Site of Care requirement for advanced radiology imaging (MR and CT)
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Defines medical necessity criteria requiring advanced imaging (MRI and CT) performed in hospital outpatient settings to meet specific factors for authorization under Aetna's Enhanced Clinical Review; affects fully insured commercial members and providers seeking authorization.
A Site of Care medical necessity requirement was added to the Enhanced Clinical Review program for fully insured commercial members effective December 1, 2021.
Site of Care Medical Necessity Criteria
Hospital outpatient advanced imaging — medically necessary Site of Care factors
An advanced imaging procedure at a hospital outpatient site is considered medically necessary when ANY of the following factors apply:
All listed items are alternative; meeting any one supports medical necessity for hospital outpatient site.
When a requested advanced radiology procedure (MR or CT) performed in a hospital outpatient site does not meet any of the listed Site of Care medical necessity factors, the service will be determined to be non‑medically necessary for the hospital outpatient site. Such requests will be subject to denial unless the imaging is performed at a freestanding or office location where the Site of Care requirement does not apply.
Advanced imaging (MR and CT) performed in a hospital outpatient setting must meet at least one of the specified Site of Care medical necessity factors (for example: patient age under 18, obstetrical or perinatology needs, transplant‑related imaging, known contrast allergy when that contrast is planned, need for hospital‑only equipment, requirement for moderate/deep sedation or general anesthesia not available at freestanding facilities, documented claustrophobia requiring open MRI, perioperative imaging integral to a hospital procedure, active COVID‑19, or other reasons rendering no appropriate alternative site). If none of these factors apply, the hospital outpatient service is not considered medically necessary and is not covered unless provided at a freestanding or office location.
Appropriate Indications for Hospital Outpatient Advanced Imaging
Appropriate indications for hospital outpatient advanced imaging
Indications for hospital outpatient MR/CT: any one of the following supports the hospital outpatient site as medically necessary.
Any one of these indications supports hospital outpatient location.
Modalities and Codes Subject to Site of Care Review
| MR | Magnetic Resonance imaging (as referenced in policy) |
| CT | Computed Tomography imaging (as referenced in policy) |
Provider Documentation, Denials, and Operational Requirements
Document a Site of Care factor for hospital outpatient imaging
Providers must have documentation showing that at least one of the Site of Care medical necessity factors applies when requesting advanced imaging (MR or CT) in a hospital outpatient setting for fully insured commercial members.
- Examples of acceptable factors include: age under 18, obstetrical observation, perinatology services, transplant-related imaging at an approved transplant facility, known contrast allergy with planned use, chronic disease with prior high‑tech imaging at the hospital-affiliated department, active COVID-19, or lack of appropriate alternative sites for specified clinical or logistical reasons.
Denial risk if Site of Care criteria are not met
Advanced radiology procedures (MR and CT) requested in a hospital outpatient site that do not meet any listed Site of Care medical necessity factors will be considered non‑medically necessary.
- Such requests will be denied unless the procedure is performed at a freestanding or office location.
Contrast Use and Allergy Considerations
Known contrast allergy with planned use supports hospital outpatient imaging
If there is a known contrast allergy and use of that contrast agent is planned, hospital outpatient imaging is considered medically necessary.
- Include documentation of the known contrast allergy and that the planned imaging requires that specific contrast agent.
Definitions and Program Names
Frequency and Limits
Not Medically Necessary / Not Covered
NOT COVERED: Advanced imaging procedures (MR and CT) performed in a hospital outpatient site that do not meet any of the listed Site of Care medical necessity factors are considered non‑medically necessary and therefore not covered for the hospital outpatient site. Coverage may be available if the imaging is performed at a freestanding or office facility.
Background and Policy Rationale
Background: Effective December 1, 2021, Aetna added a Site of Care medical necessity requirement to the Enhanced Clinical Review program for fully insured commercial members. The requirement directs that advanced radiology imaging (MR and CT) requested in a hospital outpatient setting be reviewed by eviCore for medical necessity prior to authorization and is intended to reserve hospital outpatient imaging for cases with specific clinical or logistical needs (examples include pediatric care, obstetrical/perinatology needs, transplant‑related imaging at approved facilities, planned use of contrast with known allergy, requirements for sedation or specialized equipment, documented claustrophobia, active COVID‑19, or situations where imaging outside the hospital would adversely impact or delay care).
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