Subject:

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:

• CG-SURG-10 Ambulatory or Outpatient Surgery Center Procedures
• CG-SURG-52 Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services

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 19 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