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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

Abatacept*
Abdominoplasty and Panniculectomy*
Acne Treatment
Adjustable Banding as a Treatment of Plagiocephaly
Airway Clearance Devices
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
Amino Acid-Based Elemental Formula
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*

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B

Bariatric Surgery for Morbid Obesity*
Bevacizumab (Avastin®)*
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
Bone Turnover Markers for Diagnosis and Management of Osteoporosis
Botulinum Toxin*
Brachytherapy for Prostate Cancer
Breast Brachytherapy
Bronchial Thermoplasty

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C

CINRYZE™ [C1 inhibitor (Human)]
CT or Spiral Scanning for Lung Cancer Screening
Cancer Clinical Trials
Capsule Endoscopy
Cellular Immunotherapy for Prostate Cancer*
Certolizumab Pegol (Cimzia®)*
Cervical Cancer Screening Technologies
Cetuximab*
Chelation Therapy
Chemical Peels and Dermabrasion
Chromosomal Microarray (CMA) Analysis for the Genetic Evaluation of Patients with Developmental Delay/Intellectual Disability or Autism Spectrum Disorder*
Cineradiography of the Spine or Dynamic Motion X-Ray
Clinical Trials for Non-cancer Indications
Cochlear Implants
Cognitive Rehabilitation
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 for Breast Cancer Screening and Diagnosis
Computer-assisted Navigation Systems for Orthopedic Surgery
Continuous Passive Motion (CPM) Devices
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid
Cooling Devices
Corneal Topography, Computer Assisted Photokeratography, Video-keratography
Cosmetic/Reconstructive Services
Cryoablation of Prostate Cancer

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D

DNA-based prognostic testing to predict spinal curve progression in adolescent idiopathic scoliosis
Dermatologic Applications of Photodynamic Therapy
Dermatoscopy
Detection and Quantification of Circulating Tumor Cells in the Management of Patients with Cancer
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 Speech and Language Disorders*
Digital Retinal Imaging Systems for the Screening and Detection of Diabetic Retinopathy
Drug-eluting Stents
Dynamic Posturography

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E

EGRIFTA™ (tesamorelin)
Electrical Stimulation for Scoliosis
Electrical/Magnetic Neuro Stimulators
Endometrial Ablation
Enhanced External Counterpulsation
Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCL)
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*
Fecal Calprotectin Testing
Femoroacetabular Impingement Surgery
Fetal Surgery
First-trimester Down Syndrome Screening with Ultrasound Assessment of Fetal Nuchal Translucency and Maternal Serum Markers
Functional Endoscopic Dilation of the Sinuses
Functional Intracellular Analysis
Functional Neuromuscular Electrical Stimulation

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G

GI Monitoring System for Assessing Gastric Motility
Gait Analysis
Genetic Assays of Tumor Tissue to Predict Recurrence of Colon Cancer
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

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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
In Vitro Chemoresistance and Chemosensitivity Assays
Infertility Diagnosis and Treatment*
Infliximab*
Injectable Clostridial Collagenase (Xiaflex™) for Fibroproliferative Disorders
Intensity-Modulated Radiation Therapy (IMRT)
Interspinous Distraction Devices
Intradiscal Electrothermal Annuloplasty and Percutaneous Intradiscal Radiofrequency Thermocoagulation
Investigational / Experimental
Ipilimumab (Yervoy™)

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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 Therapy
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*
Myoelectric Prostheses for the Upper Limb*

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N

Naltrexone
Natalizumab* (Tysabri®)
Negative-pressure Wound Therapy*
Neovascular Macular Degeneration Treatments
Nerve Conduction Velocity Studies
Neutralizing Antibodies against Interferon beta in Patients with Multiple Sclerosis
Not Medically Necessary

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O

Occipital Nerve Stimulation
Occupational Therapy
Ofatumumab (ARZERRA)
Off-label Drug Use
Omalizumab for Allergy Related Asthma*
Orthoptics and Scotopic Sensitivity Syndrome
Ozurdex® (Dexamethasone Intravitreal Implant)

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P

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
Phototherapeutic Keratectomy (PTK)
Phototherapy for the Treatment of Seasonal Affective and Other Depressive Disorders
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
Positron Emission Tomography (PET) Scan, Oncologic Applications
Posterior Tibial Nerve Stimulation for Voiding Dysfunction
Preimplantation Genetic Testing
Prolotherapy
Prostate-specific Antigen Screening for Prostate Cancer
Proteomics-based Testing for the Evaluation of Ovarian (Adnexal) Masses
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

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R

Radioembolization for Primary and Metastatic Tumors of the Liver
Radiofrequency Coblation (Nucleoplasty), Laser Discectomy and Automated Percutaneous Disc Decompression
Radiofrequency ablation or Cryoablation of Barrett’s Esophagus
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®)
Real-time Intra-fraction Target Tracking During Radiation Therapy
Reduction Mammoplasty*
Refractive Keratoplasty
Repository Corticotropin Injection
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)
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*
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy
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
Telemedicine
Temporomandibular Joint Dysfunction (TMJ), Treatment
Temsirolimus (Torisel^TM )
Thermal Capsulorrhaphy as a Treatment of Joint Instability
Thermography and Temperature Gradient Studies
Thoracic Electrical Bioimpedance
Tissue Engineered Skin Substitutes and Growth Factors
Tocilizumab (Actemra)*
Total Ankle Replacement
Total Hip Resurfacing*
Transarterial Chemoembolization (TACE) of the Liver
Transcatheter Aortic Valve Implantation for Aortic Stenosis
Transcranial Magnetic Stimulation
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)
Transpupillary Thermotherapy (TTT)
Transtympanic Micropressure Treatment for Ménière's Disease
Trastuzumab*
Treatment of Hyperhidrosis
Treatment of Varicose Veins
Treatment of Vascular Birthmarks
Tumor Scintigraphy

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U

Ultrasound in Maternity Care
Urinary Incontinence Treatments and Devices
Urinary Tumor Markers for Bladder Cancer
Ustekinumab (STELARA™)*
Uterine Artery Embolization for Uterine Fibroids

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V

Ventricular Assist Devices and Artificial Hearts
Vertebral Axial Decompression
Virtual Colonoscopy/CT Colonography
Viscosupplementation for Osteoarthritis
Vitamin D Testing

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