First Things First
In the absence of red flags, this initial imaging study is required for the evaluation of right upper quadrant pain including suspected gallbladder disease, prior to authorization of advanced imaging.
What is an abdominal Ultrasound (complete or limited)?
(AB-2.3)
A 70491 is being requested for a member with a possible cervical lymph node vs mass. The member noticed this neck lump for 1 month and it has not changed. On physical examination the area of concern is about 1cm. Is this approvable or does this go the Medical Review?
What is approvable?
(Neck-5.1) A possible mass with a duration of a month is approvable.
This imaging study may be indicated for suspected strangulation of a femoral hernia.
What is a CT Pelvis with contrast (CPT 72193) or without contrast (CPT 72192)?
(AB-12.1)
You will need to reroute a study requested for an indication of erectile dysfunction in a male with hypogonadism being suspected.
CR: What is the Head-Neuro specialty?
(PV-17.1, reroutes you to HD-19: Pituitary)
This imaging study must be performed as the initial imaging to evaluate for a suspected anterior neck mass without any other findings or clinical noted.
What is a Ultrasound of the neck (76536).
(Neck-5.1)
71271 is requested for a 50 year old member with 20 pack year hx of smoking. They never had imaging before. They quit 16 years ago and have no underlying health conditions or any symptoms other than an occasional cough. This member has a commercial insurance plan. Is this approvable or does it need to go to Medical Review?
What is send the case to Medical Review?
(CH-33.1) Member quit smoking 16 years ago and it needs to be 15 years or less.
This imaging study may be indicated for a suspected ingested foreign body with an initial negative plain film.
What is a CT Neck and/or Chest with or without contrast/3-D can be added?
(Neck-3.1: Dysphagia and Esophageal disorders)
You will need to reroute a study request, whose indication was for a recurrent laryngeal palsy, to this specialty?
What is Head-Neuro specialty?
(Neck-7:reroutes you to HD-7: Recurrent Laryngeal Palsy)
This initial imaging study may be useful as an initial study in the setting of a suspected superficial or subcutaneous lipoma of the chest wall.
What is a chest ultrasound (CPT 76604)?
(CH-22.1)
A screening CTC (CPT 74263) is being requested for a 76 year old Medicare member. Member has a first degree relative dx with colon cancer at age 61. The member has never had a CTC screening or colonoscopy. Is this approvable or does it need to be sent to Medical Review?
What is Send to Medical Review?
(AB-25.: CTC) This is a screening CTC and the member has Medicare. Medicare considers a CTC for screening investigational and their coverage policies will take precedence over eviCore guidelines.
What imaging study is indicated for a symptomatic member with a COVID-19 positive test who has a hx of asthma?
What is CT Chest without contrast (CPT 71250) or with contrast (CPT 71260)?
(CH-13.2)
You will need to reroute a study request for an indication for Zollinger-Ellison Syndrome, to this specialty?
What is the Oncology specialty?
(AB-15.1, reroutes you to the ONC-15: Neuroendocrine Cancers and Adrenal Tumors Guidelines)
This initial imaging study must be performed for initial evaluation of scrotal pain or mass, before advanced imaging can be performed.
What is a scrotal ultrasound and or duplex (doppler) ultrasound?
(PV-20.1)
A CT Urogram (CPT 74178) is ordered for a 48 year old female member with hematuria and no other symptoms. The member has never smoked and has no additional risk factors. At the MDO visit yesterday, the member had a positive dipstick. No other tests or imaging have been done. Is this case approvable or does it need to be sent to MD Review?
What is send the case to MD review?
(AB-39.2:Asymptomatic Hematuria) A positive dipstick alone is not approvable with asymptomatic hematuria. A microscopic examination of the urine needs to be done and would need to be read as 3-10 RBC/HPF on a single urinalysis.
Either of these two imaging studies may be indicated for a suspected fibroid.
What is a pelvic Ultrasound (CPT 76856 or CPT 76857) and/or TV ultrasound (CPT 76830)?
(PV-12.1:Leiomyomata)
You will need to reroute a study request for an indication of Thoracic Outlet Syndrome in regard to brachial plexus?
What is Head/Neuro Specialty?
(CH-31.1: reroutes you to the PN-4:Brachial Plexus in the peripheral Nerve Disorders Imaging Guidelines)
Prior to advanced imaging in a pediatric member with generalized abdominal pain, what should be part of the initial evaluation?
What is physical examination, laboratory studies, including stool for blood (and stool culture if diarrhea) and should be initially be evaluated by ultrasound.
(PEDAB-2)
An 8 year old female presents to the MDO with LLQ pain for 1 week. The member has no other symptoms. PE - guarding to LLQ. No rule out was provided. No prior labs or imaging have been done. The MDO has ordered a CT Abdomen/Pelvis with Contrast (CPT 74177). Is this case approvable or would it need to be sent to MD Review?
What is send case to MD Review?
(PEDAB-29: Left Lower Quadrant Pain) The CPT code 74177 is not listed under LLQ Pain and the Red Flags listed in PEDAB-2 apply ONLY to generalized abdominal pain unless otherwise specified within the GL.
This imaging study may be indicated for an 8 year old with asthma and pleural effusion on a recent chest x-ray.
What is a CT Chest without (CPT 71250) or with (CPT 71260) contrast?
(PEDCH-10:Asthma)
You will need to reroute a study request for an indication of a pediatric breast mass, to this specialty?
What is Oncology Specialty?
(PEDCH-12 reroutes to PEDONC-17: Pediatric Breast Masses in the Pediatric Oncology Imaging Guidelines)