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AIM Prior Authorization List 

Advanced imaging studies (MRI, MRA, CT, PET scans and Nuclear Cardiology) performed in a non-emergent outpatient setting  requires prior authorization through AIM Specialty Health (AIM).  Effective November 1, 2014, Echocardiography and Sleep testing and therapy also require prior authorization through AIM.  Please refer to the updated code list below.

Prior authorization is required for Medicare Advantage as well as most of our Commercial products. Click here to access Blue Cross of Idaho groups who are NOT participating in the prior authorization program for advanced imaging. Groups on this list do not require prior authorization for their members.

A prior authorization approval is a determination of medical necessity only and not a guarantee of reimbursement.  We determine coverage and reimbursement based on the benefits, exclusions and limitations of the specific policy. For information regarding member benefits please access our website at bcidaho.com or contact our Customer Services Department toll free at 1 866-482-2250.

Last updated 05/18/2015

 

AIM Code Grouping Parent Code      Grouped Codes                                  
(CT) Computed Tomography Scans 74150 74150, 74160, 74170
  74176 74176, 74177, 74178
  71250 71250, 71260, 71270
  73200 73200, 73201, 73202
  73700 73700, 73701, 73702
  70450 70450, 70460, 70470
  70480 70480, 70481, 70482
  70486 70486, 70487, 70488
  70490 70490, 70491, 70492
  72192 72192, 72193, 72194
  72125 72125, 72126, 72127
  72128 72128, 72129, 72130
  72131 72131, 72132, 72133
(CTA) Computed Tomography Angiography Scans 74174 74174
   74175 74175
  75635 75635
  71275 71275
  73206 73206
  73706 73706
  70496 70496
  70498 70498
  72191 72191
(MRI) Magnetic Resonance Imaging 74181 74181, 74182, 74183
  77084 77084
  77058 77058, 77059
  71550 71550, 71551, 71552
  75557 75557, 75559, 75561, 75563, 75565
  73218 73218, 73219, 73220
  73221 73221, 73222, 73223
  73721 73718, 73719, 73720, 73721, 73722, 73723
  70336 70336
  70540 70540, 70542, 70543
  70551 70551, 70552, 70553
  72195 72195, 72196, 72197
  72141 72141, 72142, 72156
  72146 72146, 72147, 72157
  72148 78148, 72149, 72158
(MRA) Magnetic Resonance Angiography 74185 74185
  71555 71555
  73225 73225
  73725 73725
  70544 70544, 70545, 70546
  70547 70547, 70548, 70549
  72198 72198
  72159 72159
(MRS) Magnetic Resonance Spectroscopy 76390 76390 
Nuclear Cardiology 78451 78451, 78452, 78453, 78454
  78469 78466, 78468, 78469
  78472 78472, 78473, 78481, 78483, 78494
(PET) Positron Emission Tomography 78608 78608, 78609
  78459 78459, 78491, 78492
PET & CT/PET 78813 78811, 78812, 78813, 78814, 78815, 78816 
Screening CT Colonoscopy 74263 74263 
Diagnostic CT Colonoscopy

74261

74261, 74262 
CT Heart without contrast 75571 75571 
CT Heart with contrast 75572 75572, 75573 
CTA Heart 75574 75574 
(fMRI) Functional MRI 70554 70554, 70555 
Secondary Codes 76376 3D interpretation and report of CT, MRI, ULS or other Tomographic modality; not requiring image post processing on an independent workstation
  76377 3D interpretation and report of CT, MRI, ULS or other Tomographic modality; requiring image post processing on an independent workstation
  78496 Add on code to 78472 ONLY
Echocardiography and Sleep Management   Effective January 1, 2015 these servies will require prior authorization through AIM Specialty Health
Transthoracic Stress Echocardiogram  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
Transthoracic Echocardiogram 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
Transesophageal Echocardiogram 93312 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report
  93313 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only
  93314 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); image acquisition, interpretation and report only
  93315 Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report
  93316 Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only
  93317 Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only
Secondary Codes 93320 secondary to 93303, 93304, 93312, 93314, 93317
  93321 secondary to 93303, 93304, 93312, 93314, 93317
  93350 secondary to 93303, 93304, 93312, 93314, 93317
  93351 secondary to 93303, 93304, 93312, 93314, 93317
  93352 secondary to 93303, 93304, 93312, 93314, 93317
Sleep Management   Effective January 1, 2015 these servies will require prior authorization through AIM Specialty Health
Home Sleep Study G0400 Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels
  95800 Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time
  95801 Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (eg, by airflow or peripheral arterial tone)
G0399 Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation
  95806 Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement)
G0398 Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation
In-Lab Sleep Study 95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist
  95808 Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist
  95810 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
  95811 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist
  95782 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
  95783 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist
Titration Study 95811 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist
  95783 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist
Multiple Sleep Latency Testing (MLST) or Multiple Wakefulness Testing (MWT) 95805 Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness
Polysomnography with MSLT or MWT 95805 Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness
  95810 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
  95782 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
BPAP/CPAP devices E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
  E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
  E0601 Continuous positive airway pressure (CPAP) device
  E0561 Humidifier, nonheated, used with positive airway pressure device
  E0562 Humidifier, heated, used with positive airway pressure device
Oral Appliance E0486 Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, custom fabricated, includes fitting and adjustment