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Effective July 1, 2026, the following procedures will be removed from prior authorization.
The following RADIOLOGY AND DIAGNOSTIC CARDIOLOGY (RBM) codes have been removed from the Evolent’s Utilization Review Matrix and no longer require prior authorization for Medicaid.
Modality
Impacted CPT
CT ORBIT/EAR/FOSSA WITH O DYE
70480,70481,70482
CT MAXLOFCE AREA; W/O CONTRAST MATL
70487,70488, 70486, 76380
DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX W/O CNTRST
71250, 71260, 71270, 71271
CT UPPER EXTREMITY WITH O DYE
73200, 73201, 73202
MRI UPPR EXTREMITY WITH OAND WITH DYE
73218, 73219, 73220
CT LOWER EXTREMITY WITH O DYE
73700, 73701, 73702
MRI FETAL SNGL/1ST GESTATION
74712, 74713
CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST
75557, 75559, 75561, 75563
CT HRT WITH 3D IMAGE CONGEN
75573
MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL
77046, 77047, 77048, 77049
CT BONE MINERL DENSITY STUDY 1/> SITS AXIAL SKE
77078
MRI BONE MARROW BLOOD SUPPLY
77084
GATED HEART PLANAR SINGLE
78472, 78473, 78494
ECHOCRDGRPHY RL TM W/2D W/WO M-MODE, TRANSESOPHAGEAL
93312, 93313, 93314, 93315, 93316, 93317, 93318
The following RADIOLOGY AND DIAGNOSTIC CARDIOLOGY (RBM) codes have been removed from the Evolent’s Utilization Review Matrix and no longer require prior authorization for Medicare.
CT SOFT TISSUE NECK WITH O DYE
70490, 70491, 70492
MRI IMAGING BRAIN; INCLUDING BRAIN STEM; WITHOUT CONTRAST MATERIAL
70551, 70552, 70553
MRI- SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL
72141, 72142, 72156
MRI, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL
72146, 72147, 72157
MRI- SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL
72148, 72149, 72158
MRI PELVIS WITH DYE
72195, 72196, 72197
MRI JOINT UPR EXTREM WITH O DYE
73221, 73222, 73223
CT ABDOMEN WITH O DYE
74150, 74160, 74170
MRI ABDOMEN WITH O DYE
74181, 74182, 74183, S8037
CT HRT WITH 3D IMAGE
75572
CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST
75574
The following RADIOLOGY AND DIAGNOSTIC CARDIOLOGY (RBM) codes have been removed from the Evolent’s Utilization Review Matrix and no longer require prior authorization for Ambetter From Fidelis Care and Essential Plans.
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