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eviCore health care Site of Care medical necessity requirement

 

Effective December 1, 2021, Aetna® will add a Site of Care medical necessity requirement to the Enhanced Clinical Review program for fully insured commercial members. As part of this change, eviCore healthcare will review advanced radiology imaging procedures (MR and CT scans) for applicable medical necessity criteria prior to authorizing services in the hospital outpatient setting.

 

An advanced imaging procedure at a hospital outpatient site is considered medically necessary when cases involve certain factors. Examples are those where:

 

  • the individual is under 18 years of age  
  • obstetrical observation is required  
  • perinatology services are required 
  • there are imaging needs related to transplant services at an approved transplant facility  
  • there is a known contrast allergy, and use of that contrast agent is planned  
  • there is a known chronic disease for which prior high-tech imaging procedures have been used for the diagnosis, management or ongoing surveillance of the disease at the hospital-affiliated imaging department 
  • there is an active coronavirus disease 2019 (COVID-19) diagnosis after positive test for SARS-CoV-2
  • there are no other appropriate alternative sites for the individual to undergo the imaging procedure for any of the following reasons:
  1. the surgery or procedure is being performed at the hospital, and preoperative/procedural or postoperative/procedural imaging is an integral component of the care
  2. the imaging procedure requires general anesthesia or moderate or deep sedation, and a freestanding facility capable of providing such sedation is not available
  3. the equipment needed to accommodate the size of the individual is available only at a hospital-affiliated imaging facility
  4. the individual has a documented diagnosis of claustrophobia requiring open magnetic resonance imaging, which is not available in a freestanding facility
  5. imaging outside the hospital-affiliated imaging department or facility is expected to adversely impact or delay care

 

All requested advanced radiology procedures that don’t meet the required criteria will be considered non-medically necessary unless performed at a freestanding or office location.

 

This policy will apply to all existing Enhanced Clinical Review program markets.

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