Medical policies

Medical Guidelines - Alphabetical Index

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

Abatacept (Orencia^®)
Accelerated Partial Breast Radiotherapy (Breast Brachytherapy)
Acoustic Cardiography
Acute and Maintenance Tocolysis
Adoptive Immunotherapy
Air Fluidized Beds
Alefacept Injection Amevive
Allergy Immunotherapy (Desensitization)
Allergy Testing
Allogeneic Hematopoietic Transplant for Genetic Diseases
Allogeneic Stem Cell Transplantation for Myelodysplastic Syndromes
Ambulance and Medical Transport Services
Ambulatory Event Monitors
Analysis of Proteomic Patterns for Early Detection of Cancer
Anesthesia Services
Ankle Replacement, Total
Anterior Cruciate Ligament Allograft
Anterior Eye Segment Optical Imaging
Antiprothrombin Antibody Testing
Aqueous Shunts and Devices for Glaucoma
Artificial Intervertebral Disc
Assays of Genetic Expression to Determine Prognosis of Breast Cancer
Autologous Cell Therapy for the Treatment of Damaged Myocardium
Autologous Chondrocyte Implantation
Automated Nerve Conduction Tests
Axial Lumbosacral Interbody Fusion

Back School
Balloon Sinuplasty for Treatment of Chronic Sinusitis
Baroreflex Stimulation Devices
Belimumab (Benlysta)
Bioengineered Skin and Tissue
Biofeedback
Bioimpedance Devices for Detection of Lymphedema
BioniCare Stimulator
Bone Mineral Density Studies
Bone Morphogenetic Protein
Bone Turnover Markers for Diagnosis and Management of Osteoporosis
Botulinum Toxin Injection
Brachytherapy, Intracavitary Balloon Catheter for Brain Cancer
Brachytherapy Treatment of Breast Cancer
BRAF Gene Mutation Testing to Select Melanoma Patients for BRAF Inhibitor Therapy
Breast Surgeries
Bronchial Thermoplasty

Canalith Repositioning for Benign Paroxysmal Positional Vertigo
Capsule Endoscopy, Wireless
Cardiac (Heart) Transplantation
Cardiac Hemodynamic Monitoring in the Outpatient Setting
Carotid Artery Angioplasty / Stenting (CAS)
Carotid Intimal-Medial Thickness Study
Catheter Ablation of the Pulmonary Veins as a Treatment for Atrial Fibrillation
Cellular Immunotherapy for Prostate Cancer
Cervicography
Charged Particle Radiotherapy Proton or Helium-ion
Chelation Therapy
Chemoembolization of the Hepatic Artery, Transcatheter Approach
Chemotherapy For Malignant Disease
Children's Mobility and Positioning Equipment
Chiropractic Services
Chromosomal Microarray (CMA) Analysis for Genetic Evaluation of Developmental Delay/Autism Spectrum Disorder
Clinical Trial Services For Life Threatening Conditions
Cochlear Implant
Collagen Implantation
Common Genetic Variants to Predict Risk of Nonfamilial Breast Cancer
Complementary and Alternative Medicine
Computed Tomography to Detect Coronary Artery Calcification
Computer-Aided Evaluation of Malignancy with MRI of the Breast
Computer Assisted Surgical Navigational Orthopedic Procedures
Computerized 2-Lead Resting Electrocardiogram Multifunction Cardiogram
Congenital Heart Defect, Repair Devices
Continuous Monitoring of Glucose in the Interstitial Fluid
Continuous Passive Motion in the Home Setting
Convection-Enhanced Delivery of Therapeutic Agents to the Brain
Cord Blood as a Source of Stem Cells
Corneal Topography
Correlated Audioelectric Cardiography
Cosmetic and Reconstructive Surgery
Cough Stimulating Device
Cryosurgical Ablation of Primary or Metastatic Liver Tumors
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors
CT Perfusion Imaging

Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)
Denosumab (Prolia^TM, XGEVA^TM)
Dental Inpatient and Outpatient Services
Dental, Reconstructive Services
Dermatoscopy
Detection of Circulating Tumor Cells
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis
Digital Breast Tomosynthesis
DNA Based Testing for Adolescent Idiopathic Scoliosis
Durable Medical Equipment (DME)
Dynamic Posturography

Electrical Bone Growth Stimulation
Electrocardiographic Body Surface Mapping
Electrodiagnostic Studies
Electroencephalograms
Electromagnetic Navigation Bronchoscopy
Electrogastrography, Cutaneous
Electrostimulation and Electromagnetic Therapy for Wounds
Electrothermal Arthroscopic Capsulorrhaphy
End Diastolic Pneumatic Compression Boot
Endobronchial Valves
Endothelial Keratoplasty
Endovascular Procedures for Intracranial Arterial Disease
Endovascular Stent Graft for Abdominal Aortic Aneurysm
Endovascular Stent Graft for Thoracic Aortic Aneurysm
Enhanced External Counterpulsation (EECP)
Enteral Nutrition
Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC)
Epiretinal Radiation Therapy for Age-Related Macular Degeneration
Epithelial Cell Cytology and Breast Cancer Risk Assessment
Esophageal pH Monitoring
E-visits (Online Medical Evaluation)
Exhaled Nitric Oxide Measurement
External Defibrillators
Extracorporeal Photopheresis as a Treatment of Graft-versus-Host Disease, Autoimmune Disease, and Cutaneous T-Cell Lymphoma
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing

Facet Joint Denervation
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
Fecal Calprotectin Test
Fecal Pancreatic Elastase-1 Test
Fetal Surgery for Malformations
Foot Care Services
Functional Capacity Assessment and Work Hardening
Functional Endoscopic Sinus Surgery (FESS)
Fundus Photography

Idiopathic Environmental Intolerance (i.e., Clinical Ecology)
Image Guided Minimally Invasive Lumbar Decompression (IG-MLD) for Spinal Stenosis
Immune Cell Function Assay in Solid Organ Transplantation
Immune Globulin Therapy
Implantable Bone Conduction Hearing Aids
Implantation of Intrastromal Corneal Ring Segments
Infertility, Diagnosis and Treatment
Infliximab (Remicade)
Infrared Heating Pad System in the Home Setting
Infusion Therapy in the Home
Ingestible pH and Pressure Capsule
Injectable Clostridial Collagenase for Fibroproliferative Disorders
Insulin Potentiation Therapy
Insulin Therapy, Chronic Intermittent Intravenous (CIIIT)
Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System
Intensity Modulated Radiation Therapy (IMRT) of Breast and Lung
Intensity Modulated Radiation Therapy (IMRT) of Head and Neck
Intensity Modulated Radiation Therapy (IMRT) of the Prostate
Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis
Interferential Stimulation
Intracellular Micronutrient Analysis
Intradialytic Parenteral Nutrition
Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty
Intraepidermal Nerve Fiber Density
Intravascular Ultrasound Imaging (IVUS)
Intravenous Antibiotic Therapy for Lyme Disease
Intravitreal Implant
In Vitro Chemoresistance and Chemosensitivity Assays
Ipilimumab (Yervoy)
Islet Cell Transplantation

None

Kappa Lambda Clonal Excess
Keratoprosthesis
KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy

Laboratory Testing to Allow Area Under the Curve (AUC) Targeted 5-Fluorouracil (5-FU) Dosing for Patients Administered 5-FU for Cancer
Laboratory Tests for Heart Transplant Rejection
Laser Treatment of Port Wine Stains
Left Atrial Appendage Closure Device for Stroke Prevention
Lipoprotein-Associated Phospholipase A2
Liver Transplant
Lumbar Spine Fusion Surgery
Lung and Lobar Lung Transplantation
Lung Cancer Screening, CT Scanning or Chest Radiographs
Lung Volume Reduction Surgery
Lymphedema Pumps -Sequential Pneumatic Compression Device
Lysis of Epidural Adhesions

Magnetic Resonance Spectroscopy
Magnetoencephalography/Magnetic Source Imaging
Melanoma Vaccines
Meniscal Allografts and Collagen Meniscus Implants
Microarray based Gene Expression Testing for Cancers of Unknown Primary
Microprocessor-Controlled Prostheses for the Lower Limb
Microwave Thermotherapy for Primary Breast Cancer
Minimally Invasive Hip and Knee Arthroplasty
Mohs' Micrographic Surgery
Monoclonal Antibody Imaging
Monoclonal Antibody Imaging for Prostate Cancer
MRI Guided High Intensity Ultrasound Ablation of Uterine Fibroids
Multigene Expression Assay for Predicting Recurrence in Colon Cancer
Myoelectric Prosthetic Components for the Upper Limb
Myolsis of Uterine Fibroids

Natalizumab (Tysabri)
Natural Killer Cell Assay for Habitual Spontaneous Abortions
Neurostimulation, Electrical
Non Contact Ultrasound Treatment for Wounds
Noninvasive Respiratory Assist Devices
Non-BRCA Breast Cancer Risk Assessment (OncoVue)
Non Pharmacologic Treatment of Rosacea

Observation Room Services
Occipital Nerve Stimulation
Optical Coherence Topography
Orthognathic Surgery
Orthopedic Applications of Stem Cell Therapy
Orthotics
Oscillatory Devices for the Treatment of Respiratory Conditions
Osteochondral Grafting in the Treatment of Articular Cartilage Lesions
Otoplasty
Ovarian and Internal Iliac Vein Embolization
Oxygen and Oxygen Supplies

Pancreas Transplant
Paraspinal Surface Electromyography
Partial Hip Resurfacing
PathFinder TG Molecular Testing
Patient Lifts
Pelvic Floor Stimulation as a Treatment of Urinary Incontinence
Percutaneous Discectomy
Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy
Periurethral Bulking Agents for the Treatment of Urinary Incontinence
Pharmacogenetic Testing for Warfarin Dose
Plugs for Fistula Repair
Positional Magnetic Resonance Imaging (MRI)
Posterior Tibial Nerve Stimulation for Voiding Dysfunction
Power Operated Vehicle (Scooter)
Pressure Reducing Support Surfaces
Private Duty Nursing Services
Progesterone Therapy in High Risk Pregnancies
Prolotherapy
Prosthetic Appliances
Proteomics Based Testing for the Evaluation of Ovarian (Adnexal) Masses
Pulmonary Hypertension, Drug Management

Quantitative Sensory Testing

Radioembolization for Primary and Metastatic Tumors of the Liver
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
Radiofrequency Tissue Remodeling for Urinary Stress Incontinence
Radiosurgery, Stereotactic Approach
Rapid Opioid Detoxification
Real Time Intra Fraction Target Tracking During Radiation Therapy
Reconstructive Eyelid Surgery and Brow Lift
Refractive Surgery
Rehabilitative Therapies
Renal (Kidney) Transplantation
Residential Treatment for Chemical Dependency
Respiratory Syncytial Virus Prophylaxis
Retinal Prosthesis
Reverse Shoulder Arthroplasty
Rhinoplasty
Rituximab for the Treatment of Rheumatoid Arthritis

Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction
Salivary Estriol as a Risk Predictor for Pretern Labor
Salivary Hormone Tests
Saturation Biopsy for Diagnosis and Staging of Prostate Cancer
Semi implantable and fully implantable middle ear hearing aid
Sensory Integration Therapy
Serum Holo-Transcobalamin as a Marker of Vitamin B12 Status
Sexual Dysfunction Treatment, Female
Sexual Dysfunction Treatment, Male
Signal Averaged ECG
Skilled Nursing Facility Care
Skilled Nursing Services
Sleep Apnea: Diagnosis and Medical Management
Small Bowel, Small Bowel with Liver, or Multivisceral Transplant
Speech Generating Devices
Spinal Cord Stimulation
Spinal Manipulation under Anesthesia
Spinal Surgery Using Interspinous Distraction Technology
Stem-cell Therapy for Peripheral Arterial Disease
Subtalar Arthroereisis
Suprachoroidal Delivery of Pharmacologic Agents
Surgery for Femoroacetabular Impingement
Surgery for Morbid Obesity
Surgery_for_obstructive_sleep_apnea_and_upper_airway_resistance_syndrome
Surgical Interruption of Pelvic Nerve Pathways for Dysmenorrhea
Surgical Treatment of Chest Wall Deformities (Congenital or Acquired)
Surgical Ventricular Restoration
Systems Pathology for Predicting Risk of Recurrence in Prostate Cancer

T - Wave Alternans
Targeted Phototherapy for Psoriasis
Telemedicine
Temporary Prostatic Stent
Temporomandibular Joint Dysfunction (TMJD) Treatment
Transanal Radiofrequence Treatment of Fecal Incontinence
Thermography
Thoracoscopic Laser Ablation of Emphysematous Pulmonary Bullae
Tinnitus Treatment
Tocilizumab (Actemra)
Topical Hyperbaric Oxygen Therapy
Topical Negative Pressure Therapy for Wounds
Total Facet Arthroplasty
Total Hip Resurfacing
Total Parenteral Nutrition
Transanal Endoscopic Microsurgery
Transanal Radiofrequency Treatment of Fecal Incontinence
Transcatheter Closure of Ventricular Septal Defects
Transcatheter Heart Valve Implantation
Transcranial Magnetic Stimulation
Transtympanic Micropressure Applicationsas a Treatment of Meniere's Disease
Treatment for Severe Primary IGF-1 Deficiency
Tyrosine Kinase Mutations in Myeloproliferative Neoplasms

Ultrasonographic Evaluation of Skin Lesions
Ultrasound Accelerated Fracture Healing Device
Urinary Tumor Markers for Bladder Cancer
Ustekinumab (Stelara)

Vagus Nerve Stimulation
Varicose Veins, Treatment for
Vertebral Axial Decompression (VAX-D)
Vertebroplasty and Kyphoplasty Percutaneous
Vesicoureteral Reflux, Treatment with Periureteral Bulking Agents

Wheelchairs
Whole Body Computed Tomography Scan as a Screening Test
Wound Therapy, Noncontact Radiant Heat Bandage

Xolair (Omalizumab)

None

To view PDF documents you need Adobe Acrobat Reader.