Preface to the Imaging Guidelines

This policy covers eviCore’s evidence-based imaging guidelines for advanced diagnostic imaging and related procedures (eg, NM, US, CT, MRI, PET), radiation oncology, sleep studies, gastrointestinal endoscopy, and cardiac and spine interventions. It applies to patients with common symptoms/symptom complexes across age groups (pediatrics <18 follow Pediatric Imaging Guidelines; adults ≥18 follow General Imaging Guidelines) and addresses clinical-trial imaging consistent with CMS CED-approved studies, noting CMS and health plan coverage take precedence for Medicare/Medicare Advantage enrollees. Major requirements/limitations include documentation of recent history, physical exam, labs and prior imaging to establish medical necessity (eg, x‑rays for spine/MSK), consideration of specialist evaluation or other meaningful clinical contact, and potential exclusion or review for atypical presentations, investigational procedures, or items outside payer policies.

"Procedural guidance may be limited or not feasible if obscured by dense bony structures (implicit limitation related to the 'when not obscured' qualifier)."