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ALASKA MEDICAID Pre-Auth List - Homepage | Qualis Health

ALASKA MEDICAID Pre-Auth List INDEX: Select Imaging - ..2. Procedures ..5. ICD-10 .11. ICD-10 Procedures ..13. ICD-10 Transplants ..4 . OUTPATIENT IMAGING - CPT. Effective - February 2018. All outpatient imaging services on this list require pre-certification CPT Code Description 76390 MR spectroscopy 70551 Magnetic resonance imaging, brain (including brain stem) without contrast material 70552 Magnetic resonance imaging, brain (including brain stem) with contrast material 70553 MRI Brain without contrast material, followed by contrast material and further sequences 70554 MRI, Brain, functional MRI including rest selection and administration of repetitive body part movement and /or visual stimulation, requiring physician or psychologist administration 70555 Magnetic resonance imaging, brain, functional MRI.

72195 72196 72197 72198 MRI, pelvis, without contrast material with contrast material without contrast material, followed by contrast material and further sections

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