Medical Policies


Medical Guidelines - Categorical Index

Back to Index

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


Drugs   top

Abatacept (Orencia®) 
Belimumab (Benlysta)
Botulinum Toxin Injection
Capsaicin (Qutenza®)
Chemotherapy For Malignant Disease
Denosumab (ProliaTM, XGEVATM)
Golimumab (Simponi Aria)
Immune Globulin Therapy
Infliximab (Remicade)
Intravenous Antiobiotic Therapy for Lyme Disease
Ipilimumab (Yervoy)
Natalizumab Tysabri
Pulmonary Hypertension, Drug Management
Repository Corticotropin (H.P. Acthar Gel)
Respiratory Syncytial Virus Prophylaxis
Rituximab for the Treatment of Rheumatoid Arthritis
Tocilizumab (Actemra)
Treatment of Hereditary Angioedema
Treatment for Severe Primary IGF-1 Deficiency
Ustekinumab (Stelara)
Xolair (Omalizumab)

Home Health/Durable Medical Equipment   top

Air Fluidized Beds
Children's Mobility and Positioning Equipment
Continuous Monitoring of Glucose in the Interstitial Fluid
Continuous Passive Motion in the Home Setting
Durable Medical Equipment (DME)
Electrical Stimulation for the Treatment of Arthritis
End Diastolic Pneumatic Compression Boot
External Defibrillators
Infusion Therapy in the Home
Interferential Stimulation
Monochromatic Infrared Energy Treatment (MIRE)
Neurostimulation, Electrical
Noninvasive Respiratory Assist Devices
Oscillatory Devices for the Treatment of Respiratory Conditions
Patient Lifts
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
Power Operated Vehicle (Scooter)
Pressure Reducing Support Surfaces
Skilled Nursing Services
Speech Generating Devices
Transtympanic Micropressure Applications as a Treatment of Meniere's Disease
Wheelchairs

Medical   top

Acoustic Cardiography
Adoptive Immunotherapy
Allergy Immunotherapy (Desensitization)
Allergy Testing
Ambulance and Medical Transport Services
Ambulatory Event Monitors
Anesthesia Services
Antiprothrombin Antibody Testing
Aqueous Shunts and Devices for Glaucoma
Assays of Genetic Expression to Determine Prognosis of Breast Cancer
Baroreflex Stimulation Devices
Biofeedback
Bioimpedance Devices for Detection of Lymphedema
BRAF Gene Mutation Testing to Select Melanoma Patients for BRAF Inhibitor Therapy
Cardiac Hemodynamic Monitoring in the Outpatient Setting
Cardiovascular Disease Risk Tests
Carotid Intimal-Medial Thickness
Carrier Testing for Genetic Disease
Chelation Therapy
Chemoembolization of the Hepatic Artery, Transcatheter Approach
Clinical Trial Services
Common Genetic Variants to Predict Risk of Nonfamilial Breast Cancer
Complementary and Alternative Medicine
Computerized 2-Lead Resting Electrocardiogram Multifunction Cardiogram
Convection-Enhanced Delivery of Therapeutic Agents to the Brain
Corneal Collagen Cross-linking
Cytochrome p450 Genotyping
Detection of Circulating Tumor Cells
Developmental Delay Screening and Testing Guidelines
DNA Based Testing for Adolescent Idiopathic Scoliosis
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis
Dynamic Posturography
Electrocardiographic Body Surface Mapping
Electrodiagnostic Studies
Electrogastrography, Cutaneous
Electromagnetic Navigation Bronchoscopy
Electrostimulation and Electromagnetic Therapy for Chronic Wounds
Enhanced External Counterpulsation (EECP)
Enteral Nutrition
Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC)
Esophageal pH Monitoring
E-visits (Online Medical Evaluation)
Exhaled Nitric Oxide Measurement
Extracorporeal Photopheresis
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer
Gene Expression Testing to Predict Coronary Artery Disease
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 the Diagnosis of Inherited Peripheral Neuropathy
Genetic Testing for Epilepsy
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 Predisposition to Inherited Hypertrophic Cardiomyopathy
Genetic Testing for Rett Syndrome
Genetic Testing for Statin-induced Myopathy
Growth Factors in Wound Healing
Hyperbaric Oxygen Pressurization
Hyperhidrosis, Treatment of
Hyperthermia Therapy
Identification of Microorganisms Using Nucleic Acid Probes
Idiopathic Environmental Intolerance (i.e. Multiple Chemical Sensitivities)
Immune Cell Function Assay
Ingestible pH and Pressure Capsule
Injectable Clostridial Collagenase for Fibroproliferative Disorders
Insulin Therapy, Chronic Intermittent Intravenous (CIIIT)
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee
Intracellular Micronutrient Analysis
Intradialytic Parenteral Nutrition
Intravenous Anesthetics for the Treatment of Chronic Pain
In Vitro Chemoresistance and Chemosensitivity Assays
JAK2 and MPL Mutations in Myeloproliferative Neoplasms
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
Lipid Apheresis
Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD)
Measurement of Serum Antibodies to Infliximab and Adalimumab
Melanoma Vaccines
Microarray based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification
Microarray based Gene Expression Testing for Cancers of Unknown Primary
Molecular Markers in Fine Needle Aspirates of the Thyroid
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
Nerve Fiber Density Testing
Non-Contact Ultrasound Treatment for Wounds
Non-BRCA Breast Cancer Risk Assessment
Non Pharmacologic Treatment of Rosacea
Observation Room Services
Occipital Nerve Stimulation
Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy
PathFinder TG Molecular Testing
Pelvic Floor Stimulation as a Treatment of Urinary Incontinence
Peripheral Arterial Tonometry (PAT)
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia
Pharmacogenetic Testing for Warfarin Dose
Private Duty Nursing Services
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia
Prolotherapy
Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers
Signal Averaged ECG
Skilled Nursing Facility Care
Skilled Nursing Services
Sleep Apnea: Diagnosis and Medical Management
Systems Pathology for Predicting Risk of Recurrence in Prostate Cancer
Telemedicine
Total Parenteral Nutrition
Tumor-Treatment Fields Therapy for Glioblastoma
Ultraviolet Light Therapy in the Home Setting(UVB)
Urinary Tumor Markers for Bladder Cancer
Whole Exome Sequencing

Mental Health/Chemical Dependency   top

Chromosomal Microarray (CMA) Analysis for Genetic Evaluation of Developmental Delay/Autism Spectrum Disorder
Genecept Assay
Quantitative Electroencephalography as a Diagnostic Aid for Attention Deficit/Hyperactivity Disorder
Rapid Opioid Detoxification
Residential Treatment for Chemical Dependency
Transcranial Magnetic Stimulation


OB-GYN Reproduction   top

Acute and Maintenance Tocolysis
Fetal RHD Genotyping Using Maternal Plasma
Fetal Surgery for Malformations
Infertility, Diagnosis and Treatment
Hormone Pellet Implantation for Hormone Replacement Therapy in Women
Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids
Ovarian and Internal Iliac Vein Embolization
Progesterone Therapy in High Risk Pregnancies
Proteomics-based Testing Related to Ovarian Cancer
Salivary Hormone Tests
Sequencing Based Tests to Determine Trisomy 21 from Maternal Plasma DNA
Surgical Interruption of Pelvic Nerve Pathways for Dysmenorrhea

Radiology   top

Accelerated Partial Breast Radiotherapy (Breast Brachytherapy)
Bone Mineral Density Studies
Brachytherapy, Intracavitary Balloon Catheter for Brain Cancer
Brachytherapy Treatment of Breast Cancer
Capsule Endoscopy, Wireless
Charged Particle Radiotherapy
Computed Tomography to Detect Coronary Artery Calcification
Computer-Aided Evaluation of Malignancy with MRI of the Breast
CT Perfusion Imaging of the Brain
Digital Breast Tomosynthesis
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography
Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System
Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis
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
Intravascular Ultrasound Imaging IVUS and Intracoronary Doppler Ultrasonography
Magnetic Resonance Spectroscopy
Magnetoencephalography/Magnetic Source Imaging
Monoclonal Antibody Imaging for Prostate Cancer
MRI-Guided Focused Ultrasound (MRgFUS)
Myocardial Sympathetic Innervation Imaging
Positional Magnetic Resonance Imaging (MRI)
Prostate Cancer Treatment with Brachytherapy
Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous

Surgery   top

Abdominoplasty, Panniculectomy and Lipectomy
Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemia
Allogeneic Stem Cell Transplantation for Myelodysplastic Syndromes
Ankle Replacement, Total
Artificial Intervertebral Disc
Autografts and Allografts in the Treatment of Focal Articular Cartilage
Autologous Chondrocyte Implantation
Autologous Fat Grafting to the Breast
Automated Percutaneous and Endoscopic Discectomy
Axial Lumbosacral Interbody Fusion
Balloon Ostial Dilation for Treatment of Chronic Sinusitis
Bioengineered Skin and Tissue
Bone Morphogenetic Protein
Breast Surgeries
Bronchial Thermoplasty
Cardiac (Heart) Transplantation
Carotid Artery Angioplasty / Stenting (CAS)
Catheter Ablation of the Pulmonary Veins as a Treatment for Atrial Fibrillation
Chromoendoscopy as an Adjunct to Colonoscopy
Cochlear Implant
Composite Allotransplantation of the Hand and Face
Computer Assisted Surgical Navigational Orthopedic Procedures
Confocal Laser Endomicroscopy
Congenital Heart Defect, Repair Devices
Cord Blood as a Source of Stem Cells
Cosmetic and Reconstructive Surgery
Cryosurgical Ablation of Primary or Metastatic Liver Tumors
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)
Dental Inpatient and Outpatient Services
Dental, Reconstructive Services
Electrical Bone Growth Stimulation
Electrothermal Arthroscopic Capsulorrhaphy
Endobronchial Valves
Endothelial Keratoplasty
Endovascular Procedures for Intracranial Arterial Disease
Epiretinal Radiation Therapy for Age-Related Macular Degeneration
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing
Facet Joint Denervation
Functional Endoscopic Sinus Surgery (FESS)
Gastric Electrical Stimulation
Gastroesophageal Reflux Disease, Transendoscopic Therapies
Gender Reassignment Surgery
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 CNS Embryonal Tumors and Ependymoma
Hematopoietic Stem-Cell Transplantation for CLL and SLL
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
Hyperthemic Intraperitoneal Chemotherapy
Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty
Intraoperative Neurophysiologic Monitoring (sensory-evoked potentials, motor-evoked potentials, EEG monitoring)
Islet Cell Transplantation
Image Guided Minimally Invasive Lumbar Decompression (IG-MLD) for Spinal Stenosis
Implantable Bone Conduction Hearing Aids
Implantable Cardioverter Defibrillator
Implantation of Intrastromal Corneal Ring Segments
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
Interspinous Fixation (Fusion) Devices
Intravitreal Implant
Keratoprosthesis
Laser Treatment of Onychomycosis
Laser Treatment of Port Wine Stains
Liver Transplant
Lumbar Spine Fusion Surgery
Lung and Lobar Lung Transplantation
Lung Volume Reduction Surgery
Lysis of Epidural Adhesions
Mechanical Embolectomy for Treatment of Acute Stroke
Meniscal Allografts and Other Meniscal Implants
Microwave Tumor Ablation
Mohs' Micrographic Surgery
Navigated Transcranial Magnetic Stimulation (nTMS)
Orthognathic Surgery
Pancreas Transplant
Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention
Plugs for Fistula Repair
Posterior Tibial Nerve Stimulation for Voiding Dysfunction
Postsurgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
Pulmonary Artery Balloon Angioplasty, Percutaneous Transluminal Approach
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
Radiofrequency Ablation of the Renal Nerves as a Treatment of Hypertension
Radiosurgery, Stereotactic Approach
Reconstructive Eyelid Surgery and Brow Lift
Refractive Surgery
Renal (Kidney) Transplantation
Retinal Prosthesis
Rhinoplasty
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction
Sacroiliac Joint Fusion
Saturation Biopsy for Diagnosis and Staging of Prostate Cancer
Semi implantable and fully implantable middle ear hearing aid
Small Bowel, Small Bowel with Liver, or Multivisceral Transplant
Spinal Cord Stimulation
Subtalar Arthroereisis
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 Management of Transcatheter Heart Valves
Surgical Treatment of Chest Wall Deformities (Congenital or Acquired)
Surgical Ventricular Restoration
Temporomandibular Joint Dysfunction (TMJD)
Tinnitus Treatment
Topical Negative Pressure Therapy for Wounds
Total Facet Arthroplasty
Transanal Endoscopic Microsurgery
Transanal Radiofrequence Treatment of Fecal Incontinence
Transcatheter Closure of Ventricular Septal Defects
Ultrasound Accelerated Fracture Healing Device
Vagus Nerve Stimulation
Varicose Veins, Treatment for
Vesicoureteral Reflux, Treatment with Periureteral Bulking Agents
Viscocanalostomy and Canaloplasty

Therapy   top

Cellular Immunotherapy for Prostate Cancer
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation
Dermatologic Applications of Photodynamic Therapy
Light Therapy for Dermatologic Conditions
Microprocessor-Controlled Prostheses for the Lower Limb
Myoelectric Prosthetic Components for the Upper Limb
Neural Therapy
Rehabilitative Therapies
Radioembolization for Primary and Metastatic Tumors of the Liver
Stem-cell Therapy for Peripheral Arterial Disease

Other Treatments   top

Chiropractic Services
Corneal Topography
Functional Capacity Assessment and Work Hardening
Fundus Photography
Optical Coherence Tomography for Imaging of Coronary Arteries
Optical Coherence Tomography (OCT) Anterior Segment of the Eye
Orthopedic Applications of Stem Cell Therapy
Orthotics
Sensory Integration Therapy
Spinal Manipulation under Anesthesia
Suprachoroidal Delivery of Pharmacologic Agents
Vertebral Axial Decompression (VAX-D)

top

Get Acrobat To view PDF documents you need Adobe Acrobat Reader.