CurrentUnitedHealthcarePolicy N/A

MRI and CT Site-of-Service Medical Necessity Review

This policy governs UnitedHealthcare's site-of-service medical necessity review process for planned MRI and CT procedures performed in outpatient hospital settings for Individual & Family (ACA Marketplace) plans in specified states, affecting providers who schedule imaging services.

Policy Summary

PayerUnitedHealthcare

PolicyMRI and CT Site-of-Service Medical Necessity Review

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization/site-of-service medical necessity review before scheduling MRI or CT procedures planned in an outpatient hospital setting.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MRI & CTmodalities covered

Outpatient hospitalsetting

Individual & Family plansapplies to

24/7 chatprovider contact

Site-of-Service Coverage Criteria for MRI and CT

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Site-of-service decisions for MRI/CT

Covered at outpatient hospital site when ALL of the following are met

Base requirement: The MRI or CT procedure is planned to be performed in an outpatient hospital setting and meets the criteria referenced in UnitedHealthcare's Magnetic Resonance Imaging (MRT) and Computed Tomography (CT) Scan Site of Service Medical Policy.

Uses policy criteria for site-of-service determinations

Exception allowance: If the nearest participating freestanding diagnostic radiology center or office lacks necessary equipment or is not within a reasonable distance, authorization for the outpatient hospital site may be approved based on submitted clinical information.

Geographic access and resource limitations considered

Clinical condition allowance: When patient-specific clinical information (for example, age or medical conditions) indicates the member requires more complex care that can only be safely delivered in an outpatient hospital, authorization may be approved after review of the submitted clinical information in accordance with the applicable medical policy.

Member-specific clinical factors considered

Site-of-service reviews are not required for procedures performed in an emergency room, an urgent care center observation unit, or during an inpatient stay.

Planned Outpatient Hospital MRI or CT — Covered Indications

Planned outpatient hospital MRI or CT

Modality and setting: MRI or CT planned in an outpatient hospital setting for members of Individual & Family (ACA Marketplace) plans in specified states.

Subject to site-of-service review using MRT/CT policy criteria

Provider Responsibilities and Authorization Requirements

Prior Authorization

Prior authorization required for outpatient hospital MRI/CT

Prior authorization/site-of-service medical necessity review is required for MRI and CT procedures planned to be performed in an outpatient hospital setting for UnitedHealthcare Individual & Family (ACA Marketplace) plans in the listed states.

Note

Procedure selection rationale

UnitedHealthcare selects procedures for site-of-service review based on whether they can be performed safely and effectively outside an outpatient hospital and on potential member out-of-pocket cost differences.

Documentation Required

Clinical information required for exceptions

Provide clinical information when requesting authorization so UnitedHealthcare can evaluate whether the outpatient hospital site is required due to patient-specific factors (for example, age or medical conditions).

Denial Risk

Failure to complete prior auth may lead to denial

If the prior authorization/notification process is not completed before the procedure is rendered, UnitedHealthcare may deny the claim and the provider cannot bill the member for the service.

Key Definitions

inv-08: Site-of-service medical necessity review — definition and short explanation

DefinitionSite-of-service medical necessity review: A review to determine if a planned MRI or CT imaging procedure requires an outpatient hospital location or can be safely and effectively performed in a lower-acuity setting (e.g., freestanding imaging center or office).

PurposeTo improve health outcomes, patient experience, and lower cost of care by determining appropriate, lower-cost settings for imaging when clinically acceptable.

ScopeApplied only when the MRI or CT procedure is planned to be performed in an outpatient hospital setting; reviews use criteria from UnitedHealthcare's MRI and CT Site of Service Medical Policy.

Use in decision-makingEvaluations consider member-specific clinical information (for example, medical conditions, age, or access to required equipment) to allow exceptions when outpatient hospital care is justified.

Not applied to emergency/inpatient careSite-of-service reviews are not required for procedures performed in the emergency room, urgent care observation units, or during an inpatient stay.

Background and Rationale

UnitedHealthcare conducts site-of-service medical necessity reviews to determine whether MRI and CT scans planned for an outpatient hospital setting could be safely and effectively performed in lower-cost settings (for example, freestanding imaging centers or office settings). Reviews apply to MRI and CT procedures planned in outpatient hospital settings for UnitedHealthcare Individual & Family (ACA Marketplace) plans in the listed states and use the criteria referenced in UnitedHealthcare's Magnetic Resonance Imaging (MRT) and Computed Tomography (CT) Scan Site of Service Medical Policy.

When requesting authorization for an outpatient hospital site, the reviewer will consider member-specific clinical information — such as age, comorbidities, or functional limitations — and access issues (for example, if the nearest participating freestanding diagnostic radiology center or office lacks necessary equipment or is an unreasonable distance). Authorization for the outpatient hospital site may be approved based on submitted clinical information when these factors demonstrate the hospital setting is required.