EmblemHealth Provider Manual

Chapter - Radiology Program

EmblemHealth Provider Manual

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Call 1-866-417-2345 for GHI HMO, HIP, EmblemHealth CompreHealth. RADIOLOGY PROGRAM. Back to Table of Contents. EmblemHealth Provider Manual. PDF ...

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RADIOLOGY PROGRAM

TABLE OF CONTENTS .O. V. .E. R. .V. I.E. W. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. .7.6. . .

.A.s.s.e. s. s. m. . e. .n.t. a. n. .d. .C. e. .rt. i.f.ic. a. .ti.o. n. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. 7. .6. . . . .

.F.i.lm. . .R.e. v. .ie. w. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. 7. .6. . . . .

.M. .E.M. .B. .E.R. .S. E. .X.E. M. . .P.T. .F.R. .O. M. . .T. H. . E. .E. M. . .B.L. E. .M. .H. .E.A. .L.T.H. . R. .A. D. .I.O. .L.O. .G. .Y. P. .R. O. .G. .R. A. .M. . . . . . . . . . . . . . . . . 4. .7.6. . .

.P.R. I.O. .R. .A. .P.P. R. .O. .V. A. .L. P. .R. O. . C. .E. D. .U. .R. E. .S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. .7.7. . .

.S.e.r.v. i.c.e.s. .R. e. .q.u.i.r.in. .g. .P.r.i.o.r. A. .p. p. .r.o.v.a. l. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. 7. .7. . . . .

.W. .h.o. .R. .e.q.u. e. .s.t.s.P. .r.io. .r.A. .p.p. r. o. .v.a.l. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. 7. .7. . . . .

.H. o. .w. .T. o. .O. .b. t. a. i.n. .P. r. i.o. r. .A. p. .p.r.o. v. a. .l . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. 7. .8. . . . .

.E.x.p. e. .d.it. e. .d. A. .p. p. .ro. .v.a.l. R. .e.q. u. .e.s.t.s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. 7. .8. . . . .

.U. r.g. e. .n.t.R. .e.q.u. e. .s.ts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. 7. .9. . . . .

.N. o. .n.-.U. r. g. .e.n.t. R. .e.q. u. .e.s.t.s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. 7. .9. . . . .

.M. .o.d. i.f.y.i.n.g. .a. P. .r.io. .r.A. .p.p. r. o. .v.a.l. R. .e.q. u. .e.s.t. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. 7. .9. . . . .

.V.e. r. i.f.y.in. .g. .th. .e. P. .r.io. .r. A. .p.p. r. o. .v.a.l. S. .ta. .tu. .s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. 7. .9. . . . .

.D. e. .te. .r.m. .in. a. .ti.o. n. . D. .i.s.a.g.r.e. e. .m. e. .n.t. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. 8. .0. . . . .

.R.a. d. .io. l.o. g. .y. P. .r.o.g. r.a. m. . .P. r. i.o.r. .A.p. p. .r.o.v. a. l. C. .o. d. .e. .L.is. t. .F. o. .r.H. .I.P.,.E. m. . b. .le. .m. H. . e. .a.lt.h. .C. .o.m. .p. r.e. H. . e. .a.lt.h. .E. P. .O. . . . . . . . .

and EmblemHealth Medicare HMO

480

.R.a. d. .io. l.o. g. .y. P. .r.o.g. r. a. m. . .P. r. i.o. r. .A. p. .p.r.o.v. a. l. .C. o. .d.e. .L.i.s.t.F. o. .r. E. .m. .b.le. .m. .H. e. .a.l.th. . E. .P.O. ./.P. P. .O. .a. n. .d. . . . . . . . . . . . . . . . . . .

EmblemHealth Medicare PPO

495

.D. e. .le. t. e. .d. E. .m. .b.l.e.m. .H. .e.a.l.th. . R. .a.d. i.o. l.o.g. y. .P. r. o. .g.r.a.m. . .C. o. .d.e.s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. 9. .6. . . . .

.R.a. d. .io. l.o. g. .y. P. .r.o.g.r.a. m. . .P.r.i.o.r. A. .p. p. .r.o.v.a. l. C. .o. d. .e. L. .is. t. .F.o. r. .G. .H. I. .H. M. . .O. .-. R. .E. T. .IR. .E. D. . . . . . . . . . . . . . . . . . . . .4. 9. .6. . . . .

.F.o. r.m. .a. l. D. .i.s.p.u. t. e. .R. .e.s.o. l.u.t.i.o.n. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. 1. .1. . . . .

.G. H. .I. H. .M. .O. .,.H. .I.P. A. .N. .D. .V. .Y.T. R. .A. .R. A. .D. .IO. . L. O. . G. .Y. .S. C. .H. .E.D. .U. .L.I.N. G. . .P.R. .O. C. .E. .D. U. .R. .E. . . . . . . . . . . . . . . . . . . . . 5. .1.1. . .

.P.l.a.n. .P.a. r. t. i.c.i.p.a.t.i.o.n. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. 1. .1. . . . .

.S.c.h. e. d. .u.l.in. .g. P. .r.o.c. e. d. .u.r.e. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. 1. .1. . . . .

.V.Y. T. .R. A. . P. .L.A. N. . S. .R. A. .D. .I.O. L. .O. .G. Y. .P. .R.O. .G. .R. A. .M. . F. .O. .R. .D. A. .T. E. .S. O. . F. .S. E. .R. V. .I.C. E. .P. R. .I.O. .R. .T.O. . J. A. .N. .U. A. .R. Y. . 1. ., . . . . . . .

2016

511

.O. v. .e.r.v.i.e.w. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. 1. .2. . . . .

.D. e. .s.ig. n. .a.t.e.d. .R. a. d. .io. .lo. .g.y. C. .e. n. .te. .r.s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. 1. .2. . . . .

.G. u. .a.r.a.n.t.e. e. .W. . a. .iv. e. r. .A. .g.r.e.e.m. .e. n. .t.f.o.r. R. .a.d. i.o. l.o. g. .y.G. .r.o. u. .p.s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. 1. .2. . . . .

.C.h. a. .n.g.i.n.g. .D. .e.s.ig. .n.a.t.e. d. .R. .a.d.i.o.l.o.g.y. .G. .r.o.u.p. s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. 1. .2. . . . .

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RADIOLOGY PROGRAM
.Q. u. .a.li.t.y. .Is. s. u. .e.s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. 1. .2. . . . . .C.o. p. .ie. .s.o. f. .X.-.R. a. .y.s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. 1. .3. . . . . .R.a. d. .ia. t.i.o.n. .T. h. .e.r.a.p. y. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. 1. .3. . . . . .D. E. .X. A. . S. .c.a.n.s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. 1. .3. . . . .
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RADIOLOGY PROGRAM
This chapter contains information about our diagnostic imaging management program for outpatient radiology services, including prior approval and radiology scheduling procedures, for all members.
OVERVIEW
The EmblemHealth Radiology Program, developed with eviCore, provides diagnostic imaging management for outpatient radiology services. Services targeted for utilization management depend on the EmblemHealth benefit plan. eviCore also conducts clinical standard and expedited appeals (excluding members with Medicare plans).
Assessment and Certification
All radiologists and non-radiologists participating in our radiology programs undergo a comprehensive site visit, as well as evaluation of equipment, technical staff credentials, continuing education, equipment maintenance records and operating policies. They may also be required to complete the appropriate assessment and certification forms. This process is based on nationally recognized requirements of the American Institute of Ultrasound in Medicine, the American College of Radiology and The Joint Commission.
Film Review
Practitioners' film images must comply with the high standards of the American College of Radiology. At least once every two years, practitioners may be required to provide EmblemHealth and/or eviCore with requested materials for an independent review and professional interpretation of films. For this review, we randomly select a sampling of patient studies. At least two board-certified radiologists then assess these studies for technical quality and diagnostic interpretation.
MEMBERS EXEMPT FROM THE EMBLEMHEALTH RADIOLOGY PROGRAM
As of January 1, 2018, ACPNY members are no longer exempt from the EmblemHealth Radiology Program. eviCore now provides utilization management (prior approval) for ACPNY radiology services. The referring provider will need to contact eviCore to get the prior approval.
As of August 20, 2018, members assigned to a PCP affiliated with St. Barnabas Hospital are no longer exempt from the EmblemHealth Radiology Program. eviCore now provides utilization management (prior approval) for these members. The referring provider will need to contact eviCore to get the prior approval.
While most of our members' covered radiology services are managed by eviCore, the following exceptions apply:
Members whose care is managed by Montefiore Medical Group (CMO) or HealthCare
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RADIOLOGY PROGRAM
Partners (HCP) must contact the applicable organization for prior approval. Check the member's ID card or eligibility information on emblemhealth.com to determine whether HIP, CMO, or HCP is the managing entity responsible for managing a member's care; if HIP is the managing entity, then eviCore is the organization to contact for prior approval. Effective January 1, 2018, this exemption no longer applies for:
Members who selected a PCP assigned to ACPNY. The prior approval request must be entered on emblemhealth.com. Effective August 20, 2018, this exemption no longer applies for: Members who selected a physician affiliated with the St. Barnabas Hospital System. The prior approval request must be entered on emblemhealth.com.
PRIOR APPROVAL PROCEDURES
Services Requiring Prior Approval
Services Requiring Prior Approval Please refer to the charts later in this chapter for a list of services (and CPT-4 codes) that require prior approval:
HIP, EmblemHealth CompreHealth EPO (Retired August 1, 2018), EmblemHealth Medicare HMO and Vytra EmblemHealth EPO/PPO and EmblemHealth Medicare PPO Each procedure requires a separate prior approval. Prior approvals are specific to the CPT-4 code and site location. They are valid for 45 days from the approval date.
Prior approval is required for services performed in the following places of service:
Outpatient hospital facilities Freestanding radiology facilities Radiology office-based settings Non-radiology office-based settings
Neither prior approval nor referral is required for:
Inpatient hospitalization Services rendered in hospital emergency departments Services provided when one of EmblemHealth's companies is the secondary insurer Pulmonary perfusion imaging
The following services do not require prior approval but may require a referral from the member's PCP:
Basic X-rays Mammograms Bone density tests
Who Requests Prior Approval
It is the responsibility of the referring practitioner (i.e., the practitioner developing the patient's
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RADIOLOGY PROGRAM
treatment plan) to obtain the prior approval before services are rendered. If the referring and rendering practitioners are different, the rendering practitioner is encouraged to confirm that a prior approval is on file before services are rendered. The rendering practitioner is ultimately responsible for ensuring that all applicable radiology imaging procedures at the applicable service location have received all necessary prior approvals.
How To Obtain Prior Approval
Before requesting prior approval from please have the patient's medical records on hand and complete the request form specific to the procedure being requested. These request forms are available at the links below and at evicore.com. They list all clinical questions the practitioner must answer during the initial prior approval review.
For MRI, General Use Clinical Certification Request Form For CT Scan, CT/CTA Clinical Certification Request Form For PET Scan, PET Scan Clinical Certification Request Form For MR/MRAs, MR/MRA Clinical Certification Request Form
Once the form is complete, submit prior approval requests in one of three ways:
Online: Visit www.evicore.com. To submit online requests, the ordering physician must be a registered user. To register for a user ID and password, visit www.evicore.com and click the "Register" button.
By phone: Call 1-866-417-2345 for GHI HMO, HIP and EmblemHealth CompreHealth EPO (Retired August 1, 2018) and Vytra plan members. Call 1-800-835-7064 for EmblemHealth EPO/PPO and EmblemHealth Medicare PPO plan members. Representatives are available Monday through Friday, from 7 am to 7 pm, EST. The program is closed New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving and Christmas Day.
By fax: Fax the completed request form to 1-800-540-2406.
Please have the following information available when you call:
The completed form, as noted above The patient's full name, member ID number and insurance information The exam(s) requested for the patient The working diagnosis or rule-out The signs and symptoms that call for the exam, as well as their duration Any previous imaging studies performed, corresponding results or pertinent lab results History of prior treatment methods, drugs, surgery or other therapies, as well as duration of prior treatment Any other information indicating the need for the exam
Expedited Approval Requests
evicore.com cannot be used for expedited approval requests. These requests must be processed through the call center. Call 1-866-417-2345 for GHI HMO, HIP, EmblemHealth CompreHealth
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RADIOLOGY PROGRAM
EPO (Retired August 1, 2018), EmblemHealth Medicare HMO, and Vytra plan members. Call 1-800-835-7064 for EmblemHealth EPO/PPO and EmblemHealth Medicare PPO plan members. Utilization review staff is available 24 hours a day, 7 days a week. The program is closed New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving and Christmas Day.
Urgent Requests
If the treatment is medically urgent and must be performed outside business hours, the physician may deliver treatment and must submit the prior approval request (with supporting clinical documentation) within two (2) business days. Urgent requests are reviewed against medical necessity criteria, and an approval is issued as long as the request meets these medical necessity criteria. Urgent requests will be completed within 24 hours of receiving the request. evicore.com cannot be used for urgent approval requests. These requests must be processed through the call center. Call 1-866-417-2345 for GHI HMO, HIP, EmblemHealth CompreHealth EPO (Retired August 1, 2018), EmblemHealth Medicare HMO and Vytra plan members. Call 1-800-835-7064 for EmblemHealth EPO/PPO and EmblemHealth Medicare PPO plan members. Utilization review staff is available 24 hours a day, 7 days a week. The program is closed New Year's Day, Memorial Day, Independence Day, Labor Day.
Non-Urgent Requests
Non-urgent requests will be completed within three (3) business days of receiving all necessary information, or within the time frames otherwise required by the member's benefit plan (see Standard Pre-Service Review in the Care Management chapter). In most cases, the staff will review and determine prior approvals during the initial phone call, as long as all the required information is provided. The review and determination processes may, however, take longer if member or practitioner eligibility verification is required, or if the request requires additional clinical review (see Standard Pre-Service Review in the Care Management chapter).
A physician with office hours later than the call center's may initiate a case through evicore.com which will be processed on the next business day.
Modifying a Prior Approval Request
If it becomes necessary to change or update the procedure after prior approval is obtained, the program must be contacted no later than 48 hours after the modified procedure is performed. If the prior approval for the treatment plan is not updated and the claim does not match the authorized procedures, the claim will be denied for payment, with no liability to the member.
Verifying the Prior Approval Status
To verify the status of a prior approval request, either call the applicable number below or visit the Authorization Lookup section at evicore.com.
Call 1-866-417-2345 for GHI HMO, HIP, EmblemHealth CompreHealth EPO (Retired August 1, 2018), EmblemHealth Medicare HMO and Vytra plan members. Call 1-800-835-7064 for EmblemHealth EPO/PPO and EmblemHealth Medicare PPO plan members.
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RADIOLOGY PROGRAM
Note: While the program may approve or deny a prior approval request, this determination is based on medical necessity only. Always verify member eligibility, benefits and copayments with EmblemHealth directly at www.emblemhealth.com.

Determination Disagreement
If the referring physician disagrees with the determination, contact the Peer-to-Peer Consultation Line to discuss the case with a medical director. Call 1-866-417-2345 for GHI HMO, HIP, EmblemHealth CompreHealth EPO (Retired August 1, 2018), EmblemHealth Medicare HMO and Vytra plans. Call 1-800-835-7064 for EmblemHealth EPO/PPO and EmblemHealth Medicare PPO plan members.
Claims will be denied and the member will not be liable for payment if:
A prior approval was required but not obtained for the CPT-4 code performed. Procedures are performed at a service location other than the address on the prior approval issued.

Radiology Program Prior Approval Code List For HIP, EmblemHealth CompreHealth EPO and EmblemHealth Medicare HMO
RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR HIP, EMBLEMHEALTH COMPREHEALTH EPO (RETIRED AUGUST 1, 2018), EMBLEMHEALTH
MEDICARE HMO AND VYTRA

Radiology CPT Code
70336 70450 70460 70470 70480 70481 70482 70486 70487
70488

Procedure Description
MAGNETIC RESONANCE IMAGING TMJ
COMPUTED TOMOGRAPHY HEAD/BRAIN WITHOUT CONTRAST
COMPUTED TOMOGRAPHY HEAD/BRAIN WITH CONTRAST
COMPUTED TOMOGRAPHY HEAD/BRAIN WITHOUT AND WITH CONTRAST
COMPUTED TOMOGRAPHY ORBIT WITHOUT CONTRAST
COMPUTED TOMOGRAPHY ORBIT WITH CONTRAST
COMPUTED TOMOGRAPHY ORBIT WITHOUT AND WITH CONTRAST
COMPUTED TOMOGRAPHY MAXILLOFACIAL WITHOUT CONTRAST
COMPUTED TOMOGRAPHY MAXILLOFACIAL WITH CONTRAST
COMPUTED TOMOGRAPHY MAXILLOFACIAL WITHOUT AND WITH CONTRAST

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RADIOLOGY PROGRAM
RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR HIP, EMBLEMHEALTH COMPREHEALTH EPO (RETIRED AUGUST 1, 2018), EMBLEMHEALTH
MEDICARE HMO AND VYTRA

Radiology CPT Code
70490 70491 70492 70496 70498 70540 70542 70543 70544 70545 70546 70547 70548 70549 70551 70552 70553 70554

Procedure Description
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT CONTRAST
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITH CONTRAST
COMPUTED TOMOGRAPHY SOFT TISSUE NECK WITHOUT AND WITH CONTRAST
COMPUTED TOMOGRAPHIC ANGIOGRAPHY HEAD
COMPUTED TOMOGRAPHIC ANGIOGRAPHY NECK
MAGNETIC RESONANCE IMAGING FACE, ORBIT, NECK WITHOUT CONTRAST
MAGNETIC RESONANCE IMAGING FACE, ORBIT, NECK WITH CONTRAST
MAGNETIC RESONANCE IMAGING FACE, ORBIT, NECK WITH AND WITHOUT CONTRAST
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITHOUT CONTRAST
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITH CONTRAST
MAGNETIC RESONANCE ANGIOGRAPHY HEAD WITH AND WITHOUT CONTRAST
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITHOUT CONTRAST
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITH CONTRAST
MAGNETIC RESONANCE ANGIOGRAPHY NECK WITH AND WITHOUT CONTRAST
MAGNETIC RESONANCE IMAGING HEAD WITHOUT CONTRAST
MAGNETIC RESONANCE IMAGING HEAD WITH CONTRAST
MAGNETIC RESONANCE IMAGING HEAD WITH AND WITHOUT CONTRAST
MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MAGNETIC RESONANCE IMAGING; INCLUDING TEST SELECTION

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RADIOLOGY PROGRAM
RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR HIP, EMBLEMHEALTH COMPREHEALTH EPO (RETIRED AUGUST 1, 2018), EMBLEMHEALTH
MEDICARE HMO AND VYTRA

Radiology CPT Code
70555
71250 71260 71270 71275 71550 71551 71552 71555 72125 72126 72127 72128 72129 72130

Procedure Description
AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION
MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MAGNETIC RESONANCE IMAGING; REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION OF ENTIRE NEUROFUNCTIONAL TESTING
COMPUTED TOMOGRAPHY THORAX WITHOUT CONTRAST
COMPUTED TOMOGRAPHY THORAX WITH CONTRAST
COMPUTED TOMOGRAPHY THORAX WITHOUT AND WITH CONTRAST
COMPUTED TOMOGRAPHIC ANGIOGRAPHY CHEST, NON-CORONARY
MAGNETIC RESONANCE IMAGING CHEST WITHOUT CONTRAST
MAGNETIC RESONANCE IMAGING CHEST WITH CONTRAST
MAGNETIC RESONANCE IMAGING CHEST WITH AND WITHOUT CONTRAST
MAGNETIC RESONANCE ANGIOGRAPHY CHEST (EXC MYOCARDIUM) WITH OR WITHOUT CONTRAST
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT CONTRAST
COMPUTED TOMOGRAPHY CERVICAL SPINE WITH CONTRAST
COMPUTED TOMOGRAPHY CERVICAL SPINE WITHOUT AND WITH CONTRAST
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT CONTRAST
COMPUTED TOMOGRAPHY THORACIC SPINE WITH CONTRAST
COMPUTED TOMOGRAPHY THORACIC SPINE WITHOUT AND WITH CONTRAST

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RADIOLOGY PROGRAM
RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR HIP, EMBLEMHEALTH COMPREHEALTH EPO (RETIRED AUGUST 1, 2018), EMBLEMHEALTH
MEDICARE HMO AND VYTRA

Radiology CPT Code
72131 72132 72133 72141 72142 72146 72147 72148 72149 72156 72157 72158 72159 72191 72192 72193 72194 72195

Procedure Description
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT CONTRAST
COMPUTED TOMOGRAPHY LUMBAR SPINE WITH CONTRAST
COMPUTED TOMOGRAPHY LUMBAR SPINE WITHOUT AND WITH CONTRAST
MAGNETIC RESONANCE IMAGING CERVICAL SPINE WITHOUT CONTRAST
MAGNETIC RESONANCE IMAGING CERVICAL SPINE WITH CONTRAST
MAGNETIC RESONANCE IMAGING THORACIC SPINE WITHOUT CONTRAST
MAGNETIC RESONANCE IMAGING THORACIC SPINE WITH CONTRAST
MAGNETIC RESONANCE IMAGING LUMBAR SPINE WITHOUT CONTRAST
MAGNETIC RESONANCE IMAGING LUMBAR SPINE WITH CONTRAST
MAGNETIC RESONANCE IMAGING C SPINE WITH AND WITHOUT CONTRAST
MAGNETIC RESONANCE IMAGING T SPINE WITH AND WITHOUT CONTRAST
MAGNETIC RESONANCE IMAGING L SPINE WITH AND WITHOUT CONTRAST
MAGNETIC RESONANCE ANGIOGRAPHY SPINAL CANAL WITH OR WITHOUT CONTRAST
COMPUTED TOMOGRAPHIC ANGIOGRAPHY PELVIS
COMPUTED TOMOGRAPHY PELVIS WITHOUT CONTRAST
COMPUTED TOMOGRAPHY PELVIS WITH CONTRAST
COMPUTED TOMOGRAPHY PELVIS WITHOUT AND WITH CONTRAST
MAGNETIC RESONANCE IMAGING PELVIS WITHOUT CONTRAST

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RADIOLOGY PROGRAM
RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR HIP, EMBLEMHEALTH COMPREHEALTH EPO (RETIRED AUGUST 1, 2018), EMBLEMHEALTH
MEDICARE HMO AND VYTRA

Radiology CPT Code
72196 72197 72198 73200 73201 73202 73206 73218 73219 73220 73221 73222 73223
73225 73700 73701 73702

Procedure Description
MAGNETIC RESONANCE IMAGING PELVIS WITH CONTRAST
MAGNETIC RESONANCE IMAGING PELVIS WITH AND WITHOUT CONTRAST
MAGNETIC RESONANCE ANGIOGRAPHY PELVIS WITH OR WITHOUT CONTRAST
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT CONTRAST
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITH CONTRAST
COMPUTED TOMOGRAPHY UPPER EXTREMITY WITHOUT AND WITH CONTRAST
COMPUTED TOMOGRAPHIC ANGIOGRAPHY UPPER EXTREMITY
MAGNETIC RESONANCE IMAGING UPPER EXTREMITY WITHOUT CONTRAST
MAGNETIC RESONANCE IMAGING UPPER EXTREMITY WITH CONTRAST
MAGNETIC RESONANCE IMAGING UPPER EXTREMITY WITH AND WITHOUT CONTRAST
MAGNETIC RESONANCE IMAGING UPPER EXTREMITY JOINT WITHOUT CONTRAST
MAGNETIC RESONANCE IMAGING UPPER EXTREMITY JOINT WITH CONTRAST
MAGNETIC RESONANCE IMAGING UPPER EXTREMITY JOINT WITH AND WITHOUT CONTRAST
MAGNETIC RESONANCE ANGIOGRAPHY UPPER EXTREMITY WITH OR WITHOUT CONTRAST
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITH CONTRAST
COMPUTED TOMOGRAPHY LOWER EXTREMITY WITHOUT AND WITH

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RADIOLOGY PROGRAM
RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR HIP, EMBLEMHEALTH COMPREHEALTH EPO (RETIRED AUGUST 1, 2018), EMBLEMHEALTH
MEDICARE HMO AND VYTRA

Radiology CPT Code
73706 73718 73719 73720 73721 73722 73723 73725 74150 74160 74170
74174
74175 74176 74177

Procedure Description
CONTRAST
COMPUTED TOMOGRAPHIC ANGIOGRAPHY LOWER EXTREMITY
MAGNETIC RESONANCE IMAGING LOWER EXTREMITY WITHOUT CONTRAST
MAGNETIC RESONANCE IMAGING LOWER EXTREMITY WITH CONTRAST
MAGNETIC RESONANCE IMAGING LOWER EXTREMITY WITH AND WITHOUT CONTRAST
MAGNETIC RESONANCE IMAGING LOWER EXTREMITY JOINT WITHOUT CONTRAST
MAGNETIC RESONANCE IMAGING LOWER EXTREMITY JOINT WITH CONTRAST
MAGNETIC RESONANCE IMAGING LOWER EXTREMITY JOINT WITH AND WITHOUT CONTRAST
MAGNETIC RESONANCE ANGIOGRAPHY LOWER EXTREMITY WITH OR WITHOUT CONTRAST
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT CONTRAST
COMPUTED TOMOGRAPHY ABDOMEN WITH CONTRAST
COMPUTED TOMOGRAPHY ABDOMEN WITHOUT AND WITH CONTRAST
COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMEN AND PELVIS, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMEN
COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL
COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)

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RADIOLOGY PROGRAM
RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR HIP, EMBLEMHEALTH COMPREHEALTH EPO (RETIRED AUGUST 1, 2018), EMBLEMHEALTH
MEDICARE HMO AND VYTRA

Radiology CPT Code
74178 74181 74182 74183 74185 74261 74262 74263 75635 76376
76377

Procedure Description
COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS
MAGNETIC RESONANCE IMAGING ABDOMEN WITHOUT CONTRAST
MAGNETIC RESONANCE IMAGING ABDOMEN WITH CONTRAST
MAGNETIC RESONANCE IMAGING ABDOMEN WITH AND WITHOUT CONTRAST
MAGNETIC RESONANCE ANGIOGRAPHY ABDOMEN WITH OR WITHOUT CONTRAST
COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITHOUT CONTRAST MATERIAL
COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITH CONTRAST MATERIAL(S) INCLUDING NON-CONTRAST IMAGES, IF PERFORMED
COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, SCREENING, INCLUDING IMAGE POSTPROCESSING
COMPUTED TOMOGRAPHIC ANGIOGRAPHY ABDOMINAL AORTA
3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND OR OTHER TOMOGRAPHIC MODALITY; NOT REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION
3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND OR OTHER TOMOGRAPHIC MODALITY; REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION

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RADIOLOGY PROGRAM
RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR HIP, EMBLEMHEALTH COMPREHEALTH EPO (RETIRED AUGUST 1, 2018), EMBLEMHEALTH
MEDICARE HMO AND VYTRA

Radiology CPT Code
76380 76390 76801 76802 76805 76810
76811
76812
76813 76814

Procedure Description
COMPUTED TOMOGRAPHY LIMITED OR LOCALIZED FOLLOW-UP STUDY
MAGNETIC RESONANCE IMAGING SPECTROSCOPY
ULTRASOUND OBSTETRICAL PELVIS, PREGNANT UTERUS, FIRST TRIMESTER <14 WEEKS SINGLE OR FIRST GESTATION
ULTRASOUND OBSTETRICAL PELVIS, PREGNANT UTERUS, FIRST TRIMESTER <14 WEEKS EACH ADDITIONAL GESTATION
ULTRASOUND OBSTETRICAL PELVIS, PREGNANT UTERUS, B-SCAN (ALLOWED ONCE PER GESTATION)
ULTRASOUND OBSTETRICAL PELVIS COMPLETE, MULTIPLE GESTATION AFTER 1ST TRIMESTER (ALLOWED ONCE FOR EACH ADDITIONAL FETUS PER GESTATION; MUST BE BILLED WITH 76805)
ULTRASOUND PREGNANT UTERUS FETAL AND MATERNAL EVAL PLUS ULTRASOUND FETAL ANATOMIC EVAL TRANSABDOMINAL SINGLE OR FIRST GESTATION (ALLOWED ONCE PER GESTATION; SECOND STUDY ALLOWED IF PERFORMED BY A DIFFERENT PHYSICIAN)
ULTRASOUND PREGNANT UTERUS FETAL AND MATERNAL EVAL PLUS ULTRASOUND FETAL ANATOMIC EVAL TRANSABDOMINAL EACH ADDITIONAL GESTATION (ALLOWED ONCE FOR EACH ADDITIONAL FETUS ULTRASOUND PER GESTATION; MUST BE BILLED WITH 76811; SECOND STUDY ALLOWED IF PERFORMED BY A DIFFERENT PHYSICIAN)
ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY MEASUREMENT, TRANSABDOMINAL OR TRANSVAGINAL APPROACH; SINGLE OR FIRST GESTATION (ALLOWED ONCE PER GESTATION)
ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL

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RADIOLOGY PROGRAM
RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR HIP, EMBLEMHEALTH COMPREHEALTH EPO (RETIRED AUGUST 1, 2018), EMBLEMHEALTH
MEDICARE HMO AND VYTRA

Radiology CPT Code
76815
76816 76817 76818 76819 76820 76821 76825 76826 76827 76828 76975 77021 77022

Procedure Description
TRANSLUCENCY MEASUREMENT, TRANSABDOMINAL OR TRANSVAGINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) (ALLOWED ONCE FOR EACH ADDITIONAL FETUS PER GESTATION)
ULTRASOUND PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (E.G., FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES
ULTRASOUND OBSTETRICAL PELVIS FOLLOW-UP OR REPEAT
ULTRASOUND PREGNANT UTERUS TRANSVAGINAL
FETAL BIOPHYSICAL PROFILE
FETAL BIOPHYSICAL PROFILE WITHOUT STRESS NON STRESS
DOPPLER VELOCIMETRY, FETAL; UMBILICAL ARTERY
DOPPLER VELOCIMETRY, FETAL; MIDDLE CEREBRAL ARTERY
ULTRASOUND OBSTETRICAL ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM
FOLLOW-UP OR REPEAT STUDY
DOPPLER ECHOCARDIOGRAPHY FETAL COMPLETE
FOLLOW-UP OR REPEAT STUDY
ULTRASOUND GASTROINTESTINAL, ENDOSCOPIC
MAGNETIC RESONANCE IMAGING GUIDANCE FOR NEEDLE PLACEMENT
MAGNETIC RESONANCE IMAGING GUIDANCE FOR AND MONITORING OF TISSUE ABLATION

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RADIOLOGY PROGRAM
RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR HIP, EMBLEMHEALTH COMPREHEALTH EPO (RETIRED AUGUST 1, 2018), EMBLEMHEALTH
MEDICARE HMO AND VYTRA

Radiology CPT Code
77058
77059
77084 78000 78001 78003 78006 78007 78010 78011 78015 78016 78018 78020 78070 78075 78102 78103 78104 78185 78195 78201 78202 78205

Procedure Description
MAGNETIC RESONANCE IMAGING BREAST WITH AND/OR WITHOUT CONTRAST; UNILATERAL MAGNETIC RESONANCE IMAGING BREAST BILATERAL MAGNETIC RESONANCE IMAGING BONE MARROW BLOOD SUPPLY THYROID RAI UPTAKE THYROID MULTIPLE UPTAKE THYROID SUPPRESS OR STIMULATION THYROID UPTAKE AND SCAN THYROID IMAGE, MULTIPLE UPTAKES THYROID SCAN ONLY THYROID IMAGING WITH FLOW THYROID MET IMAGING THYROID MET IMAGING WITH ADDITIONAL STUDIES THYROID SCAN WHOLE BODY THYROID CARCINOMA METASTASES UPTAKE PARATHYROID NUCLEAR IMAGING ADRENAL NUCLEAR IMAGING BONE MARROW IMAGING, LIMITED BONE MARROW IMAGING, MULTIPLE BONE MARROW IMAGING, WHOLE BODY SPLEEN IMAGING WITH OR WITHOUT VASCULAR FLOW LYMPH SYSTEM IMAGING LIVER IMAGING LIVER IMAGING WITH FLOW LIVER IMAGING SPECT

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RADIOLOGY PROGRAM
RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR HIP, EMBLEMHEALTH COMPREHEALTH EPO (RETIRED AUGUST 1, 2018), EMBLEMHEALTH
MEDICARE HMO AND VYTRA

Radiology CPT Code
78206
78215 78216 78226 78227 78230 78231 78232 78258 78261 78262 78264 78278 78282 78290 78291 78300 78305 78306
78315
78320 78414 78428
78445
78456
78457

Procedure Description
LIVER IMAGING SPECT WITH VASCULAR FLOW LIVER AND SPLEEN IMAGING LIVER AND SPLEEN IMAGING WITH FLOW LIVER FUNCTION STUDY HIDA SCAN SALIVARY GLAND IMAGING SERIAL SALIVARY GLAND SALIVARY GLAND FUNCTION TEST ESOPHAGUS MOTILITY STUDY GASTRIC MUCOSA IMAGING GASTROESOPHAGEAL REFLUX EXAM GASTRIC EMPTYING STUDY GI BLEEDER SCAN GI PROTEIN LOSS EXAM MECKEL'S DIVERTICULUM IMAGING LEVEEN SHUNT PATENCY EXAM BONE OR JOINT IMAGING LIMITED BONE OR JOINT IMAGING MULTIPLE BONE SCAN WHOLE BODY BONE AND/OR JOINT IMAGING; 3 PHASE STUDY BONE JOINT IMAGING TOMO TEST SPECT NON-IMAGING HEART FUNCTION CARDIAC SHUNT IMAGING RADIONUCLIDE VENOGRAM NON-CARDIAC ACUTE VENOUS THROMBOSIS IMAGING VENOUS THROMBOSIS IMAGING UNILATERAL

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RADIOLOGY PROGRAM
RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR HIP, EMBLEMHEALTH COMPREHEALTH EPO (RETIRED AUGUST 1, 2018), EMBLEMHEALTH
MEDICARE HMO AND VYTRA

Radiology CPT Code
78458 78466 78468 78469 78472 78473 78481 78483 78494 78496
78579 78580 78582
78597
78598
78600 78601 78605 78606 78607
78608

Procedure Description
VENOUS THROMBOSIS IMAGING BILATERAL
MYOCARDIAL INFARCTION SCAN
HEART INFARCT IMAGE EF
HEART INFARCT IMAGE SPECT
GATED HEART, REST OR STRESS
CARDIAC BLOOD POOL MUGA SCAN
HEART FIRST PASS SINGLE
CARDIAC BLOOD POOL IMAGING, MULTIPLE
CARDIAC BLOOD POOL IMAGING, SPECT
CARDIAC BLOOD POOL IMAGING, SINGLE AT REST
PULMONARY VENTILATION IMAGING (E.G., AEROSOL OR GAS)
PULMONARY PERFUSION IMAGING
PULMONARY VENTILATION (E.G., AEROSOL OR GAS) AND PERFUSION IMAGING
QUANTITATIVE DIFFERENTIAL PULMONARY PERFUSION, INCLUDING IMAGING, WHEN PERFORMED
QUANTITATIVE DIFFERENTIAL PULMONARY PERFUSION AND VENTILATION (E.G., AEROSOL OR GAS), INCLUDING IMAGING, WHEN PERFORMED
BRAIN IMAGING LIMITED STATIC
BRAIN LIMITED IMAGING AND FLOW
BRAIN IMAGING COMPLETE
BRAIN IMAGING COMPLETE WITH FLOW
BRAIN IMAGING SPECT
BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC EVALUATION

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RADIOLOGY PROGRAM
RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR HIP, EMBLEMHEALTH COMPREHEALTH EPO (RETIRED AUGUST 1, 2018), EMBLEMHEALTH
MEDICARE HMO AND VYTRA

Radiology CPT Code
78609 78610 78630 78635 78645 78647 78650 78660 78700 78701 78707
78708
78709 78710 78725 78730 78740 78761 78800 78801

Procedure Description
BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION EVALUATION
BRAIN FLOW IMAGING ONLY
CISTERNOGRAM (CEREBROSPINAL FLUID FLOW)
CEREBROSPINAL VENTRICULOGRAPHY
CEREBROSPINAL FLUID FLOW SHUNT EVALUATION
CEREBROSPINAL FLUID SCAN SPECT
CEREBROSPINAL FLUID FLOW LEAKAGE DETECTION AND LOCALIZATION
RADIOPHARMACEUTICAL DACRYOCYSTORGRAPHY
KIDNEY IMAGING MORPHOLOGY
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION STUDY
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW AND FUNCTION, SINGLE WITH PHARM INTERVENTION
KIDNEY IMAGING MORPHOLOGY WITH VASCULAR FLOW, MULTIPLE, WITHOUT AND WITH PHARM INTERVENTION
KIDNEY IMAGING, SPECT
KIDNEY FUNCTION STUDY, NON-IMAGE RADIOISOTROPIC
URINARY BLADDER RESIDUAL STUDY
URETERAL REFLUX STUDY
TESTICULAR IMAGING WITH VASCULAR FLOW
RADIOPHARM LOCALIZATION OF TUMOR, LIMITED AREA
RADIOPHARM LOCALIZATION OF TUMOR, MULTIPLE AREAS

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RADIOLOGY PROGRAM
RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR HIP, EMBLEMHEALTH COMPREHEALTH EPO (RETIRED AUGUST 1, 2018), EMBLEMHEALTH
MEDICARE HMO AND VYTRA

Radiology CPT Code
78802 78803 78804 78805 78806 78807 78811 78812 78813
78814
78815
78816

Procedure Description
RADIOPHARM LOCALIZATION OF TUMOR, WHOLE BODY
RADIOPHARM LOCALIZATION OF TUMOR, SPECT
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF RADIOPHARMACEUTICAL AGENT(S); WHOLE BODY, REQUIRING 2 OR MORE DAYS IMAGING
RADIOPHARM LOCALIZATION OF ABSCESS, LIMITED AREA
RADIOPHARM LOCALIZATION OF ABSCESS, WHOLE BODY
RADIOPHARM LOCALIZATION OF ABSCESS, SPECT
POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; LIMITED AREA (E.G., CHEST, HEAD/NECK)
POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; SKULL BASE TO MID-THIGH
POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; WHOLE BODY
POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; LIMITED AREA (E.G., CHEST, HEAD/NECK)
POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; SKULL BASE TO MID-THIGH
POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; WHOLE BODY

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RADIOLOGY PROGRAM
RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR HIP, EMBLEMHEALTH COMPREHEALTH EPO (RETIRED AUGUST 1, 2018), EMBLEMHEALTH
MEDICARE HMO AND VYTRA

Radiology CPT Code
C8900 C8901 C8902 C8903 C8904 C8905 C8906 C8907 C8908 C8909 C8910 C8911 C8912 C8913 C8914

Procedure Description
MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, ABDOMEN
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, ABDOMEN
MAGNETIC RESONANCE ANGIOGRAPHY WITH AND WITHOUT CONTRAST, ABDOMEN
MAGNETIC RESONANCE IMAGING WITH CONTRAST, BREAST; UNILATERAL
MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST, BREAST; UNILATERAL
MAGNETIC RESONANCE IMAGING WITH AND WITHOUT CONTRAST, BREAST; UNILATERAL
MAGNETIC RESONANCE IMAGING WITH CONTRAST, BREAST; BILATERAL
MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST, BREAST; BILATERAL
MAGNETIC RESONANCE IMAGING WITH AND WITHOUT CONTRAST, BREAST; BILATERAL
MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM)
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, CHEST (EXCLUDING MYOCARDIUM)
MAGNETIC RESONANCE ANGIOGRAPHY WITH AND WITHOUT CONTRAST, CHEST (EXCLUDING MYOCARDIUM)
MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, LOWER EXTREMITY
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, LOWER EXTREMITY
MAGNETIC RESONANCE ANGIOGRAPHY WITH AND WITHOUT CONTRAST, LOWER EXTREMITY

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RADIOLOGY PROGRAM
RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR HIP, EMBLEMHEALTH COMPREHEALTH EPO (RETIRED AUGUST 1, 2018), EMBLEMHEALTH
MEDICARE HMO AND VYTRA

Radiology CPT Code
C8918

Procedure Description
MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, PELVIS

C8919

MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, PELVIS

C8920

MAGNETIC RESONANCE ANGIOGRAPHY WITH AND WITHOUT CONTRAST, PELVIS

C8931

MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, SPINAL CANAL AND CONTENTS

C8932

MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, SPINAL CANAL AND CONTENTS

C8933

MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, SPINAL CANAL AND CONTENTS

C8934

MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, UPPER EXTREMITY

C8935

MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, UPPER EXTREMITY

C8936

MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, UPPER EXTREMITY

Note: This program does not change members' benefits, nor does it change claim submission procedures for providers with a current direct contract with one of EmblemHealth's companies. Radiologists directly contracted with eviCore are now required to submit claims to eviCore.

Radiology Program Prior Approval Code List For EmblemHealth EPO/PPO and EmblemHealth Medicare PPO

RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR GHI EPO/PPO, EMBLEMHEALTH EPO/PPO AND EMBLEMHEALTH MEDICARE PPO EFFECTIVE OCTOBER 1, 2012

Radiology CPT Code

Procedure Description

C8936

MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, UPPER EXTREMITY (crosswalked to 73225)

C8935

MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, UPPER EXTREMITY (crosswalked to 73225)

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RADIOLOGY PROGRAM
Deleted EmblemHealth Radiology Program Codes The following codes may no longer be billed for services rendered in 2011 and 2012. Please reference these codes for older claims.

DELETED EMBLEMHEALTH RADIOLOGY PROGRAM CODES

APPLICABLE TO ALL PLANS IN PROGRAM PROCEDURES THAT REQUIRED PRIOR APPROVAL, CPT-4 LIST

FOR REFERENCE FOR CLAIMS WITH DATES OF SERVICE FROM 1/1/2011 TO 12/31/2011

78596

PLEASE DO NOT USE FOR YOUR CURRENT (2012) CLAIMS BILLING. NUCLEAR MEDICINE

CPT-4 Code

Procedure Description

Note

LUNG DIFFERENTIAL FUNCTION

Code deleted 1/1/12 - use 78598

78220

LIVER FUNCTION STUDY

Code deleted 1/1/12 - use new code 78226

78223

HIDA SCAN

Code deleted 1/1/12 - use new code 78227

78586

PULMONARY VENTILATION Code deleted 1/1/12, use

IMAGING

78579

78587

PULMONARY VENTILATION Code deleted 1/1/12, use

MULTI

78579

78591

VENT IMAGE 1 BREATH, 1 PROJECTION

Code deleted 1/1/12, use 78579

78593

VENT IMAGE 1 PROJECTION, GAS

Code deleted 1/1/12, use 78579

78594

VENT IMAGE MULTI PROJECTION, GAS

Code deleted 1/1/12, use 78579

78584

PULMONARY PERFUSION Code deleted 1/1/12, use WITH VENT SINGLE BREATH 78582

78585

PULMONARY PERFUSION W/ WASHOUT OR W/O SINGLE BREATH

Code deleted 1/1/12, use 78582

78588

PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION IMAGING, AEROSOL, 1 OR MULTIPLE PROJECTIONS

Code deleted 1/1/12, use 78582

Radiology Program Prior Approval Code List For GHI HMO - RETIRED
RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR GHI HMO - RETIRED

Radiology CPT Code
70336

EFFECTIVE OCTOBER 1, 2012 UNTIL DECEMBER 31, 2015 Procedure Description
MRI TMJ

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RADIOLOGY PROGRAM

RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR GHI HMO - RETIRED

Radiology CPT Code
70450 70460 70470 70480 70481 70482 70486 70487 70488 70490 70491
70492
70496 70498 70540 70542
70543
70544 70545 70546 70547 70548 70549 70551 70552 70553
70554

EFFECTIVE OCTOBER 1, 2012 UNTIL DECEMBER 31, 2015 Procedure Description
CT HEAD/BRAIN W/O CONTRAST CT HEAD/BRAIN W/ CONTRAST CT HEAD/BRAIN W/O & W/ CONTRAST CT ORBIT W/O CONTRAST CT ORBIT W/ CONTRAST CT ORBIT W/O & W/ CONTRAST CT MAXLLFCL W/O CONTRAST CT MAXLLFCL W/ CONTRAST CT MAXLLFCL W/O & W/ CONTRAST CT SOFT TISSUE NECK W/O CONTRAST CT SOFT TISSUE NECK W/ CONTRAST CT SOFT TISSUE NECK W/O & W/ CONTRAST CT ANGIOGRAPHY HEAD CT ANGIOGRAPHY NECK MRI FACE, ORBIT, NECK W/O CONTRAST MRI FACE, ORBIT, NECK W/ CONTRAST MRI FACE, ORBIT, NECK W/ & W/O CONTRAST MRA HEAD W/O CONTRAST MRA HEAD W/ CONTRAST MRA HEAD W/ & W/O CONTRAST MRA NECK W/O CONTRAST MRA NECK W/ CONTRAST MRA NECK W/ & W/O CONTRAST MRI HEAD W/O CONTRAST MRI HEAD W/ CONTRAST MRI HEAD W/ & W/O CONTRAST MRI, BRAIN, FUNCTIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL

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RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR GHI HMO - RETIRED

Radiology CPT Code
70555
71250 71260 71270 71275 71550 71551 71552 71555 72125 72126 72127 72128 72129 72130 72131 72132 72133 72141 72142 72146 72147 72148 72149 72156

EFFECTIVE OCTOBER 1, 2012 UNTIL DECEMBER 31, 2015 Procedure Description
STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION MRI, BRAIN, FUNCTIONAL MRI; REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION OF ENTIRE NEUROFUNCTIONAL TESTING CT THORAX W/O CONTRAST CT THORAX W/ CONTRAST CT THORAX W/O & W/ CONTRAST CT ANGIOGRAPHY CHEST, NON-CORONARY MRI CHEST W/O CONTRAST MRI CHEST W/ CONTRAST MRI CHEST W/ & W/O CONTRAST MRA CHEST (EXC MYOCARDIUM) W/ OR W/O CONTRAST CT C SPINE W/O CONTRAST CT C SPINE W/ CONTRAST CT C SPINE W/O & W/ CONTRAST CT T SPINE W/O CONTRAST CT T SPINE W/ CONTRAST CT T SPINE W/O & W/ CONTRAST CT L SPINE W/O CONTRAST CT L SPINE W/ CONTRAST CT L SPINE W/O & W/ CONTRAST MRI CERVICAL SPINE W/O CONTRAST MRI CERVICAL SPINE W/ CONTRAST MRI THORACIC SPINE W/O CONTRAST MRI THORACIC SPINE W/ CONTRAST MRI LUMBAR SPINE W/O CONTRAST MRI LUMBAR SPINE W/ CONTRAST MRI C SPINE W/ & W/O CONTRAST

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RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR GHI HMO - RETIRED

Radiology CPT Code
72157 72158 72159 72191 72192 72193 72194 72195 72196 72197 72198 73200 73201 73202 73206 73218 73219 73220
73221
73222
73223
73225 73700 73701 73702

EFFECTIVE OCTOBER 1, 2012 UNTIL DECEMBER 31, 2015 Procedure Description
MRI T SPINE W/ & W/O CONTRAST
MRI L SPINE W/ & W/O CONTRAST
MRA SPINAL CANAL W/ OR W/O CONTRAST
CT ANGIOGRAPHY PELVIS
CT PELVIS W/O CONTRAST
CT PELVIS W/ CONTRAST
CT PELVIS W/O & W/ CONTRAST
MRI PELVIS W/O CONTRAST
MRI PELVIS W/ CONTRAST
MRI PELVIS W/ & W/O CONTRAST
MRA PELVIS W/ OR W/O CONTRAST
CT UPPER EXTREMITY W/O CONTRAST
CT UPPER EXTREMITY W/ CONTRAST
CT UPPER EXTREMITY W/O & W/ CONTRAST
CT ANGIOGRAPHY UPPER EXTREMITY
MRI UPPER EXTREMITY W/O CONTRAST
MRI UPPER EXTREMITY W/ CONTRAST
MRI UPPER EXTREMITY W/ & W/O CONTRAST
MRI UPPER EXTREMITY JOINT W/O CONTRAST
MRI UPPER EXTREMITY JOINT W/ CONTRAST
MRI UPPER EXTREMITY JOINT W/ & W/O CONTRAST
MRA UPPER EXTREMITY W/ OR W/O CONTRAST
CT LOWER EXTREMITY W/O CONTRAST
CT LOWER EXTREMITY W/ CONTRAST
CT LOWER EXTREMITY W/O & W/ CONTRAST

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RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR GHI HMO - RETIRED

Radiology CPT Code
73706 73718 73719 73720 73721 73722 73723 73725 74150 74160 74170
74174
74175 74176
74177
74178
74181 74182 74183

EFFECTIVE OCTOBER 1, 2012 UNTIL DECEMBER 31, 2015 Procedure Description
CT ANGIOGRAPHY LOWER EXTREMITY
MRI LOWER EXTREMITY W/O CONTRAST
MRI LOWER EXTREMITY W/ CONTRAST
MRI LOWER EXTREMITY W/ & W/O CONTRAST
MRI LOWER EXTREMITY JOINT W/O CONTRAST
MRI LOWER EXTREMITY JOINT W/ CONTRAST
MRI LOWER EXTREMITY JOINT W/ & W/O CONTRAST
MRA LOWER EXTREMITY W/ OR W/O CONTRAST
CT ABDOMEN W/O CONTRAST
CT ABDOMEN W/ CONTRAST
CT ABDOMEN W/O & W/ CONTRAST
CT ANGIOGRAPHY, ABDOMEN AND PELVIS, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING
CT ANGIOGRAPHY ABDOMEN
COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL
COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)
COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS
MRI ABDOMEN W/O CONTRAST
MRI ABDOMEN W/ CONTRAST
MRI ABDOMEN W/ & W/O CONTRAST

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RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR GHI HMO - RETIRED

Radiology CPT Code
74185 74261
74262
74263 75557
75559
75561
75563 75572 75573 75574 75635
76376

EFFECTIVE OCTOBER 1, 2012 UNTIL DECEMBER 31, 2015
Procedure Description
MRA ABDOMEN W/ OR W/O CONTRAST
COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITHOUT CONTRAST MATERIAL
COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITH CONTRAST MATERIAL(S) INCLUDING NON-CONTRAST IMAGES, IF PERFORMED
COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, SCREENING, INCLUDING IMAGE POSTPROCESSING
CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL
CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL; WITH STRESS IMAGING
CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES
CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; WITH STRESS IMAGING
CARDIAC CT FOR MORPHOLOGY
CARDIAC CT FOR CONGENITAL HD
CORONARY CTA
CT ANGIOGRAPHY ABDOMINAL AORTA
3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND OR OTHER TOMOGRAPHIC MODALITY; NOT REQUIRING IMAGE POSTPROCESSING ON

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RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR GHI HMO - RETIRED

Radiology CPT Code
76377 76380 76390 76801 76802 76805 76810 76811
76812
76813

EFFECTIVE OCTOBER 1, 2012 UNTIL DECEMBER 31, 2015
Procedure Description
AN INDEPENDENT WORKSTATION
3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND OR OTHER TOMOGRAPHIC MODALITY; REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION
CT LIMITED OR LOCALIZED FOLLOW-UP STUDY
MRI SPECTROSCOPY
U/S OB PELVIS, PREGNANT UTERUS, FIRST TRIMESTER <14 WEEKS SINGLE OR FIRST GESTATION
U/S OB PELVIS, PREGNANT UTERUS, FIRST TRIMESTER <14 WEEKS EACH ADDITIONAL GESTATION
U/S OB PELVIS, PREGNANT UTERUS, B-SCAN (Allowed once per gestation)
U/S OB PELVIS COMPLETE, MULTIPLE GESTATION AFTER 1ST TRIMESTER (Allowed once for each additional fetus per gestation; must be billed with 76805)
U/S PREGNANT UTERUS FETAL & MATERNAL EVAL PLUS FETAL ANATOMIC EVAL TRANSABDOMINAL SINGLE OR FIRST GESTATION (Allowed once per gestation; second study allowed if performed by a different physician)
U/S PREGNANT UTERUS FETAL & MATERNAL EVAL PLUS FETAL ANATOMIC EVAL TRANSABDOMINAL EACH ADDITIONAL GESTATION (Allowed once for each additional fetus per gestation; must be billed with 76811; second study allowed if performed by a different physician)
ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY MEASUREMENT, TRANSABDOMINAL OR TRANSVAGINAL APPROACH; SINGLE OR FIRST GESTATION (Allowed once per gestation)

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RADIOLOGY PROGRAM

RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR GHI HMO - RETIRED

Radiology CPT Code
76814
76815
76816 76817 76818 76819 76820 76821 76825 76826 76827 76828 77021 77058 77059 77084 78000 78001

EFFECTIVE OCTOBER 1, 2012 UNTIL DECEMBER 31, 2015 Procedure Description
ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY MEASUREMENT, TRANSABDOMINAL OR TRANSVAGINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) (Allowed once for each additional fetus per gestation)
U/S PREGNANT UTERUS, REAL TIME W/ IMAGE DOCUMENTATION, LIMITED (E.G., FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES
U/S OB PELVIS FOLLOW-UP OR REPEAT
U/S PREGNANT UTERUS TRANSVAGINAL
FETAL BIOPHYSICAL PROFILE
FETAL BIOPHYSICAL PROFILE W/O STRESS NON STRESS
DOPPLER VELOCIMETRY, FETAL; UMBILICAL ARTERY
DOPPLER VELOCIMETRY, FETAL; MIDDLE CEREBRAL ARTERY
U/S OB ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM
FOLLOW-UP OR REPEAT STUDY
DOPPLER ECHOCARDIOGRAPHY FETAL COMPLETE
FOLLOW-UP OR REPEAT STUDY
MRI GUIDANCE FOR NEEDLE PLACEMENT
MRI BREAST W/ AND/OR W/O CONTRAST; UNILATERAL
MRI BREAST BILATERAL
MRI BONE MARROW BLOOD SUPPLY
THYROID RAI UPTAKE
THYROID MULTIPLE UPTAKE

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RADIOLOGY PROGRAM

RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR GHI HMO - RETIRED

Radiology CPT Code
78003 78006 78007 78010 78011 78015
78016
78018
78020
78070 78075 78102 78103 78104 78140
78185
78190 78191 78195 78201 78202 78205
78206
78215 78216 78220 78223

EFFECTIVE OCTOBER 1, 2012 UNTIL DECEMBER 31, 2015 Procedure Description
THYROID SUPPRESS OR STIMULATION THYROID UPTAKE AND SCAN THYROID IMAGE, MULTIPLE UPTAKES THYROID SCAN ONLY THYROID IMAGING W/ FLOW THYROID MET IMAGING THYROID MET IMAGING WITH ADDITIONAL STUDIES THYROID SCAN WHOLE BODY THYROID CARCINOMA METASTASES UPTAKE (add on code - use w/ code 78018 only) PARATHYROID NUCLEAR IMAGING ADRENAL NUCLEAR IMAGING BONE MARROW IMAGING, LIMITED BONE MARROW IMAGING, MULTIPLE BONE MARROW IMAGING, WHOLE BODY LABELED RED CELL SEQUESTRATION SPLEEN IMAGING W/ OR W/O VASCULAR FLOW PLATELET SURVIVAL, KINETICS PLATELET SURVIVAL LYMPH SYSTEM IMAGING LIVER IMAGING LIVER IMAGING W/ FLOW LIVER IMAGING SPECT LIVER IMAGING SPECT W/ VASCULAR FLOW LIVER AND SPLEEN IMAGING LIVER AND SPLEEN IMAGING W/ FLOW LIVER FUNCTION STUDY HIDA SCAN

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RADIOLOGY PROGRAM

RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR GHI HMO - RETIRED

Radiology CPT Code
78226 78227 78230 78231 78232 78258 78261 78262 78264 78278 78282 78290 78291 78300 78305 78306
78315
78320 78414 78428
78445
78451 78452 78453 78454 78456
78457

EFFECTIVE OCTOBER 1, 2012 UNTIL DECEMBER 31, 2015 Procedure Description
LIVER FUNCTION STUDY HIDA SCAN SALIVARY GLAND IMAGING SERIAL SALIVARY GLAND SALIVARY GLAND FUNCTION TEST ESOPHAGUS MOTILITY STUDY GASTRIC MUCOSA IMAGING GASTROESOPHAGEAL REFLUX EXAM GASTRIC EMPTYING STUDY GI BLEEDER SCAN GI PROTEIN LOSS EXAM MECKEL'S DIVERTICULUM IMAGING LEVEEN SHUNT PATENCY EXAM BONE OR JOINT IMAGING LTD BONE OR JOINT IMAGING MULTIPLE BONE SCAN WHOLE BODY BONE AND/OR JOINT IMAGING; 3 PHASE STUDY BONE JOINT IMAGING TOMO TEST SPECT NON-IMAGING HEART FUNCTION CARDIAC SHUNT IMAGING RADIONUCLIDE VENOGRAM NON-CARDIAC MPI, SPECT, SINGLE REST OR STRESS MPI, SPECT, MULTIPLE, REST OR STRESS MPI, PLANAR, SINGLE REST OR STRESS MPI, PLANAR, MULTIPLE, REST OR STRESS ACUTE VENOUS THROMBOSIS IMAGING VENOUS THROMBOSIS IMAGING UNILATERAL

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RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR GHI HMO - RETIRED

Radiology CPT Code
78458
78459 78466 78468 78469 78472 78473 78481 78483
78491
78492
78494 78496 78579 78582
78597
78598
78600 78601 78605

EFFECTIVE OCTOBER 1, 2012 UNTIL DECEMBER 31, 2015 Procedure Description
VENOUS THROMBOSIS IMAGING BILATERAL
MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) METABOLIC EVAL
MYOCARDIAL INFARCTION SCAN
HEART INFARCT IMAGE EF
HEART INFARCT IMAGE SPECT
GATED HEART, REST OR STRESS
CARDIAC BLOOD POOL MUGA SCAN
HEART FIRST PASS SINGLE
CARDIAC BLOOD POOL IMAGING, MULTI
MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; SINGLE STUDY AT REST OR STRESS
MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; MULTIPLE STUDIES AT REST OR STRESS
CARDIAC BLOOD POOL IMAGING, SPECT
CARDIAC BLOOD POOL IMAGING, SINGLE AT REST (Use with 78472)
PULMONARY VENTILATION IMAGING (E.G., AEROSOL OR GAS)
PULMONARY VENTILATION (E.G., AEROSOL OR GAS) AND PERFUSION IMAGING
QUANTITATIVE DIFFERENTIAL PULMONARY PERFUSION, INCLUDING IMAGING WHEN PERFORMED
QUANTITATIVE DIFFERENTIAL PULMONARY PERFUSION AND VENTILATION (E.G., AEROSOL OR GAS), INCLUDING IMAGING WHEN PERFORMED
BRAIN IMAGING LTD STATIC
BRAIN LTD IMAGING AND FLOW
BRAIN IMAGING COMPLETE

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RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR GHI HMO - RETIRED

Radiology CPT Code
78606 78607 78608
78609 78610 78630 78635 78645 78647 78650 78660 78700 78701 78707
78708
78709 78710 78725 78730 78740 78761

EFFECTIVE OCTOBER 1, 2012 UNTIL DECEMBER 31, 2015 Procedure Description
BRAIN IMAGING COMPLETE W/ FLOW
BRAIN IMAGING SPECT
BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC EVALUATION
BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION EVALUATION
BRAIN FLOW IMAGING ONLY
CISTERNOGRAM (Cerebrospinal fluid flow)
CEREBROSPINAL VENTRICULOGRAPHY
CSF SHUNT EVALUATION
CEREBROSPINAL FLUID SCAN SPECT
CSF LEAKAGE DETECTION AND LOCALIZATION
RADIOPHARMACEUTICAL DACRYOCYSTORGRAPHY
KIDNEY IMAGING MORPHOLOGY
KIDNEY IMAGING MORPHOLOGY W/ VASCULAR FLOW
KIDNEY IMAGING MORPHOLOGY W/ VASCULAR FLOW AND FUNCTION STUDY
KIDNEY IMAGING MORPHOLOGY W/ VASCULAR FLOW AND FUNCTION, SINGLE W/ PHARM INTERVENTION
KIDNEY IMAGING MORPHOLOGY W/ VASCULAR FLOW, MULTI, W/O AND W/ PHARM INTERVENTION
KIDNEY IMAGING, SPECT
KIDNEY FUNCTION STUDY, NON-IMAGE RADIOISOTROPIC
URINARY BLADDER RESIDUAL STUDY
URETERAL REFLUX STUDY
TESTICULAR IMAGING W/ VASCULAR FLOW

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RADIOLOGY PROGRAM

RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR GHI HMO - RETIRED

Radiology CPT Code
78800 78801 78802 78803 78804 78805 78806 78807 78811 78812 78813
78814
78815
78816

EFFECTIVE OCTOBER 1, 2012 UNTIL DECEMBER 31, 2015
Procedure Description
RADIOPHARM LOCALIZATION OF TUMOR, LIMITED AREA
RADIOPHARM LOCALIZATION OF TUMOR, MULTI AREAS
RADIOPHARM LOCALIZATION OF TUMOR, WHOLE BODY
RADIOPHARM LOCALIZATION OF TUMOR, SPECT
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF RADIOPHARMACEUTICAL AGENT(S); WHOLE BODY, REQUIRING 2 OR MORE DAYS IMAGING
RADIOPHARM LOCALIZATION OF ABSCESS, LIMITED AREA
RADIOPHARM LOCALIZATION OF ABSCESS, WHOLE BODY
RADIOPHARM LOCALIZATION OF ABSCESS, SPECT
POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; LIMITED AREA (E.G., CHEST, HEAD/NECK)
POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; SKULL BASE TO MID-THIGH
POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; WHOLE BODY
POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; LIMITED AREA (E.G., CHEST, HEAD/NECK)
POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; SKULL BASE TO MID-THIGH
POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND

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RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR GHI HMO - RETIRED

Radiology CPT Code
0174T
0175T
C8900 C8901 C8902 C8903 C8904 C8905 C8906 C8907 C8908

EFFECTIVE OCTOBER 1, 2012 UNTIL DECEMBER 31, 2015
Procedure Description
ANATOMICAL LOCALIZATION IMAGING; WHOLE BODY
COMPUTER-AIDED DETECTION (CAD) INCLUDING COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION, WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION AND REPORT, WITH OR WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC IMAGES, CHEST RADIOGRAPH(S) PERFORMED CONCURRENT WITH PRIMARY INTERPRETATION
COMPUTER-AIDED DETECTION (CAD), INCLUDING COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION, WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION AND REPORT, WITH OR WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC IMAGES, CHEST RADIOGRAPH(S) PERFORMED REMOTE FROM PRIMARY INTERPRETATION
MRA WITH CONTRAST, ABDOMEN (crosswalked to 74185)
MRA WITHOUT CONTRAST, ABDOMEN (crosswalked to 74185)
MRA WITH AND WITHOUT CONTRAST, ABDOMEN (crosswalked to 74185)
MRI WITH CONTRAST, BREAST; UNILATERAL (crosswalked to 77058)
MRI WITHOUT CONTRAST, BREAST; UNILATERAL (crosswalked to 77058)
MRI WITH AND WITHOUT CONTRAST, BREAST; UNILATERAL (crosswalked to 77058)
MRI WITH CONTRAST, BREAST; BILATERAL (crosswalked to 77059)
MRI WITHOUT CONTRAST, BREAST; BILATERAL (crosswalked to 77059)
MRI WITH AND WITHOUT CONTRAST, BREAST; BILATERAL (crosswalked to 77059)

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RADIOLOGY PROGRAM

RADIOLOGY PROGRAM PRIOR APPROVAL CODE LIST FOR GHI HMO - RETIRED

Radiology CPT Code
C8909 C8910 C8911 C8912 C8913 C8914 C8918 C8919 C8920 C8931 C8932
C8933
C8934 C8935
C8936

EFFECTIVE OCTOBER 1, 2012 UNTIL DECEMBER 31, 2015
Procedure Description
MRA WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM) (crosswalked to 71555)
MRA WITHOUT CONTRAST, CHEST (EXCLUDING MYOCARDIUM) (crosswalked to 71555)
MRA WITH AND WITHOUT CONTRAST, CHEST (EXCLUDING MYOCARDIUM) (crosswalked to 71555)
MRA WITH CONTRAST, LOWER EXTREMITY (crosswalked to 73725)
MRA WITHOUT CONTRAST, LOWER EXTREMITY (crosswalked to 73725)
MRA WITH AND WITHOUT CONTRAST, LOWER EXTREMITY (crosswalked to 73725)
MRA WITH CONTRAST, PELVIS (crosswalked to 72198)
MRA WITHOUT CONTRAST, PELVIS (crosswalked to 72198)
MRA WITH AND WITHOUT CONTRAST, PELVIS (crosswalked to 72198)
MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, SPINAL CANAL AND CONTENTS (crosswalked to 72159)
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, SPINAL CANAL AND CONTENTS (crosswalked to 72159)
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, SPINAL CANAL AND CONTENTS (crosswalked to 72159)
MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, UPPER EXTREMITY (crosswalked to 73225)
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, UPPER EXTREMITY (crosswalked to 73225)
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, UPPER EXTREMITY (crosswalked to 73225)

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Formal Dispute Resolution

RADIOLOGY PROGRAM

Please submit to EmblemHealth:

Appeals for Medicare members. Please follow EmblemHealth's standard processes for Medicare members, described in the Dispute Resolution Medicare chapter.

Complaints and grievances. Please refer to the Dispute Resolution chapters for Commercial/CHP and Medicaid/HARP, as applicable.

Please submit to eviCore:

Expedited and standard clinical appeals for Commercial/CHP members and expedited and standard action appeals for Medicaid/HARP members. Appeals may be filed by the member, the member's delegate (including the practitioner acting as the member's delegate) or by practitioners on their own behalf. For a full description of member and practitioner rights regarding clinical and action appeals, see the Dispute Resolution chapters for Commercial/CHP and Medicaid/HARP, as applicable.

GHI HMO, HIP AND VYTRA RADIOLOGY SCHEDULING PROCEDURE
Plan Participation
Members with HIP as their managing entity (see the member's ID card or eligibility information on emblemhealth.com follow the Radiology Scheduling Procedure.
Scheduling Procedure
When a prior approval request is made, utilization review staff evaluates the requested procedure against the existing criteria and determines its medical necessity.
If the prior approval request is approved, a scheduling representative contacts the member to schedule the procedure at a participating location. Once the location is selected, the medical necessity determination is amended to include an authorization number.
Program staff attempts to contact the member for a 48-hour period. If at the end of that period the scheduling representative is unable to speak with the member, they select a participating imaging facility close to the member's home and send a letter to both the member and the referring practitioner with the contact information for the site selected.
Members may contact the scheduling department at 1-866-699-8131, Monday through Friday, from 7 am to 7 pm, EST, to schedule a procedure or change the procedure site before the appointment date.

VYTRA PLANS RADIOLOGY PROGRAM FOR DATES OF SERVICE PRIOR TO JANUARY 1, 2016

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RADIOLOGY PROGRAM
Overview
Vytra HMO contracted with various groups to provide radiology services for its members. All participating Vytra PCPs designated a radiology center that their Vytra patients used exclusively. The designated radiology center appeared on the ID card of each Vytra member on the PCP's panel.
Designated Radiology Centers
For radiology services to be covered, Vytra plan members used the designated radiology center specified on their Vytra ID card. If no radiology center appeared on the ID card, the member was able to go to any Vytra network radiologist. Participating practitioners sent members directly, without a referral, to the designated radiologist by writing a prescription detailing the test required.
PCPs with more than one office location were able to select a different radiology center for each of their offices.
In the rare instance that the designated radiology center could not meet the member's needs, the practitioner contacted Vytra's Care Management department at 1-888-288-9872 for prior approval to send the member to another facility.
Guarantee Waiver Agreement for Radiology Groups
Radiology centers treating a member outside their designation called Vytra's Provider Service Line at 1-888-288-9872 before rendering services. During this call, the center ensured prior approval was secured and use Vytra's Guarantee Waiver Agreement.
Each member seeking service outside their designated facility signed Vytra's Guarantee Waiver Agreement. This was the only waiver recognized by Vytra. At time of signing, members were advised that they would be responsible for payment of all services performed. Practitioners had the right to withhold service to any member who chose not to sign this waiver.
If the radiology facility rendered services without having a signed waiver, the member was reimbursed for any up-front payment and could not be balance billed. Vytra reserves the right to withhold future payment to the facility until the member was reimbursed.
Changing Designated Radiology Groups
PCPs were able to change their designated radiologist under the following circumstances:
PCP requested a change and Vytra's Provider Relations department deemed the change to be in the best interest of the PCP's patients (e.g., quality of care related, PCP location change) A corporate decision allowed all PCPs to change their designated radiologist Administrative purposes (e.g., correction of database)
Quality Issues All quality-related issues had to be reported to Vytra at 1-888-288-9877 promptly for immediate resolution.
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RADIOLOGY PROGRAM
Copies of X-Rays Copies of X-rays were not reimbursed unless the member received a second opinion for a cancer diagnosis and the practitioner received proper approval. Eligible copies were reimbursed at the then current fee schedule. Radiation Therapy Radiation therapy required the hematologist/oncologist to obtain prior approval. If appropriate, a Care Management representative authorized an initial series of three visits for radiation therapy. Upon completing the initial evaluation, the radiation oncologist contacted Vytra's Care Management department with the findings. The radiologist then forwarded a copy of the proposed treatment plan to the referring hematologist/oncologist. Specialists were required to communicate with the member's PCP regarding all treatment and follow-up care provided. DEXA Scans Vytra reimbursed only radiologists for dual energy X-ray absorptiometry (DEXA) scans. PCPs and specialists other than radiologists were not reimbursed for DEXA scans, regardless of any prior arrangements with or payments from Vytra. If the member's designated radiologist did not perform DEXAs, the referring physician called Vytra's Care Management department to authorize services at another network radiologist.
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