Advanced imaging — medical necessity and site of service

Coverage conditions for MRI, CT, PET and nuclear cardiology, and how the setting the study was performed in affects what is payable.

All policies

Current version

v1.3

in force since 2025-04-01 · as at 2026-04-02

Versions on file

back to 2024-01-01

Applies to

All lines of business

All states, with variations

Cited in this batch

claims tested against it

Where this sits

OwnerUtilization Management Policy

Lines of businessAll lines of business

StatesAll states, with variations

External basisCMS national and local coverage determinations · Appropriate Use Criteria programme

Variations by state and line of business

The same policy reads differently depending on where the member is covered and under which programme.

Texas Medicaid: advanced imaging performed in a freestanding centre is paid at the state fee schedule rather than the outpatient rate.

Medicare Advantage: follows the local coverage determination for the contractor covering the state of service.

Version history

Newest first

A claim is tested against the version that was in force on its date of service. For a service last autumn, that is not the version at the top of this list.

v1.3 2025-04-01 → current In force now

Repeat imaging of the same anatomical region within 90 days now requires a documented change in clinical status.

No source document in the index. A finding on this version can cite it by name but cannot quote a passage.

The study must be supported by a covered indication for the diagnosis reported.
Repeat imaging of the same region within 90 days requires a documented change in clinical status.
Where the study was authorised in advance, post-service review is limited to coding and pricing (see CPP-085).

v1.2 2024-01-01 → 2025-03-31 Superseded

Baseline advanced-imaging coverage policy.

No source document in the index. A finding on this version can cite it by name but cannot quote a passage.

The study must be supported by a covered indication for the diagnosis reported.

Claims in this batch tested against this policy

3 of 25

Claim	Date of service	Version applied	Role	Paid	At risk
CLM-0000022	10 Mar 2026	v1.3	Supporting	$316.97	—
CLM-0000023	23 Mar 2026	v1.3	Decisive	$191.72	—
CLM-0000025	05 Mar 2026	v1.3	Decisive	$254.18	$254.18

This policy is synthetic — an internal document written for this demo. The external basis it cites is real.