1. (a) The following diagnostic radiological services shall require prior authorization:

   1. (1) Computerized tomography (CT);
   2. (2) Magnetic resonance imaging (MRI);
   3. (3) Magnetic resonance angiography (MRA);
   4. (4) Positive emission tomography (PET); and
   5. (5) Nuclear cardiology.

2. (b) Diagnostic radiological services specified in (a) above shall be exempt from prior authorization requirements when services are provided:

   1. (1) As part of a hospital emergency department visit;
   2. (2) As part of a recipient’s inpatient hospitalization; or
   3. (3) Concurrently with, or on the same day as, an urgent care facility visit.

3. (c) The ordering practitioner shall initiate the prior authorization process on behalf of the recipient by:

   1. (1) Completing and submitting Form 272X, “Request for Service Authorization for Diagnostic Imaging” (June 2025) and certifying that they have obtained and attached a physician’s order and a letter of medical necessity (LMN) in addition to attaching medical records to support the medical necessity of the diagnostic imaging; and
   2. (2) Submitting the clinical information supporting the medical necessity for the request, including, but not limited to, the medical care plan, relevant diagnostic tests, and progress notes, to the department by mail, fax, or e-mail.
4. (d) When a completed prior authorization request is submitted in accordance with (c) above, the department shall send a written notice of decision to the recipient and the ordering practitioner within 2 business days of the decision being made.

5. (e) If the department denies the prior authorization request, the written denial notice, provided in accordance with (d) above shall include the following:

   1. (1) The reason for, and the legal basis of, the denial;
   2. (2) A copy of the clinical guidelines used to make the decision; and
   3. (3) Information that a fair hearing on the denial may be requested within 30 calendar days of the date on the notice of the denial, in accordance with He-C 200.

Source. (See Revision Note at chapter heading He-W 500); ss by #6575, eff 9-12-97; ss by #8400, INTERIM, eff 8-20-05, EXPIRES: 2-16-06; ss by #8562, eff 2-7-06; amd by #10342, eff 6-1-13; ss by #10517, eff 2-7-14, EXPIRED: 2-7-24 New. #14277, eff 6-24-25, EXPIRES: 6-24-35