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Medical Policies - Alphabetical Listing

To find a medical policy, either browse our alphabetical list, or use the Medical Policy Quick Search to search by key word or CPT code. 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
Acne Treatment
Adalimumab
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
Analysis of Proteomic Patterns in Serum to Identify Ovarian Cancer
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

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

CT or Spiral Scanning for Lung Cancer Screening
Capsule Endoscopy
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
Computed Tomography (CT) and Computed Tomography Angiography (CTA) for Coronary Artery Evaluation
Computer Augmented Endoscopic Sinus Surgery*
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 and Intermittent Monitoring of Glucose in the Interstitial Fluid*
Corneal Remodeling*
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

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)
Diagnostic Ultrasound for Plantar Fasciitis
Digital Mole Mapping System/Dermatoscopy
Digital Retinal Imaging Systems for the Screening and Detection of Diabetic Retinopathy
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 Stimulators for Pain, Seizures, Movement Disorders or Cerebral Palsy
Endometrial Ablation
Enhanced External Counterpulsation (EECP) for Angina Pectoris
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 for Prenatally Diagnosed Malformations
Frameless Stereotactic Radiosurgery
Functional Endoscopic Dilatation of the Sinuses
Functional Intracellular Analysis
Functional Neuromuscular Stimulation with Ergometers for Spinal Cord Injuries

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G

Gait Analysis
Gastric Electric Stimulation for Gastroparesis
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 Warfarin Sensitivity
Genotypic and Phenotypic Resistance Assays in Human Immunodeficiency Virus (HIV)
Growth Hormone Therapy*

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H

High Sensitivity C-Reactive Protein
Home Infusion Therapy Services
Home Total Parenteral Nutrition and Enteral Therapy
Home Uterine Activity Monitoring
Hyperbaric Oxygen Therapy (HBO)

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I

Infertility Diagnosis and Treatment*
Infliximab
Inhaled Iloprost for Pulmonary Hypertension
Intensity Modulated Radiation Therapy (IMRT)
Interspinous Distraction Devices
Intracoronary Brachytherapy
Intradiscal Electrothermal Annuloplasty and Percutaneous Intradiscal Radiofrequency Thermocoagulation
Intravenous Immunoglobulin

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K

Knee Braces

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L

Low-Density Lipid Apheresis
Low-Level Laser or Cold Laser Therapy
Lung Volume Reduction Surgery for Severe Emphysema
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/Magnetic Source Imaging (MSI)
Mastectomy for Gynecomastia*
Measurement of Intracellular Magnesium
Measurement of Small Low-Density Lipoprotein (LDL) Particles
Meniscal Allograft Transplant*
Microprocessor Controlled Prosthetic Knee*
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
Pancreatic Islet Cell Transplant*
Panitumumab (Vectibix^TM)*
Paraspinal Surface Electromyography
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
Positron Emission Tomography (PET) Scan, Cardiac Applications
Positron Emission Tomography (PET) Scans, Miscellaneous Applications
Preimplantation Genetic Diagnosis*
Prolotherapy
Prophylactic Treatment for Respiratory Syncytial Virus (RSV)*
Prostate Saturation Biopsy
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*
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)
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
Sleep Apnea and Upper Airway Resistance Syndrome*
Speech Therapy*
Subtalar Arthroereisis
Surgery for Morbid Obesity*
Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea
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)
Treatment of Benign Prostatic Hypertrophy
Treatment of Hyperhidrosis*
Treatment of Male Erectile Dysfunction
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
Vagus Nerve Stimulation
Ventricular Assist Devices and Artificial Hearts
Vertebral Axial Decompression
Virtual Colonoscopy/CT Colonography as a Screening Test for Colorectal Cancer
Viscosupplementation for Osteoarthritis

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

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