Updated Evolent Authorization Requirements Effective September 1, 2026

Date: 07/16/26

Effective September 1, 2026, the following procedures will be removed from prior authorization.

The following RADIOLOGY AND DIAGNOSTIC CARDIOLOGY (RBM) codes have been removed from the Evolent’s Utilization Review Matrix and no longer require prior authorization for Medicaid.

Modality	Impacted CPT
CT ORBIT/EAR/FOSSA WITH O DYE	70480, 70481, 70482
CT MAXLOFCE AREA; W/O CONTRAST MATL	70486, 70487, 70488, 76380
DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX W/O CNTRST	71250, 71260, 71270, 71271
CT UPPER EXTREMITY WITH O DYE	73200, 73201, 73202
MRI UPPR EXTREMITY WITH O AND WITH DYE	73218, 73219, 73220
CT LOWER EXTREMITY WITH O DYE	73700, 73701, 73702
MRI FETAL SNGL/1ST GESTATION	74712, 74713
CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST	75557, 75559, 75561, 75563
CT HRT WITH 3D IMAGE CONGEN	75573
MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL	77046, 77047, 77048, 77049
CT BONE MINERAL DENSITY STUDY 1/> SITES AXIAL SKELETON	77078
MRI BONE MARROW BLOOD SUPPLY	77084
GATED HEART PLANAR SINGLE	78472, 78473, 78494
ECHOCARDIOGRAPHY REAL TIME W/2D W/WO M-MODE, TRANSESOPHAGEAL	93312, 93313, 93314, 93315, 93316, 93317, 93318

The following RADIOLOGY AND DIAGNOSTIC CARDIOLOGY (RBM) codes have been removed from the Evolent’s Utilization Review Matrix and no longer require prior authorization for Wellcare (Medicare).

Modality	Impacted CPT
CT ORBIT/EAR/FOSSA WITH O DYE	70480, 70481, 70482
CT MAXLOFCE AREA; W/O CONTRAST MATL	70486, 70487, 70488, 76380
CT SOFT TISSUE NECK WITH O DYE	70490, 70491, 70492
MRI IMAGING BRAIN; INCLUDING BRAIN STEM; WITHOUT CONTRAST MATERIAL	70551, 70552, 70553
MRI - SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL	72141, 72142, 72156
MRI - SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL	72146, 72147, 72157
MRI - SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL	72148, 72149, 72158
MRI PELVIS WITH DYE	72195, 72196, 72197
CT UPPER EXTREMITY WITH O DYE	73200, 73201, 73202
MRI UPPR EXTREMITY WITH O AND WITH DYE	73218, 73219, 73220
MRI JOINT UPR EXTREM WITH O DYE	73221, 73222, 73223
CT LOWER EXTREMITY WITH O DYE	73700, 73701, 73702
CT ABDOMEN WITH O DYE	74150, 74160, 74170
MRI ABDOMEN WITH O DYE	74181, 74182, 74183, S8037
MRI FETAL SNGL/1ST GESTATION	74712, 74713
CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST	75557, 75559, 75561, 75563
CT HRT WITH 3D IMAGE	75572
CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST	75574
MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL	77046, 77047, 77048, 77049
CT BONE MINERL DENSITY STUDY 1/> SITS AXIAL SKE	77078
MRI BONE MARROW BLOOD SUPPLY	77084
GATED HEART PLANAR SINGLE	78472, 78473, 78494
ECHOCRDGRPHY RL TM W/2D W/WO M-MODE, TRANSESOPHAGEAL	93312, 93313, 93314, 93315, 93316, 93317, 93318

The following RADIOLOGY AND DIAGNOSTIC CARDIOLOGY (RBM) codes have been removed from the Evolent’s Utilization Review Matrix and no longer require prior authorization for Ambetter (Marketplace).

Modality	Impacted CPT
CT ORBIT/EAR/FOSSA WITH O DYE	70480, 70481, 70482
CT MAXLOFCE AREA; W/O CONTRAST MATL	70486, 70487, 70488, 76380
DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX W/O CNTRST	71250, 71260, 71270, 71271
MRI PELVIS WITH DYE	72195, 72196, 72197
CT UPPER EXTREMITY WITH O DYE	73200, 73201, 73202
MRI UPPR EXTREMITY WITH O AND WITH DYE	73218, 73219, 73220
CT LOWER EXTREMITY WITH O DYE	73700, 73701, 73702
MRI FETAL SNGL/1ST GESTATION	74712, 74713
CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST	75557, 75559, 75561, 75563
CT BONE MINERL DENSITY STUDY 1/> SITS AXIAL SKE	77078
GATED HEART PLANAR SINGLE	78472, 78473, 78494
ECHOCRDGRPHY RL TM W/2D W/WO M-MODE, TRANSESOPHAGEAL	93312, 93313, 93314, 93315, 93316, 93317, 93318

Last Updated: 07/16/2026