Which payers have published criteria for Nuclear imaging study to detect shunts in the heart (CPT 78428)?

The imaging guidelines used by Aetna, Anthem BCBS, Cigna, 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 Nuclear imaging study to detect shunts in the heart (CPT 78428)?

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 Nuclear imaging study to detect shunts in the heart (CPT 78428)?

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 78428: Nuclear imaging study to detect shunts in the heart - Prior Authorization and Price

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CPT 78428

Nuclear imaging study to detect shunts in the heart.

Nuclear Medicine

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Payer guidelines that apply

Payer	Reviewed using	Guideline	Sections
Aetna	eviCore	Cardiac Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pediatric Cardiac Imaging Guidelines effective Feb 3, 2026	2 that name this code
Anthem BCBS	Carelon	Imaging of the heart effective Nov 15, 2025	5 that name this code
Cigna	eviCore	Cardiac Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pediatric Cardiac Imaging Guidelines 1.0.2026, effective Feb 3, 2026	2 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	2 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 Nuclear imaging study to detect shunts in the heart. Each has its own criteria for when the study is considered appropriate.

Congenital heart disease Anthem BCBS
Coronary artery disease (applies to patients with established CAD) Anthem BCBS
Evaluation of left ventricular function Anthem BCBS
Evaluation of right ventricular function Anthem BCBS
Valvular heart disease Anthem BCBS

Typical price

Commercial insurance, median

$555

Middle half of rates: $438 to $800

Medicare, hospital outpatient

$408

Facility payment

Medicare, physician fee schedule

$172

National, non-facility

Commercial figures come from negotiated rates published by 575 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 Nuclear imaging study to detect shunts in the heart change.

CPT 78428: Nuclear imaging study to detect shunts in the heart - 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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