972 Form

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Medical Policy Carelon (formerly AIM) Advanced Imaging of the Heart
Policy Number: 972 BCBSA Reference Number: N/A NCD/LCD: N/A Effective Date: September 1, 2019 Related Policies
• Medicare Advantage: Carelon Advanced Imaging/Radiology and Sleep Disorder Management Clinical and Utilization Guidance Redirect, #923 • Carelon Advanced Imaging/Radiology, #968
• Carelon Advanced Imaging/Radiology CPT and HCPCS Codes, #900
• Carelon Sleep Disorder Management, #969
• Carelon Sleep Disorder Management CPT, HCPCS and Diagnoses Codes, #970
• Carelon Advanced Imaging of the Heart CPT, HCPCS and Diagnoses Codes, #971

Overview:
Blue Cross Blue Shield of Massachusetts has delegated utilization management to Carelon Carelon Medical Benefits Management for Advanced Imaging of the Heart.

Policy and Coverage Criteria for Commercial Products: The Carelon Medical Benefits Management Clinical Guidelines include medical necessity criteria for Advanced Imaging of the Heart:

Cardiac Computed Tomography (CT) for Quantitative Evaluation of Coronary Calcification Computed Tomography (CT) Cardiac (Structure) Coronary CT Angiography (CCTA) and CT Derived Fractional Flow Reserve (FFR-CT) Magnetic Resonance Imaging (MRI) Cardiac
Nuclear Cardiology Infarct Imaging
Nuclear Cardiology Myocardial Perfusion Imaging
Nuclear Cardiology: Cardiac Blood Pool Imaging Blood Pool Imaging includes MUGA (Multi-Gated Acquisition) & First Pass Radionuclide Ventriculography
Positron Emission Tomography (PET) Myocardial Imaging

Requesting Prior Authorization Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial The requirements of BCBSMA Radiology Management Program may require prior

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Managed Care (HMO and POS)

Commercial PPO and EPO
authorization via AIM Specialty Health. These requirements are member-specific:

Please verify member eligibility and requirements through Online Services by logging onto Provider Central. Refer to our Quick Tip for an overview of pre- certification and prior authorization requirements.

Ordering clinicians should request prior authorization from Carelon Medical Benefits Management or call 1-866-745-1783 (when applicable).

Prior authorization information for Medicare HMO Blue and Medicare PPO Blue is addressed in medical policy #923, Carelon Advanced Imaging/Radiology and Sleep Disorder Management for Medicare Advantage Products.

Indemnity Prior authorization is not required.

Advanced Imaging of the Heart for Medicare Advantage Products Prior authorization through AIM Specialty Health is required for Medicare Advantage products.

The following Advanced Imaging of the Heart medical policies will be retired effective September 1, 2019.
These policies will no longer be available on the BCBSMA website as of this date. For medically necessary indications, see the Carelon Medical Benefits Management Clinical Guidelines for Advanced Imaging of the Heart.

Retired Medical Policies Policy Number Cardiac Computed Tomography (CT) for Quantitative Evaluation of Coronary Calcification 832 Computed Tomography (CT) Cardiac (Structure)
833 Coronary CT Angiography (CCTA) and CT Derived Fractional Flow Reserve (FFR-CT)
831 Magnetic Resonance Imaging (MRI) Cardiac
835 Nuclear Cardiology Infarct Imaging
834 Nuclear Cardiology Myocardial Perfusion Imaging
836 Nuclear Cardiology: Cardiac Blood Pool Imaging Blood Pool Imaging includes MUGA (Multi-Gated Acquisition) & First Pass Radionuclide Ventriculography
830 Positron Emission Tomography (PET) Myocardial Imaging
837

Disclaimer:
Coverage is subject to applicable benefit contract. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

Member’s medical records must document that services are medically necessary for the care provided. BCBS MA maintains the right to audit the services provided to our members, regardless of the participation status of the provider. All documentation must be available upon request. Failure to produce the requested information may result in denial or retraction of payment.

References: Carelon Medical Benefits Management Clinical Guidelines for Advanced Imaging of the Heart