Download AIM Authorization List

AIM SPECIALTY HEALTH
PRIOR AUTH CODE LIST
Radiology, Diagnostic Cardiology, Sleep Programs
Effective 1/1/16
CPT
70480
70481
70482
70486
70487
70488
70450
70460
70470
70490
70491
70492
71250
71260
71270
74150
74160
74170
72192
72193
72194
72125
72126
72127
72128
72129
72130
72131
72132
72133
73200
73201
73202
73700
73701
73702
70551
70552
70553
73218
73219
73220
72141
Description
Radiology (Specialty Imaging) Program – ALL PRODUCT LINES
CT orbit, sella or posterior fossa; w/o contrast
CT orbit, sella or posterior fossa; with contrast
CT orbit, sella or posterior fossa; w/o contrast followed by contrast
CT maxillofacial area (sinus); w/o contrast
CT maxillofacial area (sinus); with contrast
CT maxillofacial area (sinus); w/o contrast followed by contrast
CT head or brain; w/o contrast
CT head or brain; with contrast
CT head or brain; w/o contrast followed by contrast
CT soft tissue neck; w/o contrast
CT soft tissue neck; with contrast
CT soft tissue neck; w/o contrast followed by contrast
CT thorax; w/o contrast (noncardiac)
CT thorax; with contrast (noncardiac)
CT thorax; w/o contrast followed by contrast (noncardiac)
CT abdomen; w/o contrast
CT abdomen; with contrast
CT abdomen; w/o contrast followed by contrast
CT pelvis; w/o contrast
CT pelvis; with contrast
CT pelvis; w/o contrast followed by contrast
CT cervical spine; w/o contrast
CT cervical spine; with contrast
CT cervical spine; w/o contrast followed by contrast
CT thoracic spine; w/o contrast
CT thoracic spine; with contrast
CT thoracic spine; w/o contrast followed by contrast
CT lumbar spine; w/o contrast
CT lumbar spine; with contrast
CT lumbar spine; w/o contrast followed by contrast
CT upper extremity; w/o contrast
CT upper extremity; with contrast
CT upper extremity; w/o contrast followed by contrast
CT lower extremity; w/o contrast
CT lower extremity; with contrast
CT lower extremity; w/o contrast followed by contrast
MRI brain; w/o contrast
MRI brain; with contrast
MRI brain; w/o contrast followed by contrast
MRI upper extremity, other than joint w/o contrast
MRI upper extremity, other than joint with contrast
MRI upper extremity, other than joint w/o contrast followed by contrast
MRI cervical spine; w/o contrast
For questions, call Customer Service Monday through Friday from 8 a.m. to 6 p.m. at 844.522.5278. CPT
72142
72156
72146
72147
72157
72148
72149
72158
70540
70542
70543
70336
71550
71551
71552
74181
74182
74183
72195
72196
72197
77058
77059
77084
70544
70545
70546
71555
74185
72198
73225
73725
72159
77078
78608
78609
73718
73719
73720
73721
73722
73723
73221
73222
73223
78459
78491
78492
70496
70498
70547
70548
70549
Description
MRI cervical spine; with contrast
MRI cervical spine; w/o contrast followed by contrast
MRI thoracic spine; w/o contrast
MRI thoracic spine; with contrast
MRI thoracic spine; w/o contrast followed by contrast
MRI lumbar spine; w/o contrast
MRI lumbar spine; with contrast
MRI lumbar spine; w/o contrast followed by contrast
MRI orbit, face and neck; w/o contrast
MRI orbit, face and neck; with contrast
MRI orbit, face and neck; w/o contrast followed by contrast
MRI temporomandibular joint(s)
MRI chest; w/o contrast
MRI chest; with contrast
MRI chest; w/o contrast followed by contrast
MRI abdomen; w/o contrast
MRI abdomen; with contrast
MRI abdomen; w/o contrast followed by contrast
MRI pelvis; w/o contrast
MRI pelvis; with contrast
MRI pelvis; w/o contrast followed by contrast
MRI breast; unilateral
MRI breast; bilateral
MRI bone marrow blood supply
MRA head; w/o contrast
MRA head; with contrast
MRA head; w/o contrast followed by contrast
MRA chest; with or w/o contrast
MRA abdomen; with or w/o contrast
MRA pelvis; with or w/o contrast
MRA upper extremity; with or w/o contrast
MRA lower extremity; with or w/o contrast
MRA spinal canal and contents with or w/o contrast
CT bone mineral density study; axial skeleton
PET brain, metabolic evaluation
PET brain, perfusion evaluation
MRI lower extremity, other than joint w/o contrast
MRI lower extremity, other than joint w contrast
MRI lower extremity, other than joint w/o contrast followed by contrast
MRI lower extremity, any joint w/o contrast
MRI lower extremity, any joint w contrast
MRI lower extremity, any joint w/o contrast followed by contrast
MRI upper extremity, any joint w/o contrast
MRI upper extremity, any joint with contrast
MRI upper extremity, any joint w/o contrast followed by contrast
PET myocardial, metabolic evaluation
PET myocardial, perfusion, single study
PET myocardial, perfusion, multiple studies
CTA head
CTA neck
MRA neck; w/o contrast
MRA neck; with contrast
MRA neck; w/o contrast followed by contrast
For questions, call Customer Service Monday through Friday from 8 a.m. to 6 p.m. at 844.522.5278. CPT
71275
72191
73206
73706
74175
74174
75635
76390
74176
74177
74178
78811
78812
78813
78814
78815
78816
70554
70555
75572
75573
75574
74176
74177
74178
74712
S8032
G0297
75557
75559
75561
75563
78451
78452
78453
78454
78466
78468
78469
78472
Description
CTA chest (noncoronary)
CTA pelvis
CTA upper extremity
CTA lower extremity
CTA abdomen
CTA Abd/Pelvis wo/w contrast
CTA Abd aorta w bilat iliofemoral low extr runoff
MR Spectroscopy
Computed tomography, abdomen and pelvis; without contrast material
Computed tomography, abdomen and pelvis; with contrast material(s)
Computed tomography, abdomen and pelvis; without contrast material in one or both body regions,
followed by contrast material(s) and further sections in one or both body regions
PET tumor imaging, limited
PET tumor imaging, skull to mid-thigh
PET tumor imaging, whole body
PET tumor imaging with concurrent CT, limited
PET tumor imaging with concurrent CT, skull to mid-thigh
PET tumor imaging with concurrent CT, whole body
Functional MRI brain not requiring physician or psychologist
Functional MRI brain requiring physician or psychologist
Computed tomography, heart, with contrast material, for evaluation of cardiac structure and
morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of
venous structures, if performed)
Computed tomography, heart, with contrast material, for evaluation of cardiac structure and
morphology in the setting of congenital heart disease (including 3D image postprocessing,
assessment of LV cardiac function, RV structure and function and evaluation of venous structures, if
performed)
Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with
contrast material, including 3D image postprocessing (including evaluation of cardiac structure and
morphology, assessment of cardiac function, and evaluation of venous structures, if performed)
CT Abdomen & Pelvis without contrast
CT Abdomen & Pelvis with contrast
CT Abdomen & Pelvis wo/w contrast
MRI Fetal
Low dose CT Lung Screening
Low dose CT Lung Screening
Echocardiography Program
(Not applicable for Florida Hospital Employee or Rosen Employee Plans)
MRI Cardiac for morphology and function without contrast material;
MRI Cardiac for morphology and function without contrast material; with stress imaging
MRI Cardiac for morphology and function without contrast material(s), followed by contrast material(s)
and further sequences;
MRI Cardiac for morphology and function without contrast material(s), followed by contrast material(s)
and further sequences; with stress imaging
Myocardial perfusion SPECT single study including qualitative or quantitative wall motion, ejection
fraction by 1st pass or gated technique, rest or stress
Myocardial perfusion SPECT multiple studies including qualitative or quantitative wall motion, ejection
fraction by 1st pass or gated technique, rest and/or stress
Myocardial perfusion planar single study including qualitative or quantitative wall motion, ejection
fraction by 1st pass or gated technique, rest or stress
Myocardial perfusion planar multiple studies including qualitative or quantitative wall motion, ejection
fraction by 1st pass or gated technique, rest and/or stress
Planar, infarct avid; qualitative or quantitative
Planar, infarct avid; with ejection fraction by first pass technique
SPECT, infarct avid; with or w/o quantification
Cardiac blood pool, gated equilibrium; planar, single study, wall motion plus ejection fraction
For questions, call Customer Service Monday through Friday from 8 a.m. to 6 p.m. at 844.522.5278. CPT
78473
78481
78483
78494
93350
93351
93303
93304
93306
93307
93308
93312
93313
93314
93315
93316
93317
95800
95801
95806
G0398
G0399
G0400
95807
95808
95810
95811
95782
95783
E0485
E0486
E0601
E0470
E0471
Description
Cardiac blood pool gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction
Cardiac blood pool first pass tech; single study, wall motion study plus ejection fraction
Cardiac blood pool first pass tech; multiple studies, wall motion study plus ejection fraction
Cardiac blood pool gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction
Transthoracic Stress Echo, complete
Transthoracic Stress Echo, complete w cont EKG
Transthoracic Echo cardiac anomalies
Transthoracic Echo cardiac anomalies, limited
Transthoracic Echo complete w color & spectral
Transthoracic Echo complete wo color & spectral
Transthoracic Echo limited
Transesophageal Echo
Transesophageal Echo probe only
Transesophageal Echo interpretation
Transesophageal Echo congenital
Transesophageal Echo congenital, probe only
Transesophageal Echo congenital interpretation
Sleep Medicine Program
(Not applicable for Florida Hospital Employee or Rosen Employee Plans)
Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis
(e.g., by air flow or peripheral arterial tone) and sleep time
Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and
respiratory analysis (e.g., by air flow or peripheral arterial tone)
Sleep study, unattended, simultaneous recording of heart rate, oxygen saturation, respiratory airflow,
and respiratory effort (e.g., thoracoabdominal movement)
Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG,
EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation
Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2
respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation
Home sleep study with type IV portable monitor, unattended; minimum of three channels
Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen
saturation, attended by a technologist
Polysomnography; Any age, sleep staging with 1-3 additional parameters of sleep, attended by a
technologist
Polysomnography; Age 6 years or older, sleep staging with 4 or more additional parameters of sleep,
attended by a technologist
Polysomnography; Age 6 years or older, sleep staging with 4 or more additional parameters of sleep,
with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a
technologist
Polysomnography; Younger than 6 years, sleep staging with 4 or more additional parameters of
sleep, attended by a technologist
Polysomnography; Younger than 6 years, sleep staging with 4 or more additional parameters of
sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by
a technologist
Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable,
prefabricated, includes fitting and adjustment
Oral device/appliance used to reduce upper airway collapsibility, adjustable or non- adjustable, custom
fabricated, includes fitting and adjustment
Continuous airway pressure (CPAP) device [may be used for either CPAP or APAP]
Respiratory assist device, bi-level pressure capability, without back-up rate feature, used with
noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive
airway pressure device)
Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive
interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure
device)
For questions, call Customer Service Monday through Friday from 8 a.m. to 6 p.m. at 844.522.5278.