NIA Claim Resolution Matrix
Utilization Review Matrix 2016CareSource Advantage The matrix below contains all of the CPT-4 codes for which NIA Magellan authorizes on behalf of CareSource Advantage. This matrix is designed to assist in the resolution of claims adjudication and claims questions related to those services authorized by NIA Magellan. If an exam is billed under any one of the given codes for that grouping and a valid authorization number has been issued within the date of service validity period, the charge for any of the codes should be allowed. If a family of CPT codes is not listed in this matrix, an exact match is required between the authorized CPT code and the billed CPT code. If the exact match does not occur, the charge should be adjudicated accordingly.*Please note: Services rendered in an Emergency Room, Observation Room, surgery center or hospital inpatient setting are not managed by NIA Magellan.Authorized CPT CodeDescriptionAllowable Billed Groupings70336MRI Temporomandibular Joint7033670450CT Head/Brain70450, 70460, 7047070480CT Orbit70480, 70481, 7048270486CT Maxillofacial/Sinus70486, 70487, 70488, 7638070490CT Soft Tissue Neck70490, 70491, 7049270496CT Angiography, Head7049670498CT Angiography, Neck7049870540MRI Orbit, Face, and/or Neck70540, 70542, 7054370551MRI Internal Auditory Canal 70551, 70552, 70553, 70540, 70542, 7054370544MRA Head70544, 70545, 7054670547MRA Neck70547, 70548, 7054970551MRI Brain70551, 70552, 7055370554 Functional MRI Brain70554, 7055571250CT Chest71250, 71260, 71270, S803271275CT Angiography, Chest (non coronary)7127571550MRI Chest71550, 71551, 7155271555MRA Chest (excluding myocardium)7155572125CT Cervical Spine72125, 72126, 7212772128CT Thoracic Spine72128, 72129, 7213072131CT Lumbar Spine72131, 72132, 7213372141MRI Cervical Spine72141, 72142, 7215672146MRI Thoracic Spine72146, 72147, 7215772148MRI Lumbar Spine72148, 72149, 7215872159MRA Spinal Canal7215972191CT Angiography, Pelvis7219172192CT Pelvis72192, 72193, 7219472196MRI Pelvis72195, 72196, 7219772198MRA Pelvis7219873200CT Upper Extremity73200, 73201, 7320273206CT Angiography, Upper Extremity7320673220MRI Upper Extremity, other than Joint73218, 73219, 7322073221MRI Upper Extremity Joint73221, 73222, 7322373225MRA Upper Extremity7322573700CT Lower Extremity73700, 73701, 7370273706CT Angiography, Lower Extremity7370673720MRI Lower Extremity73718, 73719, 73720, 73721, 73722, 7372373721MRI Hip72195, 72196, 72197, 73721, 73722, 7372373725MRA Lower Extremity7372574150CT Abdomen74150, 74160, 7417074174CT Angiography, Abdomen and Pelvis7417474175CT Angiography, Abdomen7417574176CT Abdomen and Pelvis Combination74176, 74177, 7417874181MRI Abdomen74181, 74182, 74183, S803774185MRA Abdomen7418574261 Diagnostic CT Colonoscopy (Virtual Colonoscopy, CT Colonography)74261, 7426274263 Screening CT Colonoscopy (Virtual Colonoscopy, CT Colonography)7426375557 MRI Heart75557, 75559, 75561, 75563, +7556575571 Coronary Artery Ca Score, Heart Scan, Ultrafast CT Heart, Electron Beam CT75571, S809275572CT Heart7557275573CT Heart congenital studies, non-coronary arteries7557375574CTA coronary arteries (CCTA)7557475635CT Angiography, Abdominal Arteries7563576380Follow Up, Limited or Localized CT76380, 70486, 70487, 7048876390 MR Spectroscopy7639076497Unlisted Computed Tomography Procedure7649776498Unlisted Magnetic Resonance Procedure7649877058MRI Breast 77058, 7705977078CT Bone Density Studies7707877084MRI Bone Marrow 7708478459PET Scan, Heart78459, 78491, 7849278608PET Scan, Brain78608, 7860978813 PET Scan78811, 78812, 78813, 78814, 78815, 7881678816 PET Scan with concurrently acquired CT for attenuation correction and anatomic, localization. 78811, 78812, 78813, 78814, 78815, 788160042T Cerebral Perfusion Analysis CT 0042TG0219PET imaging whole body, melanoma for non-covered indicationsG0219G0235PET imaging, any site, not otherwise specifiedG0235G0252 PET imaging, initial diagnosis of breast cancer and/or surgical planning for breast cancerG0252S8032Low Dose CT For Lung Cancer ScreeningS8032S8037MR CholangiopancreatographyS8037, 74181, 74182, 74183S8042MRI low fieldS8042+ codes (add on codes) do not require separate authorization and are to be used in conjunction with approved primary code for the service rendered.Y0119_MA-P-0019 ................
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