Commercial

Medical Policy

Title:

High-Technology Radiology Services (Independence)

Policy #:

09.00.46ax

Policy

This policy does not apply to members for whom the Carelon Medical Benefits Management program is not applicable. This policy only applies to members for whom the
program is applicable. Individual member benefits must be verified before/prior to providing services.

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 Carelon Medical Benefits Management with the exception of services performed in the emergency room or during an inpatient or observation unit stay.

In addition, starting September 1, 2026, the Company has delegated the responsibility for site of care review of clinical appropriateness and most cost-effective setting to Carelon Medical Benefits Management for select high-technology radiology services based on Carelon's Site of Care for Advanced Imaging Guidelines. The services/codes that are part of this program are indicated by an asterisk (*) in Attachment A.

Please take note of the following:

Whether Carelon Medical Benefits Management utilizes their Advanced Imaging Clinical Appropriateness Guidelines for Radiology or Cardiology or utilizes the Company's medical policies for medical necessity determinations related to high-technology radiology services.
The Company’s position is that high-technology radiology services are considered experimental/investigational when they are used for conditions that are not addressed in the Company’s policy or in either the Carelon Medical Benefits Management Advanced Imaging Clinical Appropriateness Guidelines for Radiology or in the Carelon Medical Benefits Management Advanced Imaging Clinical Appropriateness Guidelines for Cardiology.

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 Carelon Medical Benefits Management 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 Carelon Medical Benefits Management with the exception of services performed in the emergency room or during an inpatient or observation unit stay. In addition, Carelon Medical Benefits Management utilizes either their Advanced Imaging Clinical Appropriateness Guidelines for Radiology or Advanced Imaging Clinical Appropriateness Guidelines for Cardiology 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 Carelon Medical Benefits Management, 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)

Carelon Medical Benefits Management does not manage Multiparametric MRI (e.g., LiverMultiscan) (0648T, 0649T) for the Company; please refer to Company medical policy #12.01.01 Experimental/Investigational Services.

The use of any high-technology radiology service listed in this policy for conditions not addressed in the Carelon Medical Benefits Management Advanced Imaging Clinical Appropriateness Guidelines for Radiology or the Carelon Medical Benefits Management 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.

The use of any high-technology radiology service listed in this policy when associated with a noncovered service, drug and/or biologic is considered not medically necessary and, therefore, not covered.

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 of utilization management activities for certain high-technology radiology services to Carelon Medical Benefits Management, with the exception of services performed in the emergency room or during an inpatient or observation unit stay. Carelon Medical Benefits Management uses its Advanced Imaging Clinical Appropriateness Guidelines for Radiology or its Advanced Imaging Clinical Appropriateness Guidelines for Cardiology to determine medical necessity for select high-technology radiology services and to direct the application of these services for our members. In addition, Carelon Medical Benefits Management utilizes their Site of Care for Advanced Imaging Guidelines to address site of care for a select group of outpatient advanced imaging services that are routinely performed outside of a hospital setting. 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 and Molecular Imaging (SNMMI)
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

Carelon Medical Benefits Management®. Clinical Appropriateness Guidelines Advanced Imaging: Imaging of the Abdomen and Pelvis. [Carelon Web site]. 04/04/2026. Available at: Current Radiology Guidelines | Carelon Clinical Guidelines and Pathways (carelonmedicalbenefitsmanagement.com). Accessed July 15, 2026.

Carelon Medical Benefits Management®. Clinical Appropriateness Guidelines Advanced Imaging: Imaging of the Brain. [Carelon Web site]. 11/15/2025. Available at: Current Radiology Guidelines | Carelon Clinical Guidelines and Pathways (carelonmedicalbenefitsmanagement.com). Accessed July 15, 2026.

Carelon Medical Benefits Management®. Clinical Appropriateness Guidelines Advanced Imaging: Imaging of the Chest. [Carelon Web site]. 04/04/2026. Available at: Current Radiology Guidelines | Carelon Clinical Guidelines and Pathways (carelonmedicalbenefitsmanagement.com). Accessed July 15, 2026.

Carelon Medical Benefits Management®. Clinical Appropriateness Guidelines Advanced Imaging: Imaging of the Extremities. [Carelon Web site]. 11/15/2025. Available at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-radiology-guidelines/. Accessed July 15, 2026.

Carelon Medical Benefits Management®. Clinical Appropriateness Guidelines Advanced Imaging: Imaging of the Head and Neck. [Carelon Web site]. 04/04/2026. Available at: Current Radiology Guidelines | Carelon Clinical Guidelines and Pathways (carelonmedicalbenefitsmanagement.com). Accessed July 15, 2026.

Carelon Medical Benefits Management®. Clinical Appropriateness Guidelines Advanced Imaging: Oncologic Imaging. [Carelon Web site]. 04/04/2026. Available at: Current Radiology Guidelines | Carelon Clinical Guidelines and Pathways (carelonmedicalbenefitsmanagement.com). Accessed July 15, 2026.

Carelon Medical Benefits Management®. Clinical Appropriateness Guidelines Advanced Imaging: Imaging of the Spine. [Carelon Web site]. 11/15/2025. Available at: Current Radiology Guidelines | Carelon Clinical Guidelines and Pathways (carelonmedicalbenefitsmanagement.com). Accessed July 15, 2026.

Carelon Medical Benefits Management®. Clinical Appropriateness Guidelines Advanced Imaging: Vascular Imaging. [Carelon Web site]. 11/15/2025. Available at: Current Radiology Guidelines | Carelon Clinical Guidelines and Pathways (carelonmedicalbenefitsmanagement.com). Accessed July 15, 2026.

Carelon Medical Benefits Management®. Clinical Appropriateness Guidelines for Radiology. [Carelon Web site]. Available at: Current Radiology Guidelines | Carelon Clinical Guidelines and Pathways (carelonmedicalbenefitsmanagement.com). Accessed July 15, 2026.

Carelon Medical Benefits Management®. Clinical Appropriateness Guidelines for Advanced Imaging of the Heart. [Carelon Web site]. 11/15/2025. Available at: Current Cardiology Guidelines | Carelon Clinical Guidelines and Pathways (carelonmedicalbenefitsmanagement.com). Accessed July 15, 2026.

Carelon Medical Benefits Management®. Clinical Appropriateness Guidelines for Site of Care Advanced Imaging. [Carelon Web site]. 04/02/2026. Available at: Site of Care for Advanced Imaging 2024-11-17 | Carelon Clinical Guidelines and Pathways. Accessed July 15, 2026.

Department of Health and Human Services. Center for Medicare & Medicaid Services. Medicare Preventive Services. Quick Reference Information: Preventive Services. [CMS Web site]. April 2024. Available at: https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html. Accessed July 15, 2026.

Coding

CPT Procedure Code Number(s)

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

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

Follow Carelon 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.

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 09.00.46ax:

09/19/2026

This version of the policy will become effective on 09/19/2026.

Carelon Medical Benefits Management has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology. For a detailed summary of changes, see the specific guidelines that will become effective on 09/19/2026. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-radiology-guidelines/.

Revisions From 09.00.46aw:

07/01/2026

This version of the policy will become effective on 07/01/2026.

Carelon Medical Benefits Management has revised their Advanced Imaging code set groupers for Radiology. Revisions will not impact utilization management of services.

Revisions From 09.00.46av:

04/04/2026

This version of the policy will become effective on 04/04/2026.

Carelon Medical Benefits Management has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology. For a detailed summary of changes, see the specific guidelines that will become effective on 04/04/2026. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-radiology-guidelines/.

In addition, language regarding Site of Care for Advanced Imaging was incorporated into the policy for a future effective date.

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

70472

Revisions From 09.00.46au:

01/01/2026

This policy has been identified for the CPT code update, effective 01/01/2026.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

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

70471, 70473

The following CPT code has been termed and removed from Attachment A of this policy:

0042T

Revisions From 09.00.46at:

11/15/2025

This version of the policy will become effective on 11/15/2025.

Carelon Medical Benefits Management has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology. For a detailed summary of changes, see the specific guidelines that will become effective on 11/15/2025. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-radiology-guidelines/.

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

95965, 95966

Revisions From 09.00.46as:

03/23/2025

This version of the policy will become effective on 03/23/2025.

Carelon Medical Benefits Management has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology. For a detailed summary of changes, see the specific guidelines that will become effective on 03/23/2025. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-radiology-guidelines/.

Revisions From 09.00.46ar:

10/20/2024

This version of the policy will become effective on 10/20/2024.

Carelon Medical Benefits Management has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology and Cardiology. For a detailed summary of changes, see the specific guidelines that will become effective on 10/20/2024. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-radiology-guidelines/ and https://guidelines.carelonmedicalbenefitsmanagement.com/current-cardiology-guidelines/.

In addition, the following statement was added to this policy:

Revisions From 09.00.46aq:

04/14/2024

This version of the policy will become effective on 04/14/2024.

Carelon Medical Benefits Management has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology and Cardiology. For a detailed summary of changes, see the specific guidelines which will become effective 04/14/2024. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-radiology-guidelines/ and https://guidelines.carelonmedicalbenefitsmanagement.com/current-cardiology-guidelines/.

Revisions From 09.00.46ap:

01/01/2024

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.

This policy has been identified for the CPT code update, effective 01/01/2024.

The following CPT code has been added to this policy:
75580

The following CPT codes have been termed and removed from this policy:

0501T, 0502T, 0504T

Revisions From 09.00.46ao:

09/10/2023

This version of the policy will become effective on 09/10/2023.

Carelon Medical Benefits Management has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology. For a detailed summary of changes, see the specific guidelines which will become effective 09/10/2023. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-radiology-guidelines/.

Revisions From 09.00.46an:

04/09/2023

This version of the policy will become effective on 04/09/2023.

Carelon Medical Benefits Management® (formerly AIM Specialty Health® (AIM)) has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology and Cardiology. For a detailed summary of changes, see the specific guidelines which will become effective 04/09/2023. These guidelines are available online at: https://aimspecialtyhealth.com/resources/clinical-guidelines/radiology/ and https://aimspecialtyhealth.com/resources/clinical-guidelines/cardiology/.

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

0742T, 93319

Revisions From 09.00.46am:

11/06/2022

This version of the policy will become effective on 11/06/2022.

AIM Specialty Health® (AIM) has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology and Cardiology. For a detailed summary of changes, see the specific guidelines which will become effective 11/06/2022. These guidelines are available online at: https://aimspecialtyhealth.com/resources/clinical-guidelines/radiology/ and https://aimspecialtyhealth.com/resources/clinical-guidelines/cardiology/.

Revisions From 09.00.46al:

09/11/2022

This version of the policy will become effective on 09/11/2022.

AIM Specialty Health® (AIM) has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology. For a detailed summary of changes, see the specific guidelines which will become effective 09/11/2022. These guidelines are available online at:http://www.aimspecialtyhealth.com/CG-Radiology.html.

Revisions From 09.00.46ak:

06/12/2022

This version of the policy will become effective on 06/12/2022.

AIM Specialty Health® (AIM) has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology. For a detailed summary of changes, see the specific guidelines which will become effective 06/12/2022. These guidelines are available online at:http://www.aimspecialtyhealth.com/CG-Radiology.html.

In addition, the following policy disclaimer was revised to communicate:

This policy does not apply to Members for whom AIM Specialty Health® programs is not applicable. This policy only applies to members for whom the Program is applicable. Individual member benefits must be verified before/prior to providing services.

Revisions From 09.00.46aj:

03/13/2022

This version of the policy will become effective on 03/13/2022.

AIM Specialty Health® (AIM) has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology and Cardiology. For a detailed summary of changes, see the specific guidelines which will become effective 03/13/2022. These guidelines are available online at:http://www.aimspecialtyhealth.com/CG-Radiology.html and https://aimspecialtyhealth.com/resources/clinical-guidelines/cardiology/.

The following HCPCS code has been added to this policy as Medically Necessary:

0042t: Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time

Revisions From 09.00.46ai:

01/01/2022

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.

This policy has been identified for the CPT code update, effective 01/01/2022.

The following CPT narrative has been revised in this policy: 75573

Revisions From 09.00.46ah:

11/07/2021

This version of the policy will become effective on 11/07/2021.

AIM Specialty Health® (AIM) has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology and Cardiology. For a detailed summary of changes, see the specific guidelines which will become effective 11/07/2021. These guidelines are available online at:http://www.aimspecialtyhealth.com/CG-Radiology.html and https://aimspecialtyhealth.com/resources/clinical-guidelines/cardiology/.

Revisions From 09.00.46ag:

09/12/2021

This version of the policy will become effective on 09/12/2021.

AIM Specialty Health® (AIM) has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology. For a detailed summary of changes, see the specific guidelines which will become effective 09/12/2021. These guidelines are available online at:http://www.aimspecialtyhealth.com/CG-Radiology.html.

Coding:

The following CPT code has been added to this policy:

76380

The following CPT code has been removed from this this policy:

93355

Revisions From 09.00.46af:

03/14/2021

This version of the policy will become effective on 03/14/2021.

AIM Specialty Health® (AIM) has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology and Cardiology. For a detailed summary of changes, see the specific guidelines which will become effective 03/14/2021. Upon approval, these guidelines are available online at:http://www.aimspecialtyhealth.com/CG-Radiology.html and http://www.aimspecialtyhealth.com/CG-Cardiology.html.

The summary changes are as follows by section:

Chest Imaging and Head and Neck Imaging

Hoarseness, dysphonia, and vocal cord weakness/paralysis – primary voice complaint

Require laryngoscopy for the initial evaluation of all patients with primary voice complaint

Brain Imaging and Head and Neck Imaging

Hearing loss

Added CT temporal bone for evaluation of sensorineural hearing loss in any pediatric patients or in adults for whom MRI is nondiagnostic or unable to be performed
Higher allowed threshold for consecutive frequencies to establish sensorineural hearing loss (SNHL)
Remove CT brain as an alternative to evaluating hearing loss based on American College of Radiology (ACR) guidance

Tinnitus

Remove sudden onset symmetric tinnitus as an indication for advanced imaging

Head and Neck Imaging

Sinusitis/rhinosinusitis

Add more flexibility for the method of conservative treatment in chronic sinusitis.
Require conservative management prior to repeat imaging for patients with prior sinus CT.

Temporomandibular joint dysfunction

Removed requirement for radiographs/ultrasound

Cerebrospinal fluid (CSF) leak of the skull base

Added scenario for management of known leak with change in clinical condition

Brain Imaging

Ataxia, congenital or hereditary

Combine with congenital cerebral anomalies to create one section

Acoustic neuroma

More frequent imaging for a watch and wait or incomplete resection
New indication for Neurofibromatosis type 2 (NF 2)
More frequent imaging when MRI shows findings suspicious for recurrence
Single post-operative MRI following gross total resection
Include pediatrics with known acoustics (rare but NF 2)

Tumor – not otherwise specified

Repurpose for surveillance imaging of low grade neoplasms

Seizure disorder and epilepsy

Limit imaging for the management of established generalized epilepsy
Require optimal medical management (aligning adult and pediatric language) prior to imaging for management in epilepsy

Headache

Remove response to treatment as a primary headache red flag
Include pregnancy as a red flag risk factor

Mental status change and encephalopathy

Added requirement for initial clinical and lab evaluation to assess for a more specific cause

Oncologic Imaging

General enhancements: Updates to Scope/Definitions, general language standardization

General Content enhancements: Overall alignment with current oncology guideline recommendations, resulting in:

Removal of indications/parameters not addressed by National Comprehensive Cancer Network (NCCN)
Average risk inclusion criteria for CT Colonography
New allowances for MRI Abdomen and/or MRI Pelvis by tumor type, liver metastatic disease
New indications for Acute Leukemia (CT, PET/CT), Multiple Myeloma (MRI, PET/CT), Ovarian Cancer surveillance (CT), Bone Sarcoma (PET/CT)
Updated standard imaging pre-requisites prior to PET/CT for Bladder/Renal Pelvis/Ureter, Colorectal, Esophageal/GE Junction, Gastric and Non-Small Cell Lung Cancers
Additional PET/CT management scenarios for Cervical Cancer, Hodgkin Lymphoma

Other content enhancements by section:

Cancer screening: New indication for Pancreatic Cancer screening

Breast Cancer: New PET/CT indication for restaging/treatment response for bone-only metastatic disease and limitation of post-treatment Breast MRI after breast conserving therapy or unilateral mastectomy

Prostate Cancer: MRI pelvis: removal of TRUS biopsy requirement, allowance if persistent/unexplained elevation in PSA or suspicious DRE

Axumin PET/CT: Updated inclusion criteria (removal of general MRI pelvis requirement, additional allowance for rising PSA with non-diagnostic mpMRI)

Resting Transthoracic Echocardiography (TTE)

Evaluation of patients with cardiac arrhythmias

Updated repeat TTE criteria
Added restrictions for patients whose initial echocardiogram shows no evidence of structural heart disease, and follow-up echocardiography is not appropriate for ongoing management of arrhythmia.

Evaluation of signs, symptoms, or abnormal testing

Added restrictions for TTE in evaluation of palpitation and lightheadedness based on literature.

Revisions From 09.00.46ae:

01/01/2021

This policy has been identified for the CPT and HCPCS code update, effective 01/01/2021.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

The following CPT code narratives have been revised in this policy:

71250, 71260, 71270

The following CPT code has been added to this policy:

71271

The following HCPCS code has been termed and removed from this policy:

G0297 Low dose ct scan (ldct) for lung cancer screening

Revisions From 09.00.46ad:

11/23/2020

This version of the policy will become effective on 11/23/2020.

The following CPT code has been deleted from Attachment A of this policy:

76497

76498

The following HCPCS code has been deleted from Attachment A of this policy:

G0235 PET imaging, any site, not otherwise specified

Revisions From 09.00.46ac:

08/16/2020

This version of the policy will become effective on 08/16/2020.

AIM Specialty Health® (AIM) has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology. These guidelines will become effective 08/16/2020. Upon approval, these guidelines are available online at:http://www.aimspecialtyhealth.com/CG-Radiology.html.

The summary changes are as follows:

Chest Imaging updates by section:
Interstitial lung disease (ILD), non-occupational including idiopathic pulmonary fibrosis (IPF)

Defined criteria warranting advanced imaging for both diagnosis and management
Occupational lung disease (Adult only)
Moved parenchymal component of asbestosis into this indication
Added Berylliosis
Chest Wall and Diaphragmatic Conditions
Removed screening indication for implant rupture due to lack of evidence indicating that outcomes are improved
Limited evaluation of clinically suspected rupture to patients with silicone implants

Code Changes: None

Oncologic Imaging updates by section:
MRI breast

New indication for BIA-ALCL
New indication for pathologic nipple discharge
Further define the population of patients most likely to benefit from preoperative MRI

Breast cancer screening

Added new high risk genetic mutations appropriate for annual breast MRI screening

Lung cancer screening

Added asbestos-related lung disease as a risk factor

Code Changes: None

Revisions From 09.00.46ab:

07/01/2020

This policy has been identified for the HCPCS code update, effective 07/01/2020.

The following HCPCS codes have been added to Attachment A of this policy:
C9672, C9673

Revisions From 09.00.46aa:

05/17/2020

This version of the policy will become effective on 05/17/2020.

AIM Specialty Health® (AIM) has revised their Advanced Imaging Clinical Appropriateness Guidelines for Radiology. These guidelines will become effective 05/17/2020. Upon approval, these guidelines are available online at:http://www.aimspecialtyhealth.com/CG-Radiology.html.

The summary changes are as follows:
Advanced Imaging: Vascular Imaging Guideline updates by section:
Aneurysm of the abdominal aorta or iliac arteries

Added new indication for asymptomatic enlargement by imaging
Clarified surveillance intervals for stable aneurysms as follows:
- Treated with endografts, annually
- Treated with open surgical repair, every 5 years

Stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified

Added surveillance indication and interval for surgical bypass grafts

Code changes

None

Revisions From 09.00.46z:

02/09/2020

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.

Revisions From 09.00.46y:

01/01/2020

This 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

Revisions From 09.00.46x:

11/10/2019

This 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.

Revisions From 09.00.46w:

07/01/2019

This 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.

Revisions 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:

9/19/2026

Version Issued Date: