2022 AIM Prior Authorization CPT Code List Radiology ...

1 CodeDescriptionService Category:70336 MRI TEMPOROMANDIBULAR JOINTRBM70450CT HEAD/BRAIN W/O CONTRAST MATERIALRBM70460CT HEAD/BRAIN W/CONTRAST MATERIALRBM70470CT HEAD/BRAIN W/O & W/CONTRAST MATERIALRBM70480CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRLRBM70481CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRLRBM70482CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATRRBM70486CT MAXILLOFACIAL W/O CONTRAST MATERIALRBM70487CT MAXILLOFACIAL W/CONTRAST MATERIALRBM70488CT MAXILLOFACIAL W/O & W/CONTRAST MATERIALRBM70490CT SOFT TISSUE NECK W/O CONTRAST MATERIALRBM70491CT SOFT TISSUE NECK W/CONTRAST MATERIALRBM70492CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIALRBM70496CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRASTRBM70498CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRASTRBM70540 MRI ORBIT FACE &/NECK W/O CONTRASTRBM70542 MRI ORBIT FACE & NECK

2 W/CONTRAST MATERIALRBM70543 MRI ORBIT FACE & NECK W/O & W/CONTRAST MATRLRBM70544 MRA HEAD W/O CONTRST MATERIALRBM70545 MRA HEAD W/CONTRAST MATERIALRBM70546 MRA HEAD W/O & W/CONTRAST MATERIALRBM70547 MRA NECK W/O CONTRST MATERIALRBM70548 MRA NECK W/CONTRAST MATERIALRBM70549 MRA NECK W/O &W/CONTRAST MATERIALRBM70551 MRI BRAIN BRAIN STEM W/O CONTRAST MATERIALRBM70552 MRI BRAIN BRAIN STEM W/CONTRAST MATERIALRBM70553 MRI BRAIN BRAIN STEM W/O W/CONTRAST MATERIALRBM70554 MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATIONRBM70555 MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATIONRBM71250CT THORAX W/O CONTRAST MATERIALRBM71260CT THORAX W/CONTRAST MATERIALRBM71270CT THORAX W/O & W/CONTRAST MATERIALRBM71271 COMPUTED TOMOGRAPHY THORAX LW DOSE LNG CA SCR C RBM71275CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRASTRBM71550 MRI CHEST W/O CONTRAST MATERIALRBM71551 MRI CHEST W/CONTRAST MATERIALRBM71552 MRI CHEST W/O & W/CONTRAST MATERIALRBM71555 MRA CHEST W/O & W/CONTRAST MATERIALRBM2022 AIM Prior Authorization CPT code List Radiology Benefit ManagementOriginal Release Date: January 1, 2022 Updated: 5/23/2022 Note: AIM will covering these codes for Individual and Family Plans and Small Group Plans for the following states.

3 Alabama, Arizona, Colorado, Florida, Illinois, Nebraska, North Carolina, Oklahoma, South Carolina, and Tennessee72125CT CERVICAL SPINE W/O CONTRAST MATERIALRBM72126CT CERVICAL SPINE W/CONTRAST MATERIALRBM72127CT CERVICAL SPINE W/O &W/CONTRAST MATERIALRBM72128CT THORACIC SPINE W/O CONTRAST MATERIALRBM72129CT THORACIC SPINE W/CONTRAST MATERIALRBM72130CT THORACIC SPINE W/O & W/CONTRAST MATERIALRBM72131CT LUMBAR SPINE W/O CONTRAST MATERIALRBM72132CT LUMBAR SPINE W/CONTRAST MATERIALRBM72133CT LUMBAR SPINE W/O & W/CONTRAST MATERIALRBM72141 MRI SPINAL CANAL CERVICAL W/O CONTRAST MATRLRBM72142 MRI SPINAL CANAL CERVICAL W/CONTRAST MATRLRBM72146 MRI SPINAL CANAL THORACIC W/O CONTRAST MATRLRBM72147 MRI SPINAL CANAL THORACIC W/CONTRAST MATRLRBM72148 MRI SPINAL CANAL LUMBAR W/O CONTRAST MATERIALRBM72149 MRI SPINAL CANAL LUMBAR W/CONTRAST MATERIALRBM72156 MRI SPINAL CANAL CERVICAL W/O &

4 W/CONTR MATRLRBM72157 MRI SPINAL CANAL THORACIC W/O & W/CONTR MATRLRBM72158 MRI SPINAL CANAL LUMBAR W/O & W/CONTR MATRLRBM72159 MRA SPINAL CANAL W/WO CONTRAST MATERIALRBM72191CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRASTRBM72192CT PELVIS W/O CONTRAST MATERIALRBM72193CT PELVIS W/CONTRAST MATERIALRBM72194CT PELVIS W/O & W/CONTRAST MATERIALRBM72195 MRI PELVIS W/O CONTRAST MATERIALRBM72196 MRI PELVIS W/CONTRAST MATERIALRBM72197 MRI PELVIS W/O & W/CONTRAST MATERIALRBM72198 MRA PELVIS W/WO CONTRAST MATERIALRBM73200CT UPPER EXTREMITY W/O CONTRAST MATERIALRBM73201CT UPPER EXTREMITY W/CONTRAST MATERIALRBM73202CT UPPER EXTREMITY W/O & W/CONTRAST MATERIALRBM73206CT ANGIOGRAPHY UPPER EXTREMITYRBM73218 MRI UPPER EXTREMITY OTH THAN JT W/O CONTR MATRLRBM73219 MRI UPPER EXTREMITY OTH THAN JT W/CONTR MATRLRBM73220 MRI UPPER EXTREM OTHER THAN JT W/O & W/CONTRASRBM73221 MRI ANY JT UPPER EXTREMITY W/O CONTRAST MATRLRBM73222 MRI ANY JT UPPER EXTREMITY W/CONTRAST MATRLRBM73223 MRI ANY JT UPPER EXTREMITY W/O & W/CONTR MATRLRBM73225 MRA UPPER EXTREMITY W/WO CONTRAST MATERIALRBM73700CT LOWER EXTREMITY W/O CONTRAST MATERIALRBM73701CT LOWER EXTREMITY W/CONTRAST MATERIALRBM73702CT LOWER EXTREMITY W/O & W/CONTRAST MATRLRBM73706CT ANGIOGRAPHY LOWER EXTREMITYRBM73718 MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRLRBM73719 MRI LOWER EXTREM OTH/THN JT W/CONTRAST MATRLRBM73720 MRI LOWER EXTREM OTH/THN JT W/O & W/CONTR MATRRBM73721 MRI ANY JT LOWER EXTREM W/O CONTRAST MATRLRBM73722 MRI ANY JT LOWER EXTREM W/CONTRAST MATERIALRBM73723 MRI ANY JT LOWER EXTREM W/O & W/CONTRAST MATRLRBM73725 MRA

5 LOWER EXTREMITY W/WO CONTRAST MATERIALRBM74150CT ABDOMEN W/O CONTRAST MATERIALRBM74160CT ABDOMEN W/CONTRAST MATERIALRBM74170CT ABDOMEN W/O & W/CONTRAST MATERIALRBM74174CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMGRBM74175CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRASTRBM74176CT ABDOMEN & PELVIS W/O CONTRAST MATERIALRBM74177CT ABDOMEN & PELVIS W/CONTRAST MATERIALRBM74178CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RERBM74181 MRI ABDOMEN W/O CONTRAST MATERIALRBM74182 MRI ABDOMEN W/CONTRAST MATERIALRBM74183 MRI ABDOMEN W/O & W/CONTRAST MATERIALRBM74185 MRA ABDOMEN W/WO CONTRAST MATERIALRBM74261CT COLONOGRPHY DX IMAGE POSTPROCESS W/O CONTRASTRBM74262CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRASTRBM74263CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSINGRBM74712 FETAL MRI W/PLACNTL MATRNL PLVC IMG SING/1ST GESRBM75557 CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRASTRBM75559 CARDIAC MRI W/O CONTRAST W/STRESS IMAGINGRBM75561 CARDIAC MRI W/WO CONTRAST & FURTHER SEQRBM75563 CARDIAC MRI W/W/O CONTRAST W/STRESSRBM75571CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUMRBM75572CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPHRBM75573CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT DRBM75574 CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POSTRBM75635 CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POSTPRBM76390 MRI SPECTROSCOPYRBM76391 MAGNETIC RESONANCE ELASTOGRAPHYRBM77046 MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERALRBM77047 MRI BREAST WITHOUT CONTRAST MATERIAL BILATERALRBM77048 MRI BREAST W/OUT&WITH CONTRAST W/CAD UNILATERALRBM77049 MRI BREAST WITHOUT&WITH CONTRAST W/CAD BILATERALRBM77078CT BONE

6 MINERL DENSITY STUDY 1/> SITS AXIAL SKERBM77084 BONE MARROW BLOOD SUPPLYRBM78429 MYOCRD IMG PET METAB EVAL SINGLE STUDY CNCRNT CTRBM78430 MYOCRD IMG PET PRFUJ 1 STD REST/STRESS CNCRNT CTRBM78431 MYOCRD IMG PET PRFUJ MLT STD RST&STRS CNCRNT CTRBM78432 MYOCRD IMG PET PRFUJ W/METAB DUAL RADIOTRACERRBM78433 MYOCARD IMG PET PRFUJ W/METAB 2 RTRACER CNCRNT CTRBM78451 MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESSRBM78452 MYOCARDIAL SPECT MULTIPLE STUDIESRBM78453 MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESSRBM78454 MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIESRBM78459 MYOCRD IMG PET METAB EVAL SINGLE STUDYRBM78466 MYOCARDIAL IMAGING INFARCT AVID PLANAR QUAL/QUANRBM78468 MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQRBM78469 MYOCRD INFARCT AVID PLNR TOMOG SPECT W/WO QUANTJRBM78472 CARD BLOOD POOL GATED PLANAR 1 STUDY REST/STRESSRBM78473 CARD BL POOL GATED MLT STDY WAL MOTN EJECT FRACTRBM78481 CARD BL POOL PLANAR 1 STDY WAL MOTN EJECT FRACTRBM78483 CARD BL POOL PLNR MLT STDY WAL MOTN EJECT FRACTRBM78491 MYOCRD IMG PET PRFUJ SINGLE STUDY REST/STRESSRBM78492 MYOCRD IMG PET PRFUJ MULTIPLE STUDY REST&STRESSRBM78494 CARD BL POOL GATED SPECT REST WAL MOTN EJCT FRCTRBM78608 BRAIN IMAGING PET METABOLIC EVALUATIONRBM78609 BRAIN IMAGING PET PERFUSION EVALUATIONRBM78811 PET IMAGING LIMITED AREA CHEST HEAD/NECKRBM78812 PET IMAGING SKULL BASE TO MID THIGHRBM78813 PET IMAGING WHOLE BODYRBM78814 PET IMAGING CT FOR ATTENUATION LIMITED AREARBM78815 PET IMAGING CT ATTENUATION SKULL BASE MID THIGHRBM78816 PET IMAGING FOR CT ATTENUATION WHOLE BODYRBM0501 TCOR FFR DERIVED CTA DATA

7 ASSESS COR ART DISEASERBM0502 TCOR FFR DERIVED CTA DATA PREP & TRANSMISRBM0503 TCOR FFR CTA DATA ALYS & GNRJ ESTIMATED FFR MODELRBM0504 TCOR FFR CTA DATA REVIEW W/INTERPJ & FINAL REPORTRBM0633T CT BREAST W/3D RENDERING UNI WITHOUT CONTRASTRBM0634T CT BREAST W/3D RENDERING UNI WITH CONTRASTRBM0635T CT BRST W/3D RENDERING UNI WO CNTRST FLWD CNTRSTRBM0636T CT BREAST W/3D RENDERING BI WITHOUT CONTRASTRBM0637T CT BREAST W/3D RENDERING BI WITH CONTRASTRBM0638T CT BRST W/3D RENDERING BI WO CNTRST FLWD CNTRSTRBM0648T QUAN MR ALYS TISS COMPJ W/O MRI SAME SESS 1 ORGNRBM0649T QUAN MR ALYS TISS COMPOSITION W/MRI 1 ORGNRBM0042T CEREBRAL PERFUSION ANALYS CT W/BLOOD FLOW&VOLUMERBM