Which payers have published criteria for Unlisted CT procedure (CPT 76497)?

The imaging guidelines used by Aetna, 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 Unlisted CT procedure (CPT 76497)?

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 Unlisted CT procedure (CPT 76497)?

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 Unlisted CT procedure (CPT 76497) cost?

Across 621 hospitals that publish their negotiated rates, the median commercial insurance rate is $427, with the middle half of rates between $232 and $776. A patient's own cost depends on their plan, deductible and where the study is done.

What can be done if Unlisted CT procedure (CPT 76497) 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 76497: Unlisted CT procedure - Prior Authorization and Price

Home › CPT Codes › Unlisted CT procedure

CPT 76497

Unlisted CT imaging procedure.

CT Other

Build a submission checklist for this study

Payer guidelines that apply

Payer	Reviewed using	Guideline	Sections
Aetna	eviCore	Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Head Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Chest Imaging Guidelines 1.0.2026, effective Feb 3, 2026	11 that name this code
Anthem BCBS	Carelon	Current guideline	None found
Cigna	eviCore	Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Head Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Chest Imaging Guidelines 1.0.2026, effective Feb 3, 2026	11 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	10 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 Unlisted CT procedure. Each has its own criteria for when the study is considered appropriate.

Multiple Myeloma and Plasmacytomas Aetna · Cigna · UnitedHealthcare
Dyspnea/Shortness of Breath Aetna · Cigna · UnitedHealthcare
Movement Disorders Aetna · Cigna · UnitedHealthcare
Neurosurgical Imaging Aetna · Cigna · UnitedHealthcare
Trigeminal Neuralgia and other Centrally Mediated Facial Pain Syndromes Aetna · Cigna · UnitedHealthcare
Computed Tomography Medicare

Typical price

Commercial insurance, median

$427

Middle half of rates: $232 to $776

Medicare, hospital outpatient

$89

Facility payment

Commercial figures come from negotiated rates published by 621 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 Unlisted CT procedure change.

CPT 76497: Unlisted CT procedure - 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 76497: Unlisted CT procedure - 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