78807
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Documentation Required
- Consultation with the referring physician, specialist and/or individual's Primary Care Physician (PCP) may provide additional insight.
- The initial face-to-face clinical evaluation should include a relevant history and physical examination, appropriate laboratory studies, and non-advanced imaging modalities.
- Documentation that an initial face-to-face clinical evaluation was performed (must be face-to-face; other contacts are not acceptable as the initial evaluation).
- Documentation that a clinical re-evaluation occurred after a trial of failed conservative treatment (re-evaluation may be face-to-face or other meaningful contact such as email, web or telephone communications).
Key Coverage Criteria
- Infection / Osteomyelitis
- This tool addresses common symptoms and symptom complexes.
- General musculoskeletal imaging (guidance on use of imaging for musculoskeletal conditions)
- Avascular Necrosis (AVN) / Osteonecrosis
- Foreign body (evaluation and localization)
- Ganglion cysts
1 Active Policy
EVICORE-CARDIOVASCULAR_RADIOLOGY-609F6708 — Musculoskeletal MSK Imaging Guidelines
Related Codes
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