2019 MAGELLAN CLINICAL GUIDELINES MEDICAL NECESSITY …

2019 MAGELLAN1 CLINICAL GUIDELINES FOR

MEDICAL NECESSITY REVIEW

Version: 2 Effective: January 2019

"1National Imaging Associates, Inc. is a subsidiary of Magellan Healthcare, Inc."

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Guidelines for Clinical Review Determination

Preamble Magellan is committed to the philosophy of supporting safe and effective treatment for patients. The medical necessity criteria that follow are guidelines for the provision of diagnostic imaging. These criteria are designed to guide both providers and reviewers to the most appropriate diagnostic tests based on a patient's unique circumstances. In all cases, clinical judgment consistent with the standards of good medical practice will be used when applying the guidelines. Guideline determinations are made based on the information provided at the time of the request. It is expected that medical necessity decisions may change as new information is provided or based on unique aspects of the patient's condition. The treating clinician has final authority and responsibility for treatment decisions regarding the care of the patient.

Guideline Development Process These medical necessity criteria were developed by Magellan Healthcare for the purpose of making clinical review determinations for requests for diagnostic tests. The developers of the criteria sets included representatives from the disciplines of radiology, internal medicine, nursing, and cardiology and other specialty groups. They were developed following a literature search pertaining to established clinical guidelines and accepted diagnostic imaging practices.

All inquiries should be directed to: Magellan Healthcare PO Box 67390

Phoenix, AZ 85082-7390 Attn: Magellan Healthcare Chief Medical Officer

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TABLE OF CONTENTS

TOC

ADVANCED IMAGING GUIDELINES _______________________________________________ 7

70336 ? MRI Temporomandibular Joint (TMJ)_________________________________________ 7

70450 ? CT Head/Brain______________________________________________________________ 9

70480 ? CT Orbit (Includes Sella and Posterior Fossa)_________________________________ 16

70486 ? Maxillofacial/Sinus CT______________________________________________________ 20

70490 ? CT Soft Tissue Neck ________________________________________________________ 24

70496 ? CT Angiography, Head/Brain________________________________________________ 28

70498 ? CT Angiography, Neck ______________________________________________________ 31

70540 ? MRI Orbit _________________________________________________________________ 34

70544 ? MR Angiography Head/Brain________________________________________________ 38

70547 ? MR Angiography Neck ______________________________________________________ 41

70551 ? MRI Brain (includes Internal Auditory Canal) ________________________________ 44

70554 ? Functional MRI Brain ______________________________________________________ 52

71250 ? CT Chest (Thorax) _________________________________________________________ 55

71275 ? CT Angiography, Chest (non coronary) _______________________________________ 61

71550 ? MRI Chest (Thorax) ________________________________________________________ 65

71555 ? MR Angiography Chest (excluding myocardium) ______________________________ 70

72125 ? CT Cervical Spine __________________________________________________________ 75

72128 ? CT Thoracic Spine__________________________________________________________ 81

72131 ? CT Lumbar Spine __________________________________________________________ 87

72141 ? MRI Cervical Spine_________________________________________________________ 95

72146 ? MRI Thoracic Spine _______________________________________________________ 102

72148 ? MRI Lumbar Spine ________________________________________________________ 108

72159 ? MR Angiography Spinal Canal _____________________________________________ 115

72191 ? CT Angiography, Pelvis ____________________________________________________ 118

72192 ? CT Pelvis _________________________________________________________________ 123

72196 ? MRI Pelvis _______________________________________________________________ 131

72198 ? MR Angiography, Pelvis ___________________________________________________ 139

73200 ? CT Upper Extremity (Hand, Wrist, Elbow, Long Bone or Shoulder) ____________ 144

73206 ? CT Angiography, Upper Extremity__________________________________________151

73220 ? MRI Upper Extremity _____________________________________________________ 154

73225 ? MR Angiography Upper Extremity__________________________________________161

73700 ? CT Lower Extremity (Ankle, Foot, Hip or Knee) ______________________________ 164

73706 ? CT Angiography, Lower Extremity__________________________________________170

73720 ? MRI Lower Extremity (Ankle, Foot, Knee, Hip, Leg) __________________________ 174

73725 ? MR Angiography, Lower Extremity _________________________________________ 182

74150 ? CT Abdomen ______________________________________________________________ 185

74174 ? CT Angiography, Abdomen and Pelvis_______________________________________ 196

74175 ? CT Angiography, Abdomen _________________________________________________ 202

74176 ? CT Abdomen and Pelvis Combo_____________________________________________207

74181 ? MRI Abdomen ____________________________________________________________ 217

74185 ? MR Angiography, Abdomen ________________________________________________ 224

74261 ? CT Colonoscopy Diagnostic (Virtual) ________________________________________ 230

74263 - CT Colonoscopy Screening (Virtual) _________________________________________ 232

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74712 ? Fetal MRI ________________________________________________________________ 236 75557 ? MRI Heart________________________________________________________________238 75571 ? Electron Beam Tomography (EBCT) ________________________________________ 264 75572 ? CT Heart _________________________________________________________________ 269 75574 ? CTA Coronary Arteries (CCTA) _____________________________________________ 283 75635 ? CT Angiography, Abdominal Arteries _______________________________________ 293 76376 ? 3D Rendering (CT Multiplanar Reconstruction) ______________________________ 296 76390 ? MR Spectroscopy __________________________________________________________ 297 76497 ? Unlisted CT Procedure_____________________________________________________ 299 76498 ? Unlisted MRI Procedure ___________________________________________________ 300 77012 ? CT Needle Guidance _______________________________________________________ 301 77014 ? CT Guidance for Radiation Fields___________________________________________301 77021 ? MRI Guidance for Needle Placement ________________________________________ 301 77046 ? MRI Breast _______________________________________________________________ 302 77078 ? CT Bone Density Study ____________________________________________________ 309 78205 ? Liver SPECT _____________________________________________________________ 313 78320 ? Bone and/or Joint SPECT __________________________________________________ 316 77084 ? MRI Bone Marrow ________________________________________________________ 319 78451 ? Myocardial Perfusion Imaging (Nuc Card) ___________________________________ 322 78459 ? PET Scan, Heart (Cardiac) _________________________________________________ 338 78472 ? MUGA Scan ______________________________________________________________ 355 78608 ? PET Scan, Brain __________________________________________________________ 361 78647 ? Cerebrospinal Fluid Flow SPECT ___________________________________________ 363 78710 - Kidney SPECT ____________________________________________________________ 367 78813 ? PET Scan_________________________________________________________________370 0042T ? Cerebral Perfusion Analysis CT ____________________________________________ 377 +0159T ? CAD Breast MRI ________________________________________________________ 380 G0219 ? PET Imaging whole body, melanoma - noncovered ___________________________ 381 G0235 - PET imaging, any site, not otherwise specified _______________________________ 382 G0252 - PET imaging, initial diagnosis of breast cancer ______________________________ 383 0501T ? Fractional Flow Reserve CT________________________________________________384 S8037 ? MR Cholangiopancreatography (MRCP) _____________________________________ 394 G0297 ? Low Dose CT for Lung Cancer Screening____________________________________398 S8042 ? Low Field MRI ____________________________________________________________ 399 EXPANDED CARDIAC GUIDELINES______________________________________________ 401 33225 ? Cardiac Resynchronization Therapy (CRT) __________________________________ 401 33249 ? Implantable Cardioverter Defibrillator (ICD) ________________________________ 409 33208 ? Pacemaker _______________________________________________________________ 426 93307 ? Transthoracic Echocardiology (TTE) ________________________________________ 436 93312 ? Transesophageal Echocardiology (TEE) _____________________________________ 460 93350 ? Stress Echocardiography ___________________________________________________ 465 93452 ? Heart Catheterization _____________________________________________________ 481 MUSCULOSKELETAL_SPINE SURGERY GUIDELINES ___________________________ 491 22600/63001 ? Cervical Spinal Surgery _____________________________________________ 491 22612/63030 ? Lumbar Spinal Surgery ______________________________________________ 505

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62310-62311 ? Spinal Epidural Injections ___________________________________________ 516 64490-64493 ? Paravertebral Facet Joint Injections/Blocks ___________________________ 523 64633-64635 ? Paravertebral Facet Joint Neurolysis _________________________________ 527 22532 ? Thoracic Spine Surgery ____________________________________________________ 531 27096 ? Sacroiliac Joint Injections __________________________________________________ 534 27132 ? Hip Arthroplasty __________________________________________________________ 542 27130 ? Hip Arthroscopy __________________________________________________________ 550 27446 ? Knee Arthroplasty ________________________________________________________ 559 27332 ? Knee Arthroscopy _________________________________________________________ 569 23473 ? Shoulder Arthroplasty _____________________________________________________ 590 23410 ? Shoulder Arthroscopy______________________________________________________598 RADIATION ONCOLOGY GUIDELINES ___________________________________________ 612 2D ? 3D Conformal Radiation Therapy (CRT), External Beam Radiation Therapy For Other Cancers __________________________________________________________________________ 612 Anal Cancer ______________________________________________________________________ 613 Bone Metastases __________________________________________________________________ 615 Brachytherapy ____________________________________________________________________ 619 Breast Cancer ____________________________________________________________________ 624 Cervical Cancer ___________________________________________________________________ 629 Central Nervous System Metastatic Tumors_________________________________________635 Central Nervous System Primary___________________________________________________642 Colorectal Cancer _________________________________________________________________ 649 Endometrial Cancer _______________________________________________________________ 653 Gastric Cancer____________________________________________________________________659 Head and Neck Cancer ____________________________________________________________ 662 Hodgkins Lymphoma ______________________________________________________________ 667 Hyperthermia ____________________________________________________________________ 673 Intensity Modulated Radiation Therapy (IMRT) For Other Cancers ___________________ 677 Intraoperative Radiation Therapy (IORT) ___________________________________________ 688 Metastatic Disease ________________________________________________________________ 693 Neuton BeamTherapy _____________________________________________________________ 695 Non-Hodgkins Lymphoma _________________________________________________________ 698 Non Small Cell Lung Cancer _______________________________________________________ 702 Non-Cancerous Conditions _________________________________________________________ 707 Pancreatic Cancer_________________________________________________________________710 Prostate Cancer___________________________________________________________________716 Proton Beam Radiation Therapy ___________________________________________________ 721 Skin Cancer ______________________________________________________________________ 727 Small Cell Lung Cancer ___________________________________________________________ 730 Stereotactic Radiotherapy (SRS)_Stereotactic Body Radiation (SBRT) _________________ 733 ULTRASOUND GUIDELINES _____________________________________________________ 739 76536 ? Head and Neck Ultrasound ________________________________________________ 739 76700 ? Abdomen Ultrasound ______________________________________________________ 746 76856 ? Pelvic Ultrasound _________________________________________________________ 758 76870 ? Scrotum and Contents Ultrasound __________________________________________ 763

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