Prior authorization for MRI
An authorization answer is not a coverage, eligibility, or payment answer. Substrate does not submit prior authorization requests.
This filters authorization rows on this page. It is not a coding dictionary.
No row on this page matches that code.
MRI
These examples use CPT 70553 only. MRI, CT, and PET are not one requirement. The long descriptor is blank because no AMA-licensed CPT file was available to copy. The outcome in each row is the researched disposition, and the setting limits are listed with it.
| Code | Long descriptor | Code system | Plan scope | Outcome | Source |
|---|---|---|---|---|---|
| 70553 | CPT | Participating-provider plans subject to this Aetna list | Authorization requiredYes, conditional; outside inpatient, emergency-room and observation settingsState, product, setting and site-of-care exceptions remain. Precertification is not required for the Foreign Service Benefit Plan, MHBP or Rural Carrier Benefit Plan when Original Medicare is the primary payer. Otherwise, these plans use the contact information on the member ID card instead of EviCore. | p. 43, Radiology imaging: code and requirement; p. 6, outpatient scope. p. 5, Original Medicare primary-payer exception. | |
| 70553 | CPT | Aetna Student Health | Authorization not requiredNo for this listed outpatient service | p. 43, Radiology imaging: explicit Aetna Student Health exception; p. 6, scope. | |
| 70553 | CPT | Allina Health / Aetna | Authorization not requiredNo for this listed outpatient service | p. 43, Radiology imaging: explicit Allina Health / Aetna exception; p. 6, scope. |
| Code | Long descriptor | Code system | Plan scope | Outcome | Source |
|---|---|---|---|---|---|
| 70553 | CPT | Medicare Advantage HMO/PPO and listed D-SNP products; nondelegated scope | Notification requiredNotification required; this row is not labeled prior authorizationDelegated groups use their own requirements; new-member transition exceptions may apply. | p. 13, diagnostic imaging row; Additional Information says Notification Required; pp. 1–2 define scope. |
| Code | Long descriptor | Code system | Plan scope | Outcome | Source |
|---|---|---|---|---|---|
| 70553 | CPT | Local commercial PPO, fully insured / vendor-program-eligible members | Authorization requiredYes, conditional; Carelon-managed programHMO, BlueCard, Medicare, Medicaid and other excluded products are outside this list. | p. 113, 70553 and Comments; p. 1, local PPO product restrictions. | |
| 70553 | CPT | Local commercial PPO members not eligible for the vendor program | Authorization not requiredNo; explicit exception in the code row | p. 113, 70553 Comments: no authorization for members not eligible for vendor programs. |
| Code | Long descriptor | Code system | Plan scope | Outcome | Source |
|---|---|---|---|---|---|
| 70553 | CPT | Commercial non-HMO fully insured and applicable ASO accounts; outpatient services | Authorization requiredYes, conditional; Carelon program and account applicability must match | p. 73, 70553, Carelon FI & ASO accounts; p. 1, scope and renewal conditions. |
| Code | Long descriptor | Code system | Plan scope | Outcome | Source |
|---|---|---|---|---|---|
| 70553 | CPT | CountyCare Medicaid; outpatient services; applicable provider specialties | Authorization requiredYes; reviewer depends on provider specialty | All Codes!B5948/F5948; L5948 routes NCH versus Evolent; Instructions on Use defines scope. |
| Code | Long descriptor | Code system | Plan scope | Outcome | Source |
|---|---|---|---|---|---|
| 70553 | CPT | Local commercial HMO; in-network services | Authorization requiredYes under the HMO ruleDo not apply this HMO rule to EPO or PPO members. | p. 27, 70553/Carelon Radiology; p. 1, HMO services require prior approval. | |
| 70553 | CPT | Local commercial PPO | RecommendedPrior approval highly recommended; otherwise prepayment review may deny reimbursementKept distinct from mandatory HMO prior authorization. | p. 35, 70553/Carelon Radiology; p. 1, PPO approval responsibility. |
CT
No reviewed CPT row in this pilot supports a CT outcome. CT is not given the MRI answer.
PET
No reviewed CPT row in this pilot supports a PET outcome. PET is not given the MRI answer.
Category without a code
The Indiana advanced-imaging row has no CPT code. It does not become a CPT-level yes. The researched disposition is unknown.
| Code | Long descriptor | Code system | Plan scope | Outcome | Source |
|---|---|---|---|---|---|
| No code listed | Local fully insured and participating ASO commercial plans; advanced imaging category | UnknownCategory requires review; exact CPT-level requirement unresolvedDo not infer that a particular MRI CPT is covered by a category-only listing. | p. 3, Carelon advanced imaging and product scope; no CPT enumeration for this category. |
Sources
- p. 43, Radiology imaging: code and requirement; p. 6, outpatient scope. p. 5, Original Medicare primary-payer exception.
- p. 13, diagnostic imaging row; Additional Information says Notification Required; pp. 1–2 define scope.
- p. 113, 70553 and Comments; p. 1, local PPO product restrictions.
- p. 73, 70553, Carelon FI & ASO accounts; p. 1, scope and renewal conditions.
- All Codes!B5948/F5948; L5948 routes NCH versus Evolent; Instructions on Use defines scope.
- p. 27, 70553/Carelon Radiology; p. 1, HMO services require prior approval.
- p. 35, 70553/Carelon Radiology; p. 1, PPO approval responsibility.
- p. 3, Carelon advanced imaging and product scope; no CPT enumeration for this category.