CurrentHighmark Blueshield NenyPolicy N/A

Codes Requiring Prior Authorization for the Advanced Imaging and Cardiology Services Program

Lists medical procedure codes that require prior authorization under Highmark Blue Shield NE/NY's Advanced Imaging and Cardiology Services Program, effective Jan. 1, 2019; applies to providers submitting claims for these imaging and cardiology services.

Policy Summary

PayerHighmark Blueshield Neny

PolicyCodes Requiring Prior Authorization for the Advanced Imaging and Cardiology Services Program

Policy CodePolicy N/A

Change TypeCode list publication / update

Effective DateJan 1, 2019

Next Review Date

Key ActionProviders must obtain prior authorization for the listed advanced imaging and cardiology procedure codes effective Jan. 1, 2019.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

150+procedure codes listed requiring prior authorization (approximate count in this part)

~70+procedure and HCPCS/CPT codes listed (partial)

Includedcardiology-specific codes present

MRI/CT/PET/SPECTmodalities represented

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Prior authorization code list (partial)

This part of the document is a code list indicating which imaging and cardiology procedure codes require prior authorization; it does not include clinical appropriateness criteria or authorization process steps in this excerpt.

Codes listed below require prior authorization under the Advanced Imaging and Cardiology Services Program effective Jan. 1, 2019.

ALL of the following

Example head/neck CT and MRI codes (partial list)
- 70450 — CT Head Without Contrast
- 70460 — CT Head With Contrast
- 70470 — CT Head Without & With Contrast
- 70551 — MRI Head Without Contrast (listed in brief examples)
Facial/maxillofacial and orbital CT/MRI (partial)
- 70480 — CT Orbit Without Contrast
- 70481 — CT Orbit With Contrast
- 70482 — CT Orbit Without & With Contrast
- 70540 — MRI Orbit, Face, and/or Neck Without Contrast
Additional example MRI/CT chest and cardiac screening (partial)
- 71250 — CT Thorax Without Contrast (example in brief)
- 71550 — MRI Chest Without Contrast (example in brief)
- G0297 — Low-dose CT for lung cancer screening (selected advanced imaging codes)

ALL of the following

Example cardiology procedure codes (partial list)
- 93312 — Transesophageal echocardiography (TEE) 2D; including probe placement, imaging/interpretation/report
- 93313 — Transesophageal echocardiography, real-time with image documentation (2D)
- 93314 — Transesophageal echocardiography, image acquisition, interpretation and report only
- 93451 — Right heart catheterization including measurements when performed
- 93454 — Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injections for coronary angiography, imaging supervision and interpretation

ALL of the following

Selected advanced imaging / temporary technology codes (partial)
- 0501T — Noninvasive estimated coronary FFR derived from coronary CTA using CFD (data prep, transmission, analysis, model generation and comparison)
- 0502T — Noninvasive estimated coronary FFR derived from coronary CTA: data preparation and transmission
- 0482T — Absolute quantitation of myocardial blood flow, PET, rest and stress
- 0332T — Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT

This excerpt is a partial list of codes from the program; the full policy document contains the complete code set and visual indications for new codes (new codes indicated in red).

Prior authorization code list (partial)

Procedure codes listed below require prior authorization under the program.

Codes listed below require prior authorization under the Advanced Imaging and Cardiology Services Program effective Jan. 1, 2019; new codes to require prior authorization are indicated in red in the source document.

Transesophageal echocardiography (TEE) codes

93312 — TEE 2D; including probe placement, imaging/interpretation/report
93313 — Transesophageal echocardiography, real-time with image documentation (2D)
93314 — Transesophageal echocardiography, image acquisition, interpretation and report only
93315 — Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report

CPT / HCPCS Codes Requiring Prior Authorization

Examples of codes in list (partial)CPTCovered

70336	MRI, TMJ
70450	CT Head Without Contrast
70460	CT Head With Contrast
70470	CT Head Without & With Contrast
70551	MRI Head Without Contrast
71250	CT Thorax Without Contrast
71550	MRI Chest Without Contrast
75571	CT heart without contrast, coronary calcium scoring
75574	CT angiography, heart, coronary arteries and bypass grafts with contrast
93306	Echocardiography, transthoracic, 2D complete with spectral Doppler

1–10 of 11

1/2

Selected cardiology procedure codesCPTCovered

93312	TEE 2D; including probe placement, imaging/interpretation/report
93313	Transesophageal echocardiography, real-time with image documentation (2D)
93314	Transesophageal echocardiography, image acquisition, interpretation and report only
93451	Right heart catheterization including measurements when performed
93452	Left heart catheterization including intraprocedural injections for ventriculography
93454	Catheter placement in coronary artery(s) for coronary angiography

Selected advanced imaging and other HCPCS/CPT codesmixedCovered

0501T	Noninvasive estimated coronary FFR derived from coronary CTA using CFD (data prep, transmission, analysis, model generation and comparison)
0502T	Noninvasive estimated coronary FFR derived from coronary CTA - data preparation and transmission
C8925	Transesophageal echocardiography with contrast including probe placement, acquisition, interpretation and report
C8930	Transthoracic echocardiography with contrast during stress test with monitoring and physician supervision
G0297	Low-dose CT for lung cancer screening

inv-06: Effective date — Jan 1, 2019

Effective dateJan 1, 2019 — codes listed require prior authorization effective this date

ScopeApplies to procedure codes in the Advanced Imaging and Cardiology Services Program that require prior authorization (CPT/HCPCS and temporary codes)

Applies toProviders submitting claims for imaging and cardiology services under Highmark Blue Shield NE/NY

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required for many advanced imaging and cardiology procedure codes under the Advanced Imaging and Cardiology Services Program (effective Jan. 1, 2019). New codes added to the prior authorization list are indicated in the source as new (effective Jan. 1, 2019). Providers must obtain prior authorization before performing or billing these services to avoid claim denials.

Partial list of CPT/HCPCS/Category III codes requiring prior authorization includes (not all inclusive): 70336 (MRI, TMJ); 70450, 70460, 70470 (CT Head series); 70480-70482 (CT Orbit series); 70486-70488 (CT Maxillofacial series); 70490-70492 (CT Soft Tissue Neck series); 70496, 70498 (CT Angiography Head/Neck); 70540, 70542, 70543 (MRI Orbit/Face/Neck); 93316, 93317 (TEE for congenital cardiac anomalies); 93320, 93321, 93325 (Doppler echocardiography codes); 93350, 93351, 93352 (Stress transthoracic echocardiography and contrast); 93451, 93452 (Right and left heart catheterization codes); 0332T (Myocardial sympathetic innervation imaging, SPECT); 0439T (Myocardial contrast perfusion echocardiography); 0482T (Absolute quantitation of myocardial blood flow, PET); 0501T-0504T (Noninvasive estimated coronary FFR derived from coronary CTA using computational fluid dynamics)

Definitions and Notes

inv-09: Codes Requiring Prior Authorization — definitional note about scope and effective date

DefinitionCodes Requiring Prior Authorization: procedure codes listed that require prior authorization under the Advanced Imaging and Cardiology Services Program (effective Jan. 1, 2019)

Visual cue for new codesNew codes to require prior authorization are indicated in red in the code lists

Included code typesCPT, HCPCS and temporary (T/Category III) codes are included in the lists

Document noteThe lists enumerate specific procedure codes and designate newly added codes with a red visual marker in the original document

inv-10: New codes to require prior authorization are indicated in red — visual cue definition

Meaning of red highlightingRed text indicates codes that are newly added to require prior authorization

Where shownNew-code red visual cue appears within the code list tables in the policy document

Implication for providersCodes shown in red are subject to prior authorization beginning with the policy effective date (Jan. 1, 2019)

Cardiac catheterization and coronary angiography codes

93451 — Right heart catheterization including measurements when performed
93453 — Combined right and left heart catheterization including intraprocedural injections for left ventriculography, imaging supervision and interpretation, when performed
93454 — Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injections for coronary angiography, imaging supervision and interpretation
93455 — Catheter placement in coronary artery(s) for coronary angiography; with catheter placement(s) in bypass graft(s) including intraprocedural injections for bypass graft angiography
93456 — Catheter placement in coronary artery(s) for coronary angiography, with right heart catheterization

Selected temporary/advanced cardiology imaging codes

0332T — Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT
0439T — Myocardial contrast perfusion echocardiography, at rest or with stress
0482T — Absolute quantitation of myocardial blood flow, PET, rest and stress
0501T — Noninvasive estimated coronary FFR derived from coronary CTA using computational fluid dynamics; data preparation, transmission, analysis, model generation and comparison
0502T — Noninvasive estimated coronary FFR derived from coronary CTA; data preparation and transmission
0503T — Noninvasive estimated coronary FFR derived from coronary CTA; analysis and model generation
0504T — Noninvasive estimated coronary FFR derived from coronary CTA; anatomical data review in comparison with estimated FFR

OpenPayer

Codes Requiring Prior Authorization for the Advanced Imaging and Cardiology Services Program

Prior Authorization: Covered Procedures

CPT / HCPCS Codes Requiring Prior Authorization

What Providers Must Do

Definitions and Notes