Diagnostic Imaging Utilization Management and Consultation Management Programs Imaging Code Listing for Connecticut, Maine and New Hampshire

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1 Diagnostic Imaging Utilization Management and Consultation Management Programs Imaging Code Listing for Connecticut, Maine and New Hampshire The grid below contains the CPT * codes that are subject to the utilization management (UM) and consultation management (CM) programs through AIM Specialty Health SM (AIM) for dates of service on or after January 1, If an order ID number is issued by AIM, the service is eligible for coverage subject to the provisions of the member s coverage document. Services rendered as part of emergency room services, inpatient hospitalization or rehabilitation or 23-hour observation are not subject to the UM or CM programs. The grid identifies the CPT codes included within specific groupers, with the grouper number noted. Add-on or secondary codes do not require a separate prior authorization. Computerized Tomography (CT) CPT Description Abdomen CT abdomen; w/o contrast CT abdomen; with contrast CT abdomen; w/o contrast followed by contrast Chest CT thorax; w/o contrast CT thorax; with contrast CT thorax; w/o contrast followed by contrast Upper CT upper extremity; w/o contrast Extremity CT upper extremity; with contrast CT upper extremity; w/o contrast followed by contrast Lower CT lower extremity; w/o contrast Extremity CT lower extremity; with contrast CT lower extremity; w/o contrast followed by contrast Head CT head or brain; w/o contrast CT head or brain; with contrast CT head or brain; w/o contrast followed by contrast Orbit CT orbit, sella or posterior fossa; w/o contrast CT orbit, sella or posterior fossa; with contrast CT orbit, sella or posterior fossa; w/o contrast followed by contrast Sinus CT maxillofacial area; w/o contrast CT maxillofacial area; with contrast CT maxillofacial area; w/o contrast followed by contrast Neck CT soft tissue neck; w/o contrast CT soft tissue neck; with contrast CT soft tissue neck; w/o contrast followed by contrast Pelvis CT pelvis; w/o contrast CT pelvis; with contrast CT pelvis w/o contrast followed by contrast Cervical CT cervical spine; w/o contrast Spine CT cervical spine; with contrast CT cervical spine; w/o contrast followed by contrast Thoracic CT thoracic spine; w/o contrast Spine CT thoracic spine; with contrast CT thoracic spine; w/o contrast followed by contrast Lumbar CT lumbar spine; w/o contrast Spine CT lumbar spine; with contrast CT lumbar spine; w/o contrast followed by contrast Abdomen and CT abdomen and pelvis; w/o contrast Pelvis CT abdomen and pelvis; with contrast CT abdomen and pelvis; w/o contrast followed by contrast

2 Computerized Tomography Angiography (CTA) CPT Description Abdomen CTA abdomen Abdominal Arteries CTA abdominal aorta & bilateral iliofemoral lower extremity runoff CTA abdomen and pelvis Chest CTA chest Upper Extremity CTA upper extremity Lower Extremity CTA lower extremity Head CTA head Neck CTA neck Pelvis CTA pelvis Resonance Imaging (MRI) CPT Description Abdomen MRI abdomen; w/o contrast MRI abdomen; with contrast MRI abdomen; w/o contrast followed by contrast Bone Marrow MRI bone marrow blood supply Breast MRI breast; unilateral MRI breast; bilateral Chest MRI chest; w/o contrast MRI chest; with contrast MRI chest; w/o contrast followed by contrast Cardiac MRI Cardiac for morphology and function without contrast material; MRI Cardiac for morphology and function without contrast material; with stress imaging MRI Cardiac for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; MRI Cardiac for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging Upper Extremity MRI upper extremity, other than joint w/o contrast Non-joint MRI upper extremity, other than joint with contrast MRI upper extremity, other than joint w/o contrast followed by contrast Upper Extremity MRI upper extremity, any joint w/o contrast Any Joint MRI upper extremity, any joint with contrast MRI upper extremity, any joint w/o contrast followed by contrast Lower Extremity MRI lower extremity, other than joint w/o contrast MRI lower extremity, other than joint w contrast MRI lower extremity, other than joint w/o contrast followed by contrast MRI lower extremity, any joint w/o contrast MRI lower extremity, any joint w contrast MRI lower extremity, any joint w/o contrast followed by contrast TMJ MRI temporomandibular joint(s) Orbit MRI orbit, face and neck; w/o contrast MRI orbit, face and neck; with contrast MRI orbit, face and neck; w/o contrast followed by contrast Brain MRI brain; w/o contrast MRI brain; with contrast MRI brain; w/o contrast followed by contrast Pelvis MRI pelvis; w/o contrast MRI pelvis; with contrast MRI pelvis; w/o contrast followed by contrast

3 Cervical MRI cervical spine; w/o contrast Spine MRI cervical spine; with contrast MRI cervical spine; w/o contrast followed by contrast Thoracic MRI thoracic spine; w/o contrast Spine MRI thoracic spine; with contrast MRI thoracic spine; w/o contrast followed by contrast Lumbar MRI lumbar spine; w/o contrast Spine MRI lumbar spine; with contrast MRI lumbar spine; w/o contrast followed by contrast Resonance Angiography (MRA) CPT Description Abdomen MRA abdomen; with or w/o contrast Chest MRA chest; with or w/o contrast Upper Extremity MRA upper extremity; with or w/o contrast Lower Extremity MRA lower extremity; with or w/o contrast Head MRA head; w/o contrast MRA head; with contrast MRA head; w/o contrast followed by contrast Neck MRA neck; w/o contrast MRA neck; with contrast MRA neck; w/o contrast followed by contrast Pelvis MRA pelvis; with or w/o contrast Spinal Canal MRA spinal canal and contents with or w/o contrast Resonance Spectroscopy (MRS) CPT Description MR Spectroscopy QCT Bone Densitometry CPT Description CT bone mineral density study; axial skeleton Nuclear Cardiology CPT Description Myocardial Myocardial perfusion imaging, tomographic (SPECT) (including Perfusion Imaging 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 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)

4 Infarct Planar, infarct avid; qualitative or quantitative Imaging Planar, infarct avid; with ejection fraction by first pass technique Cardiac Blood Pool Imaging SPECT, infarct avid; with or w/o quantification Gated equilibrium; planar, single study, wall motion plus ejection fraction Gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction First pass tech; single study, wall motion study plus ejection fraction First pass tech; multiple studies, wall motion study plus ejection fraction Gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction Positron Emission Tomography (PET) CPT Description Brain PET brain, metabolic evaluation Imaging PET brain, perfusion evaluation Myocardial PET myocardial, metabolic evaluation Imaging PET myocardial, perfusion, single study PET myocardial, perfusion, multiple studies PET and PET/CT Fusion CPT Description PET imaging, limited PET imaging, skull to mid-thigh PET imaging, whole body PET imaging with concurrent CT, limited PET imaging with concurrent CT, skull to mid-thigh PET imaging with concurrent CT, whole body Screening CT Colonoscopy CPT Description Computed tomographic (CT) colonography, screening, including image post processing Diagnostic CT Colonography CPT Description 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 Functional MRI Brain CPT Description Functional MRI brain not requiring physician administration Functional MRI brain requiring physician administration CT Heart for Calcium Scoring CPT Description Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium

5 CT Heart for Structure & Morph CPT Description 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) CTA Heart Incl Structure & Morph CPT Description 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) Add-on Procedures CPT Description CT or MRI Grouping & D Reconstruction of CT or MRI images Cardiac MRI Cardiac magnetic resonance imaging for velocity flow mapping (List Grouping separately in addition to code for primary procedure) Cardiac Blood Pool Grouping Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (Add-on to only) Echocardiography Echocardiogram CPT Description Stress Echo (SE) Transthoracic Stress Echo, complete Transthoracic Stress Echo, complete w cont EKG Resting Trans Echo (TTE) Transesophageal Echo (TEE) Transthoracic Echo cardiac anomalies Transthoracic Echo cardiac anomalies, limited Transthoracic Echo complete w color & spectral Transthoracic Echo complete w/o color & spectral Transthoracic Echo limited Transesophageal Echo Transesophageal Echo probe only Transesophageal Echo interpretation Transesophageal Echo congenital Transesophageal Echo congenital, probe only Transesophageal Echo congenital interpretation Echo Add-On Codes CPT Description Doppler Echo complete Doppler Echo limited Doppler Echo flow velocity Echo contrast agent (SE only) Revised 7/12 Anthem Blue Cross and Blue Shield is the trade name of: In Connecticut: Anthem Health Plans, Inc. In Maine: Anthem Health Plans of Maine, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. Independent licensees of the Blue Cross and Blue Shield Association ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

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