BlueCross BlueShield of Tennessee Medical Policy Manual

Radiology

• Boron Neutron Capture Therapy (BNCT) For Glioblastoma Multiforme

• Brachytherapy for Breast Cancer

• Computed Tomography (CT) Perfusion Imaging

• Computed Tomography (CT) Scanning for Lung Cancer Screening

• Computed Tomography Angiography for Coronary Artery Evaluation

• Computed Tomography to Detect Coronary Artery Calcification

• Computer Assisted Surgical Navigational Orthopedic Procedures

• Computer-Aided Detection of Malignancy with Magnetic Resonance Imaging of the Breast

• Digital Breast Tomosynthesis

• Duplex Ultrasonography for Erectile Dysfunction

• Dynamic Infusion Cavernosometry and Cavernosography for Erectile Dysfunction

• Dynamic Spinal Visualization

• Epiretinal Radiation Therapy for Age-Related Macular Degeneration (ARMD)

• Fetal Echocardiography

• First-Trimester Detection of Down Syndrome Using Fetal Ultrasound Markers Combined with Maternal Serum Assessment

• Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis

• Ingestible Video Capsule Imaging of the Gastrointestinal Tract

• Intracavitary Balloon Catheter Brachytherapy for Malignant Gliomas or Metastases to the Brain

• Intraoperative Radiation Therapy (IORT)

• Intravascular Ultrasound (IVUS) Imaging of Coronary Arteries

• Magnetic Resonance Imaging (MRI) of the Breast

• Magnetoencephalography and Magnetic Source Imaging of the Brain

• Mammography Screening

• MRI-Guided High Intensity Ultrasound Ablation of Uterine Fibroids

• Nonoperative Diagnostic Spinal Ultrasound (Echography/Sonogram)

• Penile Brachial Index (PBI)

• Percutaneous Transluminal Angioplasty of the Aortic Arch Vessels with or without stenting (Brachiocephalic, Carotid, Subclavian, & Vertebral arteries), and of Coarctation of the Aorta

• Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty

• Positional Magnetic Resonance Imaging (MRI)

• Positron Emission Mammography

• Positron Emission Tomography (PET) for Miscellaneous Applications

• Positron Emission Tomography (PET) for Oncologic Applications

• Proton or Helium Ion Beam (Charged Particle) Radiation Therapy

• Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging) with Indium-111 Capromab Pendetide for Prostate Cancer

• Radiotherapy for Prostate Cancer

• Selective Internal Pudendal Arteriography (Angiography) for Erectile Dysfunction

• Shoulder Arthrography

• Stereotactic Radiosurgery of Central Nervous System (CNS) Lesions

• Teleradiology/ Teleimaging

• Thermography

• Three-Dimensional Magnetic Navigation Mapping System for Radiofrequency Ablation for the Treatment of Arrhythmias

• Ultrasonographic Measurements of Carotid Intima-Medial Thickness (CIMT) as an Assessment of Subclinical Atherosclerosis

• Virtual Colonoscopy (Computed Tomography Colonography)

• Whole-Body Computerized Axial Tomography (CT) Screening

• Whole Body Dual X-Ray Absorptiometry (DEXA) to Determine Body Composition

This document has been classified as public information.