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 |
|---|---|---|---|---|---|
| 06.001.028 | Computed Tomography To Detect Coronary Artery Calcification | Oct 10, 2025 | Oct 20, 2026 | 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, 2026 | Jan 20, 2027 | 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 | Dec 08, 2025 | 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 |
| 06.001.041 | Interim Positron Emission Tomography Scanning In Oncology To Detect Early Response During Treatment | Dec 12, 2025 | Dec 20, 2026 | Positron emission tomography (pet) scanning has many established roles in oncology. one potential use of pet... | View |
| 06.001.042 | Positron Emission Mammography | Feb 25, 2025 | Policy Archived | Positron emission mammography (pem) is a form of positron emission tomography that uses high-resolution,... | View |
| 06.001.043 | Cardiac Applications Of Positron Emission Tomography Scanning | Nov 21, 2025 | Nov 20, 2026 | Positron emission tomography (pet) scans use positron-emitting radionuclide tracers, which simultaneously... | View |
| 06.001.045 | Positional Magnetic Resonance Imaging | Dec 14, 2023 | Policy Archived | Positional magnetic resonance imaging (mri) permits imaging of a patient in various positions, including... | View |
| 06.001.046 | Optical Coherence Tomography Of The Anterior Eye Segment | Apr 18, 2025 | Apr 20, 2026 | Optical coherence tomography is a noninvasive, high-resolution imaging method that can be used to visualize... | View |
| 06.001.047 | Non-Invasive Arterial Vascular Studies Of Upper And Lower Extremities | Oct 14, 2022 | Policy Archived | Non-invasive studies of the arterial system of the upper and lower extremities are used primarily to... | View |
| 06.001.048 | Non Invasive Evaluation Of Extracranial Arteries | Jan 13, 2025 | Policy Archived | Non-invasive studies of the extracranial arteries consist of the direct and indirect use of ultrasound... | View |
| 06.001.049 | Estudios vasculares venosos no invasivos de extremidades superiores e inferiores | Nov 14, 2018 | Policy Archived | Noninvasive vascular studies of the upper and lower extremities veins are used primarily to establish the... | View |
| 06.001.050 | Duplex Sanning | Nov 14, 2019 | Policy Archived | A duplex scanning is a procedure of tracking by ultrasound that demonstrates the structures in two dimensions... | View |
| 06.001.051 | Digital Breast Tomosynthesis | Nov 09, 2020 | Policy Archived | Digital breast tomosynthesis (dbt) uses modified digital mammography (dm) equipment to obtain additional... | View |
| 06.001.053 | Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease | Jun 19, 2025 | Jun 20, 2026 | Alzheimer disease (ad) is a fatal neurodegenerative disease that causes progressive loss in memory, language,... | View |
| 06.001.057 | Intensity Modulated Radiation Therapy (Imrt) | Oct 24, 2024 | Oct 20, 2025 | ... | View |
