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
- AlloMap® Molecular Expression Test
- Anterior Segment – Optical Coherence Tomography (AS-OCT)\
- Anthrax Vaccine
- AntiMuSK Antibody Test
- Autonomic Nervous System Testing
- Autism Spectrum Disorders — Management
B
Pay Policies
- Bioimpedance Spectroscopy (BIS) for Early Detection and Management of Lymphedema
- Blepharoplasty
- Breast Reconstruction Procedures
- Breast Pumps
- Biofeedback for Adult Incontinence
- Biofeedback for the Treatment of Pediatric Dysfunctional Elimination Syndrome
- Bladder Tumor Antigen Test
- BRAF V600E Mutation Test for Treatment of Melanoma
C
Medical Policies*
- Canaloplasty for Primary Open-Angle Glaucoma
- 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
- Chiropractic Services and Adjunctive Procedures (Adults and Children 13 Years Old and OVER)
- 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
- Cosmetic and Reconstructive Services
D
Medical Policies*
Pay Policies
- Deep Brain Dorsal Column (Spinal Cord) Stimulators
- Dermal Injections for Facial Lipodystrophy Syndrome
E
Medical Policies*
- Experimental — Investigative Services
- External Insulin Pumps
- Extracranial Carotid Angioplasty with Stenting
Pay Policies
- End Diastolic Pneumatic Compression Therapy (Medicare Only)
- Endometrial Ablation
- Endovascular Repair/Stent for Abdominal Aortic Aneurysm
- Ex-PRESS Mini Glaucoma Shunt
- External Counterpulsation Therapy
F
Medical Policies*
Pay Policies
G
Medical Policies*
Pay Policies
H
Medical Policies*
Pay Policies
- Hepatitis A Vaccine
- High-Resolution Anoscopy (HRA)
- Home Apnea Monitoring
- Home PT/INR Monitoring
- Hospital Beds and Accessories
- Human Papilloma Virus (HPV) Testing
- HPV Vaccine
- Home Sleep Study
- Hyperbaric Oxygen
I
Medical Policies*
Pay Policies
- Infertility – Diagnosis
- Infertility – Treatment of
- Infrared Photocoagulation (IRC) of Hemorrhoids
- Intensity Modulated Radiation Therapy (IMRT)
- Intraoperative Neurophysiological Testing
- Invasive Bone Growth Stimulators
- Iontophoresis for Musculoskeletal Conditions
- Intravascular Ultrasound (IVUS)
J
Pay Policies
K
Pay Policies
L
Medical Policies*
Pay Policies
M
Medical Policies*
- Microprocessor Ankle (Medicare Only)
- 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)
N
Medical Policies*
Pay Policies
Clinical Resource Management
O
Medical Policies*
Pay Policies
- OP-1 Implant (Medicare only)
- Oral Appliances for Obstructive Sleep Apnea
- OVA1TM Test (Medicare only)
P
Medical Policies*
- Parenteral Nutrition
- Pediatric Specialty Beds (MA only)
- Power Mobility Devices
- Pressure-Reducing Support Surfaces
- Private Duty Nurse
Pay Policies
- Pancreatectomy with Islet Cell Autotransplantation
- Paravertebral Facet Joint Nerve Blocks and Sacroiliac Joint Injections
- Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea
- Presbyopia Correcting Intraocular Lenses (PIOLs)
- Prophylactic Mastectomy
- Prophylactic Salpino-Oophorectomy
Q
R
Medical Policies*
Pay Policies
- Radiofrequency Ablation for Low Back Pain
- Real Time HbA1C Glycosylated Hemoglobin Test (Medicare only)
- Reversible Shoulder Arthroplasty
- Rotateq Vaccine
- Routine Foot Care
S
Medical Policies*
- Selective Internal Radiation Therapy (SIRT)
- Surgical Management of Low Back Pain
- Surgical Procedures for Morbid Obesity
Pay Policies
- Sacral Nerve Stimulators
- 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
- Surgical Management of Chronic Hip Pain and Chronic Knee Pain
T
Medical Policies*
- Total Ankle Replacement
- 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
- Telemedicine – Telephonic Health Visits for ADHD
- Temporomandibular Joint Surgery
- Topographic Genotyping
- Transcutaneous Electrical Nerve Stimulators (TENS)
- Treatment of Varicose Veins
- Triggerpoint Injections and Transforaminal Epirdural Injections
- Trofile Co-Receptor Tropism Assay
Clinical Resource Management
U
Pay Policies
V
Medical Policies
Pay Policies
- Vagus Nerve Stimulators
- Vision Therapy
- Visual Evoked Response Test
- Voice Prosthesis and Laryngeal Devices
W
Medical Policies*
- Wearable Cardiac Defibrillators
- Wheelchair Options
- Wheelchair Seating Options
- Wireless Capsule Endoscopy
X
Medical Policies*
Pay Policies
Y
Z
Pay Policies