Medical policies for providers
See the latest updates to our medical policies.
MP320 Absorbable Hydrogel Spacer
The absorbable hydrogel spacer is designed to reduce unintentional rectal toxicity in men undergoing radiotherapy for treatment of prostate cancer.
Acupuncture involves piercing the skin with needles at specific body sites to induce anesthesia, to relieve pain, to alleviate withdrawal symptoms of substance abusers, or to treat various non-painful disorders (e.g. to relieve nausea/vomiting). In tra....
MP205-Advanced Molecular Topographic Genotyping
Advanced molecular topographic genotyping combines advanced molecular genetics with current pathology practices for a definitive diagnosis from existing specimens. The results are thought to provide useful information for physicians to plan the best c...
MP136-Alternative or Complementary Medicine Therapies
Complementary and alternative medicine, as defined by the National Institutes of Health, National Center for Complementary and Alternative Medicine (NCCAM), is a group of diverse medical and health care systems, practices and products that are not pres...
MP17-Ambulance Transport Service
Ambulance transportation services involve the use of specially designed and equipped vehicles to transport ill or injured insured individuals. Ambulance transport service typically involves ground transportation, but may involve air or sea transportati...
MP148-Ambulatory Cardiac Event Monitors
Ambulatory event monitors provide extended periods of cardiac monitoring. The recording device is either worn continuously and activated either manually or automatically when the individual experiences clinical or subclinical symptoms. The recorded EK...
MP267-Amniotic Membrane Transplant for Ocular Surface Defects
Amniotic membrane transplantation (AMT) is a procedure that utilizes amniotic membrane tissue to reconstruct damaged ocular surfaces and promote healing of corneal, conjunctival, and eyelid tissues after injury due to trauma, disease, or surgery.
MP142-Anodyne Infrared Therapy a.k.a Monochromatic Infrared Energy (MIRE)
Anodyne Infrared Therapy (aka:Monochromatic Infrared energy (MIRE) Therapy)involves the use of a device to deliver monochromatic, near-infrared photo energy through contact with the skin. The energy is emitted by an array of super-lumin...
MP243-Anorectal Fistula Repair Using an Acellular Xenogeneic Plug
An anorectal fistula repair involving the placement into the fistula tract of an acellular xenogeneic or bioprosthetic (biodegradable) “plug” is a minimally invasive procedure and affords the surgeon a sphincter-sparing option. The plug is derived fro...
Aquatic therapy is an active therapeutic intervention designed to take advantage of the unique buoyancy, support and resistance properties of water. Buoyancy lessens the pressure on muscles and joints, assists with movement and reduces swelling caused ...
MP261-Aqueous Drainage Shunt
Aqueous drainage shunts are implantable devices that are intended to reduce intra-ocular pressure (IOP) in the anterior chamber of the eye in individuals with neovascular glaucoma or with glaucoma that has not responded to medical and conventional surg...
MP147-Artificial Intervertebral Disc
Artificial intervertebral discs have been proposed as a treatment for patients with degenerative disc disease that is unresponsive to conservative therapies. Total disc replacement using an artificial intervertebral disc implant replaces the functions ...
MP232-Autism Spectrum Disorder – Evaluation and Medical Management
According to the National Institutes of Health, Autism Spectrum Disorder (ASD) encompasses five disorders categorized as Pervasive Developmental Disorders and identified by F84 diagnosis codes in the Diagnostic and Statistical Manual of Mental Disor...
MP115-Autologous Chondrocyte Implant
Autologous chondrocyte implantation (ACI) of the knee utilizes the patient’s own cartilage cells to repair damage to articular cartilage, with the intended goal of improving joint function and reducing pain...
MP233-Autologous Injectable Platelet and Blood Products
Autologous platelet-derived growth factors (APDGF), also referred to as platelet gel or platelet-rich plasma, have been proposed for use in the treatment of chronic wounds (e.g., lower extremity wounds), tendonitis, joint capsular injuries, soft tissue...
MP140-Automatic Implantable Cardioverter-Defibrillator (AICD)
The automatic implantable cardioverter-defibrillator is an electronic device designed to reduce the risk of sudden cardiac death by monitoring a member’s heart rate, recognizing life-threatening arrhythmias such as ventricular fibrillation and vent...
MP130-Automated Ambulatory Blood Pressure Monitoring
Automated ambulatory blood pressure monitoring is a non-invasive procedure using fully automated devices to measure blood pressure at frequent intervals over a 24-hour period. The purpose is to determine the variability of a person’s blood pressure due to environmentally induced stressors during daily activities.
Autonomic testing is a battery of tests that evaluates the sympathetic, parasympathetic, and enteric nervous system.
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