Medical Policies
Medical Policies
Our medical policies do not constitute medical advice. Treating practitioners are entirely responsible for medical advice and for the treatment of their patients. As a result, we recommend that you review these policies with your doctor to fully understand how a policy relates to your particular situation.
Learn more about how policies are developed .
Intention for Use:
Medical policies do not constitute medical advice. Treating practitioners are entirely responsible for medical advice and for the treatment of their patients. Medical policies are based upon a review of scientific-based evidence used to determine the scientific merit of a particular medical technology or technologies. Medical Policies can be highly technical and are designed to be used by health care practitioners when caring for our members. As a result we recommend you review these policies with your doctor to fully understand how a policy relates to your particular situation.
Medical services are constantly changing and we periodically review and update our medical policies. Although we try to maintain up-to-date medical policies online, some recent changes may not yet be included. Our most recent policies shall apply.
Medical policies guide decisions about coverage. They are statements about a particular technology or are a blend of administrative and medical appropriateness information that helps clarify coverage of services based on interpretation of member/subscriber contracts. Coverage depends on your individual contract and the medical necessity of the procedure relating to your individual situation.
These policies apply to patients with commercial contracts only. Medicare policies will be followed for patients with Medicare contracts.
Our Medical Policies contain Physician Current Procedural Terminology ("CPT"), a coding work of nomenclature and five-digit codes for reporting of physician services. CPT is protected by copyright and trademark owned by the American Medical Association ("AMA").
In order to view the item containing CPT you agree:
AMA is the owner of all copyright, trademark and other rights to CPT and its updates. AMA reserves all such rights. No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for data contained or not contained herein.
CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, implied warranties of merchantability and fitness for a particular use. AMA, Univera Healthcare and its affiliates disclaim any responsibility for any consequences or liability attributable to or related to any use, non-use or interpretation of the information containing CPT.
Use of CPT by you, your employees, agents and assigns is limited to matters in connection with submitting claims to Univera Healthcare and its affiliates, and only within the United States of America and its territories.
Any use of CPT not authorized herein in prohibited, including by way of illustration and not by way of limitation, making copies of CPT for sale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, making any commercial use of CPT, or placing CPT or information contained therein in any public electronic bulletin board or public computer based information system (including the Internet and World Wide Web).
Applicable FARS/DFARS Restrictions apply to Government Use.
You may make copies of CPT for backup or archival purposes only. Such backup or archival copy must bear notice of the AMA copyright, trademark and proprietary rights to CPT.
You must take necessary and appropriate action to assure that you, your employees, agents and assigns comply with the terms of this agreement.
This license shall terminate without notice if you violate its terms.
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Alternative Medicine
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Anesthesiology
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Behavioral Health (Psychology)
Applied Behavioral Analysis for Treatment of Autism Spectrum Disorders (ABA), Pervasive Developmental Disorders (PDD)
Policy 3.01.11 (posted 1/18/19)
Auditory Processing Disorder (APD) Testing
Policy 2.01.39 (posted 1/18/19)
Behavioral Health Treatment for Gender Dysphoria: Gender Identity Disorder (GID), Intersex, Transexualism
Policy 3.01.15 (posted 11/26/18)
Behavioral Health Treatment of Family and Couples (Couples Therapy, Family Therapy)
Policy 3.01.05 (posted 4/4/18)
Group Therapy for Mental Health
Policy 3.01.08 (posted 1/18/19)
Hypnosis
Policy 2.01.26 (posted 10/09/18)
Ketamine for the Treatment of Psychiatric Disorders
Policy 3.01.13 (posted 2/06/19)
Partial Hospitalization for Substance Use Disorders, Chemical Dependency
Policy 3.01.18 (posted 11/26/18)
Phototherapy/Light Therapy for Seasonal Affective Disorder (SAD)
Policy 1.01.24 (posted 11/26/18)
Psychological Testing
Policy 3.01.02 (posted 1/18/19)
Sex Offender Treatment Program
Policy 3.01.17 (posted 11/26/18)
Sex Specific Services, Gender dysphoria, Gender Identity Disorder, GID, transgender, transsexualism
Policy 11.01.26 (posted 1/18/19)
Standard Dialectical Behavioral Therapy (DBT)
Policy 3.01.10 (posted 11/26/18)
Transcranial Magnetic Stimulation: Deep TMS device, MagVita TMS, NeuroStar TMS device, rTMS, TMS
Policy 3.01.09 (posted 1/18/19)
Treatment of Gambling Disorder and Other Repetitive Behaviors
Policy 3.01.19 (posted 4/11/18)
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Blood Disorders (Hematology)
Chelation Therapy (e.g., EDTA, Endrate, Desferal, BAL in oil, Cuprimine, Depen, Zinecard, Exjade, Post-chelator Challenge Urinary Metal Testing. Post-provocation Urinary Metal Testing)
Policy 8.01.03 (posted 11/19/18)
Plasmapheresis, Plasma Exchange and Apheresis, Rheopheresis
Policy 8.01.04 (posted 4/4/18)
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Bone & Joints (Orthopedic)
Artificial Cervical Intervertebral Discs (e.g., Bryan, Mobi-C, PCM [Porous Coated Motion] Cervical Disc®, Prestige®, ProDisc®, Secure-C)
Policy 7.01.80 (posted 1/15/19)
Artificial Lumbar Intervertebral Disc (e.g.,ActivL®, Bryan, Charité, ProDisc)
Policy 7.01.63 (posted 1/15/19)
Autologous Chrondrocyte Implantation (e.g., Carticel®, Matrix-induced ACI, MACI, Minced cartilage, Neocartilage, Scaffold-induced ACI)
Policy 7.01.38 (posted 8/16/18)
Automated Percutaneous and Endoscopic Discectomy: Stryker DeKompressor, Nucleotome, SpineJet Hydrodiscectomy
Policy 7.01.16 (posted 8/16/18)
Bone Growth Stimulators (e.g., Electrical, Osteogenic, Sonic Accelerated Fracture Healing System - SAFHS, Ultrasonic)
Policy 7.01.40 (posted 4/4/18)
Computerized Motion Diagnostic Imaging (CMDI), Gait Analysis
Policy 2.01.13 (posted 2/06/19)
Continuous Passive Motion Device (CPM) in the Home Setting
Policy 1.01.02 (posted 10/02/18)
Cryotherapy, Cold Therapy, Ice Therapy
Policy 1.01.21 (posted 8/16/18)
Dynamic Adjustable Braces/Joint Extension Device (e.g., Dynasplint™, EMPI Advance™, LMB Proglide™, Ultraflex™
Policy 1.01.35 (posted 4/4/18)
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds: Lithotripsy, Orthotripsy, OssaTron®, EpoUltra®, SINOCUR®, Orbasone™, Orthospec™
Policy 2.01.31 (posted 8/16/18)
Hip Arthroplasty
Policy 7.01.96 (posted 1/15/19)
Interspinous and Interlaminar Stabilization/Distraction Implants (e.g., Coflex®, Interspinous Spacer, Spinal Distraction, Superion®, X STOP)
Policy 7.01.75 (posted 8/16/18)
Intervertebral Disc Decompression: Laser (Laser Discectomy) and Radiofrequency Coblation (Disc Nucleoplasty™) Techniques
Policy 7.01.62 (posted 8/16/18)
Lumbar Decompression
Policy 7.01.97 (posted 1/15/19)
Lumbar Fusion for Adults
Policy 7.01.90 (posted 2/06/19)
Lumbar Microdiscectomy
Policy 7.01.98 (posted 1/15/19)
Lumbar Traction: Vertebral Axial Decompression and Home Lumbar Traction Devices - ComfortTrac, Decompression Reduction Stabilization (DRS) System, HomeTrac, Orthotrac, VAX-D
Policy 1.01.50 (posted 9/6/18)
Manipulation Under Anesthesia (MUA), Manipulation under Joint Anesthesia (MUJA), Manipulation Under Sedation (MUS)
Policy 7.01.76 (posted 1/15/19)
Minimally Invasive Techniques for Lumbar Interbody Fusion: Anterior Lumbar (ALIF), Axial Lumbar (AxiaLIF), Direct Lateral (DLIF), Extreme Lateral (XLIF), Laparoscopic Anterior Lumbar (LALIF), Posterior Lumbar (PLIF), Transforaminal Lumbar (TLIF)
Policy 7.01.83 (posted 8/16/18)
Orthotics (e.g., OttoBock E-Mag Active KAFO, OttoBock SensorWalk Electronic KAFO, MYOMO mPower 1000 arm brace)
Policy 1.01.25 (posted 5/31/18)
Osteochondral Grafting (Allograft, Autograft): Chondrofix®, Mosaicplasty, OATS
Policy 7.01.59 (posted 8/16/18)
Percutaneous Intradiscal Electrothermal Annuloplasty (IDET, IDTA, PIRFT, Biacuplasty)
Policy 7.01.17 (posted 10/09/18)
Percutaneous Vertebroplasty, Kyphoplasty, Mechanical Vertebral Augmentation (e.g., Kyphon Inflatable Bone Tamp)
Policy 6.01.17 (posted 1/15/19)
Prolotherapy (e.g., Sarapin)
Policy 8.01.10 (posted 1/15/19)
Radiofrequency Facet Denervation
Policy 7.01.42 (posted 1/15/19)
Sacroiliac Joint Fusion, IFUSE® Implant System ,SI-FIX, SImmetry® Sacroiliac Joint Fusion System, Silex™ Sacroiliac Joint Fusion System, SI-LOK® Sacroiliac Joint Fixation System
Policy 7.01.93 (posted 1/15/19)
Shoulder Arthroplasty
Policy 7.01.95 (posted 1/15/19)
Temporomandibular Joint (TMJ) Disease
Policy 11.01.17 (posted 1/18/19)
Total Hip Resurfacing, Metal-on-Metal
Policy 7.01.74 (posted 1/15/19)
Bone Growth Stimulators for the Appendicular Skeleton
Policy 1.01.53 (posted 6/1/18)
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Cancer Treatment (Oncology)
Hyperthermia as a Cancer Treatment: Extracorporeal Whole Body, Intraperitoneal, Local, Regional, Whole Body
Policy 2.01.25 (posted 6/12/18)
Isolated Limb Perfusion and Infusion (Alkeran, L-PAM, Melphalan, Tumor Necrosis Factor)
Policy 7.01.52 (posted 10/09/18)
Photodynamic Therapy (PDT) for Malignant Disease (Photofrin, Porfimer Sodium)
Policy 8.01.06 (posted 4/4/18)
Pneumatic Compression Devices/Lymphedema Pump/Sleeve (e.g., Flexitouch™)
Policy 1.01.17 (posted 5/31/18)
Radiofrequency Tumor Ablation
Policy 7.01.32 (posted 9/6/18)
Radium-223 (Xofigo) for Treatment of Castration-Resistant Prostate Cancer
Policy 6.01.44 (posted 5/31/18)
Superficial Radiation Therapy for Treatment of Skin Cancers (Orthovoltage x-ray, SR-100, Xstrahl-100)
Policy 6.01.43 (posted 5/31/18)
Tumor-Treatment Field Therapy for Glioblastoma: Electrical Field Therapy, NovoTTF-100™ PDF
Policy 6.01.45 (posted 5/31/18)
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Children's Health (Pediatrics)
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Chiropractic
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Cosmetic / Reconstructive Surgery
Abdominoplasty and Panniculectomy (e.g., Belt Lipectomy, Lipectomy, Tummy Tuck)
Policy 7.01.53 (posted 5/31/18)
Alopecia (e.g., Areata, Androgenic, Scarring), Baldness, Hair Loss
Policy 2.01.36 (posted 1/18/19)
Blepharoplasty/Eyelid Surgery with or without Levator Muscle Advancement(Pseudoptosis Surgery, Ptosis Surgery, Brow Lift)
Policy 7.01.55 (posted 5/31/18)
Breast Reconstruction Surgery
Policy 10.01.01 (posted 10/02/18)
Cosmetic and Reconstructive Procedures: Acne Cysts, Actinic Keratoses, Collagen Injection, Complexion Analysis, Dermatoscopy, Drionic, Face Lift, Hairplasty, Hair Transplant, Hyperhydrosis, Iontophoresis, Labiaplasty, Liposuction, Prolaryn,Tattoos, Voice Lift, Benign Skin Lesion Removal, Skin Tag Removal, Keloid Scars, Chemical Peel, Dermabrasion, Port Wine Stains, Rosacea, Vitiligo
Policy 7.01.11 (posted 4/4/18)
Treatment of Hirsutism/ Hypertrichosis (Hair Removal) (e.g., Electrolysis, Epilation)
Policy 2.01.38 (posted 1/18/19)
Reduction Mammaplasty/ Breast Reduction
Policy 7.01.39 (posted 10/02/18)
Varicosities/Varicose Veins, Treatment Alternatives to Vein Stripping and Ligation (e.g., Ambulatory, Stab or Transilluminated Powered Phlebectomy, ClariVein®, Endoluminal Radiofrequency Ablation, Endovenous Embolization, Endovenous Laser Ablation, Mechanochemical Endovenous Ablation, MOCA, Sclerotherapy, Varithena™, VenaSeal™, VNUS)
Policy 7.01.47 (posted 5/7/18)
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Dental
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Diabetes (Endocrinology)
CGMS, Continuous glucose monitor, DexCom STS, Freestyle Navigator, Interstitial glucose monitoring, MiniMed CGMS® System Gold™, MiniMed Guardian® Real-Time, MiniMed Paradigm Revel® Real-Time system, DexCom G5®,Wrist glucose monitor, Continuous subcutaneous insulin infusion, CSII, Insulin pump therapy
Policy 1.01.30 (posted 11/19/18)
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Digestive System (Gastroenterology)
Colorectal Cancer Screening, Cologuard, CT Colonography, FIT, gFOBT, virtual colonoscopy, fecal DNA, fecal occult blood test
Policy 2.01.51 (posted 6/12/18)
Cryosurgical Tumor Ablation
Policy 7.01.03 (posted 5/31/18)
Fecal Bacteriotherapy, Fecal microbiota therapy (FMT), Fecal transfusion, Fecal transplant, Human probiotic infusion (HPI), Intestinal Microbiotia Transplantation (IMT), Microbiome, Stool transplant
Policy 2.01.48 (posted 10/09/18)
Fecal Incontinence, Radiofrequency Treatment (Secca procedure)
Policy 7.01.66 (posted 11/19/18)
Gastric Electrical Stimulation and Gastric Pacing
Policy 7.01.64 (posted 2/06/19)
High Resolution Anoscopy (Anal Colposcopy)
Policy 2.01.49 (posted 10/09/18)
Magnetic Esophageal Ring for the Treatment of Gastroesophageal Reflux (GERD): Esophageal Sphincter Device, LINX™ System, Magnetic Sphincter Augmentation
Policy 7.01.89 (posted 1/9/2018)
Plugs for Fistula Repair
Policy 7.01.86 (posted 5/7/18)
Surgical Management of Obesity: Adjustable Gastric Band, Bariatric Surgery, Biliopancreatic Diversion, Duodenal Switch, Endobarrier, Gastric Bypass, Gastric Plication, Imbrication, Lap Band, Restorative Obesity Surgery, Endoluminal [ROSE], Roux-en-Y, Sleeve Gastrectomy, Stomach Stapling, TOGA, Transoral or Vertical Banded Gastroplasty
Policy 7.01.29 (posted 10/02/18)
Transendoscopic Therapies for Gastroesophageal Reflux Disease (GERD): ELF, EndoCinch, Endoluminal Funcoplication, Endoluminal Gastroplication, Enteryx, EsophyX, Gatekeeper, Plexiglas Microspheres, NDO Plicator System, Radiofrequency Esophageal Treatment, Stretta
Policy 7.01.45 (posted 6/12/18)
Wireless Capsule Endoscopy/Imaging for Examination of the Gastrointestinal (GI) Tract: AGILE Patency Capsule, Given® Capsule Camera, PillCam SB, PillCam ESO
Policy 6.01.27 (posted 9/6/18)
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Drug / Medications
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Durable Medical Equipment & Supplies
Augmentative and Alternative Communication Systems: AAC, Dynavox, Introtalker, VoiceMate, Walker Talker, Say-It-All, Speech Generating Devices (SGD)
Policy 1.01.03 (posted 1/18/19)
Breast Pumps
Policy 1.01.39 (posted 5/31/18)
Cervical Traction Devices (e.g., HomeTrac Deluxe, Saunders Cervical HomeTrac, Hydraulic, Over-The-Door, Pneumatic Cervical, Pronex)
Policy 1.01.47 (posted 9/10/18)
Durable Medical Equipment (DME) - Standard and Non-Standard, Home Medical Equipment
Policy 1.01.00 (posted 10/02/18)
Electrical Stimulation: Transcutaneous Electrical Nerve (TENS), Percutaneous Electrical Nerve (PENS), H-Wave and Interferential Stimulators (IFS), Percutaneous Neuromodulation Therapy, Bionicare®
Policy 1.01.01 (posted 8/16/18)
Limb Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis: Triple Play VT®, Venodyne, VascuTherm2
Policy 1.01.51 (posted 9/6/18)
Negative Pressure Wound Therapy, PICO™ system, SNaP® system, Topical Negative Pressure therapy, Vacuum Assisted Closure therapy
Policy 1.01.38 (posted 1/2/19)
Neuromuscular Electrical Stimulation (FNS, NMES, TES, VitalStim®)
Policy 1.01.48 (posted 9/10/18)
Positive Airway Pressure Devices: CPAP, BiPAP, APAP, DPAP, C-FLex
Policy 1.01.06 (posted 11/26/18)
Standing Devices and Gait Trainers, Stander
Policy 1.01.46 (posted 4/4/18)
Surgical Stockings (e.g., Gradient Compression/GCS, Jobst, Sigvaris, TEDs) and Compression Garments (e.g., Arm Assist, Belisse Compressure Bra, Lymphedema, Mastectomy, Circaid, Juzo, Reid Sleeves)
Policy 1.01.14 (posted 10/02/18)
Vitrectomy Chair/ Face-Down Positioning System
Policy 1.01.52 (posted 5/31/18)
Wheelchairs and Power Operated Vehicles (POVs) (e.g., Scooters)
Policy 1.01.16 (posted (posted 8/16/18)
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Ear, Nose & Throat (Otorhinolaryngology)
Sinus Ostial Dilation for Treatment of Chronic Sinusitis (e.g., Balloon Sinuplasty), catheter sinusotomy
Policy 7.01.85 (posted 6/12/18)
Cochlear Implants and Auditory Brainstem Implants: Advanced Bionics® HiResolution Bionic Ear System (HiRes 90k), Cochlear® Nucleus 5, Med El® Maestro (Sonata or Pulsar), Nucleus 24® Auditory Brainstem Implant System, Nucleus® Hybrid™ L24 Cochlear Implant
Policy 7.01.26 (posted 6/12/18)
Implantable Bone Conduction Hearing Aids, Bone Anchored Hearing Aid (BAHA®), OBC bone anchored hearing aid system, Ponto Pro
Policy 7.01.77 (posted 6/12/18)
Posturography (e.g., Balance Test, Equitest)
Policy 2.01.20 (posted 1/18/19)
Treatment of Tinnitus: Habituation Therapy, Jastreboff Method, Masking, Retraining Therapy
Policy 8.01.07 (posted 2/16/18)
Sialendoscopy
Policy 7.01.94 (posted 6/12/18)
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Environmental Health
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Eyes (Ophthalmology)
Aqueous Drainage Devices (Stents and Shunts): Ahmed, Aquaflow, Baerveldt, CyPass, Ex-PRESS, Glaucoma Filtration Device, IOP, iStent, Krupin, Molteno, XEN
Policy 9.01.18 (posted 5/31/18)
Corneal Ultrasound Pachymetry
Policy 9.01.07 (posted 5/31/18)
Gas Permeable Scleral Contact Lens (e.g., Boston Ocular Surface Prosthesis, Prosthetic Replacement of the Ocular Surface Ecosystem [PROSE])
Policy 9.01.17 (posted 11/19/18)
Intraocular Lens (IOL) Implants (e.g., Accommodating, Aspheric, Crystalens, Dynamic, Monofocal, Multifocal, Pseudoaccommodating)
Policy 9.01.14 (posted 11/26/18)
Intrastromal Corneal Ring Segments (ICRS) for Keratoconus (e.g., INTACS)
Policy 9.01.13 (posted 6/12/18)
Ophthalmologic Techniques for the Diagnosis of Glaucoma (Scanning Laser Polarimetry and Scanning Laser Ophthalmoscopy): GDx Imaging, Nerve Fiber Analysis, Heidelberg Retina Tomograph, Optomap
Policy 9.01.06 (posted 1/15/19)
Optical Coherence Tomography (OCT) for Ophthalmological Applications
Policy 9.01.10 (posted 5/31/18)
Photodynamic Therapy (PDT) for Subfoveal Choroidal Neovascularization (CNV) (e.g., Verteporfin, Visudyne)
Policy 8.01.11 (posted 5/7/18)
Phototherapeutic Keratoplasty/Keratectomy, PTK
Policy 9.01.01 (posted 10/09/18)
Refractive Procedures (e.g., Artisan, Astigmatic Keratotomy, Clear Lens Extraction, Photorefractive Keratectomy - PRK, INTACS - Corneal Ring Segments, Intracorneal Inlay, Laser-Assisted Subepithelial Keratomileusis - LASIK, Phakic Intraocular Lens)
Policy 9.01.08 (posted 11/26/18)
Transpupillary Thermotherapy (TTT)
Policy 9.01.05 (posted 10/02/18)
Vision/Eye Therapy: Optometric Phototherapy, Occlusion Therapy, Orthoptics, Pleoptics
Policy 9.01.04(posted 1/18/19)
Keratoprosthesis: AlphaCor™, BIOKOP, Boston type I, Boston type II, Dolhman-Doane, KPro, OOKP
Policy #9.01.15 (posted 5/31/18)
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Feet (Podiatry)
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Food (Nutrition)
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Genetic Disease (Inherited Disease)
Chromosomal Microarray (CMA) Analysis for Prenatal Evaluation and Evaluation of Patients with Developmental Delay/ Intellectual Disability or Autism Spectrum Disorder
Policy 2.02.42 (posted 1/18/19)
Gene Expression Analysis for Prostate Cancer Management: Oncotype DX® Prostate, Prolaris®
Policy 2.02.48 (posted 1/18/19)
Genetic Assay of Tumor Tissue to Determine Prognosis of Breast Cancer (Blueprint®, OncotypeDX™, MammaPrint®, Targetprint®)
Policy 2.02.27 (posted 9/10/18)
Genetic Testing for Hereditary BRCA Mutations: BART test, BRCA1, BRCA2, CHEK2
Policy 2.02.06 (posted 2/06/19)
Genetic Testing for Cystic Fibrosis
Policy 2.02.17 (posted 9/6/18)
Genetic Testing for Familial Alzheimer's Disease
Policy 2.02.16 (posted 9/10/18)
Genetic Testing for Germline Mutations of the RET Proto Oncogene in Medullary Carcinoma of the Thyroid
Policy 2.02.07 (posted 1/18/19)
Genetic Testing for Hereditary Hemochromatosis
Policy 2.02.05 (posted 10/09/18)
Genetic Testing for Inherited Susceptibility to Colorectal Cancer: Familial Adenomatous Polyposis (FAP), Hereditary Nonpolyposis Colorectal Cancer (HNPCC), COLARIS®
Policy 2.02.11 (posted 1/2/19)
Genetic Testing for Inherited Disorders: Alpha-1-Antitrypsin Deficiency, ALS - Amyotrophic Lateral Sclerosis, Lou Gehrig's Disease, Angelman Syndromes, Becker Muscular Dystrophy, CADASIL, Charcot-Marie-Tooth Huntington's Disease, Congenital Adrenal Hyperplasia, Duchenne Muscular Dystrophy - DMD, Dystonia, Factor V, Fanconi Anemia, Fragile X syndrome, Gaucher Disease, Hemophilia A and B, Myotonic Dystrophy, Neurofibromatosis, Phenylketonuria - PKU, Prader Willi, Sickle Cell, Tay-Sachs Disease, Thalassemia
Policy 2.02.03 (posted 8/16/18)
Genetic Testing for Susceptibility to Hereditary Cancers (PTEN, Cowden Syndrome, TP53, Li Fraumeni Syndrome, BreastNext, CancerNext, OvaNext, MyRisk Hereditary Cancer, Melaris, Prolaris, Panexia)
Policy 2.02.44 (posted 11/19/18)
Genotyping Cytochrome P450 (CYP450) for Drug Metabolism: Amplichip
Policy 2.02.30 (posted 9/10/18)
Genotyping Cytochrome P450 2C9 (CYP2C9) and Vitamin K Epoxide Reductase Subunit CI (VKORC) That Affect Response to Warfarin (Coumadin®)
Policy 2.02.33 (posted 1/18/19)
Genotyping - Targeted Therapy for Non-Small Cell Lung Cancer (NSCLC) (e.g., EGFR, ALK and KRAS)
Policy 2.02.35 (posted 12/12/17)
Genotyping or Phenotyping for Thiopurine Methyltransferase (TPMT) for Patients Treated with Azathioprine (6-MP)
Policy 2.02.37 (posted 2/06/19)
Genotyping Uridine Diphosphate Glycuronosyltransferase (UGT1A1) for Patients Treated with Irinotecan
Policy 2.02.34 (posted 1/18/19)
Genetic Testing for Congenital Long QT Syndrome (Familion Test)
Policy 2.02.38 (posted 9/10/18)
Genotyping - KRAS Mutation Analysis in Metastatic Colorectal Cancer, BRAF, KRAS, NRAS, PIK3CA status, PTEN expression
Policy 2.02.41 (posted 6/12/18)
Molecular Markers in Fine Needle Aspirates of the Thyroid: Afirma® GEC, ThyroSeq®
Policy 2.02.49 (posted 1/18/19)
Prenatal Genetic Testing: Preconception genetic testing, Preimplantation genetic diagnosis (PGD), Prenatal carrier screening
Policy 4.01.03 (posted 5/7/18)
Whole Exome and Whole Genome Sequencing for the Diagnosis of Genetic Disorders
Policy #2.02.46 (posted 6/12/18)
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Heart & Blood Vessels (Cardiovascular)
Ambulatory Event Monitor (AEM): Ambulatory Electrocardiographic (AECG) Devices, Cardiac Event Detection (CED), CardioNet, Mobile Cardiac Outpatient Telemetry (MCOT), Ziopatch
Policy 2.01.03 (posted 10/02/18)
Angioplasty of Intracranial Atherosclerotic Stenoses with or without Stenting (e.g., Percutaneous Transluminal Angioplasty, Neurolink® System, Wingspan™ Stent)
Policy 7.01.70 (posted 5/7/18)
Artificial Hearts: AbioCor, CardioWest
Policy 7.01.65 (posted 8/16/18)
Cardiac Resynchronization Therapy (Biventricular Pacemakers) for the Treatment of Heart Failure (Bioimpedance, Dual Chamber Pacemaker)
Policy 7.01.58 (posted 10/02/18)
Blood Pressure Monitoring, Automated, Ambulatory
Policy 1.01.04 (posted 1/18/19)
End-Diastolic Pneumatic Compression (e.g., Circulator) Boot
Policy 1.01.31 (posted 5/31/18)
Endovascular Repair (Coil Embolization) of Intracranial Aneurysms - Enterprise Stent, Guglielmi Coil, Neuroform Stent, Pipeline Embolization Device (PEI), Transcatheter Intracranial Embolization
Policy 7.01.81 (posted 6/12/18)
Endovascular Treatment of Acute Ischemic Stroke - Mechanical Embolectomy, Merci Retriever, Penumbra, Percutaneous Transluminal Angioplasty, Solitaire, Trevo®
Policy 7.01.82 (posted 9/6/18)
Extracranial Carotid and Vertebral Artery Angioplasty and Stents (e.g., Percutaneous Transluminal Angioplasty, PTA)
Policy 7.01.60 (posted 4/4/18)
Home Automatic External Defibrillator (AEDs) and Wearable Defibrillator Vests (WCDs): HeartStart, LIFECOR
Policy 1.01.42 (posted 5/7/18)
Implantable Cardiac Hemodynamic Monitoring for Heart Failure: CardioMEMS HF, Pulmonary artery pressure sensor, Wireless hemodynamic monitor
Policy 7.01.91 (posted 10/09/18)
Implantable Cardioverter-Defibrillator (AICD, Automatic ICD, Biventricular ICD, Dual-Chamber ICD, ICD)
Policy 7.01.06 (posted 4/4/18)
Intravascular Ultrasound (IVUS)
Policy 6.01.09 (posted 9/6/18)
MAZE Procedures for Atrial Fibrillation and Flutter (e.g., Convergent procedure, COX III, Epicardial Maze, Hybrid, Mini Maze, Pulmonary Vein Isolation, Thoroscopic off-pump surgical ablation [TOPS])
Policy 7.01.27 (posted 2/16/18)
Microvolt T-Wave Alternans
Policy 2.01.45 (posted 5/7/18)
Percutaneous Left Atrial Appendage Closure Devices: Amplatzer® Amulet, Amplatzer® cardiac plug, Implantable hemodynamic monitor, Lariat®, PLAATO, Watchman™
Policy 7.01.92 (posted 1/2/19)
Signal Averaged Electrocardiogram (SAECG)
Policy 2.01.02 (posted 2/06/19)
Surgical Ventricular Reduction (e.g., Partial Ventriculectomy, Batista Procedure)
Policy 7.01.31 (posted 5/31/18)
Surgical Ventricular Restoration (SVR): DOR Procedure, Surgical Anterioe Endocardial Restoration (SAVER), Ventricular Remodeling
Policy 7.01.71 (posted 11/19/18)
Transcatheter Closure Devices for Cardiac Defects: Amplatzer Septal Occluder, Angel Wing Device, Atrial Septal Detect Occluding System (ASDOS), CardioSEAL, HELEX, Sideris Buttoned Device
Policy 7.01.34 (posted 4/4/18)
Transmyocardial Revascularization (TMR), Percutaneous Transmyocardial Revascularization (PTMR)
Policy 7.01.12 (posted 4/4/18)
Ventricular Assist Devices (VAD, LVAD)
Policy 7.01.07 (posted 8/16/18)
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Home Care
Home Exercise/Physical Therapy Equipment (e.g., Home Gym, Jacuzzi)
Policy 1.01.12 (posted 1/18/19)
Home and Community Oxygen Therapy: Long Term Oxygen Therapy (LTOT), High Altitude Stimulation Test (HAST), Oxygen Concentrator, Portable Oxygen
Policy 1.01.05 (posted 9/10/18)
Home Prothrombin Time Monitor (e.g., Acusure™, CoaguChek®, International Normalized Ratio [INR], Prothrombin Time [PTT], Protime, Rubicon®)
Policy 1.01.44 (posted 8/16/18)
Patient Lifts (e.g., Hoyer, Saralift), Seat Lift Chair Mechanisms and Ceiling Lifts
Policy 1.01.08 (posted 8/16/18)
Telemedicine and Telehealth
Policy 1.01.49 (posted 1/18/19)
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Lab Tests (Pathology)
Anticoagulation Testing
Policy 2.02.40 (posted 9/6/18)
Biochemical Markers of Bone Turnover (e.g., Collagen Cross Links, Cross Laps, ITCP, N-telopeptides, NTx, Pyrilinks)
Policy 2.02.18 (posted 9/6/18)
Cardiovascular Disease Risk Assessment - Laboratory Evaluation of Lipids: Apolipoprotein A-1, B, and E, Lipoprotein (a) Enzyme Immunoassay
Policy 2.02.29 (posted 1/18/19)
First Trimester Screening for Down Syndrome (e.g., Cell-Free Fetal DNA, Harmony™, Free Beta PAPP-A, MaterniT21™, Non-invasive Prenatal Testing, Nuchal Translucency, Panorama™, Verify®)
Policy 2.02.25 (posted 9/10/18)
Inflammatory Markers of Coronary Artery Disease Risk (High Sensitivity C-Reactive Protein, HS-CRP, Lipoprotein-Associated Phospholipase A2, Lp-PLA2, PLAC)
Policy 2.02.15 (posted 8/16/18)
Her-2 Testing in Invasive Breast Cancer Using Fluorescence in Situ Hybridization (FISH) or Immunohistochemistry (IHC) Assays: HercepTest, PathVysion, INFORM®, FISH pharmdX
Policy 2.02.31 (posted 5/7/18)
Measurement of Serum Antibodies to Infliximab and Adalimumab: Anser™IFX, Anser™ADA
Policy 2.02.47(posted 1/18/19)
Molecular Panel Testing of Cancers to Identify Targeted Therapies, Molecular Panel Testing, Targeted Therapy, Foundation One, Caris Life Sciences, OmniSeq, PyroSeq
Policy 2.02.51 (posted 1/18/19)
Non-Invasive Helicobacter Pylori (H Pylori) Testing: HpSA, Urea Breath Test
Policy 2.02.02 (posted 6/12/18)
Pathfinder TG® Molecular Testing: Redpath, Topographic Genotyping
Policy 2.02.39 (posted 2/06/19)
Proteomics-Based Testing for the Evaluation of Ovarian (Adnexal) Masses: Ova1™
Policy 2.02.43 (posted 11/19/18)
Tumor Chemoresistance and Chemosensitivity Assays: Cytoprint, EDR Assay, Extreme Drug Resistance Assay, Histoculture Drug Response Assay
Policy 2.02.32 (posted 8/16/18)
Screening for Vitamin D Deficiency
Policy 2.02.45 (posted 9/6/18)
Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease, Anti-neurtrophil Cytoplasmic Antibodies, ANCA, ASCA, Serological markers
Policy 2.02.19 (posted 1/18/19)
Serum Tumor Markers for Diagnosis and Management of Cancer (AFP, CA-125, CA-19-9, CA-15-3, CA 27, CA 29, CEA, HCG, Proteomic)
Policy 2.02.10 (posted 10/09/18)
Urinary Tumor Markers for Bladder Cancer: AccuDx, BTA Stat™, Fibrin/Fibrinogen Degradation Products (FDP), ImmunoCyt, Nuclear Matrix Protein (NMP-22), Urinary Bladder Cancer Antigen (UBC Rapid Test)
Policy 2.02.12 (posted 9/6/18)
Urine Drug Testing
Policy 2.02.50 (posted 2/06/19)
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Lungs (Respiratory)
Airway Clearance Devices: Oscillatory Devices - ABI Vest, Acapella, Flutter Valve, Lung Flute®, ThAIRapy Vest; Mechanical Percussors and Assisted Cough Devices - Cofflator, Cough-Alator, In-Exsufflator
Policy 1.01.15 (posted 1/18/19)
Bronchial Thermoplasty (e.g., Alair® System)
Policy 7.01.88 (posted 2/06/19)
Electromagnetic Navigation Bronchoscopy (ENB)
Policy 6.01.40 (posted 2/06/19)
Measurement of Exhaled Markers of Airway Inflammation in Patients with Asthma: Exhaled Breath Condensate, Exhaled Nitric Oxide, Nioxx
Policy 2.01.41 (posted 2/06/19)
Oral Appliances for the Treatment of Sleep Related Breathing Disorders: Mandibular Repositioning Device, Nocturnal Airway Patency Appliance (NAPA), Tongue Retaining Device
Policy 1.01.07 (posted 4/4/18)
Surgical Management of Sleep Disorders/Sleep Apnea: Airvance®, Atrial overdrive pacing, Aura6000 System, CAPSO, Encore™, HGNS®, Hypoglossal Nerve Stimulation, Inspire II Upper Airway Stimulation System, LAUP, Pillar™, Repose™, Snoreplasty, Somnoplasty, UPPP
Policy 7.01.41 (posted 5/31/18)
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Miscellaneous
Ambulance: Air
Policy 11.01.06 (posted 6/1/18)
Ambulance: Land/Ground
Policy 10.01.07 (posted 6/1/18)
Bioimpedance Devices for Detection and Management of Lymphedema, bioelectrical impedance spectroscopy
Policy 2.01.52 (posted 6/12/18)
Clinical Trials
Policy 11.01.10 (posted 1/18/19)
Comfort, Convenience, Custodial or Cosmetic Services
Policy 11.01.11 (posted 1/18/19)
Disability Determination for Extension of Benefits after Contract Termination
Policy 10.01.11 (posted 10/09/18)
Emergency Care Services
Policy 10.01.12 (posted 5/31/18)
Experimental or Investigational Services
Policy 11.01.03 (posted 9/10/18)
Gender Reassignment Surgery: Gender Dysphoria, Gender Identity Disorder (GID), Genital Correction Surgery, Genital Reassignment Surgery, Genital Reconstruction, Gender Realignment Surgery, Gender Confirmation Surgery, Intersex, Transsexualism, Transsexual Surgery
Policy 7.01.84 (posted 8/16/18)
Handicapped Dependent Coverage
Policy 10.01.08 (posted 11/26/18)
Hyperbaric Oxygen Therapy (HBOT): Systemic or Topical, Topical Oxygen Wound Therapy (TOWT)
Policy 2.01.07 (posted 6/12/18)
Interfacility (Hospital-to-Hospital, Inpatient, Interhospital) Transfer of a Registered Inpatient
Policy 11.01.18 (posted 5/31/18)
Medical Response to Contamination from Terrorist Attacks: Biological (e.g., Anthrax, Germ Warfare, Plague, Smallpox), Chemical, Radiation
Policy 11.01.09 (posted 10/02/18)
Medical/Non-Surgical Weight Management Programs and Services, Indirect Calorimetry, Intensive/high intensity lifestyle counseling program
Policy 11.01.01 (posted 1/18/19)
Medically Necessary Services
Policy 11.01.15 (posted 1/18/19)
Out of Area/Out of Network Services
Policy 11.01.14 (posted 5/31/18)
Private Rooms
Policy 12.01.06 (posted 1/18/19)
Second Medical and Second Surgical Opinions, Confirmatory Consultation
Policy 10.01.10 (posted 5/31/18)
External Prosthetic Devices: C-leg, Intelligent prosthesis, microprocessor-controlled lower limbs, Ossur Rheo, Vacuum-assisted-socket system (VASS)
Policy 1.01.18 (posted 10/09/18)
Skilled Nursing Facility (SNF) Care for Medicare Advantage Members
Policy 11.01.21 (posted 5/31/18)
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Nervous Systems (Neurology)
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Radiation Treatment
Brachytherapy after Breast Conserving Surgery, as Boost with Whole Breast Irradiation or Alone as Accelerated Partial Breast Irradiation: Accelerated Partial Breast Irradiation, APBI, Axxent, MammoSite
Policy 6.01.30 (posted 1/2/19)
Brachytherapy or Radioactive Seed Implantation for Prostate Cancer
Policy 6.01.16 (posted 11/19/18)
Intensity Modulated Radiation Therapy (IMRT)
Policy 6.01.24 (posted 10/02/18)
Intravascular Brachytherapy, Endovascular Radiation
Policy 6.01.15 (posted 9/6/18)
Peptide Receptor Radionuclide Therapy (PRRT, PRRNT): Receptor-Mediated Radiotherapy, Radiolabeled Nuclide Therapy, Somatostatin Analog, 90Y-DOTATOC, 177Lu-DOTA0, Tyr3, 90Y-DOTA0
Policy 7.01.78 (posted 10/02/18)
Proton Beam Radiation Therapy (Charged Particle, Conformal)
Policy 6.01.11 (posted 9/10/18)
Selective Internal Radiation Therapy (SIRT) for Hepatic Tumors (SIR-Spheres, Theraspheres)
Policy 7.01.69 (posted 9/6/18)
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy (e.g., CyberKnife, Gamma Knife Radiosurgery, Linear Accelerator, Linac)
Policy 6.01.12 (posted 9/10/18)
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Radiology (x-rays) & Imaging
Bone Densitometry/Bone Density Studies: DEXA Scan, Dual Photon Absorptiometry (DPA), Morphometric X-ray Absorptiometry, Single Photon Absorbtiometry (SPA), Ultrasound Measurement of the Heel
Policy 6.01.05 (posted 10/09/18)
Noninvasive Measurement of Cardiac Bioimpedance: Impedance Cardiography (ICG), Thoracic Electrical Bioimpedance (TEB)
Policy 6.01.26 (posted 11/19/18)
Cardiac Computed Tomographic Angiography (Calcium Scoring, Cardiac/Coronary CTA, Coronary Artery CTA, CT Angiography)
Policy 6.01.34 (posted 8/16/18)
Coronary Calcium Scoring : Electron Beam CT (EBCT), Helical CT, Spiral CT, Multidetector Row CT (MDCT), Ultrafast CT, Cardiac Calcium Scoring
Policy 6.01.13 (posted 4/4/18)
CT (Computed Tomography) Perfusion Imaging - Dynamic Perfusion CT, Multimodal CT, Perfusion CT, Xenon-enhanced CT (XeCT)
Policy 6.01.37 (posted 4/4/18)
Magnetic Resonance Imaging (MRI) of the Breast (Breast MRI, CAD MRI)
Policy 6.01.35 (posted 8/16/18)
Magnetic Resonance Imaging Prostate Multiparametric MRI
Policy 6.01.46 (posted 8/16/18)
Magnetic Resonance Spectroscopy (MRS)
Policy 6.01.03 (posted 4/4/18)
Mammography: Compuer Aided Detection (CAD): Image Checker System, MammoReader, R2 Checker, Second Look, RapidScreen
Policy 6.01.23 (posted 10/02/18)
Mammography: Digital Breast Tomosynthesis
Policy 6.01.22 (posted 9/10/18)
Positron Emission Tomography (PET) Cardiac Applications
Policy #6.01.41 (posted 4/4/18)
Positron Emission Tomography (PET) Non-Oncologic Applications (FDG PET)
Policy 6.01.07 (posted 4/4/18)
Positron Emission Tomography (PET), Oncologic Applications (FDG PET, FDG SPECT)
Policy 6.01.29 (posted 11/19/2018)
Nuclear Breast Imaging: Breast Specific Gamma Camera, BSGI, Gammagram, Miraluma, Radioimmunoscintigraphy, Scintigraphy, Scintimammography
Policy 6.01.02 (posted 4/4/18)
Low-Dose Computed Tomography (LDCT) for Lung Cancer Screening: Electron Beam Computed Tomography (EBCT), Helical CT, Low-Dose CT, Spiral CT
Policy 6.01.19 (posted 2/06/19)
Transcranial Doppler Ultrasound
Policy 6.01.18 (posted 1/18/19)
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Skin (Dermatology)
Allergen Immunotherapy: Injections, Sublingual Immunotherapy
Policy 2.01.11 (posted 10/09/18)
Allergy Testing (Allergen Specific IgE, Allergen Specific IgG, Challenge, Cytotoxic, Dipstick, Disk, Intracutaneous, Intradermal, Leukocyte Histamine Release, Mucous Membrane, Paddle, Patch, Percutaneous, Phadiatop, Prick, Provocation-Neutralization, RAST, Rinkel, Scratch, Serial Endpoint Titration, Skin End Point Titration, Skin)
Policy 2.01.10 (posted 2/06/19)
Extracorporeal Photochemotherapy/Photopheresis
Policy 8.01.01 (posted 1/2/19)
Growth Factors for Wound Healing and Other Conditions: Becaplermin, Platelet Derived Growth Factor (PDGF), Platelet Rich Plasma, Regranex
Policy 2.01.24 (posted 2/06/19)
Light and Laser Therapies for Dermatologic Conditions (BCLear Lamp, CureLight Broadband, Excilite Lamp, Levulan®, Kerastick®, Metvix®, Narrow Band Ultraviolet B, Psoralens, PUVA, Ultraviolet Light, UVA, UVB, VTRAC Lamp, XeCL, XTRAC)
Policy 8.01.21 (posted 1/2/19)
Bioengineered Tissue Products (Affinity™, AlloDerm®, AlloMax™, AlloSkin™, AlloWrap™, AmnioBand™, Amnioexcel®, AmnioMatrix®, Apligraf®, Artacent™ Wound, ArthroFlex™, Artificial skin, Avaulta Plus™, Biobrane®, Biobrane l®, Bioengineered skin, Biologic tissue, Biovance®, Clarix® Flo, Collamend, Conexa™, Cygnus Solo™, Cygnus Matrix™, Cygnus Max™, Cymetra®, Cytal™ Burn Matrix, Cytal™ Wound Matrix, DermACELL AWM™, DermaMatrix, DermaPure™, DermaSpan™, Dermavest™, Endoform Dermal Template™, ENDURAgen™, Epicel®, EpiCord™, EpiFix, Excellagen®, E-Z Derm™, FlexHD®, GammaGraft, Grafix® CORE, Grafix® PRIME, GraftJacket®, GraftJacket® Xpress, Graftskin, Guardian, hMatrix®, Hyalomatrix®, Integra™, Integra™ Bilayer Wound® Matrix, Integra™ Dermal Regeneration Matrix®, Integra™ Flowable Wound® Matrix, InteguPly™, Interfyl™, Laserskin, MariGen, Mediskin®, Miroderm®, Neoform, Neox®, Neox 1K, Neox® Flo, NuShield™, OASIS® Wound Matrix, OASIS® Burn Matrix, OASIS® Ultra, Omnigraft™, Orcel™, Orthoadapt, PalinGen® - Membrane, Hydromembrane, Flow, and SportFlow, Pelvicol, Pelvisoft, Permacol™, Primatrix, PuraPly, Restore, Revitalon™, Skin substitute, StrataGraft, Strattice™, SurgiMend®, TenSIX™, TheraSkin®, Tissuemend, TransCyte™, TranZgraft, TruSkin™, Veritas® Collagen Matrix, XCM Biological Tissue Matrix.)
Policy 7.01.35 (posted 9/10/18)
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Therapy & Rehabilitation
Cardiac Rehabilitation
Policy 8.01.14 (posted 8/16/18)
Cognitive Rehabilitation, Attention Rehabilitation, Sensory Integration Therapy
Policy 8.01.19 (posted 8/16/18)
Occupational Therapy (OT): Constraint Induced Movement Therapy (CIMT), Gait Analysis, Sensory Integration Therapy, SIT
Policy 8.01.17 (posted 10/02/18)
Physical Therapy (PT): e.g., Aquatic Therapy, Biodex, Cybex, Gait Analysis, Hippotherapy, Hydrotherapy, Isokinetic Dynamometry/Testing, Myowave, Vibromyography (VMG)
Policy 8.01.12 (posted 10/02/18)
Speech/Language Pathology and Therapy (e.g., Fast ForWord, Lee Silverman Voice Therapy [LSVT-LOUD™], Voice Therapy)
Policy 8.01.13 (posted 11/26/18)
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Transplants
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Urinary System (Genitourinary)
Cryosurgery for Prostate Cancer
Policy 7.01.01 (posted 9/6/18)
Erectile Dysfunction: Caverject, Edex, ErecAid, Intracavernosal Therapy, Intraurethral Therapy, MUSE (Medicated Urethral System for Erection), Penile Prosthesis, Penile Vein Ligation, Vacuum Erection Device, Vascular Revascularization
Policy 7.01.30 (posted 10/02/18)
Pelvic Floor Electrical Stimulation (PFES) as a Treatment of Urinary or Fecal Incontinence, Intravaginal Stimulation
Policy 1.01.19 (posted 9/6/18)
Prostate Cancer Screening, Detection and Monitoring (e.g., Digital Rectal Exam - DRE, PCA3Plus, Prostate Specific Antigen - PSA, Prostatic Acid Phosphatase - Male PAP Test)
Policy 10.01.05 (posted 1/2/19)
Sacral Nerve Stimulation for Pelvic Floor Dysfunction (Incontinence, Neuromodulation, Urinary Retention)
Policy 7.01.10 (posted 2/16/18)
Transurethral Microwave Thermotherapy (TUMT) of the Prostate (e.g., Prostatron, Targis, Urowave System, CoreTherm, Prolieve, TMx-2000)
Policy 7.01.28 (posted 1/18/19)
Bulking Agents for Treatment of Urinary or Fecal Incontinence (Bovine Collagen, Carbon Coated Beads, Coaptite®, Contigen®, Durasphere, GAX, Macroplastique®, Microballoons, Solesta, Teflon® Injections, Uryx®)
Policy 7.01.22 (posted 6/12/18)
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Vaccines (Immunizations)
Immunizations/Vaccines (e.g., Hepatitis A, Hepatitis B, Human Papillomavirus [HPV, Cervarix, Gardasil], Meningococcal, Pneumoccal [Pneumovax 23, Prevnar], Rotavirus [Rotarix], Varicella [Varivax], Varicella Zoster [Zostavax])
Policy 2.01.42 (posted 10/09/18)
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Women's Health (Obstetrics & Gynecology)
Assisted Reproductive Technologies (ART) for Infertility): COMET Assay, Hylaluronan Binding Assay (HBA), Sperm DNA Integrity, Sperm Chromatin Structure Assay (SCSA®), Sperm DNA Fragmentation Assay (SDFA™), TUNEL Assay, Artificial or Intrauterine Insemination (AI, IUI), Microsurgical Epididymal Sperm Aspiration (MESA), Microsurgical Testicular Sperm Extraction (MicroTESE), Testicular Sperm Extraction (TESE), Direct Intra-Peritoneal Insemination (DIPI), Gamete Intrafallopian Transfer (GIFT), Intracytoplasmic Sperm Injection (ICSI), In-vitro Fertilization (IVF), Zygote Intrafallopian Transfer (ZIFT)
Policy 4.01.05 (posted 11/26/18)
Cervical Cancer Screening and Human Papilloma Virus (HPV) Testing (e.g., Cervista™, Cobas® HPV test, DNA with PAP, HPV, HPV DNA testing, Human Papillomavirus, HC 2, Hybrid Capture 2, Pap/ Papanicolaou smear: Direct visualization, Monolayer, Optical; FocalPoint™, MonoPrep Pap Test (MPPT), PapSure®, Speculite®, Speculoscopy, SurePath, ThinPrep®)
Policy 2.02.04 (posted 11/26/18)
Endometrial Ablation: Her Option™, Hydro ThermAblator®, MEA System, Novasure™, Resectoscope, Rollerball, ThermaChoice®, Thermal Balloon Therapy
Policy 4.01.01 (Posted 9/10/18)
Female Sterilization (e.g., Adiana®, Essure®, Tubal Ligation)
Policy 4.01.07 (posted 11/26/18)
Home Birth by Certified Nurse Midwives
Policy 11.01.23 (posted 11/26/18)
Obstetrical Ultrasound in the Second Trimester
Policy 6.01.42 (posted 8/16/18)
Uterine Artery Occlusion in the Treatment of Uterine Fibroids: Uterine Artery/Fibroid Embolization (UAE/UFE), Uterine Artery Coagulation
Policy 4.01.04 (posted 1/2/19)