McLaren MRI User manual

MRI Pre-Authorization Guide
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MRI/MRA Categories:
Head/Brain
Cervical Spine
Thoracic Spine
Lumbosacral Spine
Orbits, Face or Neck
Tempomandibular Joints (TMJ)
Abdomen
Lower Extremity Joint (Hip, Knee, Ankle)
Lower Extremity Non Joint (Femur, Lower Leg, Foot)
Upper Extremity Joint (Shoulder, Elbow, Wrist)
Upper Extremity Non Joint (Humerus, Forearm, Hand)
Chest
Pelvis/SI Joints
Breast
MRA/MRV
Other Misc Codes
Helpful Links
MRI Health History Screening Form
Outpatient MRI Order Form
Breast MRI Order Form
Prep Reference Guide

MRI Pre-Authorization Guide
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Brain/Head (Non-MRA/MRV) (IAC’s, Pituitary, Etc…)
1. 70551 - MRI Brain without contrast
2. 70552 - MRI Brain with contrast
3. 70553 - MRI Brain with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
If MRA or MRV is also being requested, please pre-authorize separately using the MRA codes.
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MRI Pre-Authorization Guide
Page | 3
MRI Cervical Spine
1. 72141 - MRI Cervical Spine without contrast
2. 72142 - MRI Cervical Spine with contrast
3. 72156 - MRI Cervical Spine with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
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MRI Pre-Authorization Guide
Page | 4
MRI Thoracic Spine
1. 72146 - MRI Thoracic Spine without contrast
2. 72147 - MRI Thoracic Spine with contrast
3. 72157 - MRI Thoracic Spine with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
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MRI Pre-Authorization Guide
Page | 5
MRI Lumbosacral Spine
1. 72148 - MRI Lumbosacral Spine without contrast
2. 72149 - MRI Lumbosacral Spine with contrast
3. 72158 - MRI Lumbosacral Spine with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
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MRI Pre-Authorization Guide
Page | 6
MRI Orbits, Face, Neck
1. 70540 - MRI Face Neck Orbit without contrast
2. 70542 - MRI Face Neck Orbit with contrast
3. 70543 - MRI Face Neck Orbit with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
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MRI Pre-Authorization Guide
Page | 7
MRI Abdomen
1. 74181 - MRI Abdomen without contrast
2. 74182 - MRI Abdomen with contrast
3. 74183 - MRI Abdomen with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
If MRA or MRV is also being requested, please pre-authorize separately using the MRA codes.
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MRI Pre-Authorization Guide
Page | 8
MRI Pelvis
1. 72195 - MRI Pelvis without contrast
2. 72196 - MRI Pelvis with contrast
3. 72197 - MRI Pelvis with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
If MRA or MRV is also being requested, please pre-authorize separately using the MRA codes.
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MRI Pre-Authorization Guide
Page | 9
MRI Chest
1. 71550 - MRI Chest without contrast
2. 71551 - MRI Chest with contrast
3. 71552 - MRI Chest with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
If MRA or MRV is also being requested, please pre-authorize separately using the MRA codes.
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MRI Pre-Authorization Guide
Page | 10
MRI Upper Extremity Joint (Shoulder, Elbow, Wrist)
1. 73221 - MRI Upper Extremity Joint without contrast
2. 73222 - MRI Upper Extremity Joint with contrast
3. 73223 - MRI Upper Extremity Joint with and without contrast
Note:
Due to differing scan protocols or other possible contraindications to contrast at the time of
exam, if possible, we ask that all three codes be pre-authorized.
If MRA or MRV is also being requested, please pre-authorize separately using the MRA codes.
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