900 Form

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Medical Policy Carelon (formerly AIM) Advanced Imaging/Radiology CPT and HCPCS Codes Policy Number: 900 BCBSA Reference Number: N/A NCD/LCD: N/A Related Policies

• Medicare Advantage: Advanced Imaging/Radiology and Sleep Disorder Management Clinical and Utilization Guidance Redirect, #923 • Carelon Advanced Imaging of the Heart, #972
• Carelon Advanced Imaging/Radiology, #968 • Carelon Advanced Imaging of the Heart CPT and HCPCS Codes, #971
• Carelon Abdomen and Pelvic Imaging CPT and Diagnoses Codes, #930
• Carelon Brain Imaging CPT and Diagnoses Codes, #931 • Carelon Chest Imaging CPT and Diagnoses Codes, #932
• Carelon Extremity Imaging CPT and Diagnoses Codes, #933 • Carelon Head and Neck Imaging CPT and Diagnoses, #934 • Carelon Oncologic Imaging CPT and Diagnoses Codes, #929 • Carelon Spine Imaging CPT and Diagnoses Codes, #935 • Carelon Vascular Imaging CPT and Diagnoses Codes, #936 • Non-Invasive Vascular Studies - Duplex Scans, #691 Table of Contents Commercial Products ............................................................................................................................................ 2 Medicare Advantage Products .............................................................................................................................. 2 Table 1. Abdomen and Pelvic Imaging CPT, HCPCS and Diagnoses Codes ...................................................... 2 Table 2. Brain Imaging CPT, HCPCS and Diagnoses Codes ............................................................................... 2 Table 3. Chest Imaging CPT, HCPCS and Diagnoses Codes .............................................................................. 3 Table 4. Extremity Imaging CPT, HCPCS and Diagnoses Codes ........................................................................ 4 Table 5. Head and Neck Imaging CPT, HCPCS and Diagnoses Codes .............................................................. 4 Table 6. Spine Imaging CPT, HCPCS and Diagnoses Codes .............................................................................. 5 Table 7. Vascular Imaging CPT, HCPCS and Diagnoses Codes ......................................................................... 6 Table 8. Oncologic Imaging CPT, HCPCS and Diagnoses Codes ....................................................................... 7 Policy History ....................................................................................................................................................... 10 Disclaimer: ........................................................................................................................................................... 11

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Commercial Products The following CPT and HCPCS codes are in-scope under the Carelon High Technology Radiology Management Program for Commercial Managed Care (HMO and POS) and Commercial PPO and EPO. For medical necessity criteria, see Carelon Medical Benefits Management Clinical Guidelines for Advanced Imaging/Radiology.

Medicare Advantage Products The following CPT and HCPCS codes are in-scope under the Carelon Advanced Imaging/Radiology Management Program for Medicare HMO and PPO. For medical necessity criteria, see Carelon Medical Benefits Management Clinical Guidelines for Advanced Imaging/Radiology.

Table 1. Abdomen and Pelvic Imaging CPT, HCPCS and Diagnoses Codes
You may access the Abdomen and Pelvis Imaging Diagnoses Codes (#930) here..
The following codes may be applicable to abdominal and pelvic imaging and may not be all-inclusive.

CPT codes Code Description
0648T Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained without diagnostic MRI examination of the same anatomy (eg, organ, gland, tissue, target structure) during the same session; single organ 0649T Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained with diagnostic MRI examination of the same anatomy (eg, organ, gland, tissue, target structure); single organ (List separately in addition to code for primary procedure) 72192 CT pelvis without contrast 72193 CT pelvis with contrast 72194 CT pelvis without contrast, followed by re-imaging with contrast 72195 MRI pelvis without contrast 72196 MRI pelvis with contrast 72197 MRI pelvis without contrast, followed by re-imaging with contrast 74150 CT abdomen without contrast 74160 CT abdomen with contrast 74170 CT abdomen without contrast, followed by re-imaging with contrast 74176 CT abdomen and pelvis without contrast 74177 CT abdomen and pelvis with contrast 74178 CT abdomen and pelvis without contrast in one or both body regions, followed by re-imaging with contrast 74181 MRI abdomen without contrast 74182 MRI abdomen with contrast 74183 MRI abdomen without contrast, followed by re-imaging with contrast 74261 CT colonography diagnostic, including image post-processing, without contrast 74262 CT colonography diagnostic, including image post-processing, with contrast including non- contrast images, if performed 74263 CT colonography screening, including image post-processing 74712 MRI fetal, including placental and maternal pelvic imaging when performed, single or first gestation 74713 MRI fetal, including placental and maternal pelvic imaging when performed, each additional gestation
HCPCS
Code Description None None

Table 2. Brain Imaging CPT, HCPCS and Diagnoses Codes
You may access the Brain Imaging Diagnoses Codes (#931) here. The following codes may be applicable to brain imaging and may not be all-inclusive.

CPT codes Code Description

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70450 CT head/brain, without contrast
70460 CT head/brain, with contrast
70470 CT head/brain, without contrast, followed by re-imaging with contrast
70473 Computed tomographic (CT) cerebral perfusion analysis with contrast material(s), including image postprocessing performed without concurrent CT or CT angiography of the same anatomy 70480 CT orbit, sella, or posterior fossa or outer, middle or inner ear, without contrast
70481 CT orbit, sella, or posterior fossa or outer, middle or inner ear, with contrast
70482 CT orbit, sella, or posterior fossa or outer, middle or inner ear, without contrast, followed by re- imaging with contrast
70551 MRI brain (including brain stem), without contrast
70552 MRI brain (including brain stem), with contrast
70553 MRI brain (including brain stem), without contrast, followed by re-imaging with contrast
70554 MRI brain functional, not requiring physician or psychologist administration
70555 MRI brain functional, requiring physician or psychologist administration of entire neurofunctional testing 76390 MRI spectroscopy
78608 Brain imaging PET, metabolic evaluation
78609 Brain imaging PET, perfusion evaluation
95965 Magnetoencephalography (MEG), recording and analysis; for spontaneous brain magnetic activity (e.g., epileptic cerebral cortex localization) 95966 Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, single modality (e.g., sensory, motor, language, or visual cortex localization) HCPCS
Code Description None None

Table 3. Chest Imaging CPT, HCPCS and Diagnoses Codes You may access the Chest Imaging Diagnoses Codes (#932) here.
The following codes may be applicable to chest imaging and may not be all-inclusive.

CPT codes Code Description
0633T Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast material 0634T Computed tomography, breast, including 3D rendering, when performed, unilateral; with contrast material(s) 0635T Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast, followed by contrast material(s) 0636T Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast material(s) 0637T Computed tomography, breast, including 3D rendering, when performed, bilateral; with contrast material(s) 0638T Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast, followed by contrast material(s) 71250 Computed tomography, thorax, diagnostic; without contrast material 71260 Computed tomography, thorax, diagnostic; with contrast material(s) 71270 Computed tomography, thorax, diagnostic; without contrast material, followed by contrast material(s) and further sections 71271 Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s) 71550 MRI chest, without contrast 71551 MRI chest, with contrast 71552 MRI chest, without contrast, followed by re-imaging with contrast 77046 MRI breast without contrast material(s); unilateral 77047 MRI breast without contrast material(s); bilateral 77048 MRI breast without and with contrast with CAD; unilateral 77049 MRI breast without and with contrast with CAD; bilateral

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78811 PET imaging, limited area 78812 PET imaging, skull to mid-thigh 78813 PET imaging, whole body 78814 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; limited area 78815 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; skull base to mid-thigh 78816 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; whole body HCPCS Code Description C8903 Magnetic resonance imaging with contrast, breast; unilateral C8905 Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral C8906 Magnetic resonance imaging with contrast, breast; bilateral C8908 Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral

Table 4. Extremity Imaging CPT, HCPCS and Diagnoses Codes
You may access the Extremities Imaging Diagnoses Codes (#933) here.
The following codes may be applicable to extremity imaging and may not be all inclusive.

CPT codes Code Description
73200 CT upper extremity, without contrast 73201 CT upper extremity, with contrast 73202 CT upper extremity, without contrast, followed by re-imaging with contrast 73218 MRI upper extremity non-joint, without contrast 73219 MRI upper extremity non-joint, with contrast 73220 MRI upper extremity non-joint, without contrast, followed by re-imaging with contrast 73221 MRI upper extremity any joint, without contrast 73222 MRI upper extremity any joint, with contrast 73223 MRI upper extremity any joint, without contrast, followed by re-imaging with contrast 73700 CT lower extremity, without contrast 73701 CT lower extremity, with contrast 73702 CT lower extremity, without contrast, followed by re-imaging with contrast 73718 MRI lower extremity non-joint, without contrast 73719 MRI lower extremity non-joint, with contrast 73720 MRI lower extremity non-joint, without contrast, followed by re-imaging with contrast 73721 MRI lower extremity any joint, without contrast 73722 MRI lower extremity any joint, with contrast 73723 MRI lower extremity any joint, without contrast, followed by re-imaging with contrast 78811 PET imaging, limited area 78812 PET imaging, skull to mid-thigh 78813 PET imaging, whole body 78814 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; limited area 78815 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; skull base to mid-thigh 78816 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; whole body HCPCS Code Description None None

Table 5. Head and Neck Imaging CPT, HCPCS and Diagnoses Codes You may access the Head and Neck Imaging Diagnoses Codes (#934) here.
The following codes may be applicable to the head and neck imaging and may not be all inclusive.

CPT codes Code Description
70336 MRI of the temporomandibular joint(s)

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70450 CT head/brain, without contrast 70460 CT head/brain, with contrast 70470 CT head/brain, without contrast, followed by re-imaging with contrast 70480 CT of orbit, sella, or posterior fossa or outer, middle or inner ear, without contrast 70481 CT of orbit, sella, or posterior fossa or outer, middle or inner ear, with contrast 70482 CT of orbit, sella, or posterior fossa or outer, middle or inner ear, without contrast, followed by re-imaging with contrast 70486 CT of maxillofacial area, without contrast 70487 CT of maxillofacial area, with contrast 70488 CT of maxillofacial area, without contrast, followed by re-imaging with contrast 70490 CT, soft tissue neck, without contrast 70491 CT, soft tissue neck, with contrast 70492 CT, soft tissue neck, without contrast, followed by re-imaging with contrast 70540 MRI orbit, face and neck, without contrast 70542 MRI orbit, face and neck, with contrast 70543 MRI orbit, face and neck, without contrast, followed by re-imaging with contrast 70551 MRI brain (including brain stem), without contrast 70552 MRI brain (including brain stem), with contrast 70553 MRI brain (including brain stem), without contrast, followed by re-imaging with contrast HCPCS Code Description None None

Table 6. Spine Imaging CPT, HCPCS and Diagnoses Codes
You may access the Spine Imaging Diagnoses Codes (#935) here. The following codes may be applicable to the spine imaging and may not be all-inclusive.

CPT codes Code Description
72125 CT cervical spine, without contrast 72126 CT cervical spine, with contrast 72127 CT cervical spine, without contrast, followed by reimaging with contrast 72128 CT thoracic spine, without contrast 72129 CT thoracic spine, with contrast 72130 CT thoracic spine, without contrast, followed by reimaging with contrast 72131 CT lumbar spine, without contrast 72132 CT lumbar spine, with contrast 72133 CT lumbar spine, without contrast, followed by reimaging with contrast 72141 MRI cervical spine, without contrast 72142 MRI cervical spine, with contrast 72146 MRI thoracic spine, without contrast 72147 MRI thoracic spine, with contrast 72148 MRI lumbar spine, without contrast 72149 MRI lumbar spine, with contrast 72156 MRI cervical spine, without contrast, followed by reimaging with contrast 72157 MRI thoracic spine, without contrast, followed by reimaging with contrast 72158 MRI lumbar spine, without contrast, followed by reimaging with contrast 77078 CT bone mineral density study, 1 or more sites, axial skeleton 78811 PET imaging, limited area 78812 PET imaging, skull to mid-thigh 78813 PET imaging, whole body 78814 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; limited area 78815 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; skull base to mid-thigh 78816 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; whole body HCPCS Code Description

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None None

Table 7. Vascular Imaging CPT, HCPCS and Diagnoses Codes
You may access the Vascular Imaging Diagnoses Codes (#936) here. The following codes may be applicable to the vascular imaging and may not be all inclusive.

CPT codes Code Description
70450 CT head, without contrast 70460 CT head, with contrast
70470 CT head, without contrast, followed by re-imaging with contrast
70496 CT angiography head, with contrast material(s), including noncontrast images, if performed, and image post-processing
70498 CT angiography neck, with contrast material(s), including noncontrast images, if performed, and image post-processing
70544 MR angiography head, without contrast
70545 MR angiography head, with contrast
70546 MR angiography head, without contrast, followed by re-imaging with contrast
70547 MR angiography neck, without contrast
70548 MR angiography neck, with contrast
70549 MR angiography neck, without contrast, followed by re-imaging with contrast 70551 MRI head, without contrast
70552 MRI head, with contrast
70553 MRI head, without contrast, followed by re-imaging with contrast
71250 Computed tomography, thorax, diagnostic; without contrast material 71260 Computed tomography, thorax, diagnostic; with contrast material(s) 71270 Computed tomography, thorax, diagnostic; without contrast material, followed by contrast material(s) and further sections 71275 CT angiography of chest (non-coronary), with contrast material(s), including non-contrast images, if performed, and image post-processing
71550 MRI chest, without contrast
71551 MRI chest, with contrast
71552 MRI chest, without contrast, followed by re-imaging with contrast
71555 MR angiography chest (excluding the myocardium) without contrast, followed by re-imaging with contrast
72159 MR angiography spinal canal
72191 CT angiography pelvis, with contrast material(s), including non-contrast images, if performed, and image post-processing 72192 CT pelvis, without contrast
72193 CT pelvis, with contrast
72194 CT pelvis without contrast, followed by re-imaging with contrast
72195 MRI pelvis, without contrast
72196 MRI pelvis, with contrast 72197 MRI pelvis, without contrast, followed by re-imaging with contrast 72198 MR angiography pelvis; without contrast, followed by re-imaging with contrast
73206 CT angiography upper extremity, with contrast material(s), including non-contrast images, if performed, and image post-processing Vascular Imaging
73225 MR angiography upper extremity, without and with contrast
73706 CT angiography lower extremity, with contrast material(s), including noncontrast images, if performed, and image post-processing
73725 MR angiography lower extremity, without and with contrast
74150 CT abdomen, without contrast
74160 CT abdomen, with contrast
74170 CT abdomen, without contrast, followed by re-imaging with contrast
74174 CT angiography abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image post-processing
74175 CT angiography abdomen, with contrast material(s), including non-contrast images, if

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performed, and image post-processing
74176 CT abdomen and pelvis, without contrast
74177 CT abdomen and pelvis, with contrast
74178 CT abdomen and pelvis, without contrast, followed by re-imaging with contrast
74181 MRI abdomen, without contrast
74182 MRI abdomen, with contrast
74183 MRI abdomen, without contrast, followed by re-imaging with contrast
74185 MR angiography abdomen; without or with contrast
75635 CT angiography abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including non-contrast images, if performed, and image post-processing

EXCEPTIONS: The following codes do not require prior authorization through Carelon Medical Benefits Management (formerly AIM Specialty Health). These codes are addressed in Blue Cross Blue Shield of Massachusetts Medical Policy #691 Non-Invasive Vascular Studies - Duplex Scans. The codes below are considered medically necessary when the policy criteria are met. Prior authorization is not required.

93880
Duplex scan of extracranial arteries; complete bilateral study 93882 Duplex scan of extracranial arteries; unilateral or limited study 93922 Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (e.g., for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/ brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with, transcutaneous oxygen tension measurement at 1-2 levels) 93923 Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (e.g., for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more levels), or single level study with provocative functional maneuvers (e.g., measurements with postural provocative tests, or measurements with reactive hyperemia) 93924 Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (i.e., bidirectional Doppler waveform or volume plethysmography recording and analysis at rest with ankle/brachial indices immediately after and at timed intervals following performance of a standardized protocol on a motorized treadmill plus recording of time of onset of claudication or other symptoms, maximal walking time, and time to recovery) complete bilateral study 93925 Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study 93926 Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study 93930 Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study 93931 Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study 93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study 93979 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study HCPCS Code Description None None

Table 8. Oncologic Imaging CPT, HCPCS and Diagnoses Codes
You may access the Oncologic Imaging Diagnoses Codes (#929) here. Note: For oncologic imaging related to other areas of the body, see relevant tables above.
The following codes may be applicable to oncologic imaging and may not be all inclusive.

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CPT codes Code Description 70450 CT head/brain, without contrast 70460 CT head/brain, with contrast 70470 CT head/brain, without contrast, followed by re-imaging with contrast 70480 CT of orbit, sella, or posterior fossa and outer, middle or inner ear, without contrast 70481 CT of orbit, sella, or posterior fossa and outer, middle or inner ear, with contrast 70482 CT of orbit, sella, or posterior fossa and outer, middle or inner ear, without contrast, followed by re-imaging with contrast 70486 CT of maxillofacial area, without contrast 70487 CT of maxillofacial area, with contrast 70488 CT of maxillofacial area, without contrast, followed by re-imaging with contrast 70490 CT, soft tissue neck, without contrast 70491 CT, soft tissue neck, with contrast 70492 CT, soft tissue neck, without contrast, followed by re-imaging with contrast 70540 MRI orbit, face and neck, without contrast 70542 MRI orbit, face and neck, with contrast 70543 MRI orbit, face and neck, without contrast, followed by re-imaging with contrast 70551 MRI brain (including brain stem), without contrast 70552 MRI brain (including brain stem), with contrast 70553 MRI brain (including brain stem), without contrast, followed by re-imaging with contrast 70554 MRI brain functional, not requiring physician or psychologist administration 70555 MRI brain functional, requiring physician or psychologist administration of entire neurofunctional testing 71250 Computed tomography, thorax, diagnostic; without contrast material 71260 Computed tomography, thorax, diagnostic; with contrast material(s) 71270 Computed tomography, thorax, diagnostic; without contrast material, followed by contrast material(s) and further sections 71550 MRI chest, without contrast 71551 MRI chest, with contrast 71552 MRI chest, without contrast, followed by re-imaging with contrast 72125 CT cervical spine, without contrast 72126 CT cervical spine, with contrast 72127 CT cervical spine, without contrast, followed by reimaging with contrast 72128 CT thoracic spine, without contrast 72129 CT thoracic spine, with contrast 72130 CT thoracic spine, without contrast, followed by reimaging with contrast 72131 Computed tomography, lumbar spine; without contrast material 72132 Computed tomography, lumbar spine; with contrast material 72133 Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections 72141 Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material 72142 Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s) 72146 MRI of thoracic spine, without contrast 72147 MRI of thoracic spine, with contrast 72148 Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material 72149 Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s) 72156 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical 72157 MRI of thoracic spine, without contrast, followed by re-imaging with contrast 72158 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material,

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followed by contrast material(s) and further sequences; lumbar 72192 CT pelvis without contrast 72193 CT pelvis with contrast 72194 CT pelvis without contrast, followed by re-imaging with contrast 72195 MRI pelvis without contrast 72196 MRI pelvis with contrast 72197 MRI pelvis without contrast, followed by re-imaging with contrast 73200 CT upper extremity, without contrast 73201 CT upper extremity, with contrast 73202 CT upper extremity, without contrast, followed by re-imaging with contrast 73218 MRI upper extremity non-joint, without contrast 73219 MRI upper extremity non-joint, with contrast 73220 MRI upper extremity non-joint, without contrast, followed by re-imaging with contrast 73221 MRI upper extremity any joint, without contrast 73222 MRI upper extremity any joint, with contrast 73223 MRI upper extremity any joint, without contrast, followed by re-imaging with contrast 73700 CT lower extremity, without contrast 73701 CT lower extremity, with contrast 73702 CT lower extremity, without contrast, followed by re-imaging with contrast 73718 MRI lower extremity non-joint, without contrast 73719 MRI lower extremity non-joint, with contrast 73720 MRI lower extremity non-joint, without contrast, followed by re-imaging with contrast 73721 MRI lower extremity any joint, without contrast 73722 MRI lower extremity any joint, with contrast 73723 MRI lower extremity any joint, without contrast, followed by re-imaging with contrast 74150 CT abdomen without contrast 74160 CT abdomen with contrast 74170 CT abdomen without contrast, followed by re-imaging with contrast 74176 CT abdomen and pelvis without contrast 74177 CT abdomen and pelvis with contrast 74178 CT abdomen and pelvis without contrast in one or both body regions, followed by re-imaging with contrast 74181 MRI abdomen without contrast 74182 MRI abdomen with contrast 74183 MRI abdomen without contrast, followed by re-imaging with contrast 74261 CT colonography diagnostic, including image post-processing, without contrast 74262 CT colonography diagnostic, including image post-processing, with contrast including non- contrast images, if performed 74263 CT colonography screening, including image post-processing 76390 MRI spectroscopy 77046 Magnetic resonance imaging, breast, without contrast material; unilateral 77047 Magnetic resonance imaging, breast, without contrast material; bilateral 77048 MRI breast without and with contrast with CAD; unilateral 77049 MRI breast without and with contrast with CAD; bilateral 77084 MRI, bone marrow blood supply 78608 Brain imaging PET, metabolic evaluation 78609 Brain imaging PET, perfusion evaluation 78811 PET imaging, limited area 78812 PET imaging, skull to mid-thigh 78813 PET imaging, whole body 78814 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; limited area 78815 PET imaging, with concurrently acquired CT for attenuation correction and anatomic

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localization; skull base to midthigh 78816 PET imaging, with concurrently acquired CT for attenuation correction and anatomic localization; whole body HCPCS Code Description A9515 Choline c-11, diagnostic, per study dose up to 20 millicuries A9552 Fluorodeoxyglucose f-18 fdg, diagnostic, per study dose, up to 45 millicuries
Note: Prior authorization not required when billed with cardiac diagnosis.
A9580 Sodium fluoride f-18, diagnostic, per study dose, up to 30 millicuries A9586 Florbetapir f18, diagnostic, per study dose, up to 10 millicuries A9587 Gallium ga-68, dotatate, diagnostic, 0.1 millicurie A9588 Fluciclovine f-18, diagnostic, 1 millicurie A9591 Fluoroestradiol f 18, diagnostic, 1 millicurie A9592 Copper cu-64, dotatate, diagnostic, 1 millicurie A9593 Gallium ga-68 psma-11, diagnostic, (ucsf), 1 millicurie A9594 Gallium ga-68 psma-11, diagnostic, (ucla), 1 millicurie A9595 Piflufolastat f-18, diagnostic, 1 millicurie A9597 Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified A9598 Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor identification, not otherwise classified A9596 Gallium ga-68 gozetotide, diagnostic, (illuccix), 1 millicurie
A9601 Flortaucipir f 18 injection, diagnostic, 1 millicurie A9602 Fluorodopa f-18, diagnostic, per millicurie A9616 Gallium ga-68 gozetotide (gozellix), diagnostic, 1 millicurie A9800 Gallium ga-68 gozetotide, diagnostic, (locametz), 1 millicurie Q9982 Flutemetamol f18, diagnostic, per study dose, up to 5 millicuries Q9983 Florbetaben f18, diagnostic, per study dose, up to 8.1 millicuries

Policy History 5/2026 Magnetic resonance imaging codes C8903, C8905, C8906, and C8908 added. These codes require prior authorization through Carelon. Effective 5/1/2026. 2/2026 Radiotracer code A9616 added. This code requires prior authorization through Carelon.
Effective 2/1/2026. 1/2026 Computed tomographic (CT) cerebral perfusion 70473 added. These codes require prior authorization through Carelon. Effective 1/1/2026. 11/2025 Magnetoencephalography recording and analysis codes 95965; 95966 added. These codes require prior authorization through Carelon. Effective 11/15/2025.
4/2023 Radiotracer codes A9602; A9800 added. These codes require prior authorization through AIM Specialty Health. Effective 4/8/2023.
11/2022 Radiotracer codes A9596; A9601 added. These codes require prior authorization through AIM Specialty Health. Effective 11/1/2022.
10/2022 Radiotracer codes added. These codes require prior authorization through AIM Specialty Health. Effective 10/8/2022.
3/2022 Clarified coding information. 1/2021 Clarified coding information. 5/2020 Clarified coding information. 4/2020 Clarified coding information. 11/2019 Document clarified to indicate that the following codes do not require prior authorization through AIM Specialty Health. The following codes are addressed in Blue Cross Blue Shield of Massachusetts Medical Policy #691 Non-Invasive Vascular Studies - Duplex Scans. These codes do not require prior authorization: 93880, 93882, 93922, 93923, 93924, 93925, 93926, 93930, 93931, 93978, 93979.
9/2019 Links to advanced imaging/radiology diagnoses codes under each section were added. Title changed to Advanced Imaging/Radiology. Effective 9/1/2019. 3/2019 New document #900 issued. Effective 3/1/2019.

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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.