BlueAdvantage SM. & BlueChoice SM Radiology Prior Authorization Program Code List CPT /HCPS

Transcription

1 BlueAdvantage SM & BlueChoice SM Radiology Prior Authorization Program Code List CPT /HCPS MRI TMJ CT Head Without Contrast CT Head With Contrast CT Head Without & With Contrast CT Orbit Without Contrast CT Orbit With Contrast CT Orbit Without & With Contrast CT Maxillofacial Without Contrast CT Maxillofacial With Contrast CT Maxillofacial Without & With Contrast CT Soft Tissue Neck Without Contrast CT Soft Tissue Neck With Contrast CT Soft Tissue Neck Without & With Contrast CT Anqioqraphy Head CT Angiography Neck MRI Orbit, Face, Neck and/or Without Contrast MRI Face, Orbit, Neck With Contrast MRI Face, Orbit, Neck With & Without Contrast MRA Head Without Contrast MRA Head With Contrast MRA Head With & Without Contrast MRA Neck Without Contrast MRA Neck With Contrast MRA Neck With & Without Contrast MRI Head Without Contrast MRI Head With Contrast MRI Head With & Without Contrast MRI Brain, functional MRI MRI Brain, functional MRI, requiring physician CT Thorax Without Contrast CT Thorax With Contrast CT Thorax Without & With Contrast CT Angiography Chest Without Contrast Material Followed by Contrast Material and Further Sections, Including Image Post processing MRI Chest Without Contrast 1

2 71551 MRI Chest With Contrast MRI Chest With & Without Contrast Chest (Excluding Myocardium) With Or Without CT Cervical Spine Without Contrast CT Cervical Spine With Contrast CT Cervical Spine Without & With Contrast CT Thoracic Spine Without Contrast CT Thoracic Spine With Contrast CT Thoracic Spine Without & With Contrast CT Lumbar Spine Without Contrast CT Lumbar Spine With Contrast CT Lumbar Spine Without & With Contrast MRI Cervical Spine Without Contrast MRI Cervical Spine With Contrast MRI Thoracic Spine Without Contrast MRI Thoracic Spine With Contrast MRI Lumbar Spine Without Contrast MRI Lumbar Spine With Contrast MRI Cervical Spine With & Without Contrast MRI Thoracic Spine With & Without Contrast MRI Lumbar Spine With & Without Contrast MRA Spinal Canal With Or Without Contrast CT Angiography Pelvis CT Pelvis Without Contrast CT Pelvis With Contrast CT Pelvis Without & With Contrast MRI Pelvis Without Contrast MRI Pelvis With Contrast MRI Pelvis With & Without Contrast MRA Pelvis With Or Without Contrast CT Upper Extremity Without Contrast CT Upper Extremity With Contrast CT Upper Extremity Without & With Contrast CT Angiography Upper Extremity MRI Upper Extremity Without Contrast MRI Upper Extremity With Contrast MRI Upper Extremity With & Without Contrast MRI Upper Extremity Joint Without Contrast 2

3 73222 MRI Upper Extremity Joint With Contrast MRI Upper Extremity Joint With & Without Contrast MRA Upper Extremity With Or Without Contrast CT Lower Extremity Without Contrast CT Lower Extremity With Contrast CT Lower Extremity Without & With Contrast CT Angiography Lower Extremity MRI Lower Extremity Without Contrast MRI Lower Extremity With Contrast MRI Lower Extremity With & Without Contrast MRI Lower Extremity Joint Without Contrast MRI Lower Extremity Joint With Contrast MRI Lower Extremity Joint With & Without Contrast MRA Lower Extremity With Or Without Contrast CT Abdomen Without Contrast CT Abdomen With Contrast CT Abdomen Without & With Contrast CT angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image post processing CT 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 region, followed by contrast Material(s) and further sections in one or both body regions MRI Abdomen Without Contrast MRI Abdomen With Contrast MRI Abdomen With & Without Contrast MRA Abdomen With Or Without Contrast Computed tomographic (CT) colonography, diagnostic, post processing: without contrast material Computed tomographic (CT) colonography, diagnostic, including image post processing; with contrast material(s) Computed tomographic (CT) colonography, screening, including image post processing 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 3

4 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) CT Angiography Abdominal Aorta D Rendering W/0 Post processing D Rendering W Post processing CT Limited Or Localized Follow-Up Study MRI Spectroscopy Unlisted computed tomography procedure Unlisted MRl Procedure MRI Breast With And/Or Without Contrast M R 1 Breast Bilateral Computed Tomography, bone mineral density study, 1 or more sites: axial skeleton Magnetic resonance (e.g., proton) imaging, bone marrow blood supply Gastric emptying imaging study (e.g., solid, liquid, or both) Gastric emptying imaging study (e.g., solid, liquid, or both) with small bowel transit Gastric emptying imaging study (e.g., solid, liquid, or both) with small bowel and colon transit; multiple days 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) 4

5 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 Myocardial imaging, positron emission tomography (pet), metabolic evaluation Myocardial Infarction Scan Heart Infarct Image Ejection Fraction Heart Infarct Image 3D SPECT Cardiac Bloodpool Img, Single Cardiac Bloodpool Img, Multl 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 - Single Rest Unlisted Cardiovascular Procedure Brain Imaging, Positron Emission Tomography (PET) Metabolic Evaluation Brain Imaging, Positron Emission Tomography (PET) Perfusion Evaluation Positron emission tomography (PET) imaging; limited area Positron emission tomography (PET) imaging; skull base to mid-thigh Positron emission tomography (PET) imaging; whole body Positron emission tomography (PET) imaging with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; limited area Positron emission tomography (PET) imaging with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; skull base to mid-thigh Positron emission tomography (PET) imaging with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; whole body 0042T CT Perfusion Brain Computer-aided detection, including computer algorithm analysis of MRI image data 0159T for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI (List separately in addition to code for primary procedure) C8900 MRA Abdomen with contrast C8901 MRA Abdomen without contrast C8902 MRA Abdomen with and w/o contrast C8903 MRI Breast w/ contrast, unilateral C8904 MRI Breast w/o contrast, unilateral C8905 MRI Breast w. and w/o contrast, unilateral 5

6 C8906 C8907 C8908 C8909 C8910 C8911 C8912 C8913 C8914 C8918 C8919 C8920 C8931 C8932 C8933 C8934 C8935 C8936 G0219 G0235 G0252 S8032 S8035 S8037 S8042 S8085 S8092 MRI Breast Bilateral w/ Contrast MRI Breast Bilateral w/o Contrast MRI Breast Bilateral w/ and w/o Contrast MRA chest w/contrast (excluding myocardium) MRA chest w/o contrast (excluding myocardium) MRA chest (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 MRA. W/Dye, Spinal Canal MRA, W/0 Dye. Spinal Cana L MRA, W/O&W/Dye, Spinal Canal Mra, W/Dye, Upper Extremity MRA, W/0 Dye, Upper Extr MRA, W/O&W/Dye. Upper Extr 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 source imaging Magnetic resonance cholangiopancreato-graphy (MRCP) Magnetic Resonance Imaging (Mri), Low-Field Fluorine-18 Fluorodeoxyglucose (F-18 Fog) Imaging Using Dual Head Coincidence Detection System. (Non-dedicated PET scan) Electron Beam Computed Tomography (Also Known As Ultrafast CT, CINET) 6

7 BlueCross BlueShield of Tennessee, Inc., an Independent Licensees of the BlueCross BlueShield Association. CPT is a registered trademark of the American Medical Association. BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN bcbstmedicare.com CoveredServices specifically exclude mammography, inpatientradiology services,radiology services rendered in an Emergency Department of a hospital, radiation therapy services, interventional radiology procedures, services provided outside the BlueCross BlueShield of Tennessee Service Area for fully insured (non-aso) commercial Members, and all other outpatient diagnostic services other than the MRI, MRA, MRS, CT or PET services. 16PED5251 (6/16)