Guideline Updates Coverage and Clinical GuidelinesHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsMay 23, 2023

Transition to Carelon Medical Benefits Management, Inc. MRI Breast Clinical Appropriateness Guidelines

Please note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc.

Effective August 1, 2023, HealthKeepers, Inc. will transition the clinical criteria for medical necessity review of MRI Breast to the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines:

  • Oncologic imaging
  • Chest imaging

As part of this transition of clinical criteria, the following procedures will be subject to prior authorization at Carelon Medical Benefits Management*:

CPT® code

Description

77046

Magnetic resonance imaging, breast, without contrast material; unilateral

77047

Magnetic resonance imaging, breast, without contrast material; bilateral

77048

Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization, and pharmacokinetic analysis) when performed; unilateral

77049

Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization, and pharmacokinetic analysis) when performed; bilateral



HCPCS

Description

C8903

Magnetic resonance imaging with contrast, breast; unilateral

C8905

Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral

C8906

Magnetic resonance imaging with contrast, breast; bilateral

C8908

Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral





Note: This update does not apply to the Federal Employee Program® (FEP®)

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management via the ProviderPortalSM :

  • Access the Carelon Medical Benefits Management ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.

If you have questions related to clinical guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines at https://guidelines.carelonmedicalbenefitsmanagement.com/.

If you have any questions about this communication, call Anthem HealthKeepers Plus Provider Services at 800-901-0020.

* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

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PUBLICATIONS: June 2023 Provider Newsletter