Download PG0035 Outpatient Advanced Imaging

POLICY . . . . . . . . PG-0035
EFFECTIVE . . . . . .01/15/06
LAST REVIEW . . . 07/12/16
MEDICAL POLICY
Outpatient Advanced
Imaging Authorization
GUIDELINES
This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder
contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the
accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure
reporting and does not imply coverage and reimbursement.
DESCRIPTION
Prior Authorization is based on a combination of medical necessity, medical appropriateness and benefit limits.
Ordering physicians or the facility performing the imaging procedure must obtain a prior authorization for certain
outpatient, non-emergent diagnostic imaging procedures.
Outpatient advanced imaging services that require prior authorization:
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Magnetic Resonance Imaging and Magnetic Resonance Angiography (MRI/MRA)
Computerized Tomography and Computerized Tomography Angiography (CT/CTA)
Nuclear Cardiology
Molecular Breast Imaging (MBI), also known as Breast-Specific Gamma Imaging (BSGI)
To submit a prior authorization request:
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The quickest way to get approval is submitting through McKesson’s Clear Coverage™ for MRI/MRA,
CT/CTA and Nuclear Cardiology. MBI/BSGI can NOT be submitted for prior authorization per McKesson’s
Clear Coverage™
Due to the required documentation, requests and supporting medical documentation can also be submitted
via fax. (Fax form is available at paramounthealthcare.com)
The medical documentation that needs to be submitted with the fax request includes:
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Medical/clinical history
Current signs and symptoms
Results of any other pertinent diagnostic testing
Consult or other treatment documentation supporting the rationale for procedure
Authorizations will be CPT and ICD-9 specific based on your request. Claims will be paid only if the codes billed are
the same as those requested. If you find that the services rendered are different from the services approved and
the claim will have different CPT and/or ICD-9 codes, please fax the correction to the Utilization/Case Management
Department so that the authorization can be changed. This will result in your claims being paid on first pass,
instead of being denied and requiring an appeal.
Paramount has dedicated Utilization/Case Management staff supporting this process. Providers will receive a
return fax with the authorization number within five working days of receipt of the request. Referral confirmation
letters will be mailed to the facility of service and member for all approved requests. In the event of a denial,
requesting providers will receive a telephone call and a denial letter that contains rationale and appeal rights.
Ohio Revised Code 1751.82 gives the provider the right to request reconsideration on behalf of the patient if the
prior authorization request is denied.
In the event that there is a true emergency and there is no time to request prior authorization, the provider should
ALWAYS address the needs of the patient first, and deal with authorization issues the next business day.
Emergency services are defined as being required as the result of an emergency medical condition. Paramount will
review these requests against medical necessity criteria.
POLICY
Outpatient Advanced Imaging Procedures that require prior authorization for HMO, PPO, Individual
Marketplace, Elite, & Advantage:
70450, 70460, 70470, 70480, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70540, 70542, 70543, 70544,
70545, 70546, 70547, 70548, 70549, 71250, 71260, 71270, 71550, 71551, 71552, 71555, 72125, 72126, 72127,
-2-
72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158,
72159, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73218, 73219, 73220, 73221,
73222, 73223, 73225, 73700, 73701, 73702, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160,
74170, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74261, 74262, 74263, 75557, 75559, 75561, 75563,
75571, 75572, 75573, 75574, 76380, 76497, 76498, 78599, C8900, C8901, C8902, C8903, C8904, C8905, C8910,
C8911, C8912, C8913, C8914, C8918, C8919, C8920, C8931, C8932, C8933, C8934, C8935, C8936, G0235,
G0252, S8037, S8042, S8080
Outpatient Advanced Imaging Procedures that do not require prior authorization for HMO, PPO, Individual
Marketplace, Elite, & Advantage:
70336, , 70481, 70496, 70498, 70551, 70552, 70553, 70554, 70555, 70557, 70558, 70559, 71275, 72191, 73206,
73706, 74174, 74175, 74712, 74713, 75565, 75635, 76390, 77058, 77059, 77078, 77084, 78451, 78452, 78453,
78454, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78496, 78608, 78609,
78800, 78811, 78812, 78813, 78814, 78815, 78816, 96020, 93015, 93016, 93017, 93018, 93350, C8906, C8907,
C8908, C8928, C8930, G0219
MR Defecography (billed/coded with procedure codes 72195-72197) is non-covered.
HMO, PPO, Individual Marketplace, Elite, Advantage
Outpatient advanced imaging procedures may be covered services if criteria have been met. Claims will be denied
If a service requires prior authorization (as listed above) and it is not completed.
Paramount utilizes InterQual® criteria sets for medical necessity determinations for MRI/MRA, CT/CTA, and
Nuclear Cardiology.
Advanced imaging procedures performed as part of an inpatient stay or in the emergency department for diagnosis
and treatment of an emergency medical condition does not require prior authorization.
Functional Magnetic Resonance Imaging (fMRI)
Paramount considers functional magnetic resonance imaging (fMRI) (70554, 70555 & 96020) medically necessary
to identify the eloquent cortex in pre-surgical evaluation of persons with brain tumors, epilepsy, or vascular
malformations.
Paramount considers fMRI experimental and investigational for the diagnosis, monitoring, prognosis, or surgical
management of all other indications, including any of the following conditions/diseases (not an all-inclusive list)
because its effectiveness for these indications has not been established:
 Alzheimer's disease
 Bipolar disorder
 Coma/vegatative state
 Fibromyalgia
 Multiple sclerosis
 Parkinson's disease
 Schizophrenia
 Stroke/stroke rehabilitation
 Trauma (e.g., head injury)
MR Defecography
Paramount considers dynamic magnetic resonance imaging (MRI) of defecation (also known as MR defecography)
(72195-72197) experimental and investigational for the evaluation of rectal prolapse, rectal intussusception, other
pelvic floor disorders, and all other indications because its effectiveness for these indications has not been
established.
Molecular Breast Imaging (MBI)/Breast-Specific Gamma Imaging (BSGI)
Paramount has determined that MBI/BSGI (78800) is covered in the following situations.
1. Patients with findings of dense mammogram and elevated lifetime risk of breast cancer which is < 20%. AND
2. Patients in whom an MRI is contraindicated or patient unable to complete.
Results of the available studies do not provide conclusive evidence that BSGI should be relied on as a replacement
for biopsy, ultrasonography, or magnetic resonance imaging (MRI) in women who have suspicious breast lesions.
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CODING/BILLING INFORMATION
The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria
that must be met. Payment for supplies may be included in payment for other services rendered.
CPT CODES
70336 Magnetic resonance (e.g., proton) imaging, temporomandibular joint(s)
70450 Computed tomography, head or brain; without contrast material
70460 Computed tomography, head or brain; with contrast material
70470 Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections
70480 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material
70481 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material
70482 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by
contrast material(s) and further sections
70486 Computed tomography, maxillofacial area; without contrast material
70487 Computed tomography, maxillofacial area; with contrast material
70488 Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections
70490 Computed tomography, soft tissue neck; without contrast material
70491 Computed tomography, soft tissue neck; with contrast material
70492 Computed tomography, soft tissue neck; without contrast material, followed by contrast material(s) and further sections
70496 Computed tomographic angiography, head, with contrast material(s), including non-contrast images, if performed, and image
post-processing
70498 Computed tomographic angiography, neck, with contrast material(s), including non-contrast images, if performed, and image
post-processing
70540 Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s)
70542 Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; with contrast material(s)
70543 Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast
material(s) and further sequences
70544 Magnetic resonance angiography, head; without contrast material(s)
70545 Magnetic resonance angiography, head; with contrast material(s)
70546 Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences
70547 Magnetic resonance angiography, neck; without contrast material(s)
70548 Magnetic resonance angiography, neck; with contrast material(s)
70549 Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences
70551 Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material
70552 Magnetic resonance (e.g., proton) imaging, brain (including brain stem); with contrast material
70553 Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material, followed by contrast
material(s) and further
sequences
70554 Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part
movement and/or visual stimulation, not requiring physician or psychologist administration
70555 Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part
movement and/or visual stimulation, requiring physician or psychologist administration of entire neurofunctional testing
70557 MRI, brain (including brain stem and skull base), during open intracranial procedure (e.g., to assess for residual tumor or
residual vascular malformation); without contrast material
70558 MRI, brain (including brain stem and skull base), during open intracranial procedure (e.g., to assess for residual tumor or
residual vascular malformation); with contrast material
70559 MRI, brain (including brain stem and skull base), during open intracranial procedure (e.g., to assess for residual tumor or
residual vascular malformation); without contrast material(s), followed by contrast material(s) and further sequences
71250 Computed tomography, thorax; without contrast material
71260 Computed tomography, thorax; with contrast material
71270 Computed tomography, thorax; without contrast material, followed by contrast material(s) and further sections
71275 Computed tomographic angiography, chest (noncoronary), with contrast material(s), including non-contrast images, if
performed, and image post-processing
71550 Magnetic resonance (e.g., proton) imaging, chest (e.g., for evaluation of hilar and mediastinal lymphadenopathy); without
contrast material(s)
71551 Magnetic resonance (e.g., proton) imaging, chest (e.g., for evaluation of hilar and mediastinal lymphadenopathy); with
contrast material(s)
71552 Magnetic resonance (e.g., proton) imaging, chest (e.g., for evaluation of hilar and mediastinal lymphadenopathy); without
contrast material(s), followed by contrast material(s) and further sequences
71555 Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s)
72125 Computed tomography, cervical spine; without contrast material
72126 Computed tomography, cervical spine; with contrast material
-472127
72128
72129
72130
72131
72132
72133
72141
72142
72146
72147
72148
72149
72156
72157
72158
72159
72191
72192
72193
72194
72195
72196
72197
72198
73200
73201
73202
73206
73218
73219
73220
73221
73222
73223
73225
73700
73701
73702
73706
73718
73719
73720
73721
73722
73723
73725
74150
74160
74170
74174
74175
Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections
Computed tomography, thoracic spine; without contrast material
Computed tomography, thoracic spine; with contrast material
Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections
Computed tomography, lumbar spine; without contrast material
Computed tomography, lumbar spine; with contrast material
Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections
Magnetic resonance (e.g., proton) imaging, spinal canal and contents, cervical; without contrast material
Magnetic resonance (e.g., proton) imaging, spinal canal and contents, cervical; with contrast material
Magnetic resonance (e.g., proton) imaging, spinal canal and contents, thoracic; without contrast material
Magnetic resonance (e.g., proton) imaging, spinal canal and contents, thoracic; with contrast material
Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar; without contrast material
Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar; with contrast material
Magnetic resonance (e.g., proton) imaging, spinal canal and contents, without contrast material, followed by contrast
material(s) and further sequences; cervical
Magnetic resonance (e.g., proton) imaging, spinal canal and contents, without contrast material, followed by contrast
material(s) and further sequences; thoracic
Magnetic resonance (e.g., proton) imaging, spinal canal and contents, without contrast material, followed by contrast
material(s) and further sequences; lumbar
Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s)
Computed tomographic angiography, pelvis, with contrast material(s), including non-contrast images, if performed, and
image post-processing
Computed tomography, pelvis; without contrast material
Computed tomography, pelvis; with contrast material
Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections
Magnetic resonance (e.g., proton) imaging, pelvis; without contrast material(s)
Magnetic resonance (e.g., proton) imaging, pelvis; with contrast material(s)
Magnetic resonance (e.g., proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further
sequences
Magnetic resonance angiography, pelvis, with or without contrast material(s)
Computed tomography, upper extremity; without contrast material
Computed tomography, upper extremity; with contrast material
Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections
Computed tomographic angiography, upper extremity, with contrast material(s), including non-contrast images, if performed,
and image post-processing
Magnetic resonance (e.g., proton) imaging, upper extremity, other than joint; without contrast material(s)
Magnetic resonance (e.g., proton) imaging, upper extremity, other than joint; with contrast material(s)
Magnetic resonance (e.g., proton) imaging, upper extremity, other than joint; without contrast material(s), followed by
contrast material(s) and further sequences
Magnetic resonance (e.g., proton) imaging, any joint of upper extremity; without contrast material(s)
Magnetic resonance (e.g., proton) imaging, any joint of upper extremity; with contrast material(s)
Magnetic resonance (e.g., proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast
material(s) and further sequences
Magnetic resonance angiography, upper extremity, with or without contrast material(s)
Computed tomography, lower extremity; without contrast material
Computed tomography, lower extremity; with contrast material
Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections
Computed tomographic angiography, lower extremity, with contrast material(s), including non-contrast images, if performed,
and image post-processing
Magnetic resonance (e.g., proton) imaging, lower extremity other than joint; without contrast material(s)
Magnetic resonance (e.g., proton) imaging, lower extremity other than joint; with contrast material(s)
Magnetic resonance (e.g., proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast
material(s) and further sequences
Magnetic resonance (e.g., proton) imaging, any joint of lower extremity; without contrast material
Magnetic resonance (e.g., proton) imaging, any joint of lower extremity; with contrast material
Magnetic resonance (e.g., proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast
material(s) and further sequences
Magnetic resonance angiography, lower extremity, with or without contrast material(s)
Computed tomography, abdomen; without contrast material
Computed tomography, abdomen; with contrast material
Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections
CT Angiography, Abdomen and Pelvis
CT Angiography, Abdomen
-574176
74177
74178
74181
74182
74183
74185
74261
74262
74263
74712
74713
75557
75559
75561
75563
75565
75571
75572
75573
75574
75635
76380
76390
76497
76498
77058
77059
77078
77084
78451
78452
78453
78454
78459
78466
78468
78469
78472
78473
78481
78483
CT Abdomen and Pelvis combination
CT, abdomen and pelvis; with contrast material(s)
CT, 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
Magnetic resonance (e.g., proton) imaging, abdomen; without contrast material(s)
Magnetic resonance (e.g., proton) imaging, abdomen; with contrast material(s)
Magnetic resonance (e.g., proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and
further sequences
Magnetic resonance angiography, abdomen, with or without contrast material(s)
Computed tomographic (CT) colonography, diagnostic, including image post-processing; without contrast material
Computed tomographic (CT) colonography, diagnostic, including image post-processing; with contrast material(s) including
non-contrast images, if performed
Computed tomographic (CT) colonography, screening, including image post-processing
Magnetic resonance (e.g., proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or
first gestation
Magnetic resonance (e.g., proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each
additional gestation (List separately in addition to code for primary procedure)
Cardiac magnetic resonance imaging for morphology and function without contrast material;
Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging
Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast
material(s) and further sequences;
Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast
material(s) and further sequences; with stress imaging
Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure)
Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium
Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image
post-processing, 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 post-processing, 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 post processing (including evaluation of cardiac structure and morphology, assessment of cardiac
function, and evaluation of venous structures, if performed)
Computed tomographic angiography, abdominal aorta and bilateral ilio-femoral lower extremity runoff, with contrast
material(s), including non-contrast images, if performed, and image post-processing
Computed tomography, limited or localized follow-up study
Magnetic resonance spectroscopy
Unlisted computed tomography procedure (e.g., diagnostic, interventional)
Unlisted MR procedure (e.g., diagnostic, interventional)
Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral
Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral
CT, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine)
Magnetic resonance (e.g., proton) imaging, bone marrow blood supply
Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion,
ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress
(exercise or pharmacologic)
Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion,
ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or
stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
Myocardial perfusion imaging, planar (including attenuation correction, qualitative or quantitative wall motion, ejection
fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise
or pharmacologic)
Myocardial perfusion imaging, planar (including attenuation correction, qualitative or quantitative wall motion, ejection
fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress
(exercise or pharmacologic) and/or redistribution and/or rest reinjection
Myocardial imaging, positron emission tomography (PET), metabolic evaluation
Myocardial imaging, infarct avid, planar; qualitative or quantitative
Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique
Myocardial imaging, infarct avid, planar; tomographic spect with or without quantification
MUGA Scan
Gated heart multiple
Cardiac blood pool imaging, (planar), first pass technique; single study, at rest or with stress (exercise and/or
pharmacologic), wall motion study plus ejection fraction, with or without quantification
Cardiac blood pool imaging, (planar), first pass technique; multiple studies, at rest and with stress (exercise and/ or
-6pharmacologic), wall motion study plus ejection fraction, with or without quantification
Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress
Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress
Cardiac blood pool imaging, gated equilibrium, spect, at rest, wall motion study plus ejection fraction, with or without
quantitative processing
78496 Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass
technique (List separately in addition to code for primary procedure)
78599 Unlisted nervous system procedure, diagnostic nuclear medicine
78608 Brain imaging, positron emission tomography (PET); metabolic evaluation
78609 Brain imaging, positron emission tomography (PET); perfusion evaluation
78800 Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); limited area
78811 Positron emission tomography (PET) imaging; limited area (e.g., chest, head/neck)
78812 Positron emission tomography (PET) imaging; skull base to mid-thigh
78813 Positron emission tomography (PET) imaging; whole body
78814 Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and
anatomical localization imaging; limited area (e.g., chest, head/neck)
78815 Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and
anatomical localization imaging; skull base to mid-thigh
78816 Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and
anatomical localization imaging; whole body
93015 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic
monitoring, and/or pharmacological stress: with supervision, interpretation and report
93016 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic
monitoring, and/or pharmacological stress: with supervision only, without interpretation and report
93017 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic
monitoring, and/or pharmacological stress: with tracing only, without interpretation and report
93018 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic
monitoring, and/or pharmacological stress: with interpretation and report only
93350 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed,
during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with
interpretation and report
96020 Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test
administered entirely by a physician or other qualified health care professional (ie,psychologist), with review of test results
and report
HCPCS CODES
C8900 MRA with contrast, abdomen
C8901 MRA without contrast, abdomen
C8902 MRA abdomen without contrast followed by with contrast
C8903 MRI breast with contrast, breast; unilateral
C8904 MRI breast without contrast, breast; unilateral
C8905 MRI breast without contrast followed by with contrast
C8906 MRI with contrast, breast; bilateral
C8907 MRI without contrast, breast; bilateral
C8908 MRI without contrast followed by with contrast, breast
C8909 MRA with contrast, chest (excluding myocardium)
C8910 MRA without contrast, chest (excluding myocardium)
C8911 MRA chest without contrast followed by with contrast (excluding myocardium)
C8912 MRA with contrast, lower extremity
C8913 MRA without contrast, lower extremity
C8914 MRA lower extremity without contrast followed by with contrast
C8918 MRA, with contrast, pelvis
C8919 MRA, without contrast, pelvis
C8920 MRA, pelvis without contrast followed by with contrast
C8928 Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image
documentation (2d), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill,
bicycle exercise and/or pharmacologically induced stress, with interpretation and report
C8930 Transthoracic echocardiography, with contrast, or without contrast followed by with contrast, real-time with image
documentation (2d), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill,
bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous
electrocardiographic monitoring, with physician supervision
C8931 MRA spinal canal and contents without contrast followed by with contrast
C8932 MRA spinal canal and contents without contrast, spinal canal and contents
78491
78492
78494
-7C8933
C8934
C8935
C8936
G0219
G0235
G0252
S8037
S8042
S8080
MRA spinal canal and contents without contrast followed by with contrast
MRA upper extremity with contrast, upper extremity
MRA upper extremity without contrast, upper extremity
MRA upper extremity without contrast followed by with contrast
PET Imaging Whole Body, Melanoma for Non-Covered Indications
PET imaging, any site, not otherwise specified
PET Imaging, Initial Diagnosis of Breast Cancer and/or Surgical Planning for Breast Cancer
magnetic resonance cholangiopancreatography (MRCP)
MRI, low-field
Scintimammography (radioimmunoscintigraphy of the breast), unilateral, including supply of
radiopharmaceutical
TAWG REVIEW DATES: 08/10/2011, 11/14/2012, 10/23/2013, 07/18/2014, 04/23/15 (MR Defecography 7219572197), 04/22/16 (MR Defecography 72195-72197)
REVISION HISTORY EXPLANATION
01/01/07: All members will require for prior authorization review for procedure 0146T, following Medicare
guidelines.
04/30/07: Added 0151T
07/01/07: All members will require prior authorization review for procedure 0151T, following Medicare guidelines
06/01/08: Added services 0148T and 0150T. Codes 0148T and 0150T are included in coverage with prior
authorization review, following Medicare guidelines
06/01/09: Added 0145T, 0147T, 0149T. Codes 0145T, 0147T, and 0149T are all included in coverage with prior
authorization review, following Medicare guidelines
12/01/09: Updated codes
01/01/10: Codes 0144T through 0151T were deleted and assigned Category I CPT codes 75571-75574. There
was no change in coverage
03/01/11: No changes
08/02/12: Updated verbiage
01/14/14: Changed policy to cover all imaging that requires prior auth. Changed name of policy from Computed
Tomographic Angiography (CTA) of the Coronary Arteries to Outpatient Advanced Imaging Authorization. Deleted
ICD-9 codes 413.0-413.9, 414.00-414.07, 414.11, 414.12, 414.8, 414.9, 746.85, 786.51 and 794.30. Added CPT &
HCPCS codes as needed. Policy reviewed and updated to reflect most current clinical evidence. Approved by
Medical Policy Steering Committee as revised.
07/18/14: Added code S8080. Policy reviewed and updated to reflect most current clinical evidence. Approved by
TAWG as revised.
01/13/15: These procedures 70551, 70552, 70553, 70336, 70481, 78451, 78452 , 78453, 78469, 93015, 93016,
93017, 93018, 93350 C8928, C8930, 78472, 78473, 78481, 78483, 78454, 77058, 77059, 78800 no longer require
prior authorization. Functional Magnetic Resonance Imaging (fMRI) (96020) added to policy. Policy reviewed and
updated to reflect most current clinical evidence. Approved by Medical Policy Steering Committee as revised.
04/23/15: MR Defecography (72195-72197) added to policy as non-covered. Policy reviewed and updated to reflect
most current clinical evidence per TAWG.
01/12/16: These codes no longer require prior authorization: 70496, 70498, 72191, 73206, 74174, 74175, 75635,
78459, 78491, 78492, 78812-78816, C8906-C8908, G0219 Added effective 1/1/16 new codes 74712 and 74713
that do not require prior authorization.
04/22/16: Policy reviewed and updated to reflect most current clinical evidence per TAWG.
07/12/16: These procedures no longer require prior authorization: 70554, 70555, 70557, 70558, 70559, 71275,
73706, 75565, 76390, 77078, 77084, 78466, 78468, 78494, 78496, 78608, 78609, 78811, 96020. Policy reviewed
and updated to reflect most current clinical evidence per Medical Policy Steering Committee.
REFERENCES/RESOURCES
Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services
Ohio Department of Medicaid http://jfs.ohio.gov/
American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services
Industry Standard Review