76497
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- 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
Key Coverage Criteria
- 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
7 Active Policies
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
UMR-POL-UMR-virtual-upper-gastrointestinal-endoscopy — Virtual Upper Gastrointestinal Endoscopy
EVICORE-CHEST-IMAGING-GUIDELINES — Chest Imaging Guidelines
Related Codes
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