ModifiedColorado Rocky Mountain Health PlansPolicy CARDIOLOGY 025.29

Outpatient Cardiology Procedures for EviCore Arrangement (for Oxford Only)

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This policy governs prior authorization, accreditation, specialty, coding, crosswalk, and payment requirements for participating providers performing specified outpatient cardiology and advanced cardiac imaging services for UnitedHealthcare Oxford members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOutpatient Cardiology Procedures for EviCore Arrangement (for Oxford Only)

Policy CodePolicy N/A

Change TypeModified

Effective DateNovember 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization through EviCore by calling 1-877-PRE-AUTH or using the Prior Authorization and Notification App.

SourceLink

POLICY UPDATE CHANGES

The policy clarifies that the UnitedHealthcare Oxford Radiology and Cardiology Prior Authorization Crosswalk Table lists CPT codes that are interchangeable for prior authorization.

The list of CPT and HCPCS codes requiring prior authorization through EviCore was revised, including removal of codes 0571T and 0614T.

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ModifiedColorado Rocky Mountain Health PlansPolicy CARDIOLOGY 025.29

Outpatient Cardiology Procedures for EviCore Arrangement (for Oxford Only)

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Sign up for Colorado Rocky Mountain Health Plans Policy CARDIOLOGY 025.29 alerts

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Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOutpatient Cardiology Procedures for EviCore Arrangement (for Oxford Only)

Policy CodePolicy N/A

Change TypeModified

Effective DateNovember 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization through EviCore by calling 1-877-PRE-AUTH or using the Prior Authorization and Notification App.

SourceLink

POLICY UPDATE CHANGES

The policy clarifies that the UnitedHealthcare Oxford Radiology and Cardiology Prior Authorization Crosswalk Table lists CPT codes that are interchangeable for prior authorization.

The list of CPT and HCPCS codes requiring prior authorization through EviCore was revised, including removal of codes 0571T and 0614T.

45 daysAuthorization validity

2EviCore authorization options

7Procedure categories potentially requiring authorization

2Stress echocardiography crosswalk codes

93451-93461Diagnostic catheterization code range

Coverage Criteria

Payment and authorization requirements

Payment is available when all applicable requirements are met.

Outpatient cardiac service payment requirements: The service is a specified outpatient cardiac service performed by a participating provider; required prior authorization has been obtained; the provider meets the applicable specialty and accreditation requirements; the service is performed once on one date of service within the authorization's 45-day validity period; and billing complies with applicable payment guidelines.Authorization valid for 45 calendar days

Hospitals are excluded from the privileging and accreditation requirements described in this policy.

Specialty and accreditation requirements

Participating-provider specialty and accreditation requirements vary by cardiac service.

Applicable provider qualification: The participating provider must satisfy the specialty requirement applicable to the cardiac service and hold the applicable accreditation. Covered service categories include nuclear medicine, cardiac CT, cardiac PET, cardiac MRI, and diagnostic cardiac heart catheterization. The policy assumes board certification by an American Board of Medical Specialties (ABMS)-recognized board in the provider's specialty. Accreditation requirements include ACR certification for cardiac CT, IAC certification for cardiac PET, RadSite accreditation for cardiac MRI, and The Joint Commission (TJC) accreditation for nuclear medicine.

Hospitals are currently excluded from the privileging and accreditation requirements.

Hospitals are excluded from the privileging and accreditation requirements described for participating providers under this policy.

The applicable-code list is provided for reference only, may not be all inclusive, and does not independently establish whether a service is covered, non-covered, reimbursable, or guaranteed payment. Coverage is determined by the member-specific benefit plan, applicable law, and other applicable policies.

Applicable Codes and Crosswalks

Applicable CPT CodesCPT

0742T	Absolute quantitation of myocardial blood flow (AQMBF), single-photon emission computed tomography (SPECT), with exercise or pharmacologic stress, and at rest, when performed (List separately in addition to code for primary).
75557	Cardiac MRI for morphology and function without contrast material.
75559	Cardiac MRI for morphology and function without contrast material; with stress imaging.
75561	Cardiac MRI for morphology and function without contrast material(s), followed by contrast material(s) and further sequences.
75563	Cardiac MRI for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging.
75571	Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium.
75573	Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease, including 3D image postprocessing, assessment of left ventricular cardiac function, right ventricular structure and function, and evaluation of vascular structures, if performed.
75574	Computed tomographic angiography, heart, coronary arteries and bypass grafts when present, with contrast material, including 3D image postprocessing, evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed.
75577	Quantification and characterization of coronary atherosclerotic plaque to assess severity of coronary disease, derived from augmentative software analysis of the data set from a coronary computed tomographic angiography, with interpretation and report by a physician or other qualified health care professional.
75580	Noninvasive estimate of coronary fractional flow reserve (FFR) derived from augmentative software analysis of the data set from a coronary computed tomography angiography, with interpretation and report by a physician or other qualified health care professional.

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Diagnostic Catheterization CrosswalkCPT

93451	Submitted with CPT codes 93452-93461 under the diagnostic catheterization authorization crosswalk.
93452	Crosswalked with submitted codes 93451 and 93454-93461; may be substituted when authorization corresponds to the crosswalked procedure.
93453	Crosswalked with submitted codes 93452-93453 and 93455-93461; may be substituted when authorization corresponds to the crosswalked procedure.
93454	Crosswalked with submitted codes 93452-93453 and 93455-93461; may be substituted when authorization corresponds to the crosswalked procedure.
93455	Crosswalked with submitted codes 93452-93454 and 93456-93461.
93456	Crosswalked with submitted codes 93452-93455 and 93457.
93457	Crosswalked with submitted codes 93452-93456 and 93458-93461.
93458	Crosswalked with submitted codes 93452-93457 and 93459-93461.
93459	Crosswalked with submitted codes 93452-93458 and 93460-93461.
93460	Crosswalked with submitted codes 93452-93459 and 93461.

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Diagnostic Catheterization CrosswalkCPTCovered

93452	Diagnostic catheterization crosswalk code
93453	Diagnostic catheterization crosswalk code
93454	Diagnostic catheterization crosswalk code
93455	Diagnostic catheterization crosswalk code
93456	Diagnostic catheterization crosswalk code
93457	Catheter placement in bypass graft(s), including intraprocedural injection(s) for bypass graft angiography and imaging supervision and interpretation
93458	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with left heart catheterization including intraprocedural injection(s)
93459	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with left heart catheterization and catheter placement(s) in bypass graft(s)
93460	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with right and left heart catheterization
93461	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for left ventriculography, when performed, with right and left heart catheterization and catheter placement(s) in bypass graft(s)

Stress Echocardiogram CrosswalkCPTCovered

93351	Echocardiography, transthoracic, real-time with image documentation (2D), including M-mode recording when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation
93350	Stress echocardiography procedure code billed as the crosswalk substitute for CPT 93351

Codes Removed From Prior Authorization ListCPT

0571T	Code removed from the list of CPT/HCPCS codes requiring prior authorization through EviCore
0614T	Code removed from the list of CPT/HCPCS codes requiring prior authorization through EviCore

Authorization validity

Validity period45 calendar days

Authorized serviceThe authorization applies to the specific advanced outpatient imaging procedure requested.

Use limitationThe procedure must be performed one time on one date of service within the 45-day period.

Authorization and Provider Requirements

Prior Authorization

EviCore Prior Authorization Required

Prior authorization is required for applicable outpatient cardiology and cardiac imaging services under the EviCore arrangement. EviCore performs the initial review, including any applicable site-of-service review.

Applicable services include outpatient cardiology procedures and advanced cardiac imaging.
Oxford remains responsible for coverage limitation or denial decisions and appeals.

Prior Authorization

How to Request Authorization

All prior authorization requests for cardiology procedures are handled by EviCore. Providers may request authorization by telephone or through the Prior Authorization and Notification App.

Call EviCore at 1-877-PRE-AUTH (1-877-773-2884).
Log on to the Prior Authorization and Notification App.

Unsupported block type: billing_rule

Policy Scope

This policy applies to outpatient cardiac imaging and diagnostic catheterization services, including nuclear medicine, cardiac CT, cardiac PET, cardiac MRI, stress echocardiography, and diagnostic cardiac catheterization. EviCore evaluates medical necessity and appropriate billing using evidence-based cardiology and management criteria, with reviews performed by EviCore staff in conjunction with board-certified cardiologists and radiologists.

Coding and Crosswalk Definitions

Diagnostic Catheterization Crosswalk

DefinitionA mapping of CPT codes that are interchangeable for prior authorization.

Authorization useWhen prior authorization is obtained for a procedure corresponding to the crosswalk, the listed substitution is appropriate.

Covered code rangeThe diagnostic catheterization crosswalk includes CPT codes 93451 through 93461.

CPT Codes Not Subject to TC/PC Component

DefinitionCPT codes that are not subject to technical/professional component billing.

ReimbursementThese codes may be reimbursed to both the physician and facility.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOutpatient Cardiology Procedures for EviCore Arrangement (for Oxford Only)

Policy CodePolicy N/A

Change TypeModified

Effective DateNovember 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization through EviCore by calling 1-877-PRE-AUTH or using the Prior Authorization and Notification App.

SourceLink

On This Page

Prior Authorization

Outpatient Cardiology Studies Requiring Authorization

The following outpatient cardiology studies may require prior authorization through EviCore. Additional procedures may be added as necessary.

Cardiac CT (CAT) scan
Cardiac MRI
Fractional flow reserve (FFR-CT)
Nuclear stress testing
Cardiac PET scans
Elective outpatient cardiac catheterization, including left and dual procedures
Outpatient stress echocardiogram

Prior Authorization

Out-of-Network Provider Authorization

Oxford Commercial Plan members with out-of-network benefits must obtain prior authorization for applicable outpatient cardiology studies when services are provided by an out-of-network provider.

Confirm the member's out-of-network benefit status before scheduling the study.
Obtain authorization through EviCore before the applicable study is performed.

Billing Rule

Stress Echocardiogram Crosswalk

CPT 93351 and CPT 93350 are interchangeable for prior authorization and billing when the authorized procedure corresponds with the stress echocardiogram crosswalk.

Prior authorization given for CPT 93351 may be submitted and billed with CPT 93350.
The crosswalk applies to the applicable transthoracic stress echocardiography procedure.

Billing Rule

Diagnostic Catheterization Crosswalk

The diagnostic catheterization crosswalk identifies interchangeable CPT codes for prior authorization and billing. When authorization is obtained for a listed procedure, the corresponding crosswalk substitution is appropriate.

Applicable catheterization codes include 93452 through 93461.
CPT 93457 may be submitted with 93452-93456 or 93458-93461.
CPT 93458 may be submitted with 93452-93457 or 93459-93461.
CPT 93459 may be submitted with 93452-93458 or 93460-93461.
CPT 93460 may be submitted with 93452-93459 or 93461.
CPT 93461 may be submitted with 93452-93460.

Documentation Required

Clinical Submission Documentation

Treating cardiology providers may be asked to submit a clinical submission form and supporting documentation so EviCore can evaluate the treatment and billing plans.

Copies of office notes and treatment-planning documents
Results of key diagnostic studies and/or office notes
EviCore will provide written notice of services approved for payment.

Unsupported block type: documentation

Denial Risk

Authorization and Payment Requirements

Payment may be limited or denied when required authorization, notification timing, accreditation, specialty, or other policy requirements are not satisfied. Participating providers must also meet applicable specialty and accreditation requirements for payable services.

Use the authorization or notification number within its 45-calendar-day validity period.
Ensure the authorized procedure and date of service are accurate.
Confirm applicable provider specialty and accreditation requirements before performing the service.

Unsupported block type: billing_rule

Denial Risk

Missing EviCore Prior Authorization

Failure to obtain required EviCore prior authorization for an applicable outpatient cardiology study may result in nonpayment or denial.

Obtain authorization before performing the applicable study.
Do not rely on retrospective authorization to satisfy the requirement.

Denial Risk

Out-of-Network Oxford Services

Applicable outpatient cardiology studies for Oxford Commercial members with out-of-network benefits require authorization when performed by an out-of-network provider. Without the required authorization, payment may be denied or unavailable.

Check out-of-network benefit status and provider network status before scheduling.
Obtain the required EviCore authorization before the service date.

The physician and facility claims must be billed for the same date of service.