FPH MRI Precertification Requirements
First Priority Health has updated the MRI Precertification List to include MRI of the breast. First
Priority Health precertification can be conducted either by phone 1-800-962-5353, by fax 570200-6799 or via NaviNet. Pertinent clinical information
and radiology results should accompany your request for service.
CODE
DESCRIPTION
70544
MRA ANGIOGRAPHY HEAD W/O DYE
70551
MRI BRAIN W/O DYE
70552
MRI BRAIN W/DYE
70553
MRI BRAIN W/AND W/O DYE
72141
MRI NECK SPINE W/O DYE
72142
MRI NECK SPINE W/DYE
72146
MRI THORACIC SPINE W/O DYE
72148
MRI LUMBAR SPINE W/O DYE
72149
MRI LUMBAR SPINE W/DYE
72156
MRI NECK SPINE W/ AND W/O DYE
MRI THORACIC SPINE W/ AND W/O
DYE
MRI LUMBAR SPINE W/ AND W/O DYE
MRI JOINT UPPER EXTREMITY W/O
DYE
MRI JOINT UPPER EXTREMITY W/DYE
MRI JOINT LOWER EXTREMITY W/O
DYE
MRI JOINT LOWER EXTREMITY
W/DYE
MAGNETIC RESONANCE
SPECTROSCOPY
MRI THORACIC SPINE W/DYE
MRI JOINT UPPER EXTREMITY
W/AND W/O DYE
MRI JOINT LOWER EXTREMITY
W/AND W/O DYE
MRI BREAST W/AND W/O DYE
UNILATERAL
MRI BREAST W/AND W/O DYE
BILATERAL
72157
72158
73221
73222
73721
73722
76390
72147
73223
73723
76093
76094
(policy update 0802002)
Current Procedural Terminology (CPT) is copyright 2004
American Medical Association. All rights reserved. No fee schedules, basic units, relative values,
or related listings are included in CPT. The AMA assumes no liability for the data contained
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