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Medical Coverage Policies


Policy Last Revised Next Review Date
Acupuncture 12/02/2011 12/03/2012
Allogeneic Hematopoietic Stem-Cell (Bone Marrow) Transplantation 03/26/2011 03/26/2012
Apolipoprotein E Genotype or Phenotype 12/02/2011 12/02/2012
Arthroscopy for Osteoarthritis of the knee 12/02/2011 12/02/2012
Artificial Disc Replacement 12/06/2011 12/06/2012
Autologous Chondrocyte Implantation 12/02/2011 12/03/2012
Autologous Stem Cell Transplantation 03/26/2011 03/26/2012
Automated Non-Invasive Nerve Conduction Testing 12/02/2011 12/03/2012
Balloon Dilatation of the Prostate 12/02/2011 12/03/2012
Bariatric Surgery 12/16/2011 12/16/2012
Biochemical Markers of Alzheimers Disease 12/06/2011 12/06/2012
Bone Growth Stimulators 12/07/2011 12/07/2012
Bone Turnover Markers for Diagnosis and Management of Osteoporosis 12/06/2011 12/06/2012
Bone-Anchored Hearing Aids 12/06/2011 12/06/2012
Botulinum Toxin Injections Chemodenervation 12/17/2011 12/17/2012
Breast Reconstruction Surgery and Prophylactic Mastectomy 12/06/2011 12/06/2012
Cochlear Implants and Auditory Brainstem Implants 12/06/2011 12/06/2012
Cold Therapy Devices 12/06/2011 12/06/2012
Compounded Drug Products 12/06/2011 12/06/2012
Compression Stockings 12/17/2010 12/17/2012
Custodial Care 12/06/2011 12/06/2012
Deep Brain Stimulation 12/17/2011 12/17/2012
Dental and Oral Surgery 10/18/2011 10/18/2012
Dermatoscopy 12/06/2011 12/06/2012
Diathermy 12/06/2011 12/06/2012
Discography 12/06/2011 12/06/2012
Durable Medical Equipment 12/06/2011 12/06/2012
Epidural Adhesiolysis 10/17/2011 10/17/2012
Extracorporeal Shock WaveTreatment (ESWT) Plantar Fasciitis and Muscular Skeletal Conditions 12/06/2011 12/06/2012
Gastric Electrical Stimulation 12/06/2011 12/06/2012
Gender Assignment and Reassignment Surgery 12/06/2011 12/06/2012
Genetic Testing 12/06/2011 12/06/2012
Gynecomastia Surgery 12/06/2011 12/06/2012
High Frequency Chest Wall Oscillation Vest 12/06/2011 12/06/2012
Home Prothrombin Time Testing 12/02/2011 12/03/2012
Hyperbaric Oxygen Therapy 10/18/2011 10/18/2012
Immune Globulin Therapy 12/06/2011 12/06/2012
Implantable Intrathecal Drug Delivery Systems 12/06/2011 12/06/2012
IMRT for Breast Cancer 12/06/2011 12/06/2012
In-vitro Chemoresponse Assays; Assays for Response to Therapeutic Agents 12/06/2011 12/06/2012
Incontinence Bedwetting Alarms 12/06/2011 12/06/2012
Infertility, Assisted Reproductive Technology 12/06/2011 12/06/2012
Insulin Pumps and Insulin Pump Supplies 12/02/2011 12/02/2012
Interspinous Process Decompression System, X Stop 12/28/2011 12/28/2012
Joint Resurfacing - Hip and Shoulder 11/18/2011 11/18/2012
Melanoma Vaccines 12/06/2011 12/06/2012
Minimally Invasive Percutaneous Facet Joint Fusion TruFUSE 12/06/2011 12/06/2012
Mobile Cardiac Outpatient Telemetry 12/06/2011 12/06/2012
Monitoring of Regional Cerebral Blood Flow Using Implanted Cerebral Thermal Perfusion Probe 12/06/2011 12/06/2012
Nerve Graft in Association with Radical Prostatectomy 12/06/2011 12/06/2012
Neuromuscular Re-Education 10/18/2011 10/18/2012
Neuropsychological Testing 12/06/2011 12/06/2012
Neurotransplantation Treatment for Parkinsons Disease 12/06/2011 12/06/2012
Neutralizing Antibody Testing in Multiple Sclerosis Patients 12/06/2011 12/06/2012
Obstructive Sleep Apnea 11/23/2011 11/23/2012
Occipital Nerve Stimulation 12/06/2011 12/06/2012
Occupational Therapy 12/01/2011 12/01/2012
Off Label Use of FDA Approved Drugs 12/06/2011 12/06/2012
Oncotype DX 12/06/2011 12/06/2012
Orthognathic Surgery 12/06/2011 12/06/2012
Outpatient Pulmonary Rehabilitation 12/06/2011 12/06/2012
Panniculectomy 12/07/2011 12/07/2012
Percutaneous Vertebroplasty and Kyphosplasty 12/06/2011 12/06/2012
Physicial Therapy 12/16/2011 12/16/2012
PPACA, No Cost-sharing for Preventive Care Services 12/06/2011 12/06/2012
Prolotherapy 12/06/2011 12/06/2012
Psychologic Evaluation for Medical Procedures 12/08/2011 12/08/2012
Pulsed Dye Laser Treatment 10/18/2011 10/18/2012
Radiofrequency Facet Joint Denervation 12/08/2011 12/08/2012
Regional Sympathetic Blocks 10/17/2011 10/17/2012
Seizure Disorders - Invasive Treatment 12/17/2011 12/17/2012
Selective Internal Radiation Therapy 12/06/2011 12/06/2012
Solid Organ Transplantation 10/18/2011 10/18/2012
Speciality Pharmacy Drugs 12/08/2011 12/08/2012
Speech Therapy 12/08/2011 12/08/2012
Spinal Cord Stimulators 12/06/2011 12/06/2012
Spinal Curvature; Treatment of Asymptomatic Abnormalities 12/06/2011 12/06/2012
Trigger Point Injections 12/06/2011 12/06/2012
Ultrasound Phonophoresis 12/06/2011 12/06/2012
Urinary Incontinence Treatments 12/06/2011 12/06/2012
UV Light Therapy 12/08/2011 12/08/2012
Vagus Nerve Stimulation 12/06/2011 12/06/2012
Varicose Veins of the Lower Extremities 12/01/2011 12/01/2012
Wearable Cardioverter Defibrillator 12/06/2011 12/06/2012
Wireless Capsule Endoscopy 12/08/2011 12/08/2012