Clinical UM Guideline

 

Subject: Level of Care: Advanced Radiologic Imaging
Guideline #:  CG-MED-55 Publish Date:    11/09/2017
Status: Revised Last Review Date:    11/02/2017

Description

This document addresses the clinical features that may increase an individual’s risk of requiring access to a higher level of care available in a hospital outpatient department for advanced radiologic imaging.

Note: Please see the following related documents for additional information:

Clinical Indications

Note: The medical necessity of the advanced radiologic imaging procedure may be separately reviewed against the appropriate criteria. This guideline is for determination of the medical necessity of hospital outpatient level of care for the advanced radiologic imaging procedure.

Medically Necessary:

An advanced radiologic imaging procedure in the hospital outpatient department is considered medically necessary when any of the following are present:

  1. The services being provided are only available in the hospital setting; or
  2. The individual is less than 10 years old; or
  3. The individual requires an obstetrical observation; or
  4. The individual is receiving perinatology services; or
  5. There are no other geographically accessible appropriate alternative sites for the individual to undergo the procedure, including but not limited to the following:
    1. Moderate or deep sedation or general anesthesia is required for the procedure and a freestanding facility providing such sedation is not available; or
    2. The equipment for the size of the individual (that is, very small or very large) is not available in a freestanding facility; or
    3. The individual has a documented diagnosis of claustrophobia requiring open magnetic resonance imaging which is not available in a freestanding facility; or
  6. The individual has a known chronic disease that is expected to require imaging at multiple time points and the individual has had prior radiology imaging procedures for the diagnosis, management or surveillance of the disease at the hospital outpatient department or clinic (for example, follow-up of lung nodules, individuals with multiple sclerosis, aortic aneurysms, or inflammatory bowel disease, or individuals with cancer); or
  7. The individual has a known contrast allergy; or
  8. The imaging is pre-operative or pre-procedure where the surgery or procedure is being performed at the hospital or affiliated site; or
  9. Performance or imaging outside the hospital outpatient department or clinic would reasonably be expected to adversely impact or delay care.

Not Medically Necessary:

All other advanced radiologic imaging procedures in the hospital outpatient department are considered not medically necessary when the above criteria are not met.

Coding

Coding edits for medical necessity review are not implemented for this guideline. Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions. 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.

Discussion/General Information

 

Hospital-based advanced radiologic imaging procedures are generally more appropriate for individuals whose health status necessitates 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 individuals including neonates and children. Children can require specialized pediatric equipment including smaller anesthetic tools such as endotracheal tubes and monitoring equipment. Conversely, large individuals or those with claustrophobia may also require specialized equipment which could include an open magnetic resonance imaging (MRI) as opposed to a traditional MRI scanner.

 

Location of radiology equipment within a facility can be a hindrance to effective member care. For example, the MRI suite can be a hazardous location due to the presence of a very strong static magnetic field, high-frequency electromagnetic (radiofrequency) waves, and a time-varied (pulsed) magnetic field. There can be challenges to administering anesthesia and monitoring capabilities due to static and dynamic magnetic fields, and compromise of direct observation of the member. The MRI environment frequently requires the anesthesiologist to assume broader responsibility for immediate decisions related to care of the member.

 

Examples of advanced radiologic imaging include computed tomography, computed tomography angiography, magnetic resonance imaging, magnetic resonance angiography, nuclear medicine scans (for example, single photon emission computed tomography), nuclear cardiac imaging procedures (for example, myocardial perfusion scans), and positron emission tomography scans.

 

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American College of Obstetricians and Gynecologists. Committee opinion 656: Guidelines for diagnostic imaging during pregnancy and lactation. 2016. Available at: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Guidelines-for-Diagnostic-Imaging-During-Pregnancy-and-Lactation. Accessed on March 27, 2017.
  2. American Society of Anesthesiologists. Available at: https://www.asahq.org/quality-and-practice-management/standards-and-guidelines. Accessed on March 27, 2017.
    • Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging. 2015.
    • Statement on Nonoperating Room Anesthetizing Locations. 2013.
    • Statement on Practice Recommendations for Pediatric Anesthesia. 2016.
Index

Advanced radiologic imaging
Level of care

History

Status

Date

Action

Revised

11/02/2017

Medical Policy & Technology Assessment Committee (MPTAC) review. Revisions made to MN statement. Updated header language from “Current Effective Date” to “Publish Date.”

 

07/19/2017

Updated Description Section.

Revised

05/04/2017

MPTAC review. Revised MN statement regarding geographically accessible appropriate alternatives. Updated References section.

Revised

11/03/2016

MPTAC review. Clarified NMN statement.

New

08/04/2016

MPTAC review. Initial document development.