Cigna - Prior Authorization Procedure List: Radiology & Cardiology

Transcription

1 Cigna - Prior Authorization Procedure List: Radiology & Cardiology Product Category CPT Code CPT Code Description Radiology MR MRI Temporomandibular Joint(s), (TMJ) Radiology CT CT Head or Brain, without contrast Radiology CT CT Head or Brain, with contrast Radiology CT CT Head or Brain, with and without contrast Radiology CT CT Orbit, Sella, or Posterior Fossa or Outer, Middle, or Inner Ear; without contrast Radiology CT CT Orbit, Sella, or Posterior Fossa or Outer, Middle, or Inner Ear; with contrast Radiology CT CT Orbit, Sella, or Posterior Fossa or Outer, Middle, or Inner Ear; without contrast, followed by contrast and further sections Radiology CT CT Maxillofacial area, without contrast Radiology CT CT Maxillofacial area, with contrast Radiology CT CT Maxillofacial area, without contrast, followed by contrast and further sections Radiology CT CT Neck Soft Tissue, without contrast Radiology CT CT Neck Soft Tissue, with contrast Radiology CT CT Neck Soft Tissue, without contrast followed by contrast and further sections Radiology CT CTA Head, with contrast, including noncontrast images, if performed, and image post-processing Radiology CT CTA Neck, with contrast, including noncontrast images, if performed, and image post-processing Radiology MR MRI Orbit, Face, and/or Neck without contrast Radiology MR MRI Orbit, Face, and/or Neck; with contrast Radiology MR MRI Orbit, Face, and/or Neck; without contrast, followed by contrast and further sequences Radiology MR MRA Head, without contrast Radiology MR MRA Head, with contrast Radiology MR MRA Head, with and without contrast Radiology MR MRA Neck, without contrast Radiology MR MRA Neck, with contrast Radiology MR MRA Neck, with & without contrast Radiology MR MRI Brain (Head), without contrast Radiology MR MRI Brain (Head), with contrast Radiology MR MRI Brain (Head), with and without contrast Radiology MR MRI Brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration Radiology MR MRI Brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing Radiology CT CT Chest, without contrast Radiology CT CT Chest, with contrast Radiology CT CT Chest, without and with contrast Radiology CT CTA Chest, (non-coronary), with contrast, including noncontrast images, if performed, and image post-processing

2 Radiology MR MRI Chest (eg, for evaluation of hilar and mediastinal lymphadenopathy), without contrast Radiology MR MRI Chest (eg, for evaluation of hilar and mediastinal lymphadenopathy), with contrast Radiology MR MRI Chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast, followed by contrast and further sequences Radiology MR MRA Chest (excluding myocardium), with or without contrast Radiology CT CT Cervical Spine, without contrast Radiology CT CT Cervical Spine, with contrast Radiology CT CT Cervical Spine, without contrast, followed by contrast and further sections Radiology CT CT Thoracic Spine, without contrast Radiology CT CT Thoracic Spine, with contrast Radiology CT CT Thoracic Spine, without contrast, followed by contrast and further sections Radiology CT CT Lumbar Spine, without contrast Radiology CT CT Lumbar Spine, with contrast Radiology CT CT Lumbar Spine, without contrast, followed by contrast and further sections Radiology MR MRI Cervical Spine, (spinal canal and contents), without contrast Radiology MR MRI Cervical Spine, (spinal canal and contents), with contrast Radiology MR MRI Thoracic Spine, (spinal canal and contents), without contrast Radiology MR MRI Thoracic Spine, (spinal canal and contents), with contrast Radiology MR MRI Lumbar Spine, (spinal canal and contents), without contrast Radiology MR MRI Lumbar Spine, (spinal canal and contents), with contrast Radiology MR MRI Cervical Spine, (spinal canal and contents), without and with contrast Radiology MR MRI Thoracic Spine, (spinal canal and contents), without and with contrast Radiology MR MRI Lumbar Spine, (spinal canal and contents), without and with contrast Radiology MR MRA Spinal Canal, with or without contrast Radiology CT CTA Pelvis, with contrast, including noncontrast images, if performed, and image postprocessing Radiology CT CT Pelvis, without contrast Radiology CT CT Pelvis, with contrast Radiology CT CT Pelvis, without contrast, followed by contrast and further sections Radiology MR MRI Pelvis, without contrast Radiology MR MRI Pelvis, with contrast Radiology MR MRI Pelvis, without contrast, followed by contrast and further sequences Radiology MR MRA Pelvis, with or without contrast Radiology CT CT Upper Extremity, without contrast Radiology CT CT Upper Extremity, with contrast Radiology CT CT Upper Extremity, without contrast, followed by contrast and further sections Radiology CT CTA Upper Extremity, with contrast, including noncontrast images, if performed, and image postprocessing Radiology MR MRI Upper Extremity, other than joint; without contrast Radiology MR MRI Upper Extremity, other than joint, with contrast Radiology MR MRI Upper Extremity, other than joint, without contrast, followed by contrast and further sequences

3 Radiology MR MRI Upper Extremity, any joint, without contrast Radiology MR MRI Upper Extremity, any joint, with contrast Radiology MR MRI Upper Extremity, any joint, without contrast, followed by contrast and further sequences Radiology MR MRA Upper Extremity, with or without contrast Radiology CT CT Lower Extremity, without contrast Radiology CT CT Lower Extremity, with contrast Radiology CT CT Lower Extremity, without contrast, followed by contrast and further sections Radiology CT CTA Lower Extremity, with contrast, including noncontrast images, if performed, and image postprocessing Radiology MR MRI Lower Extremity, other than joint without contrast Radiology MR MRI Lower Extremity, other than joint, with contrast Radiology MR MRI Lower Extremity, other than joint, without contrast, followed by contrast and further sequences Radiology MR MRI Lower Extremity, any joint, without contrast Radiology MR MRI Lower Extremity, any joint, with contrast Radiology MR MRI Lower Extremity, any joint, without contrast, followed by contrast and further sequences Radiology MR MRA Lower Extremity, with or without contrast Radiology CT CT Abdomen, without contrast Radiology CT CT Abdomen, with contrast Radiology CT CT Abdomen, without and with contrast Radiology CT CTA ABDOMEN AND PELVIS, with contrast, including noncontrast images, if performed, and image postprocessing Radiology CT CTA Abdomen, with contrast, including noncontrast images, if performed, and image postprocessing Radiology CT CT ABDOMEN and PELVIS, without contrast Radiology CT CT ABDOMEN and PELVIS, with contrast Radiology CT CT ABDOMEN and PELVIS, without contrast in one or both body regions, followed by contrast and further sections in one or both body regions Radiology MR MRI Abdomen, without contrast Radiology MR MRI Abdomen, with contrast Radiology MR MRI Abdomen, without contrast, followed by with contrast and further sequences Radiology MR MRA Abdomen, with or without contrast Radiology CT CT Colonography, diagnostic, including image postprocessing; without contrast Radiology CT CT Colonography, diagnostic, including image postprocessing; with contrast including non-contrast images, if performed Radiology CT CT Colonography, screening, including image postprocessing Radiology MR MRI fetal, including placental and maternal pelvic imaging when performed; single or first gestation - Removed from program 10/1/2016 Radiology MR Radiology MR Cardiac MRI without contrast Radiology MR Cardiac MRI without contrast, with stress imaging MRI fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary procedure) - Removed from program 10/1/2016 Radiology MR Cardiac MRI without contrast, followed by contrast and further sequences

4 Radiology MR Cardiac MRI without contrast, followed by contrast and further sequences; with stress imaging Radiology MR Cardiac MRI for velocity flow mapping (list separately in addition to code for primary procedure) Radiology CT CT Heart, without contrast with quantitative evaluation of coronary calcium Radiology CT Radiology CT CT Heart, with contrast, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed) CT Heart, with contrast, 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) Radiology CT Radiology CT Radiology 3DI CT Heart, coronary arteries and bypass grafts (when present), with contrast, including 3D image post processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) CTA Abdominal Aorta and bilateral iliofemoral lower extremity runoff, with contrast, including noncontrast images, if performed, and image postprocessing 3D Rendering of CT, MRI, ultrasound, or other tomographic modality; not requiring an independent workstation - Removed from program 4/1/2015 Radiology 3DI D Rendering of CT, MRI, ultrasound, or other tomographic modality; requiring an independent workstation Radiology CT CT Limited Or Localized Follow-Up Study Radiology MR MR Spectroscopy (MRS) Radiology CT Unlisted CT procedure (eg, diagnostic, interventional) Radiology MR Unlisted MRI procedure (eg, diagnostic, interventional) Radiology MR MRI Breast, UNILATERAL, without and/or with contrast Radiology MR MRI Breast, BILATERAL, without and/or with contrast Radiology CT CT Bone Mineral Density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) Radiology MR MRI Bone Marrow Blood Supply Cardiac Services Nuclear Cardiology MPI, tomographic (SPECT); single study, at rest or stress (exercise or pharmacologic) Cardiac Services Nuclear Cardiology MPI, tomographic (SPECT); multiple studies, at rest and/or stress (exercise or pharmacologic) Cardiac Services Nuclear Cardiology MPI, planar; single study, at rest or stress (exercise or pharmacologic) Cardiac Services Nuclear Cardiology MPI, planar; multiple studies, at rest and/or stress (exercise or pharmacologic) Radiology PET PET Cardiac (myocardial imaging), metabolic evaluation Cardiac Services Nuclear Cardiology Myocardial Imaging, infarct avid, planar; qualitative or quantitative Cardiac Services Nuclear Cardiology Myocardial Imaging, infarct avid, planar; with EF by first pass technique Cardiac Services Nuclear Cardiology Myocardial Imaging, infarct avid, planar; tomographic SPECT Cardiac Services Nuclear Cardiology Cardiac Blood Pool imaging, gated equilibrium; planar, single study at rest or stress Cardiac Services Nuclear Cardiology Cardiac Blood Pool imaging, gated equilibrium; multiple studies, wall motion plus ejection fraction, at rest and stress Cardiac Services Nuclear Cardiology Cardiac Blood Pool imaging, (planar), first pass technique; single study, at rest or with stress, wall motion study plus ejection fraction Cardiac Services Nuclear Cardiology Cardiac Blood Pool imaging, (planar), first pass technique; multiple studies at rest and with stress, wall motion study plus ejection fraction Radiology PET PET Cardiac (myocardial imaging), perfusion single study at rest or stress Radiology PET PET Cardiac (myocardial imaging), perfusion multiple studies at rest or stress Cardiac Services Nuclear Cardiology Cardiac Blood Pool imaging, gated equilibrium, SPECT Cardiac Services Nuclear Cardiology Cardiac Blood Pool imaging, gated equilibrium, RV EF by first pass Cardiac Services Nuclear Cardiology Unlisted cardiovascular procedure, diagnostic nuclear medicine

5 Radiology PET PET Brain, metabolic evaluation Radiology PET PET Brain, perfusion evaluasion Radiology PET PET Imaging, limited area (chest, head/neck) Radiology PET PET Imaging, skull base to mid-thigh Radiology PET PET Imaging, whole body Radiology PET PET/CT Imaging, limited area (chest, head/neck) Radiology PET PET/CT Imaging, skull base to mid-thigh Radiology PET PET/CT Imaging, whole body Cardiac Services Stress Echo Echocardiography, transthoracic (TTE), during rest and cardiovascular stress test Cardiac Services Stress Echo Echocardiography, transthoracic (TTE), during rest and cardiovascular stress test including continuous EKG monitoring, with physician Cardiac Services Cardiac Catheterization Right heart catheterization Cardiac Services Cardiac Catheterization Left heart catheterization Cardiac Services Cardiac Catheterization Combined right and left heart catheterization Cardiac Services Cardiac Catheterization Catheter placement in coronary artery(s) for coronary angiography; Cardiac Services Cardiac Catheterization Catheter placement in coronary artery(s) for coronary angiography; with bypass grafts Cardiac Services Cardiac Catheterization Catheter placement in coronary artery(s) for coronary angiography; with right heart catheterization Cardiac Services Cardiac Catheterization Catheter placement in coronary artery(s) for coronary angiography; with bypass and right heart Cardiac Services Cardiac Catheterization Catheter placement in coronary artery(s) for coronary angiography; with left heart catheterization Cardiac Services Cardiac Catheterization Catheter placement in coronary artery(s) for coronary angiography; with left heart and bypass grafts Cardiac Services Cardiac Catheterization Catheter placement in coronary artery(s) for coronary angiography; with right and left heart Cardiac Services Cardiac Catheterization Catheter placement in coronary artery(s) for coronary angiography; with right & left heart and grafts Cardiac Services Cardiac Catheterization Right heart catheterization, for congenital cardiac anomalies Cardiac Services Cardiac Catheterization Combined right and left heart catheterization, for congenital cardiac anomalies Cardiac Services Cardiac Catheterization Combined right and transseptal left heart cath, intact septum, for congenital cardiac anomalies Cardiac Services Cardiac Catheterization Combined right and transseptal left heart cath, existing septal opening, congenital cardiac anomalies Radiology CT 0042T Cerebral perfusion analysis using CT with contrast Radiology MR 0159T MRI Breast, CAD, including computer algorithm analysis of MRI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation (List separately in addition to code for primary procedure) Cardiac Services Nuclear Cardiology 0331T Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; Cardiac Services Nuclear Cardiology 0332T Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT Cardiac Services Stress Echo 0439T 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.) - Add-on for or Cardiac Services CPET 0482T Absolute quantitation of myocardial blood flow, positron emission tomography (PET), rest and stress (List separately in addition to code for primary procedure) AMA Addtion Cardiac Services CCTA 0501T 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 discordantdata, interpretation and report AMA Addtion

6 Cardiac Services CCTA 0502T Cardiac Services CCTA 0503T Cardiac Services CCTA 0504T fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission AMA Addtion 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 AMA Addtion 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 AMA Addtion Radiology MR C8900 MRA Abdomen, with contrast Radiology MR C8901 MRA Abdomen, without contrast Radiology MR C8902 MRA Abdomen, with and without contrast Radiology MR C8903 MRI Breast with contrast, UNILATERAL Radiology MR C8904 MRI Breast without contrast, UNILATERAL Radiology MR C8905 MRI Breast without contrast followed by with contrast, UNILATERAL Radiology MR C8906 MRI Breast with contrast, BILATERAL Radiology MR C8907 MRI Breast without contrast, BILATERAL Radiology MR C8908 MRI Breast without contrast followed by with contrast, BILATERAL Radiology MR C8909 MRA Chest (excluding myocardium), with contrast Radiology MR C8910 MRA Chest (excluding myocardium), without contrast Radiology MR C8911 MRA Chest (excluding myocardium), without contrast followed by with contrast Radiology MR C8912 MRA Lower Extremity, with contrast Radiology MR C8913 MRA Lower Extremity, without contrast Radiology MR C8914 MRA Lower Extremity, without contrast followed by with contrast Radiology MR C8918 MRA Pelvis, with contrast Radiology MR C8919 MRA Pelvis, without contrast Radiology MR C8920 MRA Pelvis, without contrast followed by with contrast Cardiac Services Cardiac Catheterization C9741 Right heart catheterization with implantation of wireless pressure sensor in pulmonary artery, includes provision of patient home electronics unit Radiology PET G0219 Pet imaging whole body; melanoma for non-covered indications Radiology PET G0235 PET Imaging, any site, not otherwise specified Radiology PET G0252 PET Imaging, full and partial-ring PET scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes) Radiology CT G0297 Low-dose CT For Lung Cancer Screening - Effective 1/1/2016 Radiology PET Q9982 Flutemetamol f18 diagnostic Radiology PET Q9983 Florbetaben f18 diagnostic Radiology CT S8032 Low-dose CT For Lung Cancer Screening - AMA Deleted Code Effective 10/1/2016 Radiology MR S8035 Magnetic Source Imaging (MSI) Radiology MR S8037 Magnetic resonance cholangiopancreatography (MRCP) Radiology CT S8092 CT Electron Beam (also known as Ultrafast CT, Cine CT), for calcium scoring