Notification



Notification Issue Date:



Medical Policy Bulletin


Title:High-Technology Radiology Services (Independence)

Policy #:09.00.46v

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

This policy does not apply to those members for whom Independence Administrators serve as the claims administrator.

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.

Please be advised of the following:
  • Whether AIM utilizes AIM Advanced Imaging Clinical Appropriateness Guidelines for Radiology or Company medical policies for medical necessity determinations related to high-technology radiology services.
  • The Company’s position that high-technology radiology services are considered experimental/investigational when they are used for conditions that are not addressed in either the Company’s policy or in the AIM Advanced Imaging Clinical Appropriateness Guidelines for Radiology.

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 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. In addition, AIM utilizes their Advanced Imaging Clinical Appropriateness Guidelines for Radiology to determine the 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
    • Stress echocardiography (SE)
    • Resting transthoracic echocardiography (TTE)
    • Transesophageal echocardiography (TEE)

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 AIM Advanced Imaging Clinical Appropriateness Guidelines for Radiology 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.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, high-technology radiology services are covered under the medical benefits of the Company’s 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.

Description

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. AIM uses its Advanced Imaging Clinical Appropriateness Guidelines for Radiology to determine medical necessity 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]. 10/29/2018. Available at: http://aimspecialtyhealth.com/CG-Radiology.html. Accessed June 18, 2018.

Department of Health and Human Services. Center for Medicare and Medicaid Services. Medicare Preventive Services. Quick Reference Information: Preventive Services. [CMS Web site]. January 2018. Available at: https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html. Accessed June 18, 2018.





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 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 (Independence)
Description: High-Technology Radiology Services Code List




Policy History

Revision from 09.00.46v:
01/01/2019
AIM 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 09.00.46u:
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 09.00.46t:
01/01/2018
This version of the policy will become effective 01/01/2018.

The Company requires precertification/preapproval through AIM Specialty Health® (AIM) for Fractional Flow Reserve (FFR) in the context of the current coronary artery computed tomography angiography (CCTA) review for most members enrolled in its Commercial HMO and PPO products.

The following CPT codes have been added to this policy (Medically Necessary):
    0482T, 0501T, 0502T, 0503T, 0504T


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/01/2019
Version Issued Date: 01/07/2019
Version Reissued Date: N/A

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