Medical Policy List

Medical Policy List

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• 3D Rendering on CT/MRI/US

A

• Acupuncture Therapy
• Ankle Arthroplasty
• Artificial Disc Replacement
• Autologous Chondrocyte Implantation and MACI

B

• Back Pain Procedures - Epidural Injections
• Back Pain Procedures - Radiofrequency Ablation, Facet Joint and Other Injections
• Back Pain - Sacroiliac Joint and Coccydynia Treatments
• Bariatric Surgery
• Biofeedback Treatments and Devices
• Blepharoplasty, Blepharoptosis, and Brow Lift
• Bone Growth Stimulators

C

• Capsule Endoscopy
• Cartilage Transfer Procedures: OATS and Mosaicplasty
• Cell-Free Fetal DNA Testing
• Chiropractic Services
• Cochlear Implants Bone Anchored Hearing Aids
• Corneal Treatments and Specialized Contact Lenses
• Cranial Orthotic Device

D

• Deep Brain Stimulation and Responsive Cortical Stimulation

F

• Fecal Microbiota Transplant

G

• Gastrointestinal (GI) Pathogen Testing
• Gender Dysphoria Treatment
• Glaucoma Surgical Treatments

H

• Hip Replacement Surgery
• Hyperbaric Oxygen Therapy

I

• Infertility and Recurrent Pregnancy Loss Testing and Treatment

K

• Knee Replacement Surgery

M

• Meniscal Allograft Transplantation
• Microprocessor Controlled and Myoelectric Limb Prosthesis

N

• Negative Pressure Wound Therapy
• Neuropsychological Testing
• New-to-Market Medication List
• New-to-Market Medication Policy
• Non-Covered Services and Procedures

O

• Otoplasty and Reconstruction of External Ear

P

• Panniculectomy, Abdominoplasty, and Repair of Diastasis Recti
• Pectus Excavatum, Pectus Carinatum, and Poland Syndrome Treatment
• Pneumatic Compression Devices
• Pulmonary Artery Pressure Monitoring (CardioMEMS)

R

• Reduction Mammoplasty for Symptomatic Macromastia

S

• Septoplasty and Rhinoplasty
• Shoulder Replacement Surgery
• Sleep Disorder Testing
• Sleep Disorder Treatment (Oral Appliances and PAP devices)
• Spinal Cord and Peripheral Nerve Stimulators
• Surgical Removal of Redundant Skin and Face/Neck Lift Procedures

T

• Telehealth, Telemedicine (Temporary Medical Policy)
• Tumor Treating Fields (Alternating Electric Field Therapy)

U

• Urine Drug/Alcohol Screening and Testing

V

• Varicose Vein Treatments

W

• Wearable Cardiac Defibrillator Vest
• Whole Exome Sequencing (WES) and Whole Genome Sequencing (WGS)