ModifiedColorado Rocky Mountain Health PlansPolicy CARDIOLOGY 025.27

Outpatient Cardiology Procedures for EviCore Arrangement (for Oxford Only)

This policy governs prior authorization, accreditation, and billing requirements for outpatient cardiology procedures managed by EviCore for Oxford members; it affects participating cardiology and radiology providers seeking authorization for specified outpatient cardiology imaging and catheterization services.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOutpatient Cardiology Procedures for EviCore Arrangement (for Oxford Only)

Policy CodePolicy CARDIOLOGY 025.27

Change TypeCode list revised0042T added

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization from EviCore for listed outpatient cardiology procedures and submit required clinical documentation; authorization numbers are valid for 45 calendar days.

SourceLink

POLICY UPDATE CHANGES

Revised list of CPT codes requiring prior authorization through EviCore; added 0042T.

Archived previous policy version CARDIOLOGY 025.26.

45Auth validity (days)

7Procedures that may require auth

1New CPT added

2Crosswalks included

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Coverage and Authorization Criteria

Prior authorization and documentation requirements

Covered when ALL of the following are met:

EviCore prior authorization and documentation: Provider must obtain prior authorization from EviCore for outpatient cardiology procedures; providers may request authorization by phone (1-877-773-2884) or via the Prior Authorization and Notification App; authorization number is valid for 45 calendar days for one date of service.45 calendar days

Treating providers may be asked to submit a clinical submission form and supporting documentation (e.g., office notes, treatment planning documents, and results of key diagnostic studies).

Accreditation requirements

Participating providers must meet the following accreditation prerequisites to be reimbursed for specified cardiac services:

Accreditation by modality

Required accreditations: Cardiac CT Scan: ACR (American College of Radiology)
Required accreditations: Cardiac PET: IAC (Intersocietal Accreditation Commission)
Required accreditations: Cardiac MRI: RadSite (or equivalent where specified)
Required accreditations: Nuclear Medicine: The Joint Commission (TJC)

Note: Hospitals are currently excluded from the privileging and accreditation requirements listed for participating providers. The policy’s accreditation prerequisites (for example, ACR for Cardiac CT, IAC for Cardiac PET, RadSite for Cardiac MRI, and TJC for Nuclear Medicine) apply to participating outpatient facilities and individual providers as specified, but do not impose those privileging/accreditation obligations on hospitals.

This Clinical Policy is provided for informational purposes and does not constitute medical advice. When determining coverage for a specific member, the member’s benefit plan document and any applicable federal or state mandates govern and take precedence over this policy. UnitedHealthcare Oxford policies are intended to support—but not replace—the independent professional medical judgment of a qualified health care provider.

Applicable Codes and Crosswalks

Covered CPT Codes (selected cardiac & imaging)CPTCovered

0571T	Insertion or replacement of implantable cardioverter-defibrillator system with substernal electrode(s) (includes imaging guidance and electrophysiological evaluation)
0614T	Removal and replacement of substernal implantable defibrillator pulse generator
0742T	Absolute quantitation of myocardial blood flow (AQMBF), SPECT, with exercise or pharmacologic stress, and at rest (list separately)
75557	Cardiac MRI for morphology and function without contrast
75559	Cardiac MRI for morphology and function without contrast; with stress imaging
75561	Cardiac MRI for morphology and function with contrast and further sequences
75563	Cardiac MRI for morphology and function with contrast and stress imaging
75571	CT heart without contrast with coronary calcium scoring
75572	CT heart with contrast for evaluation of cardiac structure and morphology
75573	CT heart with contrast for congenital heart disease evaluation

1–10 of 31

1/4

Diagnostic Catheterization Crosswalk (prior authorization interchangeables)CPT

93452	Prior auth given for 93452; claims may be submitted with 93453-93461
93453	Prior auth given for 93453; claims may be submitted with 93451, 93452, 93454-93461
93454	Prior auth given for 93454; claims may be submitted with 93452-93453, 93455-93461
93455	Prior auth given for 93455; claims may be submitted with 93452-93454, 93456-93461
93456	Prior auth given for 93456; claims may be submitted with 93452-93455, 93457
93457	Prior auth given for 93457; claims may be submitted with 93452-93456, 93458-93461
93458	Prior auth given for 93458; claims may be submitted with 93452-93457, 93459-93461
93459	Prior auth given for 93459; claims may be submitted with 93452-93458, 93460-93461
93460	Prior auth given for 93460; claims may be submitted with 93452-93459, 93461
93461	Prior auth given for 93461; claims may be submitted with 93452-93460

Diagnostic Catheterization Crosswalk (summary)CPT

93452	Left heart catheterization — prior auth maps to 93453-93461
93453	Combined right & left — maps to 93451, 93452, 93454-93461
93454	Coronary angiography — maps to 93452-93453, 93455-93461

Stress Echocardiogram CrosswalkCPT

93350	Prior auth given for 93350; claims may be submitted with 93351
93351	Prior auth given for 93351; claims may be submitted with 93350

Updated Applicable Codes (new additions)CPTCovered

0042T

New CPT code added to list requiring prior authorization as of policy revision effective 04/01/2026

Provider Requirements and Actions

Prior Authorization

Prior authorization required — handled by EviCore; request pathways

All prior authorization requests for outpatient cardiology procedures are handled by EviCore on behalf of Colorado Rocky Mountain Health Plans. To obtain prior authorization, providers must contact EviCore by phone at 1-877-PRE-AUTH (1-877-773-2884) or via the Prior Authorization and Notification App on the EviCore website. The authorization/notification number issued by EviCore is valid for 45 calendar days and applies to the specific advanced outpatient imaging or cardiology procedure requested for a single date of service within that period.

Authorization valid for 45 calendar days and specific to the requested procedure and date of service.
Providers may be asked to submit a clinical submission form and supporting documentation (office notes, treatment planning documents, key diagnostic study results).
EviCore uses evidence-based criteria and may perform site-of-service review; Oxford remains responsible for final coverage decisions and appeals.

Prior Authorization

Procedures requiring prior authorization — list of outpatient cardiac imaging/procedures

The following outpatient cardiac imaging and procedures may require prior authorization through EviCore: cardiac CAT scan, cardiac MRI, fractional flow reserve (FFR-CT), nuclear stress testing, cardiac PET scans, outpatient cardiac catheterization (elective, left, dual), and outpatient stress echocardiogram. Additional procedures may be added as necessary.

Background and Scope

This policy describes administrative prior authorization and accreditation processes for outpatient cardiology imaging and catheterization procedures managed through Oxford’s arrangement with EviCore. Prior authorization is required for the listed outpatient cardiac procedures and EviCore manages accreditation submissions; providers should submit accreditations directly to EviCore and include all applicable facility and physician information to ensure prompt handling. The policy assumes board certification recognized by the American Board of Medical Specialties for the listed specialties.

Definitions

Clinical submission form definition

DefinitionClinical submission form — a form that treating cardiology providers may be asked to submit to EviCore when requesting prior authorization, documenting clinical indication and treatment plan.

Supporting documentationMay require copies of office notes and treatment planning documents to accompany the clinical submission form.

Diagnostic resultsMay require results of key diagnostic studies and/or office notes to support the request.

PurposeUsed by EviCore staff, in conjunction with board-certified cardiologists and radiologists, to evaluate submitted treatment and billing plans for medical necessity and appropriate billing.

Submission methodsProviders can request prior authorization (and submit required documentation) via phone (1-877-773-2884) or the Prior Authorization and Notification App, per EviCore instructions.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOutpatient Cardiology Procedures for EviCore Arrangement (for Oxford Only)

Policy CodePolicy CARDIOLOGY 025.27

Change TypeCode list revised0042T added

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization from EviCore for listed outpatient cardiology procedures and submit required clinical documentation; authorization numbers are valid for 45 calendar days.

SourceLink

On This Page

Documentation Required

Required clinical documentation — clinical submission form and supporting documentation

Providers may be required to submit supporting clinical documentation when requesting authorization. Acceptable documentation includes completed clinical submission forms, copies of office notes, treatment planning documents, and results of key diagnostic studies. In some cases, a board-certified cardiologist (or radiologist where applicable) will review the submission and may be available to discuss the decision with the treating provider.

Clinical submission form may be requested.
Include copies of office notes, treatment planning documents, and key diagnostic study results.

Denial Risk

Failure to obtain prior authorization — potential limitations or denials and Oxford responsibility

If prior authorization is not obtained when required, the claim may be subject to limitations or denial. Colorado Rocky Mountain Health Plans (Oxford) retains responsibility for coverage decisions, including denials and appeals; failure to obtain prior authorization does not change Oxford’s role in coverage determination. Providers should obtain authorization in advance to reduce risk of nonpayment or claim adjustment.

Failure to obtain prior authorization may result in claim denial or payment limitation.
Oxford is responsible for final coverage decisions and appeals even though EviCore conducts the initial review.

Billing Rule

Crosswalk documentation — rules for substituting mapped CPT codes when prior auth obtained

When prior authorization is obtained for a specific CPT code, certain CPT codes mapped in EviCore’s Crosswalk are considered interchangeable for the purposes of that authorization. Providers may submit a claim using an interchangeable (mapped) CPT code from the Diagnostic Catheterization or Stress Echocardiogram Crosswalks if prior authorization was obtained for a corresponding code. Examples include mapping between 93461 and codes billed in the range 93452–93460 (Diagnostic Catheterization Crosswalk) and mapping between 93350 and 93351 (Stress Echocardiogram Crosswalk).

Diagnostic Catheterization Crosswalk: Prior authorization for 93461 may allow submission of claims billed with codes 93452–93460 and vice versa as specified in the crosswalk documentation.
Stress Echocardiogram Crosswalk: Prior authorization for 93350 may allow claim submission with 93351, and prior authorization for 93351 may allow claim submission with 93350.

Prior Authorization

Out-of-network prior authorization requirement for members with OON benefits

Oxford Commercial Plan members who have out-of-network benefits must obtain prior authorization for outpatient cardiology studies when receiving services from an out-of-network provider.

Out-of-network prior authorization required for Oxford Commercial Plan members with OON benefits.