Kaiser Permanente high-end imaging Prior Auth

When Hospital-Based High‑Tech Imaging Is Medically Necessary

Covered when ANY of the criteria are met

Hospital-based imaging is considered medically necessary for an individual with ANY of the following:

Hospital-based imaging indications: Any one of: Less than 13 years of age (PET scan less than 17 years of age); requires obstetrical observation; requires perinatology services; imaging related to transplantation services at an approved transplantation facility; patient enrolled in an approved clinical trial and trial protocol requires imaging to be done at this site; known contrast allergy and use of that contrast agent is planned; no other appropriate alternative sites available for the individual to undergo the imaging procedure for specified reasons (see subcriteria); moderate or deep sedation or general anesthesia is required and freestanding facility providing such sedation is not available; equipment for the size of the individual is only available at a hospital-based imaging facility; documented claustrophobia requiring open MRI not available in a freestanding facility; imaging outside the hospital-based imaging department or facility is expected to adversely impact or delay care; patient has a pacemaker that requires coordination, monitoring, and a code team onsite during the MRI which are not available at a nearby freestanding site.

Subcriteria for 'no other appropriate alternative sites' include: (1) pre-operative or preprocedure imaging integral to a covered surgery or procedure performed at that specific hospital where the protocol is unique to the institution or image interpretation requires specialized radiology expertise not routinely available outside the hospital (examples: epilepsy surgery mapping, pre‑TAVR planning in certain geographies, complex breast reconstruction planning); (2) to maintain continuity within an episode of care when performed within 6 weeks of a hospital-based operation or procedure and non-hospital imaging is not available in the same care delivery system; (3) other specified reasons listed in the policy.

All other high‑tech radiology procedures performed in a hospital‑based imaging department or facility are considered not medically necessary in the absence of one of the listed indications or circumstances. This includes, but is not limited to, use of hospital imaging for pre‑procedural planning for elective procedures and robotic-assisted surgeries. When none of the specified site‑of‑care criteria apply, non‑hospital locations such as clinics or freestanding imaging centers are expected to be used; hospital‑based imaging may only be authorized when no appropriate, geographically accessible freestanding imaging center is available.

Hospital‑based imaging for high‑tech radiology (e.g., CT, CTA, MRI, MRA, PET, PET‑CT) is not medically necessary when none of the policy’s specified indications or circumstances for hospital site‑of‑care are present. In those situations, imaging should be performed at an appropriate non‑hospital site (clinic or freestanding imaging center) unless an exception in the criteria applies.

Appropriate Hospital-Based Site-of-Care Indications

Hospital-based site of care is appropriate

Hospital-based site-of-care criteria: Hospital-based site of care is appropriate when any one of the site-of-care indications listed in the policy is met (see 'Covered when ANY of the criteria are met').

Refer to the listed indications for details (pediatric age thresholds, sedation requirements, equipment availability, continuity within 6 weeks, contrast allergy, transplant/clinical trial requirements, pacemaker coordination, etc.).

CPT / HCPCS Codes and Coding Notes

Considered Medically Necessary CT/CTA codes when criteria metCPTCovered

70450	Computed tomography, head or brain; without contrast material.
70460	Computed tomography, head or brain; with contrast material(s).
70470	Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections.
70496	Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing.
70480	Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material.
70481	Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s).
70482	Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections.
70486	Computed tomography, maxillofacial area; without contrast material.
70487	Computed tomography, maxillofacial area; with contrast material(s).
70488	Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections.

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Magnetic Resonance Angiography (MRA) codes when criteria metCPT|HCPCSCovered

70544	Magnetic resonance angiography, head; without contrast material(s).
70545	Magnetic resonance angiography, head; with contrast material(s).
70546	Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences.
70547	Magnetic resonance angiography, neck; without contrast material(s).
70548	Magnetic resonance angiography, neck; with contrast material(s).
70549	Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences.
72159	Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s).
71555	Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s).
74185	Magnetic resonance angiography, abdomen, with or without contrast material(s).
72198	Magnetic resonance angiography, pelvis, with or without contrast material(s).

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Magnetic Resonance Imaging (MRI) codes when criteria metCPT|HCPCSCovered

70336	Magnetic resonance (eg, proton) imaging, temporomandibular joint(s).
70540	Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s).
70542	Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s).
70543	Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences.
70551	Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material.
70552	Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s).
70553	Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences.
70554	Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration.
70555	Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing.
71550	Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s).

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MRI CPT/HCPCS codesmixed

73718	Magnetic resonance imaging, lower extremity other than joint; without contrast material(s).
73719	Magnetic resonance imaging, lower extremity other than joint; with contrast material(s).
73720	Magnetic resonance imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences.
73721	Magnetic resonance imaging, any joint of lower extremity; without contrast material.
73722	Magnetic resonance imaging, any joint of lower extremity; with contrast material(s).
73723	Magnetic resonance imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences.
74181	Magnetic resonance imaging, abdomen; without contrast material(s).
74182	Magnetic resonance imaging, abdomen; with contrast material(s).
74183	Magnetic resonance imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences.
76391	Magnetic resonance elastography.

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PET CPT codesCPT

78811	Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck).
78812	Positron emission tomography (PET) imaging; skull base to mid-thigh.
78813	Positron emission tomography (PET) imaging; whole body.
78814	PET with concurrently acquired CT for attenuation correction and anatomical localization; limited area.
78815	PET with concurrently acquired CT for attenuation correction and anatomical localization; skull base to mid-thigh.
78816	PET with concurrently acquired CT for attenuation correction and anatomical localization; whole body.
78608	Brain imaging, PET; metabolic evaluation.
78609	Brain imaging, PET; perfusion evaluation.
78429	Myocardial imaging, PET, metabolic evaluation study; with concurrently acquired CT transmission scan.
78459	Myocardial imaging, PET, metabolic evaluation study; single study.

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Episode continuity window — 6 weeks

Episode continuity window6 weeks

Context for continuity ruleHospital-based imaging is medically necessary when performed within 6 weeks of a hospital-based operation or procedure if non-hospital imaging is not available in the same care delivery system

Applies toPre-operative or procedure-related imaging that is integral to a covered surgery or procedure at the same hospital

Documentation noteThere must be documentation that images cannot be performed at a freestanding facility and transmitted for pre-op planning or in‑OR use

Pediatric age threshold

Authorization Requirements and Provider Responsibilities

Prior Authorization

Prior authorization for site of care — required

A high-tech imaging service (MRI, MRA, CT, CTA, PET, PET-CT) must meet applicable medical necessity criteria for coverage. When coverage criteria are met for the requested imaging procedure, this policy is used to determine whether a hospital-based (hospital imaging department or facility) site of care is medically necessary for ambulatory, non-emergent imaging.

Denial Risk

All listed high‑tech modalities — hospital site-of-care criteria

All listed high‑tech modalities (MRI, MRA, CT, CTA, PET, PET‑CT) requested to be performed in a hospital-based imaging department or facility require documentation that the site‑of‑care criteria are met. In the absence of one of the allowed indications, hospital-based imaging is considered not medically necessary and non–hospital sites (clinic or free‑standing imaging centers) are expected to be used. Hospital-based imaging may be authorized if there is no appropriate geographically accessible free‑standing imaging center.

Contrast Use and Allergy Considerations

Billing Rule

Hospital‑based imaging allowed when planned contrast use with known contrast allergy

If there is a known contrast allergy and use of that contrast agent is planned, hospital‑based imaging is considered medically necessary.

Billing Rule

Use procedure code descriptors to indicate contrast status

Multiple procedure codes specify contrast status (without contrast, with contrast, and without followed by with contrast and further sequences); use the code descriptors when billing to indicate contrast status.

Clinical Rationale and Scope

Hospital‑based advanced radiologic imaging is reserved for patients who require a higher level of supportive care or resources that cannot be provided in freestanding settings. Examples include individuals needing specialized monitoring or anesthesiology support, pediatric or neonatal patients requiring pediatric‑specific equipment or perinatology/obstetrical observation, very large patients who require equipment not available elsewhere, or patients with documented conditions (e.g., severe claustrophobia) that necessitate hospital‑based capabilities. These factors justify hospital‑based imaging to minimize the risk of adverse events and to ensure appropriate peri‑procedural support.

Key Definitions

Advanced radiologic imaging examples

Advanced radiologic imaging — examplesComputed tomography (CT)

Advanced radiologic imaging — examplesComputed tomographic angiography (CTA)

Advanced radiologic imaging — examplesMagnetic resonance imaging (MRI)

Advanced radiologic imaging — examplesMagnetic resonance angiography (MRA)

Advanced radiologic imaging — examplesPositron emission tomography (PET) / PET‑CT

Services Not Medically Necessary

Hospital‑based imaging for non‑emergent, high‑tech radiology procedures is not covered when the policy’s specified indications or circumstances for hospital site‑of‑care are not met. In such cases, services should be obtained at an appropriate non‑hospital site (clinic or freestanding imaging center) unless the policy criteria explicitly authorize hospital‑based care or there is no geographically accessible freestanding facility.

OpenPayer

Clinical Review Criteria — High‑End Imaging Site of Care