72126
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
1.19
Facility
$11.03
Non-Facility
$11.03
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.
- Medical records must include history and physical notes, laboratory results, and documentation of signs and symptoms that warrant the head/neck diagnostic imaging.
- Accurate HCPCS/CPT coding must be submitted to differentiate CT and MRI scans from other radiology services and to support coverage determinations.
- Documentation and supporting information must be available to Medicare upon request.
Key Coverage Criteria
- Multiple imaging studies in oncology are covered only when reasonable and necessary as defined by Local Coverage Determination L35391.
- CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
- Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.
- G71.21 | Nemaline myopathy
- G83.0 | Diplegia of upper limbs
- H44.19 | Other endophthalmitis
20 Active Policies
L33693 — Peripheral Venous Ultrasound
J09
L37371 — Electroretinography (ERG)
J12
L35391 — Multiple Imaging in Oncology
J12
A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)
J12
L35007 — Vestibular and Audiologic Function Studies
Related Codes
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