Who reviews prior authorization requests for X-ray imaging with 3D rendering and computerized image postprocessing (CPT 76377)?

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 X-ray imaging with 3D rendering and computerized image postprocessing (CPT 76377)?

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 76377: X-ray imaging with 3D rendering and computerized image postprocessing - Prior Authorization and Price

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CPT 76377

X-ray imaging with 3D rendering and computerized image postprocessing.

Ultrasound

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Payer guidelines that apply

Payer	Reviewed using	Guideline	Sections
Aetna	eviCore	Head Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pelvis Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Abdomen Imaging Guidelines 1.0.2026, effective Feb 3, 2026 Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026	65 that name this code
Anthem BCBS	Carelon	Current guideline	None found
Cigna	eviCore	Head Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pelvis Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Abdomen Imaging Guidelines 1.0.2026, effective Feb 3, 2026 Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026	66 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	65 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 X-ray imaging with 3D rendering and computerized image postprocessing. Each has its own criteria for when the study is considered appropriate.

Cerebrovascular Disease Aetna · Cigna · UnitedHealthcare
Cerebral Aneurysm and AVM Aetna · Cigna · UnitedHealthcare
Epilepsy/Seizures Aetna · Cigna · UnitedHealthcare
Cerebral Vasculitis Aetna · Cigna · UnitedHealthcare
Multiple Sclerosis (MS) and Related Conditions Aetna · Cigna · UnitedHealthcare
Neurosurgical Imaging Aetna · Cigna · UnitedHealthcare
Sinus and Facial Imaging Aetna · Cigna · UnitedHealthcare
Temporomandibular Joint Disease (TMJ) and Dental/Periodontal/Maxillofacial Imaging Aetna · Cigna · UnitedHealthcare
Pancreatic Cancer Aetna · Cigna · UnitedHealthcare
Hematuria and Hydronephrosis Aetna · Cigna · UnitedHealthcare
Sinusitis and Allergic Rhinitis Aetna · Cigna · UnitedHealthcare
3D Rendering Aetna · Cigna · UnitedHealthcare
Adnexal Mass/Ovarian Cysts Aetna · Cigna · UnitedHealthcare
Congenital (Mullerian) Uterine and Vaginal Anomalies Aetna · Cigna · UnitedHealthcare
Hematuria Aetna · Cigna · UnitedHealthcare
Leiomyoma/Uterine Fibroids and other Uterine Masses Aetna · Cigna · UnitedHealthcare
Prostate Cancer Aetna · Cigna · UnitedHealthcare
Urinary Tract Infection (UTI) Aetna · Cigna · UnitedHealthcare
Fetal MRI and Other Pregnancy Imaging Aetna · Cigna · UnitedHealthcare
Abnormal Uterine Bleeding Aetna · Cigna · UnitedHealthcare
Cardiac Imaging in Transplants Aetna · Cigna · UnitedHealthcare
CNS Tumors Cigna
Congestive Heart Failure Aetna · Cigna · UnitedHealthcare
Craniofacial Anomalies Aetna · Cigna · UnitedHealthcare
Dysphagia and Upper Digestive Tract Disorders Aetna · Cigna · UnitedHealthcare
Epilepsy and Other Seizure Disorders Aetna · Cigna · UnitedHealthcare
Esophagus Aetna · Cigna · UnitedHealthcare
Flank Pain, Rule Out or Known Renal/Ureteral Stone Aetna · Cigna · UnitedHealthcare
Imaging Techniques Aetna · Cigna · UnitedHealthcare
Metastatic Cancer, Carcinoma of Unknown Primary Site, and Other Types of Cancer Aetna · Cigna · UnitedHealthcare
MR Cholangiopancreatography (MRCP) Aetna · Cigna · UnitedHealthcare
MRI Breast Coding Aetna · Cigna · UnitedHealthcare
Neck Pain/Neck Trauma Aetna · Cigna · UnitedHealthcare
Pectus Excavatum and Pectus Carinatum Aetna · Cigna · UnitedHealthcare
Pleural-Based Nodules and Other Abnormalities Aetna · Cigna · UnitedHealthcare
Thyroid and Parathyroid Aetna · Cigna · UnitedHealthcare
Trachea Aetna · Cigna · UnitedHealthcare
Upper GI Cancers Aetna · Cigna · UnitedHealthcare
Breast Ultrasound Aetna · UnitedHealthcare
Intrauterine Device (IUD) and Tubal Occlusion Aetna · UnitedHealthcare

Typical price

Commercial insurance, median

$541

Middle half of rates: $332 to $862

Medicare, physician fee schedule

$79

National, non-facility

Commercial figures come from negotiated rates published by 859 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 with 3D rendering and computerized image postprocessing change.

CPT 76377: X-ray imaging with 3D rendering and computerized image postprocessing - 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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