Which payers have published criteria for Nuclear imaging study of ventilation in the lungs (CPT 78579)?

The imaging guidelines used by Aetna, Anthem BCBS, 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 of ventilation in the lungs (CPT 78579)?

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 of ventilation in the lungs (CPT 78579)?

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 78579: Nuclear imaging study of ventilation in the lungs - Prior Authorization and Price

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CPT 78579

Nuclear imaging study of ventilation in the lungs.

Nuclear Medicine

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Payer guidelines that apply

Payer	Reviewed using	Guideline	Sections
Aetna	eviCore	Pediatric Chest Imaging Guidelines 2.0.2026, effective Sep 1, 2026	1 that name this code
Anthem BCBS	Carelon	Nuclear medicine imaging effective Sep 19, 2026	8 that name this code
Cigna	eviCore	Current guideline	None found
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	1 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 of ventilation in the lungs. Each has its own criteria for when the study is considered appropriate.

Congenital heart disease Anthem BCBS
Congenital pulmonary airway malformation (Pediatric only) Anthem BCBS
Congenital thoracic anomalies Anthem BCBS
Lung cancer, small cell and non-small cell Anthem BCBS
Malignant pleural mesothelioma Anthem BCBS
Perioperative evaluation, including evaluation prior to lung transplant Anthem BCBS
Pulmonary embolism Anthem BCBS
Pulmonary hypertension Anthem BCBS

Typical price

Commercial insurance, median

$671

Middle half of rates: $426 to $1,092

Medicare, hospital outpatient

$408

Facility payment

Medicare, physician fee schedule

$167

National, non-facility

Commercial figures come from negotiated rates published by 814 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 of ventilation in the lungs change.

CPT 78579: Nuclear imaging study of ventilation in the lungs - 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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