Laboratory, Radiological, and Portable Imaging Services.

22 CCR 51311

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22 CCR 51311

§ 51311. Laboratory, Radiological, and Portable Imaging Services.

(a)

Examinations, tests, and therapeutic services ordered by a licensed practitioner, within his/her scope of practice as defined by California law, for the purpose of providing information for the diagnosis, prevention, or treatment of any disease, injury or impairment of, or the assessment of the health of, human beings, or used as an aid in the prevention, prognosis, monitoring, or treatment of a physiological or pathological condition or illness in a human being are covered except that laboratory services provided for chronic outpatient hemodialysis in renal dialysis centers and community hemodialysis units are payable only when billed by the renal dialysis center or community hemodialysis unit.

(b)

Portable imaging services are covered subject to prior authorization except when they are rendered in skilled nursing and intermediate care facilities. Emergency portable imaging services performed in locations other than skilled nursing and intermediate care facilities do not require prior authorization.

(c)

Procedures and examinations that are not covered as portable imaging services include:

(1)

Procedures involving fluoroscopy;

(2)

Procedures involving the use of contrast media;

(3)

Procedures requiring the administration of a substance to the patient or injection of a substance into the patient and/or special manipulation of the patient;

(4)

Procedures that require special medical skill or knowledge possessed by a physician, dentist or podiatrist or that require that medical judgment be exercised;

(5)

Routine screening procedures;

(6)

Procedures that are not of a diagnostic nature; and

(7)

Procedures that for safety, and effectiveness to permit clear interpretation of the image by a radiologist, need to be performed in a radiology facility; and require any of the following:

(A)

Immobilization of the patient.

(B)

Avoidance of excessive radiation due to the number of views required.

(C)

Special techniques to deal with complex radiologic problems.

(D)

Special equipment and supplies.

(d)

Portable imaging services are covered only when:

(1)

The provider ordering the portable imaging services has no financial interest in the business of the portable imaging services provider; and

(2)

The patient is under the direct care of the ordering provider, not the portable imaging services provider.

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