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ACG
​
h.o.l.M.E.S.

Automated Clinical Guidelines

Musculoskeletal Imaging

Indicates Non-covered Service

CT Bone Density Study
CT Cervical Spine
CT Lower Extremity (Ankle, Foot, Hip or Knee)
CT Lumbar Spine
CT Pelvis
Computed Tomography (CT) Spine (Cervical, Thoracic, Lumbar)
Magnetic Resonance Imaging (MRI) & Computed Tomography (CT) of the Spine
FloridaBlue
Aetna
Aetna
CT Thoracic Spine
Whole Body Computed Tomography Screening Test
Magnetic Resonance Imaging (MRI) of the Ankle and Hindfoot
Humana
MRI) Lower Extremity
Aetna
FloridaBlue
MRI) Upper Extremity
FloridaBlue
Magnetic Resonance Spectroscopy
Nuclear Medicine Imaging
Anthem
Bone & Joint SPECT
Spinal Ultrasonography
UHC
3D Interpretation
& Reporting of Imaging Studies
Computerized Motion Diagnostic Imaging
Aetna
Advanced Imaging of the Ankle
Advanced Imaging of the Pelvis
Computed Tomography (CT) Extremity (Upper & Lower)
FloridaBlue
MRI Bone Marrow
FloridaBlue
MRI Lumbar Spine
MRI Upper Extremity
Magnetic Resonance Spectroscopy for Discogenic Pain
Humana
SPECT Scan for Evaluation of Spondylolysis, Spondylolisthesis & Skeletal Disorders
Bone Mineral Density Studies
FEP
FloridaBlue
Humana
Thermography
Aetna
UHC
Advanced Imaging of Chondral/
Osteochondral Lesions, Including Osteochondritis Dissecans & Fractures
Advanced Imaging of the Shoulder
CT Upper Extremity
MRI Cervical Spine
Humana
MRI Pelvis
MRI Wrist
MRI Low Field
Single Photon Emission Computed Tomography (SPECT)
Whole Body Dual X-ray Absorptiometry (DEXA) to Determine Body Composition
Aetna
Advanced Imaging of the Elbow
Advanced Imaging of the Wrist
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Extremity Imaging
Anthem
MRI Elbow
Humana
MRI 
Shoulder
Humana

Positional

 MRI

Advanced Imaging for Ganglion Cysts
Avascular Necrosis (AVN)/
Osteonecrosis Imaging
MRI Hip
Humana
MRI Spine
Aetna
FloridaBlue
Videofluoroscopy, Dynamic MRI for Musculoskel-etal Indications
Humana
Advanced Imaging of the Hand
Symptom Based Spine Imaging
MRI Knee
Humana
Magnetic Resonance Imaging (MRI) & Computed Tomography (CT) of the Spine
Aetna
Advanced Imaging of the Hip
Diagnosis Based Bone & Joint Pelvic Imaging
MRI Thoracic Spine
Advanced Imaging of the Knee
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