PET, CT, MR scans must meet medical necessity criteria.
Effective April 1, 2015, CDPHP® requires its participating physicians to obtain medical necessity review by MedSolutions for all outpatient PET, CT, MR imaging studies. Claims for these services will be denied if MedSolutions determines that the study being requested does not meet medical necessity criteria.
How to Submit a Request
The process for obtaining a medical necessity review is no different than the process CDPHP has had in place for notifications since 2009. Provider offices may reach MedSolutions in one of three ways:
CDPHP does not anticipate applying the medical necessity certification requirement to our Medicare Advantage plans until January 1, 2016. Our providers are asked to continue to notify MedSolutions regarding high-tech scans ordered for Medicare members, and make every effort to adhere to clinical guidelines.
Participating imaging providers may not balance bill our members in the event of coverage being denied for a service that is deemed medically unnecessary.
Helpful Materials for Participating Providers
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