ModifiedPHC California (Positive Healthcare California – AIDS Healthcare Foundation)Policy N/A

Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists

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Guides medical necessity and benefit determinations for services and related claims when no directly applicable Clinical UM Guideline exists, including services associated with providers on pre-payment review.

Policy Summary

PayerPHC California

PolicyPre-Payment Review Medical Necessity Determinations

Policy CodePolicy N/A

Change TypeModified

Effective DateN/A

Last ReviewDec 16, 2024

Next Review DateN/A

Key ActionDocument the determination and the resources used in the appropriate medical management system.

SourceLink

POLICY UPDATE CHANGES

The coding section was updated to reflect CPT code changes and to add or remove specific procedure codes.

CPT codes 71010, 71020, 71021, and 74020 were removed from the coding section.

The guideline's references and coding sections were periodically updated following committee review.

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ModifiedPHC California (Positive Healthcare California – AIDS Healthcare Foundation)Policy N/A

Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists

Customize your policy alerts

Sign up for all phccalifornia policy alerts

Know when phccalifornia releases new policies or updates existing guidance.

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Policy Summary

PayerPHC California

PolicyPre-Payment Review Medical Necessity Determinations

Policy CodePolicy N/A

Change TypeModified

Effective DateN/A

Last ReviewDec 16, 2024

Next Review DateN/A

Key ActionDocument the determination and the resources used in the appropriate medical management system.

SourceLink

POLICY UPDATE CHANGES

The coding section was updated to reflect CPT code changes and to add or remove specific procedure codes.

CPT codes 71010, 71020, 71021, and 74020 were removed from the coding section.

The guideline's references and coding sections were periodically updated following committee review.

Medical Necessity Coverage Criteria

Medical Necessity Determination

Medical necessity determinations for applicable services and codes should be made when no Clinical UM Guideline directly applies, using relevant resources and professional judgment.

ALL of the following

The Organization does not have a Clinical UM Guideline directly applicable to the particular medical necessity determination for the request for review or claim.
The reviewer selects and considers resources relevant to the decision; the resource list is not exhaustive, and every resource need not be used in every case.
The reviewer uses more than one relevant resource when more than one resource applies to the decision.
The reviewer exercises professional judgment in selecting appropriate resources and rendering the determination.
The determination takes the member's clinical circumstances into account.
The reviewer documents the determination and the resources used in the appropriate medical management system.

This document provides guidance and a list of resources for Organization Medical Reviewers when the Organization does not have a Clinical UM Guideline directly applicable to a particular medical necessity determination for a request for review or claim related to the services and codes identified in the guideline, in connection with a provider who is on pre-payment review. The applicable services and codes may be modified when additional inappropriate use of services is identified, and services and codes may be added accordingly. Utilization Management departments follow standard procedures to meet relevant timeframes and notification requirements for urgent and non-urgent requests, as appropriate.

Definitions of “medically necessary” or “medical necessity” and “investigational” in the covered individual's plan document apply for purposes of making benefit determinations.

The codes listed in the guideline are included for informational purposes. Inclusion or exclusion of a procedure, diagnosis, or device code does not constitute or imply member coverage or provider reimbursement policy. Refer to the member's contract benefits in effect at the time of service to determine coverage or noncoverage for an individual member.

In making benefit decisions, the Organization determines whether services are medically necessary in accordance with generally accepted standards of medical practice, taking into account credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, the views of physicians practicing in relevant clinical areas, and other relevant factors as they relate to the member's clinical circumstances.

Applicable Codes

CPTCPT

71045	Radiologic examination, chest; single view
71046	Radiologic examination, chest, 2 views
71047	Radiologic examination, chest, 3 views
72020	Radiologic examination, spine, single view, specify level
72040	Radiologic examination, spine, cervical; 2 or 3 views
72050	Radiologic examination, spine, cervical; 4 or 5 views
72052	Radiologic examination, spine, cervical; 6 or more views
72070	Radiologic examination, spine; thoracic, 2 views
72074	Radiologic examination, spine; thoracic, minimum of 4 views
72082	Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 2 or 3 views

1–10 of 62

1/7

ICD-10 DiagnosisICD-10

All diagnoses

Codes added or referenced in coding revisionsCPT

96365-96379	CPT codes added in a coding update
93886-93893	CPT codes added in a coding revision
93975	CPT code referenced in the coding history
93976	CPT code referenced in the coding history
76881	CPT code added in the coding history
76882	CPT code added in the coding history

Codes added in 2018 coding updateCPT

71045-71047	CPT codes added with a coding update
74021	CPT code added with a coding update

Codes removed from coding sectionCPTNot Covered

71010	CPT code removed from the coding section
71020	CPT code removed from the coding section
71021	CPT code removed from the coding section
74020	CPT code removed from the coding section

Reviewer and Provider Requirements

Documentation Required

Document the Determination

After making a determination, the Organization Medical Reviewer must document the decision and the resources used in the appropriate medical management system. Follow standard Utilization Management procedures for applicable timeframes and notification requirements for urgent and non-urgent requests.

Note

Use Relevant Resources and Professional Judgment

Review resources relevant to the decision and use more than one resource when more than one is relevant; the resource list is not exhaustive, and every resource need not be used in every case. Reviewers must exercise professional judgment when selecting resources and rendering the determination, considering the member’s clinical circumstances.

Documentation Required

Consult the Member’s Plan Definitions

For benefit determinations, apply the definitions of “medically necessary” or “medical necessity” and “investigational” in the covered individual’s applicable plan document.

Guideline Purpose and Scope

The Organization evaluates the medical necessity of requested or provided services when no directly applicable Clinical UM Guideline exists. The evaluation considers generally accepted medical practice, credible peer-reviewed scientific evidence, relevant physician specialty society recommendations, physician input from the applicable clinical area, other relevant factors, and the member’s clinical circumstances. The guideline applies to services and related claims identified for review, including radiographic examinations, ultrasound, transcranial Doppler, vascular duplex studies, and diagnostic or therapeutic infusion and injection services.

Key Definitions

Physician Specialty Society

DefinitionA United States medical specialty society that represents diplomates certified by a board recognized by the American Board of Medical Specialties.

Geographic scopeUnited States medical specialty society

Certification relationshipRepresents diplomates certified by a board recognized by the American Board of Medical Specialties.

Pre-Payment Review

Prior Authorization

Expect pre-payment review when applicable

Pre-payment review applies to claims or requests connected with a provider who is on pre-payment review when no other directly applicable Clinical UM Guideline exists. The listed services and corresponding codes may be modified when additional inappropriate use of services is identified.