Sample questionnaires for high-tech radiology procedures
Click on the links below to review the questions Blue Care Network will ask providers to answer when requesting an authorization for the listed procedures.
Effective October 1, 2008
Nuclear scan of heart muscle (myocardial perfusion imaging (PDF)
Effective January 1, 2009
Effective April 1, 2009
- CT of chest (PDF)
- CT of face and jaw (maxillofacial area) (PDF)
- MRI of abdomen (PDF)
- MRI of cervical spine (PDF)
- MRI of lower extremities (PDF)
- MRI of thoracic spine (PDF)
- MRI of upper extremities (PDF)
- Nuclear blood pool imaging, cardiac blood pool, heart muscle cardiac MUGA (PDF)
- Nuclear scan of biliary tract/hepatobiliary duct (HIDA) (PDF)
- Nuclear scan of liver and spleen, SPECT, vascular flow (liver-spleen scan) (PDF)
- Nuclear scan of liver function (PDF)