CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Radiology Services Coverage Criteria

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

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRadiology Services 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 Solutionsradiology management partner

1 per 11 moscreening mammogram frequency

5/1/10prior auth start

2010-04-12policy created

Coverage Criteria

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Covered Indications

General imaging ordered by provider; high-end modalities require prior authorization.

High-end imaging modalities require prior authorization; all imaging must be ordered by a Health Plan physician/provider.

Ordering: Imaging is ordered by a Health Plan physician/provider

General requirement

High-end modalities: MRI, MRA, CT, PET scans, and nuclear medicine require prior authorization

Prior authorization managed by Med Solutions effective 5/1/10

Coding and Frequency Limits

Covered categories (by service type)mixed

No codes listed

Screening mammogram frequency

Frequency limitScreening mammograms for female members: one per 11 rolling months

Medical necessityCovered when medically necessary and ordered by a Health Plan physician/provider

Applies toFemale members under Neighborhood Health Plan of Rhode Island benefit packages listed in the policy

Provider Actions and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for high-end radiology services (MRI, MRA, CT, PET, nuclear medicine) and is managed by Med Solutions. Radiology services must be ordered by a Health Plan physician/provider. Lack of required prior authorization may result in claim denial.

Effective 5/1/2010 Med Solutions provides medical review and authorizations for high-end radiology.
Applies to MRI, MRA, CT, PET scans, and nuclear medicine.
Radiology services must be ordered by a Neighborhood Health Plan physician/provider.

Note

Action Required

(Inventory placeholder for high-importance provider action callout.)

Note

Ordering and Authorization Pathway

Radiology services must be ordered by a Health Plan physician/provider. For high-end imaging, the ordering provider should initiate prior authorization through Med Solutions per Neighborhood policy.

Ordering provider must request authorization from Med Solutions for high-end imaging.
Includes MRI, MRA, CT, PET, nuclear medicine.

Denial Risk

Prior Authorization and Denial Risk

High-end radiology services require prior authorization; claims for services performed without prior authorization may be denied.

Failure to obtain prior authorization for MRI/MRA/CT/PET/nuclear medicine may result in denial.

Denial Risk

PET Screening Exclusion

PET scans performed as screening tests are not covered and may be denied as non-covered screening procedures.

Positron Emission Tomography (PET) scans are not covered when performed as screening tests.

Contrast and Interventional Radiology Rules

Billing Rule

Contrast/dyes are part of interventional radiology services

Interventional radiology procedures that involve dyes or other instruments/injectibles are considered part of radiological interventional services (contrast/dye use is integral to these procedures).

Background

Radiology services in this policy encompass both diagnostic and therapeutic imaging modalities. Coverage includes common diagnostic studies such as X-rays, Ultrasounds, and Bone Density Studies, as well as specialized services including Nuclear Medicine, Radiation Oncology, and Therapeutic Interventional Radiology. Interventional Radiology is defined as radiological services with a radiologist present where dyes or other instruments/injectibles are part of the procedure. The policy also clarifies that episodes of care may occur across multiple settings (professional, urgent care, emergency room, inpatient, outpatient).

Definitions

Interventional Radiology (definition)

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

ScopeIncludes procedures performed with radiological guidance that involve contrast dyes, catheterization, or injectable agents

Coding noteSome radiologically guided procedures may be listed under other benefit coverage summaries when categorized by body system (e.g., ERCP under digestive procedures)

Benefit relationCertain procedures (e.g., amniocentesis, ultrasound-guided fetal procedures) are covered under specific benefit summaries such as maternity