968 Form

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Medical Policy
Carelon (formerly AIM) Advanced Imaging/Radiology
Policy Number: 968 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 CPT and HCPCS Codes, #900
• Carelon Sleep Disorder Management, #969
• Carelon Sleep Disorder Management CPT and HCPCS Codes, #970
• Carelon Advanced Imaging of the Heart CPT and HCPCS Codes, #971
• Carelon Advanced Imaging of the Heart, #972

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

Policy and Coverage Criteria for Commercial Products: The Carelon Medical Benefits Management Clinical Guidelines include medical necessity criteria for Advanced Imaging/Radiology.

Abdomen and Pelvic Imaging Brain Imaging Chest Imaging Extremity Imaging Head and Neck Imaging Oncologic Imaging Spine Imaging Vascular 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 Managed Care (HMO The requirements of BCBSMA Radiology Management Program may require prior authorization via AIM Specialty Health. These requirements are member-specific:

2

and POS)

Commercial PPO and EPO
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/Radiology for Medicare Advantage Products Prior authorization through AIM Specialty Health is required for Medicare Advantage products.

The following Advanced Imaging/Radiology 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/Radiology.

Retired Medical Policies Policy Number Abdomen and Pelvic Imaging 961 Brain Imaging 962 Chest Imaging 963 Extremity Imaging 964 Head and Neck Imaging 965 Oncologic Imaging 960 Spine Imaging
966 Vascular Imaging 967

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/Radiology