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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 Medical or Drug Authorization Tables to determine when to request an authorization.

InterQual® criteria is used to evaluate whether a medical procedure or equipment is medically necessary. Contracting practitioners can view InterQual criteria via SmartSheets^TM . 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*
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, Amniotic Fluid, and Amniotic 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

Cardiovascular Disease Risk Tests
Cellular Immunotherapy for Prostate Cancer – Provenge (Sipuleucel-T)
Chemical Peels and Dermabrasion
Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsies)
Circulating Tumor DNA for Management of Non-Small Cell Lung Cancer (Liquid Biopsy)
Cochlear Implant Replacement*
Cognitive Rehabilitation
Computer-Assisted Navigation for Orthopedic Surgery
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
Cranial Remolding

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D

DNA-Based Testing for Adolescent Idiopathic Scoliosis
Deep Brain Stimulation (DBS)
Dermatologic Applications of Photodynamic Therapy
Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
Drug Testing
Dry Needling
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)
Ex Vivo/Machine Perfusion (MP) of Organs
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

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F

Facet Joint Denervation*
Fecal Bacteriotherapy (Fecal Transplant)
Fecal Incontinence Management
Functional Electrical Stimulation (FES), Neuromuscular Electrical Stimulation (NMES) and Electrical Stimulation for Muscular and Nerve Pain
Functional Endoscopic Dilation of the Sinuses and Sinus Implantable Devices

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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

Implantable Bone Conduction Hearing Devices*
Implantable Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
Implantable Peripheral Nerve Stimulation for the Treatment of Chronic Pain
Implantable and Non-Invasive Glucose Sensors
Interspinous Distraction Devices and Interspinous Fixation (Fusion) Devices

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K

KRAS/NRAS and BRAF Mutation Analysis
Ketamine
Knee Braces
Kymriah (Tisagenlecleucel)*

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L

Laboratory Testing for Transplant Rejection
Lartruvo (olaratumab)
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
Management of Dry Eye Syndrome
Manipulation under Anesthesia
Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis Using Ultrasound
Measurement of Serum Antibodies to Infliximab, Adalimumab, Vedolizumab and Ustekinumab
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 Analysis for Targeted Therapy of Non-Small Cell Lung Cancer
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
Platelet-Rich Plasma for the Treatment of Non-Orthopedic Indications
Pneumatic Compression Devices
Positron Emission Tomography (PET) for Surveillance of Oncologic Indications*
Prolotherapy
Prostate-Specific Antigen Screening for Prostate Cancer
Proteomic Testing for Systemic Therapy in Non-Small Cell Lung 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 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
Single Photon Emission Computed Tomography (SPECT) of the Brain for Behavioral Health Disorders
Small Bowel Transplant*
Small Bowel/Liver and Multivisceral Transplant*
Speech Generating Devices
Spinal Cord and Dorsal Root Ganglion Stimulation
Stem Cell Therapy for Lung Disease*
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)
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 Achalasia and Gastric Motility Disorders
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 Variants) 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)
Vyondys 53 (golodirsen)

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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

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Y

Yescarta (Axicabtagene Ciloleucel)*