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Medical Policies - Alphabetical Listing

To find a medical policy, browse the alphabetical list below or use the search function.

An asterisk (*) indicates that prior approval is recommended for this medical policy.

[ 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 ]

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A

ACTH Gel (Adrenocorticotropic Hormone)*
Abatacept*
Abdominoplasty and Panniculectomy*
Acne Treatment
Adalimumab*
Adjustable Banding as a Treatment of Plagiocephaly
Airway Clearance Devices
Alefacept (Amevive®)*
Allergy Immunotherapy
Allergy Testing
Allogeneic Hematopoietic Stem Cell Transplant*
Ambulatory Blood Pressure Monitoring
Ambulatory Cardiac Event Monitoring and Real-Time Outpatient Cardiac Telemetry
Ambulatory Esophageal pH Monitoring
Analysis of Proteomic Patterns in Serum to Identify Ovarian Cancer
Anesthesia Services for Gastrointestinal Endoscopic Procedures
Anorectal Biofeedback
Articular Cartilage Lesion Treatments (ACI and OATS)
Artificial Intervertebral Disc
Auditory Osseointegrated Implants
Augmentative and Alternative Communication Systems
Autologous Platelet-derived Growth Factors as a Primary Treatment of Wound Healing and Other Miscellaneous Conditions
Autologous Hematopoietic Stem Cell Transplant*
Axial (Percutaneous) Lumbar Interbody Fusion

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B

Bariatric Surgery for Morbid Obesity*
Beta Interferons and Copaxone for Multiple Sclerosis*
Bevacizumab*
Biochemical Markers of Liver Fibrosis for the Evaluation and Management of Liver Disease
Biofeedback as a Treatment of Headache and other Disorders
Biventricular Pacemakers for the Treatment of Congestive Heart Failure
Blepharoplasty*
Bone Growth Stimulation Devices*
Bone Mineral Density Studies
Botulinum Toxin*
Brachytherapy for Prostate Cancer
Breast Brachytherapy

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C

CINRYZE™ [C1 inhibitor (Human)]
CT or Spiral Scanning for Lung Cancer Screening
Capsule Endoscopy
Certolizumab Pegol (Cimzia®)*
Cervical Cancer Screening Technologies
Cetuximab*
Chelation Therapy
Chemical Cauterization of the Nasal Turbinates
Chemical Peels and Dermabrasion*
Cineradiography of the Spine or Dynamic Motion X-Ray
Clinical Trial Provision*
Coblation®, Laser Discectomy and Automated Percutaneous Disc Decompression
Cochlear Implants
Cognitive Rehabilitation
Collagen Cross-Link Testing for Management of Osteoporosis
Comparative Genomic Hybridization
Computed Tomography (CT) and Computed Tomography Angiography (CTA) for Coronary Artery Evaluation
Computer-aided Detection (CAD) of Malignancy with Magnetic Resonance Imaging (MRI) of the Breast
Computer-aided Detection in Conjunction with Digitized Screen-Film Mammography or Full-field Digital Mammography
Computer-assisted Navigation Systems for Orthopedic Surgery
Continuous Passive Motion (CPM) Devices
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid*
Corneal Topography, Computer Assisted Photokeratography, Video-keratography
Cosmetic/Reconstructive Services*
Cryoablation for Prostate Cancer
Cryosurgical Ablation of Breast Cancer and Fibroadenoma

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D

Dermatoscopy
Detection and Quantification of Circulating Tumor Cells in the Management of Patients with Cancer
Dexamethasone Intravitreal Implant for Macular Edema
Diabetes Outpatient Self-Management Training and Education (Iowa Only)
Diabetes Outpatient Self-Management Training and Education (South Dakota only)
Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome and Upper Airway Resistance Syndrome
Diagnosis and Treatment of Male Erectile Dysfunction
Diagnosis and Treatment of Speech and Language Disorders*
Diagnostic Ultrasound for Plantar Fasciitis
Digital Retinal Imaging Systems for the Screening and Detection of Diabetic Retinopathy
Double-Balloon Enteroscopy for the Diagnosis and Treatment of Small Bowel Disease
Down Syndrome Screening with Ultrasound Assessment of Fetal Nuchal Translucency and Maternal Serum Markers
Drug-eluting Stents
Dynamic Posturography

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E

Electrical Stimulation for Scoliosis
Electrical Neuro Stimulators
Endoluminal Radiofrequency or Laser Ablation of Varicose Veins
Endometrial Ablation
Enhanced External Counterpulsation (EECP) for Chronic Stable Angina Pectoris or Congestive Heart Failure
Etanercept*
Extracorporeal Immunoadsorption Using Protein A Columns
Extracorporeal Photopheresis
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
Extracranial Carotid Angioplasty and Stenting

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F

Facet Joint Denervation for Chronic Back and Neck Pain*
Femoroacetabular Impingement Surgery
Fetal Surgery
Foot Care Services
Frameless Stereotactic Radiosurgery
Functional Endoscopic Dilation of the Sinuses
Functional Intracellular Analysis
Functional Neuromuscular Stimulation with Ergometers for Spinal Cord Injuries

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G

GI Monitoring System for Assessing Gastric Motility
Gait Analysis
Genetic Assays of Tumor Tissue to Predict Prognosis of Breast Cancer*
Genetic Molecular Testing for Miscellaneous Indications*
Genetic Molecular Testing for Oncologic Indications*
Genetic Testing for Tamoxifen Treatment
Genetic Testing for Warfarin Sensitivity
Genotypic and Phenotypic Resistance Assays in Human Immunodeficiency Virus (HIV)
Granulocyte Colony-Stimulating Factors and Granulocyte-Macrophage Colony-Stimulating Factor
Growth Hormone Therapy*

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H

Heart Transplant*
Heart/Lung Transplant*
High Sensitivity C-Reactive Protein
Home Infusion Therapy Services
Home Total Parenteral Nutrition and Enteral Therapy
Home Uterine Activity Monitoring
Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease
Humanitarian Use Devices*
Hyperbaric Oxygen Therapy (HBO)

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I

Immune Globulin Therapy*
Implantation of Intrastromal Corneal Ring Segments
Infertility Diagnosis and Treatment*
Infliximab*
Inhaled Iloprost for Pulmonary Hypertension
Intensity-Modulated Radiation Therapy (IMRT)
Interferons for Hepatitis C*
Interspinous Distraction Devices
Intradiscal Electrothermal Annuloplasty and Percutaneous Intradiscal Radiofrequency Thermocoagulation

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K

KRAS Mutation Analysis in Metastatic Colorectal Cancer
Knee Arthroplasty*
Knee Braces

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L

Laboratory Tests for Heart Transplant Rejection
Liver Transplant*
Low-Density Lipid Apheresis
Low-Level Laser or Cold Laser Therapy
Lung Volume Reduction Surgery for Severe Emphysema
Lung and Lobar Lung Transplant*
Lysis of Epidural Adhesions with Hypertonic Saline, Steroid and Analgesics

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M

MRI-Guided High-Intensity Ultrasound Ablation of Uterine Fibroids and Other Tumors
Magnetic Resonance Imaging of the Breast
Magnetic Resonance Spectroscopy
Magnetoencephalography (MEG)/Magnetic Source Imaging (MSI)
Mastectomy for Gynecomastia*
Measurement of Intracellular Magnesium
Measurement of Small Low-Density Lipoprotein (LDL) Particles
Mechanical Stretching Devices for Contracture and Joint Stiffness
Meniscal Allograft Transplant*
Microarray-based Gene Expression Testing for Cancers of Unknown Primary
Microprocessor-Controlled Prostheses for the Lower Limb*
Minimally Invasive Surgery for Snoring, Obstructive Sleep Apnea Syndrome and Upper Airway Resistance Syndrome
Monochromatic Infrared Energy for Wound Healing and Peripheral Neuropathy
Motorized Wheelchairs and Other Power-Operated Vehicles*

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N

Naltrexone
Natalizumab*
Neovascular Macular Degeneration Treatments
Nerve Conduction Velocity Studies
Nesiritide
Neutralizing Antibodies against Interferon beta in Patients with Multiple Sclerosis

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O

Occupational Therapy
Off-label Drug Use
Omalizumab for Allergy Related Asthma*
Onychomycosis Treated with Nail Plate Perforation
Orthoptics and Scotopic Sensitivity Syndrome

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P

PET Scan, Oncologic Applications
Palivizumab (Synagis®)*
Pancreas Transplants*

(Including simultaneous pancreas-kidney, pancreas alone, and pancreas after kidney)

Pancreatic Islet Cell Transplant*
Panitumumab (Vectibix^TM)*
Paraspinal Surface Electromyography
PathFinderTG® Molecular Testing
Percutaneous Intracranial Angioplasty and Stenting
Percutaneous Vertebroplasty and Kyphoplasty*
Pharmacogenomics and Metabolite Markers for Patients Treated with Azathioprine
Photodynamic Therapy (PDT) for Malignant and Pre-malignant Indications
Photodynamic Therapy for Actinic Keratosis
Photoscreening for Amblyogenic Factors in Children
Phototherapeutic Keratectomy (PTK)
Phototherapy for the Treatment of Seasonal Affective Disorder
Physical Therapy
Plasmapheresis
Pneumatic Compression Devices
Positional Magnetic Resonance Imaging (MRI)
Positron Emission Tomography (PET) Scan, Cardiac Applications
Positron Emission Tomography (PET) Scans, Miscellaneous Applications
Posterior Tibial Nerve Stimulation for Voiding Dysfunction
Preimplantation Genetic Testing*
Prolotherapy
Prostate-specific Antigen Screening for Prostate Cancer
Proton Beam Radiation Therapy
Pulmonary Vein Isolation for the Management of Atrial Fibrillation
Pulsed Radiofrequency

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Q

Quantitative Coronary Artery Calcium Scoring as a Screening Test
Quantitative Sensory Testing or Current Perception Threshold Testing

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R

Radiofrequency and Cryosurgical Ablation of Renal Tumors
Radiofrequency and Cryoablation of Liver Tumors
Radioimmunotherapy for Non-Hodgkin's Lymphoma: Ibritumomab Tiuxetan (Zevalin®) and Tositumomab (Bexxar®)
Reduction Mammoplasty*
Refractive Keratoplasty
Rhinoplasty or Septorhinoplasty*
Rituximab*

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S

Saliva Test for Hormone Replacement Therapy in Menopausal Women
Scintimammography and Breast-specific Gamma Imaging (BSGI)
Sclerotherapy of Varicose Veins
Selective Internal Radiation Therapy for Primary and Metastatic Tumors of the Liver
Sensory Integration Therapy
Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease
Serum Tumor Markers in the Management of Malignancies
Signal Averaged ECG
Small Bowel Transplant*
Small bowel/liver and multivisceral transplant*
Spinal Fusion*
Subtalar Arthroereisis
Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea
Surgical Management of Obstructive Sleep Apnea Syndrome*
Surgical Repair of Pectus Excavatum*

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T

T-Wave Alternans
Temporomandibular Joint Dysfunction (TMJ), Treatment
Temsirolimus
Thermal Capsulorrhaphy as a Treatment of Joint Instability
Thermography and Temperature Gradient Studies
Thoracic Electrical Bioimpedance
Tilt Table Test for Syncopal Attack
Tissue Engineered Skin Substitutes and Growth Factors
Total Ankle Replacement*
Total Hip Resurfacing
Transcatheter Arterial Chemoembolization (TACE) of the Liver
Transcoronary Ablation of Septal Hypertrophy (TASH)
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)
Transpupillary Thermotherapy (TTT)
Transtympanic Micropressure Treatment for Ménière's Disease
Trastuzumab*
Treatment of Hyperhidrosis
Treatment of Psoriasis
Treatment of Varicose Veins
Treatment of Vascular Birthmarks
Tumor Scintigraphy

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U

Ultrasound in Maternity Care
Ultrasound-driven Saline Wound Treatment
Unicondylar Interpositional Spacer for Knee Surgery
Urinary Incontinence Treatments and Devices
Uterine Artery Embolization for Uterine Fibroids

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V

Vacuum-Assisted Wound Closure*
Ventricular Assist Devices and Artificial Hearts
Vertebral Axial Decompression
Virtual Colonoscopy/CT Colonography
Viscosupplementation for Osteoarthritis

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