| Program Name: | BadgerCare Plus and Medicaid | Handbook Area: | Radiology | | 05/19/2024 | Prior Authorization : Services Requiring Prior AuthorizationTopic #10734 Codes
These advanced imaging procedure codes require PA (unless the service is rendered in one of the exempted situations). This list is subject to change and is periodically updated.
| Computed Tomographic Imaging Procedure Codes Requiring Prior Authorization |
| Procedure Code |
Description |
Allowable Procedure Codes for Downcoding* |
| 70450 |
Computed tomography, head or brain; without contrast material |
N/A |
| 70460 |
with contrast material(s) |
70450 |
| 70470 |
without contrast material, followed by contrast material(s) and further sections |
70450, 70460 |
| 70480 |
Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material |
N/A |
| 70481 |
with contrast material(s) |
70480 |
| 70482 |
without contrast material, followed by contrast material(s) and further sections |
70480, 74081 |
| 70486 |
Computed tomography, maxillofacial area; without contrast material |
N/A |
| 70487 |
with contrast material(s) |
70486 |
| 70488 |
without contrast material, followed by contrast material(s) and further sections |
70486, 74087 |
| 70490 |
Computed tomography, soft tissue neck; without contrast material |
N/A |
| 70491 |
with contrast material(s) |
70490 |
| 70492 |
without contrast material, followed by contrast material(s) and further sections |
70490, 70491 |
| 70496 |
Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing |
N/A |
| 70498 |
Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing |
N/A |
| 71250 |
Computed tomography, thorax; without contrast material |
N/A |
| 71260 |
with contrast material(s) |
71250 |
| 71270 |
without contrast material, followed by contrast material(s) and further sections |
71250, 71260 |
| 71275 |
Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing |
N/A |
| 72125 |
Computed tomography, cervical spine; without contrast material |
N/A |
| 72126 |
with contrast material |
72125 |
| 72127 |
without contrast material, followed by contrast material(s) and further sections |
72125, 72126 |
| 72128 |
Computed tomography, thoracic spine; without contrast material |
N/A |
| 72129 |
with contrast material |
72128 |
| 72130 |
without contrast material, followed by contrast material(s) and further sections |
72128, 72129 |
| 72131 |
Computed tomography, lumbar spine; without contrast material |
N/A |
| 72132 |
with contrast material |
72131 |
| 72133 |
without contrast material, followed by contrast material(s) and further sections |
72131, 72132 |
| 72191 |
Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing |
N/A |
| 72192 |
Computed tomography, pelvis; without contrast material |
N/A |
| 72193 |
with contrast material(s) |
72192 |
| 72194 |
without contrast material, followed by contrast material(s) and further sections |
72192, 72193 |
| 73200 |
Computed tomography, upper extremity; without contrast material |
N/A |
| 73201 |
with contrast material(s) |
73200 |
| 73202 |
without contrast material, followed by contrast material(s) and further sections |
73200, 73201 |
| 73206 |
Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing |
N/A |
| 73700 |
Computed tomography, lower extremity; without contrast material |
N/A |
| 73701 |
with contrast material(s) |
73700 |
| 73702 |
without contrast material, followed by contrast material(s) and further sections |
73700, 73701 |
| 73706 |
Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing |
N/A |
| 74150 |
Computed tomography, abdomen; without contrast material |
N/A |
| 74160 |
with contrast material(s) |
74150 |
| 74170 |
without contrast material, followed by contrast material(s) and further sections |
74150, 74160 |
| 74174 |
Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing |
N/A |
| 74175 |
Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing |
N/A |
| 74176 |
Computed tomography, abdomen and pelvis; without contrast material |
N/A |
| 74177 |
with contrast material(s) |
N/A |
| 74178 |
without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions |
N/A |
| 74261 |
Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material |
N/A |
| 74262 |
with contrast material(s) including non-contrast images, if performed |
74261 |
| 74263 |
Computed tomographic (CT) colonography, screening, including image postprocessing |
N/A |
| 75571 |
Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium |
N/A |
| 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) |
N/A |
| 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 LV cardiac function, RV structure and function and evaluation of venous structures, if performed) |
N/A |
| 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) |
N/A |
| 75635 |
Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing |
N/A |
| 76376 |
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation |
N/A |
| 76377 |
requiring image postprocessing on an independent workstation |
N/A |
| 76380 |
Computed tomography, limited or localized follow-up study |
N/A |
| 76497 |
Unlisted computed tomography procedure (eg, diagnostic, interventional) |
N/A |
| 77078 |
Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) |
N/A |
| 78830 |
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for anatomical review, localization and determination/detection of pathology, single area (eg, head, neck, chest, pelvis), single day imaging |
|
| 78832 |
Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for anatomical review, localization and determination/detection of pathology, minimum 2 areas (eg, pelvis and knees, abdomen and pelvis), single day imaging, or single area imaging over 2 or more days |
|
| S8092 |
Electron beam computed tomography (also known as ultrafast CT, cine CT) |
N/A |
* If an allowable procedure code for downcoding is substituted for the approved procedure code, providers do not need to contact eviCore healthcare to amend the PA request.
| Magnetic Resonance Imaging Procedure Codes Requiring Prior Authorization |
| Procedure Code |
Description |
Allowable Procedure Codes for Downcoding* |
| 70336 |
Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) |
N/A |
| 70540 |
Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s) |
N/A |
| 70542 |
with contrast material(s) |
70540 |
| 70543 |
without contrast material(s), followed by contrast material(s) and further sequences |
70540, 70542 |
| 70544 |
Magnetic resonance angiography, head; without contrast material(s) |
N/A |
| 70545 |
with contrast material(s) |
70544 |
| 70546 |
without contrast material(s), followed by contrast material(s) and further sequences |
70544, 70545 |
| 70547 |
Magnetic resonance angiography, neck; without contrast material(s) |
N/A |
| 70548 |
with contrast material(s) |
70547 |
| 70549 |
without contrast material(s), followed by contrast material(s) and further sequences |
70547, 70548 |
| 70551 |
Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material |
N/A |
| 70552 |
with contrast material(s) |
70551 |
| 70553 |
without contrast material(s), followed by contrast material(s) and further sequences |
70551, 70552 |
| 70554 |
Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration |
N/A |
| 70555 |
requiring physician or psychologist administration of entire neurofunctional testing |
N/A |
| 71550 |
Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s) |
N/A |
| 71551 |
with contrast material(s) |
71550 |
| 71552 |
without contrast material(s), followed by contrast material(s) and further sequences |
71550, 71551 |
| 71555 |
Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s) |
N/A |
| 72141 |
Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material |
N/A |
| 72142 |
with contrast material(s) |
72141 |
| 72146 |
Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material |
N/A |
| 72147 |
with contrast material(s) |
72146 |
| 72148 |
Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material |
N/A |
| 72149 |
with contrast material(s) |
72148 |
| 72156 |
Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical |
72141, 72142 |
| 72157 |
thoracic |
72146, 72147 |
| 72158 |
lumbar |
72148, 72149 |
| 72159 |
Magnetic resonance angiography, spinal canal and contents, with or without contrast
material(s) |
N/A |
| 72195 |
Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s) |
N/A |
| 72196 |
with contrast material(s) |
72195 |
| 72197 |
without contrast material(s), followed by contrast material(s) and further sequences |
72195, 72196 |
| 72198 |
Magnetic resonance angiography, pelvis, with or without contrast
material(s) |
N/A |
| 73218 |
Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s) |
N/A |
| 73219 |
with contrast material(s) |
73218 |
| 73220 |
without contrast material(s), followed by contrast material(s) and further sequences |
73218, 73219 |
| 73221 |
Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s) |
N/A |
| 73222 |
with contrast material(s) |
73221 |
| 73223 |
without contrast material(s), followed by contrast material(s) and further sequences |
73221, 73222 |
| 73225 |
Magnetic resonance angiography, upper extremity, with or without contrast material(s) |
N/A |
| 73718 |
Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s) |
N/A |
| 73719 |
with contrast material(s) |
73718 |
| 73720 |
without contrast material(s), followed by contrast material(s) and further sequences |
73718, 73719 |
| 73721 |
Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material |
N/A |
| 73722 |
with contrast material(s) |
73721 |
| 73723 |
without contrast material(s), followed by contrast material(s) and further sequences |
73721, 73722 |
| 73725 |
Magnetic resonance angiography, lower extremity, with or without contrast material(s) |
N/A |
| 74181 |
Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s) |
N/A |
| 74182 |
with contrast material(s) |
74181 |
| 74183 |
without contrast material(s), followed by contrast material(s) and further sequences |
74181, 74182 |
| 74185 |
Magnetic resonance angiography, abdomen, with or without contrast material(s) |
N/A |
| 75557 |
Cardiac magnetic resonance imaging for morphology and function without contrast material; |
N/A |
| 75559 |
with stress imaging |
75557 |
| 75561 |
Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; |
75557 |
| 75563 |
with stress imaging |
75557, 75559, 75561 |
| + 75565 |
Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure) |
N/A |
| 76376 |
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation |
N/A |
| 76377 |
requiring image postprocessing on an independent workstation |
N/A |
| 76390 |
Magnetic resonance spectroscopy |
N/A |
| 76391 |
Magnetic resonance (eg, vibration) elastography |
N/A |
| 76498 |
Unlisted magnetic resonance procedure (eg, diagnostic, interventional) |
N/A |
| 77046 |
Magnetic resonance imaging, breast, without contrast material; unilateral |
N/A |
| 77047 |
bilateral |
N/A |
| 77048 |
Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization, and pharmacokinetic analysis), when performed; unilateral |
N/A |
| 77049 |
bilateral |
N/A |
| 77084 |
Magnetic resonance (eg, proton) imaging, bone marrow blood supply |
N/A |
| S8035 |
Magnetic source imaging |
N/A |
| S8037 |
Magnetic resonance cholangiopancreatography (MRCP) |
N/A |
* If an allowable procedure code for downcoding is substituted for the approved procedure code, providers do not need to contact eviCore healthcare to amend the PA request.
| Positron Emission Tomographic Imaging Procedure Codes Requiring Prior Authorization |
| Procedure Code |
Description |
Allowable Procedure Codes for Downcoding* |
| 78429 |
Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study; with concurrently acquired computed tomography transmission scan |
|
| 78430 |
Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan |
|
| 78431 |
Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies, at rest and stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan |
|
| 78432 |
Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability) |
|
| 78433 |
Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability); with concurrently acquired computed tomography transmission scan |
|
| 78459 |
Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study |
78429 |
| 78491 |
Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic) |
78430, 78431, or 78492 |
| 78492 |
Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic) |
78430, 78431, 78491 |
| 78608 |
Brain imaging, positron emission tomography (PET); metabolic evaluation |
N/A |
| 78609 |
perfusion evaluation |
N/A |
| 78811 |
Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck) |
N/A |
| 78812 |
skull base to mid-thigh |
N/A |
| 78813 |
whole body |
N/A |
| 78814 |
Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck) |
N/A |
| 78815 |
skull base to mid-thigh |
N/A |
| 78816 |
whole body |
N/A |
* If an allowable procedure code for downcoding is substituted for the approved procedure code, providers do not need to contact eviCore healthcare to amend the PA request.
|