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ARCHIVED Site of Care for Advanced Imaging 2023-07-01 to 2024-11-16

Archive Date: 11/17/2024

This document has been archived because it has outdated information. It is for historical information only and should not be consulted for clinical use. Current versions of guidelines are available on the Carelon Medical Benefits Management website at http://guidelines.carelonmedicalbenefitsmanagement.com

Link to PDF

Status: Created Effective Date: 07/01/2023

Doc ID: RBM14-0723.1 Last Review Date: 09/21/2022

Approval and implementation dates for specific health plans may vary. Please consult the applicable health plan for more details.

Clinical Appropriateness Guidelines

Advanced Imaging

Appropriate Use Criteria: Site of Care

Proprietary

© 2023 Carelon Medical Benefits Management, Inc. All rights reserved.

Table of Contents

Table of Contents

Description and Application of the Guidelines

General Clinical Guideline

Clinical Appropriateness Framework

Simultaneous Ordering of Multiple Diagnostic or Therapeutic Interventions

Repeat Diagnostic Intervention

Repeat Therapeutic Intervention

Site of Care

General Information/Overview

Clinical Indications

References

Codes

History

Description and Application of the Guidelines

The Carelon Clinical Appropriateness Guidelines (hereinafter “the Carelon Clinical Appropriateness Guidelines” or the “Guidelines”) are designed to assist providers in making the most appropriate treatment decision for a specific clinical condition for an individual. As used by Carelon, the Guidelines establish objective and evidence-based criteria for medical necessity determinations where possible. In the process, multiple functions are accomplished:

  • To establish criteria for when services are medically necessary (i.e., in general, shown to be effective in improving health outcomes and considered the most appropriate level of service)
  • To assist the practitioner as an educational tool
  • To encourage standardization of medical practice patterns
  • To curtail the performance of inappropriate and/or duplicate services
  • To advocate for patient safety concerns
  • To enhance the quality of health care
  • To promote the most efficient and cost-effective use of services

The Carelon guideline development process complies with applicable accreditation standards, including the requirement that the Guidelines be developed with involvement from appropriate providers with current clinical expertise relevant to the Guidelines under review and be based on the most up-to-date clinical principles and best practices. Relevant citations are included in the References section attached to each Guideline. Carelon reviews all of its Guidelines at least annually.

Carelon makes its Guidelines publicly available on its website twenty-four hours a day, seven days a week. Copies of the Carelon Clinical Appropriateness Guidelines are also available upon oral or written request. Although the Guidelines are publicly-available, Carelon considers the Guidelines to be important, proprietary information of Carelon, which cannot be sold, assigned, leased, licensed, reproduced or distributed without the written consent of Carelon.

Carelon applies objective and evidence-based criteria, and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services. The Carelon Guidelines are just guidelines for the provision of specialty health services. These criteria are designed to guide both providers and reviewers to the most appropriate services based on a patient’s unique circumstances. In all cases, clinical judgment consistent with the standards of good medical practice should be used when applying the Guidelines. Guideline determinations are made based on the information provided at the time of the request. It is expected that medical necessity decisions may change as new information is provided or based on unique aspects of the patient’s condition. The treating clinician has final authority and responsibility for treatment decisions regarding the care of the patient and for justifying and demonstrating the existence of medical necessity for the requested service. The Guidelines are not a substitute for the experience and judgment of a physician or other health care professionals. Any clinician seeking to apply or consult the Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment.

The Guidelines do not address coverage, benefit or other plan specific issues. Applicable federal and state coverage mandates take precedence over these clinical guidelines. If requested by a health plan, Carelon will review requests based on health plan medical policy/guidelines in lieu of the Carelon Guidelines. Pharmaceuticals, radiotracers, or medical devices used in any of the diagnostic or therapeutic interventions listed in the Guidelines must be FDA approved or conditionally approved for the intended use. However, use of an FDA approved or conditionally approved product does not constitute medical necessity or guarantee reimbursement by the respective health plan.

The Guidelines may also be used by the health plan or by Carelon for purposes of provider education, or to review the medical necessity of services by any provider who has been notified of the need for medical necessity review, due to billing practices or claims that are not consistent with other providers in terms of frequency or some other manner.

General Clinical Guideline

Clinical Appropriateness Framework

Critical to any finding of clinical appropriateness under the guidelines for a specific diagnostic or therapeutic intervention are the following elements:

  • Prior to any intervention, it is essential that the clinician confirm the diagnosis or establish its pretest likelihood based on a complete evaluation of the patient. This includes a history and physical examination and, where applicable, a review of relevant laboratory studies, diagnostic testing, and response to prior therapeutic intervention.
  • The anticipated benefit of the recommended intervention should outweigh any potential harms that may result (net benefit).
  • Current literature and/or standards of medical practice should support that the recommended intervention offers the greatest net benefit among competing alternatives.
  • Based on the clinical evaluation, current literature, and standards of medical practice, there exists a reasonable likelihood that the intervention will change management and/or lead to an improved outcome for the patient.

If these elements are not established with respect to a given request, the determination of appropriateness will most likely require a peer-to-peer conversation to understand the individual and unique facts that would supersede the requirements set forth above. During the peer-to-peer conversation, factors such as patient acuity and setting of service may also be taken into account.

Simultaneous Ordering of Multiple Diagnostic or Therapeutic Interventions

Requests for multiple diagnostic or therapeutic interventions at the same time will often require a peer-to-peer conversation to understand the individual circumstances that support the medical necessity of performing all interventions simultaneously. This is based on the fact that appropriateness of additional intervention is often dependent on the outcome of the initial intervention.

Additionally, either of the following may apply:

  • Current literature and/or standards of medical practice support that one of the requested diagnostic or therapeutic interventions is more appropriate in the clinical situation presented; or
  • One of the diagnostic or therapeutic interventions requested is more likely to improve patient outcomes based on current literature and/or standards of medical practice.

Repeat Diagnostic Intervention

In general, repeated testing of the same anatomic location for the same indication should be limited to evaluation following an intervention, or when there is a change in clinical status such that additional testing is required to determine next steps in management. At times, it may be necessary to repeat a test using different techniques or protocols to clarify a finding or result of the original study.

Repeated testing for the same indication using the same or similar technology may be subject to additional review or require peer-to-peer conversation in the following scenarios:

  • Repeated diagnostic testing at the same facility due to technical issues
  • Repeated diagnostic testing requested at a different facility due to provider preference or quality concerns
  • Repeated diagnostic testing of the same anatomic area based on persistent symptoms with no clinical change, treatment, or intervention since the previous study
  • Repeated diagnostic testing of the same anatomic area by different providers for the same member over a short period of time

Repeat Therapeutic Intervention

In general, repeated therapeutic intervention in the same anatomic area is considered appropriate when the prior intervention proved effective or beneficial and the expected duration of relief has lapsed. A repeat intervention requested prior to the expected duration of relief is not appropriate unless it can be confirmed that the prior intervention was never administered.

Site of Care

General Information/Overview

Scope

These guidelines address site of care for advanced imaging. Specifically, the guideline addresses the medical necessity of imaging at a hospital outpatient department (HOPD) where a higher level of support may be available. The appropriate place of care is defined as the facility (HOPD or freestanding) with the proper equipment and level of support to perform advanced imaging when that request meets Carelon’s radiology guidelines for appropriate use. This guideline covers all requests for advanced imaging in both pediatric and adult patients.

See the Coding section for a list of modalities included in these guidelines.

Definitions

Phases of the care continuum are broadly defined as follows:

  • Screening – testing in the absence of signs or symptoms of disease
  • Diagnosis – testing based on a reasonable suspicion of a particular condition or disorder, usually due to the presence of signs or symptoms
  • Management – testing to direct therapy of an established condition, which may include preoperative or postoperative imaging, or imaging performed to evaluate the response to nonsurgical intervention
  • Surveillance – periodic assessment following completion of therapy, or for monitoring known disease that is stable or asymptomatic

Statistical terminology

  • Confidence interval (CI) – range of values which is likely to contain the cited statistic. For example, 92% sensitivity (95% CI, 89%-95%) means that, while the sensitivity was calculated at 92% on the current study, there is a 95% chance that, if a study were to be repeated, the sensitivity on the repeat study would be in the range of 89%-95%.
  • Diagnostic accuracy – ability of a test to discriminate between the target condition and health. Diagnostic accuracy is quantified using sensitivity and specificity, predictive values, and likelihood ratios.
  • Hazard ratio – odds that an individual in the group with the higher hazard reaches the outcome first. Hazard ratio is analogous to odds ratio and is reported most commonly in time-to-event analysis or survival analysis. A hazard ratio of 1 means that the hazard rates of the 2 groups are equivalent. A hazard ratio of greater than 1 or less than 1 means that there are differences in the hazard rates between the 2 groups.
  • Likelihood ratio – ratio of an expected test result (positive or negative) in patients with the disease to an expected test result (positive or negative) in patients without the disease. Positive likelihood ratios, especially those greater than 10, help rule in a disease (i.e., they substantially raise the post-test probability of the disease, and hence make it very likely and the test very useful in identifying the disease). Negative likelihood ratios, especially those less than 0.1, help rule out a disease (i.e., they substantially decrease the post-test probability of disease, and hence make it very unlikely and the test very useful in excluding the disease).
  • Odds ratio – odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure. An odds ratio of 1 means that the exposure does not affect the odds of the outcome. An odds ratio greater than 1 means that the exposure is associated with higher odds of the outcome. An odds ratio less than 1 means that the exposure is associated with lower odds of the outcome.
  • Predictive value – likelihood that a given test result correlates with the presence or absence of disease. Positive predictive value is defined as the number of true positives divided by the number of test positives. Negative predictive value is defined as the number of true negatives divided by the number of test negative patients. Predictive value is dependent on the prevalence of the condition.
  • Pretest probability – probability that a given patient has a disease prior to testing. May be divided into very low (less than 5%), low (less than 20%), moderate (20%-75%), and high (greater than 75%) although these numbers may vary by condition.
  • Relative risk – probability of an outcome when an exposure is present relative to the probability of the outcome occurring when the exposure is absent. Relative risk is analogous to odds ratio; however, relative risk is calculated by using percentages instead of odds. A relative risk of 1 means that there is no difference in risk between the 2 groups. A relative risk of greater than 1 means that the outcome is more likely to happen in the exposed group compared to the control group. A relative risk less than 1 means that the outcome is less likely to happen in the exposed group compared to the control group.
  • Sensitivity – conditional probability that the test is positive, given that the patient has the disease. Defined as the true positive rate (number of true positives divided by the number of patients with disease). Excellent or high sensitivity is usually greater than 90%.
  • Specificity – conditional probability that the test is negative, given that the patient does not have the disease. Defined as the true negative rate (number of true negatives divided by the number of patients without the disease). Excellent or high specificity is usually greater than 90%.

Clinical Indications

The following section includes indications for which advanced imaging is considered medically necessary, along with prerequisite information and supporting evidence where available. Indications, diagnoses, or imaging modalities not specifically addressed are considered not medically necessary. 

It is recognized that imaging often detects abnormalities unrelated to the condition being evaluated. Such findings must be considered within the context of the clinical situation when determining whether additional imaging is required.

Site of Care

Imaging at a hospital outpatient site of care (HOPD) is considered medically necessary for requests that meet criteria for the service being performed in ANY of the following scenarios:

  • Advanced imaging which requires ANY of the following ancillary services:
    • Anesthesia (moderate sedation, deep sedation, or general anesthesia)
    • Obstetrical or perinatology observation
    • Additional resources for transfer or positioning in bedbound patients or in patients with advanced (stage 3 or stage 4) decubitus ulcers
    • Additional nursing or facility resources to support patients on contact or airborne precautions
    • Potential need for rapid response in patients due to underlying medical conditions (examples include documented contrast allergy to the agent requested for the exam, MRI with implantable cardiac devices, ventilated patient, or high risk of airway compromise)
  • Advanced imaging which requires ANY of the following when not available or infrequently performed by freestanding centers within the same geography:
    • Modalites
      • Specialized hardware and/or software
    • Expertise
      • Subspecialized radiologists when none are available in the community
      • Pediatric advanced imaging when performed in a Children’s Hospital or in HOPD that does the majority of pediatric imaging in a community without a Children’s Hospital
    • Technology
      • Open or large bore MRI in patients with documented claustrophobia
      • Equipment appropriate for the size of the individual
  • Advanced imaging in ANY of the following continuity of care scenarios:
    • Follow up imaging previously performed at the HOPD when differences in imaging technique may limit assessment for small changes that would impact evidence based patient management
    • Imaging required for preprocedural planning when the procedure has been scheduled at the same hospital
    • When performance of imaging outside the HOPD would reasonably be expected to create clinically significant delays in care
Rationale

Despite the increasing frequency of HOPD imaging,1 there are no studies formally comparing the quality of imaging care delivered in the HOPD and freestanding environments. The need to perform HOPD imaging is therefore based on the consideration of principle-based patient, personnel, or technical factors that are expected to offer net benefit to HOPD imaging by making it safer or consistently more accurate than imaging in surrounding freestanding facilities when available.

HOPD is a higher site of care offering ancillary services that may be important to imaging safety in select high risk patients. While they may occur in the outpatient setting, the scenarios covered by this ancillary support principle are much more common in the inpatient level of care, which is beyond the scope of this document. For instance, anesthesia beyond minimal sedation (anxiolysis with normal verbal responsiveness) requires greater patient monitoring and potentially anesthesiologist supervision. Additional ancillary support may be required to help position bedbound patients or those with advanced decubitus ulcers. While many freestanding facilities are capable of managing established relevant contrast allergies, the additional rapid response services offered by HOPD are an important safety consideration in patients with medical or device comorbidities that increase the risk of an adverse event requiring immediate medical attention (contrast reaction, cardiac devices, and potential for airway compromise).

HOPD may offer specialized technology and expertise that is not widely available in freestanding facilities. While the exact availability of services varies from market to market, the vast majority of freestanding imaging centers can accommodate routine CT and MRI examinations. Some modalities require specialized equipment , software, and/or personnel that are not widespread in the freestanding environment. For instance, functional MRI may require engagement of a speech language pathologist and specialized post processing software, neither of which is available at the majority of freestanding institutions. Not all specialized software or hardware lead to improvements in diagnostic accuracy that would reasonably be expected to positively impact patient management and outcome. For instance, 1.5T strength magnets are non-inferior to 3T in most clinical scenarios. 2 3 4 5 Furthermore, the vast majority of advanced imaging exams can be performed without specialized and uncommon technology. In some cases, the HOPD may be the only source of subspecialized radiologists. Low to very low quality evidence suggests that subspecialized radiologists are more accurate than their general radiology counterparts in the interpretation of some types of studies for instance oncologic6, 7 and interstitial lung disease8 but not for appendicitis9 and not consistently for musculoskeletal conditions.10,11 Pediatric imaging requires consistent adherence to as low as reasonable achievable (ALARA) CT dosimetry. Children’s hospitals tend to use less radiation for similar or greater diagnostic accuracy.12, 13 They may also offer supportive services to facilitate the imaging experience for children, including pediatric sedation. Pediatric radiologists are also less common than other radiology subspecialities in community practice. Finally, the HOPD may be the only site to support the types of equipment needed in patients with claustrophobia or very high BMIs.

Continuity of care and service is a third principle for hospital-based imaging in some patients. Comparison between studies is facilitated by having the same imaging protocol, performed by the same institution in the same PACS environment. It is uncommon for new episodes of care in patients without chronic disease to have relevant comparisons. However, comparison to prior studies is important for accurate diagnosis and management in patients with certain chronic conditions such as cancer and multiple sclerosis and is an indication for HOPD imaging when previously performed in that site of care. Not all patients with chronic conditions require follow up imaging at the HOPD. For instance, a patient with multiple sclerosis who requires a MRI of the knee would not meet the continuity of care principle outlined here. Relevance of the comparison to the exam indication and the importance of small changes to patient management determine applicability of the principle. Other continuity of care considerations include preprocedural imaging when surgery has been scheduled at the hospital and circumstances particular to an individual patient or community where imaging redirection to a free standing facility may result in clinical significant care delays such as untimely diagnosis for an acute or highly time sensitive condition.

References

  1. Levin DC, Rao VM, Parker L. Trends in outpatient MRI seem to reflect recent reimbursement cuts. J Am Coll Radiol. 2015;12(5):463-6.
  2. Dietzel M, Wenkel E, Hammon M, et al. Does higher field strength translate into better diagnostic accuracy? A prospective comparison of breast MRI at 3 and 1.5 Tesla. Eur J Radiol. 2019;114:51-6.
  3. Ye Y, He X, Huang C, et al. Comparison between the diagnostic performance of 1.5 T and 3.0 T field strengths for detecting deep vein thrombosis using magnetic resonance black-blood thrombus imaging. Clin Appl Thromb Hemost. 2020;26:1076029620921235.
  4. Allegre L, Aristizabal P, Nyangoh Timoh K, et al. Comparison of 3-Tesla to 1.5-Tesla magnetic resonance enterography to assess multifocal and multicentric bowel endometriosis: results in routine practice. Eur J Obstet Gynecol Reprod Biol. 2018;230:172-7.
  5. Hekimsoy I, Guler E, Harman M, et al. Characterization of adrenal lesions on chemical shift MRI: comparison of 1.5 T and 3 T MRI. Abdom Radiol. 2019;44(10):3359-69.
  6. Chung R, Rosenkrantz AB, Shanbhogue KP. Expert radiologist review at a hepatobiliary multidisciplinary tumor board: impact on patient management. Abdom Radiol. 2020;45(11):3800-8.
  7. Kalbhen CL, Yetter EM, Olson MC, et al. Assessing the resectability of pancreatic carcinoma: the value of reinterpreting abdominal CT performed at other institutions. AJR Am J Roentgenol. 1998;171(6):1571-6.
  8. Filev PD, Little BP, Duong PT. Second-opinion reads in interstitial lung disease imaging: added value of subspecialty interpretation. J Am Coll Radiol. 2020;17(6):786-90.
  9. Bracken RL, Harringa JB, Markhardt BK, et al. Abdominal fellowship-trained versus generalist radiologist accuracy when interpreting MR and CT for the diagnosis of appendicitis. Eur Radiol. 2021.
  10. Houtz CG, Schwartzberg RS, Barry JA, et al. Shoulder MRI accuracy in the community setting. J Shoulder Elbow Surg. 2011;20(4):537-42.
  11. Theodoropoulos JS, Andreisek G, Harvey EJ, et al. Magnetic resonance imaging and magnetic resonance arthrography of the shoulder: dependence on the level of training of the performing radiologist for diagnostic accuracy. Skeletal Radiol. 2010;39(7):661-7.
  12. Sharp NE, Svetanoff WJ, Alemayehu H, et al. Lower radiation exposure from body CT imaging for trauma at a dedicated pediatric hospital. J Pediatr Surg. 2014;49(12):1843-5.
  13. Marin JR, Sengupta D, Bhargavan-Chatfield M, et al. Variation in pediatric cervical spine computed tomography radiation dose index. Acad Emerg Med. 2015;22(12):1499-505.

Codes

The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.

Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.

CPT/HCPCS

CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright by the American Medical Association. All Rights Reserved. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.

70336

Magnetic resonance (eg, proton) imaging, temporomandibular joint(s)

70450

Computed tomography, head or brain; without contrast material

70460

Computed tomography, head or brain; with contrast material(s)

70470

Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections

70480

Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material

70481

Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s)

70482

Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections

70486

Computed tomography, maxillofacial area; without contrast material

70487

Computed tomography, maxillofacial area; with contrast material(s)

70488

Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections

70490

Computed tomography, soft tissue neck; without contrast material

70491

Computed tomography, soft tissue neck; with contrast material(s)

70492

Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections

70496

Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing

70498

Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing

70540

Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s)

70542

Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s)

70543

Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences

70544

Magnetic resonance angiography, head; without contrast material(s)

70545

Magnetic resonance angiography, head; with contrast material(s)

70546

Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences

70547

Magnetic resonance angiography, neck; without contrast material(s)

70548

Magnetic resonance angiography, neck; with contrast material(s)

70549

Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences

70551

Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material

70552

Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s)

70553

Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences

71250

Computed tomography, thorax, diagnostic; without contrast material

71260

Computed tomography, thorax, diagnostic; with contrast material(s)

71270

Computed tomography, thorax, diagnostic; without contrast material, followed by contrast material(s) and further sections

71271

Computed tomography thorax lw dose lng ca scr c

71275

CT angiography chest w/contrast/noncontrast

71550

Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s)

71551

Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s)

71552

Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequences

71555

Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s)

72125

Computed tomography, cervical spine; without contrast material

72126

Computed tomography, cervical spine; with contrast material

72127

Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections

72128

Computed tomography, thoracic spine; without contrast material

72129

Computed tomography, thoracic spine; with contrast material

72130

Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections

72131

Computed tomography, lumbar spine; without contrast material

72132

Computed tomography, lumbar spine; with contrast material

72133

Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections

72141

Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material

72142

Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s)

72146

Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material

72147

Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s)

72148

Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material

72149

Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s)

72156

Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical

72157

Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic

72158

Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar

72159

Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s)

72191

Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing

72192

Computed tomography, pelvis; without contrast material

72193

Computed tomography, pelvis; with contrast material(s)

72194

Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections

72195

Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s)

72196

Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s)

72197

Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences

72198

Magnetic resonance angiography, pelvis, with or without contrast material(s)

73200

Computed tomography, upper extremity; without contrast material

73201

Computed tomography, upper extremity; with contrast material(s)

73202

Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections

73206

Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing

73218

Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s)

73219

Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s)

73220

Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences

73221

Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s)

73222

Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s)

73223

Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences

73225

Magnetic resonance angiography, upper extremity, with or without contrast material(s)

73700

Computed tomography, lower extremity; without contrast material

73701

Computed tomography, lower extremity; with contrast material(s)

73702

Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections

73706

Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing

73718

Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s)

73719

Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s)

73720

Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences

73721

Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material

73722

Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s)

73723

Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences

73725

Magnetic resonance angiography, lower extremity, with or without contrast material(s)

74150

Computed tomography, abdomen; without contrast material

74160

Computed tomography, abdomen; with contrast material(s)

74170

Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections

74174

Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing

74175

Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing

74176

Computed tomography, abdomen and pelvis; without contrast material

74177

Computed tomography, abdomen and pelvis; with contrast material(s)

74178

Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions

74181

Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s)

74182

Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s)

74183

Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences

74185

Magnetic resonance angiography, abdomen, with or without contrast material(s)

74261

Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material

74262

Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed

74263

Computed tomographic (CT) colonography, screening, including image postprocessing

75635

Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing

77046

Magnetic resonance imaging, breast, without contrast material; unilateral

77047

Magnetic resonance imaging, breast, without contrast material; bilateral

77048

Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral

77049

Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral

77084

MRI of bone marrow blood supply

ICD-10 Diagnosis

Refer to the ICD-10 CM manual

History

Status

Review Date

Effective Date

Action

ArchivedN/ANot to be used for dates of service on or after 11/17/2024

Created

09/21/2022, 08/31/2021

07/01/2023

Independent Multispecialty Physician Panel (IMPP) review. Original effective date.

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