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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 


MP268-Elective Laminectomy
Laminectomy is a surgical procedure done to remove a portion of the lamina to relieve pressure on the spinal cord or on the nerve roots that emerge from the spinal canal.

MP269-Elective Spinal Fusion
Spinal fusion is a surgical procedure used to stabilize the spine by fusing together 2 or more vertebrae which eliminates motion between the vertebral sections. 

MP113-Electrical and Electromagnetic Stimulation to Promote Wound Healing
Electrical stimulation to promote wound healing involves the application of electrical current through surface electrodes placed in the wound bed and proximal to the wound. 

MP206-Electrocardiographic Body Surface Mapping
Electrocardiographic body surface mapping, or body surface potential mapping, uses 80 or more electrodes (as many as 120) to record and measure electrocardiac activity over a much larger section of the torso than the traditional 12-lead ECG.

MP372 Electrodermal and Surface Electromyographic Seizure Detection Devices
Electrodermal or surface electromyography (sEMG) devices have been proposed as an adjunctive device in recording and storing physiologic data for characterization of seizures during periods of rest.

MP370-Endobronchial Valve
Endobronchial Valves are implantable bronchial valves used for the bronchoscopic treatment of adults with hyperinflation associated with severe emphysema in regions of the lung that have little to no collateral ventilation.

MP210-Endometrial Ablation
Endometrial ablation is the removal or destruction of the endometrium (lining of the uterus). Endometrial ablation is an alternative to hysterectomy for women with heavy uterine bleeding who wish to avoid hysterectomy. 

MP211-Endovascular Repair of Intracranial Aneurysms
Endovascular repair of intracranial aneurysms, also called coil embolization, is intended as a less invasive alternative to surgical clipping. 

MP313-Environmental Lead Testing

MP352-Epidermal Nerve Fiber Density Testing
Epidermal Nerve Fiber Density (ENFD) Testing is based on the analysis of a punch biopsy of skin and is used to assist in the diagnosis of small fiber neuropathy. Small fiber peripheral neuropathy may be caused by a wide array of medical conditions or exposures. It has been long known that the most common causes are diabetes mellitus (types I and II) and idiopathic. 

MP151-Epidural Steroid Injections

MP220-Epiretinal Radiation Therapy
Intraocular epiretinal radiation technology is an intraocular device that utilizes the strontium-90 isotope to deliver and direct radiation to the choroidal vascular bed of the retina. 

MP315-Esophageal Sphincter Augmentation
LINX is an FDA-approved magnetic sphincter augmentation device composed of a series of magnets set in titanium casing and connected by titanium wires laparoscopically implanted to augment lower esophageal function in patients with gastroesophageal reflux disease refractory to nonsurgical medical therapy and maximized pharmacologic therapy. The magnetic sphincter augmentation device is an alternative to Nissen fundoplication which is an irreversible creation of a non-physiologic sphincter that prohibits belching and vomiting.

MP089-Evaluation of Breast Ductal Fluid
Ductal lavage of the breast is a method of collecting epithelial cells from the mammary ducts of the breast for cytological analysis. The fluid sample is analyzed for the presence of benign, atypical or malignant cells.

MP174-Exhaled Nitric Oxide for Asthma Management
Nitric Oxide (NO) is an important endogenous regulatory molecule widely distributed throughout the body that is a messenger in many different biological processes. 

MP015-Experimental, Investigational or Unproven service or treatment.

MP24-External Counterpulsation
External Counterpulsation (ECP), commonly referred to as Enhanced External Counterpulsation (EECP), is a noninvasive treatment that uses timed, sequential inflation of pressure cuffs on the legs to augment diastolic pressure.

MP335-Extracorporeal Photopheresis
Extracorporeal photopheresis (ECP) is a leukapheresis-based immunomodulatory procedure that involves three steps. First, the patient’s blood is centrifuged to separate the leukocyte-rich portion from the rest of the blood; then the photosensitizer agent 8-methoxypsoralen is added to the lymphocyte fraction, which is then exposed to ultraviolet-A light at a dose of 1 to 2 J/cm2. Lastly, the light-sensitized lymphocytes are reinfused into the patient.

MP066-Extracorporeal Shock Wave Treatment for Musculoskeletal Indications
Extracorporeal shock wave treatment is a non-invasive procedure that uses the force of an acoustic shock wave.

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