Transcription of Diagnostic Imaging Prior Review Code List 1st Quarter 2022
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8 72127 CT cervical spine; w/o contrast followed by contrast 2/1/2007 Thorac ic 72128 CT thoracic spine; w/o contrast 2/1/2007 This list is subject to change once per quarter.
Spine, Cervical, Contrast, Cervical spine
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MEDICARE PART D EXCLUDED DRUGS LIST 2016_updated July 2016 Reason: LIST = multiple reasons it's excluded; "not covered under Part D law". Reason: Not properly listed with FDA = CMS considers it best practice for Part D sponsors to consider the proper listing of a drug product with the FDA as a prerequisite for making a Part D …
Neuromuscular Electrical Stimulation (NMES) involves the use of a device that transmits an electrical impulse to the skin over selected muscle groups by way of electrodes. Neuromuscular stimulator devices transmit an electrical impulse to
Electrical, Stimulation, Neuromuscular, Neuromuscular electrical stimulation, Mens
Corporate Medical Policy Page 1 of 14 An Independent Licensee of the Blue Cross and Blue Shield Association Genetic Cancer Susceptibility Panels Using Next Generation
Policy, Corporate, Cross, Medical, Blue, Blue cross, Corporate medical policy blue cross nc, Corporate medical policy
Members HMO: Blue Cross and Blue Shield of North Carolina complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Cross, Carolina, Blue, Shield, North, Blue cross and blue shield of north carolina
i When this drug list (formulary) refers to “we,” “us”, or “our,” it means Blue Cross and Blue Shield of North Carolina. When it refers to “plan” or “our plan,” it means Blue Medicare HMO Essential.
Drug, Blue, Shield, Covered, Formulary, Blue shield, L ist of covered
~ Prior Authorization Guidelines ~ Services marked by a bullet in the columns to the left require prior authorization for the designated line of
Guidelines, Authorization, Prior, Prior authorization, Prior authorization guidelines
last revision february 2017 infliximab (remicade®) prior review/certification faxback form incomplete forms may delay processing all nc providers must provide their 5-digit bcbsnc provider id# below
® Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
The form is designed so that the name and address (Item 3) of the third-party payer receiving the claim (insurance company/dental The following information highlights certain form completion instructions.
Form, American, Claim, Association, Dental, American dental association claim form
The medical policy consists of medical guidelines, including diagnostic imaging management policies, payment guidelines and evidence based guidelines.
CERVICAL SPINE 73700 Without IV Contrast THORACIC SPINE 72125 Without IV Contrast 73701 With IV Contrast 72128 Without IV Contrast 72126 With IV Contrast 73702 With and Without IV Contrast 72129 With IV Contrast 72127 With and Without IV Contrast 76377 3D Image Postprocessing 72130 With and Without IV Contrast 77073 Scanogram (Leg Length) …
Pain, degenerative changes, radiculopathy MRI thoracic spine without contrast. Prior surgery: MRI cervical spine without and with contrast. MRI contradicated: CT without contrast or CT myelogram. For pain localization in setting of prior surgery or multiple degenerative findings: SPECT fusion with CT or MRI Mass MRI without and with contrast
Without, Spine, Cervical, Contrast, Without contrast, Cervical spine without, Spine without contrast
Category Diagnosis IV Contrast Suggested Exam Spine Bone Tumor/Mets Yes MRI Cervical, Thoracic or Lumbar With and Without Discitis Yes MRI Cervical, Thoracic or Lumbar With and Without Extremity Numbness/Tingling No MRI Cervical, Thoracic or Lumbar Without History of Lumbar Surgery Yes MRI Lumbar With and Without
MRI Brain with & w/o contrast 70553 MRI Cervical Spine w/o contrast 72141 MRI Cervical Spine with & w/o contrast 72156 MRI Thoracic Spine w/o contrast 72146 MRI Thoracic Spine with & w/o contrast 72157 MRI Lumbar Spine w/o contrast 72148 MRI Lumbar Spine with & w/o contrast 72158 MRI Lower Ext. Jnt. (knee/hip/ankle) w/o contrast 73721
Spine: Cervical Degenerative Disease Disc Herniation Extremity Pain/Weakness Neck Pain Radiculopathy Trauma MRI Cervical Spine without Contrast 72141 Spine: Cervical Discitis Mass/Lesion Osteomylitis MRI Cervical Spine without and with Contrast 72156 Spine: Thoracic Back Pain Compression Fx Disc Herniation Radiculopathy Trauma
Sheet, Reference, Without, Heads, Spine, Cervical, Neck, Contrast, Contrast vs, No contrast reference sheet head neck, Cervical spine without contrast, Cervical spine without
Spine: Cervical Degenerative Disease Disc Herniation Extremity Pain/Weakness Neck Pain Radiculopathy Trauma MRI Cervical Spine without Contrast 72141 Spine: Cervical Discitis Mass/Lesion Osteomylitis MRI Cervical Spine without and with Contrast 72156 Spine: Thoracic Back Pain Compression Fx Disc Herniation Radiculopathy Trauma
Sheet, Reference, Without, Heads, Spine, Cervical, Neck, Contrast, Contrast vs, No contrast reference sheet head neck, Cervical spine without contrast, Cervical spine without
Lumbar Spine disc herniation / pain No No CT Lumbar spine w/o contrast 72131 Cervical Spine abscess / mass / infection Yes No CT Cervical spine w/contrast 72126 Thoracic Spine abscess / mass / infection Yes No CT Thoracic spine w/contrast 72129 Lumbar Spine abscess / mass / infection Yes No CT Lumbar spine w/contrast 72132 Unless there is a ...
MRI Spine Cervical W/O Contrast MRI Spine Cervical W W/O Contrast MRI Spine Lumbar W/O Contrast 74185, 73725 72197, 76377 73720 73721 73723 73218 MRI Extremity Upper Joint W/O Contrast - Shoulder, Elbow, Wrist MRI Extremity Upper Joint W W/O Contrast - Shoulder, Elbow, Wrist MR Enterography W W/O Contrast MRI Orbit, Face, Neck W/O Contrast
abdomen wo contrast: 74150 bone deep 20225 abdomen w/ contrast 74160 bone marrow; 38221 abdomen w/ & wo contrast; 74170 bone superficial; 20220 cervical spine wo contrast; 72125 us guided fine needle aspiration 10005 cervical spine w/ contrast 72126 us guided fine needle aspiration; each addl lesion 10006; cervical spine w/ & wo contrast 72127
Contrast Guidelines for Common CT/CTA & MRI/MRA Updated 12/4/12 CLINICAL GUIDELINES EXAM DESCRIPTION CT/CTA CPT CODES EXAM DESCRIPTION MRI/MRA CPT CODES Cauda equina lesion MRI Lumbar spine w & wo 72158 Cervical rotation, decreased CT Cervical spine wo 72125 MRI Cervical wo 72141
Guidelines, Common, Spine, Cervical, Contrast, Contrast guidelines for common ct, Cervical spine