Why Anthem BCBS Denies CT Abdomen and Pelvis
Prior imaging not performed first (ultrasound, X-ray)
Diagnosis does not support advanced imaging
Duplicate study within short timeframe
Know Anthem / Blue Cross Blue Shield's Criteria
Anthem uses their own Clinical UM Guidelines and AIM Specialty Health for imaging. Medical policy numbers are publicly searchable.
Key policies to know:
- AIM Specialty Health manages imaging prior auth
- Clinical UM Guidelines searchable at anthem.com/provider
- Known for strict imaging prior auth requirements
- Uses evidence-based medicine approach with published policies
Building Your Medical Necessity Argument
Document why less invasive imaging is insufficient
Note acute clinical findings requiring CT
Reference abnormal lab values or physical exam findings
Cite clinical suspicion for specific pathology (abscess, mass, obstruction)
P2P Call Tips for Anthem BCBS
Reference specific Anthem Clinical UM Guideline by policy number
For imaging, address AIM criteria specifically
Anthem medical directors appreciate evidence-based arguments
Cite specific clinical criteria being met from their own policy
Guidelines to Reference
- ACR Appropriateness Criteria
- Choosing Wisely Recommendations for Abdominal Imaging
Relevant CPT Codes
Specialty: Internal Medicine / Emergency Medicine
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