Which payers have published criteria for CT chest without contrast (CPT 71250)?

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 CT chest without contrast (CPT 71250)?

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 CT chest without contrast (CPT 71250)?

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 CT chest without contrast (CPT 71250) cost?

Across 1,085 hospitals that publish their negotiated rates, the median commercial insurance rate is $691, with the middle half of rates between $333 and $1,368. A patient's own cost depends on their plan, deductible and where the study is done.

What can be done if CT chest without contrast (CPT 71250) 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 71250: CT chest without contrast - Prior Authorization and Price

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CPT 71250

Chest CT scan done without contrast dye.

CT Chest

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Payer guidelines that apply

Payer	Reviewed using	Guideline	Sections
Aetna	eviCore	Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Chest Imaging Guidelines 1.0.2026, effective Feb 3, 2026 Pediatric and Special Populations Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pediatric Chest Imaging Guidelines 2.0.2026, effective Sep 1, 2026	144 that name this code
Anthem BCBS	Carelon	Oncologic imaging effective Apr 4, 2026 Imaging of the chest effective Apr 4, 2026 Advanced imaging for vascular indications effective Sep 19, 2026	91 that name this code
Cigna	eviCore	Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Chest Imaging Guidelines 1.0.2026, effective Feb 3, 2026 Pediatric and Special Populations Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pediatric Chest Imaging Guidelines 2.0.2026, effective Sep 1, 2026	145 that name this code
Medicare	CMS	NCD 220.1: Computed Tomography effective Mar 12, 2008 L33459: Computerized Axial Tomography (CT), Thorax (Palmetto GBA) effective Jun 11, 2026	2 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	143 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 CT chest without contrast. Each has its own criteria for when the study is considered appropriate.

Neuroendocrine Cancers and Adrenal Tumors Aetna · Cigna · UnitedHealthcare
Sarcomas – Bone, Soft Tissue, and GIST Aetna · Cigna · UnitedHealthcare
Upper GI Cancers Aetna · Cigna · UnitedHealthcare
Colorectal and Small Bowel Cancer Aetna · Cigna · UnitedHealthcare
Non-Small Cell Lung Cancer Aetna · Cigna · UnitedHealthcare
Ovarian Cancer Aetna · Cigna · UnitedHealthcare
Renal Cell Cancer (RCC) Aetna · Cigna · UnitedHealthcare
Anal Cancer & Cancers of the External Genitalia Aetna · Cigna · UnitedHealthcare
Metastatic Cancer, Carcinoma of Unknown Primary Site, and Other Types of Cancer Aetna · Cigna · UnitedHealthcare
Salivary Gland Cancers Aetna · Cigna · UnitedHealthcare
Small Cell Lung Cancer Aetna · Cigna · UnitedHealthcare
Squamous Cell Carcinomas of the Head and Neck Aetna · Cigna · UnitedHealthcare
Transitional Cell Cancer Aetna · Cigna · UnitedHealthcare
Cervical Cancer Aetna · Anthem BCBS · Cigna · UnitedHealthcare
Pancreatic Cancer Aetna · Anthem BCBS · Cigna · UnitedHealthcare
Thyroid Cancer Aetna · Anthem BCBS · Cigna · UnitedHealthcare
Hematopoietic Stem Cell Transplantation Aetna · Cigna · UnitedHealthcare
Pediatric Renal Tumors Aetna · Cigna · UnitedHealthcare
Solitary Pulmonary Nodule (SPN) Aetna · Cigna · UnitedHealthcare
Dyspnea/Shortness of Breath Aetna · Cigna · UnitedHealthcare
Other Chest Infections Aetna · Cigna · UnitedHealthcare
Pediatric Liver and Pancreatic Tumors Aetna · Cigna · UnitedHealthcare
Transplant Aetna · Cigna · UnitedHealthcare
Bronchiectasis Aetna · Anthem BCBS · Cigna · UnitedHealthcare
Hemoptysis Aetna · Anthem BCBS · Cigna · UnitedHealthcare
Bone Tumors Aetna · Cigna · UnitedHealthcare
Cardiac Surgery Imaging Aetna · Cigna · UnitedHealthcare
Hematopoietic Stem Cell Transplantation (HSCT) Aetna · Cigna · UnitedHealthcare
Histiocytic Disorders Aetna · Cigna · UnitedHealthcare
Interstitial Disease Aetna · Cigna · UnitedHealthcare
Lung Transplantation Aetna · Cigna · UnitedHealthcare
Neuromuscular Disorders Aetna · Cigna · UnitedHealthcare
Non-Cardiac Chest Pain Aetna · Cigna · UnitedHealthcare
Pediatric Soft Tissue Sarcomas Aetna · Cigna · UnitedHealthcare
Pneumonia and Coronavirus Disease 2019 (COVID-19) Aetna · Cigna · UnitedHealthcare
Pneumothorax/Hemothorax Aetna · Cigna · UnitedHealthcare
Screening for Peripheral Artery /Aneurysmal Disease Aetna · Cigna · UnitedHealthcare
Screening Imaging in Cancer Predisposition Syndromes Aetna · Cigna · UnitedHealthcare
Suspected Physical Child Abuse Aetna · Cigna · UnitedHealthcare
Thyroid and Parathyroid Aetna · Cigna · UnitedHealthcare

Plus 109 more. Use the search below to find a specific condition.

Typical price

Commercial insurance, median

$691

Middle half of rates: $333 to $1,368

Medicare, hospital outpatient

$107

Facility payment

Medicare, physician fee schedule

$133

National, non-facility

Commercial figures come from negotiated rates published by 1,085 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 CT chest without contrast change.

CPT 71250: CT chest without contrast - 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

Imaging CPT Code Coverage Lookup

Quick Access - Common Imaging CPT Codes

CT

MRI

MRA

PET

CPT 71250: CT chest without contrast - 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