Which payers have published criteria for CT thoracic spine without contrast (CPT 72128)?

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 thoracic spine without contrast (CPT 72128)?

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 thoracic spine without contrast (CPT 72128)?

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 thoracic spine without contrast (CPT 72128) cost?

Across 1,090 hospitals that publish their negotiated rates, the median commercial insurance rate is $783, with the middle half of rates between $343 and $1,549. A patient's own cost depends on their plan, deductible and where the study is done.

What can be done if CT thoracic spine without contrast (CPT 72128) 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 72128: CT thoracic spine without contrast - Prior Authorization and Price

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CPT 72128

CT thoracic spine without contrast.

CT Spine

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Payer guidelines that apply

Payer	Reviewed using	Guideline	Sections
Aetna	eviCore	Spine Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pediatric Head Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pediatric Musculoskeletal Imaging Guidelines 2.0.2026, effective Sep 1, 2026	7 that name this code
Anthem BCBS	Carelon	Imaging of the spine effective Sep 19, 2026 Oncologic imaging effective Apr 4, 2026	24 that name this code
Cigna	eviCore	Spine Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pediatric Head Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pediatric Musculoskeletal Imaging Guidelines 2.0.2026, effective Sep 1, 2026	7 that name this code
Medicare	CMS	NCD 220.1: Computed Tomography effective Mar 12, 2008	1 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	7 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 thoracic spine without contrast. Each has its own criteria for when the study is considered appropriate.

Axial spondyloarthropathy Anthem BCBS
Bone Sarcoma Anthem BCBS
Cancer screening, not otherwise specified Anthem BCBS
Colorectal cancer screening Anthem BCBS
Congenital spinal cord anomalies not listed Anthem BCBS
Congenital vertebral defects Anthem BCBS
Histiocytic Neoplasms Anthem BCBS
Juvenile idiopathic arthritis (Pediatric only) Anthem BCBS
Mid-back pain or thoracic radiculopathy Anthem BCBS
Myelopathy Anthem BCBS
Neuroendocrine Tumors Anthem BCBS
Osteoporosis and osteopenia Anthem BCBS
Paget disease Anthem BCBS
Postoperative and postprocedural imaging, not otherwise specified Anthem BCBS
Scoliosis Anthem BCBS
Spinal cord infarction Anthem BCBS
Spinal dysraphism and tethered cord Anthem BCBS
Spinal infection Anthem BCBS
Spontaneous (idiopathic) intracranial hypotension (SIH) Anthem BCBS
Suspected or Known Metastases Anthem BCBS
Syringomyelia Anthem BCBS
Thoracic or lumbar trauma Anthem BCBS
Tumor Anthem BCBS
Vertebral compression fracture Anthem BCBS
Upper Back (Thoracic Spine) Pain Without/With Neurological Features (Including Stenosis) and Trauma Aetna · Cigna · UnitedHealthcare
Ataxia Aetna · Cigna · UnitedHealthcare
Neck (Cervical Spine) Pain Without/With Neurological Features (Including Stenosis) and Trauma Aetna · Cigna · UnitedHealthcare
Suspected Physical Child Abuse Aetna · Cigna · UnitedHealthcare
Computed Tomography Medicare

Typical price

Commercial insurance, median

$783

Middle half of rates: $343 to $1,549

Medicare, hospital outpatient

$107

Facility payment

Medicare, physician fee schedule

$131

National, non-facility

Commercial figures come from negotiated rates published by 1,090 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 thoracic spine without contrast change.

CPT 72128: CT thoracic spine 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

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CPT 72128: CT thoracic spine 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