Medical policies

Medical Guidelines - Alphabetical Index

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A   top

Abatacept (Orencia®)
Abdominoplasty, Panniculectomy and Lipectomy
Accelerated Partial Breast Radiotherapy (Breast Brachytherapy)
Acute and Maintenance Tocolysis
Adoptive Immunotherapy
Air Fluidized Beds
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 MGMT Promoter Methylation in Malignant Gliomas
Anesthesia Services
Antiprothrombin Antibody Testing
Aqueous Shunts and Devices for Glaucoma
Artificial Intervertebral Disc
Assays of Genetic Expression to Determine Prognosis of Breast Cancer
Autografts and Allografts in the Treatment of Focal Articular Cartilage
Autologous Chondrocyte Implantation
Automated Percutaneous and Endoscopic Discectomy
Axial Lumbosacral Interbody Fusion

B   top


Baroreflex Stimulation Devices
Belimumab (Benlysta)
Beta Amyloid Imaging With Positron Emission Tomography for Alzheimer's Disease
Bioengineered Skin and Tissue
Biofeedback
Bioimpedance Devices for Detection of Lymphedema
Bone Mineral Density Studies
Bone Morphogenetic Protein
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

C   top

Capsaicin (Qutenza®)
Capsule Endoscopy, Wireless
Cardiac (Heart) Transplantation
Cardiac Hemodynamic Monitoring in the Outpatient Setting
Cardiovascular Disease Risk Tests
Carotid Artery Angioplasty / Stenting (CAS)
Carotid Intimal-Medial Thickness
Carrier Testing for Genetic Disease
Catheter Ablation as a Treatment for Atrial Fibrillation
Cellular Immunotherapy for Prostate Cancer
Charged Particle Radiotherapy Proton or Helium-ion
Chelation Therapy
Chemoembolization of the Hepatic Artery, Transcatheter Approach
Chemotherapy For Malignant Disease
Chromosomal Microarray Testing for the Evaluation of Early Pregnancy Loss
Children's Mobility and Positioning Equipment
Chiropractic Services
Chromoendoscopy as an Adjunct to Colonoscopy
Clinical Trial Services
Cochlear Implant
Common Genetic Variants to Predict Risk of Nonfamilial Breast Cancer
Complementary and Alternative Medicine
Composite Allotransplantation of the Hand and Face
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
Confocal Laser Endomicroscopy
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 Collagen Cross-linking
Corneal Topography
Cosmetic and Reconstructive Surgery
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation
Cryosurgical Ablation of Primary or Metastatic Liver Tumors

Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors
CT Perfusion Imaging of the Brain
Cytochrome p450 Genotyping

D   top

Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)
Denosumab (ProliaTM, XGEVATM)
Dental Inpatient and Outpatient Services
Dental, Reconstructive Services
Dermatologic Applications of Photodynamic Therapy
Detection of Circulating Tumor Cells
Developmental Delay Screening and Testing Guidelines
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis
Digital Breast Tomosynthesis
DNA Based Testing for Adolescent Idiopathic Scoliosis
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography
Durable Medical Equipment (DME)
Dynamic Posturography

E   top

Eculizumab (Soliris®)
Electrical Bone Growth Stimulation
Electrical Stimulation for the Treatment of Arthritis
Electrocardiographic Body Surface Mapping
Electrodiagnostic Studies
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
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
Esophageal pH Monitoring
E-visits (Online Medical Evaluation)
Exhaled Nitric Oxide Measurement
External Defibrillators
Extracorporeal Photopheresis
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing

F   top

Facet Joint Denervation
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
Fecal Microbiota Transplantation
Fetal RHD Genotyping Using Maternal Plasma
Fetal Surgery for Malformations
Functional Capacity Assessment and Work Hardening
Fundus Photography

G   top

Gastric Electrical Stimulation
Gastroesophageal Reflux Disease, Transendoscopic Therapies
Gender Reassignment Surgery
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer
Gene Expression Testing to Predict Coronary Artery Disease
Gene Expression Profiling for Uveal Melanoma
General Approach to Evaluating the Utility of Genetic Panels
General Approach to Genetic Testing
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing
Genetic Testing for Alpha-1 Antitrypsin Deficiency
Genetic Testing for Breast and Ovarian Cancer
Genetic Testing for CADASIL Syndrome
Genetic Testing for Cardiac Ion Channelopathies
Genetic Testing for Colon Cancer
Genetic Testing for Cutaneous Malignant Melanoma
Genetic Testing for Dilated Cardiomyopathy
Genetic Testing for Epilepsy
Genetic Testing for Evaluation of Developmental Delay/Autism Spectrum Disorder
Genetic Testing for Familial Alzheimer's Disease
Genetic Testing for FMR1 Mutations Including Fragile X Syndrome
Genetic Testing for Hereditary Hemochromatosis
Genetic Testing for Hereditary Pancreatitis
Genetic Testing for Lactase Insufficiency
Genetic Testing for Macular Degeneration
Genetic Testing for Mental Health Conditions
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy
Genetic Testing for Rett Syndrome
Genetic Testing for Statin-induced Myopathy
Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathy
Golimumab (Simponi Aria)
Growth Factors in Wound Healing

H   top

Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery
Heart-Lung Transplantation
Hematopoietic Stem-Cell Transplant for Non Hodgkin's Lymphomas
Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia
Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia
Hematopoietic Stem-Cell Transplantation for Autoimmune Diseases
Hematopoietic Stem-Cell Transplantation for Breast Cancer
Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia
Hematopoietic Stem-Cell Transplantation for CLL and SLL
Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma
Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer
Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma
Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors in Adults
Hematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome
Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis
Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood
Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia
Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors
Hormone Pellet Implantation for Hormone Replacement Therapy in Women
Hyperbaric Oxygen Pressurization
Hyperhidrosis, Treatment of
Hyperthermia Therapy
Hyperthemic Intraperitoneal Chemotherapy

I   top

Identification of Microorganisms Using Nucleic Acid Probes
Idiopathic Environmental Intolerance (i.e. Multiple Chemical Sensitivities)
Image Guided Minimally Invasive Lumbar Decompression (IG-MLD) for Spinal Stenosis
Immune Cell Function Assay
Immune Globulin Therapy
Implantable Bone Conduction Hearing Aids
Implantable Cardioverter Defibrillator
Implantation of Intrastromal Corneal Ring Segments
Infertility, Diagnosis and Treatment
Infliximab (Remicade)
Infusion Therapy in the Home
Ingestible pH and Pressure Capsule
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
Injectable Clostridial Collagenase for Fibroproliferative Disorders
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
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
Interspinous Fixation (Fusion) Devices
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee
Intracellular Micronutrient Analysis
Intradialytic Parenteral Nutrition
Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty
Intraoperative Neurophysiologic Monitoring (sensory-evoked potentials, motor-evoked potentials, EEG monitoring)
Intravenous Anesthetics for the Treatment of Chronic Pain
Intravenous Antibiotic Therapy for Lyme Disease
Intravitreal Implant
Investigational (Experimental) Services
In Vitro Chemoresistance and Chemosensitivity Assays
Ipilimumab (Yervoy)
Islet Cell Transplantation

J   top

JAK2 and MPL Mutations in Myeloproliferative Neoplasms

K   top

Keratoprosthesis

L   top

Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients with Cancer
Laboratory Tests for Heart Transplant Rejection
Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids
Laser Treatment of Onychomycosis
Laser Treatment of Port Wine Stains
Light Therapy for Dermatologic Conditions
Lipid Apheresis
Liver Transplant
Lumbar Spine Fusion Surgery
Lung and Lobar Lung Transplantation
Lung Volume Reduction Surgery
Lysis of Epidural Adhesions

M   top

Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD)
Magnetic Resonance Spectroscopy
Magnetoencephalography/Magnetic Source Imaging
Measurement of Serum Antibodies to Infliximab and Adalimumab
Medical Necessity
Melanoma Vaccines
Meniscal Allografts and Other Meniscal Implants
Microarray based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification
Microarray based Gene Expression Testing for Cancers of Unknown Primary
Microprocessor-Controlled Prostheses for the Lower Limb
Microwave Tumor Ablation
Mohs' Micrographic Surgery
Molecular Markers in Fine Needle Aspirates of the Thyroid
Molecular Panel Testing of Cancers to Identify Targeted Therapies
Monochromatic Infrared Energy Treatment (MIRE)
Monoclonal Antibody Imaging for Prostate Cancer
MRI-Guided Focused Ultrasound (MRgFUS)
Multianalyte Assays for Predicting Risk of Type 2 Diabetes
Multianalyte Assays for the Evaluation and Monitoring of Patients with Liver Disease
Multigene Expression Assay for Predicting Recurrence in Colon Cancer
Myocardial Sympathetic Innervation Imaging
Myoelectric Prosthetic Components for the Upper Limb

N   top

Natalizumab (Tysabri)
Navigated Transcranial Magnetic Stimulation (nTMS)
Nerve Fiber Density Testing
Neural Therapy
Neurostimulation, Electrical
Non Contact Ultrasound Treatment for Wounds
Noninvasive Prenatal Testing for Trisomy 21 Using Cell-Free Fetal DNA
Noninvasive Respiratory Assist Devices
Non Pharmacologic Treatment of Rosacea

O   top

Observation Room Services
Occipital Nerve Stimulation
Optical Coherence Tomography (OCT) Anterior Segment of the Eye
Optical Coherence Tomography for Imaging of Coronary Arteries
Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy
Orthognathic Surgery
Orthopedic Applications of Stem Cell Therapy
Orthotics
Oscillatory Devices for the Treatment of Respiratory Conditions
Ovarian and Internal Iliac Vein Embolization

P   top

Pancreas Transplant
PathFinder TG Molecular Testing
Patient Lifts
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
Pembrolizumab (Keytruda)
Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention
Peripheral Arterial Tonometry (PAT)
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia
Pharmacogenetic Testing for Warfarin Dose
Plugs for Fistula Repair
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
Positional Magnetic Resonance Imaging (MRI)
Posterior Tibial Nerve Stimulation for Voiding Dysfunction
Postsurgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
Power Operated Vehicle (Scooter)
Pressure Reducing Support Surfaces
Private Duty Nursing Services
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia
Progesterone Therapy in High Risk Pregnancies
Prolotherapy
Proteomics-based Testing Related to Ovarian Cancer
Proteomic Testing for Targeted Therapy in Non-Small Cell Lung Cancer
Pulmonary Hypertension, Drug Management

Q   top

Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers
Quantitative Electroencephalography as a Diagnostic Aid for Attention Deficit/Hyperactivity Disorder

R   top

Radioembolization for Primary and Metastatic Tumors of the Liver
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
Radiofrequency Ablation of the Renal Nerves as a Treatment of Hypertension
Radiosurgery, Stereotactic Approach
Rapid Opioid Detoxification
Reconstructive Eyelid Surgery and Brow Lift
Refractive Surgery
Rehabilitative Therapies
Renal (Kidney) Transplantation
Repository Corticotropin (H.P. Acthar Gel)
Residential Treatment
Retinal Prosthesis
Rhinoplasty
Rituximab for the Treatment of Rheumatoid Arthritis

S   top

Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction
Sacroiliac Joint Fusion
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 Biomarker Panel Testing for Systemic Lupus Erythematosus
Serum Biomarker Tests for Multiple Sclerosis
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
Stem-cell Therapy for Peripheral Arterial Disease
Subtalar Arthroereisis
Suprachoroidal Delivery of Pharmacologic Agents
Surgery for Athletic Pubalgia
Surgery for Femoroacetabular Impingement
Surgery for Morbid Obesity
Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome
Surgical Deactivation of Headache Trigger Sites
Surgical Interruption of Pelvic Nerve Pathways for Dysmenorrhea
Surgical Management of Transcatheter Heart Valves
Surgical Treatment of Chest Wall Deformities (Congenital or Acquired)
Surgical Treatment of Sinus Disease
Surgical Ventricular Restoration
Systems Pathology for Predicting Risk of Recurrence in Prostate Cancer

T   top

Telemedicine
Temporomandibular Joint Dysfunction (TMJD)
Tinnitus Treatment
Tocilizumab (Actemra)
Topical Negative Pressure Therapy for Wounds
Total Facet Arthroplasty
Total Parenteral Nutrition
Transanal Endoscopic Microsurgery
Transanal Radiofrequency Treatment of Fecal Incontinence
Transcatheter Closure of Ventricular Septal Defects
Transcranial Magnetic Stimulation
Transtympanic Micropressure Applicationsas a Treatment of Meniere's Disease
Treatment of Hereditary Angioedema
Treatment for Severe Primary IGF-1 Deficiency
Tumor-Treatment Fields Therapy for Glioblastoma

U   top

Ultrasound Accelerated Fracture Healing Device
Ultraviolet Light Therapy in the Home Setting(UVB)
Urinary Tumor Markers for Bladder Cancer
Ustekinumab (Stelara)

V   top

Vagus Nerve Stimulation
Varicose Veins, Treatment for
Vectra® DA Blood Test for Rheumatoid Arthritis
Vedolizumab (Entyvio)
Vertebral Axial Decompression (VAX-D)
Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous
Vesicoureteral Reflux, Treatment with Periureteral Bulking Agents
Viscocanalostomy and Canaloplasty

W   top

Wheelchairs
Whole Exome Sequencing

X   top

Xolair (Omalizumab)

Y   top

None

Z   top

None

 

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