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.
- CT of abdomen and CT of abdomen and pelvis combined (PDF)
- CT of brain (PDF)
- CT of chest (PDF)
- CT of face and jaw (maxillofacial area) (PDF)
- CT of lumbar spine (PDF)
- CT of pelvis (PDF)
- MRI of abdomen (PDF)
- MRI of brain (PDF)
- MRI of cervical spine (PDF)
- MRI of lower extremities (PDF)
- MRI of lumbar spine (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 heart muscle (myocardial perfusion imaging) (PDF)
- Nuclear scan of liver and spleen, SPECT, vascular flow (liver-spleen scan) (PDF)
- Nuclear scan of liver function (PDF)