Rocky Mountain Health Plans: Radiology CPT Code List
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A payer-specific list mapping radiology CPT codes to coverage/prior authorization (PA) requirements for Rocky Mountain Health Plans members; indicates Medicare exclusion and PA Medical Necessity Review for Medicaid and Commercial lines for listed codes.
No material clinical or coverage changes in this revision.
Coverage and Authorization Summary
Coverage summary
For the radiology CPT codes listed in this document the following payer-specific stances apply:
ALL of the following
- Medicare: Excluded from Program
- Medicaid: PA Medical Necessity Review required for listed codes
- Commercial: PA Medical Necessity Review required for listed codes
Per-CPT code coverage/authorization
Per-code coverage/authorization designations:
Examples
- CPT 74182 (MRI of the abdomen without gadolinium): Medicare: Excluded from Program; Medicaid: PA Medical Necessity Review; Commercial: PA Medical Necessity Review
- CPT 74183 (MRI of the abdomen with gadolinium): Medicare: Excluded from Program; Medicaid: PA Medical Necessity Review; Commercial: PA Medical Necessity Review
- CPT 74185 (MRA of the abdomen): Medicare: Excluded from Program; Medicaid: PA Medical Necessity Review; Commercial: PA Medical Necessity Review
- CPT 74261 (Virtual colonoscopy diagnostic w/o contrast): Medicare: Excluded from Program; Medicaid: PA Medical Necessity Review; Commercial: PA Medical Necessity Review
- CPT 74262 (Virtual colonoscopy diagnostic w/ contrast): Medicare: Excluded from Program; Medicaid: PA Medical Necessity Review; Commercial: PA Medical Necessity Review
- CPT 74263 (Virtual colonoscopy diagnostic screening including image): Medicare: Excluded from Program; Medicaid: PA Medical Necessity Review; Commercial: PA Medical Necessity Review
- CPT 76376 (3D rendering without independent workstation): Medicare: No Prior Auth Required; Medicaid: PA Medical Necessity Review; Commercial: PA Medical Necessity Review
- CPT 76377 (3D rendering requiring independent workstation): Medicare: No Prior Auth Required; Medicaid: PA Medical Necessity Review; Commercial: PA Medical Necessity Review
- CPT 0609T–0612T (MR spectroscopy T-codes): Medicare: Excluded from Program; other lines as specified (often Investigational or PA Medical Necessity Review)
- CPT 70336 (MRI temporomandibular joint): Medicare: Excluded from Program; Medicaid: PA Medical Necessity Review; Commercial: PA Medical Necessity Review
This list reflects per-code designations in the CPT code list where Medicare is frequently listed as 'Excluded from Program' and Medicaid/Commercial as requiring 'PA Medical Necessity Review'. See individual CPT entries for exact designation.
CPT / Code Listings by Modality
| 70336 | MRI TEMPOROMANDIBULAR JOINT |
| 0609T | Magnetic resonance spectroscopy, determination and localization of discogenic pain; acquisition of single voxel data, per disc, on biomarkers |
| 0610T | Magnetic resonance spectroscopy, determination and localization of discogenic pain; transmission of biomarker data for software analysis |
| 0611T | Magnetic resonance spectroscopy, determination and localization of discogenic pain; postprocessing for algorithmic analysis of biomarker data |
| 0612T | Magnetic resonance spectroscopy, determination and localization of discogenic pain; interpretation and report |
Prior Authorization & Provider Guidance
General payer coverage stance and PA requirement
Medicare: Excluded from Program. Medicaid: PA Medical Necessity Review. Commercial: PA Medical Necessity Review.
- Applies to the radiology CPT codes listed in this document; providers must obtain prior authorization (PA) via medical necessity review for Medicaid and Commercial members before scheduling.
- Medicare claims for these listed codes are excluded from the eviCore prior authorization program and are designated "Excluded from Program."
MRA-specific coverage and PA requirement
For magnetic resonance angiography (MRA) codes the payer stances follow the same pattern: Medicare = Excluded from Program; Medicaid and Commercial = PA Medical Necessity Review.
- Examples in the list (e.g., MRA codes 70544–70548) are explicitly marked Excluded for Medicare and require PA Medical Necessity Review for Medicaid and Commercial.
- Obtain PA with supporting medical necessity documentation for MRA services for Medicaid and Commercial members prior to performing the service.
Prior authorization pattern for abdominal and colon CT/MRI codes
Abdominal MRI/MRA and virtual colon/colonoscopy CT codes are designated Medicare = Excluded from Program while Medicaid and Commercial require PA Medical Necessity Review.
- Examples include MRI abdomen codes 74182, 74183 and MRA 74185; CT virtual colonoscopy codes 74261–74263 are listed as Medicare Excluded and Medicaid/Commercial = PA Medical Necessity Review.
- Providers must request PA for these abdominal and colon MRI/CT/MRA services for Medicaid and Commercial members with documentation supporting medical necessity before scheduling.
Cardiac PET/CPET PA requirements (78429–78433)
Cardiac PET/CPET CPTs in the 78429–78433 range are designated No Prior Auth Required for Medicare but require PA Medical Necessity Review for Medicaid and Commercial.
- Examples include CPET CPT 78433 (myocardial PET combined perfusion with metabolic evaluation) which is No Prior Auth Required for Medicare and PA Medical Necessity Review for Medicaid and Commercial.
- Obtain PA with clinical justification for these cardiac PET/CPET studies when treating Medicaid or Commercial members.
Advanced/Investigational MR/CT T-code authorizations (e.g., 0609T–0612T)
Certain advanced MR/CT T-codes (0609T–0612T, 0633T–0634T) are listed as Excluded from Program for Medicare and are subject to PA Medical Necessity Review or investigational designations for other lines as specified.
- MR spectroscopy T-codes 0609T–0612T are indicated Excluded from Program for Medicare and Excluded for Medicaid in the source, with Commercial listed as Investigational for these examples.
- Providers should not expect Medicare prior authorization via eviCore for these T-codes; for Medicaid and Commercial lines, follow the PA process and note investigational or excluded designations as applicable when submitting requests.
Key Terms and Designations
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