Medical policy details
We base our medical policies on:
- Data from credible scientific evidence published in peer-reviewed medical literature
- National medical society position statements or guidelines and applicable governmental reports
We use the following criteria to evaluate medical technologies:
- The technology must have final approval from the appropriate governmental regulatory bodies
- The scientific evidence must permit conclusions concerning the effect of technology on health outcomes
- The technology must improve the net health outcomes
- The technology must be as beneficial as any established alternatives
- The improvement must be obtainable outside the investigational settings
Medical technology is constantly evolving. Our medical policies are subject to change without notice, except as required by law. Additional medical policies may be developed from time to time, and some may be removed from use.
A
Ablative Procedures for the Peripheral Nerves to Treat Pain*
Airway Clearance Devices in the Home Setting
Ambulatory Cardiac Event Monitors and Mobile Cardiac Outpatient Telemetry (MCOT)
Amniotic Membrane and Amniotic Fluid Grafts
Anesthesia Services for Gastrointestinal Endoscopic Procedures
Artificial Intervertebral Disc
Autologous Chondrocyte Implant for Focal Articular Cartilage Lesions
Automated Nerve Conduction Tests
Automated Percutaneous and Percutaneous Endoscopic Discectomy
B
Balloon Dilation of the Eustachian Tube
Balloon Ostial Dilation for Treatment of Recurrent Chronic Rhinosinusitis
Baroreflex Stimulation Devices Components and Ancillary Services
Bio-Engineered Skin and Soft Tissue Substitutes
Biofeedback as a Treatment of Anorectal Disorders
Biofeedback as a Treatment of Chronic Pain
Biofeedback as a Treatment of Headache
Biofeedback as a Treatment of Urinary Incontinence
Biofeedback for Miscellaneous Indications
Bioimpedance Devices for Detection and Management of Lymphedema
Biomarker Testing for Barrett's Esophagus and Other Esophageal Disorders
Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease
Bone Conduction Hearing Devices*
Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Other Conditions
C
Cardiac Contractility Modulation Therapy Device Components and Ancillary Services
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
Circulating Tumor Cells for Cancer Management
Computer-Assisted Corneal Topography
Continuous Passive Motion (CPM) Devices in the Home Setting
Contraceptives for Medical Indications (Non-Contraceptive Use)
Cosmetic and Reconstructive Services
Cranial Electrotherapy Stimulation and Auricular Electrostimulation
Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis
D
Dermatologic Applications of Photodynamic Therapy
Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
Donor Lymphocyte Infusion (DLI) and Hematopoietic Progenitor Cell (HPC) Boost
Dopamine Transporter Single-Photon Emission Computer Tomography of the Brain
Drug Testing in Pain Management and Substance Use Disorder Treatment
E
Electrical and Electromagnetc Stimulation for the Treatment of Arthritis
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus
Enteral Nutrition Therapy and Oral Formula
Exhaled Nitric Oxide and Exhaled Breath Condensate
External Upper Limb Stimulation for the Treatment of Tremors
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
F
Fecal Microbiota Transplantation
Four - Dimensional (4-D) and Five - Dimensional (5-D) Fetal Ultrasound(s)
Functional Electrical Stimulation and Neuromuscular Electrical Stimulation
H
Hematopoietic Stem Cell Transplantation Autologous and Allogeneic*
High Intensity Focused Ultrasound (HIFU)
Home Sleep Studies - Pediatric
Hyperbaric Oxygen Therapy (HBOT) Systemic* and Topical Hyperbaric Oxygen Therapy (THOT)
I
Image-Guided Minimally Invasive Decompression for Spinal Stenosis
Implantable Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
Implants for Metatarsal Joint Pain
Injection Therapy for Headache Management
Interferential Current Stimulation
Intracardiac Ischemia Monitoring
Investigational and Not Medically Necessary Services
Irreversible Electroportation of Tumors Located in the Liver Pancreas Kidney and Liver
K
L
Laparoscopic, Percutaneous and Transcervical Techniques for Uterine Fibroid Myolysis
Laser Interstitial Thermal Therapy (LITT)
Laser Treatment for Nail Fungus
M
Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease
Management of Dry Eye Syndrome
Measurement of Serum Antibodies to Selected Biologic Agents
Medical Foods and Specialized Formula for the Treatment of Inborn Errors of Metabolism
Minimally-Invasive Surgical Treatments for Scoliosis
Miscellaneous Bariatric Procedures
Miscellaneous Electrical Stimulation for the Treatment of Pain
Miscellaneous Investigational Therapies and Tests for Urinary Incontinence/Urinary Dysfunction
Miscellaneous Investigational Treatments for Reflux Disease
Miscellaneous Minimally Invasive Treatments for Benign Prostatic Hyperplasia
Miscellaneous Treatments for Varicose Veins/Venous Insufficiency
MRI-Guided High-Intensity Focused Ultrasound (MRgFUS) Ablation
N
Noncontact Ultrasound Treatment for Wounds
Non-Implantable Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy
Non-invasive Heart Failure and Arrhythmia Management and Monitoring System
O
Optical Coherence Tomography of the Anterior Eye Segment
Orally Ingested Transient Device for Constipation
Osteochondral Allografts and Autografts in the Treatment of Focal Articular Cartilage Lesions
Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome
P
Pancreatic Islet Cell Transplant
Percutaneous and Implantable Posterior Tibial Nerve Stimulation
Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome
Percutaneous Intracranial Angioplasty and Stenting
Percutaneous Left-Atrial Appendage Closure Devices
Percutaneous Ultrasonic Tenotomy and Fasciotomy
Peripheral Subcutaneous Field Stimulation (PSFS)
Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux
Periurethral Bulking Agents for the Treatment of Stress Urinary Incontinence
Peroral Endoscopic Myotomy (POEM) Procedures
Plasma-Based Proteomic Screening in the Management of Pulmonary Nodules
Platelet Rich Plasma and Autologous Protein Solution for Orthopedic Applications
Pneumatic Compression Devices in the Home Setting
Prostate-Specific Antigen Screening for Prostate Cancer
R
Renal Denervation for Uncontrolled Hypertension
Radium Ra 223 Dichloride (Xofigo)
Remote Electrical Neuromodulation for Migraines
Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
S
Sacral Nerve Neuromodulation/Stimulation
Screening for Vertebral Fracture with Densitometry or Biomechanical Computed Tomography
Sensory Integration Therapy and Auditory Integration Therapy
Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases
Small Bowel/Liver and Multivisceral Transplant*
Spinal Cord and Dorsal Root Ganglion Stimulation
Stem Cell Therapy for Lung Disease*
Stem Cell Therapy for Peripheral Arterial Disease
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)
Steroid – Eluting Sinus Stents and Implants
Surface Electromyography (sEMG)
Surgical Treatment for Lipedema*
T
Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia
Temporomandibular Joint (TMJ) Dysfunction: Diagnosis and Treatments
Therapeutic Plasmapheresis or Plasma Exchange
Thermography and Temperature Gradient Studies
Tonic Motor Activation for Restless Legs Syndrome
Transcranial Magnetic Stimulation*
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
Treatment of Congenital Athymia (Rethymic)
Treatment of Nasal Valve Collapse
Treatment of Speech and Language Disorders*
Treatments for Occipital Neuralgia, Chronic Headaches and Persistent Idiopathic Facial Pain*
V
Vagus Nerve Stimulation (VNS) and Vagal Nerve Blocking Therapy
Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ophthalmic Use
Disclaimers
*Prior approval from Wellmark is required. Refer to Wellmark's Medical Authorization Table for more details.
Wellmark's medical policies address the complex issue of technologically assessing new and emerging treatments, devices, drugs, etc. Policies are developed to assist in the administration of plan benefits and are not offers of medical coverage or advice. They contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide medical treatment and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies are subject to change without notice.