CurrentCignaPolicy 0550

Site of Care for High‑Tech Imaging (MRI/MRA/CT/CTA)

Defines when hospital-based imaging departments/facilities are considered medically necessary for high‑tech imaging (MRI, MRA, CT, CTA) versus freestanding imaging facilities for Cigna-administered health plans.

Policy Summary

PayerCigna

PolicySite of Care for High‑Tech Imaging (MRI/MRA/CT/CTA)

Policy CodePolicy 0550

Change TypeNo material changes

Effective DateMar 15, 2025

Next Review DateMar 15, 2026

Key ActionObtain Cigna-eviCore pre-certification for certain high‑tech imaging CPT codes when required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MRI/MRA/CT/CTAmodalities covered

18 and underautomatic hospital-based indication (age)

No clinical statement changesrevision note

3/15/2025policy effective date

Coverage Criteria — When Hospital-Based Imaging Is Medically Necessary

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Hospital-based imaging medically necessary when any listed condition is present: age 18 and under; requires obstetrical observation; requires perinatology services; imaging related to transplantation services at an approved transplantation facility; known contrast allergy and use of that contrast agent is planned; there are no other appropriate alternative sites for the individual to undergo the imaging procedure for any of the following reasons: surgery or procedure is being performed at the hospital and pre-operative or preprocedure imaging is an integral component of the procedure; moderate or deep sedation or general anesthesia is required for the imaging procedure and a freestanding facility providing such sedation is not available; equipment for the size of the individual is only available at a hospital-based imaging facility; individual has a documented diagnosis of claustrophobia requiring open magnetic resonance imaging which is not available in a freestanding facility; known chronic disease where imaging needs to be performed at a hospital-based facility for comparison to prior studies; imaging is emergent or urgent and imaging outside the hospital-based imaging department or facility is expected to adversely impact or delay care.

Modeled as ANY — presence of any single listed condition supports hospital-based site

inv-02: Policy exceptions — This Policy does not apply if:

This Policy does not apply if:

Policy exceptions (do not apply): there is no free-standing facility in the individual's geographic area; utilizing the free-standing facility in the individual's geographic area would cause a health disparity (e.g., the hospital-based facility provides needed resources the free-standing imaging facility does not such as ease of transportation, disability/language support).

If either condition is true, the standard policy choice between freestanding vs hospital does not apply.

inv-03: Not medically necessary when criteria not met — All other high‑tech radiology procedures at a hospital-based imaging department or facility are considered:

All other high‑tech radiology procedures at a hospital-based imaging department or facility are considered:

Default stance for hospital-based imaging not meeting criteria: All other high-tech radiology (imaging) procedures at a hospital-based imaging department or facility are considered not medically necessary.

If none of the covered indications are present, hospital-based site is not medically necessary.

This policy does not apply if there is no freestanding facility in the individual’s geographic area or if using a freestanding facility would cause a health disparity (for example, when the hospital provides needed resources that the freestanding site does not, such as ease of transportation or disability/language support).

When none of the listed indications for hospital-based imaging are present, hospital-based high‑tech imaging (MRI/MRA/CT/CTA) is considered not medically necessary. Examples of situations that support hospital-based imaging (and that, if absent, would not support hospital-based care) include: patient age ≤ 18 years, obstetrical or perinatal care needs, transplant‑related imaging, planned use of a contrast agent when a known contrast allergy exists, need for moderate/deep sedation or general anesthesia unavailable at freestanding sites, equipment size limitations, documented claustrophobia requiring open MRI only available at a hospital, chronic-disease imaging that requires hospital comparison studies, or emergent/urgent imaging where routing outside the hospital would delay care.

Appropriate Indications for Hospital-Based MRI/MRA/CT/CTA

inv-13: Appropriate indications for hospital-based MRI/MRA/CT/CTA — 1 top-level node

Indications requiring hospital-based MRI/MRA/CT/CTA:

Indications requiring hospital-based imaging: pediatrics (<=18 years); obstetrical or perinatal care needs; imaging related to transplantation services at an approved transplantation facility; known contrast allergy when use of that contrast agent is planned (requires hospital resources for emergency treatment); need for moderate/deep sedation or general anesthesia when a freestanding facility providing such sedation is not available; equipment limitation for patient size necessitating hospital-based equipment; documented claustrophobia requiring open MRI not available at freestanding facility; known chronic disease requiring imaging at the hospital for comparison to prior studies; emergent or urgent imaging where imaging outside the hospital would be expected to adversely impact or delay care.

Derived from policy indications and supporting professional society guidance on sedation, contrast, and pediatric care.

Provider Actions, Billing, and Prior Authorization

Prior Authorization

Pre-certification Required

Certain CPT codes referenced in Cigna-eviCore pre-certification lists require pre-certification as of 01/01/2025. Providers must obtain pre-certification through Cigna-eviCore for hospital-based high-tech imaging services when the procedure code appears on the pre-certification list; failure to pre-certify may result in claim denial or reduced reimbursement.

Applies to MRI, MRA, CT, and CTA codes listed on the Cigna-eviCore pre-certification lists.
Effective date: 2025-01-01 (pre-cert requirement in effect).

Note

Provider Action Required

When submitting prior authorization requests or scheduling services, providers must confirm member eligibility, benefits, and any plan-specific requirements. Initiate pre-certification or authorization requests through the designated Cigna-eviCore channels and include all required clinical information to support medical necessity.

Verify member coverage and benefit limits before scheduling.
Include relevant history, indication, and prior imaging when requesting authorization.

Documentation Required

Billing Codes and Documentation

Use the most appropriate and specific CPT/HCPCS/ICD-10 codes as of the date of service. Claims submitted without covered diagnosis or procedure codes under this Coverage Policy will be denied. Maintain and submit supporting documentation (clinical notes, prior imaging, authorization reference number) to substantiate medical necessity.

Bill with the exact CPT/HCPCS codes that describe the service performed and supporting ICD-10 diagnosis codes that justify medical necessity.
Include the Cigna-eviCore authorization/pre-certification number on claims when applicable.
Retain clinical documentation and make it available upon request to avoid documentation-based denials.

Denial Risk

Coding-based Denials

Claims lacking covered or applicable codes per the Coverage Policy, or claims for services requiring pre-certification that were performed without prior authorization, are subject to coding-based denials. Denials may occur when billed codes do not match covered services, when modifiers are used incorrectly, or when supporting documentation is insufficient.

Services billed with non-covered CPT/HCPCS codes will be denied.
Procedures requiring pre-certification but performed without authorization may be denied or downcoded.
Incorrect or missing modifiers and unsupported ICD-10 diagnoses increase denial risk.

Prior Authorization Requirements

Prior Authorization

MRI/MRA/CT/CTA subject to Cigna‑eviCore pre‑certification

High‑tech imaging modalities (MRI, MRA, CT, CTA) are subject to the Cigna‑eviCore CPT pre‑certification lists as of 1/01/2025; confirm pre‑certification requirements for these modalities when performed in hospital‑based settings.

Contrast Use and Allergy Guidance

Documentation Required

Known contrast allergy — hospital‑based imaging required when that agent will be used

If there is a known contrast allergy and that contrast agent is planned to be used, hospital‑based imaging is considered medically necessary so that appropriate emergency equipment and medications are immediately available to manage adverse events.

Definitions

Site of Care

Definition'Site of Care' refers to the location where a procedure or scan is performed.

Typical settingsFreestanding imaging facility or hospital-based imaging department/facility.

Use case — freestanding facilityMay be appropriate for medically necessary nonemergent high‑tech imaging when the individual's health status does not require higher-level supportive care.

Use case — hospital-based facilityRequired when the individual's condition necessitates availability of higher‑level resources (e.g., need for anesthesiologist, emergency support, pediatric/complex care).

Cost considerationFreestanding facilities may offer a lower cost alternative for Cigna members compared with hospital-based imaging for nonemergent procedures.

Background

“Site of Care” refers to the location where an imaging procedure is performed. For nonemergent high‑tech imaging (MRI/MRA/CT/CTA), freestanding imaging facilities are generally the preferred site when medically appropriate because they may offer lower cost for routine procedures. Hospital-based imaging departments or facilities are required when the individual’s clinical needs or the procedure demand higher-level resources — for example, pediatric patients (≤ 18 years), obstetrical/perinatal services, transplant-related care, need for moderate/deep sedation or general anesthesia not available freestanding, equipment capable of accommodating the patient’s size, management of known contrast allergy when the planned contrast agent is to be used, or emergent/urgent studies where delays or transfer would adversely affect care.

Not Covered

Hospital-based imaging for high‑tech radiology (MRI/MRA/CT/CTA) is not covered (considered not medically necessary) when none of the specified indications for hospital-based care are present. If the listed criteria — such as age ≤ 18, need for obstetrical or perinatal care, transplant-related imaging, planned use of a contrast agent in a person with a known contrast allergy, requirements for sedation/anesthesia unavailable at freestanding sites, equipment size limitations, documented claustrophobia requiring open MRI, need for hospital comparison studies for chronic disease, or emergent/urgent imaging where outside imaging would delay care — are absent, hospital-based imaging should not be billed as medically necessary under this policy.