM Aetna · Cigna · UnitedHealthcare
Epilepsy and Other Seizure Disorders Aetna · Cigna · UnitedHealthcare
Epilepsy/Seizures Aetna · Cigna · UnitedHealthcare

Plus 5 more. Use the search below to find a specific condition.

Typical price

Commercial insurance, median

$691

Middle half of rates: $367 to $1,381

Medicare, hospital outpatient

$244

Facility payment

Medicare, physician fee schedule

$380

National, non-facility

Commercial figures come from negotiated rates published by 565 hospitals; Medicare figures from CMS fee schedules. Rates vary widely by hospital and plan. Pricing data from CenterIQ.

Get notified when the rules for this study change

Payers update imaging guidelines several times a year. We will email you when the criteria for Functional MRI brain change.

CPT 70554: Functional MRI brain - Prior Authorization and Price

Payer guidelines that apply

Conditions the guidelines address for this study

Typical price

Get notified when the rules for this study change

Frequently asked questions

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CPT 70554: Functional MRI brain - Prior Authorization and Price

Payer guidelines that apply

Conditions the guidelines address for this study

Typical price

Get notified when the rules for this study change

Frequently asked questions

Related studies

Imaging CPT Code Coverage Lookup

Quick Access - Common Imaging CPT Codes

CT

MRI

MRA

PET