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ACG
​
h.o.l.M.E.S.

Automated Clinical Guidelines

Computed Tomographic (CT) Colonography for Diagnostic Uses (L33562)
FloridaBlue
CT Angiography, Abdomen and Pelvis
FloridaBlue
CT Angiography, Head & Brain
FloridaBlue
CT Head/Brain
FloridaBlue
Multiple Imaging in Oncology
Computed Tomography Cerebral Perfusion Analysis (CTP)
Aetna
CT Angiography, Chest (non-coronary)
FloridaBlue
CT Angiography, Lower Extremity
FloridaBlue
CT Pelvis
CT, Sinus Maxillofacial

Imaging

Computerized Diagnostic Imaging for Complex Maxillofacial Procedures
Computed Tomography Angiography (CTA) Neck
FloridaBlue
CT Soft Tissue Neck
FloridaBlue
SPECT/CT Fusion Imaging
Anthem
CT Abdomen
Humana
CT Angiography, Pelvis
Computed Tomography of the Thorax
FloridaBlue
CT, Temporal Bone, Mastoid, & Orbits
FloridaBlue
CT Abdomen & Pelvis
FloridaBlue
Humana
Medicare
CT Angiography, Upper Extremity
FloridaBlue
Fractional Flow Reserve CT
FloridaBlue
Computed Tomography (CT) Temporal Bone/Mastoid & Maxillofacial
FloridaBlue
CT Angiography, Abdominal Arteries
CT Angiography, Abdomen
Humana

Indicates Non-covered Service

Whole Body Computed Tomography Scan as a Screening Test
FloridaBlue
Breast Imaging: Breast Echography (Sonography)/ Breast MRI/ Ductography
Ferriscan R2-MRI
Fetal MRI
Functional MRI Brain (fMRI)
Magnetic Resonance Guided Focused Ultrasound
Magneto-encephalography/Magnetic Source Imaging
FloridaBlue
Aetna
FloridaBlue
Aetna
FloridaBlue
Anthem
Magnetic Resonance Angiography (MRA) of the Abdomen
Magnetic Resonance Angiography (MRA) Abdomen & Pelvis
Magnetic Resonance Angiography (MRA) Brain (Head)
MR Angiography Chest
Magnetic Resonance Angiography (MRA) Extremity
Magnetic Resonance Angiography (MRA) of Head & Neck
Magnetic Resonance Angiography (MRA) Neck
Humana
FloridaBlue
FloridaBlue
Medicare
FloridaBlue
Medicare
FloridaBlue
Medicare
FloridaBlue
Magnetic Resonance Angiography (MRA) of the Pelvis
Medicare
Magnetic Resonance Angiography (MRA) of Peripheral Arteries of Lower Extremities
Magnetic Resonance Angiography (MRA) Spinal Canal
Magnetic Resonance Imaging Angiography Upper Extremity
Magnetic Resonance Angiography of Vessels of the Head, Neck, Abdomen, Pelvis & Lower Extremity
Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV)
Magnetic Resonance Imaging of the Abdomen
Magnetic Resonance Imaging (MRI) Abdomen & Pelvis
Medicare
FloridaBlue
Humana
FloridaBlue
Aetna
Magnetic Resonance Imaging (MRI) Brain & Head
MRI Brain (includes Internal Auditory Canal)
MRI of the Breast
MRI Chest (Thorax)
Magnetic Resonance Cholangio-pancreatography (MRCP)
MRI Elastography
FloridaBlue
Anthem
Aetna
FloridaBlue
UHC
FloridaBlue
Humana
FloridaBlue
Aetna
MRI of Face, Neck, Orbit, & Sinus
Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor
Magnetic Resonance Imaging (MRI) to Monitor Integrity of Silicone Gel-Filled Breast Implants
MRI MRCP  Abdomen
MRI Orbit, Face, Temporo-mandibular Joint (TMJ) & Neck
MRI Pelvis
Humana
FloridaBlue
MRI Spectroscopy (MRS)
MRI TMJ
Multiparametric MRI Fusion Imaging Targeted Prostate Biopsy
Multiple Imaging in Oncology
 Face, Neck, Orbit, & Sinus MRI
FloridaBlue
Aetna
Magnetic Resonance Spectroscopy
MRI TMJ

Positional

 MRI

Videofluoroscopy, Dynamic MRI for Musculoskeletal Indications
Humana
AndreView (Iobenguane I-123 injection)
CEA-Scan
Cholecystokinin cholescintigraphy
Hepatobiliary Imaging
Lymphoscintigraphy & Sentinel Lymph Node Biopsy
Malignant Melanoma Surveillance
Meta-Iodobenzyl-guanidine (MIBG) Imaging & Therapy
Cigna
OctreoScan
Oncoscint immuno-scintigraphy
ProstaScint
Radioactive Seed Localization of Nonpalpable Breast Lesions
Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging) Using In-111 Satumomab Pendetide (OncoScint) or Tc-99m Arcitumomab (IMMU-4, CEA-Scan)
Scintigraphy of Acute Deep Venous Thrombus
Scintigraphy & Uptake Measurement for Benign & Malignant Thyroid Disease
Scinti-mammography & Gamma Imaging of the Breast & Axilla
Technetium-99m-Sestamibi Scintigraphy
Technetium-Tc 99m Tilmanocept (Lymphoseek)
Radioimmuno-scintigraphy Imaging (Monoclonal Antibody Imaging) Using Technetium-99m Nofetumomab Merpentan (Verluma)
Radioimmuno-scintigraphy (Monoclonal Antibody Imaging) With Indium 111 Capromab Pendetide for Prostate Cancer
AcuTect Scintigraphic Imaging for Detection of Lower Limb Deep Vein Thrombosis
Aetna
Brain SPECT Scan
Cerebrospinal Fluid Flow SPECT
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography (DAT-SPECT)
FDG Using Camera-Based Imaging (FDG-SPECT)
Fusion Imaging
Gallium Ga68 Dotatate Scan
FloridaBlue
Humana
FloridaBlue
FloridaBlue
Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment
Kidney Dynamic Planar Scan with SPECT
Liver SPECT
Oncologic Applications of PET Scanning
PET & PET-CT Fusion for Oncologic Conditions
SPECT/CT Fusion Imaging
Single Photon Emission Computed Tomography (SPECT)
FloridaBlue
Aetna
Beta Amyloid Imaging with Positron Emission Tomography (PET) for Alzheimer's Disease
Positron Emission Mammography (PEM)
Abdominal Aortic Aneurysm Screening
Abdominal Echography
Arterial Ultrasound (Duplex Ultrasounds & Physiologic Testing)
Breast Echography (Sonography)
Breast Echography (Sonography)/ Breast MRI/ Ductography
Duplex Scan of Hemodialysis Access
Medicare
FloridaBlue
Duplex Scan for Erectile Dysfunction
Duplex Scan to Evaluate for Carotid Artery Stenosis
Duplex Scan of Lower Extremity Arteries
Duplex Scanning of Arterial Inflow and Venous Outflow of Abdominal, Pelvic, Scrotal Contents and/or Retroperitoneal Organs
Non-Invasive Evaluation of Extremity Veins
Commercial
Cigna
MA
Non-invasive Extracranial Arterial Studies
Fetal Echocardiography
Head & Neck Ultrasound
Noninvasive Assessment of Hepatic Fibrosis
Noninvasive Physiologic Studies of Upper or Lower Extremity Arteries
Noninvasive Vascular Studies of Abdominal, Pelvic, Scrotal Contents and/or Retroperitoneal Organs
Cigna
Noninvasive Physiologic Studies of Upper or Lower Extremity Arteries for HBO
Medicare
Non-Obstetric Gynecologic Duplex Ultrasonography of the Abdomen & Pelvis
Nonobstetric Pelvic Ultrasound
Nonvascular Extremity Ultrasound
Post-Voiding Residual Ultrasound
Scrotal Ultrasonography
Aetna
Cigna
Anthem
Transcranial Doppler Studies
Ultrasound Transient Elastography (FibroScan)
Ultrasound in Pregnancy
Transrectal Ultrasound
Transvaginal Ultrasonography (TV-US)
Ultrasound in Maternity Care
Ultrasound for Pregnancy Plus Detailed Fetal Anatomic Examination
FloridaBlue
Aetna
FloridaBlue
Retroperitoneal Ultrasound
Ultrasound, Soft Tissues of Head & Neck
Ultrasound Spine
UHC
Quantitative Ultrasound for Tissue Characterization
Ultrasound for the Evaluation of Paranasal Sinuses
Ultrasono-graphic Evaluation of Skin Lesions
Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis
FloridaBlue
Anthem
Aortography & Peripheral Angiography Abdominal Aortography
Aortography & Peripheral Angiography Illiac & Lower Extremity Angiography
Peripheral Artery Angiography, Rehabilitation & Revascularization - Lower Extremities
Aortography & Peripheral Angiography Renal Aortography
Three-Dimensional (3-D) Rendering, Interpretation, & Reporting of Imaging Studies
Barium Swallow Studies, Modified: Dysphagia with Secondary Diagnosis
Humana
Anthem
Barium Swallow Studies, Modified: Pneumonitis Due to Inhalation of Food & Vomit
Barium Swallow Studies, Modified: Sequelae of Cerebrovascular Disease
Breast Echography (Sonography) /Breast MRI/ Ductography
Breast Imaging
Chest X-Ray
Defecography
Humana
Humana
UHC
Diagnostic Abdominal Aortography and Renal Angiography
Diagnostic Mammography
Digital Breast Tomosynthesis
Ductography
Dysphagia
Imaging Evaluation
Radiologic Examination, Chest
Renal Angiography
Aetna
Humana
Screening Mammography
Sinus 
X-rays
Swallow Evaluation & Dysphagia Treatment
Thoracic Aortography & Carotid, Vertebral, & Subclavian Angiography
Computerized Motion Diagnostic Imaging
Dynamic Spinal Visualization (Including Digital Motion X-ray & Cineradio-graphy/ Videofluoros-copy)
Thermography
Aetna
Videofluoro-scopic Evaluation of Velopharyngeal Dysfunction
Whole Body Dual X-ray Absorptiometry (DEXA) to Determine Body Composition
Aetna
UHC
Anthem
FloridaBlue
Cigna

71250, 71260, 71270, 71271, 71275, 71550, 71551, 71552, 71555, 76377, 76380, 78580, 78582, 78597, 78598, 78815, 78830, G0296

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