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.
Medical Policies table
| ID | Title | Review | Description | Access |
|---|---|---|---|---|
| 06.001.020 | Virtual Colonoscopy/Computed Tomography Colonography | Oct 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 2019 | 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 2023 | 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 2022 | 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 2016 | ... | View |
| 06.001.026 | Contrast-Enhanced Computed Tomographic Angiography For Coronary Artery Evaluation | Oct 2025 | Contrast-enhanced coronary computed tomography angiography (ccta) is a noninvasive imaging test that requires... | View |
| 06.001.027 | Vertebral Fracture Assessment With Densitometry | Oct 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 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 2023 | 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 2024 | 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 2024 | 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 2019 | 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 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 | Dec 2025 | Dynamic spinal visualization is a general term addressing different imaging technologies that simultaneously... | View |
| 06.001.040 | Magnetoencephalography/Magnetic Source Imaging | Oct 2021 | 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 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 2025 | 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 2025 | Positron emission tomography (pet) scans use positron-emitting radionuclide tracers, which simultaneously... | View |
| 06.001.045 | Positional Magnetic Resonance Imaging | Dec 2023 | 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 2026 | Escription optical coherence tomography is a noninvasive, high-resolution imaging method that can be used to... | View |