Prior authorization and eviCore review note

These guidelines include procedures that eviCore does not review for Cigna; providers should refer to the Cigna CPT code list for the current list of high‑tech imaging procedures reviewed by eviCore when determining whether prior authorization from eviCore is required.

Prior authorization not specified in this excerpt

This excerpt is a table of contents and does not specify any prior authorization rules or payer prior‑auth processes for individual studies.

Prior authorization — not specified in this fragment

This fragment contains section listings and page numbers and does not state specific prior authorization requirements.

Provider prior authorization for listed procedure codes

The listed CPT procedure codes (MRI, CT, ultrasound and related musculoskeletal imaging CPTs) are associated with services managed by eviCore for Cigna and may require authorization per payer arrangements; providers should confirm authorization requirements for the specific CPT code requested.

• See Procedure Codes Associated with Musculoskeletal Imaging (MSP.GG.ProcedureCodes.C) for CPT enumerations.

Coordinated imaging session recommended

When multiple body areas require MRI, obtain imaging of all necessary areas in the same session and coordinate exam selection with the imaging facility to minimize repeat studies and anesthesia exposure.

Advanced imaging prior authorization guidance

Requests for MRI or CT for soft tissue masses or bone lesions should document prior imaging and clinical rationale; CT is indicated only when MRI is contraindicated or unavailable.

• Plain x‑rays are required prior to advanced imaging for masses and bone lesions.
• If ultrasound is abnormal and x‑ray is negative, MRI with and without contrast is medically necessary; CT is the alternative if MRI contraindicated.

Advanced imaging sequencing (prior auth guidance)

Clinical sequencing is required for hip/limb evaluations: begin with plain radiographs for trauma, use ultrasound for hip effusion/DDH screening in defined age windows, and reserve MRI/CT for situations when plain films or ultrasound are non‑diagnostic; prior authorization may be required if these prior steps are not documented.

• Follow-up x‑rays at 7–10 days are expected when initial films are negative and symptoms persist.
• DDH ultrasound screening is indicated in specific age/risk windows (4 weeks–4 months).

Prior authorization for advanced imaging

Advanced imaging (MRI, CT) is medically necessary for the listed clinical indications in the guidelines; when prior authorization is required by the payer, providers should obtain authorization per payer processes for the modality CPT codes requested.

• Examples include MRI hip for uncertain AVN (CPT 73721/73723) and CT/MRI in suspected abuse or spine/head injuries.

Whole body MRI for CRMO

Whole body MRI (CPT 76498) is medically necessary for suspected CRMO when characteristic MR findings would obviate biopsy and for monitoring established CRMO every 6–12 months; documentation of the clinical indication should accompany authorization requests.

• Indications: suspected CRMO to avoid biopsy; surveillance every 6–12 months for established CRMO.

Site-specific MRI/CT studies

Certain site‑specific MRI and CT studies (for example annual TMJ MRI CPT 70336 and CT/MRI for juvenile dermatomyositis progressive calcification) are specified as medically necessary in defined contexts and may require documentation of the indication when requesting prior authorization.

• MRI TMJ annually for silent TMJ arthritis in JIA (CPT 70336).
• CT (CPT 73700) or MRI (CPT 73718) for following progressive muscle calcification in juvenile dermatomyositis; CT chest (71260) and CT abdomen/pelvis (74177) with contrast for palpable adenopathy/hepatosplenomegaly.

Baker cyst initial imaging

For suspected Baker (popliteal) cyst, ultrasound (CPT 76881/76882) is the medically necessary initial study; if ultrasound is non‑diagnostic or for preoperative planning, MRI without contrast (CPT 73721) is medically necessary and should be documented when requesting authorization.

Juvenile dermatomyositis imaging

For juvenile dermatomyositis, MRI without contrast is medically necessary to confirm diagnosis and may avoid biopsy; CT (CPT 73700) or MRI (CPT 73718) may be used to follow progressive muscle calcification, and CT chest/abdomen/pelvis with contrast is indicated for palpable adenopathy or hepatosplenomegaly—document indications when requesting advanced imaging.

• MRI to confirm diagnosis and avoid biopsy.
• CT or MRI to follow progressive calcification; CT chest (71260) and CT abdomen/pelvis (74177) with contrast for systemic findings.

Prior authorization for advanced imaging modalities

Advanced imaging modalities (MRI, CT, ultrasound) are designated medically necessary for the pediatric conditions listed when indications are met after initial radiographs or other required steps; providers should follow the guideline‑specified prerequisites and obtain prior authorization per payer policy when applicable.

These guidelines state that some procedures are not reviewed by eviCore for Cigna; refer to the Cigna CPT code list and the CRMO/whole‑body MRI section for CPT 76498 when documenting necessity and seeking authorization.

No step therapy requirements in this excerpt

No step therapy requirements are present in this excerpt; there are no payer‑mandated trial sequences described beyond guideline‑directed conservative care and imaging sequencing.

No step therapy rules present

No step therapy rules are specified in this content.

Conservative care recommended before advanced imaging

Provider‑directed conservative care (for example R.I.C.E., NSAIDs, immobilization, home exercise or physical medicine) should generally be attempted prior to advanced imaging unless the guideline specifically supports immediate advanced imaging or the imaging results will affect immediate management.

• Conservative care examples include rest/ice/compression/elevation, NSAIDs, analgesics, corticosteroids, viscosupplementation, home exercise, physical medicine, or immobilization.

Plain radiographs and conservative care expected before advanced imaging

For many fracture and stress/occult fracture evaluations, plain radiographs and/or a period of conservative care or follow‑up radiographs (commonly 7–10 days or 10 days of conservative care) are expected before advanced imaging unless the fracture is in a high‑risk site where immediate MRI/CT is indicated.

• High‑risk sites (pelvis, sacrum, hip, femur, tibia, tarsal navicular, proximal 5th metatarsal, scaphoid) may require MRI/CT immediately if x‑ray non‑diagnostic.
• For other sites, obtain follow‑up x‑rays after ~10 days of conservative care before MRI/CT unless initial non‑diagnostic x‑ray was obtained ≥14 days after symptom onset.

Conservative care follow-up for stress/occult fractures

When conservative care is used for suspected stress/occult fractures outside high‑risk sites, follow-up plain x‑rays after approximately 10 days are expected; if follow‑up films remain non‑diagnostic, MRI or CT without contrast is medically necessary.

• Exception: if initial non‑diagnostic x‑ray was obtained ≥14 days after symptom onset, advanced imaging may be indicated without additional conservative care.

Imaging stepwise approach (x‑ray → ultrasound → MRI/CT)

The guidelines specify a stepwise imaging approach: begin with plain radiographs for trauma and most evaluations, use ultrasound for hip effusion and DDH screening in defined age/risk windows, and reserve MRI for cases where plain films or ultrasound are non‑diagnostic or for preoperative/postreduction assessment; CT is used if MRI is contraindicated or unavailable.

Plain radiography first-line before MRI/CT

Plain radiography is the initial study and may be all that is necessary prior to progressing to MRI or CT; advanced imaging should be pursued only when radiographs are inconclusive or when results will change management.

Start with ultrasound for suspected Baker cyst

Start with ultrasound (CPT 76881/76882) for suspected Baker cyst; proceed to MRI without contrast (CPT 73721) only if ultrasound is non‑diagnostic or for preoperative planning.

Preferred initial modality in infants

In infants with nonossified tarsal bones (e.g., club foot evaluation), ultrasound may be used preferentially to characterize cartilaginous tarsal bones and alignment prior to CT or MRI when appropriate.

Refer to customer's benefit plan for medical necessity and authorization

Providers and reviewers should refer to the applicable customer's benefit plan document and relevant coverage policies when documenting medical necessity and when determining whether prior authorization is required for a requested study.

No documentation requirements present in this excerpt

No specific documentation requirements are present in this excerpt; the content is section listings and page numbers.

No documentation requirements in table of contents

No documentation requirements are specified in the table‑of‑contents portion of the document.

Provide recent plain x‑ray results and clinical evaluation

Requesting providers should have results of plain x‑rays performed after onset or change of current symptoms available and document the clinical evaluation (history and exam) when ordering advanced imaging.

• Plain x‑rays performed after the current episode of symptoms started or changed need to be available to the requesting provider.

Clinical evaluation and plain radiographs required

A pertinent clinical evaluation including detailed history, focused physical examination, and plain x‑rays should be performed and documented prior to consideration of advanced imaging for fracture, mass, or other indications.

• Meaningful technological contact (telehealth, phone, electronic messaging) can serve as pertinent clinical evaluation.

Clinical evaluation and plain x‑ray documentation for bone lesions

For bone lesions, document a detailed history and focused exam and obtain plain x‑rays of the entire bone containing the lesion prior to advanced imaging; imaging for preoperative planning or diagnostic uncertainty should be clearly justified in the request.

• Surveillance of benign bony lesions is with plain x‑ray; MRI/CT required if diagnosis uncertain or for preoperative planning.

Required clinical documentation

Required clinical documentation includes history and focused exam identifying suspected etiology (trauma, infection, or other), localization of symptoms, and prior plain radiograph findings and clinical course when requesting follow‑up or advanced imaging.

Document imaging rationale and patient age for contact/abuse cases

For contact children and suspected abuse cases, document the child’s age, clinical examination findings, and rationale for the imaging modality chosen (e.g., neuroimaging in contacts <12 months; skeletal survey in contacts 12–24 months).

• Contacts <12 months: neuroimaging (CT head or MRI brain) and skeletal survey.
• Contacts 12–24 months: skeletal survey.

Required clinical evaluation prior to advanced imaging

A pertinent clinical evaluation (history, exam, and plain x‑rays) should be performed and documented prior to considering advanced imaging; the indication must specify how advanced imaging will affect management.

Clinical indication must document specific reason for advanced imaging

When ordering advanced imaging, the clinical indication must document the specific reason (for example: biopsy site selection, concern for progression, treatment monitoring, or preoperative planning) to support medical necessity.

Clinical documentation to support advanced imaging

Document clinical suspicion (for example limp, groin/thigh/knee pain, restricted hindfoot motion, nonossified tarsal bones, or rotational deformity) and provide prior plain radiograph results when ordering MRI, CT, or ultrasound for pediatric musculoskeletal conditions.

Coverage determinations and plan terms

Coverage determinations require consideration of the applicable benefit plan document, laws/regulations, relevant collateral materials (including coverage policies), and the specific facts of the situation; conflicts are resolved by the customer's benefit plan document.

No explicit denial triggers present

This excerpt (table of contents) does not present explicit denial triggers.

No denial rules in this fragment

No denial rules are present in the table‑of‑contents portion of this document fragment.

Denial risk if clinical evaluation or basic imaging missing

Advanced imaging requests may be denied if a pertinent clinical evaluation (history, physical exam, labs) and basic imaging such as plain x‑rays or ultrasound were not performed or documented prior to the advanced imaging request.

Denial risk when plain x‑rays already diagnostic

Advanced imaging may be denied if plain x‑rays are positive and the case is not complex; further advanced imaging is not medically necessary except for complex joint fractures or other stated indications.

Plain x‑ray prerequisite — denial risk

Advanced imaging requests may be denied if plain x‑rays were not performed first when required by the guideline (for example stress/occult fractures and soft tissue/bone mass evaluations).

Trauma imaging sequencing — denial risk

Failure to obtain initial plain x‑rays for suspected trauma, or failure to obtain follow‑up x‑rays at 7–10 days when symptoms persist after negative initial films, may risk denial when advanced imaging is requested without documented clinical indication.

DDH ultrasound appropriateness — denial risk

Requesting DDH screening hip ultrasound outside the recommended risk‑factor window (not between 4 weeks and 4 months without qualifying risk factors), or ordering hip ultrasound for infants older than 6 months when plain x‑ray is preferred, may be denied.

• Screening ultrasound medically necessary for infants 4 weeks–4 months with risk factors; hip ultrasound NOT medically necessary for infants >6 months when x‑ray is preferred.

MRI may be denied if diagnosis certain on x‑ray

Requests for MRI may be denied if the diagnosis is already certain on plain x‑ray or if the imaging will not change management.

Denial risk for incomplete abuse imaging

Failure to perform an indicated skeletal survey or appropriate CT/MRI for suspected spine/head injuries may lead to denial of coverage for alternative or incomplete evaluations.

JIA routine MRI follow‑up may be unsupported

Requests for routine MRI for follow‑up of juvenile idiopathic arthritis (except annual TMJ screening) may be unsupported since routine MRI follow‑up is not medically necessary.

• MRI TMJ (CPT 70336) is medically necessary annually for silent TMJ arthritis; other routine MRI follow‑up is not medically necessary.

Limit imaging in juvenile dermatomyositis to specified indications

Ordering CT/MRI for juvenile dermatomyositis should be limited to specified indications (confirming diagnosis, following calcification, or systemic evaluation when adenopathy/hepatosplenomegaly present); inappropriate routine imaging may be denied.

SCFE imaging sequence — denial risk

Failure to obtain plain AP and lateral (frog‑leg or cross‑table lateral) x‑rays of both hips may lead to missed SCFE diagnosis and could risk denial if diagnostic imaging steps are not followed; MRI is medically necessary when radiographs are negative but suspicion persists.

• If plain films negative and suspicion remains, MRI CPT 73721/73723 is medically necessary.

Congenital foot anomalies — follow x‑ray first rule

Not performing initial plain radiographs for suspected tarsal coalition, club foot, or vertical talus before advanced imaging may not follow guideline‑recommended imaging sequence and could risk denial; use ultrasound in infants with nonossified bones when appropriate.

• Plain x‑rays first; ultrasound for infants with nonossified tarsal bones; CT (73700) or MRI (73718) if radiographs inconclusive.