Updated Evolent Authorization Requirements Effective July 1, 2026
2026/5/28
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Posted by Provider Relations
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Provider News
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.
|
Modality
|
Impacted CPT
|
|
CT ORBIT/EAR/FOSSA WITH O DYE
|
70480,70481,70482
|
|
CT MAXLOFCE AREA; W/O CONTRAST MATL
|
70487,70488, 70486, 76380
|
|
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
|
|
CT UPPER EXTREMITY WITH O DYE
|
73200, 73201, 73202
|
|
MRI UPPR EXTREMITY WITH OAND WITH DYE
|
73218, 73219, 73220
|
|
MRI JOINT UPR EXTREM WITH O DYE
|
73221, 73222, 73223
|
|
CT LOWER EXTREMITY WITH O DYE
|
73700, 73701, 73702
|
|
CT ABDOMEN WITH O DYE
|
74150, 74160, 74170
|
|
MRI ABDOMEN WITH O DYE
|
74181, 74182, 74183, S8037
|
|
MRI FETAL SNGL/1ST GESTATION
|
74712, 74713
|
|
CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST
|
75557, 75559, 75561, 75563
|
|
CT HRT WITH 3D IMAGE
|
75572
|
|
CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST
|
75574
|
|
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 Ambetter From Fidelis Care and Essential Plans.
|
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
|
|
MRI PELVIS WITH DYE
|
72195, 72196, 72197
|
|
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 BONE MINERL DENSITY STUDY 1/> SITS AXIAL SKE
|
77078
|
|
GATED HEART PLANAR SINGLE
|
78472, 78473, 78494
|
|
ECHOCRDGRPHY RL TM W/2D W/WO M-MODE, TRANSESOPHAGEAL
|
93312, 93313, 93314, 93315, 93316, 93317, 93318
|