Which payers have published criteria for Limited ultrasound imaging of one breast (CPT 76642)?

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 Limited ultrasound imaging of one breast (CPT 76642)?

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 Limited ultrasound imaging of one breast (CPT 76642)?

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.

What can be done if Limited ultrasound imaging of one breast (CPT 76642) 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 76642: Limited ultrasound imaging of one breast - Prior Authorization and Price

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CPT 76642

Limited ultrasound imaging of one breast.

Ultrasound

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Payer guidelines that apply

Payer	Reviewed using	Guideline	Sections
Aetna	eviCore	Breast Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pediatric and Special Populations Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Chest Imaging Guidelines 1.0.2026, effective Feb 3, 2026	15 that name this code
Anthem BCBS	Carelon	Current guideline	None found
Cigna	eviCore	Breast Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pediatric and Special Populations Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Chest Imaging Guidelines 1.0.2026, effective Feb 3, 2026	15 that name this code
Medicare	CMS	L33585: Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography (Wellpoint Federal) effective Apr 1, 2026 L33950: Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography (CGS Administrators) effective Dec 4, 2025	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	15 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 Limited ultrasound imaging of one breast. Each has its own criteria for when the study is considered appropriate.

Breast Evaluation in Pregnant or Lactating Females Aetna · Cigna · UnitedHealthcare
Breast Imaging in Males Aetna · Cigna · UnitedHealthcare
Breast Mass Aetna · Cigna · UnitedHealthcare
Breast Pain (Mastodynia) Aetna · Cigna · UnitedHealthcare
Nipple Discharge/Galactorrhea Aetna · Cigna · UnitedHealthcare
Nipple Inversion/Retraction Aetna · Cigna · UnitedHealthcare
Skin Changes Aetna · Cigna · UnitedHealthcare
Transgender Breast Cancer Supplemental Screening Aetna · Cigna · UnitedHealthcare
Breast Ultrasound Aetna · UnitedHealthcare
Pediatric Breast Masses Aetna · Cigna · UnitedHealthcare
Breast Cancer Aetna · Cigna · UnitedHealthcare
Non-Hodgkin Lymphomas Aetna · Cigna · UnitedHealthcare
Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography Medicare
Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography Medicare

Typical price

Commercial insurance, median

$262

Middle half of rates: $155 to $458

Medicare, hospital outpatient

$89

Facility payment

Medicare, physician fee schedule

$84

National, non-facility

Commercial figures come from negotiated rates published by 1,003 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 Limited ultrasound imaging of one breast change.

CPT 76642: Limited ultrasound imaging of one breast - 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

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