Evolent Codes No Longer Requiring Prior Auth, effective 4/1/2026

Date: 01/23/26

Evolent (Formerly National Imaging Associates)

Prior Authorization Update - Effective 4/1/2026

Effective April 4, 2026, Evolent will no longer require prior authorization for the Radiology and Diagnostic Cardiology (RBM) procedure codes listed by line of business (Arizona Complete Health – Complete Care Plan [Medicaid], Wellcare [Medicare] and Ambetter from Arizona Complete Health [Marketplace]) in the tables below.

Important Notes:

Non-participating providers still require prior authorization for all services unless otherwise specified.
The ordering/prescribing provider is responsible for verifying which codes require prior authorization.
Always verify member eligibility and benefits before providing service. Payment, regardless of prior authorization, is contingent on the member’s eligibility at the time service is rendered.

Questions? Contact your Provider Engagement Account Manager. Need their contact information? Email us at:

📧 AzCHProviderEngagement@azcompletehealth.com.

Arizona Complete Health-Complete Care Plan (Medicaid)

Modality	Impacted CPT
CT ORBIT/EAR/FOSSA WITH O DYE	70480,70481,70482
CT MAXLOFCE AREA; W/O CONTRAST MATL	70487,70488, 70486, 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 OAND 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 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

Wellcare (Medicare)

Modality	Impacted CPT
CT ORBIT/EAR/FOSSA WITH O DYE	70480,70481,70482
CT MAXLOFCE AREA; W/O CONTRAST MATL	70487,70488, 70486, 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

Wellcare (Medicare) - continued

Modality	Impacted CPT
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 OAND 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

Ambetter from Arizona Complete Health (Marketplace)

Modality	Impacted CPT
CT ORBIT/EAR/FOSSA WITH O DYE	70480,70481,70482
CT MAXLOFCE AREA; W/O CONTRAST MATL	70487,70488, 70486, 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 OAND 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