August 04, 2020
Area(s) of Interest: Payor Issues and Reimbursement
On August 1, 2020, Cigna implemented a new policy restricting outpatient advanced radiologic imaging procedures in the hospital setting. Under the new policy, advanced radiologic imaging procedures performed in the hospital outpatient department—including certain magnetic resonance imaging, magnetic resonance angiography and computed tomography imaging procedures—are only considered medically necessary under the following circumstances:
- Patient is than 10 years of age
- Patient requires obstetrical observation
- Patient requires perinatology services
- Imaging is related to transplantation services at an approved transplantation facility
- Patient has a known contrast allergy and use of that contrast agent is planned
- There are no other appropriate alternative sites for the individual to undergo the imaging procedure for any of the following reasons:
- Surgery or procedure is being performed at the hospital and pre-operative or pre-procedure imaging is an integral component of the procedure
- Moderate or deep sedation or general anesthesia is required for the imaging procedure and a freestanding facility providing such sedation is not available
- Equipment for the size of the individual is only available at a hospital-based imaging facility
- Individual has a documented diagnosis of claustrophobia requiring open magnetic resonance imaging, which is not available in a freestanding facility
- Imaging outside the hospital-based imaging department or facility is expected to adversely impact or delay care
Cigna will utilize eviCore to administer clinical appropriateness reviews for all advanced imaging services, including making the determination if an imaging service requires a hospital-based outpatient setting or if a free-standing imaging center will be chosen to perform the service.
The Cigna policy is similar to policies implemented by Anthem Blue Cross in 2017 and UnitedHealthcare in 2019.
For more information on the new policy, Cigna has published the High-Tech Radiology Site of Care FAQ or physicians can visit the Cigna website.