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Effective July 1, 2017, we're lifting medical necessity review requirements for 101 experimental and investigational (EIV) codes.
>> View the complete list of affected codes
Medical Protocol Introduction
Our Corporate Medical Protocols provide a concise overview of the criteria used for clinical determinations for a member’s coverage.
Medical Protocol Search
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You searched in the "Radiology" category.
- Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions
- Computed Tomography Perfusion Imaging of the Brain
- Computer-Aided Evaluation of Malignancy With Magnetic Resonance Imaging of the Breast
- Diagnosis and Treatment of Sacroiliac Joint Pain
- Dopamine Transporter Imaging With Single-Photon Emission Computed Tomography
- Drug Testing in Pain Management and Substance Abuse Treatment
- Dynamic Spinal Visualization
- Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer
- Intensity-Modulated Radiotherapy: Abdomen and Pelvis
- Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid
Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions
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- Actigraphy
- Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias
- Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms
- Allogeneic Pancreas Transplant
- Ambulance (Emergency)
- Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
- Amniotic Membrane and Amniotic Fluid
- Antigen Leukocyte Antibody Test
- Aqueous Shunts and Stents for Glaucoma
- Artificial Intervertebral Disc: Cervical Spine
- Artificial Intervertebral Disc: Lumbar Spine
- Artificial Pancreas Device Systems
- Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
- Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
- Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions
- Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients With Elevated Office Blood Pressure
- Automated Percutaneous and Percutaneous Endoscopic Discectomy
- Autonomic Nervous System Testing
- Axial Lumbosacral Interbody Fusion
- Balloon Ostial Dilation for Treatment of Chronic Rhinosinusitis
- Bariatric Surgery
- Bioengineered Skin and Soft Tissue Substitutes
- Biofeedback as a Treatment of Chronic Pain
- Biofeedback as a Treatment of Fecal Incontinence or Constipation
- Biofeedback as a Treatment of Headache
- Biofeedback as a Treatment of Urinary Incontinence in Adults
- Biofeedback for Miscellaneous Indications
- Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure
- Blepharoplasty
- Bronchial Thermoplasty
- Cardiac Rehabilitation in the Outpatient Setting
- Cardiovascular Risk Panels
- Carrier Screening for Genetic Diseases
- Catheter Ablation as Treatment for Atrial Fibrillation
- Catheter Ablation for Cardiac Arrhythmias
- Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions
- Chelation Therapy for Off-Label Uses
- Chromosomal Microarray Testing for the Evaluation of Pregnancy Loss
- Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)
- Circulating Tumor DNA for Management of Non-Small-Cell Lung Cancer (Liquid Biopsy)
- Closure Devices for Patent Foramen Ovale and Atrial Septal Defects
- Cochlear Implant
- Cognitive Rehabilitation
- Computed Tomography Perfusion Imaging of the Brain
- Computer-Aided Evaluation of Malignancy With Magnetic Resonance Imaging of the Breast
- Computer-Assisted Navigation for Orthopedic Procedure
- Confocal Laser Endomicroscopy
- Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid
- Continuous Passive Motion in the Home Setting
- Cooling Devices Used in the Outpatient Setting
- Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy
- Cosmetic vs. Reconstructive Surgery or Services
- Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors
- Cryosurgical Ablation of Primary or Metastatic Liver Tumors
- Cytochrome P450 Genotyping
- Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies
- Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)
- Deep Brain Stimulation
- Dermatologic Applications of Photodynamic Therapy
- Diagnosis and Management of Idiopathic Environmental Intolerance and Intracellular Micronutrient Analysis
- Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
- Diagnosis and Treatment of Sacroiliac Joint Pain
- DNA-Based Testing for Adolescent Idiopathic Scoliosis
- Dopamine Transporter Imaging With Single-Photon Emission Computed Tomography
- Drug Testing in Pain Management and Substance Abuse Treatment
- Dynamic Posturography
- Dynamic Spinal Visualization
- Electrical Bone Growth Stimulation of the Appendicular Skeleton
- Electrical Stimulation for the Treatment of Arthritis
- Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
- Electromagnetic Navigation Bronchoscopy
- Electrostimulation and Electromagnetic Therapy for Treating Wounds
- Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer
- Endometrial Ablation
- Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus
- Endothelial Keratoplasty
- Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
- Endovascular Stent Grafts for Abdominal Aortic Aneurysms
- Endovascular Therapies for Extracranial Vertebral Artery Disease
- Enhanced External Counterpulsation
- Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies
- Extracorporeal Photopheresis
- Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
- Extracranial Carotid Artery Stenting
- Gastric Electrical Stimulation
- Gender Reassignment Surgery
- Gene Expression Testing in the Evaluation of Patients with Stable Ischemic Heart Disease
- Gene Expression-Based Assays for Cancers of Unknown Primary
- General Approach to Evaluating the Utility of Genetic Panels
- General Approach to Genetic Testing
- Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing
- Genetic Testing for Alpha1-Antitrypsin Deficiency
- Genetic Testing for Alzheimer Disease
- Genetic Testing for Breast Cancer Gene Expression Prognosis Assay
- Genetic Testing for Cardiac Ion Channelopathies
- Genetic Testing for Cystic Fibrosis
- Genetic Testing for Developmental Delay and Autism Spectrum Disorder
- Genetic Testing for Duchenne and Becker Muscular Dystrophy
- Genetic Testing for Epilepsy
- Genetic Testing for Familial Cutaneous Malignant Melanoma
- Genetic Testing for FAP and Lynch Syndrome
- Genetic Testing for Hereditary Breast and Ovarian Cancer Syndrome
- Genetic Testing for Hereditary Hearing Loss
- Genetic Testing for Hereditary Hemochromatosis
- Genetic Testing for Human Leukocyte Genes (HLA)
- Genetic Testing for Lactase Insufficiency
- Genetic Testing for Leukemia and Lymphoma
- Genetic Testing for Li-Fraumeni Syndrome
- Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment
- Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders
- Genetic Testing for Mental Health Conditions
- Genetic Testing for Mitochondrial Disorders
- Genetic Testing for Noninvasive Prenatal Testing
- Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy
- Genetic Testing for PTEN Hamartoma Tumor Syndrome
- Genetic Testing for Statin-Induced Myopathy
- Genetic Testing for Tamoxifen Treatment
- Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies
- Genetic Testing for Warfarin Dose
- Genetic Testing of CADASIL Syndrome
- Heart Transplant
- Heart/Lung Transplant
- Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
- Hematopoietic Cell Transplantation for Autoimmune Diseases
- Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma
- Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma
- Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia
- Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer
- Hematopoietic Cell Transplantation for Hodgkin Lymphoma
- Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults
- Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome
- Hematopoietic Cell Transplantation for Primary Amyloidosis
- Hematopoietic Cell Transplantation for Waldenström Macroglobulinemia
- Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors
- Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia
- Hematopoietic Stem Cell Transplantation for Non-Hodgkin Lymphomas
- Hematopoietic Stem Cell Transplantation for Solid Tumors of Childhood
- Hip Resurfacing
- Hippotherapy
- Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disease
- Hyperbaric Oxygen Therapy
- Image-Guided Minimally Invasive Decompression for Spinal Stenosis
- Immune Cell Function Assay
- Implantable Bone-Conduction and Bone-Anchored Hearing Aids
- Implantable Cardioverter Defibrillators
- Implantable Sinus Stents for Postoperative Use Following Endoscopic Sinus Surgery and for Recurrent Sinus Disease
- Implantation of Intrastromal Corneal Ring Segments
- In Vitro Chemoresistance and Chemosensitivity Assays
- Ingestible pH and Pressure Capsule
- Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
- Intensity-Modulated Radiotherapy: Abdomen and Pelvis
- Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid
- Intensity-Modulated Radiotherapy: Central Nervous System Tumors
- Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
- Interspinous Fixation (Fusion) Devices
- Intra-Articular Hyaluronan Injections for Osteoarthritis
- Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas
- Intradialytic Parenteral Nutrition
- Intraoperative Neurophysiologic Monitoring
- Invasive Prenatal (Fetal) Diagnostic Testing
- Islet Transplantation
- Isolated Small Bowel Transplant
- Magnetic Resonance Imaging‒Targeted Biopsy of the Prostate
- Magnetic Resonance-Guided Focused Ultrasound
- Magnetoencephalography/Magnetic Source Imaging
- Manipulation Under Anesthesia
- Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders
- Measurement of Serum Antibodies to Infliximab and Adalimumab
- Meniscal Allografts and Other Meniscal Implants
- Microprocessor-Controlled Prostheses for the Lower Limb
- Microwave Tumor Ablation
- Miscellaneous Genetic and Molecular Diagnostic Tests
- Molecular Analysis for Targeted Therapy of Non-Small-Cell Lung Cancer
- Molecular Markers in Fine Needle Aspirates of the Thyroid
- Multigene Expression Assay for Predicting Recurrence in Colon Cancer
- Multimarker Serum Testing Related to Ovarian Cancer
- Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis
- Myoelectric Prosthetic Components for the Upper Limb
- Occipital Nerve Stimulation
- Occlusion of Uterine Arteries Using Transcatheter Embolization
- Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus
- Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)
- Optical Coherence Tomography of the Anterior Eye Segment
- Orthognathic Surgery
- Orthopedic Applications of Platelet-Rich Plasma
- Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used With Autologous Bone Marrow)
- Orthoptic/Vision Therapy
- Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions
- Outpatient Pulmonary Rehabilitation
- Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
- Panniculectomy and Abdominoplasty
- PathFinderTG® Molecular Testing
- Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
- Percutaneous Balloon Kyphoplasty and Mechanical Vertebral Augmentation
- Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy
- Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty
- Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
- Percutaneous Tibial Nerve Stimulation
- Percutaneous Vertebroplasty and Sacroplasty
- Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux
- Pharmacogenetic Testing for Pain Management
- Pharmacogenomic and Metabolite Markers for Patients Treated With Thiopurines
- Photodynamic Therapy for Choroidal Neovascularization
- Placental and Umbilical Cord Blood as a Source of Stem Cells
- Plasma Exchange
- Plugs for Anal Fistula Repair
- Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
- Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
- Preimplantation Genetic Testing
- Progenitor Cell Therapy for the Treatment of Damaged Myocardium due to Ischemia
- Prolotherapy
- Prophylactic Mastectomy
- Prostatic Urethral Lift
- Protein and Genetic Testing for Prostate Cancer
- Radioembolization for Primary and Metastatic Tumors of the Liver
- Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
- Radiofrequency Ablation of Primary or Metastatic Liver Tumors
- Radioimmunoscintigraphy (Monoclonal Antibody Imaging) With Indium 111 Capromab Pendetide for Prostate Cancer
- Reconstructive Breast Surgery/Management of Breast Implants
- Reduction Mammaplasty for Breast-Related Symptoms
- Sacral Nerve Neuromodulation/Stimulation
- Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer
- Scintimammography and Gamma Imaging of the Breast and Axilla
- Semi-Implantable and Fully Implantable Middle Ear Hearing Aids
- Sensory Integration Therapy and Auditory Integration Therapy
- Small Bowel/Liver and Multivisceral Transplant
- Spinal Cord and Dorsal Root Ganglion Stimulation
- Stem Cell Therapy for Peripheral Arterial Disease
- Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
- Subtalar Arthroereisis
- Surgical Treatment of Bilateral Gynecomastia
- Surgical Treatment of Femoroacetabular Impingement
- Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
- Surgical Ventricular Restoration
- Technology Assessment
- Temporomandibular Joint Dysfunction
- Thermography
- Total Artificial Hearts and Implantable Ventricular Assist Devices
- Transanal Radiofrequency Treatment of Fecal Incontinence
- Transcatheter Aortic Valve Implantation for Aortic Stenosis
- Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies
- Transcatheter Mitral Valve Repair
- Transcatheter Pulmonary Valve Implantation
- Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
- Transcutaneous Electrical Nerve Stimulation
- Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
- Transmyocardial Revascularization
- Treatment of Hyperhidrosis
- Treatment of Tinnitus
- Treatment of Varicose Veins/Venous Insufficiency
- Tumor Treatment Fields Therapy for Glioblastoma
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Protocol Cover Letters
Protocol Cover Letters prior to the dates shown can be obtained by contacting the Provider Call Center.
- March 1, 2018
- December 1, 2017
- September 1, 2017
- June 1, 2017
- February 28, 2017
- December 1, 2016
- September 1, 2016
- June 1, 2016
- March 1, 2016
- December 1, 2015
- September 1, 2015
- June 1, 2015
- March 2, 2015
- December 1, 2014
- September 2, 2014
- June 2, 2014
- March 3, 2014
- December 2, 2013
- September 3, 2013
- May 31, 2013
- March 1, 2013
- November 30, 2012
- September 1, 2012
- June 1, 2012
- March 1, 2012