Medical policies for providers
See the latest updates to our medical policies.
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.
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.
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.
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.
Interferential stimulation is a type of electrical stimulation that uses paired electrodes of two independent circuits carrying medium-frequency alternating currents.
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.
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.
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.
Intradiscal biacuplasty involves the use of two cooled radiofrequency electrodes placed on the posterolateral sides of the intervertebral annulus fibrosus.
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.
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.
MP346-Intraoperative Neurophysiologic Monitoring
Intraoperative neurophysiologic monitoring (IONM) is a technique used to reduce the risk of neurological deficits after operations that involve the nervous system.
Iontophoresis is 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.
Irreversible electroporation (IRE) also known as the NanoKnife® System, is a surgical method used to destroy soft tissue through non-thermal ablation. IRE employs direct-current electrical fields applied to soft tissue. When the high energy level electrical field is applied long enough, it permanently damages the tissue by creating small holes referred to as nanopores or micropores in the cell membranes of the tissue.
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