CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Radiology / Diagnostic Imaging — Coverage Criteria

Defines coverage, limitations, prior authorization requirements, and exclusions for radiology and diagnostic imaging services for Neighborhood Health Plan of Rhode Island members and applicable benefit packages.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRadiology / Diagnostic Imaging — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization from Med Solutions for high-end imaging (MRI, MRA, CT, PET, nuclear medicine).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Med Solutionsprior auth vendor

1/11 momammogram freq

Excludedscreening PET

Multiplebenefit packages

Coverage Criteria

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Ordering: Ordered by a Health Plan physician/provider

Service type: Includes diagnostic and therapeutic imaging services such as X-rays, ultrasounds, bone density studies, therapeutic interventional radiology, nuclear medicine, and radiation oncology

Benefit package: Member enrolled in an applicable Neighborhood Health Plan benefit package (RIte Care, Children with Special Health Care Needs, Substitute Care, Rhody Health Plan, Rhody Health Options Phase One, ACA Adult Expansion)

Extended Family Planning (EFP) members are excluded from the plan’s comprehensive radiology benefits; EFP members do not have a full radiology benefit package and should not be billed under Neighborhood Health Plan’s standard radiology coverage.

In addition, Positron Emission Tomography (PET) scans are not covered when submitted as a screening test. Providers must ensure the indication submitted with PET requests documents diagnostic or staging intent rather than screening to avoid denial.

Coding and Frequency Limits

CPT alignment notemixed

No codes listed

inv-05: Screening mammogram frequency — one per 11 rolling months.

Screening mammogram frequencyOne screening mammogram per rolling 11 months for female members when medically necessary.

ApplicabilityApplies to female members covered under Neighborhood Health Plan benefit packages listed in the policy (e.g., RIte Care, CSHCN, Substitute Care, RHP, RHO Phase One, ACA Adult Expansion).

Medical necessity requirementScreening mammograms must be medically necessary to be covered under this frequency limit.

inv-11: Interventional Radiology definition — radiological services with radiologist present involving dyes/injectables.

DefinitionInterventional Radiology: radiological services with a radiologist present where dyes or other instruments/injectibles are part of the procedure.

Examples of proceduresIncludes therapeutic interventional radiology procedures that use contrast, dyes, or injectables.

Billing/benefit noteSome image-guided procedures may be listed under other benefit coverage summaries (e.g., maternity for amniocentesis).

inv-13: mammogram (screening) frequency limit — one per 11 rolling months.

Frequency limitOne screening mammogram is covered per rolling 11 months.

ConditionCovered when medically necessary and ordered by a Health Plan physician/provider.

Related policiesBone Mineral Density Testing frequency/criteria and other screening guidelines referenced in the clinical medical policy.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for high-end imaging studies. Authorization for MRI, MRA, CT, PET, and nuclear medicine is managed by Med Solutions (effective 5/1/2010).

Affected services: MRI, MRA, CT, PET, Nuclear Medicine
Authorization vendor: Med Solutions (effective 5/1/2010)

Documentation Required

Provider Ordering Requirement

Order radiology services only when requested by a Health Plan physician/provider. Ensure prior authorization is obtained for high-end imaging per plan requirements.

Denial Risk

PET Screening Exclusion

Positron Emission Tomography (PET) scans are not covered as a screening test. PETs require prior authorization when used for diagnostic purposes; screening PETs are excluded from coverage.

PET scans: Not covered for screening

Contrast and Interventional Procedures

Billing Rule

Contrast and radiologist presence for interventional procedures

Interventional radiology procedures involve use of dyes or injectables and require a radiologist to be present for the procedure.

Document use of contrast, dyes or injectables in the procedure note.
Confirm a radiologist is present and document their involvement in the record.

Background

This policy addresses radiology services across diagnostic and therapeutic imaging modalities, including X-rays, ultrasounds, bone density studies, therapeutic interventional radiology, nuclear medicine, radiation oncology, and screening mammography. Interventional radiology is defined as radiological procedures performed with a radiologist present where dyes or other injectables or instruments are used. Note that certain services (for example, amniocentesis and ultrasound‑guided fetal procedures) are covered under separate maternity benefit summaries and may be billed under those benefit areas rather than the radiology benefit.