Medical Policies


Evidence Based Guidelines - Categorical Index

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Administrative |  Drugs |  Home Health/Durable Medical Equipment |  Medical |  Mental Health/Chemical Dependency |  OB−GYN Reproduction |  Radiology |  Surgery |  Therapy |  Other Treatments

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Administrative   top

NONE

Drugs   top

Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER-2 Positive Malignancies
Erythropoiesis-Stimulating Agents (ESAs)
Intravitreal Angiogenesis Inhibitors for Choroidal and Retinal Vascular Conditions
Pertuzumab for Treatment of Malignancies
Trastuzumab

Home Health/Durable Medical Equipment   top

Apnea Monitor for Use in the Home
Blood Glucose Monitors for Use in the Home
External Insulin Pumps
Implantable Infusion Pumps
Photodynamic Therapy Ocular
Prothrombin Time Monitoring In The Home
Therapeutic Apheresis

Medical   top

Ambulatory Blood Pressure Monitoring
Arthroscopic Debridement and Lavage as Treatment of Knee Osteoarthritis
Automated Nerve Conduction Tests
BCR-ABL1 Testing for Diagnosis, Monitoring, and Drug Resistance Mutation Detection in Chronic Myelogenous Leukemia
Bevacizumab in Advanced Adenocarcinoma of the Pancreas
Biochemical Markers of Alzheimer's Disease
Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover
Cardiac Rehabilitation
Diagnosis and Treatment of Sacroiliac Joint Pain
Donor Lymphocyte Infusion
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett's Esophagus
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
Fecal Calprotectin Test
Genetic Testing for Alpha Thalassemia
Genetic Testing for CHARGE Syndrome
Genetic Testing for Duchenne and Becker Muscular Dystrophy
Genetic Testing for Facioscapulohumeral Muscular Dystrophy
Genetic Testing for FLT3 and NPM1 Mutations in Acute Myeloid Leukemia
Genetic Testing for Li-Fraumeni Syndrome
Genetic Testing for Hereditary Hearing Loss
Genetic Testing for PTEN Hamartoma Tumor Syndrome
Homocysteine Testing in Cardiac Disease Risk Assessment
Human Leukocyte Antigen (HLA) Testing for Celiac Disease
Inhaled Nitric Oxide
Intraoperative Neurophysiologic Monitoring (sensory-evoked potentials, motor-evoked potentials, EEG monitoring)
KRAS and BRAF Mutation Analysis in Cancer
Laboratory Testing for HIV Tropism
Monitored Anesthesia Care (MAC)
Monoclonal Antibodies for Non-Hodgkin Lymphoma and Acute Myeloid Leukemia
Ocriplasmin for Symptomatic Vitreomacular Adhesion
Paraspinal Surface Electromyography (EMG)
Pharmacogenomic and Metabolite Markers for Treatment with Thiopurines
Photodynamic Therapy for Treatment of Specific Cancers
Photodynamic Therapy Ocular
Quantitative Sensory Testing
Radiofrequency Ablation of Primary or Metastatic Liver Tumors
Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma
Serum Biomarker Human Epididymis Protein 4 (HE4)
Thermography
Therapeutic Apheresis
Total Body Photography
Ultrafiltration in Decompensated Heart Failure

Mental Health/Chemical Dependency   top

Psychoanalysis

OB-GYN Reproduction   top

Intrauterine Ablation or Resection of the Endometrium 
Maternal and Fetal Diagnostics
Uterine Artery Occlusion in the Treatment of Uterine Fibroids

Radiology   top

Charged Particle Radiotherapy
Endobronchial Brachytherapy
Intraoperative Radiation Therapy
Prostate Cancer Treatment with Brachytherapy
Screening for Vertebral Fracture with Dual X-Ray Absorptiometry (DEXA)

Surgery   top

Auditory Brain Stem Implant
Biventricular Pacemakers/Cardiac Resynchronization Therapy for Heart Failure
Cryoablation of Prostate Cancer
Deep Brain Stimulation
Endovascular Stent Graft for Abdominal Aortic Aneurysm
Endovascular Stent Graft for Thoracic Aortic Aneurysm
Hip Resurfacing
Laser Assisted Tonsillectomy
Maze Procedure for Atrial Fibrillation or Flutter
Septoplasty
TENS (Transcutaneous Electrical Nerve Stimulator)
Transmyocardial Revascularization (TMR)
Ventricular Assist Devices and Total Artificial Hearts
Vertical Expandable Prosthetic Titanium Rib

Therapy   top

Interventions for Progressive Scoliosis
Transurethral Microwave Thermotherapy for Benign Prostatic Hyperplasia

Other Treatments   top

Diabetic Retinopathy Telescreening
Glaucoma, Evaluation by Ophthalmic Techniques
Pulmonary Rehabilitation

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