Medicare Advantage

Medical Policy

Notification

High-Technology Radiology Services

Notification Issue Date:

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. Upon approval, these guidelines are available online at:http://www.aimspecialtyhealth.com/CG-Radiology.html.

The summary changes are as follows by section:

Title:

High-Technology Radiology Services

Policy #:

MA09.002ai

Policy

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.

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 Local Coverage Determinations (LCD), National Coverage Determinations (NCD), or 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. To determine medical necessity for these services, Carelon Medical Benefits Management first utilizes Medicare guidelines (e.g., LCD, NCD). If no Medicare guidelines exist, Carelon Medical Benefits Management 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)
CT 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)
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)

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 CT scan screening
Quantitative CT (QCT) for bone mineral densitometry of axial skeleton only
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 #MA00.005 Experimental/Investigational Services.

The use of any high-technology radiology service listed in this policy for conditions not addressed in the Medicare or Carelon Medical Benefits Management Advanced Imaging Clinical Appropriateness Guidelines for Radiology or 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 unless the individual is being considered for participation in a clinical trial.

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

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

Carelon Medical Benefits Management 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 NCD, LCD, and/or The Guide to Medicare Preventive Services.

The Center for Medicare & 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
The Joint Commission

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. To determine medical necessity for these services,

Carelon Medical Benefits Management first utilizes Medicare guidelines based on applicable statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents. If no Medicare guidelines exist,

Carelon Medical Benefits Management 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

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.

Centers for Medicare & Medicaid Services (CMS). MLN Matters. Effective February 10, 2022. MM12691 – National Coverage Determination (NCD) 210.14 Reconsideration-Screening for Lung Cancer with Low Dose Computed Tomography (LDCT). Available at:

MM12691 - National Coverage Determination (NCD) 210.14 Reconsideration – Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (cms.gov). Accessed July 15, 2026.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 210.14 for Lung Cancer with Low Dose Computed Tomography (LDCT) [CMS Web site]. 02/10/2022. Available at: NCD - Lung Cancer Screening with Low Dose Computed Tomography (LDCT) (210.14) (cms.gov). Accessed July 15, 2026.

Centers for Medicare & Medicaid Services (CMS). National Coverage Analysis Decision Memo CAG-00439R. Screening for Lung Cancer with Low Dose Computed Tomography (LDCT). [CMS Web site]. 02/10/2022. Available at: https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=304. Accessed July 15, 2026.

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==&l. Accessed July 15, 2026.

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: National Coverage Determination (NCD) for Single Photon Emission Computed Tomography (SPECT) (220.12) (cms.gov). Accessed July 15, 2026.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 220.2 for Magnetic Resonance Imaging [CMS Web site]. 04/10/2018. Available at: NCD - Magnetic Resonance Imaging (220.2) (cms.gov). Accessed July 15, 2026.

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==&. Accessed July 15, 2026.

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==&. Accessed July 15, 2026.

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: NCD - Positron Emission Tomography (FDG) for Oncologic Conditions (220.6.17) (cms.gov). Accessed July 15, 2026.

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]. 12/15/2021. Available at: NCD - Positron Emission Tomography (NaF-18) to Identify Bone Metastasis of Cancer (220.6.19). Accessed July 15, 2026.

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==&. Accessed July 15, 2026.

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==&. 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.

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]. 10/01/2015. Revised 11/22/2023. Available at: Article - Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions (A53134) (cms.gov). Accessed July 15, 2026.

Novitas Solutions, Inc. Local Coverage Determination (LCD) L35083 Cardiovascular Nuclear Medicine. [Novitas Solutions Web site]. 10/01/2015. Revised 04/25/2021. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35083&ver=79&Date=09/30/2020&SearchType=Advanced&DocID=L35083&search_id=&service_date=&bc=KAAAAAIAAAAA&. Accessed July 15, 2026.

Novitas Solutions, Inc. Local Coverage Determination (LCD) L34865 Magnetic Resonance Angiography (MRA). [Novitas Solutions Web site]. 10/01/15. Revised 07/01/2020. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34865&ver=72&Date=09/30/2020&SearchType=Advanced&DocID=L34865&search_id=&service_date=&bc=KAAAAAIAAAAA&. 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 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.

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA09.002ai:

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 MA09.002ah:

05/17/2026

This version of the policy will become effective on 05/17/2026.

Carelon Medical Benefits Management has revised their Advanced Imaging code set groupers for Radiology. Revisions will not impact policy criteria.

Revisions From MA09.002ag:

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/.

The following CPT code has been added to Attachment A of this policy:
70472

Revisions From MA09.002af:

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 MA09.002ae:

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 codes were added to Attachment A of the policy:

95965, 95966

Revisions From MA09.002ad:

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 MA09.002ac:

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. 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 the policy:

Revisions From MA09.002ab:

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. 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 MA09.002aa:

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 MA09.002z:

01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
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/.

01/01/2024

Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.

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 MA09.002y:

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 MA09.002x:

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 MA09.002w:

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 MA09.002v:

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.

Revisions From MA09.002u:

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 MA09.002t:

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 MA09.002s:

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 MA09.002r:

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 MA09.002q:

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 MA09.002p:

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 MA09.002o:

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 MA09.002n:

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:

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

Chest Imaging updates by section:

Tumor or Neoplasm

Allowed follow up of nodules less than 6 mm in size seen on incomplete thoracic CT, in alignment with follow up recommendations for nodules of the same size seen on complete thoracic CT

Added new criteria for which follow up is indicated for mediastinal and hilar lymphadenopathy

Separated mediastinal/hilar mass from lymphadenopathy, which now has its own entry

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 MA09.002m:

07/01/2020

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

The following HCPCS codes have been added to Attachment A of this policy:
C9762, C9763

Revisions From MA09.002l:

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 MA09.002k:

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 MA09.002j:

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 MA09.002i:

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 MA09.002h:

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 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:

01/01/2018

This version of the policy will become effective 01/01/2018.

The Company requires precertification/preapproval through AIM Specialty Health^SM (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:

09/22/2017

This 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:

11/23/2016	This policy has been reviewed and reissued to communicate the Company’s continuing position on High-Technology Radiology Services.
10/01/2016	Revised 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:

01/01/2016

This 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:

07/01/2015

The 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:

05/08/2015

The 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:

01/01/2015

This 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:

9/19/2026

Version Issued Date:

9/19/2026

Version Reissued Date: