76499
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Comparison with prior examination(s) when available (explicitly referenced for Category 0 management).
- Imaging report documenting BI-RADS assessment category and recommended management (recall, routine screening, short-interval follow-up, or tissue diagnosis).
- Please refer to CMS Medicare Coverage Database for the most current applicable CMS NCD/LCD/LCA.
- Refer to CMS website for the most current applicable CMS Online Manual System (IOMs) and Transmittals.
Key Coverage Criteria
- Per NCD 220.6.17 (Transmittal 168), the term FDG PET includes PET/computed tomography (CT) and PET/magnetic resonance (MRI).
- Breast echography (A-mode) and breast sonography (B-scan) are nationally covered indications per NCD 220.5 Ultrasound Diagnostic Procedures.
- Diagnostic breast ultrasound — Humana and subsidiaries may consider CMS Local Coverage Determination L33585 - Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography to interpret or supplement NCD 220.5 criteria to determine medical necessity.
- Diagnostic breast ultrasound is considered medically necessary when the clinical criteria contained in LCD - Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography - (L33585) are met.
- For jurisdictions without a local LCD (J5, J8, JE, JF, JH, JJ, JL, JM, JN), Humana and subsidiaries may determine medical necessity for diagnostic breast ultrasound based on the criteria contained in LCD L33585.
- 76499 - Unlisted diagnostic radiographic procedure
8 Active Policies
HUMANA-BREAST-IMAGING-MA — Breast Imaging - Medicare Advantage
ANTHEM-RAD.00038 — RAD.00038 Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care
BCBSIL-RAD601.046 — Dynamic Spinal Visualization and Vertebral Motion Analysis
BCBSMT-RAD601.046 — Dynamic Spinal Visualization and Vertebral Motion Analysis
BCBSNM-RAD601.046 — Dynamic Spinal Visualization and Vertebral Motion Analysis
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.