What should be in the clinical notes before requesting X-ray imaging of the lymphatic system in the arm or leg reviewed by a radiologist (CPT 75801)?

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.

CPT 75801: X-ray imaging of the lymphatic system in the arm or leg reviewed by a radiologist - Prior Authorization and Price

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CPT 75801

X-ray imaging of the lymphatic system in the arm or leg reviewed by a radiologist.

Other Imaging

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Payer guidelines that apply

Payer	Reviewed using	Guideline	Sections
Aetna	eviCore	Peripheral Vascular Disease (PVD) Imaging Guidelines 2.0.2026, effective Sep 1, 2026	1 that name this code
Anthem BCBS	Carelon	Current guideline	None found
Cigna	eviCore	Peripheral Vascular Disease (PVD) Imaging Guidelines 2.0.2026, effective Sep 1, 2026	1 that name this code
Medicare	CMS	—	None found
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	1 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.

Typical price

Commercial insurance, median

$798

Middle half of rates: $566 to $1,195

Medicare, hospital outpatient

$641

Facility payment

Medicare, physician fee schedule

$44

National, non-facility

Commercial figures come from negotiated rates published by 507 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 X-ray imaging of the lymphatic system in the arm or leg reviewed by a radiologist change.

CPT 75801: X-ray imaging of the lymphatic system in the arm or leg reviewed by a radiologist - Prior Authorization and Price

Payer guidelines that apply

Typical price

Get notified when the rules for this study change

Frequently asked questions

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