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  • Cardiology Imaging Program > Prior Approval Procedures

    Services Requiring Prior Approval

    Please refer to the charts later in this chapter for a list of services (and CPT-4 codes) that require prior approval. Note: All echocardiography exams require a prior approval regardless of the number of exams the member has had previously.

    Each procedure requires a separate prior approval. Prior approvals are specific to the CPT-4 code and site location. They are valid for 45 days from the approval date.

    Claims will be denied for procedures that require but did not receive prior approval through this program. In such cases, the member will not be liable for billing or payment.

    Prior approval is required for services performed in the following places of service:

    • Outpatient hospital facilities
    • Freestanding radiology facilities
    • Radiology office-based settings
    • Non-radiology office-based settings

      Prior approval is required for the following types of services:

      • Services with the CPT-4 codes later in this chapter
      • All coronary computed tomographic angiography (CCTA) services
      • Services performed in ambulatory surgery centers (cardiac catheterization procedures only)

        Prior approval is not required for services performed in the following places of service:

        • Inpatient hospital facilities
        • Hospital emergency departments
        • Services provided when one of EmblemHealth's companies is the secondary insurer

          Who Requests Prior Approval

          We encourage PCPs or specialists to initiate the prior approval request. But requests will be accepted from the physician's office staff.

          PCPs referring patients to a cardiologist for testing are responsible for initiating the prior approval request according to the instructions in this chapter. In cases where a cardiologist is already treating the patient, that cardiologist should initiate the request. The treating practitioner is ultimately responsible for ensuring that all applicable cardiology imaging procedures at the applicable service location have received prior approval.

          How To Obtain Prior Approval

          You may submit prior approval requests in one of three ways:

          • Online: Visit www.evicore.com. To submit online prior approval requests, the ordering physician must be a registered user. To register for a user ID and password, visit www.evicore.com and click the "Register" button.
          • By phone: Call 1-866-417-2345 for HIP, EmblemHealth CompreHealth EPO, EmblemHealth Medicare HMO, GHI HMO and Vytra plan members. Call 1-800-835-7064 for EmblemHealth Medicare PPO plan members. Program representatives are available Monday through Friday, from 7 am to 7 pm. The Program is closed New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving and Christmas Day. Multiple requests may be handled with one call.
          • By fax: The fax option applies only to prior approval requests for cardiac imaging codes. You may fax these requests to 1-888-622-7369. With your fax submission, please include an EmblemHealth-specific cardiac imaging clinical request form. This form is available at www.evicore.com.

            Please have the following information available when you call:

            • The patient's full name, member ID number and insurance information
            • The exam(s) requested for the patient
            • The working diagnosis or rule-out
            • The signs and symptoms that call for the exam, as well as their duration
            • Any previous imaging studies performed, corresponding results or pertinent lab results
            • History of prior treatment methods, drugs, surgery or other therapies, as well as duration of prior treatment
            • Any other information indicating the need for the exam

              Expedited Approval Requests

              The website cannot be used for expedited approval requests. These requests must be processed through the call center. Call 1-866-417-2345 for HIP, EmblemHealth CompreHealth EPO, GHI HMO, Vytra and EmblemHealth Medicare HMO plan members. Call 1-800-835-7064 for EmblemHealth Medicare PPO plan members. Program representatives are available 24 hours a day, 7 days a week. The program is closed New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving and Christmas Day.

              Urgent Requests

              If the cardiology treatment is medically urgent and must be performed outside the Program’s  business hours, the physician may deliver treatment and must submit the prior approval request (with supporting clinical documentation) within two business days. Urgent requests are reviewed against medical necessity criteria, and an approval is issued as long as the request meets these medical necessity criteria. Urgent requests will be completed within 24 hours of receiving the request.

              The website cannot be used for urgent approval requests. These requests must be processed through the call center. Call 1-866-417-2345 for HIP, EmblemHealth CompreHealth EPO, GHI HMO, Vytra and EmblemHealth Medicare HMO plan members. Call 1-800-835-7064 for EmblemHealth Medicare PPO plan members. Program representatives are available 24 hours a day, 7 days a week. The program is closed New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving and Christmas Day.

              Non-Urgent Requests

              Non-urgent requests will be completed within three business days of receiving all necessary information, or within the time frames otherwise required by the member's benefit plan (see Standard Pre-Service Review in the Care Management chapter). In most cases, we will review and determine prior approvals during the initial phone call, as long as all the required information is provided. The review and determination processes may, however, take longer if member or practitioner eligibility verification is required, or if the request requires additional clinical review (see Standard Pre-Service Review in the Care Management chapter).

              A physician with office hours later than the Program's call center may initiate a case through the Program’s website. We will process the request on the next business day.

              Modifying a Prior Approval Request

              If it becomes necessary to change or update the procedure after prior approval is obtained, we must be contacted no later than 48 hours after the modified procedure is performed. If the prior approval for the treatment plan is not updated and the claim does not match the authorized procedures, the claim will be denied for payment, with no liability to the member.

              Verifying the Prior Approval Status

              To verify the status of a prior approval request, either call the numbers that follow or visit the Authorization Lookup section of the website at www.evicore.com. Call 1-866-417-2345 for HIP, EmblemHealth CompreHealth EPO, GHI HMO, Vytra and EmblemHealth Medicare HMO plan members. Call 1-800-835-7064 for EmblemHealth Medicare PPO plan members.

              Note: While we may approve or deny a prior approval request, this determination is based on medical necessity only. Always verify member eligibility, benefits and copayments directly with EmblemHealth at www.emblemhealth.com.

              Determination Disagreement

              If a physician disagrees with the determination, contact the Program’s Peer-to-Peer Consultation Line to discuss the case with a medical director. Call 1-866-417-2345 for HIP, EmblemHealth CompreHealth EPO, GHI HMO, Vytra and EmblemHealth Medicare HMO plans. Call 1-800-835-7064 for EmblemHealth Medicare PPO plan members.

              CPT-4 Codes Requiring Prior Approval

              The following CPT-4 codes require prior approval for all plans covered by the EmblemHealth Cardiology Imaging Program:

              Cardiology Imaging Prior Approval Code List
              For EmblemHealth CompreHealth EPO, EmblemHealth
              Medicare HMO/PPO, GHI HMO and HIP Benefit Plans

              Effective October 1, 2012 (Vytra EFFECTIVE JANUARY 1, 2016)

              Cardiology Imaging CPT Code Procedure Description

              75557

              CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL

              75559

              CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL; WITH STRESS IMAGING

              75561

              CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES

              75563

              CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; WITH STRESS IMAGING

              75571*

              COMPUTED TOMOGRAPHY, HEART, WITHOUT CONTRAST MATERIAL, WITH QUANTITIVE EVALUATION OF CORONARY CALCIUM

              75572

              COMPUTED TOMOGRAPHY, HEART, WITH CONTRAST MATERIAL, FOR EVALUATION OF CARDIAC STRUCTURE AND MORPHOLOGY (INCLUDING 3D IMAGE POSTPROCESSING, ASSESSMENT OF CARDIAC FUNCTION, AND EVALUATION OF VENOUS STRUCTURES, IF PERFORMED)

              75573

              COMPUTED TOMOGRAPHY, HEART, WITH CONTRAST MATERIAL, FOR EVALUATION OF CARDIAC STRUCTURE AND MORPHOLOGY IN THE SETTING OF CONGENITAL HEART DISEASE (INCLUDING 3D IMAGE POSTPROCESSING,ASSESSMENT OF LV CARDIAC FUNCTION, RV STRUCTURE AND FUNCTION AND EVALUATION OF VENOUS STRUCTURES, IF PERFORMED)

              75574

              COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEART, CORONARY ARTERIES AND BYPASS GRAFTS (WHEN PRESENT), WITH CONTRAST MATERIAL, INCLUDING 3D IMAGE POSTPROCESSING (INCLUDING EVALUATION OF CARDIAC STRUCTURE AND MORPHOLOGY, ASSESSMENT OF CARDIAC FUNCTION, AND EVALUATION OF VENOUS STRUCTURES, IF PERFORMED)

              78451

              MYOCARDIAL PERFUSION IMAGING, TOMOGRAPHIC (SPECT) (INCLUDING ATTENUATION CORRECTION, QUALITATIVE OR QUANTITATIVE WALL MOTION, EJECTION FRACTION BY FIRST PASS OR GATED TECHNIQUE, ADDITIONAL QUANTIFICATION, WHEN PERFORMED); SINGLE STUDY, AT REST OR STRESS (EXERCISE OR PHARMACOLOGIC)

              78452

              MYOCARDIAL PERFUSION IMAGING, TOMOGRAPHIC (SPECT) (INCLUDING ATTENUATION CORRECTION, QUALITATIVE OR QUANTITATIVE WALL MOTION, EJECTION FRACTION BY FIRST PASS OR GATED TECHNIQUE, ADDITIONAL QUANTIFICATION, WHEN PERFORMED); MULTIPLE STUDIES, AT REST AND/OR STRESS (EXERCISE OR PHARMACOLOGIC) AND/OR REDISTRIBUTION AND/OR REST REINJECTION

              78453

              MYOCARDIAL PERFUSION IMAGING, PLANAR (INCLUDING QUALITATIVE OR QUANTITATIVE WALL MOTION, EJECTION FRACTION BY FIRST PASS OR GATED TECHNIQUE, ADDITIONAL QUANTIFICATION, WHEN PERFORMED); SINGLE STUDY, AT REST OR STRESS (EXERCISE OR PHARMACOLOGIC)

              78454

              MYOCARDIAL PERFUSION IMAGING, PLANAR (INCLUDING QUALITATIVE OR QUANTITATIVE WALL MOTION, EJECTION FRACTION BY FIRST PASS OR GATED TECHNIQUE, ADDITIONAL QUANTIFICATION, WHEN PERFORMED); MULTIPLE STUDIES, AT REST AND/OR STRESS (EXERCISE OR PHARMACOLOGIC) AND/OR REDISTRIBUTION AND/OR REST REINJECTION

              78459

              MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) METABOLIC EVALUATION

              78491

              MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; SINGLE STUDY AT REST OR STRESS

              78492

              MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; MULTIPLE STUDIES AT REST AND/OR STRESS

              93303

              TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; COMPLETE

              93304

              TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; FOLLOW-UP OR LIMITED STUDY

              93306

              ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY

              93307

              ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, COMPLETE, WITHOUT SPECTRAL OR COLOR DOPPLER ECHOCARDIOGRAPHY

              93308

              ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D) INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY

              93350

              ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, DURING REST AND CARDIOVASCULAR STRESS TEST USING TREADMILL, BICYCLE EXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITH INTERPRETATION AND REPORT

              93351

              ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, DURING REST AND CARDIOVASCULAR STRESS TEST USING TREADMILL, BICYCLE EXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITH INTERPRETATION AND REPORT; INCLUDING PERFORMANCE OF CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, WITH SUPERVISION BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL.

              93452

              LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION, WHEN PERFORMED

              93453

              COMBINED RIGHT AND LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION, WHEN PERFORMED

              93454

              CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION

              93455

              CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH CATHETER PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY, FREE ARTERIAL VENOUS GRAFTS) INCLUDING INTRAPROCEDURAL INJECTION(S) FOR BYPASS GRAFT ANGIOGRAPHY

              93456

              CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH RIGHT HEART CATHETERIZATION

              93457

              CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH CATHETER PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS GRAFTS), INCLUDING INTRAPROCEDURAL INJECTION(S) FOR BYPASS GRAFT ANGIOGRAPHY AND RIGHT HEART CATHETERIZATION

              93458

              CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN PERFORMED

              93459

              CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH LEFT HEART CATHETERIZATION, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN PERFORMED, CATHETER PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS GRAFTS) WITH BYPASS GRAFT ANGIOGRAPHY

              93460

              CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH RIGHT AND LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN PERFORMED

              93461

              CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH RIGHT AND LEFT HEART CATHETERIZATION, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN PERFORMED, CATHETER PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS GRAFTS) WITH BYPASS GRAFT ANGIOGRAPHY

              93462

              LEFT HEART CATHETERIZATION BY TRANSSEPTAL PUNCTURE THROUGH INTACT SEPTUM OR BY TRANSAPICAL PUNCTURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

              C8921

              TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, FOR CONGENITAL CARDIAC ANOMALIES; COMPLETE

              C8922

              TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, FOR CONGENITAL CARDIAC ANOMALIES; FOLLOW-UP OR LIMITED STUDY

              C8923

              TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, COMPLETE, WITHOUT SPECTRAL OR COLOR DOPPLER ECHOCARDIOGRAPHY

              C8924

              TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY

              C8928

              TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, DURING REST AND CARDIOVASCULAR STRESS TEST USING TREADMILL, BICYCLE EXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITH INTERPRETATION AND REPORT

              C8929

              TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY

              C8930

              TRANSTHORACIC ECHOCARDIOGRAPHY, WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, DURING REST AND CARDIOVASCULAR STRESS TEST USING TREADMILL, BICYCLE EXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITH INTERPRETATION AND REPORT; INCLUDING PERFORMANCE OF CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, WITH PHYSICIAN SUPERVISION

              *GHI HMO exception: 75571 is not a GHI HMO contracted code.

              The following codes may no longer be billed. Please reference these codes for older claims (claims for dates of service prior to 1/1/2011).

              Cardiology Imaging Procedures Requiring Prior Approval
              CPT-4 Code List

              Effective 1/1/2011 to 12/31/11
              For Reference Only - Do Not Use

              CPT-4
              Code

              Procedure Description

              75557

              Cardiac magnetic resonance imaging (MRI) for morphology and function without contrast material

              75559

              Cardiac MRI for morphology and function without contrast material; with stress imaging

              75561

              Cardiac MRI for morphology and function without contrast material(s), followed by contrast material(s) and further sequences

              75563

              Cardiac MRI for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging

              75571

              Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium

              75572

              Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology

              75573

              Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease

              75574

              Computed tomographic angiography, heart, coronary arteries and bypass grafts, with contrast material, including 3D image postprocessing

              78451

              Myocardial perfusion imaging, tomographic (SPECT), single study, at rest or stress

              78452

              Myocardial perfusion imaging, tomographic (SPECT), multiple studies, at rest and/or stress and/or redistribution and/or rest reinjection

              78453

              Myocardial perfusion imaging, planar, single study, at rest or stress

              78454

              Myocardial perfusion imaging, planar, multiple studies, at rest or stress and/or redistribution and/or rest reinjection

              78456

              Acute venous thrombosis imaging, peptide

              78457

              Venous thrombosis imaging, venogram, unilateral

              78458

              Venous thrombosis imaging, venogram, bilateral

              78459

              Myocardial imaging, positron emission tomography (PET), metabolic evaluation

              93303

              Transthoracic echocardiography for congenital cardiac anomalies, complete

              93304

              Transthoracic echocardiography for congenital cardiac anomalies, follow-up or limited study

              93306

              Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography

              93307

              Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography

              93308

              Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study

              93350

              Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test

              93351

              Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress, including performance of continuous electrocardiographic monitoring, with physician supervision

              93451

              Right heart catheterization, including measurement(s) of oxygen saturation and cardiac output, when performed

              93452

              Left heart catheterization, including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed

              93453

              Combined right and left heart catheterization, including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed

              93454
              (replaces 93508)

              Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation

              93455
              (replaces 93508)

              Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts), including intraprocedural injection(s) for bypass graft angiography

              93456

              Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization

              93457

              Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts), including intraprocedural injection(s) for bypass graft angiography and right heart catheterization

              93458
              (replaces 93510)

              Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with left heart catheterization, including intraprocedural injection(s) for left ventriculography, when performed

              93459 (replaces 93510)

              Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with left heart catheterization, including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography

              93460
              (replaces 93526)

              Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with right and left heart catheterization, including intraprocedural injection(s) for left ventriculography, when performed

              93461
              (replaces 93526)

              Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization, including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography

              93462
              (replaces 93524)

              Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (list separately in addition to code for primary procedure)

              Formal Dispute Resolution

              Please submit to EmblemHealth:

              Please submit to the Program:

              • Expedited and standard clinical appeals for Commercial/CHP members and expedited and standard action appeals for Medicaid members. Appeals may be filed by the member, the member's delegate (including the practitioner acting as the member's delegate) or by practitioners on their own behalf. For a full description of member and practitioner rights regarding clinical and action appeals, see the Dispute Resolution chapters for Commercial/CHP and Medicaid, as applicable.

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              Glossary terms found on this page:

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              • Denial or limited authorization of a service authorization request, including the type or level of service
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              A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

              A request to change an adverse determination that was based on administrative policies, procedures or guidelines.

              An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.

              An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

              • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
              • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
              • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
              • Maintains medical records for all patients
              • Has a requirement that every patient be under the care of a member of the medical staff
              • Provides 24-hour patient services
              • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

              A unique number which identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as Member ID Number.

              Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

              Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

              A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

              A doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and is an employee of, or party to a contract with, a utilization management organization, and has responsibility for clinical oversight of the utilization management organization's utilization management, credentialing, quality management and other clinical functions.

              A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

              An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

              A unique number that identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as ID Number.

              The physician or other provider who specifically prescribes the health care service being reviewed.

              A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.

              A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

              A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

              The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.

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