UPMC Health Plan Policy & Procedure Manual

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

A

Medical Policies*

• Abdominoplasty - Panniculectomy
• Acupuncture for Nausea and Vomiting

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B

Pay Policies

• Breast Reconstruction Procedures
• Biofeedback for Adult Incontinence
• Biofeedback for the Treatment of Pediatric Dysfunctional Elimination Syndrome
• Bladder Tumor Antigen Test

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C

Medical Policies*

• Chiropractic Services and Adjunctive Procedures
• Cochlear Implants and Bone Conduction Devices (BAHA)
• Dental Anesthesia
• Cranial Remolding Orthosis

Pay Policies

• Chelation Therapy
• Computed Tomography Angiography of the Chest
• Computer-aided Detection Mammography
• Continuous Glucose Monitoring
• Continuous Home Pulse Oximetry

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D

Medical Policies*

• Durable Medical Equipment and Corrective Appliances

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E

Medical Policies*

• Endovasc Stent for Abdominal Aortic Aneurysm
• Extracranial Carotid Angioplasty with Stenting

Pay Policies

• Experimental or Investigative Services

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F

Pay Policies

• Full Spectrum Light Therapy for Seasonal Affective Disorder (SAD)

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G

Pay Policies

• Gradient Compression

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H

Medical Policies*

• High Frequency Chest Wall Oscillation Devices
• Home Based Real Time Cardiac Surveillance Systems
• Home Telemonitoring

Pay Policies

• Hepatitis A Vaccine
• Home Apnea Monitoring
• Human Papilloma Virus (HPV) Testing
• Human Papilloma Virus (HPV) Vaccine (Gardasil)

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I

Medical Policies*

• Intracranial Stenting (Medicare only)

Pay Policies

• Infertility - Diagnosis
• Infertility - Treatment
• Intensity Modulated Radiation Therapy (IMRT)
• Invasive Bone Growth Stimulators

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J

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K

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L

Medical Policies*

• Lymphedema Pumps and Appliances

Pay Policies

• Lifestyle Modification Program - Heart Disease

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M

Medical Policies*

• Magneto-Encephalography
• Maze Procedure for Atrial Ablation - Thoracoscopic approach (Medicare only)
• Microprocessor Controlled Knee Prostheses
• Molecular Susceptibility Testing for Breast Cancer - Ovarian Cancer
  (BRCA Testing)

Pay Policies

• Mechanical In-Exsufflation Device
• Meningococcal Vaccines

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N

Medical Policies*

• Negative Pressure Wound Therapy
• Non Invasive Bone Growth Stimulators (BGS)
• Nutritional Products
• Nutrition Therapy / Nutritional Supplements

Pay Policies

• Nerve Conduction Velocity Studies

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O

Medical Policies*

• Oncotype DX Assay for Breast Cancer

Pay Policies

• OP-1 Implant (Medicare only)

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P

Medical Policies*

• Power Mobility Devices
• Private Duty Nurse
• Prophylactic Bilateral Salpingo-oophorectomy
• Prophylactic Mastectomy

Pay Policies

• Presbyopia Correcting Intraocular Lenses (PIOLs)

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Q

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R

Medical Policies*

• Reduction Mammaplasty

Pay Policies

• Real Time HbA1C Glycosylated Hemoglobin Test (Medicare only)
• Reversible Shoulder Arthroplasty
• Rotateq Vaccine
• Routine Foot Care

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S

Medical Policies*

• Septoplasty-Rhinoplasty
• Surgical Procedures for Mobid Obesity

Pay Policies

• Speech Generating Devices and Accessories

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T

Medical Policies*

• Transplant - Adult Heart
• Transplant - Bone Marrow or Stem Cell Allogeneic
• Transplant - Bone Marrow or Stem Cell Autologous
• Transplant - Heart-Lung
• Transplant - Liver
• Transplant - Lung-Lobar Lung
• Transplant - Pancreas Alone and Pancreas-Kidney
• Transplant - Pancreas-Kidney
• Transplant - Pediatric Heart
• Transplant - Renal
• Transplant - Small Bowel
• Transplant - Small Bowel-Liver-Multivisceral

Pay Policies

• Topographic Genotyping
• Trofile Co-Receptor Tropism Assay

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U

Pay Policies

• Ultraviolet Light Box Therapy in the Home

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V

Pay Policies

• Visual Evoked Response Test

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W

Medical Policies*

• Wearable Cardiac Defibrillators
• Wheelchair Options and Accessories
• Wheelchair Seating Options
• Wireless Capsule Endoscopy

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X

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Y

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Z

Pay Policies

• Zostavax Vaccine

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