Status: Revised Effective Date: 11/17/2024
Doc ID: RBM14-1124.1 Last Review Date: 04/15/2024
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 for Advanced Imaging
Proprietary
© 2024 Carelon Medical Benefits Management, Inc. All rights reserved.
Table of Contents
Description and Application of the Guidelines
Site of Care for Advanced Imaging
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. The Guidelines establish objective and evidence-based criteria for medical necessity determinations, where possible, that can be used in support of the following:
- To establish criteria for when services are medically necessary
- 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 and legal 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. Resources reviewed include widely used treatment guidelines, randomized controlled trials or prospective cohort studies, and large systematic reviews or meta-analyses. Carelon reviews all of its Guidelines at least annually.
Carelon makes its Guidelines publicly available on its website. Copies of the Guidelines are also available upon oral or written request. Additional details, such as summaries of evidence, a list of the sources of evidence, and an explanation of the rationale that supports the adoption of the Guidelines, are included in each guideline document.
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, and in the case of reviews for Medicare Advantage Plans, the Guidelines are only applied where there are not fully established CMS criteria. 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 including from delay or decreased access to services that may result (net benefit).
- Widely used treatment guidelines and/or current clinical literature and/or standards of medical practice should support that the recommended intervention offers the greatest net benefit among competing alternatives.
- There exists a reasonable likelihood that the intervention will change management and/or lead to an improved outcome for the patient.
Providers may be required to submit clinical documentation in support of a request for services. Such documentation must a) accurately reflect the clinical situation at the time of the requested service, and b) sufficiently document the ordering provider’s clinical intent.
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 justify a finding of clinical appropriateness. During the peer-to-peer conversation, factors such as patient acuity and setting of service may also be taken into account to the extent permitted by law.
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. Requests for on-going services may depend on completion of previously authorized services in situations where a patient’s response to authorized services is relevant to a determination of clinical appropriateness.
Site of Care for Advanced Imaging
“Site of Care,” “Site of Service” or another term such as “Setting” or “Place of Service” may be terms used in benefit plans, provider contracts, or other materials instead of or in addition to “Level of Care” and, in some plans, these terms may be used interchangeably.
General Information
Scope
These guidelines address site of care for a select group of outpatient advanced imaging services that are routinely performed outside of a hospital setting. 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 applicable clinical guidelines for appropriate use. This guideline pertains to requests for advanced imaging in both pediatric and adult patients.
This guideline does not address the clinical appropriateness of individual imaging services but rather restricts its focus to the selection of optimal site of care where the service is rendered. Some services may also be subject to clinical appropriateness review; in which case, a separate clinical guideline or policy may be used to adjudicate clinical appropriateness.*
This guideline does not address the availability of alternative non-hospital sites to perform an individual service. The purpose of this guideline is to define the clinical scenarios in which hospital-based care is medically necessary and, by exclusion, when it is clinically reasonable to provide services in a non-hospital setting.
See the Codes section for a list of modalities included in these guidelines.
*Note: Not all services that are subject to Site of Service review also require medical necessity review of the service itself. Some may only be subject to Site of Care review.
Definitions
Hospital outpatient department (HOPD): Hospital department at which services are rendered to outpatients
Nonhospital: Freestanding surgical facility or provider office that is not owned/operated by a hospital
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
Sedation:
- Mild Sedation/Anxiolysis: Drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected.
- Moderate Sedation: Drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
- Deep Sedation: Drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
- General Anesthesia: Drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.
Clinical Indications
Site of Care
Imaging at a hospital outpatient site of care (HOPD) is considered medically necessary for requests that meet applicable medical necessity criteria for the service being performed in ANY of the following scenarios:
- Advanced imaging which requires ANY of the following ancillary services when not available in freestanding centers within the same geography:
- Anesthesia (moderate sedation, deep sedation, or general anesthesia)
- Obstetrical or perinatology observation
- Additional resources required to establish and/or maintain IV access in patients with previous difficulty
- 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:
- Modalities
- Specialized hardware, software, and/or imaging protocols required for evaluation
- 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
- Modalities
- 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 pre-procedural 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, most 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 most freestanding institutions. Not all specialized software or hardware led 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 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 an 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 includes preprocedural imaging when surgery has been scheduled at the hospital and circumstances particular to an individual patient or community where imaging redirection to a freestanding facility may result in clinically significant care delays such as untimely diagnosis for an acute or highly time sensitive condition.
References
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Houtz CG, Schwartzberg RS, Barry JA, et al. Shoulder MRI accuracy in the community setting. J Shoulder Elbow Surg. 2011;20(4):537-42.
- 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.
- 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.
- 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, low dose for lung cancer screening, without contrast material(s) |
| 71275 | CT angiography of chest (non-coronary), with contrast material(s), including non-contrast images, if performed, and image post-processing |
| 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, followed by reimaging with contrast |
| 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 |
|---|---|---|---|
| Revised | 04/15/2024 | 11/17/2024 | Independent Multispecialty Physician Panel (IMPP) review. Scope and Definitions sections updated and aligned with all Carelon MBM Site of Care Guidelines. Expanded Site of Care guideline title for clarity. Added criteria for “Additional resources required to establish and/or maintain IV access in patients with previous difficulty.” Added required language to General Clinical Guideline per new Medicare regulations. |
| Created | 09/21/2022, 08/31/2021 | 07/01/2023 | IMPP review. Original effective date. |