Use this reference to quickly determine the correct …

1 Body PartProcedure for Pre-authorizationcPt codeindications for exam or studycontrast*sPecBrain mriMRI Brain without contrast70551 Alzheimer s Stroke/CVAM ental status change TIA (transient ischemic attack)Confusion TraumaDementia Dizziness/VertigoMemory Loss HeadachesSuspected MSNo ContrastneuroMRI Brain with and without contrast70553 Tumor/Mass/Cancer Pituitary lesionCranial nerve lesions Acoustic neuromaHIV/AIDS Syringomyelia (Syrinx)Infection Visual changeMS (Multiple Sclerosis) MetastasesNeurofibromatosis Vascular lesions (AVM)Hearing loss, IAC mass Elevated prolactinBell s Palsy (facial weakness)Yes Contrastneuromra Brain: Arterial CirculationCircle of Willis (COW)MRA Brain without contrast70544 Aneurysm, family historyTIA (transient ischemic attack)Stroke/CVA (cerebrovascular accident)No Contrastneuromra Brain.

2 Venous CirculationMRA Brain without contrast70544 Venous thrombosisNo ContrastneuroMRA Brain with and without contrast70546 AVM Sinus thrombosisVenous circulatory symptomsAs determined by radiologistneuromra necKMRA Neck with and without contrast70549 BruitStroke CVA (cerebrovascular accident)TIA (transient ischemic attack)Abnormal doppler or dizzinessYes Contrastneuromri orBitsIncludes brain plus cuts thru the orbitsMRI Brain with and without contrast70553 Trauma PseudotumorGraves Disease Tumor/Mass/Cancer/MetsExopthalmos/propto sis Vascular lesions (Hemangioma)Yes Contrastneuromri necKSoft TissueMRI Orbits/Face/Neck with and without contrast70543 Infection Tumor/Mass/Cancer/MetsPain Vocal Cord ParalysisYes Contrastneuromri sPine: CervicalMRI Cervical Spine without contrast72141 Neck pain NumbnessArm/Shoulder pain Degenerative disk diseaseDisk herniation (HNP) RadiculopathyNo ContrastneuroorthoMRI Cervical Spine with and without contrast72156 Syringomyelia (Syrinx) MyelopthyDiscitis (disk infection) MS (Multiple Sclerosis)Osteomyelitis Tumor/Mass/Cancer/MetsYes Contrastneuroorthomri sPine.

3 ThoracicMRI Thoracic Spine without contrast72146 Back Pain TraumaDegenerative disk disease Compression fractureDisk herniation (HNP) (No history of malignancy)Radiculopathy No ContrastneuroorthoMRI Thoracic Spine with and without contrast72157 Syringomyelia (Syrinx) MyelopthyDiscitis (disk infection) MS (Multiple Sclerosis)Osteomyelitis Tumor/Mass/Cancer/MetsYes Contrastneuroorthomri sPine: LumbarMRI Lumbar Spine without contrast72148 Back/leg pain Sciatica/radiculopathyDegenerative disk disease SpondylolisthesisDisk herniation (HNP) Spinal stenosisRadiculopathy Compression fractureTrauma (No history of malignancy)ScoliosisNo ContrastneuroorthoMRI Lumbar Spine with and without contrast72158 Discitis (disk infection) Post-op Hx of back surgeryOsteomyelitis Tumor/Mass/Cancer/MetsYes Contrastneuroorthomri LumBosacraL PLexusMRI Pelvis without contrast72195 Leg Pain/sciatica Lumbar plexopathyRadiculopathy Sacral/coccyx painNo Contrastneuromri BrachiaL PLexusMRI Upper Extremity Non-joint with and without contrast73220 Shoulder injury Brachial plexopathyNerve avulsionDetermined by Radiologistneuromri chest.

4 MediastinumMRI Chest/Mediastinum with and without contrast71552 Tumor/Mass/Cancer/MetsYes ContrastBodymra aortaMRA Aorta with and without contrast74185 Abdominal aortic dissectionYes ContrastBodymra aorta: With peripheral runoffMRA Aorta with and without contrast MRA Lower Extremity with or without contrast74185 73725 Peripheral vascular disease ClaudicationNo ContrastBodymra chestMRI Chest with and without contrast71555 Excluding cardiac myocardiumThoracic aortaYes ContrastBodyBreast mriMRI Breast Bilateral with and without contrast77059 Newly diagnosed breast cancer Family history of breast cancerBRCA 1 or BRCA 2 genes (Some criteria may apply)Implant integrity/RuptureYes ContrastBodymri aBdomen: GeneralMRI Abdomen with and without contrast74183 Tumor/Mass/Cancer/MetsAbdominal painYes ContrastBodymri aBdomen: LiverPost embolization HepatitisHemangioma CirrhosisHepatoma Increased liver function testsmri aBdomen: RenalHematuria (blood in urine) Renal mass (cyst or solid)Transitional cell carcinoma of kidneyAbnormal findingsmri aBdomen: AdrenalMRI Abdomen with and without contrast74183 Adrenal mass or lesion HypertensionPheochromocytomaDetermined by RadiologistBodymrcP: BiliaryMRI Abdomen with and without contrast74183 Abdominal pain JaundiceBiliary obstruction Abnormal enzymesStonesYes ContrastBodymrcP.

5 PancreasMRI Abdomen with and without contrast74183 Pancreatitis Increased liver function testsPancreas mass Painless jaundiceCholangiocarcinoma Ampulla evaluationPSC (Primary Sclerosing Cholangitis)Yes ContrastBodymra aBdomenMRA Abdomen with and without contrast74185 Renal artery stenosis Mesenteric arterialHypertension IschemiaYes ContrastBodymra PeLvis:Iliac vesselsMRA Pelvis with and without contrast72198 Pelvic venous thrombosisYes ContrastBodymri PeLvis Soft Tissue: GeneralMRI Pelvis with and without contrast72197 Pain Tumor/Mass/Cancer/MetsAbscess Decubitus ulcerYes ContrastBodymri PeLvis Soft Tissue:Uterus/OvariesMRI Pelvis with and without contrast72197 Fibroid Pre/Post-Uterine Fibroid Embolization (UFE)Adenomyosis EndometriomaInfertility Ovarian MassYes ContrastBodymr enterograPhyDual Study:MRI Abdomen with and without contrastMRI Pelvis with and without contrast7418372197 Crohn s disease Crohn s fistulous diseaseCeliac disease (Sprue) Small bowel tumor Yes Contrast and glucagonBodymri extremity,non-Joint:ForearmHumerusLower Leg/CalfFemur/ThighMRI Non-Joint without contrast:Upper ExtremityLower Extremity7321873718 FractureStress fractureMuscle or tendon tearNo ContrastorthoMRI Non-Joint with and without contrast.

6 Upper ExtremityLower Extremity7322073720 Abscess MyositisUlcer OsteomyelitisTumor/Mass/Mets Morton s neuromaPlantar fasciitis Soft tissue tumor or mass Yes Contrastorthomri extremity, Joint:uPPerHandWristElbowShoulderSC JointLoWerFootAnkleKneeHip MRI Joint without contrast:Upper ExtremityLower Extremity7322173721 Arthritis Meninscal tearAvascular necrosis (AVN) Muscle tearStress fracture Ligament tearInternal derangement Cartilage tearJoint pain Ostochondritis dissecans (OCD)No ContrastorthoMRI Joint with and without contrast:Upper ExtremityLower Extremity7322373723 Abscess OsteomyelitisUlcer Inflammatory arthritisCellulitis Septic arthritisPlantar fasciitis Tumor/Mass/MetsMyositis Labral tearYes Contrastorthomri PeLvis/hiP(Bony)

7 MRI Pelvis without contrast72195 Fracture TraumaHip/Pelvis Pain Muscle/Tendon tearNo ContrastorthoMRI Pelvis with and without contrast72197 Tumor/Mass/Cancer/Mets Septic arthritisOsteomyelitisYes Contrastorthomra uPPer extremityMRA Upper Extremity with and without contrast73225 Subclavian TendernessRedness or swellingYes Contrastorthomra LoWer extremityMRA Lower Extremity with and without contrast73725 Peripheral vascular diseaseYes Contrastorthomr arthrogramUpper ExtremityShoulderElbow WristMRI Upper Extremity Joint with contrast73222 Slap tear Ligament InjuryLabral tear Tunnel syndromeLoose bodyTFCC tearYes Contrastorthomr arthrogramLower ExtremityHipKneeAnkleMRI Lower Extremity Joint with contrast73722 Labral tearFAI (Femoroacetabular impingement)Loose bodyOCD lesion (Osteochondritis Dissecans)Yes ContrastorthoMRI EXAM CPT CODE REFERENCEUse this reference to quickly determine the correct exam for your patients based on the indications described herein and the CPT for the their comfort, iv sedation is available for your patients upon request.

8 Patients receiving sedation must be accompanied by a review the mri safety checklist with each patient. Notify WR Express Scheduling if your patient has a history of renal failure. Creatinine levels can be obtained prior to contrasted studies, if needed at all WR MRI locations. Call if you have any questions 919-232-4700.