M.13 MA Radiology (Preauthorization Required)
MA Radiology (Preauthorization Required)
M.13
M.13 MA Radiology (Preauthorization Required)
Policy
Services that require a pre-service review include the following:
- Computed Tomography (CT/CTA)
- Magnetic Resonance Imaging (MRI/MRA)
- Nuclear Cardiology
- Positron Emission Tomography (PET)
NOTE: Plain radiology films, imaging studies performed in conjunction with emergency room services, inpatient hospitalization, urgent care centers, and 23-hour observations are excluded from this requirement.
Criteria is Intequal
Dates
-
Original Effective
11-01-2024
-
Last Review
08-07-2024
-
Next Review
08-06-2025
Quick Code Search
Procedure
Diagnosis
Codes
Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast material
Computed tomography, breast, including 3D rendering, when performed, unilateral; with contrast material(s)
Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast, followed by contrast material(s)
Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast material(s)
Computed tomography, breast, including 3D rendering, when performed, bilateral; with contrast material(s)
Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast, followed by contrast material(s)
Magnetic resonance (eg, proton) imaging, temporomandibular joint(s)
Computed tomography, head or brain; without contrast material
Computed tomography, head or brain; with contrast material(s)
Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections
Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material
Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s)
Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections
Computed tomography, maxillofacial area; without contrast material
Computed tomography, maxillofacial area; with contrast material(s)
Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections
Computed tomography, soft tissue neck; without contrast material
Computed tomography, soft tissue neck; with contrast material(s)
Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections
Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing
Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing
Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s)
Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s)
Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences
Magnetic resonance angiography, head; without contrast material(s)
Magnetic resonance angiography, head; with contrast material(s)
Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences
Magnetic resonance angiography, neck; without contrast material(s)
Magnetic resonance angiography, neck; with contrast material(s)
Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences
Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s)
Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences
Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration
Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing
Computed tomography, thorax; without contrast material
Computed tomography, thorax; with contrast material(s)
Computed tomography, thorax; without contrast material, followed by contrast material(s) and further sections
Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s)
Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing
Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s)
Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s)
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
Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s)
Computed tomography, cervical spine; without contrast material
Computed tomography, cervical spine; with contrast material
Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections
Computed tomography, thoracic spine; without contrast material
Computed tomography, thoracic spine; with contrast material
Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections
Computed tomography, lumbar spine; without contrast material
Computed tomography, lumbar spine; with contrast material
Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections
Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material
Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s)
Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material
Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s)
Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material
Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s)
Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical
Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic
Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar
Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s)
Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing
Computed tomography, pelvis; without contrast material
Computed tomography, pelvis; with contrast material(s)
Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections
Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s)
Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s)
Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences
Magnetic resonance angiography, pelvis, with or without contrast material(s)
Computed tomography, upper extremity; without contrast material
Computed tomography, upper extremity; with contrast material(s)
Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections
Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing
Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s)
Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s)
Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences
Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s)
Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s)
Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences
Magnetic resonance angiography, upper extremity, with or without contrast material(s)
Computed tomography, lower extremity; without contrast material
Computed tomography, lower extremity; with contrast material(s)
Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections
Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing
Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s)
Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s)
Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences
Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material
Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s)
Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences
Magnetic resonance angiography, lower extremity, with or without contrast material(s)
Computed tomography, abdomen; without contrast material
Computed tomography, abdomen; with contrast material(s)
Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections
Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing
Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing
Computed tomography, abdomen and pelvis; without contrast material
Computed tomography, abdomen and pelvis; with contrast material(s)
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
Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s)
Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s)
Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences
Magnetic resonance angiography, abdomen, with or without contrast material(s)
Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material
Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed
Computed tomographic (CT) colonography, screening, including image postprocessing
Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation
Cardiac magnetic resonance imaging for morphology and function without contrast material
Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging
Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences
Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging
CARDIAC MAGNETIC RESONANCE IMAGING FOR VELOCITY FLOW MAPPING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium
Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed)
Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function and evaluation of venous structures, if performed)
Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)
Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation
Computed tomography, limited or localized follow-up study
Magnetic resonance spectroscopy
Magnetic resonance (eg, vibration) elastography
MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT CONTRAST MATERIAL; UNILATERAL
MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT CONTRAST MATERIAL; BILATERAL
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
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
Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)
Magnetic resonance (eg, proton) imaging, bone marrow blood supply
Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study; with concurrently acquired computed tomography transmission scan
Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan
Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan
Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability);
Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability); with concurrently acquired computed tomography transmission scan
Absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest and pharmacologic stress (List separately in addition to code for primary procedure)
Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
Myocardial imaging, positron emission tomography (PET), metabolic evaluation
Myocardial imaging, infarct avid, planar; qualitative or quantitative
Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique
Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification
Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing
Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification
Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification
Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification
Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress
Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress
Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing
CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM, SINGLE STUDY, AT REST, WITH RIGHT VENTRICULAR EJECTION FRACTION BY FIRST PASS TECHNIQUE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
Brain imaging, positron emission tomography (PET); metabolic evaluation
Brain imaging, positron emission tomography (PET); perfusion evaluation
Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)
Positron emission tomography (PET) imaging; skull base to mid-thigh
Positron emission tomography (PET) imaging; whole body
Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)
Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh
Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body
Magnetic resonance angiography with contrast, abdomen
Magnetic resonance angiography without contrast, abdomen
Magnetic resonance angiography without contrast followed by with contrast, abdomen
Magnetic resonance imaging with contrast, breast; unilateral
Magnetic resonance imaging without contrast, breast; unilateral
Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral
Magnetic resonance imaging with contrast, breast; bilateral
Magnetic resonance imaging without contrast, breast; bilateral
Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral
Magnetic resonance angiography with contrast, chest (excluding myocardium)
Magnetic resonance angiography without contrast, chest (excluding myocardium)
Magnetic resonance angiography without contrast followed by with contrast, chest (excluding myocardium)
Magnetic resonance angiography with contrast, lower extremity
Magnetic resonance angiography without contrast, lower extremity
Magnetic resonance angiography without contrast followed by with contrast, lower extremity
Magnetic resonance angiography with contrast, pelvis
Magnetic resonance angiography without contrast, pelvis
Magnetic resonance angiography without contrast followed by with contrast, pelvis
Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with strain imaging
Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imaging
Pet imaging whole body; melanoma for non-covered indications
Pet imaging, any site, not otherwise specified
Low dose ct scan (ldct) for lung cancer screening
3d radiodensity-value bone imaging, algorithm derived, from previous magnetic resonance examination of the same anatomy
Patient did not have at least two hpv vaccines (with at least 146 days between the two) or three hpv vaccines on or between the patient's 9th and 13th birthdays
Low-dose Computed Tomography For Lung Cancer Screening
Magnetic resonance imaging (mri), low-field
Revisions
03-26-2025
Added new HCPC code effective 04/01/2025 G0566 |