CurrentAetnaPolicy N/A

Site of Care requirement for advanced radiology imaging (MR and CT)

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.

Policy Summary

PayerAetna

PolicySite of Care requirement for advanced radiology imaging (MR and CT)

Policy CodePolicy N/A

Change TypeAdded Site of Care medical necessity requirement

Effective DateDec 1, 2021

Next Review DateN/A

Key ActionRequesting providers must submit documentation showing at least one listed Site of Care medical necessity factor when seeking authorization for hospital outpatient MR or CT; eviCore will review prior to authorization.

SourceLink

POLICY UPDATE CHANGES

A Site of Care medical necessity requirement was added to the Enhanced Clinical Review program for fully insured commercial members effective December 1, 2021.

MR & CTModalities

Fully insured commercialMember Impact

eviCoreReviewer

Hospital outpatientTarget Site

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:

Site of Care medical necessity factors: The individual is under 18 years of age; obstetrical observation is required; perinatology services are required; there are imaging needs related to transplant services at an approved transplant facility; there is a known contrast allergy and use of that contrast agent is planned; there is a known chronic disease for which prior high-tech imaging procedures have been used for the diagnosis, management, or ongoing surveillance of the disease at the hospital-affiliated imaging department; active case of COVID-19 after positive test for SARS-CoV-2; or there are no other appropriate alternative sites for the individual to undergo the imaging procedure because: the surgery or procedure is being performed at the hospital and preoperative/procedural or postoperative/procedural imaging is an integral component of care; moderate or deep sedation or general anesthesia is required and a freestanding facility capable of providing such sedation is not available; equipment needed to accommodate the size of the individual is available only at a hospital-affiliated imaging facility; the individual has documented claustrophobia requiring open MRI not available in a freestanding facility; or imaging outside the hospital-affiliated imaging department is expected to adversely impact or delay care.

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.

Policy Summary

PayerAetna

PolicySite of Care requirement for advanced radiology imaging (MR and CT)

Policy CodePolicy N/A

Change TypeAdded Site of Care medical necessity requirement

Effective DateDec 1, 2021

Next Review DateN/A

SourceLink

On This Page

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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.

Indications for hospital outpatient MR/CT: Under 18 years of age; 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 a hospital‑affiliated imaging department for diagnosis, management, or surveillance; active COVID-19 after positive SARS‑CoV‑2 test; or lack of appropriate alternative sites because perioperative imaging is integral to a surgery/procedure at the hospital; required moderate/deep sedation or general anesthesia and no freestanding facility can provide it; equipment to accommodate the individual's size is available only at the hospital; documented claustrophobia requiring open MRI not available in a freestanding facility; or imaging outside the hospital‑affiliated imaging department is expected to adversely impact or delay care.

Any one of these indications supports hospital outpatient location.

Modalities and Codes Subject to Site of Care Review

Covered modalities subject to Site of Care reviewmixed

MR	Magnetic Resonance imaging (as referenced in policy)
CT	Computed Tomography imaging (as referenced in policy)

Supplemental coding/key-value

Covered modalitiesMR (Magnetic Resonance) and CT (Computed Tomography)

Coding systemModality names referenced as MR and CT in policy (no CPT/HCPCS codes listed)

ScopeAdvanced radiology imaging procedures subject to Site of Care review when performed in hospital outpatient setting

Prior Authorization Requirements

Prior Authorization

MRI and CT — reviewed by eviCore prior to authorization

Advanced radiology imaging procedures (MRI and CT) requested for hospital outpatient sites require prior review by eviCore for medical necessity before authorization.

Applies to MR and CT scans at hospital outpatient sites
Effective Date: 2021-12-01
Applies to fully insured commercial members in Enhanced Clinical Review program

Prior Authorization

Prior authorization review by eviCore

Prior authorization review for applicable imaging requests in the hospital outpatient setting is performed by eviCore as part of the Site of Care requirement under the Enhanced Clinical Review program.

eviCore performs medical necessity review for hospital outpatient advanced imaging
Non‑meeting requests are considered non‑medically necessary for hospital outpatient site

Documentation Required

Providers must document and justify the medical necessity for hospital outpatient advanced imaging. Examples of situations that may support medical necessity for hospital outpatient MR/CT include: patient age under 18, obstetrical or perinatology needs, transplant‑related imaging at approved transplant facilities, known contrast allergy with planned use, chronic disease requiring hospital‑affiliated imaging for diagnosis/management/surveillance, active COVID‑19 after positive SARS‑CoV‑2 test, or absence of appropriate alternative sites for reasons such as concurrent hospital surgery, need for moderate/deep sedation or general anesthesia not available at freestanding centers, equipment size limitations, documented claustrophobia requiring open MRI not available elsewhere, or concern that imaging outside the hospital would adversely impact or delay care.

Document specific supporting reason(s) when requesting hospital outpatient MR/CT
Include evidence for reasons such as: age <18; obstetrical/perinatology care; transplant services; contrast allergy; chronic disease surveillance; active COVID‑19; lack of alternative site due to concurrent surgery, anesthesia/sedation needs, equipment, claustrophobia, or potential delay/impact to care

Provider Documentation, Denials, and Operational Requirements

Documentation Required

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

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

Billing Rule

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

MR and CT — definition of advanced radiology imaging procedures

DefinitionAdvanced radiology imaging procedures

Examples includedMagnetic Resonance (MR) and Computed Tomography (CT)

ContextThese modalities are subject to medical necessity review by eviCore when requested in the hospital outpatient setting

Aetna program that includes Site of Care reviews managed by eviCore

Program nameEnhanced Clinical Review program

Operational changeAdded Site of Care medical necessity requirement effective December 1, 2021

Vendor managing reviewseviCore (reviews MR and CT for medical necessity prior to authorization)

Population affectedFully insured commercial members

Frequency and Limits

Frequency limits

Frequency limits presentNone specified in this policy

Frequency fieldsPolicy frequency_limits entries are empty (no modality-specific limits provided)

Implication for providersNo explicit repeat-imaging intervals or numeric limits set — clinical necessity and Site of Care factors determine appropriateness

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).