CurrentFidelis CarePolicy N/A

Advanced Imaging/Cardiac Services - Medicaid Members

Defines the CPT-4 codes and allowable billed groupings that Evolent manages on behalf of Fidelis Care for advanced imaging and cardiac services for Medicaid members; excludes services rendered in ED, observation, surgery center, urgent care, or inpatient settings.

Policy Summary

PayerFidelis Care

PolicyAdvanced Imaging/Cardiac Services - Medicaid Members

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain Evolent authorization for listed CPT codes or submit the exact authorized CPT if the family is not listed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

dozensCPT codes enumerated

ED/Obs/ASC/UC/IPSettings excluded

conditionalAdd-on payment

G0252Explicit non-covered

Coverage Criteria and Billing Rules

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Member must be eligible at the time of service (coverage is conditioned on member eligibility).

Service must be authorized by Evolent for the listed CPT code or an authorized family listed in the matrix; if a family is not listed, the billed CPT must exactly match the authorized CPT.

Claim must include an appropriate diagnosis code, applicable re-bundling rules must be applied, and the service must be performed within the authorization validity period.

Services rendered in Emergency Room, Observation Status, Surgery Center, Urgent Care Center, or Hospital Inpatient settings are excluded from Evolent management (not managed by Evolent).

Evolent will determine whether a PET scan is indicated but will not adjudicate which specific CPT code within an authorized family is clinically required; the imaging facility must bill the code that accurately describes what was performed.

When a PET fusion study (simultaneous PET and diagnostic CT on same machine) is performed, both the PET and the diagnostic CT code should be billed; the CT code should be appended with modifier 59 and Evolent will review medical necessity for both codes.

Payment for add-on (+) codes may depend on their appropriateness relative to the approved primary code.

Certain codes are identified as non-covered for specific indications (for example, G0252 is noted as a non-covered indication for tumor imaging in breast cancer; +0742T is non-covered).

CPT / HCPCS Codes and Allowable Billed Groupings

Selected example CPT/HCPCS codes and allowable billed groupingsmixedCovered

70450	CT Head/Brain; allowable billed groupings include 70450, 70460, 70470, +0722T
70551	MRI Brain; allowable billed groupings include 70551, 70552, 70553, +0698T
75574	CTA coronary arteries (CCTA); allowable billed groupings = 75574
78816	PET Scan with CT for attenuation; allowable billed groupings include 78811, 78812, 78813, 78814, 78815, 78816
G0252	PET imaging, initial diagnosis of breast cancer and/or surgical planning for breast cancer (listed as a non-covered indication in this document)

Provider Responsibilities, Authorizations, and Scope

Prior Authorization

Evolent manages prior authorization and adjudication; follow family-of-code submission rules

Evolent manages prior authorization and claim adjudication for the CPT-4 codes listed in the matrix on behalf of Fidelis Care. If a family of CPT codes is listed in the matrix, any one of the listed procedure codes may be submitted on a claim representing the authorized service; if a family is not listed, an exact match between the authorized CPT code and the billed CPT code is required.

Submitted claim must assume member eligibility at time of service, appropriate re-bundling rules, an appropriate diagnosis code, and service performed within the validity period.
When the family is not listed in the matrix, lack of exact match should be adjudicated accordingly.

Documentation Required

Evolent determines PET indication but not selection between CPTs; add-on payment may be conditional

Evolent will determine whether a PET scan (the imaging study) is indicated but will not make medical necessity determinations between individual CPT codes within an authorized PET family; the imaging facility is expected to bill accurately for the service performed. Payment for add-on (+) codes may be conditional on the appropriateness of their application relative to the approved primary code.

If PET and diagnostic CT are performed simultaneously (PET fusion), bill both PET and the CT body-region code and append modifier 59 to the CT; Evolent will review medical necessity for both codes.
Codes in the 78814 series and non-CT PET series are both acceptable when PET is indicated; Evolent's tumor imaging guidelines do not distinguish technique for indication.

Denial Risk

Services in ED, observation, surgery center, urgent care, and inpatient settings are excluded

Services rendered in Emergency Room, Observation Status, Surgery Center, Urgent Care Center, or Hospital Inpatient settings are not managed by Evolent and therefore are excluded from Evolent prior authorization and adjudication.

Do not submit requests for Evolent authorization for services performed in the excluded settings listed above.

Definitions and Billing Clarifications

inv-06: Allowable billed groupings

RuleIf a family of CPT codes is listed in the matrix, any one of the listed procedure codes may be submitted on a claim representing an authorized service; otherwise an exact match between the authorized and billed CPT code is required.

ConditionsSubmission of an alternate code from a listed family assumes member eligibility at time of service, appropriate re-bundling rules, an appropriate diagnosis code, and service performed within the validity period.

AdjudicationIf an exact match is required but the billed code does not match the authorized CPT, the charge should be adjudicated accordingly.

ScopeThe matrix is intended to assist in resolution of claims adjudication and claims questions related to services authorized by Evolent.

inv-07: Evolent's role in medical necessity determination

Evolent's determinationEvolent will determine whether the PET scan itself is indicated but will not determine which specific CPT within an authorized family is clinically appropriate; imaging facility must bill to accurately describe what was performed.

Add-on/technique distinctionEvolent's tumor imaging guidelines do not distinguish between PET with or without CT component; either series is acceptable when PET is indicated.

PET fusion billingFor PET fusion studies (simultaneous PET and diagnostic CT), both the PET CPT and the CT code for the body region should be billed; the CT code should be appended with modifier 59 and Evolent will review medical necessity for both codes.

Non-covered exampleG0252 (tumor imaging PET for breast cancer under a specific indication) is noted as a non-covered indication in the document.