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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

Use this feature to find out if a procedure and diagnosis code pair will be approved, denied or held for review. Simply put in the procedure code, then the diagnosis code, then click "Add Code Pair". If the codes are listed in this policy, we will help you by showing a dropdown to help you.

Procedure

Enter at least the first 3 characters of the code


Diagnosis

Enter at least the first 3 characters of the code


Both a procedure and diagnosis are required.Code pair was previously added.

Codes

      
          Full Description
            Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast material
      
          Full Description
            Computed tomography, breast, including 3D rendering, when performed, unilateral; with contrast material(s)
      
          Full Description
            Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast, followed by contrast material(s)
      
          Full Description
            Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast material(s)
      
          Full Description
            Computed tomography, breast, including 3D rendering, when performed, bilateral; with contrast material(s)
      
          Full Description
            Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast, followed by contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, temporomandibular joint(s)
      
          Full Description
            Computed tomography, head or brain; without contrast material
      
          Full Description
            Computed tomography, head or brain; with contrast material(s)
      
          Full Description
            Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections
      
          Full Description
            Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material
      
          Full Description
            Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s)
      
          Full Description
            Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections
      
          Full Description
            Computed tomography, maxillofacial area; without contrast material
      
          Full Description
            Computed tomography, maxillofacial area; with contrast material(s)
      
          Full Description
            Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections
      
          Full Description
            Computed tomography, soft tissue neck; without contrast material
      
          Full Description
            Computed tomography, soft tissue neck; with contrast material(s)
      
          Full Description
            Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections
      
          Full Description
            Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing
      
          Full Description
            Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing
      
          Full Description
            Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences
      
          Full Description
            Magnetic resonance angiography, head; without contrast material(s)
      
          Full Description
            Magnetic resonance angiography, head; with contrast material(s)
      
          Full Description
            Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences
      
          Full Description
            Magnetic resonance angiography, neck; without contrast material(s)
      
          Full Description
            Magnetic resonance angiography, neck; with contrast material(s)
      
          Full Description
            Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences
      
          Full Description
            Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
      
          Full Description
            Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences
      
          Full Description
            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
      
          Full Description
            Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing
      
          Full Description
            Computed tomography, thorax; without contrast material
      
          Full Description
            Computed tomography, thorax; with contrast material(s)
      
          Full Description
            Computed tomography, thorax; without contrast material, followed by contrast material(s) and further sections
      
          Full Description
            Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s)
      
          Full Description
            Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing
      
          Full Description
            Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s)
      
          Full Description
            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
      
          Full Description
            Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s)
      
          Full Description
            Computed tomography, cervical spine; without contrast material
      
          Full Description
            Computed tomography, cervical spine; with contrast material
      
          Full Description
            Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections
      
          Full Description
            Computed tomography, thoracic spine; without contrast material
      
          Full Description
            Computed tomography, thoracic spine; with contrast material
      
          Full Description
            Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections
      
          Full Description
            Computed tomography, lumbar spine; without contrast material
      
          Full Description
            Computed tomography, lumbar spine; with contrast material
      
          Full Description
            Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections
      
          Full Description
            Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material
      
          Full Description
            Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material
      
          Full Description
            Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material
      
          Full Description
            Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical
      
          Full Description
            Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic
      
          Full Description
            Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar
      
          Full Description
            Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s)
      
          Full Description
            Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing
      
          Full Description
            Computed tomography, pelvis; without contrast material
      
          Full Description
            Computed tomography, pelvis; with contrast material(s)
      
          Full Description
            Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections
      
          Full Description
            Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences
      
          Full Description
            Magnetic resonance angiography, pelvis, with or without contrast material(s)
      
          Full Description
            Computed tomography, upper extremity; without contrast material
      
          Full Description
            Computed tomography, upper extremity; with contrast material(s)
      
          Full Description
            Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections
      
          Full Description
            Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing
      
          Full Description
            Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences
      
          Full Description
            Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences
      
          Full Description
            Magnetic resonance angiography, upper extremity, with or without contrast material(s)
      
          Full Description
            Computed tomography, lower extremity; without contrast material
      
          Full Description
            Computed tomography, lower extremity; with contrast material(s)
      
          Full Description
            Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections
      
          Full Description
            Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing
      
          Full Description
            Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences
      
          Full Description
            Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material
      
          Full Description
            Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences
      
          Full Description
            Magnetic resonance angiography, lower extremity, with or without contrast material(s)
      
          Full Description
            Computed tomography, abdomen; without contrast material
      
          Full Description
            Computed tomography, abdomen; with contrast material(s)
      
          Full Description
            Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections
      
          Full Description
            Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing
      
          Full Description
            Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing
      
          Full Description
            Computed tomography, abdomen and pelvis; without contrast material
      
          Full Description
            Computed tomography, abdomen and pelvis; with contrast material(s)
      
          Full Description
            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
      
          Full Description
            Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences
      
          Full Description
            Magnetic resonance angiography, abdomen, with or without contrast material(s)
      
          Full Description
            Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material
      
          Full Description
            Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed
      
          Full Description
            Computed tomographic (CT) colonography, screening, including image postprocessing
      
          Full Description
            Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation
      
          Full Description
            Cardiac magnetic resonance imaging for morphology and function without contrast material
      
          Full Description
            Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging
      
          Full Description
            Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences
      
          Full Description
            Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging
      
          Full Description
            CARDIAC MAGNETIC RESONANCE IMAGING FOR VELOCITY FLOW MAPPING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
      
          Full Description
            Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium
      
          Full Description
            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)
      
          Full Description
            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)
      
          Full Description
            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)
      
          Full Description
            Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing
      
          Full Description
            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
      
          Full Description
            Computed tomography, limited or localized follow-up study
      
          Full Description
            Magnetic resonance spectroscopy
      
          Full Description
            Magnetic resonance (eg, vibration) elastography
      
          Full Description
            MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT CONTRAST MATERIAL; UNILATERAL
      
          Full Description
            MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT CONTRAST MATERIAL; BILATERAL
      
          Full Description
            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
      
          Full Description
            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
      
          Full Description
            Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)
      
          Full Description
            Magnetic resonance (eg, proton) imaging, bone marrow blood supply
      
          Full Description
            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
      
          Full Description
            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
      
          Full Description
            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
      
          Full Description
            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);
      
          Full Description
            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
      
          Full Description
            Absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest and pharmacologic stress (List separately in addition to code for primary procedure)
      
          Full Description
            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)
      
          Full Description
            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
      
          Full Description
            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)
      
          Full Description
            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
      
          Full Description
            Myocardial imaging, positron emission tomography (PET), metabolic evaluation
      
          Full Description
            Myocardial imaging, infarct avid, planar; qualitative or quantitative
      
          Full Description
            Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique
      
          Full Description
            Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification
      
          Full Description
            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
      
          Full Description
            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
      
          Full Description
            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
      
          Full Description
            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
      
          Full Description
            Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress
      
          Full Description
            Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress
      
          Full Description
            Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing
      
          Full Description
            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)
      
          Full Description
            Brain imaging, positron emission tomography (PET); metabolic evaluation
      
          Full Description
            Brain imaging, positron emission tomography (PET); perfusion evaluation
      
          Full Description
            Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)
      
          Full Description
            Positron emission tomography (PET) imaging; skull base to mid-thigh
      
          Full Description
            Positron emission tomography (PET) imaging; whole body
      
          Full Description
            Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)
      
          Full Description
            Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh
      
          Full Description
            Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body
      
          Full Description
            Magnetic resonance angiography with contrast, abdomen
      
          Full Description
            Magnetic resonance angiography without contrast, abdomen
      
          Full Description
            Magnetic resonance angiography without contrast followed by with contrast, abdomen
      
          Full Description
            Magnetic resonance imaging with contrast, breast; unilateral
      
          Full Description
            Magnetic resonance imaging without contrast, breast; unilateral
      
          Full Description
            Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral
      
          Full Description
            Magnetic resonance imaging with contrast, breast; bilateral
      
          Full Description
            Magnetic resonance imaging without contrast, breast; bilateral
      
          Full Description
            Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral
      
          Full Description
            Magnetic resonance angiography with contrast, chest (excluding myocardium)
      
          Full Description
            Magnetic resonance angiography without contrast, chest (excluding myocardium)
      
          Full Description
            Magnetic resonance angiography without contrast followed by with contrast, chest (excluding myocardium)
      
          Full Description
            Magnetic resonance angiography with contrast, lower extremity
      
          Full Description
            Magnetic resonance angiography without contrast, lower extremity
      
          Full Description
            Magnetic resonance angiography without contrast followed by with contrast, lower extremity
      
          Full Description
            Magnetic resonance angiography with contrast, pelvis
      
          Full Description
            Magnetic resonance angiography without contrast, pelvis
      
          Full Description
            Magnetic resonance angiography without contrast followed by with contrast, pelvis
      
          Full Description
            Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with strain imaging
      
          Full Description
            Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imaging
      
          Full Description
            Pet imaging whole body; melanoma for non-covered indications
      
          Full Description
            Pet imaging, any site, not otherwise specified
      
          Full Description
            Low dose ct scan (ldct) for lung cancer screening
      
          Full Description
            3d radiodensity-value bone imaging, algorithm derived, from previous magnetic resonance examination of the same anatomy
      
          Full Description
            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
      
          Full Description
            Low-dose Computed Tomography For Lung Cancer Screening
      
          Full Description
            Magnetic resonance imaging (mri), low-field




Revisions

03-26-2025

Added new HCPC code effective 04/01/2025 G0566