BlueCross BlueShield of Tennessee Medical Policy Manual

Radiology

• Bone Mineral Density Studies

• Boron Neutron Capture Therapy (BNCT) For Glioblastoma Multiforme

• Brachytherapy for Breast Cancer

• 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

• Duplex Ultrasonography for Erectile Dysfunction

• Dynamic Infusion Cavernosometry and Cavernosography for Erectile Dysfunction

• Dynamic Spinal Visualization

• Fetal Echocardiography

• Herniography

• Ingestible Video Capsule Imaging of the Gastrointestinal Tract

• Intracoronary Radiation Therapy for the Prevention and Management of Restenosis

• Intraoperative Radiation Therapy (IORT)

• Intravascular Ultrasound (IVUS) Imaging of Coronary Arteries

• Magnetic Resonance Imaging (MRI) of the Breast

• Magnetic Resonance Spectroscopy (MRS)

• 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)

• Nuchal Translucency with or without Maternal Serum PAPP-A and Free ß-hCG Levels as a First-Trimester Screening for Down Syndrome (Trisomy 21) and Edward Syndrome (Trisomy 18)

• 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 and Kyphoplasty

• Positional Magnetic Resonance Imaging (MRI)

• 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

• Scintimammography

• 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 Intimal-Medial Thickness (IMT) as an Assessment of Subclinical Atherosclerosis

• Videofluoroscopic Evaluation of Velopharyngeal Closure (Speech Pathology)

• Virtual Colonoscopy (Computed Tomography Colonography)

• Whole-Body Computerized Axial Tomography (CT) Screening

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