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Medical policies for providers

See the latest updates to our medical policies. 

Choose a letter to view policies by first letter.

A B C D E F G H I J K L M N O P Q R S T U V W 


MP260-Canaloplasty and Viscocanalostomy
Canaloplasty and Viscocanalostomy have been proposed as treatments for open angle glaucoma. Viscocanalostomy involves creation of superficial and deep scleral flaps, excision of the deep scleral flap to create a scleral reservoir, and unroofing of Schl...

MP100-Cardiac Monitoring by Thoracic Electrical Bioimpedance
Thoracic Electrical Bioimpedance (TEB) is a non-invasive method of measuring cardiac output based on detection of changes in impedance caused by the electrical conductivity of blood that occurs as blood is pumped into the aorta. The proce...

MP150-Carotid Artery Stent
Carotid stents are positioned at the site of carotid stenotic or occlusive lesions to enhance primary patency following percutaneous transluminal angioplasty.

MP081 -Chelation Therapy

MP185-Chemosensitivity and Chemoresistance Assays
A chemosensitivity assay refers to any in vitro laboratory analysis that is performed especially to determine whether tumor growth is inhibited by a known chemotherapeutic agent or a panel of drugs. Conversely, chemoresistance assays are used to determ...

Chelation therapy is the administration of chelating agents to rid the body of toxic levels of heavy metal ions by forming complexes that render them physiologically inactive and enhancing their excretion in the urine.

MP225-Circulating Tumor Cell Testing
Circulating tumor cells have been proposed as a method to assess response to chemotherapy rather than relying on changes in imaging studies (i.e., CT scans). Additionally, the presence of circulating tumor cells has been investigated as a prognostic fa...

MP171-Clinical Guideline Development, Implementation and Review Process

MP053-Cochlear Implant
The cochlear implant is a single or multiple channel device intended to restore a level of auditory sensation to individuals with severe to profound sensorineural hearing loss by means of electrical stimulation of the auditory nerve. The components com...

MP252-Colon Motility Test
Colonic motility studies are used to assess the flow of intraluminal contents, the motions of the colonic wall that induce flow, and the control systems that integrate and regulate these processes. Most approaches consist of manometric techni...

MP255-Comparative Genomic Hybridization or Chromosomal Microarray Analysis (CMA)
Comparative Genomic Hybridization (CGH), or Chromosomal Microarray Analysis (CMA), is an array-based cytogenetic test that is used for the detection of submicroscopic genomic abnormalities or imbalances (e.g., deletions, duplications or amplifications)...

MP189-Computer Aided Detection Technology
The computer-aided detection (CAD) system uses computerized algorithms to identify suspicious regions of interest on imaging studies. The CAD system is intended to be used only after a radiologist has completed an evaluation of the image. Although CAD ...

MP191-Computerized Cognitive Health Assessment Systems
Computerized Cognitive Health Assessment Systems have been proposed for use in assessing cognitive function of patients with a variety of neurological and mental health conditions including but not limited to mild cognitive impairment, dementia, trauma...

MP213-Computerized Corneal Topography
Computerized Corneal Topography, also known as videokeratography and Computer- assisted Keratography, is a technique used for mapping the surface curvature of the cornea. The process utilizes a special instrument which projects a series of light rings ...

MP309-Computerized Dynamic Posturography
Computerized dynamic posturography (CDP), (also known as dynamic posturography or moving platform posturography) uses an enclosed platform surrounded by a visual field to evaluate a person’s functional ability to maintain balance...
MP083-Contact lenses
Contact lenses are considered medical devices and can be worn to correct refractive error, for cosmetic or therapeutic reasons. A rigid, gas-permeable contact lens is able to replace the natural shape of the cornea with a new refracting surface or to c...

MP158-Continuous Passive Motion
Continuous passive motion (CPM) is a post-operative treatment modality developed to aid in recovery after joint surgery. A motorized device is used to passively (without patient effort) move the joint through a defined range of motion.

MP071-Continuous Subcutaneous Glucose Monitor (CSGM)
Continuous subcutaneous glucose monitors (CSGM) measure and record blood glucose levels in interstitial fluid and produce data that demonstrate trends in glucose measurements. The continuous subcutaneous glucose monitor reads the glucose level every 5 ...

MP104-Continuous Subcutaneous Insulin Infusion Pump (CSII)
CSII pump requests are pre-certified through the Plan’s Medical Management department prior to delivery. CSII pumps are utilized for the glycemic management of insured individuals with Type 1 and Type 2 diabetes mellitus and gestational diabetes. Cover...

MP196-Convection-Enhanced Drug Delivery
Convection-enhanced drug delivery (CED) is an innovative drug delivery technique used to circumvent the blood-brain barrier and deliver therapeutic agents directly into the parenchyma. CED uses a pressure gradient established at the tip of an infusion ...

MP155-Cooling Devices
Cooling devices, both passive and active, for use after joint surgery or injury are devices through which fluid flows into a blanket or cuff, providing cooling to an affected area. Passive devices (e.g.; Cryocuff, Polar Care Cub, etc.) utili...

MP207-Corneal Hysteresis
Corneal hysteresis is a measure of the viscous damping characteristics of the corneal tissue. It is calculated by deflecting the cornea with a rapid air pulse, and then using an advanced electro-optical system to obtain two intraocular pressu...

MP199-Corneal Pachymetry
Corneal pachymetry is the measurement of central corneal thickness by either ultrasound or optical biometry.

MP183-Cranial Electrotherapy Stimulation
Cranial Electrotherapy Stimulation has been proposed as a treatment for anxiety, depression and insomnia as well as many other conditions such as fibromyalgia and substance abuse. Also known as transcranial electrical stimulation, cranial transcutaneou...

MP125-Cranial Remodeling Orthotic
Cranial remodeling orthotic devices are intended to apply pressure to prominent regions of the cranium in order to improve cranial symmetry in infants with moderate to severe nonsynostotic positional plagiocephaly.

MP095-Craniosacral Therapy
Craniosacral therapy is based on the theory that movement restrictions at the cranial sutures of the skull negatively affect rhythmic impulses conveyed through the cerebrospinal fluid from the cranium to the sacrum.  Proponents maintain that removing r...

Cryosurgery or cryoablation is a technique involving the use of extremely low temperatures to destroy tumors that are left in place to be reabsorbed. It is a focal therapy that allows treatment of specific lesions with preservation of normal tissue.

MP093-Cystourethroscopy, with Insertion of Urethral Stent
Endoprostheses for recurrent urethral strictures are implantable prostheses which have been approved by the Food and Drug Administration (FDA) for maintaining patency of the urethra when obstructed due to stenosis or strictures. The Urolume® endoprosth...

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