Who reviews prior authorization requests for Nuclear imaging of heart muscle that includes a metabolic evaluation (CPT 78459)?

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 of heart muscle that includes a metabolic evaluation (CPT 78459)?

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 78459: Nuclear imaging of heart muscle that includes a metabolic evaluation - Prior Authorization and Price

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CPT 78459

Nuclear imaging of heart muscle that includes a metabolic evaluation.

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	4 that name this code
Anthem BCBS	Carelon	Current guideline	None found
Cigna	eviCore	Cardiac Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pediatric Cardiac Imaging Guidelines 1.0.2026, effective Feb 3, 2026	4 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	4 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

$2,655

Middle half of rates: $1,749 to $4,518

Medicare, hospital outpatient

$1,323

Facility payment

Medicare, physician fee schedule

$71

National, non-facility

Commercial figures come from negotiated rates published by 562 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 of heart muscle that includes a metabolic evaluation change.

CPT 78459: Nuclear imaging of heart muscle that includes a metabolic evaluation - 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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