Louisiana Healthcare Connections Policies and Procedures Updates : Evolent
Date: 01/09/25
Louisiana Healthcare Connections is sharing with providers the below policies and procedures that were developed and/or revised; posted for public comment and approved by LDH in accordance with La. R.S. 46:460.54. Non-material revisions do not require LDH approvals.
Please share this notice with other members of your practice and office staff as necessary.
These guidelines will be implemented 30 days from the date of this notice and will be posted on NIA’s Website at www.RadMD.com.
Policy ID
| Policy & Procedure Title |
Evolent_CG_001 | Brain (Head) MRI/Brain (Head) MRI w IAC (Internal Auditory Canal) |
Evolent_CG_002 | Brain (Head) CT |
Evolent_CG_003 | Brain (Head) MRS |
Evolent_CG_004-1 | Brain (Head) CTA |
Evolent_CG_004-2 | Brain (Head) MRA/MRV |
Evolent_CG_006 - 1 | Temporal Bone, Mastoid, Orbits, Sella, Internal Auditory Canal CT |
Evolent_CG_007 | Temporomandibular Joint (TMJ) MRI |
Evolent_CG_008-1 | Neck CT (soft tissue) |
Evolent_CG_009 | Sinus & Maxillofacial CT limited or localized f/u Sinus CT |
Evolent_CG_012-1 | Neck CTA |
Evolent_CG_012-2 | Neck MRA/MRV |
Evolent_CG_013 | Functional Brain MRI |
Evolent_CG_014 | Sinus, Face, Orbit, Neck, and IAC MRI |
Evolent_CG_015 | Cerebral Perfusion CT |
Evolent_CG_020 | Chest (Thorax) CT |
Evolent_CG_020-1 | Low Dose CT for Lung Cancer Screening |
Evolent_CG_021 | Chest (Thorax) MRI |
Evolent_CG_022-1 | Chest CTA |
Evolent_CG_023 | Breast MRI |
Evolent_CG_024 | Myocardial Perfusion Imaging (Nuclear Cardiac Imaging Study) |
Evolent_CG_025 | Heart CT Congenital |
Evolent_CG_026 | Stress Echocardiography |
Evolent_CG_027 | MUGA (Multiple Gated Acquisition) Scan |
Evolent_CG_028 | Heart MRI |
Evolent_CG_029 | ELECTRON-BEAM TOMOGRAPHY (EBCT) or Non-Contrast CCT |
Evolent_CG_030 | Abdomen CT |
Evolent_CG_031 | Abdomen MRI MRCP MRE MRU |
Evolent_CG_033-1 | CT (VIRTUAL) COLONOSCOPY DIAGNOSTIC |
Evolent_CG_033-2 | CT (Virtual) Colonoscopy – Screening |
Evolent_CG_034-1 | ABDOMEN CTA (Angiography) |
Evolent_CG_034-2 | Abdomen MRA/MRV (Angiography) |
Evolent_CG_035 | CTA Aortogram with Runoff |
Evolent_CG_036 | Pelvis CT |
Evolent_CG_037 | Pelvis MRI |
Evolent_CG_038 | Pelvis CTA Angiography |
Evolent_CG_039 | Pelvis MRA/MRV |
Evolent_CG_040 | Cervical Spine MRI |
Evolent_CG_041 | Cervical Spine CT |
Evolent_CG_042 | Thoracic Spine MRI |
Evolent_CG_043 | Thoracic Spine CT |
Evolent_CG_044 | Lumbar Spine MRI |
Evolent_CG_045 | Lumbar Spine CT |
Evolent_CG_046 | Spinal Canal MRA/MRV |
Evolent_CG_057-1 | Upper Extremity CT (Hand, Wrist, Long bone, or Shoulder CT) |
Evolent_CG_057-2 | Lower Extremity CT (foot, ankle, leg or hip CT) |
Evolent_CG_057-3 | Upper Extremity MRI (Hand, Wrist, Elbow, Long bone, or Shoulder MRI) |
Evolent_CG_057-4 | Lower Extremity MRI |
Evolent_CG_058-1 | Lower Extremity MRA/MRV |
Evolent_CG_058-2 | Upper Extremity MRA/MRV |
Evolent_CG_059 | Bone Marrow MRI |
Evolent_CG_060-2 | CT Bone Density Study |
Evolent_CG_061-1 | Lower Extremity CTA/CTV |
Evolent_CG_061-2 | Upper Extremity CTA/CTV |
Evolent_CG_062 | CT Coronary Angiography (CCTA) |
Evolent_CG_062-1 | Fractional Flow Reserve CT |
Evolent_CG_063 | Unlisted Studies |
Evolent_CG_065 | Heart Catheterization |
Evolent_CG_068 | Abdomen/Pelvis CT Combo |
Evolent_CG_069 | Abdomen/Pelvis CTA |
Evolent_CG_070-1 | PET Scans |
Evolent_CG_070-2 | Tumor Imaging PET Unlisted PET |
Evolent_CG_070-3 | Tumor Imaging PET - Breast Cancer |
Evolent_CG_070-4 | Tumor Imaging PET Melanoma |
Evolent_CG_071 | Brain PET Scan |
Evolent_CG_072 | Heart (cardiac) PET |
Evolent_CG_078 | Single Photon Emission Computed Tomography SPECT |
Evolent_CG_079 | Heart PET with CT Attenuation |
Evolent_CG_100 | Urgent Emergent Criteria |
Evolent_CG_110 | Fetal MRI |
Evolent_CG_320 | Cardiac Resynchronization Therapy (CRT) |