Codes Requiring Prior Authorization for the Advanced Imaging and Cardiology Services Program
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Lists CPT/HCPCS procedure codes that require prior authorization under Highmark BlueShield's Advanced Imaging and Cardiology Services Program; applies to providers submitting imaging and cardiology service claims.
No material clinical or coverage changes in this revision.
Prior Authorization Coverage Criteria
Prior authorization by code
Prior authorization is required by code for procedures listed under the Advanced Imaging and Cardiology Services Program (effective Jan 1, 2019).
Prior authorization code lists
Codes listed below require prior authorization under the Advanced Imaging and Cardiology Services Program (effective Jan 1, 2019).
ALL of the following
Echocardiography and Doppler codes
- 93316 - 93352: Transesophageal and transthoracic echocardiography, Doppler and stress echocardiography codes (including use of contrast during stress echocardiography)
Cardiac catheterization and coronary angiography codes
- 93451 - 93462: Right and left heart catheterization and coronary angiography catheter placement codes (including combined right and left procedures)
Advanced imaging temporary and proprietary codes
- 0042T, 0331T - 0504T: Temporary (T) codes for advanced PET/CT, CT-derived FFR, myocardial blood flow quantitation, myocardial innervation imaging, myocardial contrast perfusion and related services
- C8900 - C8936: Proprietary C- codes for various MRA and echocardiography services (with and without contrast)
New codes to require prior authorization are indicated in red in the source document.
Procedure and CPT/HCPCS Codes Requiring Authorization
| 70336 | MRI; TMJ |
| 70450 | CT Head without contrast |
| 75571 | Computed tomography, heart; without contrast material, with quantitative evaluation of coronary calcium |
| 93306 | Echocardiography, transthoracic, real-time with image documentation (2D), complete; with spectral Doppler and color flow |
| 93454 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) and imaging supervision |
| 93316-93352 | Various transthoracic and transesophageal echocardiography and Doppler codes listed requiring prior authorization. |
| 93451-93462 | Right and left heart catheterization and coronary angiography catheter placement codes listed requiring prior authorization. |
| 93530-93533 | Heart catheterization codes for congenital heart disease (CHD) variants requiring prior authorization. |
| 0042T, 0331T-0504T | Advanced imaging and PET/CT/CT-PET related temporary (T) codes including CT perfusion, myocardial innervation imaging, myocardial contrast perfusion, myocardial blood flow quantitation, and CT-derived FFR codes. |
| C8900-C8936 | Proprietary C- codes for various MRA and echocardiography with/without contrast requiring prior authorization. |
| 60297, S8037, S8042, S8085, S8092 | Additional imaging screening and modality-specific codes (low-dose CT lung screening, MRCP, low-field MRI, FDG dual-head coincidence detection, electron beam CT) listed requiring prior authorization. |
Provider Requirements and Actions
Prior Authorization Required
Prior authorization is required for the listed advanced imaging and cardiology procedure codes under the Advanced Imaging and Cardiology Services Program (effective Jan 1, 2019).
- Codes Requiring Prior Authorization for the Advanced Imaging and Cardiology Services Program (Effective Jan 1, 2019). New codes to require prior authorization are indicated in red.
- CPT codes requiring prior authorization include (non-exhaustive list shown below):
Codes Requiring Prior Authorization — Code List
Codes requiring prior authorization (effective Jan 1, 2019):
- 70336 - MRI; Temporomandibular Joint (TMJ)
- 70450 - CT Head without contrast
- 70460 - CT Head with contrast
- 70470 - CT Head without & with contrast
- 70480 - CT Orbit without contrast
- 70481 - CT Orbit with contrast
- 70482 - CT Orbit without & with contrast
- 70486 - CT Maxillofacial without contrast
- 70487 - CT Maxillofacial with contrast
- 70488 - CT Maxillofacial without & with contrast
- 70490 - CT Soft Tissue Neck without contrast
- 70491 - CT Soft Tissue Neck with contrast
- 70492 - CT Soft Tissue Neck without & with contrast
- 70496 - CT Angiography, Head
- 70498 - CT Angiography, Neck
- 70540 - MRI; Orbit, Face, and/or Neck without contrast
- 70542 - MRI; Face, Orbit, and/or Neck with contrast
- 70543 - MRI; Face, Orbit, and/or Neck with & without contrast
- 93316 - Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only
- 93317 - Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only
- 93320 - Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; complete
- 93321 - Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; follow-up or limited study
- 93325 - Doppler echocardiography, color flow velocity mapping
- 93350 - Echocardiography, transthoracic, real-time with image documentation (2D), with or without m-mode recording, during rest and cardiovascular stress test; with interpretation and report
- 93351 - Echocardiography, transthoracic; real-time with image documentation (2D), includes m-mode recording, when performed; during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation
- 93352 - Use of echocardiographic contrast agent during stress echocardiography (list separately)
- 93451 - Right heart catheterization including measurement(s) of oxygen saturation
- 93452 - Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation when performed
- 93453 - Combined right and left heart catheterization including intraprocedural injection(s) for ventriculography
Definitions and Notes on Code Presentation
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