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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

Ablative Procedures of the Peripheral Nerves to Treat Pain*
Ablative Treatments for Occipital Neuralgia, Chronic Headaches and Atypical Facial Pain*
Adjustable Banding as a Treatment of Plagiocephaly
Air Ambulance*
Airway Clearance Devices
Allergy Immunotherapy and Rapid Desensitization
Allergy Testing
Ambulatory Cardiac Event Monitoring and Real-Time Outpatient Cardiac Telemetry
Ambulatory Esophageal pH Monitoring
Amniotic Ophthalmic Grafts and Amniotic Fluid Injections
Analysis of MGMT Promoter Methylation
Anesthesia Services for Gastrointestinal Endoscopy Procedures
Anorectal Biofeedback
Application/Injections of Local Anesthetic for Headaches
Artificial Intervertebral Disc
Autologous Chondrocyte Implant
Automated Nerve Conduction Tests

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B

Bio-Engineered Skin and Soft Tissue Substitutes
Biofeedback/Neurofeedback as a Treatment of Headache and other Disorders
Bioimpedance Devices for Detection and Management of Lymphedema
Biomarker Testing for Autoimmune Disease
Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Other Conditions
Bronchial Thermoplasty

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C

CAR-T Cell Therapy and Adoptive Immunotherapy*
Cardiovascular Disease Risk Tests
Cellular Immunotherapy for Prostate Cancer – Provenge (Sipuleucel-T)
Chemical Peels and Dermabrasion
Cochlear Implant Replacement*
Cognitive Rehabilitation
Computer-Assisted Navigation Systems for Orthopedic Surgery
Computer-aided Detection (CAD)/Computer Aided Evaluation (CAE) of Malignancy with Magnetic Resonance Imaging (MRI) of the Breast
Continuous Passive Motion (CPM) Devices in the Home Setting
Corneal Cross-Linking
Corneal Topography, Computer Assisted Photokeratoscopy, Video-keratography, and Optical Coherence Tomography
Coronary Artery Calcium Scoring
Cosmetic/Reconstructive Services

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D

DNA-Based Testing for Adolescent Idiopathic Scoliosis
Deep Brain Stimulation (DBS)
Dermatologic Applications of Photodynamic Therapy
Detection of Circulating Tumor Cells in the Management of Patients with Cancer
Drug Testing
Dynamic Posturography

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E

EGRIFTA™ (tesamorelin)
Echosclerotherapy, Mechanochemical Ablation, Endovenous Cryoablation, Photothermal and Pelvic Sclerosis and Cyanoacrylate Adhesive
Enteral Therapy and Oral Formula
Enzyme Replacement Therapy for Lysosomal Storage Diseases
Epidermal Growth Factor Receptor (EGFR) testing
Eustachian Tube Dysfunction Treatment
Evzio (naloxone auto-injector)
Exhaled Nitric Oxide and Exhaled Breath Condensate
Exondys 51 (eteplirsen)
Expanded Genetic Panels to Assess Cancer Risk
Expanded Genetic Panels to Identify Targeted Cancer Therapy
Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome (e.g. Lipiflow)

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F

Facet Joint Denervation*
Fecal Bacteriotherapy (Fecal Transplant)
Fecal Incontinence Management
Functional Electrical Stimulation (FES), Neuromuscular Electrical Stimulation (NMES) and Miscellaneous Electrical Stimulation
Functional Endoscopic Dilation of the Sinuses and Sinus Stents

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G

Gastric Electrical Stimulation
Gene Expression Based Assays for Cancer of Unknown Primary
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management
Gene Expression Profiling for Cutaneous Melanoma
Gene Expression Profiling for the Management of Breast Cancer
Gene Expression Profiling for Uveal Melanoma
Genetic Testing for BCR-ABL Fusion Gene
Genetic Testing for Familial Cutaneous Malignant Melanoma
Genetic Testing for Inherited Thrombophilia
Genetic Testing for Variants Found in Leukemia
Genetic Testing of BRCA for Indications Outside of Breast and Ovarian Cancers*
Genetic Testing to Determine Cardiac Disease
Genetic Testing in Myeloproliferative Disease
Genetic and Laboratory Testing for 5-fluorouracil (5-FU) Sensitivity
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer

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H

Heart/Lung Transplant*
Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant) Autologous and Allogeneic*
High Dollar Drug Review
High Intensity Focused Ultrasound (HIFU)
Home Sleep Studies - Pediatric
Homocysteine Testing
Hormone Replacement Using Subcutaneous Pellet Implantation
Humanitarian Use Devices
Hyperbaric Oxygen Therapy (HBOT) Systemic and Topical and Topical Continuous Oxygen Therapy (TCOT)

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I

Image-Guided Minimally Invasive Lumbar Decompression (IG-MILD) for Spinal Stenosis
Implantable Bone Conduction Hearing Devices*
Implantable Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
Interspinous Distraction Devices and Interspinous Fixation (Fusion) Devices

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K

KRAS/NRAS and BRAF Mutation Analysis
Knee Braces

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L

Laser Treatment for Nail Fungus
Leadless Cardiac Pacemaker
Low Frequency, Non-Contact Ultrasound for Wounds
Low-Level/Cold Laser and High Powered Laser Therapy
Lung and Lobar Lung Transplant*
Lutathera (Lutetium Lu 177 Dotatate)*

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M

MRI-Guided High-Intensity Focused Ultrasound (MRgFUS) Ablation
Manipulation under Anesthesia
Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis Using Ultrasound
Measurement of Serum Antibodies to Infliximab, Adalimumab and Vedolizumab
Mechanical Stretching Devices including Dynamic Splinting Devices
Medical Foods and Specialized Formula for the Treatment of Inborn Errors of Metabolism
Miscellaneous Bariatric Procedures
Miscellaneous Cardiac Treatments and Monitors
Miscellaneous Electrical Stimulation
Miscellaneous Surgical Treatments of Back Pain
Molecular Markers in Fine Needle Aspirates of the Thyroid
Molecular Testing in the Management of Pulmonary Nodules
Molecular Topographic Genotyping
Multigene Expression Assays for Predicting Recurrence of Colon Cancer
Multimarker Serum Testing Related to Ovarian Cancer

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N

Non-Powered Negative Pressure Wound Therapy
Noninvasive Measurement of Cardiac Bioimpedance in the Outpatient Setting
Noninvasive Prenatal Screening for Fetal Aneuploidies Using Cell - Free Fetal DNA in Maternal Plasma

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O

Occipital Nerve Stimulation
Off-label Drug Use
Osteochondral Allografts and Autografts

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P

Pancreas Transplants* (Including simultaneous pancreas-kidney, pancreas alone, and pancreas after kidney)
Pancreatic Islet Cell Transplant
Percutaneous Intracranial Angioplasty and Stenting
Percutaneous Kyphoplasty, Percutaneous Vertebroplasty, and Sacroplasty
Peripheral Subcutaneous Field Stimulation (PSFS)
Pharmacogenomic Testing for Drug Metabolism
Plasmapheresis/Plasma Exchange
Platelet - Rich Plasma and Autologous Protein Solution for Orthopedic Applications
Pneumatic Compression Devices
Positron Emission Tomography (PET) for Surveillance of Oncologic Indications*
Prolotherapy
Prostate-Specific Antigen Screening for Prostate Cancer
Proton Beam Radiation Therapy*
Pulsed Radiofrequency

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Q

Quantitative Sensory Testing

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R

Radium Ra 223 Dichloride (Xofigo)
Responsive Neurostimulation for the Treatment of Refractory Partial (Focal) Epilepsy

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S

Sacral Nerve Stimulation/Neuromodulation
Saliva Hormone Tests
Scintimammography/Gamma Imaging of the Breast and Axilla/Molecular Breast Imaging (MBI) including Positron Emission Mammography (PEM)
Screening for Lung Cancer Using Low Dose Computed Tomography (LDCT)
Sensory Integration Therapy and Auditory Integration Therapy
Serum Tumor Markers in the Management of Malignancies
Small Bowel Transplant*
Small Bowel/Liver and Multivisceral Transplant*
Spinal Cord Stimulation
Stem Cell Therapy for Orthopedic Indications (Including Allograft Bone Products Used With Stem Cells)*
Stem Cell Therapy for Peripheral Arterial Disease
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)
Subcutaneous and Extravascular Implantable Cardioverter Defibrillator (ICD)
Subtalar Arthroereisis and Subtalar Joint Implant
Surface Electromyography (sEMG)
Surgical Treatment of Lymphedema

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T

Temporomandibular Joint Dysfunction (TMJ/TMD) Treatment
Testing in the Diagnosis and Management of Inflammatory Bowel Disease (IBD)
Thermography and Temperature Gradient Studies
Transcranial Magnetic Stimulation*
Treating Benign Prostatic Hyperplasia
Treatment of Speech and Language Disorders*
Treatment for GERD and Barrett's Esophagus
Tumor Treatment Fields

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U

Ultrasound in Maternity Care
Urinary Incontinence/ Voiding Dysfunction Treatments and Devices
Use of Fractional CO2 Laser Therapy (MonaLisa Touch), Radiofrequency Technology and ER YAG Laser Therapy for Vaginal Rejuvenation and Vaginal Tightening
Use of Common Genetic Variants (Single Nucleotide Polymorphisms) to Predict Risk of Non-familial Breast Cancer

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V

Vagus Nerve Stimulation (VNS) and Vagal Blocking Therapy
Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ophthalmic Use
Vertebral Axial Decompression
Vertebral Fracture Assessment
Vision Therapy/Orthoptic Training
Vitamin D Testing
Vivitrol (naltrexone for extended-release injectable suspension)

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W

Whole Body Dual X-Ray Absorptiometry (DXA) and Bioelectrical Impedance Analysis (BIA) to Determine Body Composition
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders