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Medical policies for providers

See the latest updates to our medical policies. 

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MP236-Immune Cell Function Assay for Transplant Rejection
Immune cell function assay is intended for use in the detection of cell mediated immunity (CMI) in patients undergoing immunosuppressive therapy post solid organ treatment. The assay is proposed to measure immune suppression and identify patients at ri...

MP092-Implantable Cardiac Loop Recorder
The implantable cardiac loop recorder is a patient-activated monitoring system that records electrocardiographic (ECG) tracings. The device is a programmable event recorder with looping memory and is implanted subcutaneously in the chest. When symptoms...

MP090-Injectable Bulking Agents for Treatment of Urinary Incontinence
Periurethral injections of bulking agents such as collagen and synthetic agents (e.g. Durasphere™) are used for the management of patients with urinary incontinence resulting from intrinsic sphincter deficiency.

MP144-Injectable Vitamin B12 Therapy
Vitamin B12, also known as cobalamin plays an essential role in DNA synthesis, cell maturation and neurologic function. Deficiency results in a wide spectrum of anemias and neuropsychiatric disorders.

MP331 Inpatient Rehabilitation

MP192-Intensity Modulated Radiation Therapy (IMRT)
Intensity modulated radiation therapy (IMRT) is a method of planning and delivering radiation therapy in a focused three dimensional conformal dose. By utilizing non-uniform radiation beam intensities and a methodology known as inverse planning or forw...

MP074-Interactive Metronome Training
This therapy consists of a series of hand and foot exercises using a steady auditory reference rhythm to guide the patient toward more precise timing. It is theorized that this therapy improves the patients timing, focus and concentration.

MP294-Intercostal Nerve Block

MP202-Interferential Stimulation
Interferential stimulation is a type of electrical stimulation that uses paired electrodes of two independent circuits carrying medium-frequency alternating currents. The electrodes are aligned on the skin so that the current flowing between each pair ...

MP190-Interspinous Distraction Technology
Interspinous Distraction Technology is a technique in which an oval spacer is inserted between the spinous processes for the treatment of neurogenic intermittent claudication resulting from lumbar spinal stenosis. The implant is thought to act as a phy...

MP120-Intracavitary Balloon Brachytherapy for Breast Cancer
The MammoSite® Radiation Therapy System is a minimally invasive method of delivering internal radiation therapy following a lumpectomy for breast cancer. A small balloon catheter is inserted inside the tumor resection cavity. A tiny radioactive seed is...

MP184-Intracranial Percutaneous Transluminal Angioplasty
Intracranial Percutaneous Transluminal Angioplasty has been proposed to improve cerebral artery lumen diameter in patients with intracranial atherosclerotic disease and cerebral vasospasm after aneurysmal subarachnoid hemorrhage. The device consists of...

MP222-Intradiscal Biacuplasty
Intradiscal biacuplasty involves the use of two cooled radiofrequency electrodes placed on the posterolateral sides of the intervertebral annulus fibrosus. It is proposed that by cooling the probes a larger area may be treated than with a regular needl...

MP30-Intradiscal Electrothermal Therapy (IDET)
Intradiscal Electrothermal Therapy (IDET™), also known as Intradiscal electrothermal annuloplasty, is an invasive procedure reported in the medical literature to treat lumbar disc pain. The procedure is performed under local anesthesia with intravenous...

MP293-Intrathecal Infusion Pump
An implantable infusion pump that is intended to provide long-term, continuous or intermitted infusion for the treatment of severe and chronic pain.

Iontophoresis a method of transdermal local drug delivery using an electrical current. When drug and the Iontophoresis setting have the same polarity, drug molecules are forced into the skin by electrostatic repulsion.




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