CareCore National Preauthorization List (As of 3/9/15)
CPT CODE
PROCEDURE DESCRIPTION
70492
MRI TMJ CT Head/Brain w/o Contrast CT Head/Brain w/o & w/ Contrast CT Orbit w/o Contrast CT Orbit w/ Contrast CT Maxllfcl w/o Contrast CT Maxllfcl w/o & w/ Contrast CT Soft Tissue Neck w/o Contrast CT Soft Tissue Neck w/ Contrast CT Soft Tissue Neck w/o & w/ Contrast
70540
MRI Face, Orbit, Neck w/o Contrast
70542
MRI Face, Orbit, Neck w/ Contrast MRA Head w/o Contrast MRA Head w/ Contrast MRA Head w & w/o Contrast MRA Neck w/o Contrast MRA Neck w & w/o Contrast MRI Head w/o Contrast MRI Head w/ Contrast MRI Head w/ & w/o Contrast
70336 70450 70470 70480 70481 70486 70488 70490 70491
70544 70545 70546 70547 70549 70551 70552 70553
70554
MRI, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration
70555
MRI, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing
71250
CT Thorax w/o Contrast
71260
71550
CT Thorax w/ Contrast CT Thorax w/o & w/ Contrast Ct Angiography Chest MRI Chest w/o Contrast
72128
CT T Spine w/o Contrast
72129
CT T Spine w/ Contrast
72130
CT T Spine w/o & w/ Contrast CT L Spine w/o Contrast MRI Cervical Spine w/o Contrast MRI Cervical Spine w/ Contrast MRI Thoracic Spine w/o Contrast MRI Thoracic Spine w/ Contrast MRI Lumbar Spine w/o Contrast
71270 71275
72131 72141 72142 72146 72147 72148
ADDITIONAL INFORMATION Tempomandibular joint/jaw
Temporal Bone/Mastoid/Ears Temporal Bone/Mastoid/Ears Sinus/Denta Scan/TMJ Sinus/Denta Scan/TMJ Parotid; Not used for Cervical Bone Parotid; Not used for Cervical Bone Parotid; Not used for Cervical Bone Sinus/3 areas (soft tissue neck) eyes/temporal Gadolinium Also known as MRV Gadolinium/ Also known as MRV Gadolinium/ Also known as MRV Also known as MRV Gadolinium/ Also known as MRV IACs (Internal Auditory Canal) IACs (Internal Auditory Canal) IACs (Internal Auditory Canal)
Can be CT Chest or a Ultrafast-CT/EBT/EBCT Chest/Ultrafast CT/EBT/EBCT Chest/Ultrafast CT/EBT/EBCT Brachial Plexus
Includes Sacrum Vertebrae of the Neck Gadolinium Gadolinium Includes Sacrum
1
CareCore National Preauthorization List (As of 3/9/15)
CPT CODE
PROCEDURE DESCRIPTION
73221
MRI Lumbar Spine w/ Contrast MRI C Spine w/ & w/o Contrast MRI T Spine w/ & w/o Contrast MRI L Spine w/ & w/o Contrast MRA Spinal Canal w/ or w/o Contrast CT Angiography Pelvis CT Pelvis w/o Contrast CT Pelvis w/o & w/ Contrast MRI Pelvis w/o Contrast MRI Pelvis w & w/o Contrast MRA Pelvis w/ or w/o Contrast CT Upper Extremity w/o Contrast CT Upper Extremity w/ Contrast CT Upper Extremity w/o & w/ Contrast CT Angiography Upper Extremity MRI Upper Extremity w/o Contrast MRI Upper Extremity w & w/o Contrast MRI Upper Extremity w/o Contrast
73222
MRI Upper Extremity w/ Contrast
73223
73721
MRI Upper Extremity Joint w & w/o Contrast MRA Upper Extremity w/ or w/o Contrast CT Lower Extremity w/o Contrast CT Lower Extremity w/o & w/ Contrast MRI Lower Extremity w/o Contrast MRI Lower Extremity w/ Contrast MRI Lower Extremity w/o Contrast
73722
MRI Lower Extremity w/ Contrast
73723
MRI Lower Extremity Joint w/ & w/o Contrast MRA Lower Extremity w/ or w/o Contrast CT Abdomen w/o Contrast CT Abdomen w/ Contrast CT Abdomen w/o & w/ Contrast Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing Ct Angiography Abdomen Computed Tomography, Abdomen and Pelvis; without Contrast Material
72149 72156 72157 72158 72159 72191 72192 72194 72195 72197 72198 73200 73201 73202 73206 73218 73220
73225 73700 73702 73718 73719
73725 74150 74160 74170 74174 74175 74176
74177 74178
ADDITIONAL INFORMATION Gadolinium - Includes Sacrum Gadolinium Gadolinium Gadolinium - Includes Sacrum Gadolinium/ Also known as MRV Aortic Aneurysm Below Belly Button/Coccyx Below Belly Button/Coccyx Coccyx Gadolinium/coccyx Gadolinium/ Also known as MRV Hand/Arm/Shoulder/ Elbow/Wrist Hand/Arm/Shoulder/ Elbow/Wrist Hand/Arm/Shoulder/ Elbow/Wrist Hand/Arm/Shoulder/ Elbow/Wrist Hand/Arm/Axilla Hand/Arm/Axilla-Gadolinium Shoulder/Elbow/Wrist Arthrogram Shoulder/Elbow/Wrist-Gadolinium Shoulder/Elbow/Wrist-Gadolinium Gadolinium/ Also known as MRV Hip/Leg/Knee/Ankle/ Foot Hip/Leg/Knee/Ankle/ Foot Foot/Leg Foot/Leg-Gadolinium Hip/Knee/Ankle Arthrogram Hip/Knee/Ankle-Gadolinium Hip/Knee/Ankle-Gadolinium Gadolinium/ Also known as MRV Diaphragm to Belly Button Aneurysm/Diaphragm to Belly Button Diaphragm to Belly Button
Diaphragm to Belly Button
Computed Tomography, Abdomen and Pelvis; with Contrast Material(s) Computed Tomography, Abdomen And Pelvis; Without Contrast Material In One Or Both Body Regions, Followed By Contrast
2
CareCore National Preauthorization List (As of 3/9/15)
CPT CODE
PROCEDURE DESCRIPTION
74181
MRI Abdomen w/o Contrast
74183
MRI Abdomen w/ & w/o Contrast
74261
74262
74263 75559
75563 75573 75574 75635 76376
77059
77084
MRI Bone Marrow Blood Supply
78012
Thyroid Uptake, Single or Multiple Quantitative Measurements(s) (Including Stimulation, Suppression, or Discharge, When Performed)
78013
Thyroid Imaging (Including Vascular Flow, When Performed);
78014
Thyroid Imaging (Including Vascular Flow, When Performed); With Single or Multiple Uptake(s) Quantitative Measurement(s) (Including
78015
Thyroid Met Imaging
78016
Thyroid Met Imaging with Additional Studies
76380 76975 77058
MRCP-MR Cholangiogram MRCP-MR Cholangiogram Gadolinium
Computed Tomographic (CT) Colonography, Diagnostic, Including Image Postprocessing; Without Contrast Material Computed Tomographic (CT) Colonography, Diagnostic, Including Image Postprocessing; With Contrast Material(s) Including NonContrast Images, If Performed Computed Tomographic (CT) Colonography, Screening, Including Image Postprocessing Cardiac MRI For Morphology And Function Without Contrast Material; With Stress Imaging Cardiac MRI For Morphology And Function Without Contrast Material(s), Followed By Contrast Material(s) And Further Sequences; With Stress Imaging Cardiac CT For Congenital HD CT Angio Coronary Artery CT Angiography Abdominal Aorta Aortic Aneurysm 3D Rendering With Interpretation And Reporting Of Computed 3D Rendering With Interpretation And Reporting Of Computed Tomography, Magnetic Resonance Imaging, Ultrasound, Or Other Tomographic Modality With Image Postprocessing Under Concurrent Supervision; Requiring Image Postprocessing On An Independent Workstation CT Limited or Localized Follow-Up Study U/S Gastrointestinal, Endoscopic MRI Breast w/ and/or w/O Contrast; Unilateral MRI Breast Bilateral
76377
ADDITIONAL INFORMATION
Unilateral-One-Gadolinium Both
3
CareCore National Preauthorization List (As of 3/9/15)
CPT CODE 78020 78071
78072
PROCEDURE DESCRIPTION Thyroid Carcinoma Metastases Uptake Parathyroid Planar Imaging (Including Subtraction, When Performed); With Tomographic (Spect) Parathyroid Planar Imaging (Including Subtraction, When Performed); With Tomographic (Spect), And Concurrently Acquired Computed Tomography (CT) For Anatomical Localization
78102
Adrenal Nuclear Imaging Bone Marrow Imaging, Limited
78103
Bone Marrow Imaging, Multiple
78104
Bone Marrow Imaging, Whole Body
78185
Spleen Imaging w & w/o Vascular Flow
78201
Liver Imaging
78202
Liver Imaging w/ Flow
78205
Liver Imaging Spect
78206
Liver Imaging Spect w/ Vascular Flow
78215
Liver and Spleen Imaging Liver and Spleen Imaging w/ Flow Hepatobiliary system imaging, including gallbladder when present;
78075
78216 78226
78227
Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed
78230
Salivary Gland Imaging
78231
Serial Salivary Gland
78232
Salivary Gland Function Test Esophagus Motility Study Gastric Mucosa Imaging Gastroesophagael Reflum Emam Gastric Emptying Study Meckel's Diverticulum Imaging
78258 78261 78262 78264 78290
ADDITIONAL INFORMATION
MIBG
Red Cell Tagging
4
CareCore National Preauthorization List (As of 3/9/15)
CPT CODE
PROCEDURE DESCRIPTION
78305
Leveen Shunt Patency Exam Bone or Joint Imaging Ltd Bone or Joint Imaging Multiple
78306
Bone Scan Whole Body
78428
Cardiac Shunt Imaging
78445
Radionuclide Venogram Non-Cardiac
78452
MPI, Spect, Multiple Rest or Stress
78453
MPI, Planar, Single Rest or Stress
78454
MPI, Planar, Multiple Rest or Stress
78456
78466
Acute Venous Thrombosis Imaging Venous Thrombosis Imaging Unilateral Venous Thrombosis Imaging Bilateral Myocardial Imaging, Positron Emission Tomography (PET) Metabolic Eval. Myocardial Infarction Scan
78468
Heart Infarct Image Ef
78469
Heart Infarct Image Spect
78481
Heart First Pass Single
78291 78300
78457 78458 78459
ADDITIONAL INFORMATION
One Bone More than one Bone Used Often with CA studies/All bones
2nd (or more) exam within one year from date of service requires preauthorization medical necessity review. 2nd (or more) exam within one year from date of service requires preauthorization medical necessity review. 2nd (or more) exam within one year from date of service requires preauthorization medical necessity review.
5
CareCore National Preauthorization List (As of 3/9/15)
CPT CODE
PROCEDURE DESCRIPTION
78483
Cardiac Blood Pool Imaging, Multi
78491
Myocardial Imaging, Positron Emission Tomography (PET), Perfusion; Single Study At Rest Or Stress
78492
Myocardial Imaging, Positron Emission Tomography (PET), Perfusion; Multiple Studies At Rest Or Stress
ADDITIONAL INFORMATION 2nd (or more) exam within one year from date of service requires preauthorization medical necessity review.
2nd (or more) exam within one year from date of service requires preauthorization medical necessity review. 2nd (or more) exam within one year from date of service requires preauthorization medical necessity review.
78494
Cardiac Blood Pool Imaging, Spect
78496
Cardiac Blood Pool Imaging, Single at Rest (Use with 78472)
78579
Pulmonary ventilation imaging (eg, aerosol or gas) Quantitative differential pulmonary perfusion, including imaging when performed Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed Brain Imaging Ltd Static Brain Ltd Imaging and Flow Brain Imaging Complete Brain Imaging Complete w/ Flow Brain Flow Imaging Only Cisternogram (Cerebrospinal Fluid Flow) Cerebrospinal Ventriculography CSF Shunt Evaluation Cerebrospinal Fluid Scan Spect CSF Leakage Detection and Localization Radiopharmaceutical Dacryocystorgraphy Kidney Imaging Morphology Kidney Imaging Morphology w/ Vascular Flow Captorpril/Renal Scan/MAG 3 Kidney Imaging Morphology w/ Vascular Flow, Multi, w/o and w/ Pharm Intervention Kidney Imaging, Spect Urinary Bladder Residual Study Ureteral Reflum Study VCUG/Cystogram Radiopharm Localization of Tumor, Limited Area Radiopharm Localization of Tumor, Multi Areas Gallium Scan/FUO Radiopharmaceutical Localization of Tumor or Distribution of Radiopharmaceutical Agent(s); Whole Body, Requiring 2 or More Days Imaging
78597 78598 78600 78601 78605 78606 78610 78630 78635 78645 78647 78650 78660 78700 78701 78709 78710 78730 78740 78800 78801 78804
6
CareCore National Preauthorization List (As of 3/9/15)
CPT CODE
PROCEDURE DESCRIPTION
ADDITIONAL INFORMATION Gallium Scan/Indium Scan/WBC Scan/MBIG
78806
Radiopharm Localization of Abscess, Whole Body
78807
Radiopharm Localization of Abscess, Spect
78811
Positron Emission Tomography (PET) Imaging; Limited Area (Eg, Chest, Galliium Scan/Indium Scan/WBC Scan/MBIG Head/Neck)
78812
Positron Emission Tomography (PET) Imaging; Skull Base To Mid-Thigh
78813
Positron Emission Tomography (PET) Imaging; Whole Body
78814
Positron Emission Tomography (PET) with Concurrently Acquired Computer Tomography (CT) for Attenuation Correction and Anatomical Localization Imaging; Limited Area (Eg Chest, Head/Neck)
78815
Positron Emission Tomography (PET) with Concurrently Acquired Computer Tomography (CT) for Attenuation Correction and Anatomical Localization Imaging; Skull Base to Mid-Thigh
Gallium Scan/Indium Scan/WBC Scan/MBIG
PET with CT
PET with CT
7
