Outpatient Cardiology Procedures for EviCore Arrangement (for Oxford Only)
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Defines prior authorization, accreditation, payment, and coding requirements for outpatient cardiology imaging and diagnostic catheterization services managed by EviCore for Oxford members and participating providers.
Revised applicable procedure and CPT code lists; specific CPT codes 93306, 93307, and 93308 were removed from the authorization requirement.
Title changed and references to 'eviCore healthcare' replaced with 'EviCore' and 'EviCore by Evernorth (Evicore)'.
Removed EviCore fax number and some prior accreditation submission instructions.
Clarified EviCore's role to perform initial reviews (which may include site-of-service review) and to manage accreditation processes; Oxford retains final coverage decision authority.
Coverage and Authorization Requirements
Coverage with authorization and provider accreditation
Covered when prior authorization is obtained and accreditation and documentation requirements are met:
Authorization specific to requested procedure and date of service.
EviCore may request specific records; decisions informed by EviCore cardiology/radiology review and a board-certified cardiologist is available where required by state regulations.
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.
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.
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
| 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. |
| 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. |
| 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. |
| 93350 | 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. |
| 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. |
| 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. |
| 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. |
| 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. |
What Providers Must Do
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 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.
- Crosswalks map interchangeable CPT codes so prior authorization for one mapped code covers the appropriate substitution.
Provider Documentation and Submission
Treating providers may be asked to submit clinical documentation to support prior authorization requests. EviCore may request office notes, treatment planning documents, results of key diagnostic studies, and completed clinical submission forms. Providers will be informed in writing of approvals; where available, a board-certified cardiologist will be available to discuss decisions.
- Copies of office notes and treatment planning documents may be required.
- Results of key diagnostic studies and/or office notes may be required.
- Treating cardiology providers may be asked to complete and submit an EviCore clinical submission form.
Out-of-Network Prior Authorization Requirement
Oxford commercial members with out-of-network benefits must still obtain prior authorization for outpatient cardiology studies when receiving services from an out-of-network provider.
- Out-of-network benefit status does not waive the EviCore prior authorization requirement for outpatient cardiology procedures.
Accreditation Submission
Accreditations and related credentialing materials for providers and facilities should be submitted directly to EviCore via their website. Include all applicable facility and physician information to ensure prompt handling.
- Submit accreditation documents and facility/physician information through the EviCore Prior Authorization and Notification App or EviCore website.
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
Document Changes
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.
EviCore fax number and some prior accreditation submission instructions were removed from the policy wording.
Revised list of modalities and CPT codes requiring prior authorization; specific CPT codes 93306, 93307, and 93308 were removed from the applicable codes list.
Clarified EviCore's role to perform initial reviews that may include a site-of-service review and to manage accreditation processes and submission routing to the EviCore website.
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