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ACG
​
h.o.l.M.E.S.

Automated Clinical Guidelines

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

Imaging

Cardiac Single-Photon Emission Computed Tomography (SPECT)
Coronary Artery Calcium Scoring and Coronary Computed Tomography Angiography
Computed Tomographic (CT) Colonography for Diagnostic Uses (L33562)
Computed Tomography Cerebral Perfusion Analysis (CTP)
Computerized Diagnostic Imaging for Complex Maxillofacial Procedures
Humana
Humana
Aetna
Cardiac Computed Tomography (CCT) & Coronary Computed Tomography Angiography (CCTA)
FloridaBlue
CT Abdomen & Pelvis
CT Angiography, Abdominal Arteries
CT Angiography, Abdomen
CT Angiography, Abdomen and Pelvis
CT Angiography, Chest (non-coronary)
Computed Tomographic Angiography (CTA) Heart
Humana
FloridaBlue
CT Abdomen
Humana

Indicates Non-covered Service

Humana
FloridaBlue
Medicare
FloridaBlue
FloridaBlue
CT Angiography, Lower Extremity
Computed Tomography Angiography (CTA) Neck
CT Angiography, Pelvis
CT Angiography, Upper Extremity
FloridaBlue
CT Angiography, Head & Brain
FloridaBlue
FloridaBlue
FloridaBlue
CT Heart
CT Pelvis
CT Soft Tissue Neck
Computed Tomography of the Thorax
Fractional Flow Reserve CT
CT Head/Brain
FloridaBlue
FloridaBlue
FloridaBlue
FloridaBlue
FloridaBlue
Multiple Imaging in Oncology
CT, Sinus Maxillofacial
SPECT/CT Fusion Imaging
CT, Temporal Bone, Mastoid, & Orbits
Computed Tomography (CT) Temporal Bone/Mastoid & Maxillofacial
FloridaBlue
Anthem
FloridaBlue
FloridaBlue
Cigna
Whole Body Computed Tomography Scan as a Screening Test
Cardiac Magnetic Resonance
Ferriscan R2-MRI
Fetal MRI
Functional MRI Brain (fMRI)
Magnetic Resonance Guided Focused Ultrasound
Magneto-encephalography/Magnetic Source Imaging
FloridaBlue
Breast Imaging: Breast Echography (Sonography)/ Breast MRI/ Ductography
FloridaBlue
FloridaBlue
FloridaBlue
Aetna
Aetna
Anthem
Humana
Magnetic Resonance Angiography (MRA) Abdomen & Pelvis
MR Angiography Chest
Magnetic Resonance Angiography (MRA) Extremity
Magnetic Resonance Angiography (MRA) of Head & Neck
Magnetic Resonance Angiography (MRA) Neck
FloridaBlue
Magnetic Resonance Angiography (MRA) of the Abdomen
FloridaBlue
Medicare
FloridaBlue
Medicare
FloridaBlue
FloridaBlue
Medicare
Magnetic Resonance Angiography (MRA) of the Pelvis
Medicare
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
Aetna
Magnetic Resonance Angiography (MRA) of Peripheral Arteries of Lower Extremities
FloridaBlue
Humana
FloridaBlue
Medicare
Magnetic Resonance Angiography (MRA) Brain (Head)
Humana
MRI Brain (includes Internal Auditory Canal)
MRI of the Breast
Magnetic resonance imaging (MRI) of the cardiovascular system
MRI Chest (Thorax)
Magnetic Resonance Cholangio-pancreatography (MRCP)
MRI Elastography
FloridaBlue
Magnetic Resonance Imaging (MRI) Brain & Head
UHC
FloridaBlue
FloridaBlue
Aetna
Anthem
Aetna
Aetna
FloridaBlue
Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor
MRI of the Heart
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
MRI of Face, Neck, Orbit, & Sinus
FloridaBlue
Aetna
FloridaBlue
MRI TMJ
Multiparametric MRI Fusion Imaging Targeted Prostate Biopsy
Multiple Imaging in Oncology
 Face, Neck, Orbit, & Sinus MRI
MRI Spectroscopy (MRS)
MRI TMJ

Positional

 MRI

Videofluoroscopy, Dynamic MRI for Musculoskeletal Indications
Magnetic Resonance Spectroscopy
Humana
CEA-Scan
Cholecystokinin cholescintigraphy
Hepatobiliary Imaging
Lymphoscintigraphy & Sentinel Lymph Node Biopsy
Malignant Melanoma Surveillance
Meta-Iodobenzyl-guanidine (MIBG) Imaging & Therapy
AndreView (Iobenguane I-123 injection)
Cigna
Myocardial Perfusion Imaging
OctreoScan
Oncoscint immuno-scintigraphy
ProstaScint
Radioactive Seed Localization of Nonpalpable Breast Lesions
MUGA Scan
FloridaBlue
FloridaBlue
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)
Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging) Using In-111 Satumomab Pendetide (OncoScint) or Tc-99m Arcitumomab (IMMU-4, CEA-Scan)
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
Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure
Aetna
Cardiac PET
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
Brain SPECT Scan
Humana
FloridaBlue
FloridaBlue
FloridaBlue
FloridaBlue
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)
Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment
FloridaBlue
Aetna
Positron Emission Mammography (PEM)
Beta Amyloid Imaging with Positron Emission Tomography (PET) for Alzheimer's Disease
Abdominal Echography
Arterial Ultrasound (Duplex Ultrasounds & Physiologic Testing)
Breast Echography (Sonography)
Breast Echography (Sonography)/ Breast MRI/ Ductography
Color-Flow Doppler Echocardiography in Adults
Duplex Scan of Hemodialysis Access
Abdominal Aortic Aneurysm Screening
Medicare
FloridaBlue
Duplex Scan to Evaluate for Carotid Artery Stenosis
Duplex Scan of Lower Extremity Arteries
Duplex Scanning of Aorta, Inferior Vena Cava, Iliac Vasculature, or Bypass Grafts
Duplex Scanning of Arterial Inflow and Venous Outflow of Abdominal, Pelvic, Scrotal Contents and/or Retroperitoneal Organs
Non-Invasive Evaluation of Extremity Veins
Echocardio-graphy
Duplex Scan for Erectile Dysfunction
FloridaBlue
Cigna
Commercial
MA
Fetal Echocardiography
Intracoronary Doppler Ultrasound
Noninvasive Assessment of Hepatic Fibrosis
Noninvasive Physiologic Studies of Upper or Lower Extremity Arteries
Noninvasive Physiologic Studies of Upper or Lower Extremity Arteries for HBO
Non-invasive Extracranial Arterial Studies
Medicare
Cigna
Non-Obstetric Gynecologic Duplex Ultrasonography of the Abdomen & Pelvis
Nonobstetric Pelvic Ultrasound
Nonvascular Extremity Ultrasound
Post-Voiding Residual Ultrasound