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Cigna (eviCore) — CT Head

This page shows prior authorization criteria extracted from Cigna (eviCore)'s published imaging guidelines. 82 matching coverage rules found for this procedure.

Coverage Rules from Cigna (eviCore) Policy

Abnormal Blood Clotting

Indication Code: HD-11.9

Achondroplasia

Indication Code: PEDSP-7.1

Acute Lymphoblastic Leukemia (ALL)

Indication Code: PEDONC-3.2

Advanced Imaging Indications Related To Migraines

Indication Code: HD-11.17

Arteriovenous Malformations (AVMs) and Related Lesions

Indication Code: HD-12.2

Ataxia

Indication Code: PEDHD-20.1

Ataxia

Indication Code: HD-3.1

Atypical Teratoid/Rhabdoid Tumors (ATRT)

Indication Code: PEDONC-4.5

Autoimmune/Paraneoplastic Encephalitis & Neuroinflammatory Disorders

Indication Code: HD-14.3

Basilar Impression/Basilar Invagination

Indication Code: HD-5.4

Behavioral and Psychiatric Disorders

Indication Code: PEDHD-18.1

Cerebral Venous Sinus Thrombosis

Indication Code: HD-21.8

Chiari III and IV Malformations

Indication Code: HD-5.3

CNS and Head Infection

Indication Code: HD-14.1

CNS Germinomas and Non-Germinomatous Germ Cell Tumors (NGGCT)

Indication Code: PEDONC-4.7

CNS High Grade Gliomas (HGG)

Indication Code: PEDONC-4.3

CNS Infection

Indication Code: PEDHD-29.1

CNS Low Grade Gliomas (LGG)

Indication Code: PEDONC-4.2

Craniopharyngioma and Other Tumors of the Sellar Region

Indication Code: PEDONC-4.10

Craniosynostosis Imaging

Indication Code: PEDHD-8.1

CT or MRI Perfusion

Indication Code: HD-24.5

Dizziness/Vertigo

Indication Code: HD-23.1

Empty Sella Turcica

Indication Code: HD-19.3

Epilepsy/Seizures

Indication Code: HD-9.1

Eye Disorders and Visual Loss

Indication Code: HD-32.1

Facial Trauma

Indication Code: PEDHD-4.2

Facial Trauma

Indication Code: HD-13.2

Febrile Seizures

Indication Code: PEDHD-6.4

General Guidelines

Indication Code: ONC-1.0

General Guidelines

Indication Code: PEDONC-1.0

General Guidelines

Indication Code: HD-1.0

General Guidelines – CT Head

Indication Code: HD-1.4

General Guidelines – Modality

Indication Code: HD-1.2

Head Trauma

Indication Code: PEDHD-4.1

Head Trauma

Indication Code: HD-13.1

Headache General Guidelines

Indication Code: HD-11.0

Headaches Associated With Head Trauma

Indication Code: HD-11.12

Hydrocephalus Shunts

Indication Code: HD-11.14

Hydrocephalus, Shunts, and Endoscopic Third Ventriculostomy (ETV)

Indication Code: PEDHD-7.3

Imaging Indications in Sinusitis

Indication Code: PEDHD-5.2

Initial Imaging of Non-Febrile Seizures

Indication Code: PEDHD-6.1

Key Principles

Indication Code: ONC-1.1

Low-Pressure Headache and CSF Leak

Indication Code: HD-11.15

Macrocephaly

Indication Code: PEDHD-7.1

Medulloblastoma (MDB), Other CNS Embryonal Tumors, and Pineoblastoma

Indication Code: PEDONC-4.4

Mental Health Related Disorders

Indication Code: HD-4.1

Mental Status Change

Indication Code: HD-4.2

Mild Cognitive Impairment (MCI) and Dementia - MRI/CT

Indication Code: HD-8.1

Movement Disorders

Indication Code: HD-15.1

Neuro-COVID-19 and Sars-CoV-2 Vaccines

Indication Code: HD-14.2

Neuroblastoma – Initial Staging

Indication Code: PEDONC-6.3

Neuronavigation

Indication Code: HD-28.2

New Headache Onset Older than Age 50

Indication Code: HD-11.7

Non-Small Cell Lung Cancer – Initial Work-Up/Staging

Indication Code: ONC-8.3

Normal Pressure Hydrocephalus (NPH)

Indication Code: HD-8.4

Papilledema/Pseudotumor Cerebri

Indication Code: HD-17.1

Pediatric Head Imaging Modality General Considerations

Indication Code: PEDHD-1.3

Pediatric Headache

Indication Code: PEDHD-3.1

Pediatric Intracranial Aneurysms and Subarachnoid Hemorrhage

Indication Code: PEDHD-10.1

Pediatric Intracranial Arteriovenous Malformations (AVM)

Indication Code: PEDHD-10.2

Pediatric Leukemia General Considerations

Indication Code: PEDONC-3.1

Pediatric Lymphoma – General Considerations

Indication Code: PEDONC-5.1

Pediatric NPC – Imaging

Indication Code: PEDONC-13.2

Pediatric Stroke Initial Imaging

Indication Code: PEDHD-12.2

Physical Exertion

Indication Code: HD-11.11

Pituitary

Indication Code: HD-19.1

Platybasia

Indication Code: HD-5.5

Post-Operative Imaging

Indication Code: HD-28.3

Post-Transplant Imaging

Indication Code: PEDONC-20.2

Pregnancy

Indication Code: HD-11.10

Primary Central Nervous System Tumors – General Considerations

Indication Code: ONC-2.1

Scalp and Skull Lesions

Indication Code: PEDHD-30.1

Scalp and Skull Lesions

Indication Code: HD-20.1

Skull Base, Orbit, Periorbital or Oromaxillary

Indication Code: HD-11.5

Spinal Dysraphism

Indication Code: PEDSP-4.4

Stroke/TIA

Indication Code: HD-21.1

Sudden Onset of Headache

Indication Code: HD-11.3

Suspected Physical Child Abuse

Indication Code: PEDMS-7

Suspected Physical Child Abuse

Indication Code: PEDMS-7

Syncope

Indication Code: HD-23.2

Systemic Infections

Indication Code: HD-11.13

Thyroid Cancer – Initial Work-Up/Staging

Indication Code: ONC-6.2

How to Submit a Prior Authorization Request

Submit via: Cigna Provider Portal (provider.cigna.com) or eviCore at 1-800-252-2021

📄 Required Documentation Checklist

Patient demographics and insurance information
Ordering provider NPI and contact information
Specific clinical indication with ICD-10 diagnosis code(s)
Relevant clinical history and physical exam findings
Results of prior conservative treatment (if applicable)
Prior imaging results relevant to the indication
Supporting lab or diagnostic results where applicable

⏱ Turnaround Times

Standard prior authorization requests are typically processed within 3–5 business days. Urgent/expedited requests may be processed within 24–72 hours when clinically necessary.

📣 Appeal Window

Most plans allow 30–60 days to file a first-level appeal. Expedited appeals for urgent cases are typically processed within 72 hours.

⚠ Common Denial Reasons

Insufficient clinical documentation to establish medical necessity
Clinical criteria not met per payer guidelines
Lack of documented prior conservative treatment
Missing required prior imaging as step therapy
Incorrect or unsupported ICD-10 diagnosis code pairing
Request submitted outside of authorization timeframe

⚠ This study uses ionizing radiation. Payers may ask that non-ionizing alternatives (MRI, ultrasound) be considered first when clinically appropriate.

Clinical Approval Criteria

✓ Generally Approved When:

Emergency indications: document acute presentation — prior auth typically not required
Outpatient: document why CT is preferred over MRI (contraindication, urgency, prior MRI result)
Contrast upgrade: document specific clinical reason

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Disclaimer: Coverage criteria shown on this page are sourced from publicly available payer guidelines and are provided for informational and educational purposes only. Prior authorization requirements change frequently. Always verify current criteria directly with the payer or their delegated utilization management company before submitting an authorization request. This page does not constitute medical or legal advice.