Does 70540 require prior authorization?

Yes, 70540 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for 70540?

Medicare facility rate: $7.73. Non-facility rate: $7.73. Work RVU: 1.32.

Verity

`70540`

HCPCS/CPT

Prior Authorization

Prior Auth Required

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

Medicare Pricing

Work RVU

1.32

Facility

$7.73

Non-Facility

$7.73

Documentation Required

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.
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.

Key Coverage Criteria

G71.21 | Nemaline myopathy
G83.0 | Diplegia of upper limbs
H44.19 | Other endophthalmitis
H44.532 | Leucocoria, left eye
H44.533 | Leucocoria, bilateral
H53.11 | Day blindness

20 Active Policies

L33693 — Peripheral Venous Ultrasound

J09

L35007 — Vestibular and Audiologic Function Studies

J12

L35434 — Oximetry Services

J12

L35451 — Peripheral Venous Ultrasound

J12

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

Have a follow-up question?

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

This information must be available to Medicare upon request.

Diagnoses used must be supported by appropriate documentation of medical necessity in the medical record.

L37371 — Electroretinography (ERG)

J12

CARELON-head-and-neck-imaging-2023-04-09 — Head and Neck Imaging

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

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

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

AETNA-CPB-0390 — Smell and Taste Disorders: Diagnosis

EVICORE-PEDIATRIC-NECK-IMAGING-GUIDELINES — Pediatric Neck Imaging Guidelines

EVICORE-PEDIATRIC-PND-IMAGING-GUIDELINES — Pediatric Peripheral Nerve Disorders (PND) Imaging Guidelines

EVICORE-PEDIATRIC-PNND-IMAGING-GUIDELINES — Pediatric Peripheral Nerve and Neuromuscular Disorders (PNND) Imaging Guidelines

EVICORE-CARDIOVASCULAR_RADIOLOGY-1E474864 — Pediatric Peripheral Nerve Disorders PND Imaging Guidelines

EVICORE-HEAD-IMAGING-GUIDELINES — Head Imaging Guidelines

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

70540