Cigna has recently issued a new policy, set to begin April 15th, 2020, which updates the insurer’s definition of medical necessity for MRI and CT imaging services.  The new outline limits the circumstances for which MRI and CT’s are covered in hospital-based settings, navigating beneficiaries towards having these procedures performed at freestanding imaging centers.

A price comparison study performed by the Healthcare Financial Management Association (HFMA) in 2017 showed that MRI and CT imaging can cost up to 149% higher in a hospital setting versus a freestanding center. Cigna believes that this move will also be cost effective for patients, estimating that some could save upwards of $1,000 of out of pocket expenses by implementing new medical necessity requirements for these scans.

Other major payors have made similar policy updates in recent years, which indicates a newer trend in insurers dictating where radiology services are delivered rather than just when. Anthem enacted a similar policy in 2017, providing a list of eligible centers for patient referrals to doctors who request non-emergency outpatient MRI or CT scans.  In 2018, UnitedHealthcare updated their prior authorization process for MRI and CT scans to include a medical necessity review for site of care. Each insurer cites the goal of minimizing out-of-pocket costs while aiming to improve patient care as key drivers of the policy updates.

For Cigna, circumstances where MRI and CT imaging in a hospital-based setting will still be approved include:

  • Patients aged 10 years or younger
  • Obstetrical observation patients
  • Perinatology services
  • Imaging related to transplant services
  • Patients with a known contrast allergy
  • When no other appropriate alternative site of service is available, including circumstances which would negatively impact or delay patient care

All other MRI and CT services at a hospital-based imaging facility, including an off-campus outpatient hospital facility billing under place of service code 19, will be considered not medically necessary by Cigna.

As always, ADVOCATE will keep you up to date on this and all issues impacting radiology as they become available.

Kayley Jaquet
Manager of Regulatory Affairs