General Guidelines for Prior Authorizations

MRI, when performed in Food and Drug Administration approved units, may be authorized when it is documented that (1) other information or techniques cannot establish the presumptive diagnosis. (2) a less costly service would not aequately meet the patient’s medical needs. and (3) MRI is not contraindicated.

MRI is not reimbursable when used to verify the existence of lesions already identified by Computerized Tomography (CT-Scan), sonographic evaluation, or other comparable diagnostic methods.


Treatment Authorization Requests

(TARs) must be accompanied by the following supportive documentation: complete history and physical, copies of X-ray reports (must have had X-Rays and/or CT Scans done), and justification that other techniques were inadequate for diagnosis. The TAR should be signed by the referring physician (and printed below the signature).


Billing for MRI

If two or more modifiers are necessary to identify a radiological procedure. Use modifier -99 on the claim line, and list and explain the applicable modifiers in the Remarks area/Reserved for Local Use field (Box 19) of the claim. Refer to Section 200-125 Surgeries for further instructions about using modifier -99.

Reimbursement for MRI services is notbased on the number of sequences performed: therefore documentation of the need for sequences is not required.


TAR for Split-Billed

When requestiong a TAR for split-billed MRI codes, indicate MRI authorization is being requested for both modifier -ZS (professional component) and modifier -TC (technical component). One provider may obtain the TAR for both providers of service by noting to the field office that two lines: one with modifier -26, the other with modifier -TC; need to be authorized. By requesting the TAR in this manner, both providers may bill from the same TAR.

Note: This procedure is not necessary if both services have been performed by the same provider. Modifier -ZS would be used for authorization in this case.