What Anthem, Cigna, UnitedHealth's hospital-based imaging policies entail

Morgan Haefner - Print  | 

Anthem, Cigna and UnitedHealthcare have issued new policies in the last few years that narrow what imaging they will cover in the hospital setting. 

The insurers say the policies, commonly referred to as "site of service medical necessity reviews," help lower costs for their commercially insured patients. For example, UnitedHealthcare has found its members could save up to $2,163 on a spinal cervical MRI with or without contrast if the procedure is completed in an ambulatory surgery center instead of an outpatient hospital setting. However, the policies are likely to have a negative effect on reimbursement for hospitals.

Below is what hospital-based imaging policies look like for Anthem, Cigna and UnitedHealthcare:

Anthem 

In 2017, Anthem issued a policy to limit what hospital-based CT scans and MRIs it covers. Under the policy, Anthem subsidiary AIM Specialty Health evaluates whether it is medically necessary for an imaging service to be performed in a hospital setting. 

Under Anthem's policy, an MRI or CT scan provided in a hospital outpatient department is not considered medically necessary unless any of the following criteria are met: 

Cigna 

Effective Aug. 1, Cigna stopped covering MRIs and CT scans performed in a hospital setting that don't meet new medical necessity requirements. Cigna told Becker's that the policy helps direct members "to a freestanding radiology center or other office-based setting when there is not a clinical reason for services to be performed at a more costly hospital setting while continuing to allow coverage for services to be performed at a hospital location when the customer's condition truly warrants that level of care."

For Cigna's policy, an MRI or CT scan provided in a hospital outpatient department is not considered medically necessary unless any of the following criteria are met:

UnitedHealthcare

UnitedHealthcare began limiting what hospital-based MRIs and CT scans it will cover in January 2019. The policy applies to UnitedHealthcare's commercial plans, including its Neighborhood Health Partnership, UnitedHealthcare of the River Valley and Oxford plans. At this time, the site of service policy doesn't apply to UnitedHealthcare West or Sierra, or for providers in Alaska, Connecticut (except for Oxford members), Iowa, Kentucky, Maine, Maryland, Massachusetts, New Hampshire, Texas, Utah, Vermont or Wisconsin. 

Under UnitedHealthcare's policy, an MRI or CT scan provided in a hospital outpatient department is not considered medically necessary unless any of the following criteria are met: 

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