78805
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Documentation Required
- Plain X-ray imaging and results (many indications specify plain X-ray as initial study and require plain X-ray to be negative/equivocal/nondiagnostic before advanced imaging).
- Evidence of conservative treatment when the 'Conservative Treatment' column lists 'Yes' (e.g., documentation of trial and duration of conservative therapy).
- For Plantar Fasciitis: provider-directed conservative treatment must be for 6 months or more prior to MRI for preoperative planning.
- Initial face-to-face clinical evaluation must be documented and performed within 60 days prior to advanced imaging; initial evaluation must include relevant history, physical examination, appropriate laboratory studies, and non-advanced imaging modalities.
Key Coverage Criteria
- MS-27: Foot — Suspected Plantar Fascia Rupture or Tear: > MRI foot without contrast (CPT ® 73718)
- MS-24: Hip — Insufficiency Fracture: > MRI hip without contrast (CPT ® 73721) or CT hip without contrast (CPT ® 73700)
- MS-25: Knee — Ligament Tear: > MRI knee without contrast (CPT ® 73721)
- MS-27: Foot — Plantar Fasciitis: > MRI foot without contrast (CPT ® 73718) for preoperative planning (Provider-directed conservative treatment must be for 6 months or more)
- General: Advanced diagnostic imaging (MRI or CT) considered when initial face-to-face clinical evaluation performed and clinical re-evaluation after trial of failed conservative treatment documents need for further imaging.
- 3-D rendering: Indicated for preoperative planning when conventional imaging is insufficient for complex fractures/dislocations (comminuted or displaced) of any joint, spine fractures, pelvic/acetabulum fractures, and intra-articular fractures.
2 Active Policies
EVICORE-CARDIOVASCULAR_RADIOLOGY-B4503FFE — Musculoskeletal (MSK) Imaging Guidelines
EVICORE-CARDIOVASCULAR_RADIOLOGY-609F6708 — Musculoskeletal MSK Imaging Guidelines
Related Codes
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