Anthem Blue Cross and Blue Shield Virginia Advanced Imaging Procedures Requiring Precertification Revised 02/13/2013

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1 Anthem Blue Cross and Blue Shield Virginia Advanced Imaging Procedures Requiring Precertification Revised 02/13/2013 Modality and CT Head CTA Head: Cerebrovascular MRI Head MRA Head: Cerebrovascular Functional MRI (fmri) Code Code Description Head and Neck Imaging CT head, without contrast CT head, with contrast CT head, without contrast followed by re-imaging with contrast 0042T Cerebral perfusion analysis using computed tomography with contrast administration. Including post-processing of parametric maps with determination of cerbral blood flow, cerebral blood volume, and mean transit time CTA head, with contrast material(s), including noncontrast images, if performed, and image postprocessing MRI head, without contrast MRI head, with contrast MRI head, without contrast, followed by re-imaging with contrast MRA head, without contrast MRA head, with contrast MRA head, without contrast followed by re-imaging with contrast MRI brain, functional MRI; including test selection and admin of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration MRI brain, functional MRI; including test selection and admin of repetitive body part movement and/or visual stimulation, requiring physician or psychologist administration of entire neurofunctional testing PET Brain Imaging PET brain, metabolic evaluation PET brain, perfusion evaluation Magnetic Source MEG recording and analysis; for spontaneous brain magnetic activity Imaging and MEG recording and analysis; for evoked magnetic fields, single modality Magnetoencephal MEG recording and analysis; for evoked magnetic fields, each additional modality ography -- S8035 Magnetic Source Imaging MEG CT Orbit, Sella Turcica, Posterior Fossa, Temporal Bone, including MRI Orbit, Face and Neck (Soft Tissues) CT Paranasal Sinus and Maxillofacial Area MRI TMJ MRI temporomandibular joint(s) CT soft tissue neck, without contrast CT Neck for Soft CT soft tissue neck, with contrast Tissue Evaluation CT soft tissue neck, without contrast followed by re-imaging with contrast CT orbit, sella or posterior fossa and outer, middle or inner ear, without contrast CT orbit, sella or posterior fossa and outer, middle or inner ear, with contrast CT orbit, sella or posterior fossa and outer, middle or inner ear, without contrast, followed by reimaging with contrast MRI orbit, face and neck, without contrast MRI orbit, face and neck, with contrast MRI orbit, face and neck, without contrast followed by re-imaging with contrast CT maxillofacial areak, without contrast CT maxillofacial area, with contrast CT maxillofacial area, without contrast followed by re-imaging with contrast CTA Neck CTA neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing MRA neck, without contrast MRA Neck MRA neck, with contrast MRA neck, without contrast followed by re-imaging with contrast SPECT 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 Chest Imaging CT chest, without contrast CT Chest CT chest, with contrast Page 1 of 6

2 CT Chest CTA Chest MRI Chest Code Code Description CT chest, without contrast followed by re-imaging with contrast S8092 Electron beam CT (also known as ultrafast CT, cine CT) CTA chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image post-processing MRI chest, without contrast MRI chest, with contrast MRI chest, without contrast followed by re-imaging with contrast MRA Chest MRA chest (excluding myocardium), without contrast, followed by re-imaing with contrast MRI breast, without and/or with contrast material(s); unilateral MRI breast, without and/or with contrast material(s); bilateral C8903 MRI breast, unilateral with contrast MRI Breast C8904 MRI breast, unilateral without contrast C8905 MRI breast, unilateral without contrast followed by with contrast C8906 MRI breast, bilateral with contrast C8907 MRI breast, bilateral without contrast C8908 MRI breast, bilateral without contrast followed by with contrast Other S8080 Scintimammography, unilateral (including supply of radiopharmaceutical) Cardiac Imaging Nuclear Cardiology Myocardial Perfusion Imaging 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) 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 Gated equilibrium; planar, single study, at rest or stress, wall motion plus ejection fraction Gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction, at rest and stress Nuclear Cardiology Cardiac Blood Pool Imaging Includes MUGA (Multi-Gated Acquisition) and First Pass Radionuclide Ventriculography Nuclear Cardiology Infarct Imaging Stress Echocardiography (SE) First pass technique; single study, wall motion study plus ejection fraction, at rest or with stress First pass technique; multiple studies, at rest and with stress, wall motion study plus ejection fraction Gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction This code is an add-on code to be used in conjunction with As such, this code does not require separate review. Gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique Planar, infarct avid; qualitative or quantitative Planar, infarct avid; with ejection fraction by first pass technique SPECT, infarct avid; with or without quantification Echocardiography, transthoracic during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report Echocardiography, transthoracic 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 This code is an add-on code to be used in conjunction with and As such, this code This code is an add-on code to be used in conjunction with and As such, this code This code is an add-on code to be used in conjunction with and As such, this code This code is an add-on code to be used in conjunction with and As such, this code TEE real-time with image documentation (2-D) (with or without M-mode recording) Placement of transesophageal probe only Image acquisition, interpretation and report only Page 2 of 6

3 Transesophageal Echocardiography (TEE) Transthoracic Echocardiography (TTE) CT Cardiac (Structure) CT Angiography Coronary Arteries (CCTA) Cardiac CT for Quantitative Evaluation of Cornoary Calcification MRI Cardiac PET Myocardial Imaging Other Cardiac CT Abdomen MRI Abdomen Code Code Description TEE for congenital cardiac anomalies Placement of transesophageal probe only Image acquisition, interpretation and report only This code is an add-on code to be used in conjunction with and As such, this code This code is an add-on code to be used in conjunction with and As such, this code This code is an add-on code to be used in conjunction with and As such, this code 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 Transthoracic echocardiography; complete, without spectral Doppler echocardiography, or color flow Doppler echocardiography Transthoracic echocardiography; complete, without spectral Doppler echocardiography, or color flow Doppler echocardiography follow-up or limited study This code is an add-on code to be used in conjunction with and As such, this code This code is an add-on code to be used in conjunction with and As such, this code This code is an add-on code to be used in conjunction with and As such, this code CT, heart, with contrast material, for evaulation of cardiac structure and morphology (including 3-D post processing, assessment of cardiac function, and evaluation of venous structures if performed) CT, heart, with contrast material, for evaulation of cardiac structure and morphology in the setting of congenital heart disease (including 3-D post processing, assessment of left ventricular cardiac function, right ventricular structure and function and evaluation of venous structures, if performed) CT angiography, heart, coronary arteries and any coronary bypass grafts (where present), with contrast material, including 3-D image post processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) CT, heart, without contrast material, with quantitative evaluation of coronary artery calcium Cardiac MRI for morphology and function, without contrast material Cardiac MRI for morphology and function, without contrast material, with stress imaging Cardiac MRI for morphology and function, without contrast material, followed by contrast material Cardiac MRI for morphology and function, without contrast material, followed by contrast material with stress imaging This is an add-on code to be used in conjunction with 75557, 75559, and As such, this code PET myocardial perfusion, single study PET myocardial perfusion, multiple studies PET myocardial, metabolic evaluation Intravascular optical coherence tomography (coronary native vessel or graft) during diagnostic 0291T evaluation and/or therapeutic intervention, including imaging supervision, interpretation, and report; initial vessel Intravascular optical coherence tomography (coronary native vessel or graft) during diagnostic evaluation and/or therapeutic intervention, including imaging supervision, interpretation, and report; 0292T each additional vessel Intravascular catheter-based coronary vessel or graft spectroscopy (e.g. infared) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report, 0205T each vessel (add -on) Abdominal and Pelvic Imaging CT abdomen, without contrast CT abdomen, with contrast CT abdomen, without contrast, followed by re-imaging with contrast MRI abdomen; without contrast (See also S8037) Page 3 of 6

4 Code Code Description MRI Abdomen MRI abdomen; with contrast MRI abdomen; without contrast, followed by re-imaging with contrast CTA Abdomen CTA, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing MRA Abdomen MRA abdomen, without or with contrast CTA of the Abdominal Aorta - Lower Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing (See also 74174) Run-Off CT pelvis, without contrast CT Pelvis CT pelvis, with contrast CT pelvis without contrast, followed by re-imaging with contrast MRI pelvis, without contrast MRI Pelvis MRI pelvis, with contrast MRI pelvis, without contrast, followed by re-imaging with contrast CTA Pelvis CTA, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing MRA Pelvis MRA, pelvis, without contrast, followed by re-imaging with contrast CT, abdomen and pelvis, without contrast CT Abdomen and CT, abdomen and pelvis, with contrast Pelvis CT, abdomen and pelvis, without contrast in one or both body regions, followed by re-imaging with Combination contrast material(s) in one or both body regions CTA Abdomen and Pelvis Combination CTA, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing Screening CT colonography including image postprocessing CT Colonography Diagnostic CT colonography without contrast Diagnostic CT colonography with contrast including non-contrast images if performed MRCP S8037 Magnetic Resonance Cholangiopancreatography (MRCP) (See also 74181) CT Cervical Spine MRI Cervical Spine CT Thoracic Spine MRI Thoracic Spine CT Lumbar Spine MRI Lumbar Spine Spine Imaging CT cervical spine, without contrast CT cervical spine, with contrast CT cervical spine, without contrast, followed by re-imaging with contrast MRI cervical spine, without contrast MRI cervical spine, with contrast MRI cervical spine, without contrast, followed by re-imaging with contrast CT thoracic spine, without contrast CT thoracic spine, with contrast CT thoracic spine, without contrast, followed by re-imaging with contrast MRI thoracic spine, without contrast MRI thoracic spine, with contrast MRI thoracic spine, without contrast, followed by re-imaging with contrast CT lumbar spine, without contrast CT lumbar spine, with contrast CT lumbar spine, without contrast, followed by re-imaging with contrast MRI lumbar spine, without contrast MRI lumbar spine, with contrast MRI lumbar spine, without contrast, followed by re-imaging with contrast MRA Spinal Canal MRA spinal canal C8931 Magnetic resonance angiography with contrast, spinal canal and contents C8932 Magnetic resonance angiography without contrast, spinal canal and contents C8933 Magnetic resonance angiography without contrast followed by contrast, spinal canal and contents Discogram Cervical-Thoracic Discogram Upper Imaging CT Upper MRI Upper (Any Joint) MRI Upper (Non CT upper extremity, without contrast CT upper extremity, with contrast CT upper extremity, without contrast, followed by re-imaging with contrast MRI upper extremity, any joint, without contrast MRI upper extremity, any joint, with contrast MRI upper extremity, any joint, without contrast, followed by re-imaging with contrast MRI upper extremity, other than joint, without contrast Page 4 of 6

5 Code Code Description (Non MRI upper extremity, other than joint, with contrast Joint) MRI upper extremity, other than joint, without contrast, followed by re-imaging with contrast CTA, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing CTA/MRA Upper MRA, upper extremity, without and with contrast (Note: Upper MRA is not currently a covered benefit by the Centers for Medicare and Medicaid Services, through a National Coverage Determination) Lower Imaging CT, lower extremity, without contrast CT Lower CT, lower extremity, with contrast CT, lower extremity, without contrast, followed by re-imaging with contrast MRI, lower extremity, other than joint, without contrast MRI, lower extremity, other than joint, with contrast MRI Lower MRI, lower extremity, other than joint, without contrast followed by re-imaging with contrast (Joint MRI, lower extremity, any joint, without contrast and Non-Joint) MRI,lower extremity, any joint, with contrast MRI, lower extremity, any joint, without contrast followed by re-imaging with contrast CTA Lower CTA, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing MRA Lower MRA, lower extremity, without contrast followed by re-imaging with contrast PET - Other Applications, Including Oncologic Tumor Imaging PET imaging, limited area PET imaging, skull to mid-thigh Dedicated PET PET imaging, whole body Imaging G0219 PET imaging whole body; melanoma for non covered indications G0235 PET imaging, any site, not otherwise specified G0252 PET imaging, full and partial-ring PET scanners only, for initial A9586 Florbetapir F 18, diagnostic, per study dose, up to 10 millicuries (AMYViD) PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; limited area PET/CT Imaging PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; skull base to mid-thigh PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; whole body Other MRS Magnetic Resonance Spectroscopy (MRS) MRI - Bone Marrow Blood Supply MRI bone marrow blood supply SPECT for Non- Cardiovascular Indications Other CT Other MRI Other Liver imaging, SPECT Liver imaging with vascular flow, SPECT Bone and/or joint imaging; tomographic SPECT Brain imaging, tomographic (SPECT) Cerebrospinal fluid flow, tomographic (SPECT) Kidney imaging morphology; tomographic (SPECT) Radiopharmaceutical localization of tumor; tomographic SPECT Radiopharmaceutical localization of inflammatory process tomographic SPECT A9507 Indium In-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries [Prostascint] CT, limited or localized follow up study Unlisted CT Unlisted MRI S8042 MRI, low field Unlisted diagnostic radiographic procedure Unlisted miscellaneous procedure, diagnostic nuclear medicine Unlisted nervous system procedure, diagnostic nuclear medicine (when specified as SPECT/ SISCOM for the preoperative evaluation of individuals with intractable focal epliepsy S8085 Fluorine-18 fluorodeoxyglucose (F-18 FDG) imaging using dual-head coincidence detection system (non dedicated PET scan) A9584 (SPECT) Iodine I -123 ioflupane, diagnostic, per study dose, up to 5 millicuries (DaT scan) 340 Nuclear Medicine - General Page 5 of 6

6 Revenue Codes Post-Service Review of 3D Rendered Images Code Code Description 341 Nuclear Medicine - Diagnostic 349 Nuclear Medicine - Other 350 CT Scan - General 351 CT Scan - Head Scan 352 CT Scan - Body Scan 359 CT Scan - Other 404 Other Imaging - PET 610 Magnetic Resonance Technology - General Classification 611 Magnetic Resonance Technology MRI - Brain 612 Magnetic Resonance Technology MRI - Spinal Cord 614 Magnetic Resonance Technology MRI - Other 615 Magnetic Resonance Technology MRA - Head and Neck 616 Magnetic Resonance Technology MRA - Lower Extremities 618 Magnetic Resonance Technology MRA - Other 619 Magnetic Resonance Imaging - Other 3D rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation. This code is used in conjunction with code(s) for base imaging procedure(s). 3D rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation. This code is used in conjunction with code(s) for base imaging procedure(s). Page 6 of 6