Medical Policy List

Medical Policy List

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• 3D Rendering on CT/MRI/US

A

• 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
• Blepharoplasty, Blepharoptosis, and Brow Lift
• Bone Growth Stimulators

C

• Cartilage Transfer Procedures: OATS and Mosaicplasty
• Cochlear Implants Bone Anchored Hearing Aids
• Corneal Treatments and Specialized Contact Lenses

E

• Emergency Air Ambulance medical policy effective 11/1/24

G

• 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
• MRI (Magnetic Resonance Imaging), MRE (Magnetic Resonance Enterography), and MRCP (Magnetic Resonance Cholangiopancreatography) of the Abdomen
• MRI (Magnetic Resonance Imaging) of the Breast
• MRI (Magnetic Resonance Imaging) Cardiac
• MRI (Magnetic Resonance Imaging) of the Chest
• MRI (Magnetic Resonance Imaging) of the Head/Brain
• MRI (Magnetic Resonance Imaging) of the Neck, Face, Orbit
• MRI (Magnetic Resonance Imaging) of the Pelvis
• MRI (Magnetic Resonance Imaging) of the Spine (Cervical, Thoracic, Lumbar)
• MRI (Magnetic Resonance Imaging) of Upper and Lower Extremities
• Multiplex Polymerase Chain Reaction (mPCR) or Nucleic acid Pathogen Testing for Infectious Disease

N

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

P

• Panniculectomy, Abdominoplasty, and Repair of Diastasis Recti
• Pectus Excavatum, Pectus Carinatum, and Poland Syndrome Treatment
• PET Scan (Positron Emission Tomography)
• Physical and Occupational Therapy Services
• Pneumatic Compression Devices

R

• Reduction Mammoplasty for Symptomatic Macromastia

S

• Septoplasty and Rhinoplasty
• Shoulder Replacement Surgery
• Skin and Soft Tissue Substitutes
• Sleep Disorder Testing
• Sleep Disorder Treatment (Oral Appliances and PAP devices)
• Spinal Cord and Peripheral Nerve Stimulators
• Spinal Manipulation and Chiropractic Services

T

• Tumor Treating Fields (Alternating Electric Field Therapy)

U

• Urine Drug/Alcohol Screening and Testing

V

• Varicose Vein Treatments

W

• Whole Exome Sequencing (WES) and Whole Genome Sequencing (WGS)