Medical policies for providers
See the latest updates to our medical policies.
MP73-Deep Brain Stimulation
Unilateral deep brain stimulation of the thalamus, or bilateral stimulation of the globus pallidus or sub-thalamic nucleus refers to a neurosurgical procedure where a device is implanted in the brain for the control of tremors in selected members who h...
MP240-Dermal Injections for Treatment of Facial Lipodystrophy Syndrome (LDS)
Facial Lipodystrophy Syndrome is characterized by facial wasting of fat under the skin of the face resulting in a gaunt or wasted appearance. Dermal fillers comprised of Poly-L-lactic acid and synthetic calcium hydroxylapatite can be used to restore a...
MP300-Digital Breast Tomosynthesis
Digital Breast Tomosynthesis (DBT) is a method for performing high-resolution limited-angle tomography at mammographic dose levels. Digital breast tomosynthesis produces a three dimensional image by taking multiple low-dose images per view along an ...
Functional anesthetic discography (FAD) is a diagnostic procedure that involves injecting an anesthetic agent directly into a spinal disc. During this procedure, under light sedation and x-ray guidance, a small catheter is inserted into the suspected d...
MP021 -Dorsal Column Stimulation
Spinal cord stimulation, also known as dorsal column stimulation, blocks pain conduction pathways to the brain. The neurostimulator electrodes used for this purpose are implanted percutaneously in the epidural space via a special needle. Some insured i...
MP322-Drug Testing in Substance Abuse Treatment
Drug Testing in Substance Abuse Treatment is divided into two categories: Qualitative (also known as Presumptive) and Quantitative (also known as Confirmatory) immunoassay.
Dry hydrotherapy, also known as aquamassage and/or hydromassage, is a technique where a patient either lies or sits on a waterbed-like device that contains interior jets, which rotate and pulsate while releasing streams of pressurized heated water alon...
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