Updated Evolent Authorization Requirements Effective April 1, 2026
Date: 01/29/26
Effective April 1, 2026, the following procedures will be removed from prior authorization requirements for Evolent.
The following RADIOLOGY AND DIAGNOSTIC CARDIOLOGY (RBM) codes have been removed from the Evolent’s Utilization Review Matrix and no longer require prior authorization for 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 |