S8042, Magnetic resonance imaging (mri), low-field
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Policy indicates CPT and HCPCS codes are covered "if selection criteria are met" (selection criteria are required but not detailed in this document).
- No explicit documentation checklist (e.g., required clinical notes, prior tests, or imaging results) is specified in the text of this CPB.
Key Coverage Criteria
- Aetna considers magnetic resonance imaging (MRI) medically necessary for appropriate indications without regard to the field strength or configuration of the MRI unit.
- Aetna considers intermediate and low field strength MRI units to be an acceptable alternative to standard full strength MRI units.
- Aetna considers "open" MRI units of any configuration, including MRI units that allow imaging when standing (Stand-Up MRI) or when sitting, to be an acceptable alternative to standard "closed" MRI units.
- CPT codes listed in the policy (e.g., 70551-70553, 70554-70555, 72141-72142,72156, 72195-72197, 73218-73223, 73718-73723, 74181-74183) are covered if selection criteria are met.
- HCPCS code S8042 (Magnetic resonance imaging (MRI), low-field) is covered if selection criteria are met.
- Standing/sitting/open MRI may be used as an alternative to closed MRI for patients who cannot tolerate closed MRI (e.g., claustrophobia) (policy notes standing/sitting MRI as an alternative).
6 Active Policies
AETNA-CPB-0093, Open Air, Low Field Strength, and Positional Magnetic Resonance Imaging (MRI) Units
EVICORE-HPLAN-AETNA-5BB4F6E94100, Aetna Cardiology and Radiology Code List - Effective 01/01/2026
EVICORE-HPLAN-CIGNA_MEDICARE-4510B5F98EEE, 1199SEIU Radiology and Cardiology PA Code List - Effective 01/01/2026
EVICORE-HPLAN-EMBLEM_GHI-47D7797307C9, GHI/Emblem Non-City of New York & Medicare Radiology and Cardiology Code List - Effective 01/01/2026
Related Codes
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