Imaging approval guidelines Form

Effective December 1, 2021, Aetna® added a Site of Care medical necessity requirement to the Enhanced Clinical Review program for fully insured commercial members. As part of this change, advanced radiology imaging procedures (MR and CT scans) will be reviewed by eviCorehealthcarefor applicablemedicalnecessity criteriaprior to authorizationofservices in the hospital outpatient setting. An advanced imaging procedure at a hospital outpatient site is considered medically necessary when cases involve certain factors. Examples are those where: • the individual is under 18 years of age • obstetrical observation is required • perinatology services are required • there are imaging needs related to transplant services at an approved transplant facility • there is a known contrast allergy, and use of that contrast agent is planned • there is a known chronic disease for which prior high-tech imaging procedures have been used for the diagnosis, management or ongoing surveillance of the disease at the hospital-affiliated imaging department • active case of COVID-19 after positive test for SARS-CoV-2 • thereare no other appropriatealternativesitesfor the individualto undergotheimaging procedure for any of the following reasons: o the surgery or procedure is being performed at the hospital, and preoperative/procedural or postoperative/procedural imaging is an integral component of the care o moderate or deep sedation or general anesthesia is required for the imaging procedure, and a freestanding facility capable of providing such sedation is not available o equipment needed to accommodate the size of the individual is available only at a hospital-affiliated imaging facility o the individual has a documented diagnosis of claustrophobia requiring open magnetic resonance imaging, which is not available in a freestanding facility o imaging outside the hospital-affiliated imaging department or facility is expected to adversely impact or delay care All requestedadvancedradiology proceduresthatdon’tmeettherequiredcriteriawill be considered non-medicallynecessary unless performed at a freestanding or office location. This policy will apply to all existing Enhanced Clinical Review program markets. 898900-01-01