CurrentCignaPolicy 0550

Site of Care: High-tech Radiology

Defines when hospital-based imaging departments/facilities are considered medically necessary for high‑tech imaging (MRI/MRA/CT/CTA) and who is affected (Cigna plan members and providers submitting claims/authorization requests).

Policy Summary

PayerCigna

PolicySite of Care: High-tech Radiology

Policy CodePolicy 0550

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization via Cigna/EviCore resources for MRI/MRA/CT/CTA and submit appropriate diagnosis and procedure codes to avoid claim denials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MRI,MRA,CT,CTAmodalities covered by the policy

Age ≤18automatic indication for hospital-based imaging

No changesmost recent annual review note

Cigna-administeredpayers/administration

When Hospital-Based High‑Tech Imaging Is Medically Necessary

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Hospital-based imaging medically necessary when any condition met

No other appropriate alternative sites — reasons: surgery or procedure is being performed at the hospital and pre-operative or preprocedure imaging is an integral component of the procedure OR moderate or deep sedation or general anesthesia is required for the imaging procedure and freestanding facility providing such sedation is not available OR equipment for the size of the individual is only available at a hospital-based imaging facility OR an open MRI is required because clinical circumstances make a standard closed-bore MRI unsafe, intolerable, or impractical and no open MRI is available in a freestanding facility OR known cancer diagnosis and/or chronic disease where imaging needs to be performed at a hospital-based facility for comparison to prior studies, interpretation by a radiology subspecialist at that facility, or coordination with treatment services at that facility
These sub-conditions individually satisfy the 'no other appropriate alternative site' reason.

Policy Applicability Exceptions

When the following apply, this policy does not mandate hospital-based care (exceptions listed):

Policy exceptions: There is no freestanding facility in the individual's geographic area OR utilizing the freestanding facility in the individual's geographic area would cause a health disparity (for example, the hospital-based facility provides needed resources the freestanding facility does not, such as transportation or language/disability support).

Conditions where the site-of-care guidance is not applicable.

Not Medically Necessary — Hospital-based Imaging

Default stance for other situations:

Not medically necessary default: All other high-tech radiology (imaging) procedures at a hospital-based imaging department or facility are considered not medically necessary.

Applies when none of the medically necessary conditions or exceptions are met.

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

Except as explicitly allowed by the listed medically necessary indications or exceptions, all other high‑tech radiology procedures performed at a hospital-based imaging department or facility are considered not medically necessary. That is, if none of the hospital-based indications or policy exceptions apply, hospital-based imaging for MRI/MRA/CT/CTA is not supported by this policy.

Appropriate Indications for Hospital-Based Imaging

Appropriate indications warranting hospital-based MRI/MRA/CT/CTA

Appropriate indications warranting hospital-based MRI/MRA/CT/CTA:

Indications for hospital-based site: age ≤ 18; requires obstetrical observation; requires perinatology services; imaging related to transplantation services at an approved transplantation facility; known contrast allergy with planned use of that contrast agent; emergent or urgent imaging where imaging outside the hospital-based facility is expected to adversely impact or delay care; requirement for moderate/deep sedation or general anesthesia when a freestanding facility providing such sedation is not available; equipment size limitations (only available at hospital); need for open MRI because standard closed-bore MRI is unsafe, intolerable, or impractical and no open MRI is available in a freestanding facility; known cancer diagnosis and/or chronic disease necessitating hospital-based comparison, subspecialist interpretation, or coordination with treatment services.

Single top-level node enumerating appropriate indications.

Prior Authorization Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for hospital-based high‑tech imaging (MRI, MRA, CT, CTA). Providers must obtain authorization via Cigna/EviCore before scheduling services to avoid claim denials or payment delays.

Affected services: MRI, MRA, CT, CTA
Follow Cigna/EviCore for CPT code-specific prior authorization guidance and submission instructions
Failure to obtain prior authorization may result in denied or reduced payment

Denial Risk

Coding & Claim Submission Risk

When submitting claims, ensure accurate CPT coding and include the prior authorization reference number. Incomplete or incorrect coding and missing authorization numbers increase the risk of claim denial or delays.

Include EviCore/Cigna prior authorization number on claims
Verify CPT code selection against Cigna/EviCore CPT code reference for the specific high‑tech imaging procedure
Document medical necessity in the medical record to support the authorization and claim

Provider Documentation, Billing, and Submission Requirements

Billing Rule

Use appropriate, current codes at time of submission

When billing, providers must use the most appropriate procedure and diagnosis codes as of the date of submission; reimbursement is only provided if the requested service is submitted in accordance with the relevant Coverage Policy criteria, including covered diagnosis and/or procedure code(s).

Use codes current on the date of submission.
Submit the requested service with covered diagnosis and/or procedure code(s) per the Coverage Policy.

Denial Risk

Risk of denial for missing covered codes

Claims for services that are not accompanied by covered diagnosis and/or procedure codes under the applicable Coverage Policy will be denied as not covered.

Note

Confirm medical necessity indications for hospital-based imaging

Follow policy indications for when hospital-based imaging is considered medically necessary (e.g., age ≤18, obstetrical/perinatology needs, transplantation-related imaging, known contrast allergy planned, emergent/urgent imaging where non‑hospital imaging would delay care).

If none of the listed indications or exceptions apply, hospital-based imaging is considered not medically necessary.

Contrast Agent Considerations

Documentation Required

Known contrast allergy — hospital-based imaging considered medically necessary

If a known contrast allergy exists and that contrast agent is planned for use, hospital-based imaging is considered medically necessary; ensure contrast‑related safety resources and emergency equipment/medications are immediately available per professional guidance.

Document the known contrast allergy and the plan to use the specified contrast agent.
Have emergency equipment and medications immediately available as outlined by ACR practice parameters.

Not Medically Necessary / Not Covered

Hospital-based imaging for high‑tech radiology (MRI/MRA/CT/CTA) is not medically necessary when none of the policy’s listed indications or exceptions apply. Providers should expect that requests for hospital-based site of care will default to not covered unless one or more specific indications or the applicability exceptions are met.

Key Definitions

Site of Care

Definition'Site of Care' refers to the location where a procedure or scan is performed; distinguishes freestanding imaging facilities from hospital-based imaging departments/facilities.

Freestanding facility roleFreestanding imaging facilities may offer Cigna members a lower-cost alternative to hospital-based imaging for medically necessary nonemergent procedures.

Appropriate useNonemergent MRI and CT may be performed at either freestanding or hospital-based imaging locations when the individual’s health status does not require higher-level supportive care.

Higher-level care requirementCertain high-risk medical conditions may necessitate hospital resources such as an anesthesiologist to be present during advanced radiologic imaging.

ScopeApplies to nonemergent high‑tech radiology procedures/scans including MRI and CT (and related modalities).

Background and Scope

Site of Care guidance addresses whether nonemergent high‑tech imaging (MRI/CT and related angiography) should be performed at freestanding imaging facilities or at hospital-based imaging departments. Freestanding facilities may be appropriate and lower cost for medically necessary nonemergent imaging when the patient’s health status does not require hospital-level resources. Certain clinical situations and patient needs—such as pediatric age (≤18 years), obstetrical or perinatology services, transplant-related imaging at an approved transplant center, known contrast allergy when that contrast will be used, need for anesthesia or specialized equipment, emergent/urgent care concerns, or lack of available freestanding resources—warrant hospital-based imaging.

OpenPayer