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Medical Policies
Medical policies are documents that define the plan coverage for technologies, procedures and treatments. The statements of medical necessity in the policies, about whether a technology, procedure, treatment, supply, equipment, drug or other service improves the health outcome of the population for which said technology or treatment was designed are based on scientific evidence, clinical studies and professional opinions from our providers and recognized medical organizations.
Each document displayed on this website is provided for informational purposes only and is not an authorization, explanation of benefits, or contract. Receiving benefits is subject to satisfaction of all terms and conditions of coverage. Medical technology is constantly changing, and we reserve the right to periodically review and update our policies.
| ID | Title | Last Review | Next Review | Description | Access |
|---|---|---|---|---|---|
| 06.001.010 | Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer | Oct 22, 2024 | Oct 20, 2025 | All policy statements below refer to performing magnetic resonance imaging (mri) of the breast with contrast... | View |
| 06.001.011 | Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography | Nov 06, 2024 | Nov 20, 2025 | Positron emission tomography (pet) using 2-[fluorine-18]-fluoro-2-deoxy-d-glucose (fdg) may be considered... | View |
| 06.001.014 | Oncologic Applications of Positron Emission Tomography Scanning | Jan 10, 2025 | Oct 20, 2025 | All policy statements apply to both positron emission tomography (pet) scans and pet plus computed tomography... | View |
| 06.001.015 | Stereotactic Radiosurgery and Stereotactic Body Radiotherapy | Aug 09, 2024 | Aug 20, 2025 | Stereotactic radiosurgery using a gamma-ray or linear accelerator unit may be considered medically... | View |
| 06.001.016 | Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds | Aug 19, 2024 | Aug 20, 2025 | Brachytherapy using permanent transperineal implantation of radioactive seeds may be considered medically... | View |
| 06.001.018 | Minimally Invasive Approaches to Vertebral Fractures and Osteolytic Lesions of the Spine | May 10, 2024 | May 20, 2025 | Percutaneous vertebroplasty, percutaneous balloon kyphoplasty, radiofrequency kyphoplasty, and mechanical... | View |
| 06.001.020 | Virtual Colonoscopy/Computed Tomography Colonography | Oct 07, 2024 | Oct 20, 2025 | Computed tomography colonography (ctc) may be considered medically necessary for the purposes of colon... | View |
| 06.001.021 | Computer-Aided detection in Conjuction with Digitized Screen-Film Mammography or Ful-Field Digital Mammography | Dec 16, 2019 | Policy Archived | Computer-aided detection devices as an adjunct to single-reader interpretation of digitized screen-film... | View |
| 06.001.022 | Intravascular Ultrasound Imaging of Coronary Arteries | Aug 31, 2023 | Policy Archived | The use of ivus in transcatheter revascularization therapy of coronary artery disease may be considered... | View |
| 06.001.023 | Magnetic Resonance Angiography of Vessels of the Head, Neck,Abdomen, Pelvis, and Lower Extremity | Jul 19, 2022 | Policy Archived | Mra of the head may be considered medically necessary for the assessment of: ï· patients suspected of... | View |
| 06.001.025 | TOMOGRAFIA COMPUTADORIZADA DEL CUERPO ENTERO COMO METODO DE CERNIMIENTO | May 16, 2016 | Policy Archived | Tomografía computadorizada de cuerpo entero cómo un método de cernimiento no se considera para pago. el... | View |
| 06.001.026 | Contrast-Enhanced Computed Tomographic Angiography for Coronary Artery Evaluation | Oct 07, 2024 | Oct 20, 2025 | Contrast-enhanced coronary computed tomography angiography (ccta) for evaluation of individuals with acute... | View |
| 06.001.027 | Vertebral Fracture Assessment with Densitometry | Nov 26, 2024 | Nov 20, 2025 | Screening for vertebral fractures using dual-energy x-ray absorptiometry or biomechanical computed tomography... | View |
| 06.001.028 | Computed Tomography to Detect Coronary Artery Calcification | Oct 07, 2024 | Oct 20, 2025 | When quantitative assessment is performed as part of the same encounter as contrast-enhanced cardiac computed... | View |
| 06.001.030 | ENDOSCOPIC ULTRASONOGRAPHY | Aug 23, 2023 | Policy Archived | Endoscopic ultrasonography is considered for payment, as recommended by the american society for... | View |
| 06.001.034 | Functional Magnetic Resonance Imaging of the Brain for Presurgical Mapping or Seizure Focus Localization | Nov 07, 2024 | Policy Archived | Functional magnetic resonance imaging may be considered medically necessary as a complementary test in the... | View |
| 06.001.035 | FDG Using Camera-Based Imaging (FDG-SPECT) | Sep 18, 2024 | Policy Archived | Spect is considered for payment to demonstrate myocardial viability. spect is not considered for payment... | View |
| 06.001.037 | Scintigraphy of Acute Deep Venous Thrombus | Sep 05, 2019 | Policy Archived | Scintigraphic imaging of acute venous thrombus in the lower extremities may be considered medically necessary... | View |
| 06.001.038 | Computed Tomography Perfusion Imaging of the Brain | Jan 07, 2025 | Jan 20, 2026 | Computed tomography perfusion imaging may be considered medically necessary to select patients with anterior... | View |
| 06.001.039 | Dynamic Spinal Visualization and Vertebral Motion Analysis | Oct 08, 2024 | Policy Archived | The use of dynamic spinal visualization is considered investigational. vertebral motion analysis is... | View |
