CurrentFidelis CarePolicy N/A

Imaging utilization review matrix (CPT/HCPCS groupings)

Defines allowable billed code groupings and utilization review stance for imaging procedures for Fidelis Care NY Medicaid members (2026 matrix). Applies to imaging providers and utilization management staff submitting or reviewing authorization requests.

Policy Summary

PayerFidelis Care

PolicyImaging utilization review matrix (CPT/HCPCS groupings)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionEvolent will determine whether the PET scan itself is indicated and the imaging facility must bill accurately for what was performed; when PET fusion is performed, UM determinations will be issued for both PET and the diagnostic CT codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+imaging CPT/HCPCS codes listed with allowable billed groupings

PET series includedPET and PET/CT code guidance provided

G0252specific tumor-imaging PET code noted as non-covered for breast cancer indication

Modifier 59billing instruction for PET fusion with diagnostic CT

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PET-specific coverage and billing rules

General utilization review approach for PET imaging and combined studies

Evolent will review medical necessity for the PET scan itself; the imaging facility is expected to bill accurately for what was performed.

If a PET fusion study is performed (simultaneous PET and diagnostic CT on the same machine), Evolent will review medical necessity for both the PET and the diagnostic CT and issue utilization management determinations on both codes.

When a PET fusion study is billed, the diagnostic CT code should be appended with modifier 59.

If a PET scan is clinically indicated, either PET-only or PET/CT code series (78811–78816, including the 78814 series) are acceptable; the tumor-imaging guideline does not distinguish clinically between techniques.

G0252 (tumor imaging PET for initial diagnosis or surgical planning of breast cancer) is identified as a non-covered indication.

CPT / HCPCS Code Groupings and Status

Representative CPT groupings and allowable billed groupingsCPTCovered

70450	CT Head/Brain; allow groupings 70450, 70460, 70470, +0722T
70551	MRI Brain; allow groupings 70551, 70552, 70553, +0698T
72141	MRI Cervical Spine; allow groupings 72141, 72142, 72156, +0698T
74181	MRI Abdomen; allow groupings 74181, 74182, 74183, S8037, +0698T, +0724T

HCPCS tumor/PET codes with coverage notesHCPCSNot Covered

G0252	Tumor imaging PET for breast cancer — noted as non-covered indication
G0219	PET imaging whole body, melanoma for non-covered indications

Authorization and Billing Expectations

Prior Authorization

PET authorization and billing expectations

Evolent will determine whether the PET scan itself is indicated; the imaging facility must bill in a manner that accurately describes what was performed. When PET fusion (simultaneous PET and diagnostic CT) is performed, Evolent will review medical necessity for both the PET and the diagnostic CT and issue utilization management determinations on both codes.

If PET fusion is performed, bill both the PET and the diagnostic CT CPT codes and expect UM review of both codes.
Imaging facility billing should reflect the actual procedure performed (PET-only vs PET/CT/fusion).

PET Technical Definitions

inv-05: PET fusion — definition/explanatory note

DefinitionA PET fusion study is when a PET scan and a diagnostic CT scan are performed on the same machine simultaneously; CPT instructs billing both the PET CPT code and the CT code describing the body region and procedure performed.

Billing instructionWhen PET fusion is performed, bill both the PET code and the diagnostic CT code; append modifier 59 to the CT code to ensure proper payment.

Utilization review handlingEvolent will review medical necessity for both the PET and the diagnostic CT codes and issue UM determinations on both codes.

inv-06: PET with CT (78814/78816 series)

Acceptable techniquePET with CT for attenuation (78816 series / 78814 series usage) is an acceptable technique and, when a PET scan is clinically indicated, use of either PET-only or PET/CT code series is acceptable.

Clinical equivalenceEvolent's tumor imaging clinical guidelines do not distinguish clinically between PET alone and PET/CT for tumor imaging determinations.

Billing guidanceThese PET/CT codes are included in the Allowable Billed Groupings (78811–78816); codes in the 78814 series are not to be used for PET fusion billing (see PET fusion guidance).