New authorization procedures for certain advanced imaging studies

Beginning May 19, 2020, CareOregon/Health Share, Jackson Care Connect, Columbia Pacific CCO and CareOregon Advantage will change how we authorize and cover certain advanced imaging studies. These changes will apply to all Medicaid and Medicare members. We are changing our process to align with national recommendations and existing coverage criteria for Oregon Health Plan (OHP) members.

As unnecessary imaging leads to increased costs, and potential harms in the form of radiation exposure, incidental findings, increased patient anxiety and increased risk of undergoing surgery without improved outcomes, MRI and CT scans will require prior authorization when delivered in outpatient settings, excluding the Emergency Department. Authorization can be requested through our Connect portal.

On the back of this letter is a list of imaging studies, by CPT code, that will require preauthorization. OHP has coverage criteria for several studies defined throughout the Prioritized List (PL), including lumbar spine MRI defined in Diagnostic Guidelines D4. For all requests, ensure records include pertinent history, a current physical exam and the reason for the study. If your patient’s condition does not meet coverage criteria, please consider other evidence-based management strategies.

When talking with your patients about why they might not benefit from commonly requested imaging, such as spine or brain, you may wish to use materials developed by the Choosing Wisely campaign. Patient handouts can be found here: https://www.choosingwisely.org/patient-resources/ Back pain: http://www.choosingwisely.org/patient-resources/imaging-tests-for-back-pain/ Headaches: https://www.choosingwisely.org/patient-resources/imaging-tests-for-headaches/ 

Please contact Customer Service at 800-224-4840 should you have any questions.