Cigna - Prior Authorization Procedure List: Radiology & Cardiology Product Category CPT Code CPT Code Description Radiology MR 70336 MRI Temporomandibular Joint(s), (TMJ) Radiology CT 70450 CT Head or Brain, without contrast Radiology CT 70460 CT Head or Brain, with contrast Radiology CT 70470 CT Head or Brain, with and without contrast Radiology CT 70480 CT Orbit, Sella, or Posterior Fossa or Outer, Middle, or Inner Ear; without contrast Radiology CT 70481 CT Orbit, Sella, or Posterior Fossa or Outer, Middle, or Inner Ear; with contrast Radiology CT 70482 CT Orbit, Sella, or Posterior Fossa or Outer, Middle, or Inner Ear; without contrast, followed by contrast and further sections Radiology CT 70486 CT Maxillofacial area, without contrast Radiology CT 70487 CT Maxillofacial area, with contrast Radiology CT 70488 CT Maxillofacial area, without contrast, followed by contrast and further sections Radiology CT 70490 CT Neck Soft Tissue, without contrast Radiology CT 70491 CT Neck Soft Tissue, with contrast Radiology CT 70492 CT Neck Soft Tissue, without contrast followed by contrast and further sections Radiology CT 70496 CTA Head, with contrast, including noncontrast images, if performed, and image post-processing Radiology CT 70498 CTA Neck, with contrast, including noncontrast images, if performed, and image post-processing Radiology MR 70540 MRI Orbit, Face, and/or Neck without contrast Radiology MR 70542 MRI Orbit, Face, and/or Neck; with contrast Radiology MR 70543 MRI Orbit, Face, and/or Neck; without contrast, followed by contrast and further sequences Radiology MR 70544 MRA Head, without contrast Radiology MR 70545 MRA Head, with contrast Radiology MR 70546 MRA Head, with and without contrast Radiology MR 70547 MRA Neck, without contrast Radiology MR 70548 MRA Neck, with contrast Radiology MR 70549 MRA Neck, with & without contrast Radiology MR 70551 MRI Brain (Head), without contrast Radiology MR 70552 MRI Brain (Head), with contrast Radiology MR 70553 MRI Brain (Head), with and without contrast Radiology MR 70554 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 70555 MRI Brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing Radiology CT 71250 CT Chest, without contrast Radiology CT 71260 CT Chest, with contrast Radiology CT 71270 CT Chest, without and with contrast Radiology CT 71275 CTA Chest, (non-coronary), with contrast, including noncontrast images, if performed, and image post-processing
Radiology MR 71550 MRI Chest (eg, for evaluation of hilar and mediastinal lymphadenopathy), without contrast Radiology MR 71551 MRI Chest (eg, for evaluation of hilar and mediastinal lymphadenopathy), with contrast Radiology MR 71552 MRI Chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast, followed by contrast and further sequences Radiology MR 71555 MRA Chest (excluding myocardium), with or without contrast Radiology CT 72125 CT Cervical Spine, without contrast Radiology CT 72126 CT Cervical Spine, with contrast Radiology CT 72127 CT Cervical Spine, without contrast, followed by contrast and further sections Radiology CT 72128 CT Thoracic Spine, without contrast Radiology CT 72129 CT Thoracic Spine, with contrast Radiology CT 72130 CT Thoracic Spine, without contrast, followed by contrast and further sections Radiology CT 72131 CT Lumbar Spine, without contrast Radiology CT 72132 CT Lumbar Spine, with contrast Radiology CT 72133 CT Lumbar Spine, without contrast, followed by contrast and further sections Radiology MR 72141 MRI Cervical Spine, (spinal canal and contents), without contrast Radiology MR 72142 MRI Cervical Spine, (spinal canal and contents), with contrast Radiology MR 72146 MRI Thoracic Spine, (spinal canal and contents), without contrast Radiology MR 72147 MRI Thoracic Spine, (spinal canal and contents), with contrast Radiology MR 72148 MRI Lumbar Spine, (spinal canal and contents), without contrast Radiology MR 72149 MRI Lumbar Spine, (spinal canal and contents), with contrast Radiology MR 72156 MRI Cervical Spine, (spinal canal and contents), without and with contrast Radiology MR 72157 MRI Thoracic Spine, (spinal canal and contents), without and with contrast Radiology MR 72158 MRI Lumbar Spine, (spinal canal and contents), without and with contrast Radiology MR 72159 MRA Spinal Canal, with or without contrast Radiology CT 72191 CTA Pelvis, with contrast, including noncontrast images, if performed, and image postprocessing Radiology CT 72192 CT Pelvis, without contrast Radiology CT 72193 CT Pelvis, with contrast Radiology CT 72194 CT Pelvis, without contrast, followed by contrast and further sections Radiology MR 72195 MRI Pelvis, without contrast Radiology MR 72196 MRI Pelvis, with contrast Radiology MR 72197 MRI Pelvis, without contrast, followed by contrast and further sequences Radiology MR 72198 MRA Pelvis, with or without contrast Radiology CT 73200 CT Upper Extremity, without contrast Radiology CT 73201 CT Upper Extremity, with contrast Radiology CT 73202 CT Upper Extremity, without contrast, followed by contrast and further sections Radiology CT 73206 CTA Upper Extremity, with contrast, including noncontrast images, if performed, and image postprocessing Radiology MR 73218 MRI Upper Extremity, other than joint; without contrast Radiology MR 73219 MRI Upper Extremity, other than joint, with contrast Radiology MR 73220 MRI Upper Extremity, other than joint, without contrast, followed by contrast and further sequences
Radiology MR 73221 MRI Upper Extremity, any joint, without contrast Radiology MR 73222 MRI Upper Extremity, any joint, with contrast Radiology MR 73223 MRI Upper Extremity, any joint, without contrast, followed by contrast and further sequences Radiology MR 73225 MRA Upper Extremity, with or without contrast Radiology CT 73700 CT Lower Extremity, without contrast Radiology CT 73701 CT Lower Extremity, with contrast Radiology CT 73702 CT Lower Extremity, without contrast, followed by contrast and further sections Radiology CT 73706 CTA Lower Extremity, with contrast, including noncontrast images, if performed, and image postprocessing Radiology MR 73718 MRI Lower Extremity, other than joint without contrast Radiology MR 73719 MRI Lower Extremity, other than joint, with contrast Radiology MR 73720 MRI Lower Extremity, other than joint, without contrast, followed by contrast and further sequences Radiology MR 73721 MRI Lower Extremity, any joint, without contrast Radiology MR 73722 MRI Lower Extremity, any joint, with contrast Radiology MR 73723 MRI Lower Extremity, any joint, without contrast, followed by contrast and further sequences Radiology MR 73725 MRA Lower Extremity, with or without contrast Radiology CT 74150 CT Abdomen, without contrast Radiology CT 74160 CT Abdomen, with contrast Radiology CT 74170 CT Abdomen, without and with contrast Radiology CT 74174 CTA ABDOMEN AND PELVIS, with contrast, including noncontrast images, if performed, and image postprocessing Radiology CT 74175 CTA Abdomen, with contrast, including noncontrast images, if performed, and image postprocessing Radiology CT 74176 CT ABDOMEN and PELVIS, without contrast Radiology CT 74177 CT ABDOMEN and PELVIS, with contrast Radiology CT 74178 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 74181 MRI Abdomen, without contrast Radiology MR 74182 MRI Abdomen, with contrast Radiology MR 74183 MRI Abdomen, without contrast, followed by with contrast and further sequences Radiology MR 74185 MRA Abdomen, with or without contrast Radiology CT 74261 CT Colonography, diagnostic, including image postprocessing; without contrast Radiology CT 74262 CT Colonography, diagnostic, including image postprocessing; with contrast including non-contrast images, if performed Radiology CT 74263 CT Colonography, screening, including image postprocessing Radiology MR 74712 MRI fetal, including placental and maternal pelvic imaging when performed; single or first gestation - Removed from program 10/1/2016 Radiology MR 74713 Radiology MR 75557 Cardiac MRI without contrast Radiology MR 75559 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 75561 Cardiac MRI without contrast, followed by contrast and further sequences
Radiology MR 75563 Cardiac MRI without contrast, followed by contrast and further sequences; with stress imaging Radiology MR 75565 Cardiac MRI for velocity flow mapping (list separately in addition to code for primary procedure) Radiology CT 75571 CT Heart, without contrast with quantitative evaluation of coronary calcium Radiology CT 75572 Radiology CT 75573 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 75574 Radiology CT 75635 Radiology 3DI 76376 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 76377 3D Rendering of CT, MRI, ultrasound, or other tomographic modality; requiring an independent workstation Radiology CT 76380 CT Limited Or Localized Follow-Up Study Radiology MR 76390 MR Spectroscopy (MRS) Radiology CT 76497 Unlisted CT procedure (eg, diagnostic, interventional) Radiology MR 76498 Unlisted MRI procedure (eg, diagnostic, interventional) Radiology MR 77058 MRI Breast, UNILATERAL, without and/or with contrast Radiology MR 77059 MRI Breast, BILATERAL, without and/or with contrast Radiology CT 77078 CT Bone Mineral Density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) Radiology MR 77084 MRI Bone Marrow Blood Supply Cardiac Services Nuclear Cardiology 78451 MPI, tomographic (SPECT); single study, at rest or stress (exercise or pharmacologic) Cardiac Services Nuclear Cardiology 78452 MPI, tomographic (SPECT); multiple studies, at rest and/or stress (exercise or pharmacologic) Cardiac Services Nuclear Cardiology 78453 MPI, planar; single study, at rest or stress (exercise or pharmacologic) Cardiac Services Nuclear Cardiology 78454 MPI, planar; multiple studies, at rest and/or stress (exercise or pharmacologic) Radiology PET 78459 PET Cardiac (myocardial imaging), metabolic evaluation Cardiac Services Nuclear Cardiology 78466 Myocardial Imaging, infarct avid, planar; qualitative or quantitative Cardiac Services Nuclear Cardiology 78468 Myocardial Imaging, infarct avid, planar; with EF by first pass technique Cardiac Services Nuclear Cardiology 78469 Myocardial Imaging, infarct avid, planar; tomographic SPECT Cardiac Services Nuclear Cardiology 78472 Cardiac Blood Pool imaging, gated equilibrium; planar, single study at rest or stress Cardiac Services Nuclear Cardiology 78473 Cardiac Blood Pool imaging, gated equilibrium; multiple studies, wall motion plus ejection fraction, at rest and stress Cardiac Services Nuclear Cardiology 78481 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 78483 Cardiac Blood Pool imaging, (planar), first pass technique; multiple studies at rest and with stress, wall motion study plus ejection fraction Radiology PET 78491 PET Cardiac (myocardial imaging), perfusion single study at rest or stress Radiology PET 78492 PET Cardiac (myocardial imaging), perfusion multiple studies at rest or stress Cardiac Services Nuclear Cardiology 78494 Cardiac Blood Pool imaging, gated equilibrium, SPECT Cardiac Services Nuclear Cardiology 78496 Cardiac Blood Pool imaging, gated equilibrium, RV EF by first pass Cardiac Services Nuclear Cardiology 78499 Unlisted cardiovascular procedure, diagnostic nuclear medicine
Radiology PET 78608 PET Brain, metabolic evaluation Radiology PET 78609 PET Brain, perfusion evaluasion Radiology PET 78811 PET Imaging, limited area (chest, head/neck) Radiology PET 78812 PET Imaging, skull base to mid-thigh Radiology PET 78813 PET Imaging, whole body Radiology PET 78814 PET/CT Imaging, limited area (chest, head/neck) Radiology PET 78815 PET/CT Imaging, skull base to mid-thigh Radiology PET 78816 PET/CT Imaging, whole body Cardiac Services Stress Echo 93350 Echocardiography, transthoracic (TTE), during rest and cardiovascular stress test Cardiac Services Stress Echo 93351 Echocardiography, transthoracic (TTE), during rest and cardiovascular stress test including continuous EKG monitoring, with physician Cardiac Services Cardiac Catheterization 93451 Right heart catheterization Cardiac Services Cardiac Catheterization 93452 Left heart catheterization Cardiac Services Cardiac Catheterization 93453 Combined right and left heart catheterization Cardiac Services Cardiac Catheterization 93454 Catheter placement in coronary artery(s) for coronary angiography; Cardiac Services Cardiac Catheterization 93455 Catheter placement in coronary artery(s) for coronary angiography; with bypass grafts Cardiac Services Cardiac Catheterization 93456 Catheter placement in coronary artery(s) for coronary angiography; with right heart catheterization Cardiac Services Cardiac Catheterization 93457 Catheter placement in coronary artery(s) for coronary angiography; with bypass and right heart Cardiac Services Cardiac Catheterization 93458 Catheter placement in coronary artery(s) for coronary angiography; with left heart catheterization Cardiac Services Cardiac Catheterization 93459 Catheter placement in coronary artery(s) for coronary angiography; with left heart and bypass grafts Cardiac Services Cardiac Catheterization 93460 Catheter placement in coronary artery(s) for coronary angiography; with right and left heart Cardiac Services Cardiac Catheterization 93461 Catheter placement in coronary artery(s) for coronary angiography; with right & left heart and grafts Cardiac Services Cardiac Catheterization 93530 Right heart catheterization, for congenital cardiac anomalies Cardiac Services Cardiac Catheterization 93531 Combined right and left heart catheterization, for congenital cardiac anomalies Cardiac Services Cardiac Catheterization 93532 Combined right and transseptal left heart cath, intact septum, for congenital cardiac anomalies Cardiac Services Cardiac Catheterization 93533 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 93350 or 93351 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) -2018 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 -2018 AMA Addtion
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 -2018 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 -2018 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 -2018 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