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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 |
|---|---|---|---|---|---|
| 06.001.011 | Miscellaneous (Noncardiac, Nononcologic) Applications Of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography | Nov 06, 2024 | Nov 20, 2025 | Positron emission tomography (pet) images biochemical and physiologic functions by measuring concentrations... | View |
| 06.001.014 | Oncologic Applications Of Positron Emission Tomography Scanning | Feb 13, 2025 | Oct 20, 2025 | Positron emission tomography (pet) scans are based on the use of positron-emitting radionuclide tracers... | View |
| 06.001.015 | Stereotactic Radiosurgery And Stereotactic Body Radiotherapy | Feb 13, 2025 | Aug 20, 2025 | Stereotactic radiosurgery (srs) and stereotactic body radiotherapy (sbrt) are 3-dimensional conformal... | View |
| 06.001.016 | Brachytherapy For Clinically Localized Prostate Cancer Using Permanently Implanted Seeds | Aug 19, 2024 | Aug 20, 2025 | Brachytherapy is a procedure in which a radioactive source (eg, radioisotope "seeds") is... | View |
| 06.001.018 | Percutaneous Vertebroplasty And Sacropasty | 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), also known as virtual colonoscopy, is an imaging modality that has... | 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 (cad) has been suggested as an adjunct to screening mammograms to decrease errors in... | View |
| 06.001.022 | Uso del ultrasonido intravascular en las arterias coronarias | Aug 31, 2023 | Policy Archived | Transcatheter intravascular ultrasound (ivus) imaging is a technique in which a miniaturized ultrasound... | View |
| 06.001.023 | Magnetic Resonance Angiography Of Vessels Of The Head, Neck, Abdomen, Pelvis, And Lower Extremity | Jul 19, 2022 | Policy Archived | Magnetic resonance angiography (mra) is a technique for imaging vascular anatomy and pathology that does not... | View |
| 06.001.025 | Tomografía computadorizada del cuerpo entero como método de cernimiento | May 16, 2016 | Policy Archived | ... | 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) is a noninvasive imaging test that requires... | View |
| 06.001.027 | Vertebral Fracture Assessment With Densitometry | Nov 26, 2024 | Nov 20, 2025 | Vertebral fracture assessment (vfa) with densitometry is a technique to assess vertebral fractures at the... | View |
| 06.001.028 | Computed Tomography To Detect Coronary Artery Calcification | Oct 07, 2024 | Oct 20, 2025 | Several types of fast computed tomography (ct) imaging, including electron-beam ct and spiral ct, allow the... | View |
| 06.001.030 | Ultrasonografia Endoscópica | Aug 23, 2023 | Policy Archived | Endoscopic ultrasonography (eus) has evolved from a diagnostic imaging modality to one that can also be used... | View |
| 06.001.034 | Functional Magnetic Resonance Imaging Of The Brain | Nov 07, 2024 | Policy Archived | Functional magnetic resonance imaging (fmri) is a noninvasive method for localizing areas of brain function... | View |
| 06.001.035 | Fdg Using Camera-Based Imaging (Fdg-Spect) | Sep 18, 2024 | Policy Archived | Spect (single photo emission computed tomography) is a radiological diagnostic test. unlike ct, mri that... | View |
| 06.001.037 | Scintigraphy Of Acute Deep Venous Thrombus | Sep 05, 2019 | Policy Archived | Deep vein thrombosis (dvt) is a common occurrence. it is estimated that in the united states approximately 5... | View |
| 06.001.038 | Computed Tomography Perfusion Imaging Of The Brain | Jan 07, 2025 | Jan 20, 2026 | Computed tomography perfusion (ctp) imaging provides an assessment of cerebral blood flow that may help... | View |
| 06.001.039 | Dynamic Spinal Visualization And Vertebral Motion Analysis | Oct 08, 2024 | Policy Archived | Dynamic spinal visualization is a general term addressing different imaging technologies that simultaneously... | View |
| 06.001.040 | Magnetoencephalography/Magnetic Source Imaging | Oct 13, 2021 | Policy Archived | Magnetoencephalography (meg) is a noninvasive functional imaging technique that records weak magnetic forces.... | View |
