Coverage Policy

The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients.

Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy.

In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document.

Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation.

Each coverage request should be reviewed on its own merits. Medical directors are expected to exercise clinical judgment and have discretion in making individual coverage determinations. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines.

In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations.

Coverage Policy

This Coverage Policy addresses the medical necessity of a hospital-based imaging department or facility for the following high-tech imaging services: magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), computed tomography (CT), and computed tomography angiography (CTA).

A high-tech imaging service (i.e. MRI/MRA/CT/CTA) must meet applicable medical necessity criteria for coverage. When coverage criteria are met for the requesting imaging procedure, this coverage policy is used to help determine the medical necessity of the requested site of care.

A high-tech imaging procedure in a hospital-based imaging department or facility is considered medically necessary for an individual with ANY of the following indications:

• age 18 and under
• Medical Coverage Policy: 0550
• requires obstetrical observation
• requires perinatology services
• imaging related to transplantation services at an approved transplantation facility
• known contrast allergy and use of that contrast agent is planned

There are no other appropriate alternative sites for the individual to undergo the imaging procedure for any of the following reasons:

1. surgery or procedure is being performed at the hospital and pre-operative or pre-procedure imaging is an integral component of the procedure
2. moderate or deep sedation or general anesthesia is required for the imaging procedure and freestanding facility providing such sedation is not available
3. equipment for the size of the individual is only available at a hospital-based imaging facility
4. individual has a documented diagnosis of claustrophobia requiring open magnetic resonance imaging which is not available in a freestanding facility
5. systemic cancer on active treatment, where restaging studies need comparison to prior studies obtained at a hospital-based facility or the individual is receiving care at a well-recognized Oncology Center of Excellence
6. known chronic systemic disease or organ-specific disease where follow-up imaging needs to be performed at a hospital-based facility for comparison to prior studies obtained or the individual is receiving care at a well-recognized Center of Excellence for the diagnosis
7. imaging is emergent or urgent and not immediately available at a freestanding facility

All other high-tech radiology (imaging) procedures at a hospital-based imaging department or facility are considered not medically necessary. This includes but is not limited to:

• orthopedic-specific imaging
• screening high risk individuals for cancer
• suspected or known cancer for initial diagnosis and/or staging
• surveillance of known cancer with no clinical suspicion for change in disease status

General Background

'Site of Care' refers to the location where a procedure or scan is performed. In general, non-emergent high-tech radiology (imaging) procedures/scans including magnetic resonance imaging (MRI) and computed tomography (CT) may be performed at either a freestanding imaging facility or a hospital-based imaging department/facility. Freestanding imaging facilities may offer Cigna members a lower cost alternative than a hospital-based imaging department or facility for medically necessary non-emergent imaging procedures. Imaging procedures may appropriately be performed at freestanding imaging facility for individuals whose health status does not necessitate the availability of a higher-level of supportive care for the minimization of the risks associated adverse health events.

Certain high-risk medical conditions can necessitate the need for an anesthesiologist to be present during the advanced radiologic imaging for certain individuals. Professional Societies/Organizations

The American Society of Anesthesiologists (ASA) Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging (2015) states that risks related to the patient may include age-related risks, health-related risks, and risks from foreign bodies located in or on the patient or implanted ferromagnetic items. Age-related risks apply to neonates or premature infants and elderly patients.

• Health-related risks include, but are not limited to:
  • need for intensive or critical care
  • changes in level of sedation, muscle relaxation, or ventilation
  • hemodynamic instability and vasoactive infusion requirements
  • impaired respiratory function (e.g., tonsillar hypertrophy and sleep apnea)
  • Medical Coverage Policy: 0550 comorbidities that may contribute to adverse MRI effects (e.g., burns or temperature increases in patients with obesity or peripheral vascular disease)
• Foreign bodies include nonmedical ferromagnetic items imbedded in the patient (e.g., eyeliner tattoos and metallic intraocular fragments) or attached to the patient (e.g., pierced jewelry and magnetic dental keepers). Implanted ferromagnetic items may include items such as aneurysm clips, prosthetic heart valves, or coronary arterial stents.

The American College of Radiology (ACR) Practice Parameter for the Use of Intravascular Contrast Media (Revised 2022) states that appropriate emergency equipment and medications must be immediately available to treat adverse events related to contrast media administration, including equipment, medications, and other emergency support appropriate for the range of ages and/or sizes in the patient population. The ACR Practice Parameter for Minimal and/or Moderate Sedation/Analgesia (2020) notes that Facility policies for monitoring and evaluating the function of all equipment should be followed. Any location where sedation is administered and recovery from sedation is provided must have equipment and drugs for emergency resuscitation readily available. It is critical that a complete range of sizes of emergency and monitoring equipment be available in the immediate area for all ages and sizes of patients treated at the facility.

The American Society of Anesthesiologists (ASA) Statement on Practice Recommendations for Pediatric Anesthesia (last amended October 13, 2021) states that radiology services should be contemporaneously available when pediatric patients are receiving care at the facility.

The American College of Obstetrics and Gynecology (ACOG) Committee Opinion (Number 723, Reaffirmed October 2021) Guidelines for Diagnostic Imaging During Pregnancy and Lactation states "Ultrasonography and magnetic resonance imaging are not associated with risk and are the imaging techniques of choice for the pregnant patient, but they should be used prudently and only when use is expected to answer a relevant clinical question or otherwise provide medical benefit to the patient. With few exceptions, radiation exposure through radiography, computed tomography scan, or nuclear medicine imaging techniques is at a dose much lower than the exposure associated with fetal harm. If these techniques are necessary in addition to ultrasonography or magnetic resonance imaging or are more readily available for the diagnosis in question, they should not be withheld from a pregnant patient. Breastfeeding should not be interrupted after gadolinium administration."

Use Outside the U.S.

The European Society of Radiology (ESR) and European Federation of Radiographer Societies (EFRS) published a Statement paper titled Patient Safety in Medical Imaging (2019). The ESR/EFRS noted the following: "The radiology department has usually been considered a low risk environment for infections associated with healthcare (nosocomial infections), but the potential for transmission of infectious pathogens to both patients and healthcare professionals exists. Radiology departments have a steady stream of a wide variety of patients each day. Patients referred from ambulatory care and emergency departments often mix with inpatients. All of these patients can contaminate the environment of the radiology department with pathogens."

Given the large number of patients with confirmed infections and those undiagnosed as infected that go to the radiology department, and the potential to contaminate both objects and the air with pathogens, surface cleaning must be done between all patients, with more rigorous cleaning protocols at periodic intervals. The radiology department must also maintain good communication with the clinical areas referring patients for radiologic procedures, in order to properly identify those patients that need extra precautions.">