RADIOLOGY PROGRAM TABLE OF CONTENTS. OVERVIEW. . Assessment... and... Certification
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1 TABLE OF CONTENTS. OVERVIEW Assessment and..... Certification Film..... Review MEMBERS EXEMPT FROM THE..... EMBLEMHEALTH RADIOLOGY PROGRAM PRIOR APPROVAL PROCEDURES Services Requiring Prior..... Approval Who..... Requests Prior Approval How..... To... Obtain Prior Approval Expedited Approval Requests Urgent Requests Non-Urgent Requests Modifying a. Prior Approval Request Verifying the... Prior Approval Status Determination Disagreement Radiology Program Prior Approval Code List.... For.... HIP,..... EmblemHealth CompreHealth EPO and EmblemHealth Medicare HMO 404. Radiology Program Prior Approval Code List.... For.... EmblemHealth EPO/PPO and EmblemHealth Medicare PPO 420. Deleted EmblemHealth Radiology Program Codes Radiology Program Prior..... Approval Code List..... For.... GHI..... HMO RETIRED Formal Dispute Resolution GHI.... HMO, HIP.... AND VYTRA RADIOLOGY SCHEDULING PROCEDURE Plan..... Participation Scheduling Procedure VYTRA PLANS RADIOLOGY PROGRAM FOR DATES OF.... SERVICE PRIOR TO... JANUARY , Overview Designated Radiology Centers Guarantee Waiver Agreement for... Radiology Groups Changing Designated Radiology Groups Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
2 . Quality Issues Copies of... X-Rays Radiation Therapy DEXA Scans OVERVIEW Assessment and..... Certification Film..... Review OVERVIEW Assessment and..... Certification Film..... Review OVERVIEW Assessment and..... Certification Film..... Review Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
3 This chapter contains information about our diagnostic imaging management program for outpatient radiology services, including prior approval and radiology scheduling procedures, for all members. OVERVIEW The EmblemHealth Radiology Program, developed with evicore, provides diagnostic imaging management for outpatient radiology services. Services targeted for utilization management depend on the EmblemHealth benefit plan. evicore also conducts clinical standard and expedited appeals (excluding members with Medicare plans). Assessment and Certification All radiologists and non-radiologists participating in our radiology programs undergo a comprehensive site visit, as well as evaluation of equipment, technical staff credentials, continuing education, equipment maintenance records and operating policies. They may also be required to complete the appropriate assessment and certification forms. This process is based on nationally recognized requirements of the American Institute of Ultrasound in Medicine, the American College of Radiology and The Joint Commission. Film Review Practitioners' film images must comply with the high standards of the American College of Radiology. At least once every two years, practitioners may be required to provide EmblemHealth and/or evicore with requested materials for an independent review and professional interpretation of films. For this review, we randomly select a sampling of patient studies. At least two board-certified radiologists then assess these studies for technical quality and diagnostic interpretation. MEMBERS EXEMPT FROM THE EMBLEMHEALTH While most of our members' covered radiology services are managed by evicore, the following exceptions apply. Members whose care is managed by Montefiore Medical Group (CMO) or HealthCare Partners (HCP) must contact the applicable organization for prior approval. See the member's ID card or eligibility information on emblemhealth.com to determine whether HIP, CMO, or HCP is the managing entity responsible for managing a member's care; if HIP is the managing entity, then evicore is the organization to contact for prior approval. Members who selected a PCP assigned to AdvantageCare Physicians or St. Barnabas Hospital System (see member's ID card), as well as Vytra benefit plans prior to January 1, 2016, are excluded from this program. PCPs in the physician group practices must enter a prior approval request on emblemhealth.com. Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
4 The Prior Approval HIP CPT code list later in this chapter applies to the members listed above as well. Only the managing entity varies. Please refer to the Care Management chapter for information on how to obtain prior approval for these members. GHI The following groups are exempt from prior approval requirements for all radiology services. Group names, numbers and category codes appear on the member's ID card. GHI Group Name Category Code(s) Group Number(s) Fidelis Child Health Plus (family planning only) 18D N Jefferson County 79B, 7EG N3683, N3684, N4093, N4453 N4725 Vytra (Prior to January 1, 2016) Prior to January 1, 2016, Vytra HMO and Vytra ASO plans covered radiology services for their members and were excluded from the EmblemHealth Radiology Program. The terms of this coverage are described at the end of this chapter. Effective January 1, 2016, members with Vytra benefit plans or Vytra Premium Network are included in the EmblemHealth Radiology Program. PRIOR APPROVAL PROCEDURES Services Requiring Prior Approval Please refer to the charts later in this chapter for a list of services (and CPT-4 codes) that require prior approval: HIP, EmblemHealth CompreHealth EPO, EmblemHealth Medicare HMO and Vytra EmblemHealth EPO/PPO and EmblemHealth Medicare PPO Each procedure requires a separate prior approval. Prior approvals are specific to the CPT-4 code and site location. They are valid for 45 days from the approval date. Prior approval is required for services performed in the following places of service: Outpatient hospital facilities Freestanding radiology facilities Radiology office-based settings Non-radiology office-based settings Neither prior approval nor referral is required for: Inpatient hospitalization Services rendered in hospital emergency departments Services provided when one of EmblemHealth's companies is the secondary insurer Pulmonary perfusion imaging Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
5 The following services do not require prior approval but may require a referral from the member's PCP: Basic X-rays Mammograms Bone density tests Who Requests Prior Approval It is the responsibility of the referring practitioner (i.e., the practitioner developing the patient's treatment plan) to obtain the prior approval before services are rendered. If the referring and rendering practitioners are different, the rendering practitioner is encouraged to confirm that a prior approval is on file before services are rendered. The rendering practitioner is ultimately responsible for ensuring that all applicable radiology imaging procedures at the applicable service location have received all necessary prior approvals. How To Obtain Prior Approval Before requesting prior approval from please have the patient's medical records on hand and complete the request form specific to the procedure being requested. These request forms are available at the links below and at evicore.com. They list all clinical questions the practitioner must answer during the initial prior approval review. For MRI, General Use Clinical Certification Request Form For CT Scan, CT/CTA Clinical Certification Request Form For PET Scan, PET Scan Clinical Certification Request Form For MR/MRAs, MR/MRA Clinical Certification Request Form Once the form is complete, submit prior approval requests in one of three ways: Online: Visit To submit online requests, the ordering physician must be a registered user. To register for a user ID and password, visit and click the "Register" button. By phone: Call for GHI HMO, HIP and EmblemHealth CompreHealth EPO and Vytra plan members. Call for EmblemHealth EPO/PPO and EmblemHealth Medicare PPO plan members. Representatives are available Monday through Friday, from 7 am to 7 pm, EST. The program is closed New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving and Christmas Day. By fax: Fax the completed request form to Please have the following information available when you call: The completed form, as noted above The patient's full name, member ID number and insurance information The exam(s) requested for the patient The working diagnosis or rule-out The signs and symptoms that call for the exam, as well as their duration Any previous imaging studies performed, corresponding results or pertinent lab results History of prior treatment methods, drugs, surgery or other therapies, as well as duration of Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
6 prior treatment Any other information indicating the need for the exam Expedited Approval Requests evicore.com cannot be used for expedited approval requests. These requests must be processed through the call center. Call for GHI HMO, HIP, EmblemHealth CompreHealth EPO, EmblemHealth Medicare HMO, and Vytra plan members. Call for EmblemHealth EPO/PPO and EmblemHealth Medicare PPO plan members. Utilization review staff is available 24 hours a day, 7 days a week. The program is closed New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving and Christmas Day. Urgent Requests If the treatment is medically urgent and must be performed outside business hours, the physician may deliver treatment and must submit the prior approval request (with supporting clinical documentation) within two (2) business days. Urgent requests are reviewed against medical necessity criteria, and an approval is issued as long as the request meets these medical necessity criteria. Urgent requests will be completed within 24 hours of receiving the request. evicore.com cannot be used for urgent approval requests. These requests must be processed through the call center. Call for GHI HMO, HIP, EmblemHealth CompreHealth EPO, EmblemHealth Medicare HMO and Vytra plan members. Call for EmblemHealth EPO/PPO and EmblemHealth Medicare PPO plan members. Utilization review staff is available 24 hours a day, 7 days a week. The program is closed New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving and Christmas Day. Non-Urgent Requests Non-urgent requests will be completed within three (3) business days of receiving all necessary information, or within the time frames otherwise required by the member's benefit plan (see Standard Pre-Service Review in the Care Management chapter). In most cases, the staff will review and determine prior approvals during the initial phone call, as long as all the required information is provided. The review and determination processes may, however, take longer if member or practitioner eligibility verification is required, or if the request requires additional clinical review (see Standard Pre-Service Review in the Care Management chapter). A physician with office hours later than the call center's may initiate a case through evicore.com which will be processed on the next business day. Modifying a Prior Approval Request If it becomes necessary to change or update the procedure after prior approval is obtained, the program must be contacted no later than 48 hours after the modified procedure is performed. If the prior approval for the treatment plan is not updated and the claim does not match the authorized procedures, the claim will be denied for payment, with no liability to the member. Verifying the Prior Approval Status Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
7 To verify the status of a prior approval request, either call the applicable number below or visit the Authorization Lookup section at evicore.com. Call for GHI HMO, HIP, EmblemHealth CompreHealth EPO, EmblemHealth Medicare HMO and Vytra plan members. Call for EmblemHealth EPO/PPO and EmblemHealth Medicare PPO plan members. Note: While the program may approve or deny a prior approval request, this determination is based on medical necessity only. Always verify member eligibility, benefits and copayments with EmblemHealth directly at Determination Disagreement If the referring physician disagrees with the determination, contact the Peer-to-Peer Consultation Line to discuss the case with a medical director. Call for GHI HMO, HIP, EmblemHealth CompreHealth EPO, EmblemHealth Medicare HMO and Vytra plans. Call for EmblemHealth EPO/PPO and EmblemHealth Medicare PPO plan members. Claims will be denied and the member will not be liable for payment if: A prior approval was required but not obtained for the CPT-4 code performed. Procedures are performed at a service location other than the address on the prior approval issued. Radiology Program Prior Approval Code List For HIP, EmblemHealth CompreHealth EPO and EmblemHealth Medicare HMO PRIOR APPROVAL CODE LIST FOR GHI HMO, HIP, EMBLEMHEALTH COMPREHEALTH EPO, EMBLEMHEALTH MEDICARE HMO AND VYTRA EFFECTIVE JANUARY 1, 2016 (GHI HMO AND VYTRA EFFECTIVE JANUARY 1, 2016) MAGNETIC RESONANCE IMAGING TMJ COMPUTED TOMOGRAPHY HEAD/BRAIN WITHOUT COMPUTED TOMOGRAPHY HEAD/BRAIN WITH COMPUTED TOMOGRAPHY HEAD/BRAIN WITHOUT AND WITH COMPUTED TOMOGRAPHY ORBIT WITHOUT COMPUTED TOMOGRAPHY ORBIT WITH COMPUTED TOMOGRAPHY ORBIT WITHOUT AND WITH Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
8 PRIOR APPROVAL CODE LIST FOR GHI HMO, HIP, EMBLEMHEALTH COMPREHEALTH EPO, EMBLEMHEALTH MEDICARE HMO AND VYTRA EFFECTIVE JANUARY 1, 2016 (GHI HMO AND VYTRA EFFECTIVE JANUARY 1, 2016) COMPUTED TOMOGRAPHY MAXILLOFACIAL WITHOUT COMPUTED TOMOGRAPHY MAXILLOFACIAL WITH COMPUTED TOMOGRAPHY MAXILLOFACIAL WITHOUT AND WITH COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT AND WITH COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK MAGNETIC RESONANCE IMAGING FACE, ORBIT, NECK WITHOUT MAGNETIC RESONANCE IMAGING FACE, ORBIT, NECK WITH MAGNETIC RESONANCE IMAGING FACE, ORBIT, NECK WITH AND WITHOUT HEAD WITHOUT HEAD WITH HEAD WITH AND WITHOUT NECK WITHOUT NECK WITH NECK WITH AND WITHOUT Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
9 PRIOR APPROVAL CODE LIST FOR GHI HMO, HIP, EMBLEMHEALTH COMPREHEALTH EPO, EMBLEMHEALTH MEDICARE HMO AND VYTRA EFFECTIVE JANUARY 1, 2016 (GHI HMO AND VYTRA EFFECTIVE JANUARY 1, 2016) MAGNETIC RESONANCE IMAGING HEAD WITHOUT MAGNETIC RESONANCE IMAGING HEAD WITH MAGNETIC RESONANCE IMAGING HEAD WITH AND WITHOUT MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MAGNETIC RESONANCE IMAGING; 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 MAGNETIC RESONANCE IMAGING; REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION OF ENTIRE NEUROFUNCTIONAL TESTING COMPUTED TOMOGRAPHY THORAX WITHOUT COMPUTED TOMOGRAPHY THORAX WITH COMPUTED TOMOGRAPHY THORAX WITHOUT AND WITH COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST, NON-CORONARY MAGNETIC RESONANCE IMAGING CHEST WITHOUT MAGNETIC RESONANCE IMAGING CHEST WITH MAGNETIC RESONANCE IMAGING CHEST WITH AND WITHOUT CHEST (EXC MYOCARDIUM) WITH OR WITHOUT COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
10 PRIOR APPROVAL CODE LIST FOR GHI HMO, HIP, EMBLEMHEALTH COMPREHEALTH EPO, EMBLEMHEALTH MEDICARE HMO AND VYTRA EFFECTIVE JANUARY 1, 2016 (GHI HMO AND VYTRA EFFECTIVE JANUARY 1, 2016) COMPUTED TOMOGRAPHY CERVICAL SPINE WITH COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT AND WITH COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT COMPUTED TOMOGRAPHY THORACIC SPINE WITH COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT AND WITH COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT COMPUTED TOMOGRAPHY LUMBAR SPINE WITH COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT AND WITH MAGNETIC RESONANCE IMAGING CERVICAL SPINE WITHOUT MAGNETIC RESONANCE IMAGING CERVICAL SPINE WITH MAGNETIC RESONANCE IMAGING THORACIC SPINE WITHOUT MAGNETIC RESONANCE IMAGING THORACIC SPINE WITH MAGNETIC RESONANCE IMAGING LUMBAR SPINE WITHOUT MAGNETIC RESONANCE IMAGING LUMBAR SPINE WITH MAGNETIC RESONANCE IMAGING C SPINE WITH AND WITHOUT MAGNETIC RESONANCE IMAGING T SPINE WITH AND WITHOUT MAGNETIC RESONANCE IMAGING L SPINE WITH AND WITHOUT SPINAL CANAL WITH OR WITHOUT Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
11 PRIOR APPROVAL CODE LIST FOR GHI HMO, HIP, EMBLEMHEALTH COMPREHEALTH EPO, EMBLEMHEALTH MEDICARE HMO AND VYTRA EFFECTIVE JANUARY 1, 2016 (GHI HMO AND VYTRA EFFECTIVE JANUARY 1, 2016) COMPUTED TOMOGRAPHIC ANGIOGRAPHY PELVIS COMPUTED TOMOGRAPHY PELVIS WITHOUT COMPUTED TOMOGRAPHY PELVIS WITH COMPUTED TOMOGRAPHY PELVIS WITHOUT AND WITH MAGNETIC RESONANCE IMAGING PELVIS WITHOUT MAGNETIC RESONANCE IMAGING PELVIS WITH MAGNETIC RESONANCE IMAGING PELVIS WITH AND WITHOUT PELVIS WITH OR WITHOUT COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT AND WITH COMPUTED TOMOGRAPHIC ANGIOGRAPHY UPPER EXTREMITY MAGNETIC RESONANCE IMAGING UPPER EXTREMITY WITHOUT MAGNETIC RESONANCE IMAGING UPPER EXTREMITY WITH MAGNETIC RESONANCE IMAGING UPPER EXTREMITY WITH AND WITHOUT MAGNETIC RESONANCE IMAGING UPPER EXTREMITY JOINT WITHOUT MAGNETIC RESONANCE IMAGING UPPER EXTREMITY JOINT WITH Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
12 PRIOR APPROVAL CODE LIST FOR GHI HMO, HIP, EMBLEMHEALTH COMPREHEALTH EPO, EMBLEMHEALTH MEDICARE HMO AND VYTRA EFFECTIVE JANUARY 1, 2016 (GHI HMO AND VYTRA EFFECTIVE JANUARY 1, 2016) MAGNETIC RESONANCE IMAGING UPPER EXTREMITY JOINT WITH AND WITHOUT UPPER EXTREMITY WITH OR WITHOUT COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT AND WITH COMPUTED TOMOGRAPHIC ANGIOGRAPHY LOWER EXTREMITY MAGNETIC RESONANCE IMAGING LOWER EXTREMITY WITHOUT MAGNETIC RESONANCE IMAGING LOWER EXTREMITY WITH MAGNETIC RESONANCE IMAGING LOWER EXTREMITY WITH AND WITHOUT MAGNETIC RESONANCE IMAGING LOWER EXTREMITY JOINT WITHOUT MAGNETIC RESONANCE IMAGING LOWER EXTREMITY JOINT WITH MAGNETIC RESONANCE IMAGING LOWER EXTREMITY JOINT WITH AND WITHOUT LOWER EXTREMITY WITH OR WITHOUT COMPUTED TOMOGRAPHY ABDOMEN WITHOUT COMPUTED TOMOGRAPHY ABDOMEN WITH COMPUTED TOMOGRAPHY ABDOMEN WITHOUT AND WITH Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
13 PRIOR APPROVAL CODE LIST FOR GHI HMO, HIP, EMBLEMHEALTH COMPREHEALTH EPO, EMBLEMHEALTH MEDICARE HMO AND VYTRA EFFECTIVE JANUARY 1, 2016 (GHI HMO AND VYTRA EFFECTIVE JANUARY 1, 2016) COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMEN AND PELVIS, WITH MATERIAL(S), INCLUDING NON IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT MATERIAL COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH MATERIAL(S) COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS MAGNETIC RESONANCE IMAGING ABDOMEN WITHOUT MAGNETIC RESONANCE IMAGING ABDOMEN WITH MAGNETIC RESONANCE IMAGING ABDOMEN WITH AND WITHOUT ABDOMEN WITH OR WITHOUT COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITHOUT MATERIAL COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITH MATERIAL(S) INCLUDING NON- IMAGES, IF PERFORMED COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, SCREENING, INCLUDING IMAGE POSTPROCESSING Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
14 PRIOR APPROVAL CODE LIST FOR GHI HMO, HIP, EMBLEMHEALTH COMPREHEALTH EPO, EMBLEMHEALTH MEDICARE HMO AND VYTRA EFFECTIVE JANUARY 1, 2016 (GHI HMO AND VYTRA EFFECTIVE JANUARY 1, 2016) COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND OR OTHER TOMOGRAPHIC MODALITY; NOT REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND OR OTHER TOMOGRAPHIC MODALITY; REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION COMPUTED TOMOGRAPHY LIMITED OR LOCALIZED FOLLOW-UP STUDY MAGNETIC RESONANCE IMAGING SPECTROSCOPY ULTRASOUND OBSTETRICAL PELVIS, PREGNANT UTERUS, FIRST TRIMESTER <14 WEEKS SINGLE OR FIRST GESTATION ULTRASOUND OBSTETRICAL PELVIS, PREGNANT UTERUS, FIRST TRIMESTER <14 WEEKS EACH ADDITIONAL GESTATION ULTRASOUND OBSTETRICAL PELVIS, PREGNANT UTERUS, B-SCAN (ALLOWED ONCE PER GESTATION) ULTRASOUND OBSTETRICAL PELVIS COMPLETE, MULTIPLE GESTATION AFTER 1ST TRIMESTER (ALLOWED ONCE FOR EACH ADDITIONAL FETUS PER GESTATION; MUST BE BILLED WITH 76805) ULTRASOUND PREGNANT UTERUS FETAL AND MATERNAL EVAL PLUS ULTRASOUND FETAL ANATOMIC EVAL TRANSABDOMINAL SINGLE OR FIRST GESTATION (ALLOWED ONCE PER GESTATION; SECOND STUDY ALLOWED IF PERFORMED BY A DIFFERENT PHYSICIAN) Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
15 PRIOR APPROVAL CODE LIST FOR GHI HMO, HIP, EMBLEMHEALTH COMPREHEALTH EPO, EMBLEMHEALTH MEDICARE HMO AND VYTRA EFFECTIVE JANUARY 1, 2016 (GHI HMO AND VYTRA EFFECTIVE JANUARY 1, 2016) ULTRASOUND PREGNANT UTERUS FETAL AND MATERNAL EVAL PLUS ULTRASOUND FETAL ANATOMIC EVAL TRANSABDOMINAL EACH ADDITIONAL GESTATION (ALLOWED ONCE FOR EACH ADDITIONAL FETUS ULTRASOUND PER GESTATION; MUST BE BILLED WITH 76811; SECOND STUDY ALLOWED IF PERFORMED BY A DIFFERENT PHYSICIAN) ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY MEASUREMENT, TRANSABDOMINAL OR TRANSVAGINAL APPROACH; SINGLE OR FIRST GESTATION (ALLOWED ONCE PER GESTATION) ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY MEASUREMENT, TRANSABDOMINAL OR TRANSVAGINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) (ALLOWED ONCE FOR EACH ADDITIONAL FETUS PER GESTATION) ULTRASOUND PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (E.G., FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES ULTRASOUND OBSTETRICAL PELVIS FOLLOW-UP OR REPEAT ULTRASOUND PREGNANT UTERUS TRANSVAGINAL FETAL BIOPHYSICAL PROFILE FETAL BIOPHYSICAL PROFILE WITHOUT STRESS NON STRESS DOPPLER VELOCIMETRY, FETAL; UMBILICAL ARTERY Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
16 PRIOR APPROVAL CODE LIST FOR GHI HMO, HIP, EMBLEMHEALTH COMPREHEALTH EPO, EMBLEMHEALTH MEDICARE HMO AND VYTRA EFFECTIVE JANUARY 1, 2016 (GHI HMO AND VYTRA EFFECTIVE JANUARY 1, 2016) DOPPLER VELOCIMETRY, FETAL; MIDDLE CEREBRAL ARTERY ULTRASOUND OBSTETRICAL ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM FOLLOW-UP OR REPEAT STUDY DOPPLER ECHOCARDIOGRAPHY FETAL COMPLETE FOLLOW-UP OR REPEAT STUDY ULTRASOUND GASTROINTESTINAL, ENDOSCOPIC MAGNETIC RESONANCE IMAGING GUIDANCE FOR NEEDLE PLACEMENT MAGNETIC RESONANCE IMAGING GUIDANCE FOR AND MONITORING OF TISSUE ABLATION MAGNETIC RESONANCE IMAGING BREAST WITH AND/OR WITHOUT ; UNILATERAL MAGNETIC RESONANCE IMAGING BREAST BILATERAL MAGNETIC RESONANCE IMAGING BONE MARROW BLOOD SUPPLY THYROID RAI UPTAKE THYROID MULTIPLE UPTAKE THYROID SUPPRESS OR STIMULATION THYROID UPTAKE AND SCAN THYROID IMAGE, MULTIPLE UPTAKES THYROID SCAN ONLY THYROID IMAGING WITH FLOW THYROID MET IMAGING THYROID MET IMAGING WITH ADDITIONAL STUDIES THYROID SCAN WHOLE BODY Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
17 PRIOR APPROVAL CODE LIST FOR GHI HMO, HIP, EMBLEMHEALTH COMPREHEALTH EPO, EMBLEMHEALTH MEDICARE HMO AND VYTRA EFFECTIVE JANUARY 1, 2016 (GHI HMO AND VYTRA EFFECTIVE JANUARY 1, 2016) THYROID CARCINOMA METASTASES UPTAKE PARATHYROID NUCLEAR IMAGING ADRENAL NUCLEAR IMAGING BONE MARROW IMAGING, LIMITED BONE MARROW IMAGING, MULTIPLE BONE MARROW IMAGING, WHOLE BODY SPLEEN IMAGING WITH OR WITHOUT VASCULAR FLOW LYMPH SYSTEM IMAGING LIVER IMAGING LIVER IMAGING WITH FLOW LIVER IMAGING SPECT LIVER IMAGING SPECT WITH VASCULAR FLOW LIVER AND SPLEEN IMAGING LIVER AND SPLEEN IMAGING WITH FLOW LIVER FUNCTION STUDY HIDA SCAN SALIVARY GLAND IMAGING SERIAL SALIVARY GLAND SALIVARY GLAND FUNCTION TEST ESOPHAGUS MOTILITY STUDY GASTRIC MUCOSA IMAGING GASTROESOPHAGEAL REFLUX EXAM GASTRIC EMPTYING STUDY GI BLEEDER SCAN GI PROTEIN LOSS EXAM MECKEL'S DIVERTICULUM IMAGING LEVEEN SHUNT PATENCY EXAM Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
18 PRIOR APPROVAL CODE LIST FOR GHI HMO, HIP, EMBLEMHEALTH COMPREHEALTH EPO, EMBLEMHEALTH MEDICARE HMO AND VYTRA EFFECTIVE JANUARY 1, 2016 (GHI HMO AND VYTRA EFFECTIVE JANUARY 1, 2016) BONE OR JOINT IMAGING LIMITED BONE OR JOINT IMAGING MULTIPLE BONE SCAN WHOLE BODY BONE AND/OR JOINT IMAGING; 3 PHASE STUDY BONE JOINT IMAGING TOMO TEST SPECT NON-IMAGING HEART FUNCTION CARDIAC SHUNT IMAGING RADIONUCLIDE VENOGRAM NON-CARDIAC ACUTE VENOUS THROMBOSIS IMAGING VENOUS THROMBOSIS IMAGING UNILATERAL VENOUS THROMBOSIS IMAGING BILATERAL MYOCARDIAL INFARCTION SCAN HEART INFARCT IMAGE EF HEART INFARCT IMAGE SPECT GATED HEART, REST OR STRESS CARDIAC BLOOD POOL MUGA SCAN HEART FIRST PASS SINGLE CARDIAC BLOOD POOL IMAGING, MULTIPLE CARDIAC BLOOD POOL IMAGING, SPECT CARDIAC BLOOD POOL IMAGING, SINGLE AT REST PULMONARY VENTILATION IMAGING (E.G., AEROSOL OR GAS) PULMONARY PERFUSION IMAGING PULMONARY VENTILATION (E.G., AEROSOL OR GAS) AND PERFUSION IMAGING Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
19 PRIOR APPROVAL CODE LIST FOR GHI HMO, HIP, EMBLEMHEALTH COMPREHEALTH EPO, EMBLEMHEALTH MEDICARE HMO AND VYTRA EFFECTIVE JANUARY 1, 2016 (GHI HMO AND VYTRA EFFECTIVE JANUARY 1, 2016) QUANTITATIVE DIFFERENTIAL PULMONARY PERFUSION, INCLUDING IMAGING, WHEN PERFORMED QUANTITATIVE DIFFERENTIAL PULMONARY PERFUSION AND VENTILATION (E.G., AEROSOL OR GAS), INCLUDING IMAGING, WHEN PERFORMED BRAIN IMAGING LIMITED STATIC BRAIN LIMITED IMAGING AND FLOW BRAIN IMAGING COMPLETE BRAIN IMAGING COMPLETE WITH FLOW BRAIN IMAGING SPECT BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC EVALUATION BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION EVALUATION BRAIN FLOW IMAGING ONLY CISTERNOGRAM (CEREBROSPINAL FLUID FLOW) CEREBROSPINAL VENTRICULOGRAPHY CEREBROSPINAL FLUID FLOW SHUNT EVALUATION CEREBROSPINAL FLUID SCAN SPECT CEREBROSPINAL FLUID FLOW LEAKAGE DETECTION AND LOCALIZATION RADIOPHARMACEUTICAL DACRYOCYSTORGRAPHY KIDNEY IMAGING MORPHOLOGY KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION STUDY Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
20 PRIOR APPROVAL CODE LIST FOR GHI HMO, HIP, EMBLEMHEALTH COMPREHEALTH EPO, EMBLEMHEALTH MEDICARE HMO AND VYTRA EFFECTIVE JANUARY 1, 2016 (GHI HMO AND VYTRA EFFECTIVE JANUARY 1, 2016) KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION, SINGLE WITH PHARM INTERVENTION KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW, MULTIPLE, WITHOUT AND WITH PHARM INTERVENTION KIDNEY IMAGING, SPECT KIDNEY FUNCTION STUDY, NON-IMAGE RADIOISOTROPIC URINARY BLADDER RESIDUAL STUDY URETERAL REFLUX STUDY TESTICULAR IMAGING WITH VASCULAR FLOW RADIOPHARM LOCALIZATION OF TUMOR, LIMITED AREA RADIOPHARM LOCALIZATION OF TUMOR, MULTIPLE AREAS RADIOPHARM LOCALIZATION OF TUMOR, WHOLE BODY RADIOPHARM LOCALIZATION OF TUMOR, SPECT RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF RADIOPHARMACEUTICAL AGENT(S); WHOLE BODY, REQUIRING 2 OR MORE DAYS IMAGING RADIOPHARM LOCALIZATION OF ABSCESS, LIMITED AREA RADIOPHARM LOCALIZATION OF ABSCESS, WHOLE BODY RADIOPHARM LOCALIZATION OF ABSCESS, SPECT POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; LIMITED AREA (E.G., CHEST, HEAD/NECK) POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; SKULL BASE TO MID-THIGH Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
21 PRIOR APPROVAL CODE LIST FOR GHI HMO, HIP, EMBLEMHEALTH COMPREHEALTH EPO, EMBLEMHEALTH MEDICARE HMO AND VYTRA EFFECTIVE JANUARY 1, 2016 (GHI HMO AND VYTRA EFFECTIVE JANUARY 1, 2016) POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; WHOLE BODY C8900 C8901 C8902 C8903 C8904 C8905 C8906 C8907 POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; LIMITED AREA (E.G., CHEST, HEAD/NECK) POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; SKULL BASE TO MID-THIGH POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; WHOLE BODY WITH, ABDOMEN WITHOUT, ABDOMEN WITH AND WITHOUT, ABDOMEN MAGNETIC RESONANCE IMAGING WITH, BREAST; UNILATERAL MAGNETIC RESONANCE IMAGING WITHOUT, BREAST; UNILATERAL MAGNETIC RESONANCE IMAGING WITH AND WITHOUT, BREAST; UNILATERAL MAGNETIC RESONANCE IMAGING WITH, BREAST; BILATERAL MAGNETIC RESONANCE IMAGING WITHOUT, BREAST; BILATERAL Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
22 PRIOR APPROVAL CODE LIST FOR GHI HMO, HIP, EMBLEMHEALTH COMPREHEALTH EPO, EMBLEMHEALTH MEDICARE HMO AND VYTRA C8908 EFFECTIVE JANUARY 1, 2016 (GHI HMO AND VYTRA EFFECTIVE JANUARY 1, 2016) MAGNETIC RESONANCE IMAGING WITH AND WITHOUT, BREAST; BILATERAL C8909 C8910 C8911 C8912 C8913 C8914 C8918 C8919 C8920 C8931 C8932 C8933 C8934 C8935 WITH, CHEST (EXCLUDING MYOCARDIUM) WITHOUT, CHEST (EXCLUDING MYOCARDIUM) WITH AND WITHOUT, CHEST (EXCLUDING MYOCARDIUM) WITH, LOWER EXTREMITY WITHOUT, LOWER EXTREMITY WITH AND WITHOUT, LOWER EXTREMITY WITH, PELVIS WITHOUT, PELVIS WITH AND WITHOUT, PELVIS WITH, SPINAL CANAL AND CONTENTS WITHOUT, SPINAL CANAL AND CONTENTS WITHOUT FOLLOWED BY WITH, SPINAL CANAL AND CONTENTS WITH, UPPER EXTREMITY WITHOUT, UPPER EXTREMITY Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
23 PRIOR APPROVAL CODE LIST FOR GHI HMO, HIP, EMBLEMHEALTH COMPREHEALTH EPO, EMBLEMHEALTH MEDICARE HMO AND VYTRA C8936 EFFECTIVE JANUARY 1, 2016 (GHI HMO AND VYTRA EFFECTIVE JANUARY 1, 2016) WITHOUT FOLLOWED BY WITH, UPPER EXTREMITY Note: This program does not change members' benefits, nor does it change claim submission procedures for providers with a current direct contract with one of EmblemHealth's companies. Radiologists directly contracted with evicore are now required to submit claims to evicore. Radiology Program Prior Approval Code List For EmblemHealth EPO/PPO and EmblemHealth Medicare PPO PRIOR APPROVAL CODE LIST FOR GHI EPO/PPO, EMBLEMHEALTH EPO/PPO AND EMBLEMHEALTH MEDICARE PPO EFFECTIVE OCTOBER 1, 2012 C8936 WITHOUT FOLLOWED BY WITH, UPPER EXTREMITY (crosswalked to 73225) C8935 C8934 C8933 C8932 C8931 C8920 C8919 C8918 WITHOUT, UPPER EXTREMITY (crosswalked to 73225) WITH, UPPER EXTREMITY (crosswalked to 73225) WITHOUT FOLLOWED BY WITH, SPINAL CANAL AND CONTENTS (crosswalked to 72159) WITHOUT, SPINAL CANAL AND CONTENTS (crosswalked to 72159) WITH, SPINAL CANAL AND CONTENTS (crosswalked to 72159) MRA WITH AND WITHOUT, PELVIS (crosswalked to 72198) MRA WITHOUT, PELVIS (crosswalked to 72198) MRA WITH, PELVIS (crosswalked to 72198) Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
24 PRIOR APPROVAL CODE LIST FOR GHI EPO/PPO, EMBLEMHEALTH EPO/PPO AND EMBLEMHEALTH MEDICARE PPO EFFECTIVE OCTOBER 1, 2012 C8914 MRA WITH AND WITHOUT, LOWER EXTREMITY (crosswalked to 73725) C8913 C8912 C8911 C8910 C8909 C8908 C8907 C8906 C8905 C8904 C8903 C8902 C8901 C T MRA WITHOUT, LOWER EXTREMITY (crosswalked to 73725) MRA WITH, LOWER EXTREMITY (crosswalked to 73725) MRA WITH AND WITHOUT, CHEST (EXCLUDING MYOCARDIUM) (crosswalked to 71555) MRA WITHOUT, CHEST (EXCLUDING MYOCARDIUM) (crosswalked to 71555) MRA WITH, CHEST (EXCLUDING MYOCARDIUM) (crosswalked to 71555) MRI WITH AND WITHOUT, BREAST; BILATERAL (crosswalked to 77059) MRI WITHOUT, BREAST; BILATERAL (crosswalked to 77059) MRI WITH, BREAST; BILATERAL (crosswalked to 77059) MRI WITH AND WITHOUT, BREAST; UNILATERAL (crosswalked to 77058) MRI WITHOUT, BREAST; UNILATERAL (crosswalked to 77058) MRI WITH, BREAST; UNILATERAL (crosswalked to 77058) MRA WITH AND WITHOUT, ABDOMEN (crosswalked to 74185) MRA WITHOUT, ABDOMEN (crosswalked to 74185) MRA WITH, ABDOMEN (crosswalked to 74185) COMPUTER-AIDED DETECTION (CAD), INCLUDING COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION, WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION AND REPORT, WITH OR WITHOUT Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
25 PRIOR APPROVAL CODE LIST FOR GHI EPO/PPO, EMBLEMHEALTH EPO/PPO AND EMBLEMHEALTH MEDICARE PPO EFFECTIVE OCTOBER 1, 2012 DIGITIZATION OF FILM RADIOGRAPHIC IMAGES, CHEST RADIOGRAPH(S) PERFORMED REMOTE FROM PRIMARY INTERPRETATION 0174T COMPUTER-AIDED DETECTION (CAD), INCLUDING COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION, WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION AND REPORT, WITH OR WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC IMAGES, CHEST RADIOGRAPH(S) PERFORMED CONCURRENT WITH PRIMARY INTERPRETATION POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; WHOLE BODY POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; SKULL BASE TO MID-THIGH POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; LIMITED AREA (E.G., CHEST, HEAD/NECK) POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; WHOLE BODY POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; SKULL BASE TO MID-THIGH POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; LIMITED AREA (E.G., CHEST, HEAD/NECK) RADIOPHARM LOCALIZATION OF ABSCESS, SPECT RADIOPHARM LOCALIZATION OF ABSCESS, WHOLE BODY Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
26 PRIOR APPROVAL CODE LIST FOR GHI EPO/PPO, EMBLEMHEALTH EPO/PPO AND EMBLEMHEALTH MEDICARE PPO EFFECTIVE OCTOBER 1, RADIOPHARM LOCALIZATION OF ABSCESS, LIMITED AREA RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF RADIOPHARMACEUTICAL AGENT(S); WHOLE BODY, REQUIRING 2 OR MORE DAYS IMAGING RADIOPHARM LOCALIZATION OF TUMOR, SPECT RADIOPHARM LOCALIZATION OF TUMOR, WHOLE BODY RADIOPHARM LOCALIZATION OF TUMOR, MULTI AREAS RADIOPHARM LOCALIZATION OF TUMOR, LIMITED AREA TESTICULAR IMAGING W/ VASCULAR FLOW URETERAL REFLUX STUDY URINARY BLADDER RESIDUAL STUDY KIDNEY FUNCTION STUDY, NON-IMAGE RADIOISOTROPIC KIDNEY IMAGING, SPECT KIDNEY IMAGING MORPHOLOGY W/ VASCULAR FLOW, MULTI, W/O AND W/ PHARM INTERVENTION KIDNEY IMAGING MORPHOLOGY W/ VASCULAR FLOW AND FUNCTION, SINGLE W/ PHARM INTERVENTION KIDNEY IMAGING MORPHOLOGY W/ VASCULAR FLOW AND FUNCTION STUDY KIDNEY IMAGING MORPHOLOGY W/ VASCULAR FLOW KIDNEY IMAGING MORPHOLOGY RADIOPHARMACEUTICAL DACRYOCYSTORGRAPHY CSF LEAKAGE DETECTION AND LOCALIZATION CEREBROSPINAL FLUID SCAN SPECT Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
27 PRIOR APPROVAL CODE LIST FOR GHI EPO/PPO, EMBLEMHEALTH EPO/PPO AND EMBLEMHEALTH MEDICARE PPO EFFECTIVE OCTOBER 1, CSF SHUNT EVALUATION CEREBROSPINAL VENTRICULOGRAPHY CISTERNOGRAM (Cerebrospinal fluid flow) BRAIN FLOW IMAGING ONLY BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION EVALUATION BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC EVALUATION BRAIN IMAGING SPECT BRAIN IMAGING COMPLETE W/ FLOW BRAIN IMAGING COMPLETE BRAIN LTD IMAGING AND FLOW BRAIN IMAGING LTD STATIC QUANTITATIVE DIFFERENTIAL PULMONARY PERFUSION AND VENTILATION (E.G., AEROSOL OR GAS), INCLUDING IMAGING WHEN PERFORMED QUANTITATIVE DIFFERENTIAL PULMONARY PERFUSION, INCLUDING IMAGING WHEN PERFORMED PULMONARY VENTILATION (E.G., AEROSOL OR GAS) AND PERFUSION IMAGING PULMONARY VENTILATION IMAGING (E.G., AEROSOL OR GAS) CARDIAC BLOOD POOL IMAGING, SINGLE AT REST (Use with 78472) CARDIAC BLOOD POOL IMAGING, SPECT MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; MULTIPLE STUDIES AT REST OR STRESS MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; SINGLE STUDY AT REST OR STRESS Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
28 PRIOR APPROVAL CODE LIST FOR GHI EPO/PPO, EMBLEMHEALTH EPO/PPO AND EMBLEMHEALTH MEDICARE PPO EFFECTIVE OCTOBER 1, CARDIAC BLOOD POOL IMAGING, MULTI HEART FIRST PASS SINGLE CARDIAC BLOOD POOL MUGA SCAN GATED HEART, REST OR STRESS HEART INFARCT IMAGE SPECT HEART INFARCT IMAGE EF MYOCARDIAL INFARCTION SCAN MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) METABOLIC EVAL VENOUS THROMBOSIS IMAGING BILATERAL VENOUS THROMBOSIS IMAGING UNILATERAL ACUTE VENOUS THROMBOSIS IMAGING MPI, PLANAR, MULTIPLE, REST OR STRESS MPI, PLANAR, SINGLE REST OR STRESS MPI, SPECT, MULTIPLE, REST OR STRESS MPI, SPECT, SINGLE REST OR STRESS RADIONUCLIDE VENOGRAM NON-CARDIAC CARDIAC SHUNT IMAGING NON-IMAGING HEART FUNCTION BONE JOINT IMAGING TOMO TEST SPECT BONE AND/OR JOINT IMAGING; 3 PHASE STUDY BONE SCAN WHOLE BODY BONE OR JOINT IMAGING MULTIPLE BONE OR JOINT IMAGING LTD LEVEEN SHUNT PATENCY EXAM MECKEL'S DIVERTICULUM IMAGING GI PROTEIN LOSS EXAM Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
29 PRIOR APPROVAL CODE LIST FOR GHI EPO/PPO, EMBLEMHEALTH EPO/PPO AND EMBLEMHEALTH MEDICARE PPO EFFECTIVE OCTOBER 1, GI BLEEDER SCAN GASTRIC EMPTYING STUDY GASTROESOPHAGEAL REFLUX EXAM GASTRIC MUCOSA IMAGING ESOPHAGUS MOTILITY STUDY SALIVARY GLAND FUNCTION TEST SERIAL SALIVARY GLAND SALIVARY GLAND IMAGING HIDA SCAN LIVER FUNCTION STUDY HIDA SCAN LIVER FUNCTION STUDY LIVER AND SPLEEN IMAGING W/ FLOW LIVER AND SPLEEN IMAGING LIVER IMAGING SPECT W/ VASCULAR FLOW LIVER IMAGING SPECT LIVER IMAGING W/ FLOW LIVER IMAGING LYMPH SYSTEM IMAGING PLATELET SURVIVAL PLATELET SURVIVAL, KINETICS SPLEEN IMAGING W/ OR W/O VASCULAR FLOW LABELED RED CELL SEQUESTRATION BONE MARROW IMAGING, WHOLE BODY BONE MARROW IMAGING, MULTIPLE BONE MARROW IMAGING, LIMITED ADRENAL NUCLEAR IMAGING PARATHYROID NUCLEAR IMAGING Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
30 PRIOR APPROVAL CODE LIST FOR GHI EPO/PPO, EMBLEMHEALTH EPO/PPO AND EMBLEMHEALTH MEDICARE PPO EFFECTIVE OCTOBER 1, THYROID CARCINOMA METASTASES UPTAKE (add on code - use w/ code only) THYROID SCAN WHOLE BODY THYROID MET IMAGING WITH ADDITIONAL STUDIES THYROID MET IMAGING THYROID IMAGING W/ FLOW THYROID SCAN ONLY THYROID IMAGE, MULTIPLE UPTAKES THYROID UPTAKE AND SCAN THYROID SUPPRESS OR STIMULATION THYROID MULTIPLE UPTAKE THYROID RAI UPTAKE MRI BONE MARROW BLOOD SUPPLY MRI BREAST BILATERAL MRI BREAST W/ AND/OR W/O ; UNILATERAL MRI GUIDANCE FOR NEEDLE PLACEMENT MRI SPECTROSCOPY CT LIMITED OR LOCALIZED FOLLOW-UP STUDY 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, OR OTHER TOMOGRAPHIC MODALITY; REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, OR OTHER TOMOGRAPHIC MODALITY; NOT REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION CT ANGIOGRAPHY ABDOMINAL AORTA Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
31 PRIOR APPROVAL CODE LIST FOR GHI EPO/PPO, EMBLEMHEALTH EPO/PPO AND EMBLEMHEALTH MEDICARE PPO EFFECTIVE OCTOBER 1, CORONARY CTA CARDIAC CT FOR CONGENITAL HD CARDIAC CT FOR MORPHOLOGY CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT MATERIAL(S), FOLLOWED BY MATERIAL(S) AND FURTHER SEQUENCES; WITH STRESS IMAGING CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT MATERIAL(S), FOLLOWED BY MATERIAL(S) AND FURTHER SEQUENCES CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT MATERIAL; WITH STRESS IMAGING CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT MATERIAL COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, SCREENING, INCLUDING IMAGE POSTPROCESSING COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITH MATERIAL(S), INCLUDING NON IMAGES, IF PERFORMED COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITHOUT MATERIAL MRA ABDOMEN W/ OR W/O MRI ABDOMEN W/ & W/O MRI ABDOMEN W/ MRI ABDOMEN W/O COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT MATERIAL IN ONE OR BOTH BODY Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
32 PRIOR APPROVAL CODE LIST FOR GHI EPO/PPO, EMBLEMHEALTH EPO/PPO AND EMBLEMHEALTH MEDICARE PPO EFFECTIVE OCTOBER 1, 2012 REGIONS, FOLLOWED BY MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH MATERIAL(S) COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT MATERIAL CT ANGIOGRAPHY ABDOMEN CT ANGIOGRAPHY, ABDOMEN AND PELVIS, WITH MATERIAL(S), INCLUDING NON IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING CT ABDOMEN W/O & W/ CT ABDOMEN W/ CT ABDOMEN W/O MRA LOWER EXTREMITY W/ OR W/O MRI LOWER EXTREMITY JOINT W/ & W/O MRI LOWER EXTREMITY JOINT W/ MRI LOWER EXTREMITY JOINT W/O MRI LOWER EXTREMITY W/ & W/O MRI LOWER EXTREMITY W/ MRI LOWER EXTREMITY W/O CT ANGIOGRAPHY LOWER EXTREMITY CT LOWER EXTREMITY W/O & W/ CT LOWER EXTREMITY W/ CT LOWER EXTREMITY W/O MRA UPPER EXTREMITY W/ OR W/O Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
33 PRIOR APPROVAL CODE LIST FOR GHI EPO/PPO, EMBLEMHEALTH EPO/PPO AND EMBLEMHEALTH MEDICARE PPO EFFECTIVE OCTOBER 1, MRI UPPER EXTREMITY JOINT W/ & W/O MRI UPPER EXTREMITY JOINT W/ MRI UPPER EXTREMITY JOINT W/O MRI UPPER EXTREMITY W/ & W/O MRI UPPER EXTREMITY W/ MRI UPPER EXTREMITY W/O CT ANGIOGRAPHY UPPER EXTREMITY CT UPPER EXTREMITY W/O & W/ CT UPPER EXTREMITY W/ CT UPPER EXTREMITY W/O MRA PELVIS W/ OR W/O MRI PELVIS W/ & W/O MRI PELVIS W/ MRI PELVIS W/O CT PELVIS W/O & W/ CT PELVIS W/ CT PELVIS W/O CT ANGIOGRAPHY PELVIS MRA SPINAL CANAL W/ OR W/O MRI L SPINE W/ & W/O MRI T SPINE W/ & W/O MRI C SPINE W/ & W/O MRI LUMBAR SPINE W/ MRI LUMBAR SPINE W/O MRI THORACIC SPINE W/ MRI THORACIC SPINE W/O Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
34 PRIOR APPROVAL CODE LIST FOR GHI EPO/PPO, EMBLEMHEALTH EPO/PPO AND EMBLEMHEALTH MEDICARE PPO EFFECTIVE OCTOBER 1, MRI CERVICAL SPINE W/ MRI CERVICAL SPINE W/O CT L SPINE W/O & W/ CT L SPINE W/ CT L SPINE W/O CT T SPINE W/O & W/ CT T SPINE W/ CT T SPINE W/O CT C SPINE W/O & W/ CT C SPINE W/ CT C SPINE W/O MRA CHEST (EXC MYOCARDIUM) W/ OR W/O MRI CHEST W/ & W/O MRI CHEST W/ MRI CHEST W/O CT ANGIOGRAPHY CHEST, NON-CORONARY CT THORAX W/O & W/ CT THORAX W/ CT THORAX W/O MRI, BRAIN, FUNCTIONAL MRI; REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION OF ENTIRE NEUROFUNCTIONAL TESTING MRI, BRAIN, FUNCTIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION MRI HEAD W/ & W/O MRI HEAD W/ Back to Table of Contents EmblemHealth Provider Manual Last Updated: 02/02/
AI CPT Codes. x x. 70336 MRI Magnetic resonance (eg, proton) imaging, temporomandibular joint(s)
Code Category Description Auth Required Medicaid Medicare 0126T IMT Testing Common carotid intima-media thickness (IMT) study for evaluation of atherosclerotic burden or coronary heart disease risk factor
CPT Radiology Codes Requiring Review by AIM Effective 01/01/2016
CPT Radiology Codes Requiring Review by AIM Effective 01/01/2016 When a service is authorized only one test per group is payable. *Secondary codes or add-on codes do not require preauthorization or separate
Diagnostic Imaging Prior Review Code List 3 rd Quarter 2016
Computerized Tomography (CT) Abdomen 6 Abdomen/Pelvis Combination 101 Service 74150 CT abdomen; w/o 74160 CT abdomen; with 74170 CT abdomen; w/o followed by 74176 Computed tomography, abdomen and pelvis;
Computed Tomography, Head Or Brain; Without Contrast Material, Followed By Contrast Material(S) And Further Sections
1199SEIU BENEFIT AND PENSION FUNDS High Tech Diagnostic Radiology and s # 1 70336 Magnetic Resonance (Eg, Proton) Imaging, Temporomandibular Joint(S) 2 70450 Computed Tomography, Head Or Brain; Without
CPT * Codes Included in AIM Preauthorization Program for 2013 With Grouper Numbers
CPT * Codes Included in AIM Preauthorization Program for 2013 With Grouper Numbers Computerized Tomography (CT) CPT Description Abdomen 74150 CT abdomen; w/o contrast 6 74160 CT abdomen; with contrast
CPT CODE PROCEDURE DESCRIPTION. CT Scans 70450 CT HEAD/BRAIN W/O CONTRAST 70460 CT HEAD/BRAIN W/ CONTRAST 70470 CT HEAD/BRAIN W/O & W/ CONTRAST
CPT CODE PROCEDURE DESCRIPTION CT Scans 70450 CT HEAD/BRAIN W/O CONTRAST 70460 CT HEAD/BRAIN W/ CONTRAST 70470 CT HEAD/BRAIN W/O & W/ CONTRAST 70480 CT ORBIT W/O CONTRAST 70481 CT ORBIT W/ CONTRAST 70482
NM- Nuclear Medicine
NM- Nuclear Medicine CODE DESCRIPTION 78000 Thyroid uptake; single determination 78001 Thyroid uptake; multiple determinations 78003 Thyroid uptake; stimulation, suppression or discharge 78006 Thyroid
YourCare Health Plan 2015 CPT Code/Prior Authorization List
Programs:, Cardiology, Radiation Therapy, and Sleep Management MRI 70336 MRI TMJ Tempomandibular joint/jaw CT SCANS 70450 CT Head/Brain w/o Contrast CT SCANS 70470 CT Head/Brain w/o & w/ Contrast CT SCANS
CT Scan. CT Angiography, Neck, W/O Contrast Matl(s), Followed By Contrast Matl(s), W/Image
CT Scan CPT 70450 CT Scan, Head/Brain; W/O Contrast Matl 70460 CT Scan, Head/Brain; W/Contrast Matl(s) 70470 CT Scan, Head/Brain; W/O Contrast Matl, Then W/Contrast Matl(s) 70480 CT Scan, Orbit/Sella/Posterior
2016 CPT Radiology, ECHO, and PET Codes Requiring Review Modality Body Part Group # CPT Description Default CPT "1"
26 CPT Radiology, ECHO, and PET Codes Requiring Review (Please Note: Group # and Default CPT "" are for internal claims processing use only) Modality Body Part Default CPT "" CT Head 748 CT orbit, sella
DIAGNOSTIC IMAGING SERVICES
DIAGNOSTIC IMAGING SERVICES Policy NHP reimburses contracted providers for medically necessary diagnostic imaging services delivered in non-institutional settings such as an office or free-standing facility,
Procedure Codes. RadConsult provides real-time decision support for physicians who order high-cost imaging procedures RADIATION THERAPY
Procedure Codes 2011 RadConsult provides real-time decision support for physicians who order high-cost imaging procedures RADIATION THERAPY 2D3D Therapeutic radiology treatment planning; simple 77261 Therapeutic
Radiology Management Program
Highmark Blue Shield Radiology Management Program Prior Authorization Reference Guide* Effective with service dates of April 1, 2006, and beyond *Originally published December 2005; revised January 2007
CARDIOLOGY PROCEDURES REQUIRING PRECERTIFICATION
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