Description MRI, TMJ C T Head Without Contrast C T Head With Contrast C T Head Without & With Contrast

Transcription

1 s Requiring Prior Authorization for the Advanced Imaging MRI, TMJ C T Head Without Contrast C T Head With Contrast C T Head Without & With Contrast C T Orbit Without Contrast C T Orbit With Contrast C T Orbit Without & With Contrast C T Maxillofacial Without Contrast C T Maxillofacial With Contrast C T Maxillofacial Without & With Contrast C T Soft Tissue Neck Without Contrast C T Soft Tissue Neck With Contrast C T Soft Tissue Neck Without & With Contrast C T Angiography Head C T Angiography Neck M R I Orbit, Face, and/or Neck Without Contrast M R I Face, Orbit, and/or Neck With Contrast M R I Face, Orbit, and/or Neck With & Without Contrast Page 1 of 19 Last updated Dec. 4, 2018

2 s Requiring Prior Authorization for the Advanced Imaging M R A Head Without Contrast M R A Head With Contrast M R A Head With & Without Contrast M R A Neck Without Contrast M R A Neck With Contrast M R A Neck With & Without Contrast M R I Head Without Contrast M R I Head With Contrast M R I Head With & Without Contrast MRI Brain, functional MRI MRI Brain, functional MRI, requiring physician C T Thorax Without Contrast C T Thorax With Contrast C T Thorax Without & With Contrast C T Angiography Chest Without Contrast Material, Followed by Contrast Material and Further Sections, Including Image Postprocessing M R I Chest Without Contrast M R I Chest With Contrast M R I Chest With & Without Contrast Page 2 of 19 Last updated Dec. 4, 2018

3 s Requiring Prior Authorization for the Advanced Imaging M R A Chest (Excluding Myocardium) With or Without Contrast C T Cervical Spine Without Contrast C T Cervical Spine With Contrast C T Cervical Spine Without & With Contrast C T Thoracic Spine Without Contrast C T Thoracic Spine With Contrast C T Thoracic Spine Without & With Contrast C T Lumbar Spine Without Contrast C T Lumbar Spine With Contrast C T Lumbar Spine Without & With Contrast M R I Cervical Spine Without Contrast M R I Cervical Spine With Contrast M R I Thoracic Spine Without Contrast M R I Thoracic Spine With Contrast M R I Lumbar Spine Without Contrast M R I Lumbar Spine With Contrast M R I Cervical Spine With & Without Contrast M R I Thoracic Spine With & Without Contrast Page 3 of 19 Last updated Dec. 4, 2018

4 s Requiring Prior Authorization for the Advanced Imaging M R I Lumbar Spine With & Without Contrast M R A Spinal Canal With or Without Contrast C T Angiography Pelvis C T Pelvis Without Contrast C T Pelvis With Contrast C T Pelvis Without & With Contrast M R I Pelvis Without Contrast M R I Pelvis With Contrast M R I Pelvis With & Without Contrast M R A Pelvis With or Without Contrast C T Upper Extremity Without Contrast C T Upper Extremity With Contrast C T Upper Extremity Without & With Contrast C T Angiography Upper Extremity M R I Upper Extremity Without Contrast M R I Upper Extremity With Contrast M R I Upper Extremity With & Without Contrast M R I Upper Extremity Joint Without Contrast Page 4 of 19 Last updated Dec. 4, 2018

5 s Requiring Prior Authorization for the Advanced Imaging M R I Upper Extremity Joint With Contrast M R I Upper Extremity Joint With & Without Contrast M R A Upper Extremity With or Without Contrast C T Lower Extremity Without Contrast C T Lower Extremity With Contrast C T Lower Extremity Without & With Contrast C T Angiography Lower Extremity M R I Lower Extremity Without Contrast M R I Lower Extremity With Contrast M R I Lower Extremity With & Without Contrast M R I Lower Extremity Joint Without Contrast M R I Lower Extremity Joint With Contrast M R I Lower Extremity Joint With & Without Contrast M R A Lower Extremity With or Without Contrast C T Abdomen Without Contrast C T Abdomen With Contrast C T Abdomen Without & With Contrast CT angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing Page 5 of 19 Last updated Dec. 4, 2018

6 s Requiring Prior Authorization for the Advanced Imaging C T Angiography Abdomen CT Abdomen and Pelvis Without Contrast CT Abdomen and Pelvis With Contrast 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 M R I Abdomen Without Contrast M R I Abdomen With Contrast M R I Abdomen With & Without Contrast M R A Abdomen With or Without Contrast Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed Computed tomographic (CT) colonography, screening, including image postprocessing Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation Magnetic resonance (eg, 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 Page 6 of 19 Last updated Dec. 4, 2018

7 s Requiring Prior Authorization for the Advanced 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 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) C T Angiography Abdominal Aorta D Rendering w/o Postprocessing D Rendering with Postprocessing C T Limited or Localized Follow-Up Study M R I Spectroscopy Unlisted computed tomography procedure Unlisted MRI Procedure Magnetic resonance imaging guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation Magnetic resonance imaging guidance for, and monitoring of, parenchymal tissue ablation Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral Page 7 of 19 Last updated Dec. 4, 2018

8 s Requiring Prior Authorization for the Advanced Imaging Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral Computed Tomography, bone mineral density study, 1 or more sites; axial skeleton Magnetic resonance (eg, proton) imaging, bone marrow blood supply Thyroid uptake, single or multiple quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) Thyroid imaging (including vascular flow, when performed) Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) Thyroid Met Imaging Thyroid Met Imaging With Additional Studies Thyroid Scan Whole Body Thyroid Carcinoma Metastases Uptake Parathyroid planar imaging (including subtraction, when performed) Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT) Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization Adrenal Nuclear Imaging Bone Marrow Imaging, Limited Bone Marrow Imaging, Multiple Bone Marrow Imaging, Whole Body Page 8 of 19 Last updated Dec. 4, 2018

9 s Requiring Prior Authorization for the Advanced Imaging Labeled Red Cell Sequestration Spleen Imaging With & Without Vascular Flow Lymph System Imaging Liver Imaging Liver Imaging With Flow Liver Imaging SPECT (3D) Liver Imaging SPECT With Vascular Flow Liver & Spleen Imaging Liver & Spleen Imaging With Flow Hepatobiliary system imaging, including gallbladder when present; Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed Salivary Gland Imaging Serial Salivary Gland Salivary Gland Function Exam Esophageal Motility Gastric Mucosa Imaging Gastroesophageal Reflux Exam Gastric Emptying Study Page 9 of 19 Last updated Dec. 4, 2018

10 s Requiring Prior Authorization for the Advanced Imaging Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel transit Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel and colon transit, multiple days GI Bleeder Scan Meckels Diverticulum Imaging Leveen Shunt Patency Exam Bone or Joint Imaging Limited Bone or Joint Imaging Multiple Bone Scan Whole Body Bone Scan 3 Phase Study Bone Joint Imaging Tomo Test SPECT Non-Imaging Heart Function Cardiac Shunt Imaging Radionuclide Venogram Non-Cardiac 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 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) Page 10 of 19 Last updated Dec. 4, 2018

11 s Requiring Prior Authorization for the Advanced Imaging Myocardial perfusion imaging, planar (including 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 Acute Venous Thrombosis Imaging Venous Thrombosis Imaging Unilateral Venous Thrombosis Images, Bilateral Myocardial imaging, positron emission tomography (PET), metabolic evaluation Myocardial Infarction Scan Heart Infarct Image Ejection Fraction Heart Infarct Image 3D SPECT Cardiac blood pool imaging, Single Cardiac blood pool imaging, Multiple Heart First Pass Single Cardiac blood pool imaging, Multiple 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, SPECT 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) Unlisted Cardiovascular Procedure Page 11 of 19 Last updated Dec. 4, 2018

12 s Requiring Prior Authorization for the Advanced Imaging Pulmonary ventilation imaging (eg, aerosol or gas) Pulmonary perfusion imaging (eg, particulate) Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging Quantitative differential pulmonary perfusion, including imaging when performed Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed Brain Imaging Limited Static Brain Limited Imaging and Flow Brain Imaging Complete Brain Imaging Complete With Flow Brain Imaging 3D Brain Imaging, Positron Emission Tomography (PET) Metabolic Evaluation Brain Imaging, Positron Emission Tomography (PET) Perfusion Evaluation Brain Flow Imaging Only Cisternogram (Cerebrospinal Fluid Flow) Cerebrospinal Ventriculography CSF Shunt Evaluation Cerebrospinal Fluid Scan (Tomographic) SPECT C S F Leakage Detection and Localization Page 12 of 19 Last updated Dec. 4, 2018

13 s Requiring Prior Authorization for the Advanced Imaging Radiopharmaceutical Dacryocystography Unlisted Nuclear Medicine Procedures on the Nervous System Kidney Imaging Morphology Kidney Imaging With Vascular Flow Kidney Imaging With Vascular Flow & Function Single Study Without Pharmacological Intervention Kidney Imaging Single Study With Pharmacological Intervention Kidney Imaging - Multiple Studies Without & With Pharmacological Intervention Kidney Imaging - Tomographic (SPECT) Kidney Function Study - Non-Imaging Radioisotopic Urinary Bladder Residual Study Ureteral Reflux Study Testicular Imaging With Vascular Flow Radiopharm Localization of Tumor, Limited Area Radiopharm Localization of Tumor, Multiple Areas Radiopharm Localization of Tumor, Whole Body Single Day Study Radiopharm Localization of Tumor Tomographic (SPECT) Radiopharm Localization of Tumor, Whole Body Two or More Days Radiopharm Localization of Abscess, Limited Area Page 13 of 19 Last updated Dec. 4, 2018

14 s Requiring Prior Authorization for the Advanced Imaging Radiopharm Localization of Abscess, Whole Body Radiopharm Localization of Abscess, Tomographic SPECT PET Imaging; limited area PET Imaging: skull base to mid-thigh PET Imaging: whole body PET With Concurrently Acquired CT; Limited Area PET With Concurrently Acquired CT; Skull Base to Mid-Thigh PET With Concurrently Acquired CT; Whole Body Unlisted procedure, diagnostic nuclear medicine-radiation therapy treatment planning Transthoracic echocardiography for congenital cardiac anomalies; complete Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study Echocardiography, transthoracic, real-time with image documentation (2D), includes m-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography Echocardiography, transthoracic, real-time with image documentation (2D) with or without m-mode recording; complete Echocardiography, transthoracic, real-time with image documentation (2D) with or without m-mode recording; follow-up or limited study TEE 2D; Incl Probe Placement, Imaging/Interp/Report Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); image acquisition, interpretation and report only Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report Page 14 of 19 Last updated Dec. 4, 2018

15 s Requiring Prior Authorization for the Advanced Imaging Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; complete Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; follow-up or limited study Doppler echocardiography color flow velocity mapping Echocardiography, transthoracic, real-time with image documentation (2D), with or without m-mode recording, during rest and cardiovascular stress test, with interpretation and report 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 Use of echocardiographic contrast agent during stress echocardiography (list separately in addition to code for primary procedure) Right Heart Catheterization Including Measurement(s) of Oxygen Saturation and Cardiac Output, When Performed Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts) including intraprocedural injection(s) for bypass graft angiography Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization Page 15 of 19 Last updated Dec. 4, 2018

16 s Requiring Prior Authorization for the Advanced Imaging Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (list separately in addition to code for primary procedure) Right Heart Catheterization (CHD) Right/Left Heart Catheterization (CHD) Right/Left Heart Catheterization (CHD-TS) Right/Left Heart Catheterization (CAD-ASD) 0042T 0331T CT Perfusion Brain Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment Page 16 of 19 Last updated Dec. 4, 2018

17 s Requiring Prior Authorization for the Advanced Imaging 0332T 0439T 0482T 0501T 0502T 0503T 0504T C8900 Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT Myocardial contrast perfusion echocardiography, at rest or with stress, for assessment of myocardial ischemia or viability (List separately in addition to code for primary procedure) Absolute quantitation of myocardial blood flow, PET, rest and stress Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission, analysis of fluid dynamics and simulated maximal coronary hyperemia, generation of estimated FFR model, with anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report MRA Abdomen with contrast C8901 C8902 C8909 C8910 MRA Abdomen without contrast MRA Abdomen with and w/o contrast MRA chest w/contrast (excluding myocardium) MRA chest w/o contrast (excluding myocardium) Page 17 of 19 Last updated Dec. 4, 2018

18 s Requiring Prior Authorization for the Advanced Imaging C8911 C8912 C8913 C8914 C8918 C8919 C8920 C8921 C8922 C8923 C8924 C8925 C8926 C8928 C8929 MRA chest w/ and w/o contrast (excluding myocardium) MRA lower extremity w/ contrast MRA lower extremity w/o contrast MRA lower extremity w/ and w/o contrast MRA pelvis w/ contrast MRA pelvis w/o contrast MRA pelvis w/ and w/o contrast Transthoracic echocardiography w/contrast for congenital cardiac anomalies; complete Transthoracic echocardiography w/contrast for congenital cardiac anomalies; f/u or limited study Transthoracic echocardiography w/contrast, real-time w/image documentation (2D), w/wo m-mode recording; complete Transthoracic echocardiography w/contrast, real-time w/image documentation (2D), w/wo m-mode recording; f/u or limited study Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, real time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report Transthoracic echocardiography w/contrast, real-time w/image documentation (2D), w/wo m-mode recording, during rest and cardiovascular stress test, w/interpretation and report Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes m-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography Page 18 of 19 Last updated Dec. 4, 2018

19 s Requiring Prior Authorization for the Advanced Imaging C8930 C8931 C8932 C8933 C8934 C8935 C8936 G0219 G0235 G0252 G0297 S8037 S8042 S8085 S8092 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 MRA, w/dye, Spinal Canal MRA, w/o Dye, Spinal Canal MRA, w/o & w/dye, Spinal Canal MRA, w/dye, Upper Extremity MRA, w/o Dye, Upper Extremity MRA, w/o & w/dye, Upper Extremity PET Imaging Whole Body; Melanoma for Non-Covered Indications PET Imaging, Any Site, Not Otherwise Specified PET Imaging, Full and Partial-Ring PET Scanners Only for Initial Diagnosis of Breast Cancer and/or Surgical Planning for Breast Cancer Low-dose Computed Tomography for Lung Cancer Screening Magnetic resonance cholangiopancreatography (MRCP) Magnetic Resonance Imaging (MRI), Low-Field Fluorine-18 Fluorodeoxyglucose (F-18 fdg) Imaging Using Dual Head Coincidence Detection System. (Non-Dedicated PET Scan) Electron Beam Computed Tomography (Also Known as Ultrafast CT, CINET) Page 19 of 19 Last updated Dec. 4, 2018