Prior Authorization for Outpatient Advanced Diagnostic Imaging, Sleep Studies, and Genetic Testing
Customize your policy alerts
Sign up for all Health-New-England policy alerts
Know when Health-New-England releases new policies or updates existing guidance.
Monitor payer policy activity
This policy governs prior authorization requirements and utilization management for outpatient advanced diagnostic imaging (CT, MRI/MRA, PET, nuclear cardiology), sleep studies, and genetic lab testing for Health-New-England products. It affects ordering physicians and facilities rendering outpatient services.
No material clinical or coverage changes in this revision.
Coverage Criteria
Authorization and Accreditation Requirements
Covered when outpatient services meet prior authorization and facility accreditation requirements
Order must include patient symptoms, past clinical history, and prior treatment information at the time of the prior authorization request; failure to obtain prior authorization may result in denial of payment; this policy does not apply to emergency room, observation, or inpatient imaging procedures.
This policy does not apply to imaging performed in the emergency room, observation, or inpatient settings. The requirements and prior authorization processes described here are limited to outpatient services only; inpatient and emergent care pathways follow separate authorization and coverage rules.
Advanced Diagnostic Imaging procedures, sleep studies, and genetic testing performed in the outpatient setting require prior authorization through eviCore healthcare. Failure to obtain prior authorization for the listed outpatient procedures may result in denial of payment. This policy applies to all Health‑New‑England products and applies when the facility and suppliers meet any applicable accreditation requirements for the technical component of advanced imaging.
Coding / Procedure Codes
| CT Scan | CT Scan |
| MRI/MRA | MRI/MRA |
| PET Scan | PET Scan |
| Nuclear Cardiology | Nuclear Cardiology |
| Sleep Studies | Sleep Studies |
| Genetic Lab Testing | Genetic Lab Testing |
Provider Actions and Requirements
Prior Authorization Required
Prior authorization is required for outpatient advanced diagnostic imaging, sleep studies, and genetic lab testing performed in an outpatient setting. eviCore healthcare performs utilization management for these services on behalf of Health-New-England. This requirement does not apply to emergency room, observation, or inpatient imaging procedures. Failure to obtain prior authorization for listed procedures may result in denial of payment.
- Applies to all HNE products
- Excludes emergency room, observation, and inpatient imaging
Provider Actions — Authorization Responsibility
The ordering physician is responsible for obtaining prior authorization from eviCore healthcare for the requested service. The facility providing radiological services is responsible for ensuring authorization has been obtained prior to rendering service. Providing services without prior authorization may result in denial of payment.
- Ordering physician must obtain prior authorization
- Facility must confirm authorization prior to service
Documentation Required at Time of Request
Patient symptoms, past clinical history, and prior treatment information must be available at the time of the prior authorization request. eviCore healthcare may require this documentation during the review.
- Include patient symptoms, past clinical history, and prior treatments with the request
Submission Channels and Timing
eviCore can accept prior authorization requests online via the secure portal at https://www.evicore.com/ (available 24/7) or by phone at (888) 693-3211 during call center hours (Mon–Fri, 8 a.m.–9 p.m. EST). Studies ordered after hours or on weekends may be performed, but the ordering physician must contact eviCore within 48 hours of the next business day to obtain proper authorization; such reviews remain subject to medical necessity.
- Online portal: https://www.evicore.com/ (24/7)
- Phone: (888) 693-3211 (Mon–Fri, 8 a.m.–9 p.m. EST)
- After-hours studies require eviCore contact within 48 hours of next business day
Denial Risk — Failure to Obtain Authorization
Denial risk: Failure to obtain prior authorization or to provide required documentation may result in denial of payment for the service.
- Services rendered without authorization are at risk of payment denial
- Incomplete documentation at time of request may delay or lead to denial
Covered Indications and Settings
Prior authorization required for listed modalities when outpatient
Prior authorization is required when any of the following modalities are performed in the outpatient setting:
Prior authorization requests must be submitted to eviCore (web portal available 24/7 or by phone during call center hours).
Prior Authorization Summary
Prior authorization required for listed outpatient modalities
Advanced Diagnostic Imaging (CT, MRI/MRA, PET, Nuclear Cardiology), Sleep Studies, and Genetic Lab Testing require prior authorization when performed in an outpatient setting for all HNE products.
- Procedures listed: CT Scan; MRI/MRA; PET Scan; Nuclear Cardiology; Sleep Studies; Genetic Lab Testing.
- This prior authorization requirement does not apply to emergency room, observation, or inpatient imaging procedures.
Definitions
Contrast and Technical-Supplier Rules
Accreditation required for technical component suppliers of advanced imaging
Suppliers of the technical component (TC) of advanced diagnostic imaging services must be accredited per CMS requirements; this applies to physicians, nonphysician practitioners, and Independent Testing Facilities, but excludes hospitals.
- Accreditation requirement follows CMS definitions for advanced diagnostic imaging (MRI, CT, PET).
- Requirement applies to suppliers furnishing the technical component, not to physicians interpreting studies.
Background
This policy describes utilization management and prior authorization processes rather than clinical indications. It governs the administrative requirements for outpatient advanced diagnostic imaging, sleep studies, and genetic lab testing — including when prior authorization is required and potential payment denial for services rendered without authorization — and is applicable across all HNE products.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.