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 |
|---|---|---|---|---|---|
| 06.001.039 | 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 |
| 06.001.041 | Interim Positron Emission Tomography Scanning In Oncology To Detect Early Response During Treatment | Aug 20, 2024 | Oct 20, 2025 | 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 | Oct 09, 2024 | Oct 20, 2025 | ... | 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 |
| 06.001.059 | Dopamine Transporter Single-Photon Emission Computed Tomography | Nov 12, 2024 | Nov 20, 2025 | Dopamine transporter imaging with single-photon emission computed tomography (dat-spect), using... | View |
| 06.001.060 | Endobronchial Ultrasound For Diagnosis And Staging Of Lung Cancer | Oct 22, 2024 | Oct 20, 2025 | Endobronchial ultrasound (ebus) is an imaging technique for adjunctive use with standard flexible... | View |
| 06.001.061 | Diagnosis And Treatment Of Sacroiliac Joint Pain | Dec 09, 2024 | Dec 20, 2025 | Sacroiliac joint (sij) arthrography using fluoroscopic guidance with an injection of an anesthetic has been... | View |
| 06.001.062 | Coronary Computed Tomography Angiography With Selective Noninvasive Fractional Flow Reserve | Jun 19, 2025 | Jun 20, 2026 | Invasive coronary angiography (ica) is clinically useful in stable ischemic heart disease when there is... | View |
| 06.001.063 | Therapeutic Radiopharmaceuticals In Oncology | Nov 07, 2024 | Nov 20, 2025 | Radiopharmaceuticals are composed of a radioisotope bond to an organic molecule and are used for diagnostic... | View |
| 06.001.064 | Thermography | Dec 03, 2024 | Policy Archived | Thermography is a noninvasive imaging technique that measures temperature distribution in organs and tissues.... | View |
