Does 70460 require prior authorization?

Yes, 70460 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for 70460?

Medicare facility rate: $5.72. Non-facility rate: $5.72. Work RVU: 1.10.

Verity

`70460`

HCPCS/CPT

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Medicare Pricing

Work RVU

1.10

Facility

$5.72

Non-Facility

$5.72

Documentation Required

Claims must meet the reasonable and necessary documentation requirements specified in LCD L35391; refer to that LCD for required medical record elements and prior authorization rules.
Title XVIII of the Social Security Act, Section 1833(e) prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.
Documentation must support that the scan is reasonable and necessary.
Accurate coding information must be provided with claims to differentiate CT and/or MRI scans from other radiology services and to make coverage determinations.

Key Coverage Criteria

Multiple imaging studies in oncology are covered only when reasonable and necessary as defined by Local Coverage Determination L35391.
G71.21 | Nemaline myopathy
G83.0 | Diplegia of upper limbs
H44.19 | Other endophthalmitis
H44.532 | Leucocoria, left eye
H44.533 | Leucocoria, bilateral

20 Active Policies

L33693 — Peripheral Venous Ultrasound

J09

L35391 — Multiple Imaging in Oncology

J12

A56848 — Billing and Coding: Multiple Imaging in Oncology

J12

L35434 — Oximetry Services

J12

L35451 — Peripheral Venous Ultrasound

Have a follow-up question?

Ask Verity about documentation requirements, denial risks, or coverage in your state.

Sufficient documentation such as, history and physical notes, laboratory results, signs and symptoms of the disease to warrant the diagnostic test and to support the claim of reasonable and necessary must be included in the medical records.

This information must be available to Medicare upon request.

A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)

J12

L35007 — Vestibular and Audiologic Function Studies

J12

L37371 — Electroretinography (ERG)

J12

CARELON-imaging-of-the-brain-2024-10-20 — Imaging of the Brain

CARELON-imaging-of-the-head-and-neck-2024-04-14 — Imaging of the Head and Neck

AMBETTER-CP.BH.124 — Attention Deficit Hyperactivity Disorder Assessment and Treatment

CARELON-site-of-care-for-advanced-imaging-2024-11-17 — Site of Care for Advanced Imaging

CARELON-vascular-imaging-2024-10-20 — Vascular Imaging

UHC-POL-mri-ct-scan-site-of-service — Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scan – Site of Service

UMR-POL-UMR-mri-ct-scan-site-of-service — Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scan – Site of Service

A57215 — Billing and Coding: MRI and CT Scans of the Head and Neck

EVICORE-HEAD-IMAGING-GUIDELINES — Head Imaging Guidelines

A57807 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)

L35175 — MRI and CT Scans of the Head and Neck

CARELON-oncologic-imaging-2023-04-09 — Oncologic Imaging

70460