Does 74263 require prior authorization?

No, 74263 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 74263?

Medicare facility rate: $8.59. Non-facility rate: $8.59. Work RVU: 2.22.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

2.22

Facility

$8.59

Non-Facility

$8.59

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested.
Documentation supporting participation in a clinical trial and that the trial requires a specific imaging protocol or equipment not available in a freestanding facility
Documentation of scheduling showing the MRI/CT is within 24 hours of a hospital specialist appointment at the same hospital-based facility
Documentation of a known allergy to the contrast agent intended for use

A magnetic resonance imaging (MRI) or computed tomography (CT) imaging procedure in the hospital outpatient department is considered medically necessary for individuals who meet any of the following criteria:
Are participating in a clinical trial that requires a specific imaging protocol or equipment not available in a freestanding facility
Are scheduled for the MRI/CT imaging procedure within 24 hours of a hospital specialist appointment at the same hospital-based facility where the procedure is requested
Have a known allergy to a contrast agent used for the procedure
Have a known chronic disease undergoing active treatment, when direct comparison to prior studies requires the same imaging protocol or equipment obtained at the same hospital-based facility where the procedure is requested
Have a systemic cancer on active treatment, when restaging studies require the same imaging protocol or equipment used for prior studies obtained at the same hospital-based facility where the procedure is requested

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

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