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Effective: 1/1/2021CategoryCPT Code2CPT Code DescriptionPrior Authorization Required3DI763763D Rendering W/O PostprocessingYes3DI763773D Rendering W PostprocessingYesBMRI77046Magnetic resonance imaging, breast, without contrast material; unilateralYesBMRI77047Magnetic resonance imaging, breast, without contrast material; bilateralYesBMRI77048Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateralYesBMRI77049Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateralYesCardiac Implantables33274Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performedYesCardiac Implantables33275Transcatheter removal of permanent leadless pacemaker, right ventricular - Effective 1/1/19 InvestigationalCardiac Implantables33289Transcatheter

Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s) Yes CT 71275 C T Angiography Chest Without Contrast Material, Followed by Contrast Material and Further Sections,Including Image

  Dose, Tomography, Computed, Computed tomography

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