TL;DR: UnitedHealthcare modified its noninvasive FFR-ct coverage policy for Medicare Advantage, effective March 2, 2026. Here's what billing teams need to do.
UnitedHealthcare updated its non-invasive fractional flow reserve coverage policy under policy code noninvasive-fractional-flow-reserve-ffr-ischemic-heart-disease, with changes effective March 2, 2026. This policy governs CPT 75580 — the code for noninvasive coronary FFR derived from augmentative software — and it applies to Medicare Advantage members. The criteria are narrow, the exclusions are long, and the difference between a paid claim and a claim denial often comes down to one missing documentation element.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | UnitedHealthcare |
| Policy | Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease – Medicare Advantage Medical Policy |
| Policy Code | noninvasive-fractional-flow-reserve-ffr-ischemic-heart-disease |
| Change Type | Modified |
| Effective Date | March 2, 2026 |
| Impact Level | High |
| Specialties Affected | Cardiology, Interventional Cardiology, Radiology |
| Key Action | Audit all CPT 75580 claims to confirm the patient meets all positive criteria and clears all exclusions before billing |
UnitedHealthcare Non-Invasive FFR Coverage Criteria and Medical Necessity Requirements 2026
The UHC non-invasive fractional flow reserve coverage policy covers CPT 75580 only when the patient meets a specific combination of clinical conditions. Miss one criterion and you're looking at a denial.
FFR-ct — fractional flow reserve derived from computed tomography — takes a previously acquired CCTA (coronary CT angiography) and runs it through FDA-approved software to estimate blood pressure changes across coronary stenoses. It is not a standalone imaging study. The CCTA must be completed and interpreted first.
Medical necessity under this coverage policy requires that the patient falls into one of four clinical scenarios:
| # | Covered Indication |
|---|---|
| 1 | No prior coronary disease + acute (anginal) chest pain: FFR-ct is covered for intermediate-risk patients with troponin elevation after a CCTA finding of 40–90% stenosis in a proximal or middle coronary artery. |
| 2 | Known coronary artery disease + acute (anginal) chest pain: Same threshold — intermediate-risk patients with troponin elevation and 40–90% stenosis on CCTA in a proximal or middle coronary artery. |
| 3 | No prior coronary disease + stable (anginal) chest pain: FFR-ct is covered for intermediate-risk patients after a 40–90% stenosis finding on CCTA in a proximal or middle coronary artery. |
| 4 | Known coronary disease + persistent stable (anginal) chest pain: FFR-ct is covered after any 40–90% stenosis finding on CCTA — no location restriction. |
The 40–90% stenosis window is the core of this policy. If CCTA shows stenosis above 90%, the policy treats FFR-ct as not medically necessary — that patient should go straight to catheterization. If stenosis is below 40%, there's no indication for further functional evaluation. CPT 75580 only fits in the middle.
FFR-ct must also be used as an alternative to stress testing, not in addition to it. The policy does allow an exception: if the CCTA wasn't sufficient quality for FFR-ct analysis, a stress test can be ordered as an alternative study. Document that exception explicitly if you need it.
Because no NCD exists for this service at the CMS level, UnitedHealthcare Medicare Advantage coverage defaults to Local Coverage Determinations (LCDs) where they exist. Where your Medicare Administrative Contractor has an active LCD for non-invasive FFR, that LCD controls. Where no LCD exists, UHC's own criteria apply. Know which situation your MAC puts you in before you bill CPT 75580.
Prior authorization requirements for CPT 75580 under this policy are not explicitly detailed in the published criteria, but the complexity and specificity of the medical necessity criteria make pre-service documentation essential. If you're unsure whether your MAC's LCD or UHC's internal criteria govern a given claim, talk to your compliance officer before the effective date of March 2, 2026.
UnitedHealthcare Non-Invasive FFR Exclusions and Non-Covered Indications
This is where the policy gets long — and where denials happen. The exclusion list covers nine specific clinical circumstances where FFR-ct is not covered, regardless of stenosis findings.
UHC will not cover CPT 75580 when any of the following apply:
| # | Excluded Procedure |
|---|---|
| 1 | Prior placement of prosthetic valves |
| 2 | Prior coronary artery bypass grafting (CABG) with graft placement |
| 3 | Suspicion of acute coronary syndrome where MI or unstable angina has not been ruled out |
| 4 | Intracoronary metallic stent in place |
| 5 | Status post-heart transplantation |
| 6 | Recent MI within 30 days |
| 7 | Prior pacemaker or defibrillator lead placement |
| 8 | Newly diagnosed systolic heart failure with no prior left heart catheterization |
| 9 | Non-obstructing stenosis (less than 50% in all major epicardial vessels) on CTA or catheterization within the past 12 months, in the absence of a new symptom complex |
| 10 | Turnaround time concerns that would delay prompt clinical care decisions |
The stent and CABG exclusions are the ones most likely to trip up cardiology billing teams. These are common patient histories in the population most likely to get a CCTA. Your charge capture workflow needs to screen for these before CPT 75580 goes on the claim.
The acute coronary syndrome exclusion is also worth flagging. The policy explicitly says FFR-ct is not appropriate where urgent or timely workup is critical. If a patient came in as a rule-out ACS and that's still on the table, don't bill 75580.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Intermediate-risk, no prior CAD, acute anginal chest pain, troponin elevation, 40–90% stenosis on CCTA (proximal/middle artery) | Covered | CPT 75580, ICD-10 R93.1 | CCTA must be completed and interpreted first |
| Intermediate-risk, known CAD, acute anginal chest pain, troponin elevation, 40–90% stenosis on CCTA (proximal/middle artery) | Covered | CPT 75580, ICD-10 R93.1 | FFR-ct as alternative to stress testing |
| Intermediate-risk, no prior CAD, stable anginal chest pain, 40–90% stenosis on CCTA (proximal/middle artery) | Covered | CPT 75580, ICD-10 R93.1 | FFR-ct as alternative to stress testing |
| Known CAD, persistent stable anginal chest pain, any 40–90% stenosis on CCTA | Covered | CPT 75580, ICD-10 R93.1 | No location restriction on stenosis |
| Stenosis greater than 90% on CCTA | Not Covered | CPT 75580 | Patient should proceed to catheterization |
| Stenosis less than 40% on CCTA | Not Covered | CPT 75580 | No additional confirmatory data required |
| Unstable coronary syndrome / suspected ACS (MI or unstable angina not ruled out) | Not Covered | CPT 75580 | Urgent workup required — FFR-ct not appropriate |
| Post-CABG with graft placement | Not Covered | CPT 75580 | Hard exclusion |
| Intracoronary metallic stent present | Not Covered | CPT 75580 | Hard exclusion |
| Prosthetic valve in place | Not Covered | CPT 75580 | Hard exclusion |
| Recent MI (within 30 days) | Not Covered | CPT 75580 | Hard exclusion |
| Prior pacemaker or defibrillator lead | Not Covered | CPT 75580 | Hard exclusion |
| Post-heart transplant | Not Covered | CPT 75580 | Hard exclusion |
| Newly diagnosed systolic heart failure, no prior left heart cath | Not Covered | CPT 75580 | Hard exclusion |
| Non-obstructing stenosis on CTA or cath within past 12 months, no new symptom complex | Not Covered | CPT 75580 | Hard exclusion |
| FFR-ct used alongside stress testing (non-exception) | Not Covered | CPT 75580 | Exception only if CCTA quality insufficient |
UnitedHealthcare Non-Invasive FFR Billing Guidelines and Action Items 2026
This policy has real financial exposure for cardiology and interventional cardiology practices that bill CPT 75580 to UnitedHealthcare Medicare Advantage. The exclusion list alone creates multiple denial pathways. Act on these before claims hit the queue.
| # | Action Item |
|---|---|
| 1 | Audit your CPT 75580 charge capture workflow before March 2, 2026. Add a pre-bill screening step that checks the nine exclusion criteria — especially stent history, CABG history, and recent MI — against patient records before the claim goes out. |
| 2 | Confirm the stenosis window is documented in the CCTA report. The billing guidelines require stenosis between 40–90%. The CCTA read must explicitly state the degree of stenosis in a proximal or middle coronary artery. If the report says "significant stenosis" without a percentage, that's not enough to support medical necessity. |
| 3 | Document the FFR-ct as an alternative to stress testing. If stress testing was ordered alongside FFR-ct without the CCTA quality exception, you're outside the coverage policy. Make sure the ordering physician's note reflects the alternative-to-stress-testing rationale. |
| 4 | Identify which LCD governs your claims. Check with your Medicare Administrative Contractor to determine whether an active local coverage determination exists for non-invasive FFR in your state. Where an LCD applies, UHC Medicare Advantage follows it. Where no LCD exists, UHC's own criteria apply. The answer changes your documentation requirements. |
| 5 | Pair CPT 75580 with ICD-10 R93.1 on claims. R93.1 — abnormal findings on diagnostic imaging of heart and coronary circulation — is the diagnosis code that aligns with this policy. Make sure your coding team maps it consistently, and review any existing claims where a different primary diagnosis was used. |
| 6 | Don't use CPT 75580 for post-CABG or stented patients. These are hard exclusions with no clinical exception pathway. If your cardiology team is ordering FFR-ct for these patients, loop in your medical director and compliance officer. The reimbursement risk is real, and it's not just a billing problem — it's a documentation problem upstream. |
| 7 | Flag turnaround time in the clinical record when relevant. If FFR-ct was not used because turnaround time would delay care, that exclusion needs to be in the record too. It protects you on any retrospective review. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Non-Invasive FFR Under noninvasive-fractional-flow-reserve-ffr-ischemic-heart-disease
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 75580 | CPT | Noninvasive estimate of coronary fractional flow reserve (FFR) derived from augmentative software analysis of images from previously performed coronary computed tomographic angiography (CTA) |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| R93.1 | Abnormal findings on diagnostic imaging of heart and coronary circulation |
One more note on CPT 75580 non-invasive FFR billing: this is a post-processing code, not an imaging code. The CCTA is billed separately. CPT 75580 covers only the FFR-ct software analysis performed on previously acquired DICOM data. If your team is bundling the CCTA and FFR-ct analysis under a single code, that's a billing error that will generate a denial — or worse, a recoupment request.
The real issue with this UHC coverage policy is the gap between how FFR-ct is ordered clinically and what documentation actually supports the claim. Physicians order it. The software runs. The report goes in the chart. But if nobody documented the stenosis percentage, the clinical scenario, the absence of exclusion criteria, and the stress-testing rationale, the claim fails. Build your documentation checklist now, before March 2, 2026.
Get the Full Picture for CPT 75580
Track this policy across versions, search 1,500+ policies by CPT code, and get real-time alerts when any payer changes coverage.