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

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: 

  • The services are only available in a hospital setting 
  • The patient is less than 10 years old 
  • The patient needs an obstetrical observation 
  • The patient receives perinatology services 
  • There are no appropriate alternative sites that are geographically accessible in cases requiring anesthesia, larger or smaller equipment and an open MRI for patients with claustrophobia 
  • The patient has a chronic illness requiring imaging at multiple times
  • The imaging is preoperative
  • Imaging outside of the hospital adversely affects care

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:

  • The patient is less than 10 years old 
  • The patient needs obstetrical observation
  • The patient requires perinatology services
  • The patient needs imaging related to a transplant procedure
  • The patient has an allergy to the contrast used in the imaging
  • There is no other appropriate site due to surgery, anesthesia and equipment size needs
  • The patient has a diagnosis of claustrophobia and needs an open MRI
  • Imaging outside of the hospital would delay/adversely affect care

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: 

  • The patient is less than 19 years old 
  • The patient requires obstetrical observation 
  • The patient requires perinatology services 
  • The patient is allergic to contrast used for the imaging
  • The patient has a chronic illness and needs frequent monitoring
  • Any preprocedure imaging is done within 24 hours of a surgery
  • There are no geographically accessible alternative sites that can provide the imaging with required anesthesia or appropriately sized equipment
  • An open MRI is needed because of claustrophobia
  • Imaging outside of a hospital outpatient department would delay/adversely affect care 

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