Notification

High-Technology Radiology Services


Notification Issue Date: 11/11/2019

This version of the policy will become effective on 02/09/2020.

AIM Specialty Health® (AIM) has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology and the Heart. These guidelines will become effective 02/09/2020. These guidelines are available online at:http://www.aimspecialtyhealth.com/CG-Radiology.html or http://www.aimspecialtyhealth.com/CG-Cardiology.html.
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Note: on 01/02/2020 this policy Notification was updated to incorporate CPT coding updates effective 01/01/2020.

The following CPT codes have been added to the policy: 78429, 78430, 78431, 78432, 78433, & 78434 (Medically Necessary)

The following CPT codes have been deleted to the policy: 0482T

The following CPT codes have been revised in the policy: 78459, 78491, & 78492.

The policy number was revised from MA09.002k to MA09.002l.



Medicare Advantage Policy

Title:High-Technology Radiology Services
Policy #:MA09.002l

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Refer to the following News Article: Update to AIM Specialty Health® (AIM) Advanced Imaging of Chest Clinical Appropriateness Guideline to allow CT for diagnosis of COVID-19 pneumonia for Medicare Advantage members


The intent of this policy is to communicate that the Company has delegated the responsibility for utilization management activities of certain high-technology radiology services to AIM Specialty Health® (AIM) with the exception of services performed in the emergency room or during an inpatient or observation unit stay.

This policy does not apply to studies performed during an emergency room visit or during an inpatient or observation unit stay.

For information on policies related to this topic, refer to the Cross References section in this policy.

Please refer to the References section of this policy for a link to applicable LCD, NCD, or the entire AIM Speciality Health® Advanced Imaging Clinical Appropriateness Guidelines for high-technology radiology services that are part of this program. Refer to Attachment A of this policy for a complete list of codes for high-technology radiology services.

The Company has delegated the responsibility for utilization management activities for the following high-technology radiology services to AIM Specialty Health® (AIM), with the exception of services performed in the emergency room or during an inpatient or observation unit stay. To determine medical necessity for these services, AIM first utilizes Medicare guidelines (e.g., Local Coverage Determinations [LCD], National Coverage Determinations [NCD]). If no Medicare guidelines exist, AIM will utilize their Advanced Imaging Clinical Appropriateness Guidelines for Radiology or AIM Advanced Imaging Clinical Appropriateness Guidelines for Cardiology to determine medical necessity for these services.
  • Computed tomography (CT)
  • Computed tomography angiography (CTA)
  • Coronary artery CTA (CCTA)/Fractional Flow Reserve (FFR)
  • CT colonography (virtual colonoscopy)
  • Functional magnetic resonance imaging (fMRI)
  • Magnetic resonance angiography (MRA) of the spine
  • Magnetic resonance imaging (MRI)
  • Magnetic resonance imaging (MRI) of the breast
  • Magnetic resonance spectroscopy
  • Nuclear cardiology
  • Positron emission tomography (PET) (with the exception of PET of the breast, known as positron emission mammography [PEM])
  • Echocardiography
    • Resting transthoracic echocardiography (TTE)
    • Stress echocardiography (SE)
    • Transesophageal echocardiography (TEE)

AIM updated their Advanced Imaging Clinical Appropriateness Guidelines for Radiology to determine the medical necessity for the above services to specify the following anatomical locations and indications:
  • Abdomen and pelvic imaging
  • Brain imaging
  • Chest imaging
  • Extremity imaging
  • Head and neck imaging
  • Spine imaging
  • Vascular imaging
  • Oncologic imaging

The Company has delegated the responsibility for utilization management activities for the following high-technology radiology services to AIM, with the exception of services performed in the emergency room or during an inpatient or observation unit stay; however, the Company policies on these services are used to determine medical necessity:
  • Electron beam computed tomography (EBCT) for screening evaluations
  • Full-body computerized tomography (CT) scan screening
  • Quantitative CT (QCT) for bone mineral densitometry of axial skeleton only
  • Positron emission mammography (PEM) (PET of the breast)

The use of any high-technology radiology service listed in this policy for conditions not addressed in the Medicare or AIM Advanced Imaging Clinical Appropriateness Guidelines for Radiology or AIM Advanced Imaging Clinical Appropriateness Guidelines for Cardiology is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of such applications cannot be established by review of the available published peer-reviewed literature.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, high-technology radiology services are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria for the services are met. However, services that are identified in this policy as experimental/investigational are not eligible for coverage or reimbursement by the Company.

HIGH-TECHNOLOGY RADIOLOGY SERVICES FOR DIAGNOSTIC PURPOSES

Coverage determinations for the use of high-technology radiology services for diagnostic purposes will be based on the National Coverage Determination (NCD) and/or Local Coverage Determination (LCD). If an NCD and LCD do not exist, then the Company's medical policy or the American Imaging Management, Inc. (AIM) Advanced Imaging Clinical Appropriateness Guidelines for Radiology or Cardiology will apply.

HIGH-TECHNOLOGY RADIOLOGY SERVICES FOR SCREENING PURPOSES

Coverage determinations for the use of high-technology radiology services for screening purposes will be based on the National Coverage Determination (NCD), Local Coverage Determination (LCD), and/or The Guide to Medicare Preventive Services.

The Center for Medicare and Medicaid Services (CMS) requires providers of advanced diagnostic imaging (MRI, CT, PET, and nuclear studies) to be accredited by one of the CMS-recognized entities listed below. This requirement applies to the technical component only--not the professional component. There are three CMS-recognized entities:
  • American College of Radiology
  • Intersocietal Accreditation Commission
  • Joint Commission

Description

The Company has delegated the responsibility of utilization management activities for certain high-technology radiology services to AIM Specialty Health® (AIM), with the exception of services performed in the emergency room or during an inpatient or observation unit stay. To determine medical necessity for these services, AIM first utilizes Medicare guidelines (e.g., Local Coverage Determinations (LCD), National Coverage Determinations NCD). If no Medicare guidelines exist, AIM will utilize their Advanced Imaging Clinical Appropriateness Guidelines for select high-technology radiology services and to direct the application of these services for our members. Multiple sources were used to develop these guidelines, including technology assessments, peer-reviewed medical literature, clinical outcomes research, and consensus opinion in medical practice. The primary resources include:
  • American College of Radiology (ACR) Appropriateness Criteria
  • American Institute of Ultrasound Medicine (AIUM)
  • Society of Interventional Radiology
  • Society of Nuclear Medicine (SNM)
  • American Academy of Neurology (AAN)
  • American Academy of Pediatrics (AAP)
  • American College of Cardiology (ACC)
  • American Heart Association (AHA)
  • Agency for Healthcare Research and Quality (AHRQ)
  • Centers for Medicare & Medicaid Services (CMS)
  • National Guideline Clearinghouse

References

American Imaging Management (AIM) Specialty Health®. AIM Advanced Imaging Clinical Appropriateness Guidelines for Radiology. [AIM Web site]. 03/09/2019. Available at: http://aimspecialtyhealth.com/CG-Radiology.html. Accessed August 05, 2019.

American Imaging Management (AIM) Specialty Health®. AIM Advanced Imaging Clinical Appropriateness Guidelines for Cardiology. [AIM Web site]. 03/09/2019. Available at: http://www.aimspecialtyhealth.com/CG-Cardiology.html. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). Decision Memo (CAG-00439N) for Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) [CMS Web site]. 02/05/2015. Available at: http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.20 for Beta Amyloid Positron Tomography in Dementia and Neurodegenerative Disease [CMS Web site]. 09/27/2013. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=356&ncdver=1&year=2014&DocType=NCD&bc=AQAAAIAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.1 for Computed Tomography [CMS Web site]. 03/12/2008. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=176&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d&l. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.12 for Single Photon Emission Computed Tomography (SPECT) [CMS Web site]. 10/01/2002. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=271&ncdver=1&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.2 for Magnetic Resonance Imaging [CMS Web site]. 07/07/2011. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=177&ncdver=5&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.2 for Magnetic Resonance Imaging [CMS Web site]. 04/10/2018. Available at:
https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=177&ncdver=6&bc=AgAAgAAACAAA&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.2.1 for Magnetic Resonance Spectroscopy [CMS Web site]. 09/10/2004. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=287&ncdver=1&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.3 for Magnetic Resonance Angiography [CMS Web site]. 07/01/2003. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=178&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6 for Positron Emission Tomography (PET) Scans [CMS Web site]. 03/07/2013. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=211&ncdver=5&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.1 for PET for Perfusion of the Heart [CMS Web site]. 04/03/2009. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=292&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.10 for FDG PET for Breast Cancer [CMS Web site]. 04/03/2009. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=297&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.11 for FDG PET for Thyroid Cancer [CMS Web site]. 04/03/2009. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=302&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.12 for FDG PET for Soft Tissue Sarcoma [CMS Web site]. 04/03/2009. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=303&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.13 for FDG PET for Dementia and Neurodegenerative Diseases [CMS Web site]. 04/03/2009. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=288&ncdver=3&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.14 for FDG PET for Brain, Cervical, Ovarian, Pancreatic, Small Cell Lung, and Testicular Cancers [CMS Web site]. 04/03/2009. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=295&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.15 for FDG PET for All Other Cancer Indications Not Previously Specified [CMS Web site]. 04/03/2009. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=296&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.16 for FDG PET for Infection and Inflammation [CMS Web site]. 03/19/2008. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=323&ncdver=1&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.17 for Positron Emission Tomography (FDG) for Oncologic Conditions [CMS Web site]. 08/04/2010. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=331&ncdver=3&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.17 for Positron Emission Tomography (FDG) for Oncologic Conditions [CMS Web site]. 06/11/2013. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=331&ncdver=4&bc=AgAAgAAACAAA&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.19 for Positron Emission Tomography (NaF-18) to Identify Bone Metastasis of Cancer [CMS Web site]. 02/26/2010. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=336&ncdver=1&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.2 for FDG PET for Lung Cancer [CMS Web site]. 04/03/2009. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=301&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.3 for FDG PET for Esophageal Cancer [CMS Web site]. 04/03/2009. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=293&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.4 for FDG PET for Colorectal Cancer [CMS Web site]. 04/03/2009. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=299&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.5 for FDG PET for Lymphoma [CMS Web site]. 04/03/2009. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=300&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.6 for FDG PET for Melanoma [CMS Web site]. 04/03/2009. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=304&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.7 for FDG PET for Head and Neck Cancers [CMS Web site]. 04/03/2009. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=305&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.8 for FDG PET for Myocardial Viability [CMS Web site]. 01/28/2005. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=298&ncdver=1&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.6.9 for FDG PET for Refractory Seizures [CMS Web site]. 01/28/2005. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=294&ncdver=1&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 05, 2019.

Department of Health and Human Services. Center for Medicare and Medicaid Services. Medicare Preventive Services. Quick Reference Information: Preventive Services. June 2019. Available at: https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html. Accessed August 05, 2019.

Novitas Solutions,Inc. Local Coverage Article for NCD coding article for positron emission tomography (PET) scans used for non-oncologic conditions (A53134). [Novitas Solutions Web site]. 10/01/2018. Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53134&ver=48&Date=03%2f18%2f2019&SearchType=Advanced&ContrId=&DocID=A53134&bc=JAAAABgAAAAA&. Accessed August 05, 2019.

Novitas Solutions, Inc. Local Coverage Article for NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Oncologic Conditions (A53132). [Novitas Solutions Web site].11/08/2018. Available at:https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53132&ver=84&SearchType=Advanced&CoverageSelection=Local&ArticleType=SAD%7cEd&PolicyType=Both&s=45&DateFrom=01012014&DateTo=01012019&kq=true&bc=IAAAACAAAAAA&. Accessed August 05, 2019.

Novitas Solutions, Inc. Local Coverage Determination (LCD) L35083 Cardiovascular Nuclear Medicine. [Novitas Solutions Web site]. 10/01/2017. Revised 03/28/2019. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35083. Accessed August 05, 2019.

Novitas Solutions, Inc. Local Coverage Determination (LCD) L34865 Magnetic Resonance Angiography (MRA). [Novitas Solutions Web site]. 10/01/2018. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34865. Accessed August 05, 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

Refer to Attachment A for a list of procedure codes applicable to high-technology radiology services.


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Follow AIM Guidelines for medical necessity


HCPCS Level II Code Number(s)

Refer to Attachment A for a list of HCPCS codes applicable to high-technology radiology services.


Revenue Code Number(s)

Refer to Attachment A for a list of revenue codes applicable to high-technology radiology services.

Coding and Billing Requirements


Cross References

Attachment A: High-Technology Radiology Services
Description: High-Technology Radiology Services Code List







Policy History

Revision from MA09.002l:
02/09/2020This version of the policy will become effective on 02/09/2020.

AIM Specialty Health® (AIM) has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology and the Heart. These guidelines will become effective 02/09/2020. These guidelines are available online at:http://www.aimspecialtyhealth.com/CG-Radiology.html or http://www.aimspecialtyhealth.com/CG-Cardiology.html.

Revisions from MA09.002k:
01/01/2020This version of the policy will become effective on 01/01/2020. This policy has been identified for the CPT code update, effective 01/01/2020.

The following CPT codes have been added to the policy: 78429, 78430, 78431, 78432, 78433, & 78434 (Medically Necessary)

The following CPT codes have been deleted to the policy: 0482T

The following CPT codes have been revised in the policy: 78459, 78491, & 78492

Revision from MA09.002j:
11/10/2019This version of the policy will become effective on 11/10/2019.

AIM Specialty Health® (AIM) has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology and the Heart. These guidelines will become effective 11/10/2019. These guidelines are available online at:http://www.aimspecialtyhealth.com/CG-Radiology.html or http://www.aimspecialtyhealth.com/CG-Cardiology.html.

This information was previously communicated on 08/08/2019 via a News Article on the Medical Policy Portal.

Revision from MA09.002i:
07/01/2019This version of the policy will become effective on 07/01/2019.

AIM Specialty Health® (AIM) has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology and the Heart. These guidelines will become effective 07/01/2019. These guidelines are available online at:http://www.aimspecialtyhealth.com/CG-Radiology.html or http://www.aimspecialtyhealth.com/CG-Cardiology.html.

Revision from MA09.002h:
01/01/2019AIM Specialty Health® (AIM) has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology. These guidelines will become effective 01/01/2019. Upon approval, these guidelines will be available online at: http://aimspecialtyhealth.com/CG-Radiology.html.

The following CPT codes have been added to Attachment A of this policy:

76391, 77046, 77047, 77048, 77049

The following CPT codes have been removed from Attachment A of this policy:

77058, 77059, C8904, C8907

Revisions from MA09.002g
10/29/2018
AIM Specialty Health® (AIM) has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology. These guidelines will become effective 10/29/2018. Upon approval, these guidelines will be available online at: http://aimspecialtyhealth.com/CG-Radiology.html.

AIM will now utilize their Advanced Imaging Clinical Appropriateness Guidelines for Radiology to determine the medical necessity for magnetic resonance imaging (MRI) of the breast for monitoring the integrity of silicone-gel-filled breast implants in asymptomatic individuals.

All language referring to Precertification/Preapproval has been removed from this policy.

The following HCPCS codes have been removed from Attachment A of this policy: S8092, G0219, G0252

Revisions from MA09.002f
01/01/2018This version of the policy will become effective 01/01/2018.

The Company requires precertification/preapproval through AIM Specialty HealthSM (AIM) for Fractional Flow Reserve (FFR) in the context of the current coronary artery computed tomography angiography (CCTA) review.

The following CPT codes have been added to this policy (Medically Necessary):

0482T, 0501T, 0502T, 0503T, 0504T

Revisions from MA09.002e:
09/22/2017This version of the policy will become effective 09/22/2017.

The following policy has been updated to clarify the Company’s delegation of precertification/preapproval of high-technology radiology services to AIM Specialty Health® (AIM) for the Company's products.

Revisions from MA09.002d:
11/23/2016This policy has been reviewed and reissued to communicate the Company’s continuing position on High-Technology Radiology Services.
10/01/2016Revised policy #MA09.002d was issued as a result of the ICD-10 Coding update for 10/01/2016 . This update does not imply a full review of the policy was completed at this time. The following coding changes were made:

The following HCPCS code has been Deleted from the policy S8032

Revisions from MA09.002c:
01/01/2016This policy has been identified for the CPT and HCPCS code update, effective 01/01/2016.

The following CPT codes have been added to Attachment A of this policy: 74712, 74713

The following HCPCS code has been added to Attachment A of this policy: G0297

Revisions from MA09.002b:
07/01/2015The following HCPCS codes have been added to Attachment A of this policy: C8900, C8901, C8902, C8903, C8904, C8905, C8906, C8907, C8908, C8909, C8910, C8911, C8912, C8913, C8914, C8918, C8919, C8920, C8931, C8932, C8933, C8934, C8935, C8936.

Revisions from MA09.002a:
05/08/2015The following language was removed from the policy because annual CT screening for lung cancer in high-risk individuals is covered by Medicare:
    Note: Annual CT screening for lung cancer in high-risk individuals is not covered by the Company because it is a service not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

In Attachment A of this policy, code S8032 (Low-dose computed tomography for lung cancer screening) was changed to indicate that this service is covered by Medicare.

Following CPT codes have been removed from Attachment A of this policy because these services are not managed by AIM, retro effective back to 01/01/2015: 77061, 77062, 77063.

Revisions from MA09.002:
01/01/2015This is a new policy.

Note: On 12/23/2014, the policy was identified for CPT code update. Effective 01/01/2015, the following CPT codes have been added to this policy: 77061, 77062, 77063, 93355




Version Effective Date: 02/09/2020
Version Issued Date: 02/10/2020
Version Reissued Date: N/A