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12437 Results

Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material

Service Code
72141 (CPT) Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s)

Service Code
72142 (CPT) Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material

Service Code
72146 (CPT) Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s)

Service Code
72147 (CPT) Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material

Service Code
72148 (CPT) Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s)

Service Code
72149 (CPT) Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical

Service Code
72156 (CPT) Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic

Service Code
72157 (CPT) Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar

Service Code
72158 (CPT) Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s)

Service Code
72159 (CPT) Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Radiologic examination, pelvis; 1 or 2 views

Service Code
72170 (CPT) Radiologic examination, pelvis; 1 or 2 views
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Radiologic examination, pelvis; complete, minimum of 3 views

Service Code
72190 (CPT) Radiologic examination, pelvis; complete, minimum of 3 views
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing

Service Code
72191 (CPT) Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Computed tomography, pelvis; without contrast material

Service Code
72192 (CPT) Computed tomography, pelvis; without contrast material
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Computed tomography, pelvis; with contrast material(s)

Service Code
72193 (CPT) Computed tomography, pelvis; with contrast material(s)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections

Service Code
72194 (CPT) Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s)

Service Code
72195 (CPT) Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s)

Service Code
72196 (CPT) Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences

Service Code
72197 (CPT) Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Magnetic resonance angiography, pelvis, with or without contrast material(s)

Service Code
72198 (CPT) Magnetic resonance angiography, pelvis, with or without contrast material(s)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent