sierra health and life MRI CT Site-of-Service Policy Update

Coverage Criteria for Hospital Outpatient MRI and CT

Medically necessary hospital outpatient MRI/CT

Covered when ANY of the following are met

Hospital outpatient medical necessity criteria: Are participating in a clinical trial that requires a specific imaging protocol or equipment not available in a freestanding facility; OR Scheduled for the MRI/CT imaging procedure within 24 hours of a hospital specialist appointment at the same hospital-based facility where the procedure is requested; OR Have a known allergy to a contrast agent used for the procedure; OR Have a known chronic disease undergoing active treatment when direct comparison to prior studies requires the same imaging protocol or equipment obtained at the same hospital-based facility where the procedure is requested; OR Have a systemic cancer on active treatment when restaging studies require the same imaging protocol or equipment used for prior studies obtained at the same hospital-based facility where the procedure is requested; OR Pre-procedure imaging done within 24 hours of the interventional or surgical procedure and is an integral part of the planned procedure; OR Require obstetrical observation; OR Require perinatology services; OR Under 18 years of age; OR No geographically accessible appropriate alternative site exists (including but not limited to: moderate or deep sedation or general anesthesia is required and a freestanding facility providing such sedation is not available; the equipment for the size of the individual is not available; or open MRI is required because the member has a documented diagnosis of claustrophobia and/or severe anxiety not available in a freestanding facility);

Logical group: any one condition suffices

Not medically necessary

Not medically necessary when ANY of the following indications are the reason for hospital outpatient imaging

Not medically necessary uses: Cancer screening; OR Initial diagnosis and/or initial staging for suspected or known cancer; OR Non-cancerous musculoskeletal conditions; OR Surveillance of cancer in remission with no clinical suspicion for change in disease status;

Use of hospital outpatient setting for these indications is considered not medically necessary

Indications warranting hospital outpatient MRI/CT

Indications warranting hospital outpatient MRI/CT: See medically necessary criteria list including: participation in a clinical trial requiring specific protocol/equipment not available in freestanding facility; MRI/CT scheduled within 24 hours of a hospital specialist appointment at the same hospital-based facility; known allergy to a contrast agent; known chronic disease on active treatment when direct comparison to prior studies requires same protocol/equipment obtained at the same hospital-based facility; systemic cancer on active treatment when restaging requires same protocol/equipment used for prior studies at the same hospital-based facility; pre-procedure imaging within 24 hours integral to planned interventional or surgical procedure; require obstetrical observation; require perinatology services; pediatric patients (<18 years); no geographically accessible appropriate alternative site (including need for deeper sedation/anesthesia, equipment size limitations, or need for open MRI due to documented claustrophobia/severe anxiety)

Imaging during pregnancy and lactation

Imaging during pregnancy and MRI anesthesia considerations

Pregnancy imaging modality preference: Ultrasonography and MRI are preferred for pregnant patients and should be used prudently when expected to answer a relevant clinical question

Per ACOG

Radiation-based imaging: Radiography, CT, and nuclear medicine involve radiation exposure at doses much lower than exposures associated with fetal harm; use should still be clinically justified

Gadolinium use in pregnancy: Gadolinium contrast should be limited and used only if it significantly improves diagnostic performance and is expected to improve fetal or maternal outcome

Per ACOG

MRI anesthesia risks: Consider age-related risks, health-related risks (including need for intensive care, impaired respiratory function, changes in sedation or ventilation, hemodynamic instability, comorbidities) and risks from foreign bodies or implanted ferromagnetic items when planning anesthesia for MRI

Authorization is not required for MRI or CT procedures performed in an emergency room, observation unit, urgent care center, or during an inpatient stay. This exception applies regardless of whether the imaging is performed in a hospital-based imaging department. Providers should still document the clinical indication and setting in the medical record to support appropriate billing and any subsequent review.

Unless one of the specified hospital outpatient medical necessity criteria is met, all other MRI/CT imaging procedures performed in a hospital-based imaging department or facility are considered not medically necessary. Examples include imaging for cancer screening, initial diagnosis and/or initial staging for suspected or known cancer, non-cancerous musculoskeletal conditions, and surveillance of cancer in remission with no clinical suspicion for change in disease status.

This Medical Policy does not apply to the state of Massachusetts. The policy was updated to add this state-specific exclusion as part of administrative/template and code list updates effective 01/01/2026.

General clinical coverage guidance

General clinical coverage guidance: Authorization is not required for procedures performed in an emergency room, observation unit, urgent care center, or during an inpatient stay; when deciding imaging modality and site of service, consider pregnancy guidance (prefer ultrasound and MRI; limit gadolinium) and anesthesia-related MRI risks per ASA when sedation/anesthesia is contemplated

Applicable CPT/HCPCS Codes and Coding Notes

Computed Tomography (selected)CPT

70450	Computed tomography, head or brain; without contrast material.
70460	Computed tomography, head or brain; with contrast material(s).
70470	Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections.
70480	Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material.
70481	Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s).
70482	Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections.
70486	Computed tomography, maxillofacial area; without contrast material.
70487	Computed tomography, maxillofacial area; with contrast material(s).
70488	Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections.
70490	Computed tomography, soft tissue neck; without contrast material.

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Additional CT codes (selected)CPT

70498	Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing.
71250	Computed tomography, thorax, diagnostic; without contrast material.
71260	Computed tomography, thorax, diagnostic; with contrast material(s).
71270	Computed tomography, thorax, diagnostic; without contrast material, followed by contrast material(s) and further sections.
71271	Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s).
71275	Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing.
72125	Computed tomography, cervical spine; without contrast material.
72126	Computed tomography, cervical spine; with contrast material.
72127	Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections.
72128	Computed tomography, thoracic spine; without contrast material.

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Magnetic Resonance Imaging (selected)CPT

70336	Magnetic resonance (e.g., proton) imaging, temporomandibular joint(s).
70540	Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s).
70542	Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; with contrast material(s).
70543	Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences.
70544	Magnetic resonance angiography, head; without contrast material(s).
70545	Magnetic resonance angiography, head; with contrast material(s).
70546	Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences.
70547	Magnetic resonance angiography, neck; without contrast material(s).
70548	Magnetic resonance angiography, neck; with contrast material(s).
70549	Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences.

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HCPCS MRI codeHCPCS

S8037

Magnetic resonance cholangiopancreatography (MRCP)

Applicable CPT Codes (updated)CPT

0042T

removed

Time proximity to specialist appointment or procedure — within 24 hours

Time windowWithin 24 hours of a hospital specialist appointment at the same hospital-based facility

Also applies to pre-procedure imagingPre-procedure imaging performed within 24 hours of the interventional or surgical procedure when integral to the planned procedure

PurposeEnsures access to hospital-only protocols, equipment, or coordinated care tied to the specialist visit

Gadolinium use threshold — use only if it significantly improves diagnostic performance and expected outcomes

Gadolinium use ruleLimit use in pregnancy; use only if it significantly improves diagnostic performance and is expected to improve fetal or maternal outcome

Prior Authorization and Plan Verification

Prior Authorization

Prior Authorization Required

Authorization may be required per the member-specific benefit plan. Before scheduling or performing MRI/CT imaging, check the member-specific plan for prior authorization requirements. When applicable, obtain prior authorization to avoid claim denials or delays.

Verify prior authorization requirements with the member-specific benefit plan.
Prior authorization rules and applicable CPT/HCPCS codes may change; confirm current requirements at time of service.

Denial Risk

Hospital Outpatient Imaging — Not Medically Necessary (except specific exceptions)

An MRI/CT imaging procedure in the hospital outpatient department is considered medically necessary only when imaging in a physician's office or freestanding imaging center would reasonably be expected to delay care and adversely impact health outcome. All other MRI/CT imaging procedures at a hospital-based imaging department or facility are considered not medically necessary.

Provider Responsibilities and Documentation

Denial Risk

Avoid hospital outpatient imaging for specified not-medically-necessary indications

Do not schedule hospital outpatient imaging for indications that are considered not medically necessary in the hospital outpatient setting (unless another medically necessary criterion is met). Imaging in the hospital outpatient department is considered not medically necessary when used for cancer screening, initial diagnosis or initial staging of suspected or known cancer, non-cancer musculoskeletal conditions, or surveillance of cancer in remission with no clinical suspicion for change in disease status.

Examples of not medically necessary uses: cancer screening; initial diagnosis/initial staging for suspected or known cancer; non-cancerous musculoskeletal conditions; surveillance of cancer in remission with no clinical suspicion for change in disease status.

Documentation Required

Provide medical records to support clinical criteria and coverage

Be prepared to provide medical records to demonstrate that the member meets the clinical criteria for hospital outpatient MRI/CT coverage; benefit coverage is determined by the member-specific benefit plan and applicable laws.

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage.

Contrast Agent Use and Safety Considerations

Billing Rule

Document known contrast allergy when selecting hospital outpatient setting

Known allergy to a contrast agent is a listed criterion supporting use of the hospital outpatient setting for MRI/CT; identify and document contrast allergies when considering site of service.

If the member has a known allergy to the contrast agent used for the procedure, hospital outpatient setting may be appropriate.

Billing Rule

Restrict gadolinium use in pregnancy/lactation per ACOG

Limit use of gadolinium contrast in pregnancy or lactation; use gadolinium only if it significantly improves diagnostic performance and is expected to improve fetal or maternal outcome (per ACOG).

Gadolinium should be used in pregnant or lactating patients only when it significantly improves diagnostic performance and is expected to improve fetal or maternal outcome.

Definitions and Key Terms

hospital outpatient department — definition/key value

DefinitionHospital outpatient department: hospital-based facility where MRI/CT may be medically necessary when site-specific protocols, equipment, sedation, or coordinated specialist/perinatology services are required

Examples of required capabilitiesAvailability of specific imaging protocols/equipment not available in freestanding centers; moderate/deep sedation or general anesthesia capacity; perinatology or obstetrical observation services

Age-based considerationServices for individuals under 18 may require hospital outpatient setting

Gadolinium contrast — definition/usage note for pregnancy

Pregnancy guidanceGadolinium contrast should be limited during pregnancy and used only if it significantly improves diagnostic performance and is expected to improve fetal or maternal outcome

Background and Rationale

MRI and CT studies sometimes require specialized equipment, patient management, or protocols that are available only in hospital-based facilities — for example, equipment sized for larger patients, open MRI for severe claustrophobia, or on-site capabilities for moderate/deep sedation or general anesthesia. In pregnant patients, imaging modality selection should prioritize ultrasonography and MRI when clinically appropriate; when gadolinium is considered, it should be limited and used only if it significantly improves diagnostic performance and is expected to improve fetal or maternal outcome. When anesthesia is needed for MRI, consider age- and health-related risks as well as safety concerns such as ferromagnetic implants or foreign bodies when planning care.

Not Covered Services

Hospital outpatient MRI or CT is not covered when the sole reason for use is cancer screening, initial cancer diagnosis or staging, non-cancer musculoskeletal conditions, or routine surveillance of cancer in remission with no clinical suspicion for change. Such indications are considered not medically necessary in the hospital outpatient setting unless another listed hospital outpatient criterion is met.

Policy Revision History

2026-01-01template_and_code_updateLatest

Created shared policy version to support application to Oxford plan membership; added language excluding Massachusetts; updated applicable CPT codes and removed 0042T; archived previous policy versions MP.13.18 and RADIOLOGY 041.12

OpenPayer

Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scan - Site of Service