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Medical Policies - Alphabetical Listing

To Search for Medical Policies:  use the search function at the top of the page
or view our alphabetical listing of Medical Policies


View the Authorization Table to determine when to request a pre-service review.

 

InterQual® criteria is used to evaluate whether a medical procedure or equipment is medically necessary. Contracting practitioners can view InterQual criteria via SmartSheetsTM . DME providers and out-of-state providers can receive the SmartSheets via fax by calling 800-552-3993.

 


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A

Abatacept*
Adjustable Banding as a Treatment of Plagiocephaly
Air Ambulance*
Airway Clearance Devices
Allergy Immunotherapy: Rapid Desensitization
Allergy Testing
Ambulatory Blood Pressure Monitoring
Ambulatory Cardiac Event Monitoring and Real-Time Outpatient Cardiac Telemetry
Ambulatory Esophageal pH Monitoring
Amino Acid-Based Elemental Formula and Medical Foods for the Treatment of Inborn Errors of Metabolism
Anesthesia Services for Gastrointestinal Endoscopic Procedures
Anorectal Biofeedback
Anser IFX Assay and Anser ADA Assay
Application of Anesthetic to Sphenopalatine Ganglion for Headaches
Artificial Intervertebral Disc
Autologous Chondrocyte Implant
Autologous Platelet-derived Growth Factors
Automated Nerve Conduction Tests
Avastin® (bevacizumab) for Non-Ophthalmologic Conditions*
Axial Lumbar Interbody Fusion (axial LIF)

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B

Bio-Engineered Skin and Soft Tissue Substitutes
Biofeedback/Neurofeedback as a Treatment of Headache and other Disorders
Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Other Conditions
Bronchial Thermoplasty

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C

CYP450 Genotyping to Determine Drug Metabolizer Status
Capsule Endoscopy in the Pediatric Population*
Cardiovascular Disease Risk Tests
Certolizumab Pegol (Cimzia®)*
Chelation Therapy
Chemical Peels and Dermabrasion
Cineradiography of the Spine or Dynamic Motion X-Ray
Clinical Trials, Coverage of Routine Patient Care Costs
Cognitive Rehabilitation
Computed Tomography Angiography of the Coronary Arteries (CCTA) 
Computer-aided Detection (CAD) of Malignancy with Magnetic Resonance Imaging (MRI) of the Breast
Computer-assisted Navigation Systems for Orthopedic Surgery
Continuous Passive Motion (CPM) Devices
Cooling Devices
Corneal Topography, Computer Assisted Photokeratography, Video-keratography
Cosmetic/Reconstructive Services

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D

Deep Brain Stimulation (DBS)
Dermatologic Applications of Photodynamic Therapy
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 in Adults
Digital Breast Tomosynthesis
Disposable Non-Powered Mechanical Negative Pressure Wound Care System or Single Use Non-Electrically Powered Negative Pressure Wound Care Therapy
Dynamic Posturography

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E

EGRIFTA™ (tesamorelin)
Electrical Stimulation for Scoliosis
Electrical Stimulation for the Treatment of Arthritis
Electronic Brachytherapy
Endoscopic Therapies for GERD and Barrett's Esophagus
Exhaled Nitric Oxide and Exhaled Breath Condensate

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F

Facet Joint Denervation for the Treatment of Thoracic Facet Joint Pain or Sacroiliac Joint Pain
Fecal Calprotectin Testing
Fecal Incontinence Management
Functional Endoscopic Dilation of the Sinuses 
Functional Neuromuscular Stimulation (FNS) and Neuromuscular Electrical Stimulation (NMES)

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G

GI Monitoring Systems for Assessing Gastric Motility
Gastric Electrical Stimulation
Gender Reassignment Surgery(group specific)
Genetic Expression Testing to Predict Coronary Artery Disease
Genetic Testing for Familial Cutaneous Malignant Melanoma
Genetic Testing for MTHFR
Genetic Testing for Warfarin Sensitivity

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H

Heart/Lung Transplant*
Hereditary Angioedema Therapies*
High Intensity Focused Ultrasound (HIFU)
Homocysteine Testing
Hormone Replacement in Women Using Subcutaneous Pellet Implantation
Humanitarian Use Devices
Hyperbaric Oxygen Therapy (HBO)

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I

Immune Globulin Therapy*
Infertility Treatment*
Infliximab*
Interferential Current (IFC) Stimulation
Interspinous Distraction Devices
Intradiscal Electrothermal Annuloplasty, Biacuplasty, and Percutaneous Intradiscal Radiofrequency Thermocoagulation
Intravitreal Angiogenesis Inhibitors for Retinal Vascular Conditions
Investigational / Experimental

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K

KRAS and BRAF Mutation Analysis
Knee Braces

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L

Laser Treatment for Nail Fungus
Low Frequency, Non-Contact Ultrasound for Wounds
Low-Level Laser Therapy
Lung and Lobar Lung Transplant*

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M

MRI-Guided High-Intensity Focused Ultrasound Ablation of Uterine Fibroids and Other Tumors
Magnetic Resonance Spectroscopy
Manipulation under Anesthesia
Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis Using Ultrasound
Mechanical Stretching Devices for Contracture and Joint Stiffness
Minimally Invasive Lumbar Decompression (MILD)
Multigene Expression Assays for Predicting Recurrence of Colon Cancer

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N

Naltrexone
Neuromuscular Blocking Agents*
Not Medically Necessary

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O

Occipital Nerve Stimulation
Occupational Therapy
Off-label Drug Use
Orthoptics and Scotopic Sensitivity Syndrome
Osteochondral Allografts and Autografts

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P

Palivizumab (Synagis®)*
Pancreas (Including simultaneous pancreas-kidney, pancreas alone, and pancreas after kidney) Transplants*
Pancreatic Islet Cell Transplant
Paraspinal Surface Electromyography
Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)
Percutaneous Intracranial Angioplasty and Stenting
Physical Therapy
Plasmapheresis/Plasma Exchange
Pneumatic Compression Devices
Prolotherapy
Prostate-Specific Antigen Screening for Prostate Cancer and Gene Based Testing for Screening, Detection and/or Management of Prostate Cancer
Proteomics-Based Testing for the Evaluation of Ovarian (Adnexal) Masses
Proton Beam Radiation Therapy
Pulsed Radiofrequency

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Q

Quantitative Coronary Artery Calcium Scoring
Quantitative Sensory Testing

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R

Radiofrequency Coblation (Nucleoplasty), Laser Discectomy and Automated Percutaneous Disc Decompression
Rituximab*

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S

Sacral Nerve Stimulation/Neuromodulation
Saliva Test for Hormone Evaluation
Scintimammography/Breast-specific Gamma Imaging (BSGI)/Molecular Breast Imaging (MBI)
Screening for Lung Cancer Using Low Dose Computed Tomography
Sensory Integration Therapy
Serum Tumor Markers in the Management of Malignancies
Signal-averaged ECG
Small Bowel Transplant*
Small bowel/liver and multivisceral transplant*
Spinal Cord Stimulation
Subcutaneous ICD
Subtalar Arthroereisis and Subtalar Joint Implant

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T

Temporomandibular Joint Dysfunction (TMJ) Treatment
Testing for Common Genetic Variants to Predict Risk of Nonfamilial Breast Cancer
Thermography and Temperature Gradient Studies
Tocilizumab (Actemra)*
Transcranial Magnetic Stimulation
Treatment of Neovascular Macular Degeneration and Other Choroidal Vascular Conditions
Treatment of Speech and Language Disorders*
Treatment of Varicose Veins 
Tumor Chemosensitivity Assays

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U

Ultrasound in Maternity Care
Urinary Incontinence/ Voiding Dysfunction Treatments and Devices
Ustekinumab (STELARA™)*

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V

Vagus Nerve Stimulation (VNS)
Ventricular Assist Devices and Artificial Hearts
Vertebral Axial Decompression
Vertebral Fracture Assessment using Dual X-ray Absorptiometry
Viscosupplementation for Osteoarthritis
Vitamin D Testing

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W

Whole Body Dual X-Ray Absorptiometry (DEXA or DXA) to Determine Body Composition

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X

Xolair® (omalizumab)*
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