Medical policies for providers
See the latest updates to our medical policies.
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. The procedure involves placing extra bone (bone graft) to fill the space between the...
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. Electromagnetic therapy involves the use of a pulsed magnetic field to induce c...
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 in order to...
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. The objective is to occlude blood flow to the vascular lesion by using electrolytically detachable coils and/...
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. Using a standard vitrectomy procedure, the cannula tip of ...
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. The results are used to provide ...
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. In biological tissue, nitric oxide is highly reactive making a determination of the amou...
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, decrease left ventri...
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. Although there is support in the medical literature for the efficacy of this treatment for plantar fasciitis, the healing mechanism of extrac...
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