Despite the increasing frequency of HOPD imaging,1 there are no studies formally comparing the quality of imaging care delivered in the HOPD and freestanding environments. The need to perform HOPD imaging is therefore based on the consideration of principle-based patient, personnel, or technical factors that are expected to offer net benefit to HOPD imaging by making it safer or consistently more accurate than imaging in surrounding freestanding facilities when available.

CPT 72195vs 72197

Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences

CPT72148

Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed

Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s)

The Guidelines may also be used by the health plan or by Carelon for purposes of provider education, or to review the medical necessity of services by any provider who has been notified of the need for medical necessity review, due to billing practices or claims that are not consistent with other providers in terms of frequency or some other manner.

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Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequences

Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s)

Imaging at a hospital outpatient site of care (HOPD) is considered medically necessary for requests that meet criteria for the service being performed in ANY of the following scenarios:

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Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences

In general, repeated testing of the same anatomic location for the same indication should be limited to evaluation following an intervention, or when there is a change in clinical status such that additional testing is required to determine next steps in management. At times, it may be necessary to repeat a test using different techniques or protocols to clarify a finding or result of the original study.

Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences

Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing

Repeated testing for the same indication using the same or similar technology may be subject to additional review or require peer-to-peer conversation in the following scenarios:

CPT72196

The following section includes indications for which advanced imaging is considered medically necessary, along with prerequisite information and supporting evidence where available. Indications, diagnoses, or imaging modalities not specifically addressed are considered not medically necessary.

73221CPT description

These guidelines address site of care for advanced imaging. Specifically, the guideline addresses the medical necessity of imaging at a hospital outpatient department (HOPD) where a higher level of support may be available. The appropriate place of care is defined as the facility (HOPD or freestanding) with the proper equipment and level of support to perform advanced imaging when that request meets Carelon’s radiology guidelines for appropriate use. This guideline covers all requests for advanced imaging in both pediatric and adult patients.

Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections

The Guidelines do not address coverage, benefit or other plan specific issues. Applicable federal and state coverage mandates take precedence over these clinical guidelines. If requested by a health plan, Carelon will review requests based on health plan medical policy/guidelines in lieu of the Carelon Guidelines. Pharmaceuticals, radiotracers, or medical devices used in any of the diagnostic or therapeutic interventions listed in the Guidelines must be FDA approved or conditionally approved for the intended use. However, use of an FDA approved or conditionally approved product does not constitute medical necessity or guarantee reimbursement by the respective health plan.

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Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences

MyelogramCPT Code

72196CPT code description

Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing

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Requests for multiple diagnostic or therapeutic interventions at the same time will often require a peer-to-peer conversation to understand the individual circumstances that support the medical necessity of performing all interventions simultaneously. This is based on the fact that appropriateness of additional intervention is often dependent on the outcome of the initial intervention.

CPT72197 medical necessity

HOPD is a higher site of care offering ancillary services that may be important to imaging safety in select high risk patients. While they may occur in the outpatient setting, the scenarios covered by this ancillary support principle are much more common in the inpatient level of care, which is beyond the scope of this document. For instance, anesthesia beyond minimal sedation (anxiolysis with normal verbal responsiveness) requires greater patient monitoring and potentially anesthesiologist supervision. Additional ancillary support may be required to help position bedbound patients or those with advanced decubitus ulcers. While many freestanding facilities are capable of managing established relevant contrast allergies, the additional rapid response services offered by HOPD are an important safety consideration in patients with medical or device comorbidities that increase the risk of an adverse event requiring immediate medical attention (contrast reaction, cardiac devices, and potential for airway compromise).

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Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences

Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing

CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright by the American Medical Association. All Rights Reserved. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.

Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical

Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections

Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing

Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences

Computed tomography, thorax, diagnostic; without contrast material, followed by contrast material(s) and further sections

Carelon applies objective and evidence-based criteria, and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services. The Carelon Guidelines are just guidelines for the provision of specialty health services. These criteria are designed to guide both providers and reviewers to the most appropriate services based on a patient’s unique circumstances. In all cases, clinical judgment consistent with the standards of good medical practice should be used when applying the Guidelines. Guideline determinations are made based on the information provided at the time of the request. It is expected that medical necessity decisions may change as new information is provided or based on unique aspects of the patient’s condition. The treating clinician has final authority and responsibility for treatment decisions regarding the care of the patient and for justifying and demonstrating the existence of medical necessity for the requested service. The Guidelines are not a substitute for the experience and judgment of a physician or other health care professionals. Any clinician seeking to apply or consult the Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment.

Critical to any finding of clinical appropriateness under the guidelines for a specific diagnostic or therapeutic intervention are the following elements:

HOPD may offer specialized technology and expertise that is not widely available in freestanding facilities. While the exact availability of services varies from market to market, the vast majority of freestanding imaging centers can accommodate routine CT and MRI examinations. Some modalities require specialized equipment , software, and/or personnel that are not widespread in the freestanding environment. For instance, functional MRI may require engagement of a speech language pathologist and specialized post processing software, neither of which is available at the majority of freestanding institutions. Not all specialized software or hardware lead to improvements in diagnostic accuracy that would reasonably be expected to positively impact patient management and outcome. For instance, 1.5T strength magnets are non-inferior to 3T in most clinical scenarios. 2 3 4 5 Furthermore, the vast majority of advanced imaging exams can be performed without specialized and uncommon technology. In some cases, the HOPD may be the only source of subspecialized radiologists. Low to very low quality evidence suggests that subspecialized radiologists are more accurate than their general radiology counterparts in the interpretation of some types of studies for instance oncologic6, 7 and interstitial lung disease8 but not for appendicitis9 and not consistently for musculoskeletal conditions.10,11 Pediatric imaging requires consistent adherence to as low as reasonable achievable (ALARA) CT dosimetry. Children’s hospitals tend to use less radiation for similar or greater diagnostic accuracy.12, 13 They may also offer supportive services to facilitate the imaging experience for children, including pediatric sedation. Pediatric radiologists are also less common than other radiology subspecialities in community practice. Finally, the HOPD may be the only site to support the types of equipment needed in patients with claustrophobia or very high BMIs.

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Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing

Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral

Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences

Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing

Carelon makes its Guidelines publicly available on its website twenty-four hours a day, seven days a week. Copies of the Carelon Clinical Appropriateness Guidelines are also available upon oral or written request. Although the Guidelines are publicly-available, Carelon considers the Guidelines to be important, proprietary information of Carelon, which cannot be sold, assigned, leased, licensed, reproduced or distributed without the written consent of Carelon.

The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.

Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.

In general, repeated therapeutic intervention in the same anatomic area is considered appropriate when the prior intervention proved effective or beneficial and the expected duration of relief has lapsed. A repeat intervention requested prior to the expected duration of relief is not appropriate unless it can be confirmed that the prior intervention was never administered.

Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing

Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic

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

If these elements are not established with respect to a given request, the determination of appropriateness will most likely require a peer-to-peer conversation to understand the individual and unique facts that would supersede the requirements set forth above. During the peer-to-peer conversation, factors such as patient acuity and setting of service may also be taken into account.

Approval and implementation dates for specific health plans may vary. Please consult the applicable health plan for more details.

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Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing

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Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences

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Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral

It is recognized that imaging often detects abnormalities unrelated to the condition being evaluated. Such findings must be considered within the context of the clinical situation when determining whether additional imaging is required.

Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences

Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar

72197CPT code

The Carelon guideline development process complies with applicable accreditation standards, including the requirement that the Guidelines be developed with involvement from appropriate providers with current clinical expertise relevant to the Guidelines under review and be based on the most up-to-date clinical principles and best practices. Relevant citations are included in the References section attached to each Guideline. Carelon reviews all of its Guidelines at least annually.

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Continuity of care and service is a third principle for hospital-based imaging in some patients. Comparison between studies is facilitated by having the same imaging protocol, performed by the same institution in the same PACS environment. It is uncommon for new episodes of care in patients without chronic disease to have relevant comparisons. However, comparison to prior studies is important for accurate diagnosis and management in patients with certain chronic conditions such as cancer and multiple sclerosis and is an indication for HOPD imaging when previously performed in that site of care. Not all patients with chronic conditions require follow up imaging at the HOPD. For instance, a patient with multiple sclerosis who requires a MRI of the knee would not meet the continuity of care principle outlined here. Relevance of the comparison to the exam indication and the importance of small changes to patient management determine applicability of the principle. Other continuity of care considerations include preprocedural imaging when surgery has been scheduled at the hospital and circumstances particular to an individual patient or community where imaging redirection to a free standing facility may result in clinical significant care delays such as untimely diagnosis for an acute or highly time sensitive condition.

Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences

The Carelon Clinical Appropriateness Guidelines (hereinafter “the Carelon Clinical Appropriateness Guidelines” or the “Guidelines”) are designed to assist providers in making the most appropriate treatment decision for a specific clinical condition for an individual. As used by Carelon, the Guidelines establish objective and evidence-based criteria for medical necessity determinations where possible. In the process, multiple functions are accomplished: