Site of Care Review for High-tech Radiology (MRI/CT)
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Defines eviCore's expansion of prior authorization to include medical necessity review of the site of care for CT and MRI for Cigna commercial (non‑Medicare) and self-funded customers, guiding providers on submission and approval considerations.
eviCore will expand precertification requirements to include a medical necessity review of the site of care for CT and MRI beginning September 1, 2021, for customers with self-insured plans.
All Cigna commercial (non‑Medicare) customers may be subject to the site-of-care medical necessity review.
Precertification requests must include both the procedure and the proposed site of care; services will only be covered if both are approved.
Coverage Criteria
General coverage stance
Covered when ALL of the following are met
Services will only be covered if both procedure and site are approved.
CT and MRI site-of-care review
Precertification is required for MRI and CT scans; site-of-care review may be performed as part of precertification.
Site-of-care review may not be applied uniformly across all regions. eviCore may not review the site of care in all geographic markets while regulatory approval or network arrangements are pending. Additionally, some hospitals with competitive costs may be exempt from the site-of-care review based on market or contractual considerations.
When a request is subject to the site-of-care review, coverage is contingent on approval of both the procedure and the proposed site. Services subject to a site-of-care review will only be covered if both the procedure and the site are approved; if the site is not approved, the request may be denied or not covered.
Prior Authorization
Precertification required; site-of-care review may be performed
Precertification (prior authorization) is required for CT and MRI requests; the precertification process may include a site-of-care medical necessity review as part of that authorization. Continue to submit prior authorization requests using your existing eviCore processes (online portal or phone).
- Precertification requests must include the proposed site of care in addition to the procedure.
- eviCore may perform a site-of-care medical necessity review and will approve an outpatient hospital setting when medically necessary or when an alternative site is not available.
Provider Actions and Requirements
Precertification required; site-of-care review may be included
Continue to use existing prior authorization submission methods for MRI and CT precertification; eviCore may perform a site-of-care medical necessity review in addition to the procedure review.
Site-of-care review added to precertification workflow
Operational note: site-of-care review is being added to the existing precertification workflow effective September 1, 2021 for applicable customers.
Include procedure and proposed site; use existing submission channels
Precertification requests must include both the requested procedure and the proposed site of care; submit requests via the eviCore website or by phone.
- Online: eviCore website (eviCore.com > PROVIDERS)
- Phone: 888.693.3297
Denial risk if site of care not approved
Services will only be covered when both the procedure and the proposed site of care are approved through the precertification/site-of-care review.
Definitions
Contrast Rules
Contrast rules: applies to CT and MRI (no modality‑specific rules listed)
This policy applies to CT and MRI modalities; there are no modality‑specific contrast rules specified in this notification.
Background
This policy implements an administrative review of the appropriateness of the site of care (freestanding facility versus outpatient hospital) for CT and MRI services rather than reassessing the clinical appropriateness of the imaging study itself. The intent is to encourage use of an appropriate, lower-cost site of care when medically suitable while permitting outpatient hospital settings when medically necessary or when alternatives are unavailable. Operationally, this site-of-care review is layered into existing precertification workflows and may be applied differently across markets or exempted for certain hospitals.
Not Covered
There are no additional explicit “not covered” items listed in this notification beyond the standard consequence for disallowed site/procedure combinations. Requests subject to a site-of-care review that do not receive approval for both the procedure and the proposed site may be denied/not covered.
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