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Radiology Procedures Requiring Precertification for ...

Radiology Procedures Requiring Precertification for eviCore healthcare Arrangement Page 1 of 13 UnitedHealthcare Oxford Clinical Policy Effective 12/01/2017 1996-2017, Oxford Health Plans, LLC Radiology Procedures Requiring Precertification FOR EVICORE HEALTHCARE ARRANGEMENT Policy Number: Radiology T2 Effective Date: December 1, 2017 Table of Contents Page INSTRUCTIONS FOR USE .. 1 CONDITIONS OF COVERAGE .. 1 BENEFIT CONSIDERATIONS .. 2 COVERAGE RATIONALE .. 2 BACKGROUND .. 3 APPLICABLE CODES .. 3 POLICY HISTORY/REVISION INFORMATION .. 13 INSTRUCTIONS FOR USE This Clinical Policy provides assistance in interpreting Oxford benefit plans. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify its policies as necessary.

Nuclear medicine imaging Positron Emission Tomography (PET) scans Obstetrical ultrasound (fourth and subsequent procedure per Member per pregnancy requires authorization) Note: Other procedures may be added to the list of procedures requiring precertification through eviCore healthcare, as necessary.

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