Radiology Program
Prior Authorization Code Listing
The matrix below contains all those CPT-4 codes NIA will authorize on behalf of Anthem Blue Cross and
Blue Shield. This matrix shows the codes for those services subject to prior authorization by NIA. If a service is
billed under any one of the given codes for that grouping and a valid authorization number has been issued by
NIA, the service is eligible for coverage, subject to the provisions of the member’s coverage document.
Services rendered as part of emergency room services or in the hospital inpatient setting, or in an urgent
care setting at the time of the urgent care visit, are not subject to prior authorization
*Coverage is based on the provider contract, and the provisions of the subscriber agreement, master group policy, or other applicable coverage
document.
Authorized
CPT Code
Description
Allowable Billed Groupings
70336
70450
70480
70486
70490
70496
70498
70540
70551
70544
70547
70551
71250
71275
71550
71555
72125
72128
72131
72141
72146
72148
72159
72191
72192
72196
72198
73200
73206
73220
73221
73225
73700
73706
73720
73721
73721
73725
74150
74175
74181
74185
75552
75635
76070
MRI Temporomandibular Joint
CT Head/Brain
CT Orbit
CT Maxillofacial/Sinus
CT Soft Tissue Neck
CT Angiography, Head
CT Angiography, Neck
MRI Orbit, Face, Neck
MRI Internal Auditory Canal
MRA Head
MRA Neck
MRI Brain
CT Chest
CT Angiography, Chest
MRI Chest
MRA Chest
CT Cervical Spine
CT Thoracic Spine
CT Lumbar Spine
MRI Cervical Spine
MRI Thoracic Spine
MRI Lumbar Spine
MRA Spinal Canal
CT Angiography, Pelvis
CT Pelvis
MRI Pelvis
MRA Pelvis
CT Upper Extremity
CT Angiography, Upper Extremity
MRI Upper Extremity, other than Joint
MRI Upper Extremity Joint
MRA Upper Extremity
CT Lower Extremity
CT Angiography, Lower Extremity
MRI Lower Extremity, other than Joint
MRI Lower Extremity Joint
MRI Hip
MRA Lower Extremity
CT Abdomen
CT Angiography, Abdomen
MRI Abdomen
MRA Abdomen
MRI Heart
CT Angiography, Abdominal Arteries
CT Bone Density Studies
70336
70450, 70460, 70470
70480, 70481, 70482
70486, 70487, 70488, 76380
70490, 70491, 70492
70496
70498
70540, 70542, 70543
70551, 70552, 70553, 70540, 70542, 70543
70544, 70545, 70546
70547, 70548, 70549
70551, 70552, 70553
71250, 71260, 71270
71275
71550, 71551, 71552
71555
72125, 72126, 72127
72128, 72129, 72130
72131, 72132, 72133
72141, 72142, 72156
72146, 72147, 72157
72148, 72149, 72158
72159
72191
72192, 72193, 72194
72195, 72196, 72197
72198
73200, 73201, 73202
73206
73218, 73219, 73220
73221, 73222, 73223
73225
73700, 73701, 73702
73706
73718, 73719, 73720, 73721, 73722, 73723
73721, 73722, 73723, 73718, 73719, 73720
72195, 72196, 72197, 73721, 73722, 73723
73725
74150, 74160, 74170
74175
74181, 74182, 74183, S8037
74185
75552, 75553, 75554, 75555, 75556
75635
76070, 76071
(Over)
76093
76360
76375
MRI Breast
CT Guidance
Coronal, Sagittal, Multiplanar, Oblique, 3-D and/or holographic
reconstruction of CT, MRI or other tomographic modality
76380
76390
76393
76400
78459
CT Limited or Follow-Up
MR Spectroscopy
MR Guidance for Needle Placement
MRI Bone Marrow
PET Scan, Heart
78460
Myocardial Perfusion Imaging – Nuclear Cardiology
78608
78810
PET Scan, Brain
PET Scan, Tumor Imaging
G0125
G0210
PET imaging regional or whole body, single pulmonary nodule
PET imaging whole body, diagnosis, lung cancer, non-small
cell.
PET imaging whole body, initial staging, lung cancer, non-small
cell.
PET imaging whole body, restaging, lung cancer, non-small cell.
PET imaging whole body, diagnosis, colorectal cancer
PET imaging whole body, initial staging, colorectal cancer
PET imaging whole body, restaging, colorectal cancer
PET imaging whole body, diagnosis, melanoma
PET imaging whole body, initial staging, melanoma
PET imaging whole body, restaging, melanoma
PET imaging whole body, melanoma for non-covered
indications
PET imaging whole body, diagnosis, lymphoma
PET imaging whole body, staging, lymphoma
PET imaging whole body, restaging, lymphoma
PET imaging whole body or regional, diagnosis, head and neck
cancer
PET imaging whole body or regional, initial staging, head and
neck cancer
PET imaging whole body or regional, restaging, head and neck
cancer
PET imaging whole body, diagnosis, esophageal cancer
PET imaging whole body, initial staging, esophageal cancer
PET imaging whole body, restaging, esophageal cancer
PET whole body, recurrence of colorectal or colorectal
metastatic cancer
PET whole body, recurrence of lymphoma
PET whole body, recurrence of melanoma
PET regional or whole body, solitary pulmonary nodule following
CT or for initial staging of nonsmall cell lung cancer
PET imaging, initial diagnosis of breast cancer and/or surgical
planning for breast cancer
PET imaging for breast cancer, staging/restaging of local
regional recurrence or distant metastases
PET imaging for breast cancer, evaluation of response to
treatment, performed during course of treatment
PET imaging, whole body, restaging, thyroid CA, follicular cell,
negative radio iodine study
Electron Beam CT
MR Cholangiopancreatography
G0211
G0212
G0213
G0214
G0215
G0216
G0217
G0218
G0219
G0220
G0221
G0222
G0223
G0224
G0225
G0226
G0227
G0228
G0231
G0232
G0233
G0234
G0252
G0253
G0254
G0296
S8092
S8037
76093, 76094
76355, 76360, 76362
76375 is considered an add-on code. Therefore, by
definition, it is allowed on the same date of service as the
primary CT/MRI code. If the primary CT/MRI is authorized,
this code should be allowed in addition when billed on the
same date of service. No separate authorization is given.
76380
76390
76393, 76394
76400
78459, 78491, 78492, G0030 – G0047, G0230
Also allow billing for the corresponding Cardiovascular
Stress Test 9-range (93015 – 93018)
78460, 78461, 78464, 78465, 78466, 78468, 78469, 78472,
78473, 78478, 78480, 78481, 78483, 78494, 78496, 78499,
Also included in this auth is the corresponding 9- range
(93015-93018) and the radiopharmaceutical charges
(78990, and A9500-A9605).
78608, 78609, G0229
78810, G0125, G0210, G0211, G0212, G0213, G0214,
G0215, G0216, G0217, G0218, G0219, G0220, G0221,
G0222, G0223, G0224, G0225, G0226, G0227, G0228,
G0231, G0232, G0233, G0234, G0252, G0253, G0254,
G0296
G0125, 78810
G0210, 78810
G0211, G0212, G0234, 78810
G0212, G0211, G0234, 78810
G0213, 78810
G0214, G0215, G0231, 78810
G0215, G0214, G0231, 78810
G0216, 78810
G0217, G0218, G0233, 78810
G0218, G0217, G0233, 78810
G0219, 78810
G0220, 78810
G0221, G0222, G0232, 78810
G0222, G0221, G0232, 78810
G0223, 78810
G0224, G0225, 78810
G0225, G0224, 78810
G0226, 78810
G0227, G0228, 78810
G0228, G0227, 78810
G0214, G0231, G0215, 78810
G0221, G0232, G0222, 78810
G0217, G0233, G0218, 78810
G0212, G0234, G0211, 78810
G0252, 78810
G0253, G0254, 78810
G0254, G0253, 78810
G0296, 78810
S8092, 71250
S8037, 74181. 74182, 74183