Sample questionnaires for high-tech radiology procedures (for dates of service on or before June 30, 2014)
Click on the links below to review the questions Blue Care Network asks providers to answer when requesting clinical review for the procedures listed here.
- 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)