Prior authorization for echo and stress tests in New York

Traditional Medicare doesn’t run a prior authorization program for echocardiograms or stress tests in New York. Almost everyone else might. Medicare Advantage plans, commercial plans and Medicaid each publish their own lists, often run by a radiology benefit manager, and the lists differ by test: a transthoracic echo, a stress echo and a nuclear stress test can each have a different answer at the same plan. UnitedHealthcare, for one, took transthoracic echo off its commercial and Oxford lists on January 1, 2026. The only safe habit is to check the exact CPT code with the exact plan before the patient is scheduled.

The tests, by code family

CPT descriptors are paraphrased here.

Traditional Medicare: no prior auth for these tests

CMS’s prior authorization model for traditional Medicare, WISeR, started on January 1, 2026, in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. New York isn’t one of them, and the services in the model are things like knee arthroscopy, nerve stimulators, epidural steroid injections, cervical fusion and skin substitutes, not cardiac imaging (CMS, WISeR model; CMS, WISeR provider and supplier guide, as of November 2026).

No prior auth doesn’t mean automatic payment. Medicare still pays a test only when the diagnosis supports medical necessity under the applicable coverage policy. When coverage is in doubt, the practice needs a signed Advance Beneficiary Notice before the test to bill the patient if Medicare denies it (CMS, FFS ABN).

Medicare Advantage, Medicaid and the new federal deadlines

Medicare Advantage plans set their own prior authorization lists. Since January 1, 2026, the CMS Interoperability and Prior Authorization final rule (CMS-0057-F) has required Medicare Advantage plans, Medicaid and CHIP fee-for-service programs, and Medicaid and CHIP managed care plans to (CMS fact sheet, CMS-0057-F):

• decide expedited (urgent) requests within 72 hours
• decide standard requests within 7 calendar days
• give a specific reason when they deny a request
• publish prior authorization metrics on their website each year (the first set was due March 31, 2026)

A Prior Authorization API, which lets practice systems request and track approvals electronically, is required from January 1, 2027.

New York’s own deadline for state-regulated plans

For insurers regulated by New York, Insurance Law §4903 requires a decision on a pre-authorization request within three business days of receiving the necessary information, with notice to the patient and the provider by phone and in writing. If the plan misses the deadline, the request is treated as an adverse determination that can be appealed. A denial notice must give the reasons and explain the appeal options (NY Insurance Law §4903, revision of June 2026).

The clock starts when the plan has the information it needs, so incomplete requests are the usual cause of slow answers. Self-funded employer plans are governed by federal law, not §4903, so ask the plan which rules it follows.

What New York payers publish

This table only states what each payer’s own public documents said when we read them in November 2026. A blank means we couldn’t find a current, public answer for these tests, not that no authorization is needed.

Notes on the rows:

• NY Medicaid fee-for-service. Ordering providers must get an approval number through RadConsult for CT, CTA, MRI, MRA, cardiac nuclear and PET. Dual-eligible patients and Medicaid managed care members aren’t included; their plan’s rules apply (eMedNY Radiology).
• UnitedHealthcare commercial. The November 2026 list says prior auth is required for participating physicians for outpatient and office diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echocardiograms, and that nuclear cardiology falls under the radiology program. UHC’s separate notice removed the transthoracic echo codes 93306–93308 and 93319 from January 1, 2026. Check the code list on UHC’s cardiology page for the codes still on it.
• Oxford. EviCore does the initial review; Oxford makes the final decision and handles appeals. Oxford keeps a crosswalk of codes that can be substituted for one another under one approval, for example between 93350 and 93351 (Oxford policy).
• EmblemHealth. EmblemHealth’s guide says EviCore does pre-service reviews for cardiology imaging in most outpatient settings, and is the prior approval contact when HIP is the member’s managing entity. Members managed by other groups, and HMO or POS members with an AdvantageCare Physicians or St. Barnabas primary care provider, are excluded. EmblemHealth’s quick guide doesn’t list the tests or a date, so check EviCore’s lookup by code.

Medicare Advantage plans from the same companies often have separate lists from their commercial plans. Look up the plan the patient actually has.

A front-desk workflow that prevents these denials

1. Check at the order, by code. Look up the exact CPT code the test will be billed under, for the patient’s exact plan, on the day the test is ordered.
2. Know who has to ask. Most programs put the request on the ordering provider. If you perform tests ordered by others, confirm an approval exists before booking.
3. Send complete clinicals the first time. Under §4903 the clock starts when the plan has the necessary information. Office notes, symptoms, prior test results and the reason this test is needed now are what reviewers ask for.
4. Match the billed code to the approved code. If the test changes on the day (a stress echo becomes a nuclear study, or a limited echo becomes complete), check the plan’s crosswalk or update the authorization before the claim goes out.
5. Put the authorization number on the claim and keep the approval with the visit record.
6. Track expiry dates. Approvals can expire. Check the validity window on each one and schedule inside it.

When a request or claim is denied

• Read the reason. For plans under CMS-0057-F, and for NY-regulated plans under §4903, the denial must say why.
• Ask for a peer-to-peer with the plan’s reviewer when the reason is clinical. Oxford’s policy notes a board-certified cardiologist is available to discuss decisions where state rules provide for it.
• Appeal in writing within the plan’s deadline, citing the clinical criteria the plan used. NY-regulated plans must tell you how to get those criteria.
• A missed deadline counts. Under §4903, if a NY-regulated plan doesn’t decide in time, that is itself an adverse determination you can appeal.

Authorization denials are one of the claim problems covered in the most common claim denials.

Sources

• CMS, WISeR model
• CMS, WISeR provider and supplier operational guide
• CMS, Interoperability and Prior Authorization final rule (CMS-0057-F) fact sheet
• NY Insurance Law §4903, utilization review determinations
• eMedNY, Physician Procedure Codes: Radiology (April 2026)
• UnitedHealthcare, Commercial prior authorization requirements, effective Nov 1, 2026
• UnitedHealthcare, Radiology and cardiology prior authorization CPT code reductions, effective Jan 1, 2026
• UnitedHealthcare Oxford, Outpatient Cardiology Procedures for EviCore Arrangement, effective Nov 1, 2026
• CMS, Advance Beneficiary Notice of Non-coverage
• EmblemHealth, Quick guide to radiation therapy, cardiology imaging and radiology programs

General information, not advice on a specific claim, contract or legal question. Rules and rates change; check the linked sources for the current version. CPT® is a registered trademark of the American Medical Association. Code descriptions here are paraphrased.