Clinical UM Guideline
Subject: Site of Care: Advanced Radiologic Imaging
Guideline #: CG-MED-55 Publish Date: 08/20/2020
Status: Revised Last Review Date: 08/13/2020
Description

This document addresses the clinical features that may increase an individual’s risk of requiring access to care available in a hospital outpatient department for advanced radiologic imaging.

Note: In some plans, “level of care,” “site of service” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts, or other materials instead of or in addition to “site of care” and, in some plans, these terms may be used interchangeably.

Note: Please see the following related documents for additional information:

Clinical Indications

Note: The medical necessity of the advanced radiologic imaging procedure may be separately reviewed against the appropriate criteria. This guideline is for determination of the medical necessity of hospital outpatient site of care for the advanced radiologic imaging procedure.

Medically Necessary:

An advanced radiologic imaging procedure in the hospital outpatient department is considered medically necessary when any of the following are present:

  1. The services being provided are only available in the hospital setting; or
  2. The individual is less than 10 years old; or
  3. The individual requires an obstetrical observation; or
  4. The individual is receiving perinatology services; or
  5. There are no other geographically accessible appropriate alternative sites for the individual to undergo the procedure, including but not limited to the following:
    1. Moderate or deep sedation or general anesthesia is required for the procedure and a freestanding facility providing such sedation is not available; or
    2. The equipment for the size of the individual (that is, very small or very large) is not available in a freestanding facility; or
    3. The individual has a documented diagnosis of claustrophobia requiring open magnetic resonance imaging which is not available in a freestanding facility; or
  6. The individual has a known chronic disease that is expected to require imaging at multiple time points and the individual has had prior radiology imaging procedures for the diagnosis, management or surveillance of the disease at the hospital outpatient department or clinic (for example, follow-up of lung nodules, individuals with multiple sclerosis, aortic aneurysms, or inflammatory bowel disease, or individuals with cancer); or
  7. The individual has a known contrast allergy; or
  8. The imaging is pre-operative or pre-procedure where the surgery or procedure is being performed at the hospital or affiliated site; or
  9. Performance or imaging outside the hospital outpatient department or clinic would reasonably be expected to adversely impact or delay care.

Not Medically Necessary:

All other advanced radiologic imaging procedures in the hospital outpatient department are considered not medically necessary when the above criteria are not met.

Coding

Coding edits for medical necessity review are not implemented for this guideline. Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Discussion/General Information

Hospital-based advanced radiologic imaging procedures are generally more appropriate for individuals whose health status necessitates the availability of more supportive care for the minimization of the risks associated adverse health events.

Certain high-risk medical conditions can necessitate the need for an anesthesiologist to be present during the advanced radiologic imaging for individuals including neonates and children. Children can require specialized pediatric equipment including smaller anesthetic tools such as endotracheal tubes and monitoring equipment. Conversely, large individuals or those with claustrophobia may also require specialized equipment which could include an open magnetic resonance imaging (MRI) as opposed to a traditional MRI scanner.

Location of radiology equipment within a facility can be a hindrance to effective member care. For example, the MRI suite can be a hazardous location due to the presence of a very strong static magnetic field, high-frequency electromagnetic (radiofrequency) waves, and a time-varied (pulsed) magnetic field. There can be challenges to administering anesthesia and monitoring capabilities due to static and dynamic magnetic fields, and compromise of direct observation of the member. The MRI environment frequently requires the anesthesiologist to assume broader responsibility for immediate decisions related to care of the member.

Examples of advanced radiologic imaging include computed tomography, computed tomography angiography, magnetic resonance imaging, magnetic resonance angiography, nuclear medicine scans (for example, single photon emission computed tomography), nuclear cardiac imaging procedures (for example, myocardial perfusion scans), and positron emission tomography scans.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American College of Obstetricians and Gynecologists. Committee opinion 723: Guidelines for diagnostic imaging during pregnancy and lactation. 2017; reaffirmed 2019. Available at: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/10/guidelines-for-diagnostic-imaging-during-pregnancy-and-lactation. Accessed on July 21, 2020.
  2. American Society of Anesthesiologists. Available at: https://www.asahq.org/quality-and-practice-management/standards-guidelines-and-related-resources-search. Accessed on July 21, 2020.
Index

Advanced radiologic imaging
Site of care

History

Status

Date

Action

Revised

08/13/2020

Medical Policy & Technology Assessment Committee (MPTAC) review. Title changed to “Site of Care: Advanced Radiologic Imaging.” Updated Description, Discussion/General Information, References, and Index sections.

Reviewed

02/20/2020

MPTAC review. Updated References section.

Reviewed

03/21/2019

MPTAC review. Updated References section.

Reviewed

03/22/2018

MPTAC review. Updated References section.

Revised

11/02/2017

MPTAC review. Revisions made to MN statement. Updated header language from “Current Effective Date” to “Publish Date.”

 

07/19/2017

Updated Description Section.

Revised

05/04/2017

MPTAC review. Revised MN statement regarding geographically accessible appropriate alternatives. Updated References section.

Revised

11/03/2016

MPTAC review. Clarified NMN statement.

New

08/04/2016

MPTAC review. Initial document development.


Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

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