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 |
|---|---|---|---|---|---|
| 06.001.035 | FDG Using Camera-Based Imaging (FDG-SPECT) | Aug 23, 2023 | 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 | Oct 04, 2023 | Oct 20, 2024 | 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 05, 2023 | Oct 20, 2024 | The use of dynamic spinal visualization is considered investigational. vertebral motion analysis is... | View |
| 06.001.040 | Magnetoencephalography/Magnetic Source Imaging | Oct 13, 2021 | Policy Archived | Magnetoencephalography/magnetic source imaging as part of the preoperative evaluation of patients with... | View |
| 06.001.041 | Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment | Oct 11, 2023 | Oct 20, 2024 | The use of interim fluorine 18 fluorodeoxyglucose positron emission tomography scans to determine response to... | View |
| 06.001.042 | Positron Emission Mammography | Nov 05, 2020 | Policy Archived | The use of positron emission mammography is considered investigational for all... | View |
| 06.001.043 | Cardiac Applications of Positron Emission Tomography Scanning | Oct 11, 2023 | Oct 20, 2024 | Cardiac positron emission tomography (pet) scanning may be considered medically necessary to assess... | View |
| 06.001.045 | Positional Magnetic Resonance Imaging | Dec 14, 2023 | Policy Archived | Positional (nonrecumbent) magnetic resonance imaging is considered investigational, including its use in the... | View |
| 06.001.046 | Optical Coherence Tomography of the Anterior Eye Segment | Mar 05, 2024 | Mar 20, 2025 | Scanning computerized ophthalmic (eg, optical coherence tomography) imaging of the anterior eye segment is... | View |
| 06.001.047 | NON-INVASIVE ARTERIAL VASCULAR STUDIES OF UPPER AND LOWER EXTREMITIES | Oct 14, 2022 | Policy Archived | To perform a duplex scanning it is necessary to perform a real time scan, therefore the billing of a duplex... | View |
| 06.001.048 | NON INVASIVE EVALUATION OF EXTRACRANIAL ARTERIES | Nov 09, 2022 | Policy Archived | Non-invasive studies are recognized for payment if the results impact the clinical course of the patient, for... | View |
| 06.001.049 | NON INVASIVE VASCULAR STUDIES UPPER AND LOWER EXTREMITIES | Nov 14, 2018 | Policy Archived | To perform a duplex scanning sweep is needed in real time, therefore the billing of a duplex scanning and... | View |
| 06.001.050 | Duplex Sanning | Nov 14, 2019 | Policy Archived | The duplex scanning in the evaluation of the arterial / venous flow of abdominal, pelvic organs and of the... | View |
| 06.001.051 | Digital Breast Tomosynthesis | Nov 09, 2020 | Nov 09, 2021 | 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 | Nov 13, 2023 | Nov 20, 2024 | Amyloid beta imaging with positron emission tomography (pet) to predict conversion to alzheimer disease is... | View |
| 06.001.057 | INTENSITY MODULATED RADIATION THERAPY (IMRT) | Oct 26, 2023 | Oct 20, 2024 | Imrt is considered reasonable and medically necessary in instances where sparing the surrounding normal... | View |
| 06.001.059 | Dopamine Transporter Single-Photon Emission Computed Tomography | Nov 13, 2023 | Nov 20, 2024 | Dopamine transporter imaging with single-photon emission computed tomography may be considered medically... | View |
| 06.001.060 | Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer | Oct 18, 2023 | Oct 20, 2024 | Endobronchial ultrasound-guided transbronchial needle aspiration (ebus-tbna) may be considered medically... | View |
| 06.001.061 | Diagnosis and Treatment of Sacroiliac Joint Pain | Dec 04, 2023 | Dec 20, 2024 | Arthrography of the sacroiliac joint (sij) is considered investigational. injection of anesthetic for... | View |
