sierra health and life outpatient cardiology Prior Auth

Coverage and Authorization Requirements

Coverage with authorization and provider accreditation

Covered when prior authorization is obtained and accreditation and documentation requirements are met:

Prior Authorization: Prior authorization for the outpatient cardiology procedure has been obtained from EviCore (authorization number is valid for 45 calendar days for a single date of service)45 days

Authorization specific to requested procedure and date of service.

Documentation: Required documentation (e.g., clinical submission form, office notes, diagnostic study results) has been submitted to EviCore for review

EviCore may request specific records; decisions informed by EviCore cardiology/radiology review and a board-certified cardiologist is available where required by state regulations.

Accreditation/Provider Requirements: Participating providers meet the service-specific accreditation and specialty requirements (for example, ACR for Cardiac CT, IAC for Cardiac PET, RadSite for Cardiac MRI, TJC for Nuclear Medicine)

Hospitals are currently excluded from the privileging and accreditation requirements in this policy.

Prior Authorization Requirements

Prior authorization required for specified outpatient cardiology procedures when submitted through EviCore; crosswalks permit substitution of certain CPT codes when prior authorization was obtained for the mapped code.

Prior Authorization Required: Requestor must obtain prior authorization through EviCore for outpatient cardiac CAT (CCTA), cardiac MRI, FFR-CT, nuclear stress testing, cardiac PET, outpatient cardiac catheterization (elective, left, dual), and outpatient stress echocardiogram.

Authorization requests are managed by EviCore; member benefit documents govern coverage and additional procedures may be added to the list.

CPT Crosswalk Coverage Logic

If prior authorization is obtained for one CPT in a crosswalk, substitution with the mapped CPT is acceptable.

Crosswalk substitution: Authorizations obtained for a CPT listed in a crosswalk may be used interchangeably with the mapped CPT(s) identified in the Diagnostic Catheterization and Stress Echocardiogram crosswalks (e.g., 93350↔93351; mappings among 93452–93461 as specified).

Providers must follow the specific CPT mappings shown in the policy crosswalk charts when submitting claims.

Hospitals are excluded from the privileging and service-specific accreditation requirements described for participating providers. The policy lists accreditation expectations for outpatient cardiac services (for example, ACR for Cardiac CT, IAC for Cardiac PET, RadSite for Cardiac MRI, and TJC for Nuclear Medicine) that apply to participating non-hospital providers; hospitals are not required to meet these privileging/accreditation elements under this policy.

Participating providers (non-hospital) must meet the specialty and accreditation requirements to be reimbursed for radiology and cardiology services rendered in office or outpatient settings, and prior authorization is required for these services.

This Clinical Policy is intended to assist interpretation of UnitedHealthcare Oxford standard benefit plans; however, member-specific benefit plan documents govern if terms differ. Unless explicitly stated otherwise, Oxford policies do not apply to Medicare Advantage members. Before relying on this policy, verify the member’s benefit document and any applicable federal or state mandates.

Applicable Procedure Codes and Authorization Validity

MRI / CT / deviceCPT

0571T	Insertion or replacement of implantable cardioverter-defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters), when performed.
0614T	Removal and replacement of substernal implantable defibrillator pulse generator.
75557	Cardiac MRI for morphology and function without contrast material.
75559	Cardiac MRI for morphology and function without contrast material; with stress imaging.
75561	Cardiac MRI for morphology and function without contrast material(s), followed by contrast material(s) and further sequences.
75563	Cardiac MRI for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging.
75571	Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium.

Cardiac CT / FFR-CTCPT

75571	Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium.
75572	Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed).
75573	Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of left ventricular [LV] cardiac function, right ventricular [RV] structure and function and evaluation of vascular structures, if performed).
75574	Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed).
75580	Noninvasive estimate of coronary fractional flow reserve (FFR) derived from augmentative software analysis of the data set from a coronary computed tomography angiography, with interpretation and report by a physician or other qualified health care professional.

Nuclear Medicine / PETCPT

78451	Myocardial perfusion imaging, tomographic (SPECT); single study, at rest or stress (exercise or pharmacologic).
78452	Myocardial perfusion imaging, tomographic (SPECT); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection.
78453	Myocardial perfusion imaging, planar; single study, at rest or stress (exercise or pharmacologic).
78454	Myocardial perfusion imaging, planar; multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection.
78459	Myocardial imaging, PET, metabolic evaluation study; single study.
78491	Myocardial imaging, PET, perfusion study; single study, at rest or stress (exercise or pharmacologic).
78492	Myocardial imaging, PET, perfusion study; multiple studies at rest and stress.

Stress EchocardiogramCPT

93350

93351

Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional.

Diagnostic Cardiac Heart CatheterizationsCPT

93452	Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed.
93453	Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed.
93454	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) 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 injection(s) for bypass graft angiography.
93456	Catheter placement in coronary artery(s) for coronary angiography; with right heart catheterization.
93457	Catheter placement in coronary artery(s) for coronary angiography; with catheter placement(s) in bypass graft(s) including bypass graft angiography and right heart catheterization.
93458	Catheter placement in coronary artery(s) for coronary angiography; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed.
93459	Catheter placement in coronary artery(s) for coronary angiography; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) with bypass graft angiography.
93460	Catheter placement in coronary artery(s) for coronary angiography; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed.
93461	Catheter placement in coronary artery(s) for coronary angiography; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) with bypass graft angiography.

Diagnostic catheterization crosswalkCPT

93452-93459	Diagnostic catheterization procedure code range referenced as billed codes in crosswalk.
93460	Intraprocedural injection(s) for left ventriculography, when performed (as referenced).
93461	Catheter placement in coronary artery(s) for coronary angiography with right and left heart catheterization including intraprocedural injections; includes bypass graft angiography when performed.

Stress echocardiogram crosswalkCPT

93350	Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test; prior authorization given for this CPT may be submitted with code 93351.
93351	Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test; prior authorization given for this CPT may be submitted with code 93350.

Revised applicable codesCPT

93306	Removed from list of CPT codes that require prior authorization (previously listed).
93307	Removed from list of CPT codes that require prior authorization (previously listed).
93308	Removed from list of CPT codes that require prior authorization (previously listed).

Authorization validity

Authorization validity periodAuthorization number is valid for 45 calendar days and applies to a single date of service within that period.

Scope of validityValid for the specific advanced outpatient imaging procedure requested and for one performance (single date of service).

Use limitationAuthorization covers one date of service only; separate authorization required for additional dates or procedures.

What Providers Must Do

Prior Authorization

Prior Authorization Required

All requests for prior authorization for cardiology procedures are managed by EviCore (Evernorth). Oxford/Sierra Health and Life retains final coverage authority and is responsible for any decisions to limit or deny coverage and for appeals.

Providers must obtain prior authorization through EviCore for listed cardiology procedures and advanced outpatient imaging.
To obtain authorization providers may call 1-877-PRE-AUTH (1-877-773-2884) or use the Prior Authorization and Notification App on the EviCore website.

Prior Authorization

Prior Authorization Required (Crosswalks Supported)

Authorization through EviCore is required for specified outpatient cardiac imaging and catheterization procedures. EviCore supports crosswalks for certain CPT codes (for example diagnostic catheterization and stress echocardiogram crosswalks); if prior authorization is obtained for a code listed in a crosswalk, substitution with the corresponding code is appropriate.

Authorized notification numbers are valid for 45 calendar days and are specific to the advanced outpatient imaging procedure, one date of service within that period.

Program and Review Background

EviCore performs initial management of prior authorization requests and accreditation processing for outpatient cardiac services. Reviews are informed by board-certified cardiologists and radiologists who evaluate submitted treatment and billing plans for medical necessity and appropriate billing; providers should submit required clinical documentation and accreditation information to EviCore for review.

Definitions and Accreditation Notes

EviCore review

Initial review performed by EviCoreEviCore performs initial reviews of prior authorization requests and evaluates submitted treatment and billing plans.

Site-of-service assessmentInitial reviews may include a site-of-service review as part of EviCore's evaluation.

Oxford final decision authorityOxford retains responsibility for final decisions to limit or deny coverage and for appeals following EviCore's review.

Accreditation requirements

Required accreditations by serviceCardiac CT: ACR; Cardiac PET: IAC; Cardiac MRI: RadSite (or equivalent); Nuclear Medicine: The Joint Commission (TJC).

Submission routingAccreditations should be submitted directly to the EviCore website and include all applicable facility and physician information to ensure prompt handling.

Document Changes

01/01/2026Title and vendor naming revisionLatest

Title changed and references to 'eviCore healthcare' were replaced with 'EviCore' (and 'EviCore by Evernorth (Evicore)') to standardize vendor naming; related wording adjusted in policy header.

01/01/2026Administrative removal

EviCore fax number and some prior accreditation submission instructions were removed from the policy wording.

01/01/2026Coding and modality update (material)

OpenPayer

Outpatient Cardiology Procedures for EviCore Arrangement (for Oxford Only)