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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

*Medical Policies require Prior Authorization from our Medical Management department. They can be contacted at 1-800-425-7800.

A

Medical Policies*

• Abdominoplasty — Panniculectomy
• Acupuncture for Nausea and Vomiting
• Autism Spectrum Disorders — Management

Pay Policies

• Anterior Segment — Optical Coherence Tomography (AS-OCT)\
• AntiMuSK Antibody Test
• Autonomic Nervous System Testing

 

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B

Pay Policies

• Blepharoplasty
• Breast Reconstruction Procedures
• Breast Pumps
• 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
• Clinical Trials
• Cochlear Implants and Bone Conduction Devices (BAHA)
• Continuous Glucose Monitoring — Long-Term Interstitial
• Cranial Remolding Orthosis

Pay Policies

• Chelation Therapy
• ChemoFX Assay
• Computer Tomographic (CT) Colonography
• Computed Tomography Angiography of the Chest
• Computer-aided Detection Mammography
• Continuous Glucose Monitoring
• Continuous Home Pulse Oximetry
• Continuous Passive Motion Devices

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D

Medical Policies*

• Durable Medical Equipment and Corrective Appliances
• Dental Anesthesia

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E

Medical Policies*

• Endovascular Stent for Abdominal Aortic Aneurysm
• Experimental — Investigative Services
• External Insulin Pumps
• Extracranial Carotid Angioplasty with Stenting

Pay Policies

• Endometrial Ablation
• Ex-PRESS Mini Glaucoma Shunt

 

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F

Medical Policies*

• Functional Electrical Stimulators

Pay Policies

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

 

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G

Medical Policies*

• Genetic Testing for Long QT Syndrome

Pay Policies

• Gradient Compression Garments / Stockings
• Genetic Testing for Inherited Colorectal Cancers

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H

Medical Policies*

• High Frequency Chest Wall Oscillation Devices
• Home Telemonitoring

Pay Policies

• Hepatitis A Vaccine
• Home Apnea Monitoring
• Home PT/INR Monitoring
• Hospital Beds and Accessories
• Human Papilloma Virus (HPV) Testing
• HPV Vaccine
• Home Sleep Study
• Hyperbaric Oxygen

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I

Medical Policies*

• Intracranial Stenting (Medicare only)

Pay Policies

• Infertility — Diagnosis
• Infertility — Treatment of
• Intensity Modulated Radiation Therapy (IMRT)
• Intraoperative Neurophysiological Testing
• Invasive Bone Growth Stimulators
• Iontophoresis for Musculoskeletal Conditions

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J

Pay Policies

• Joint Active Systems (JAS) (Medical Assistance Only)

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K

Pay Policies

• KRAS  Mutation Testing

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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*

• Microprocessor Controlled Knee Prostheses
• Molecular Susceptibility Testing for Breast Cancer and/or Ovarian Cancer
  (BRCA Testing)

Pay Policies

• Magnetoencephalography
• Management of Unlisted Non-specific HCPCS CPT Codes
• Maze Procedure for Atrial Ablation — Thoracoscopic approach
• Mechanical In-Exsufflation Device
• Medical Nutrition Therapy
• Meningococcal Vaccines
• MIST Therapy for Wound Care (Medicare only)

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N

Medical Policies*

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

Pay Policies

• Nerve Conduction Velocity Studies

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O

Medical Policies*

• Oncotype Dx Assay for Breast Cancer
• Outpatient-Mobile Real Time Cardiac Surveillance Systems

Pay Policies

• OP-1 Implant (Medicare only)
• Oral Appliances for Obstructive Sleep Apnea

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P

Medical Policies*

• Parenteral Nutrition
• Pediatric Specialty Beds (MA only)
• Power Mobility Devices
• Pressure-Reducing Support Surfaces
• Private Duty Nurse
• Prophylactic Mastectomy

Pay Policies

• Pancreatectomy with Islet Cell Autotransplantation
• PLAC Test
• Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea
• Presbyopia Correcting Intraocular Lenses (PIOLs)
• Prophylactic Salpino-Oophorectomy

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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*

• Selective Internal Radiation Therapy (SIRT)
• Surgical Procedures for Morbid Obesity

Pay Policies

• Septoplasty-Rhinoplasty
• Skin Substitutes (Human Skin Equivalents in the Treatment of Chronic Cutaneous Ulcer Wounds)
• Speech Generating Devices and Accessories
• Surgical Dressings - Wound Care Supplies

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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 — Pediatric Heart
• Transplant — Renal
• Transplant — Small Bowel
• Transplant — Small Bowel/Liver-Multivisceral

Pay Policies

• Telemedicine — Telephonic Health Visits for ADHD
• Temporomandibular Joint Surgery
• Topographic Genotyping
• Total Ankle Replacement
• Treatment of Varicose Veins
• 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
• Voice Prosthesis and Laryngeal Devices

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W

Medical Policies*

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

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X

Medical Policies*

• X-Stop^TM Interspinous Process Decompression

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Y

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Z

Pay Policies

• Zostavax Vaccine

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*Medical Policies require Prior Authorization from our Medical Management department. They can be contacted at 1-800-425-7800.