| Clinical UM Guideline |
| Subject: Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists | |
| Guideline #: CG-ADMIN-01 | Publish Date: 06/28/2024 |
| Status: Reviewed | Last Review Date: 05/09/2024 |
| Description |
The Company reviews services provided, or proposed to be provided, to its members to determine benefits coverage based on whether the services are medically necessary or not medically necessary. In making such benefit decisions, the Company determines whether such services are in accordance with generally accepted standards of medical practice, taking into account credible scientific evidence published in peer reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, and the views of physicians practicing in relevant clinical areas, and other relevant factors, as they relate to the member's clinical circumstances.
This document provides guidance to be followed and a list of resources available to Company Medical Reviewers when the Company does not have a Clinical UM Guideline directly applicable to a particular medical necessity determination for a request for review or claim related to the services and codes noted in the table below in connection with a provider who is on pre-payment review. These services and corresponding codes may be modified when additional inappropriate use of services is identified; services and codes may be added to the table accordingly.
After Company Medical Reviewers have made their determination, they should document their decision and the resources used in the appropriate medical management system. Utilization Management departments will follow their standard procedures to meet relevant timeframes and notification requirements as appropriate for urgent and non-urgent requests.
NOTE: PLEASE SEE THE DEFINITIONS OF "MEDICALLY NECESSARY" OR "MEDICAL NECESSITY" AND "INVESTIGATIONAL" IN THE COVERED INDIVIDUAL'S PLAN DOCUMENT FOR THE PURPOSE OF MAKING BENEFIT DETERMINATIONS.
| Coding |
The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
| CPT |
|
| 71045 | Radiologic examination, chest; single view |
| 71046 | Radiologic examination, chest, 2 views |
| 71047 | Radiologic examination, chest, 3 views |
| 72020 | Radiologic examination, spine, single view, specify level |
| 72040 | Radiologic examination, spine, cervical; 2 or 3 views |
| 72050 | Radiologic examination, spine, cervical; 4 or 5 views |
| 72052 | Radiologic examination, spine, cervical; 6 or more views |
| 72070 | Radiologic examination, spine; thoracic, 2 views |
| 72074 | Radiologic examination, spine; thoracic, minimum of 4 views |
| 72082 | Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 2 or 3 views |
| 72110 | Radiologic examination, spine, lumbosacral; minimum of 4 views |
| 72114 | Radiologic examination, spine, lumbosacral; complete, including bending views, minimum of 6 views |
| 72170 | Radiologic examination, pelvis; 1 or 2 views |
| 73030 | Radiologic examination, shoulder; complete, minimum of 2 views |
| 73060 | Radiologic examination; humerus, minimum of 2 views |
| 73070 | Radiologic examination, elbow; 2 views |
| 73080 | Radiologic examination, elbow; complete, minimum of 3 views |
| 73090 | Radiologic examination; forearm, 2 views |
| 73110 | Radiologic examination, wrist; complete, minimum of 3 views |
| 73130 | Radiologic examination, hand; minimum of 3 views |
| 73502 | Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views |
| 73503 | Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views |
| 73521 | Radiologic examination, hips, bilateral, with pelvis when performed; 2 views |
| 73522 | Radiologic examination, hips, bilateral, with pelvis when performed; 3-4 views |
| 73523 | Radiologic examination, hips, bilateral, with pelvis when performed; minimum of 5 views |
| 73560 | Radiologic examination, knee; 1 or 2 views |
| 73564 | Radiologic examination, knee; complete, 4 or more views |
| 73590 | Radiologic examination, tibia and fibula, 2 views |
| 73600 | Radiologic examination, ankle; 2 views |
| 73610 | Radiologic examination, ankle; complete, minimum of 3 views |
| 73620 | Radiologic examination, foot; 2 views |
| 73630 | Radiologic examination, foot; complete, minimum of 3 views |
| 73660 | Radiologic examination; toe(s), minimum of 2 views |
| 74021 | Radiologic examination, abdomen; 3 or more views |
| 76536 | Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation |
| 76700 | Ultrasound, abdominal, real time with image documentation; complete |
| 76705 | Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) |
| 76770 | Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete |
| 76775 | Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited |
| 76881 | Ultrasound, complete joint (ie, joint space and peri-articular soft tissue structures), real-time with image documentation |
| 76882 | Ultrasound, limited, joint or focal evaluation of other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscles[s], nerve[s], other soft tissue structure[s], or soft tissue mass[es]), real-time with image documentation |
| 93886 | Transcranial Doppler study of the intracranial arteries; complete study |
| 93888 | Transcranial Doppler study of the intracranial arteries; limited study |
| 93890 | Transcranial Doppler study of the intracranial arteries; vasoreactivity study |
| 93892 | Transcranial Doppler study of the intracranial arteries; emboli detection without intravenous microbubble injection |
| 93893 | Transcranial Doppler study of the intracranial arteries; emboli detection with intravenous microbubble injection |
| 93975 | Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study |
| 93976 | Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study |
| 96365 | Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour |
| 96366 | Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) |
| 96367 | Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure) |
| 96368 | Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure) |
| 96369 | Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s) |
| 96370 | Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) |
| 96371 | Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure) |
| 96372 | Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular |
| 96373 | Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intra-arterial |
| 96374 | Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug |
| 96375 | Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) |
| 96376 | Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure |
| 96377 | Application of on-body injector (includes cannula insertion) for timed subcutaneous injection |
| 96379 | Unlisted therapeutic, prophylactic, or diagnostic intravenous or intra-arterial injection or infusion |
|
|
|
| ICD-10 Diagnosis |
|
|
| All diagnoses |
**Note: In determining if there is a relevant Clinical UM Guideline, the reviewer will not consider procedure code alone. If an 'unlisted' or 'not otherwise classified' code is reported, the detailed description of service will be the determining factor.
| Discussion/General Information |
As noted above, this document provides guidance to be followed when the Company does not have a Clinical UM Guideline directly applicable to a particular medical necessity determination for a claim related to the above services and codes in connection with a provider who is on pre-payment review. The list of resources included herein is not meant to be exhaustive. Reviewers should use those resources that may be relevant to the decision at hand, but not necessarily use every resource in every case. Reviewers should use more than one resource when more than one resource is relevant to their decision. Reviewers should exercise their professional judgment in selecting appropriate resources and in rendering their determination.
| Definitions |
Physician Specialty Society: A United States medical specialty society that represents diplomates certified by a board recognized by the American Board of Medical Specialties.
| References |
Government Agency, Medical Society, and Other Authoritative Publications:
| General Certificate(s) | Specialty Society (+) Indicates Guidelines Publicly Available | Subspecialty Certificate(s) |
| Allergy and Immunology | American Academy of Asthma, Allergy and Immunology (AAAAI) (+) American College of Allergy, Asthma and Immunology (ACAAI) (-) | None |
| Anesthesiology | American Society of Anesthesiologists®
|
|
| Colon and Rectal Surgery | American Society of Colon and Rectal Surgeons (ASCRS) (+) | None |
| Dermatology | American Academy of Dermatology (AAD) (+) |
|
| Emergency Medicine | American College of Emergency Physicians® (ACEP) (+) |
|
| Family Medicine | American Academy of Family Practice (AAFP) (-) |
|
| Internal Medicine
| American College of PhysiciansSM (ACP) (+) |
|
| Medical Genetics
| American College of Medical Genetics (ACMG) (+) |
|
| Neurological Surgery | American Association of Neurological Surgeons (AANS) (+) | None |
| Nuclear Medicine | American College of Nuclear Medicine (ACNM) (-) | None |
| Obstetrics and Gynecology | American Congress of Obstetricians and Gynecologists (ACOG) (-) |
|
| Ophthalmology | American Academy of Ophthalmology (AAO) (+) | None |
| Orthopaedic Surgery | American Academy of Orthopaedic Surgeons (AAOS) (+) |
|
| Otolaryngology | American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) (+) |
|
| Pathology
| College of American Pathologists |
|
| American Society for Clinical Pathology (ASCP) (+) | ||
| Pediatrics | American Academy of Pediatrics (AAP) (+) |
|
| Physical Medicine and Rehabilitation | American Academy of Physical Medicine and Rehabilitation (AAPM&R) (+) |
|
| Plastic Surgery | American Society of Plastic Surgeons® (ASPS) (+) |
|
| Preventive Medicine
| American College of Preventive Medicine (AAPM) (-) |
|
| American College of Occupational and Environmental Medicine (ACOEM) (+) | ||
| Psychiatry and Neurology
| American Psychiatric Association (APA) (+) |
|
| American Academy of Child & Adolescent Psychiatry (AACAP) (+) | ||
| American Academy of Neurology® (AAN) (+) Child Neurology Society (CNS) (-) | ||
| Radiology
| American College of Radiology (ACR®) (+) |
|
| American Society for Therapeutic Radiation and Oncology ASTRO (+) | ||
| Surgery and Vascular Surgery | American College of Surgeons (ACS) (+) |
|
| Thoracic and Cardiac Surgery | Society of Thoracic Surgeons (STS) (+) |
|
| Urology | American Urological Association (AUA) (+) For additional information visit the AUA website: |
|
Subspecialty Societies
| Subspecialty Certificate | Specialty Society (+) Indicates Guidelines Publicly Available |
| Cardiology | American College of Cardiology (ACC) (+) Society for Cardiovascular Angiography and Interventions (SCAI) (+) |
| Clinical Cardiac Electrophysiology | Heart Rhythm SocietySM (HRS) (+) (collaborative with ACC) |
| Critical Care Medicine | Society of Critical Care Medicine (SCCM) (+) For additional information visit the SCCM website: |
| Endocrinology, Diabetes and Metabolism | American Association of Clinical Endocrinologists AACE (+) |
| Endocrine Society (+) | |
| Gastroenterology | American College of Gastroenterology (ACG) (+) American Gastroenterological Association (AGA) (+) |
| Society of American Gastrointestinal and Endoscopic Surgeons SAGES (+) | |
| Geriatric Medicine | American Geriatrics Society (AGS) (+) |
| Geriatric Psychiatry | American Association for Geriatric Psychiatry (AAGP) (-) |
| Gynecologic Oncology | Society of Gynecologic Oncology (SGO) (+) |
| Hematology | American Society of Hematology (ASH) (+) |
| Hospice and Palliative Medicine | American Academy of Hospice and Palliative Medicine (AAHPM) (+) |
| Infectious Disease | Infectious Disease Society of America (IDSA) (+) |
| Medical Toxicology | American College of Medical Toxicology (+) |
| Nephrology | American Society of Nephrology (ASN) (-) |
| Neuromuscular | American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) (+) |
| Neuroradiology | American Society of Neuroradiology (ASNR) (-) |
| Oncology | American Society of Clinical Oncology (ASCO®) (+) |
| Pain Medicine | American Chronic Pain Association (ACPA) (+) |
| American Academy of Pain Medicine (AAPM) (+) | |
| Pulmonary Disease | American College of Chest Physicians® (ACCP) (+) |
| Reproductive Endocrinology/Infertility | American Society for Reproductive Medicine (ASRM) (+) |
| Rheumatology | American College of Rheumatology (ACR) (+) For additional information visit the ACR website: NOTE: Do not confuse with American College of Radiology |
| Sleep Medicine | American Academy of Sleep Medicine (AASM) (+) |
| Sports Medicine | American Orthopaedic Society for Sports Medicine (AOSSM) (-) |
| Surgery of the Hand | American Society for Surgery of the Hand (ASSH) (-) |
| Transplant Hepatology | American Association for the Study of Liver Diseases (AASLD) (+) |
| American Society of Transplantation (AST) (+) | |
| Undersea and Hyperbaric Medicine | Undersea and Hyperbaric Medical Society (UHMS) (+) |
| Vascular and Interventional Radiology | Society of Interventional Radiology (SIR) (+) |
| Vascular Surgery | Society for Vascular Surgery (SVS) (+) |
| Index |
Radiograph
Ultrasound
X-Ray
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
| History |
| Status | Date | Action |
| Reviewed | 05/09/2024 | Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section. |
| Reviewed | 05/11/2023 | MPTAC review. Updated References section. |
|
| 12/28/2022 | Updated Coding section with 01/01/2023 CPT changes; revised descriptor for 76882. |
| Reviewed | 05/12/2022 | MPTAC review. Updated References. |
| Reviewed | 05/13/2021 | MPTAC review. |
| Reviewed | 05/14/2020 | MPTAC review. Updated References. |
| Revised | 06/06/2019 | MPTAC review. Revised Coding and References section to create separate sections. Updated References. Updated Coding section with CPT codes 96365-96379. |
| Revised | 09/13/2018 | MPTAC review. Added new entry and references for CPT codes 93886-93893. Added reference for AIUM practice guideline for the performance of ultrasound of the female pelvis to 93975 and 93976. Updated References. |
| Reviewed | 02/27/2018 | MPTAC review. |
|
| 01/01/2018 | The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Coding section with 01/01/2018 CPT changes; added codes 71045-71047 and 74021, removed codes 71010, 71020, 71021, and 74020 deleted 12/31/2017. |
| Revised | 02/02/2017 | MPTAC review. Updated document with references for added CPT codes 76881, 76882, 93975 and 93976. |
| New | 08/04/2016 | MPTAC review. Initial document development. |
Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.
Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.
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