11/18/ CPT Preauthorization Groupings Effective January 1, Computerized Tomography (CT) Abdomen 6. CPT Description SEGR CT01

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1 Computerized Tomography (CT) 6 & Upper Extremity 11 Lower Extremity 12 Head 3 Orbit 1 Sinus 2 Neck 4 7 Cervical Spine 8 Thoracic Spine 9 Lumbar Spine 10 Colon 13 CPT Description SEGR ADD- ON CT abdomen; w/o contrast CT abdomen; with contrast CT abdomen; w/o contrast followed by contrast CT, abdomen and pelvis, w/o contrast CT, abdomen and pelvis, with contrast CT, abdomen and pelvis, w/o contrast in one or both regions, followed by contrast and further in one or both regions CT thorax; w/o contrast CT thorax; with contrast CT thorax; w/o contrast followed by contrast CT upper extremity; w/o contrast CT upper extremity; with contrast CT upper extremity; w/o contrast followed by contrast CT lower extremity; w/o contrast CT lower extremity; with contrast CT lower extremity; w/o contrast followed by contrast CT head or brain; w/o contrast CT head or brain; with contrast CT head or brain; w/o contrast followed by contrast CT orbit, sella or posterior fossa; w/o contrast CT orbit, sella or posterior fossa; with contrast CT orbit, sella or posterior fossa; w/o contrast followed by contrast CT maxillofacial area; w/o contrast CT maxillofacial area; with contrast CT maxillofacial area; w/o contrast followed by contrast CT soft tissue neck; w/o contrast CT soft tissue neck; with contrast CT soft tissue neck; w/o contrast followed by contrast CT pelvis; w/o contrast CT pelvis; with contrast CT pelvis w/o contrast followed by contrast CT cervical spine; w/o contrast CT cervical spine; with contrast CT cervical spine; w/o contrast followed by contrast CT thoracic spine; w/o contrast CT thoracic spine; with contrast CT thoracic spine; w/o contrast followed by contrast CT lumbar spine; w/o contrast CT lumbar spine; with contrast CT lumbar spine; w/o contrast followed by contrast CT colonography; diagnostic without contrast CT colonography; diagnostic with contrast including noncontrast images if performed CT colonography; screening including image post processing CT01 CT28 CT02 CT03 CT04 CT05 CT06 CT07 CT08 CT09 CT10 CT11 CT12 CT29 11/18/2011 1

2 Computerized Tomography Angiography (CTA) 79 Abdominal Arteries Upper Extremity Head 72 Neck CT Heart for Calcium Scoring 98 CT Heart for Structure & Morph 99 CTA Heart Including Structure & Morph 100 CPT Description CTA abdomen & pelvis EFFECTIVE MARCH 1, 2012 CTA abdomen; w/o contrast followed by contrast and further CTA abdominal aorta & bilateral iliofemoral lower extremity runoff; w/o contrast followed by contrast and further CTA chest; w/o contrast followed by contrast and further CTA upper extremity; w/o contrast followed by contrast and further CTA lower extremity; w/o contrast followed by contrast and further CTA head; w/o contrast followed by contrast and further CTA neck; w/o contrast followed by contrast and further CTA pelvis; w/o contrast followed by contrast and further CT heart; w/o contrast with quantitative evaluation of coronary calcium CT heart; w contrast for eval of cardiac structure and morphology (including 3D image post-processing, assessment of cardiac function, and evaluation of venous structures, if performed) CT heart; w contrast for eval of cardiac structure and morphology in setting of congenital heart disease (including 3D image post-processing, assessment of LV function, RV structure and function and evaluation of venous structures, if performed) CTA heart, coronary arteries and bypass grafts (when present); w contrast including 3D image post-processing (including eval of cardiac structure and morphology, assessment of cardiac function and eval of venous structures, if performed) Image Reading Provider Code Row SEGR CT13 CT14 CT15 CT16 CT17 CT18 CT19 CT20 CT25 CT26 CT27 CT99 11/18/2011 2

3 Magnetic Resonance (MRI) 26 Bone Marrow 30 Breast Cardiac 18 Upper Extremity Non-joint TMJ 24 Orbit 23 Brain 13 CPT Description MRI abdomen; w/o contrast MRI abdomen; with contrast MRI abdomen; w/o contrast followed by contrast SEGR MR MRI bone marrow MR MRI breast; unilateral w/wo contrast MRI breast; bilateral w/wo contrast MR MRI chest; w/o contrast MR MRI chest; with contrast MRI chest; w/o contrast followed by contrast MRI cardiac; w/o contrast MR MRI cardiac; w/o contrast; with stress imaging MRI cardiac; w/o contrast; followed by contrast and further sequences MRI cardiac; w/o contrast; followed by contrast and further sequences; with stress imaging MRI upper extremity, other than joint w/o contrast MR MRI upper extremity, other than joint with contrast MR MRI upper extremity, other than joint w/o contrast followed by contrast MR MRI upper extremity, any joint w/o contrast MR MRI upper extremity, any joint with contrast MR MRI upper extremity, any joint w/o contrast followed by contrast MR MRI lower extremity, other than joint w/o contrast MR MRI lower extremity, other than joint w contrast MRI lower extremity, other than joint w/o contrast followed by contrast MRI lower extremity, any joint w/o contrast MRI lower extremity, any joint w contrast MRI lower extremity, any joint w/o contrast followed by contrast MR MRI temporomandibular joint(s) MR MRI orbit, face and neck; w/o contrast MRI orbit, face and neck; with contrast MRI orbit, face and neck; w/o contrast followed by contrast MRI brain; w/o contrast MRI brain; with contrast MRI brain; w/o contrast followed by contrast MRI brain, functional MRI, not requiring physician or psychologist administration MRI brain, functional MRI, requiring physician or psychologist administration MR15 MR16 27 Cervical Spine 15 Thoracic Spine 16 Lumbar Spine ADD- ON MRI pelvis; w/o contrast MRI pelvis; with contrast MRI pelvis; w/o contrast followed by contrast MRI cervical spine; w/o contrast MRI cervical spine; with contrast MRI cervical spine; w/o contrast followed by contrast MRI thoracic spine; w/o contrast MRI thoracic spine; with contrast MRI thoracic spine; w/o contrast followed by contrast MRI lumbar spine; w/o contrast MRI lumbar spine; with contrast MRI lumbar spine; w/o contrast followed by contrast MR17 MR18 MR19 MR20 11/18/2011 3

4 Magnetic Resonance Angiography (MRA) Upper Extremity Head 31 Neck Spinal Canal 37 CPT Description SEGR MRA abdomen; with or w/o contrast MR MRA chest; with or w/o contrast MR MRA upper extremity; with or w/o contrast MR MRA lower extremity; with or w/o contrast MR MRA head; w/o contrast MRA head; with contrast MRA head; w/o contrast followed by contrast MRA neck; w/o contrast MRA neck; with contrast MRA neck; w/o contrast followed by contrast MR25 MR MRA pelvis; with or w/o contrast MR MRA spinal canal and contents with or w/o contrast MR28 Magnetic Resonance SEGR CPT Description Spectroscopy (MRS) MR Spectroscopy MR29 Image Reading Provider Code Row MR99 Bone Densitometry CPT Description SEGR CT bone mineral density axial CT21 11/18/2011 4

5 Nuclear Cardiology CPT Description SEGR Myocardial Perfusion SPECT, single study SPECT, multiple studies MPI, single study MPI, multiple studies NC01 Infarct 44 Cardiac Blood Pool Planar, infarct avid; qualitative or quantitative Planar, infarct avid; with ejection fraction by first pass technique SPECT, infarct avid; with or w/o quantification Gated equilibrium; planar, single study, wall motion plus ejection fraction Gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction First pass tech; single study, wall motion study plus ejection fraction First pass tech; multiple studies, wall motion study plus ejection fraction Gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction Image Reading Provider Code Row NC02 NC03 NC99 Positron Emission Tomography (PET) Brain 42 Myocardial 71 PET & PET/CT Tumor 84 CPT Description SEGR PET brain, metabolic evaluation PET brain, perfusion evaluation PET myocardial, metabolic evaluation PET myocardial, perfusion, single study PET myocardial, perfusion, multiple studies PET imaging, limited area (e.g., chest; head/neck) PET imaging, skull base to mid-thigh PET imaging, whole body PET imaging with concurrently acquired CT for attenuation correction and anatomical localization, limited area (e.g., chest; head/neck) PET imaging with concurrently acquired CT for attenuation correction and anatomical localization, skull base to mid-thigh PET imaging with concurrently acquired CT for attenuation correction and anatomical localization, whole body PT01 PT02 PT03 PT04 11/18/2011 5

6 Add-on Procedures CPT Description SEGR Add-on Procedure Codes are those CPT codes that do not standalone but are adjunct codes to other CPT codes. These add-on codes are often performed in addition to the above listed preauthorized procedures and do not require separate preauthorization. The inclusion of these codes into a preauthorization program is determined by agreement with the health plan. CT or MRI Grouping Groups 1-12, 13-18, 23-27, 29, 30, 46, 47, 101 CT Grouping Groups 1-13 MRI Cardiac Grouping Group 18 Cardiac Blood Pool Grouping Group 82 valid with code only & Reconstruction of CT or MRI images replacement for deleted code CT Limited follow-up CT CT Cardiac MRI for velocity flow mapping MR Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (Add-on to only) NC06 11/18/2011 6