2016 NIA Clinical Guidelines for Medical Necessity …

1 NIA Clinical Guidelines 2016 Magellan Health, Inc. Proprietary Page 1 of 659 2016 NIA Clinical Guidelines for Medical Necessity Review _____ NIA Clinical Guidelines 2016 Magellan Health, Inc. Proprietary Page 2 of 659 Guidelines for Clinical Review Determination Preamble NIA is committed to the philosophy of supporting safe and effective treatment for patients. The Medical Necessity criteria that follow are Guidelines for the provision of diagnostic imaging.

2 These criteria are designed to guide both providers and reviewers to the most appropriate diagnostic tests based on a patient s unique circumstances. In all cases, Clinical judgment consistent with the standards of good Medical practice will be used when applying the Guidelines . Guideline determinations are made based on the information provided at the time of the request. It is expected that Medical Necessity decisions may change as new information is provided or based on unique aspects of the patient s condition. The treating clinician has final authority and responsibility for treatment decisions regarding the care of the patient.

3 Guideline Development Process These Medical Necessity criteria were developed by NIA for the purpose of making Clinical review determinations for requests for diagnostic tests. The developers of the criteria sets included representatives from the disciplines of radiology, internal medicine, nursing, and cardiology. They were developed following a literature search pertaining to established Clinical Guidelines and accepted diagnostic imaging practices. All inquiries should be directed to: National Imaging Associates, Inc. 6950 Columbia Gateway Drive Columbia, MD 21046 Attn: NIA Associate Chief Medical Officer NIA Clinical Guidelines 2016 Magellan Health, Inc.

4 Proprietary Page 3 of 659 TABLE OF CONTENTS TOC ADVANCED IMAGING Guidelines _____ 7 70336 MRI Temporomandibular Joint (TMJ) _____ 7 70450 CT Head/Brain _____ 9 70480 CT Orbit (Includes Sella and Posterior Fossa) _____ 15 70480 CT Internal Auditory Canal _____ 17 70480 CT Sella _____ 20 70486 Face CT _____ 22 70486 Maxillofacial/Sinus CT _____ 24 70490 CT Soft Tissue Neck _____ 27 70496 CT Angiography, Head/Brain _____ 30 70498 CT Angiography, Neck _____ 33 70540 MRI Orbit _____ 35 70540 MRI Face _____ 38 70540 MRI Neck _____ 39 70540 MRI Sinus _____ 42 70544 MR Angiography Head/Brain _____ 43 70547 MR Angiography Neck _____ 46 70551 MRI Brain (includes Internal Auditory Canal)

5 _____ 48 70554 Functional MRI Brain _____ 55 71250 CT Chest (Thorax) _____ 57 71275 CT Angiography, Chest (non coronary) _____ 62 71550 MRI Chest (Thorax) _____ 64 71555 MR Angiography Chest (excluding myocardium)_____ 67 72125 CT Cervical Spine _____ 70 72128 CT Thoracic Spine _____ 74 72131 CT Lumbar Spine _____ 78 72141 MRI Cervical Spine _____ 83 72146 MRI Thoracic Spine _____ 88 72148 MRI Lumbar Spine _____ 92 72159 MR Angiography Spinal Canal _____ 97 72191 CT Angiography, Pelvis _____ 99 72192 CT Pelvis _____ 102 72196 MRI Pelvis _____ 109 72198 MR Angiography, Pelvis _____ 115 73200 CT Upper Extremity (Hand, Wrist, Elbow, Long Bone or Shoulder)

6 _____ 118 73206 CT Angiography, Upper Extremity _____ 124 73220 MRI Upper Extremity _____ 126 73225 MR Angiography Upper Extremity _____ 131 73700 CT Lower Extremity (Ankle, Foot, Hip or Knee) _____ 133 73706 CT Angiography, Lower Extremity _____ 138 73720 MRI Lower Extremity (Ankle, Foot, Knee, Hip, Leg) _____ 140 73725 MR Angiography, Lower Extremity _____ 145 _____ NIA Clinical Guidelines 2016 Magellan Health, Inc. Proprietary Page 4 of 659 74150 CT Abdomen _____ 147 74174 CT Angiography, Abdomen and Pelvis _____ 155 74175 CT Angiography, Abdomen _____ 158 74176 CT Abdomen and Pelvis Combo _____ 161 74181 MRI Abdomen _____ 169 74185 MR Angiography, Abdomen _____ 174 74261 CT Colonoscopy Diagnostic (Virtual) _____ 178 74263 - CT Colonoscopy Screening (Virtual) _____ 180 75557 MRI Heart _____ 181 75571 Electron Beam Tomography (EBCT)

7 _____ 190 75572 CT Heart _____ 191 75574 CTA Coronary Arteries (CCTA) _____ 200 75635 CT Angiography, Abdominal Arteries _____ 211 76390 MR Spectroscopy _____ 213 76497 Unlisted CT Procedure _____ 215 76498 Unlisted MRI Procedure _____ 216 77058 MRI Breast _____ 217 77078 CT Bone Density Study _____ 221 78205 Liver SPECT _____ 224 78320 Bone and/or Joint SPECT _____ 226 77084 MRI Bone Marrow _____ 228 78451 Myocardial Perfusion Imaging (Nuc Card) _____ 230 78459 PET Scan, Heart (Cardiac) _____ 242 78472 MUGA Scan_____ 249 78607 Brain SPECT _____ 252 78608 PET Scan, Brain_____ 255 78647 Cerebrospinal Fluid Flow SPECT _____ 259 78710 - Kidney SPECT_____ 261 78813 PET Scan _____ 263 0042T Cerebral Perfusion Analysis CT _____ 268 +0159T CAD Breast MRI _____ 270 G0219 PET Imaging whole body, melanoma - noncovered _____ 271 G0235 - PET imaging, any site, not otherwise specified _____ 272 G0252 - PET imaging, initial diagnosis of breast cancer _____ 273 S8037 MR Cholangiopancreatography (MRCP)

8 _____ 274 S8032 Low Dose CT for Lung Cancer Screening _____ 277 S8042 Low Field MRI _____ 278 EXPANDED CARDIAC Guidelines _____ 279 33249 Implantable Cardioverter Defibrillator (ICD) _____ 279 33208 Pacemaker _____ 286 93307 Transthoracic Echocardiology (TTE) _____ 293 93312 Transesophageal Echocardiology (TEE) _____ 307 93350 Stress Echocardiography _____ 311 93452 Heart Catheterization_____ 323 _____ NIA Clinical Guidelines 2016 Magellan Health, Inc. Proprietary Page 5 of 659 MUSCULOSKELETAL_SPINE SURGERY Guidelines _____ 326 22600/63001 Cervical Spinal Surgery _____ 326 22612/63030 Lumbar Spinal Surgery _____ 337 22532 Thoracic Spine Surgery _____ 346 62310-62311 Spinal Epidural Injections _____ 349 64490-64493 Paravertebral Facet Joint Injections/Blocks _____ 354 64633-64635 Paravertebral Facet Joint Neurolysis _____ 357 27096 Sacroiliac Joint Injections _____ 360 27132 Hip Arthroplasty _____ 367 27130 Hip

9 Arthroscopy _____ 374 27446 Knee Arthroplasty _____ 381 27332 Knee Arthroscopy _____ 387 RADIATION ONCOLOGY Guidelines _____ 400 2D 3D Conformal Radiation Therapy (CRT), External Beam Radiation Therapy For Other Cancers _____ 400 Anal Cancer _____ 401 Bone Metastases _____ 403 Brachytherapy _____ 407 Breast Cancer _____ 411 Central Nervous System Metastases _____ 415 Cervical Cancer _____ 421 Central Nervous System Primary _____ 426 Colorectal Cancer _____ 433 Endometrial Cancer _____ 436 Endometrial Cancer _____ 441 Head and Neck Cancer _____ 443 Hodgkins Lymphoma _____ 447 Hyperthermia _____ 452 Intensity Modulated Radiation Therapy (IMRT) For Other Cancers _____ 455 Intraoperative Radiation Therapy (IORT)

10 _____ 466 Metastatic Disease _____ 470 Neuton BeamTherapy _____ 472 Non-Hodgkins Lymphoma _____ 474 Non Small Cell Lung Cancer _____ 477 Non-Cancerous Conditions _____ 480 Pancreatic Cancer _____ 482 Prostate Cancer _____ 488 Proton Beam Radiation Therapy _____ 492 Small Cell Lung Cancer _____ 501 Stereotactic Radiotherapy (SRS)_Stereotactic Body Radiation (SBRT) _____ 504 ultrasound Guidelines _____ 509 76536 Head and Neck ultrasound _____ 509 76700 Abdomen ultrasound _____ 513 76856 Pelvic ultrasound _____ 530 76870 Scrotum and Contents ultrasound _____ 534 _____ NIA Clinical Guidelines 2016 Magellan Health, Inc.