Cigna - Prior Authorization Procedure List: Radiology ...

1 Updated: 1/31 : 1/17/2019 Category CPT CodeCPT Code DescriptionCardiac Catheterization93451 Right heart catheterizationCardiac Catheterization93452 Left heart catheterizationCardiac Catheterization93453 Combined right and left heart catheterizationCardiac Catheterization93454 Catheter placement in coronary artery(s) for coronary angiography;Cardiac Catheterization93455 Catheter placement in coronary artery(s) for coronary angiography; with bypass graftsCardiac Catheterization93456 Catheter placement in coronary artery(s) for coronary angiography; with right heart catheterizationCardiac Catheterization93457 Catheter placement in coronary artery(s) for coronary angiography; with bypass and right heartCardiac Catheterization93458 Catheter placement in coronary artery(s) for coronary angiography; with left heart catheterizationCardiac Catheterization93459 Catheter placement in coronary artery(s) for coronary angiography; with left heart and bypass graftsCardiac Catheterization93460 Catheter placement in coronary artery(s) for coronary angiography; with right and left heartCardiac Catheterization93461 Catheter placement in coronary artery(s) for coronary angiography.

2 With right & left heart and graftsCardiac Catheterization93530 Right heart catheterization, for congenital cardiac anomaliesCardiac Catheterization93531 Combined right and left heart catheterization, for congenital cardiac anomaliesCardiac Catheterization93532 Combined right and transseptal left heart cath, intact septum, for congenital cardiac anomaliesCardiac Catheterization93533 Combined right and transseptal left heart cath, existing septal opening, congenital cardiac anomaliesCigna - Prior Authorization Procedure List: Radiology & CardiologyUpdated: 1/31 : 1/17/2019 Category CPT CodeCPT Code DescriptionCardiac CatheterizationC9741 Right heart catheterization with implantation of wireless pressure sensor in pulmonary artery, includes provision of patient home electronics unitCCTA0501 TNoninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease.

3 Data preparation and transmission, analysis of fluid dynamics and simulated maximal coronary hyperemia, generation of estimated FFR model, with anatomical data review in comparison with estimated FFR model to reconcile discordantdata, interpretation and report CCTA0502 TNoninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmissionCCTA0503 TNoninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model CCTA0504 TNoninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease.

4 Anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report CPET0482 TAbsolute quantitation of myocardial blood flow, positron emission tomography (PET), rest and stress (List separately in addition to code for primary Procedure )Nuclear Cardiology78451 MPI, tomographic (SPECT); single study, at rest or stress (exercise or pharmacologic)Nuclear Cardiology78452 MPI, tomographic (SPECT); multiple studies, at rest and/or stress (exercise or pharmacologic)Nuclear Cardiology78453 MPI, planar; single study, at rest or stress (exercise or pharmacologic)Nuclear Cardiology78454 MPI, planar; multiple studies, at rest and/or stress (exercise or pharmacologic)Nuclear Cardiology78466 Myocardial Imaging, infarct avid, planar; qualitative or quantitativeNuclear Cardiology78468 Myocardial Imaging, infarct avid, planar; with EF by first pass techniqueNuclear Cardiology78469 Myocardial Imaging, infarct avid, planar; tomographic SPECTN uclear Cardiology78472 Cardiac Blood Pool imaging, gated equilibrium; planar, single study at rest or stressUpdated: 1/31 : 1/17/2019 Category CPT CodeCPT Code DescriptionNuclear Cardiology78473 Cardiac Blood Pool imaging, gated equilibrium.

5 Multiple studies, wall motion plus ejection fraction, at rest and stressNuclear Cardiology78481 Cardiac Blood Pool imaging, (planar), first pass technique; single study, at rest or with stress, wall motion study plus ejection fractionNuclear Cardiology78483 Cardiac Blood Pool imaging, (planar), first pass technique; multiple studies at rest and with stress, wall motion study plus ejection fractionNuclear Cardiology78494 Cardiac Blood Pool imaging, gated equilibrium, SPECTN uclear Cardiology78496 Cardiac Blood Pool imaging, gated equilibrium, RV EF by first passNuclear Cardiology78499 Unlisted cardiovascular Procedure , diagnostic nuclear medicineNuclear Cardiology0331 TMyocardial sympathetic innervation imaging, planar qualitative and quantitative assessment;Nuclear Cardiology0332 TMyocardial sympathetic innervation imaging, planar qualitative and quantitative assessment.

6 With tomographic SPECTS tress Echo93350 Echocardiography, transthoracic (TTE), during rest and cardiovascular stress testStress Echo93351 Echocardiography, transthoracic (TTE), during rest and cardiovascular stress test including continuous EKG monitoring, with physician3DI763773D Rendering of CT, MRI, ultrasound, or other tomographic modality; requiring an independent workstationBMRI77046 Magnetic resonance imaging, breast, without contrast material; unilateral - 1/1/2018 AMA additionBMRI77047 Magnetic resonance imaging, breast, without contrast material; bilateral - 1/1/2018 AMA additionBMRI77048 Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral - 1/1/2018 AMA additionBMRI77049 Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed.

7 Bilateral - 1/1/2018 AMA additionBMRIC8937 Computer aided detection, including computer algorithm analysis of breast MRI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation - Effective 1/17/2019CT70450CT Head or Brain, without contrastCT70460CT Head or Brain, with contrastCT70470CT Head or Brain, with and without contrastCT70480CT Orbit, Sella, or Posterior Fossa or Outer, Middle, or Inner Ear; without contrastUpdated: 1/31 : 1/17/2019 Category CPT CodeCPT Code DescriptionCT70481CT Orbit, Sella, or Posterior Fossa or Outer, Middle, or Inner Ear; with contrastCT70482CT Orbit, Sella, or Posterior Fossa or Outer, Middle, or Inner Ear.

8 Without contrast, followed by contrast and further sectionsCT70486CT Maxillofacial area, without contrastCT70487CT Maxillofacial area, with contrastCT70488CT Maxillofacial area, without contrast, followed by contrast and further sectionsCT70490CT Neck Soft Tissue, without contrastCT70491CT Neck Soft Tissue, with contrastCT70492CT Neck Soft Tissue, without contrast followed by contrast and further sectionsCT70496 CTA Head, with contrast, including noncontrast images, if performed, and image post-processingCT70498 CTA Neck, with contrast, including noncontrast images, if performed, and image post-processingCT71250CT Chest, without contrastCT71260CT Chest, with contrastCT71270CT Chest, without and with contrastCT71275 CTA Chest, (non-coronary)

9 , with contrast, including noncontrast images, if performed, and image post-processingCT72125CT Cervical Spine, without contrastCT72126CT Cervical Spine, with contrastCT72127CT Cervical Spine, without contrast, followed by contrast and further sectionsCT72128CT Thoracic Spine, without contrastCT72129CT Thoracic Spine, with contrastCT72130CT Thoracic Spine, without contrast, followed by contrast and further sectionsCT72131CT Lumbar Spine, without contrastCT72132CT Lumbar Spine, with contrastCT72133CT Lumbar Spine, without contrast, followed by contrast and further sectionsCT72191 CTA Pelvis, with contrast, including noncontrast images, if performed, and image postprocessingCT72192CT Pelvis, without contrastUpdated: 1/31.

10 1/17/2019 Category CPT CodeCPT Code DescriptionCT72193CT Pelvis, with contrastCT72194CT Pelvis, without contrast, followed by contrast and further sectionsCT73200CT Upper Extremity, without contrastCT73201CT Upper Extremity, with contrastCT73202CT Upper Extremity, without contrast, followed by contrast and further sectionsCT73206 CTA Upper Extremity, with contrast, including noncontrast images, if performed, and image postprocessingCT73700CT Lower Extremity, without contrastCT73701CT Lower Extremity, with contrastCT73702CT Lower Extremity, without contrast, followed by contrast and further sectionsCT73706 CTA Lower Extremity, with contrast, including noncontrast images, if performed, and image postprocessingCT74150CT Abdomen, without contrastCT74160CT Abdomen, with contrastCT74170CT Abdomen, without and with contrastCT74174 CTA ABDOMEN AND PELVIS, with contrast, including noncontrast images, if performed, and image postprocessingCT74175 CTA Abdomen, with contrast, including noncontrast images, if performed, and image postprocessingCT74176CT ABDOMEN and PELVIS, without contrastCT74177CT ABDOMEN and PELVIS, with contrastCT74178CT ABDOMEN and PELVIS, without contrast in one or both body regions, followed by contrast and further sections in one or both body regionsCT74261CT Colonography, diagnostic, including image postprocessing.