76017 prior authorization | Blue Shield of California Promise Health Plan

76017, MR safety medical physics examination customization, planning and performance monitoring by medical physicist or MR safety expert, with review and analysis by physician or other qualified health care professional to prioritize and select views and imaging sequences, to tailor MR acquisition specific to restrictive requirements or artifacts associated with MR conditional implants or to mitigate risk of non-conditional implants or foreign bodies, with written report, is on the Blue Shield of California Promise Health Plan Medi-Cal prior authorization list. Not a coverage or referral decision.

Code

76017

Description

MR safety medical physics examination customization, planning and performance monitoring by medical physicist or MR safety expert, with review and analysis by physician or other qualified health care professional to prioritize and select views and imaging sequences, to tailor MR acquisition specific to restrictive requirements or artifacts associated with MR conditional implants or to mitigate risk of non-conditional implants or foreign bodies, with written report

Source

Medi-Cal Prior Authorization List, Pg 5 Original policy

Blue Shield of California Promise Health Plan prior authorization