Medical policies for providers

See the latest updates to our medical policies. 

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MP266-Magnetoencephalography (MEG) and Magnetic Source Imaging (MSI)
Magnetoencephalography (MEG) is a noninvasive functional imaging technique that records magnetic fields generated by brain activity. When the information is superimposed on an anatomic image of the brain such as a magnetic resonance imaging scan, the i...

MP056-Management of Excessive Skin and Subcutaneous Tissue
Panniculectomy, Lipectomy, Liposuction, Abdominoplasty:Defined as excision of excessive skin and subcutaneous tissue including but not limited to Panniculectomy (Abdominoplasty) or Lipectomy by any other method (excision, suction assisted, liposuction,...

MP126-Massage Therapy
Massage therapy is the manipulation of tissues with the hand or an instrument for therapeutic purposes.

MP055-Mastectomy for Gynecomastia
Gynecomastia -  The American Society of Plastic Surgeons (ASPS) defines gynecomastia as:•    Grade I Small breast enlargement with localized button of tissue that is concentrated around the areola.•    Grade II Moderate breast enlargement exceeding are...

MP299-Measurement of Serum Antibodies to Infliximab and Adalimumab
Prometheus® Laboratories Inc. offers non-radiolabeled fluid-phase HMSA tests called the Anser™IFX test for infliximab and Anser™ADA for adalimumab. Both tests measure antidrug antibodies in the presence of detectable drug levels, improving upon a major...

MP209-Medical Error “Never Events” and Hospital Acquired Conditions and Hospital Readmission Review
The intent of this policy is to implement a strategy to monitor for a safe environment for medical services that minimizes avoidable risks to patients and to hold the member and payer/employer financially harmless for the event and its sequelae. If pat...

MP176-Meniett Device
The Meniett™ Device, an aural low-pulse pressure generator, is used to deliver low frequency, low-amplitude pressure pulses to the middle ear through a close fitting ear cuff and a previously placed tympanostomy tube. Although the precise mechanism of ...

MP133-Meniscal Allograft Transplantation
Meniscal allograft transplantation is a surgical procedure that is proposed as a treatment to restore knee function in a subset of patients with damaged or absent menisci by replacing the damaged menisci with tissue obtained from a suitable cadaver don...

MP262-Microarray-based Gene Expression testing for Cancer of Unknown Origin
Microarray-based gene expression testing, measures the expression of more than 1,500 genes, and compares the similarity of the gene expression profile of a cancer of unknown primary to a database of known profiles from 15 tissues with more than 60 hist...

MP172-MicroVas Vascular Treatment System
MicroVas Vascular Treatment System is a form of electrical stimulation thought to cause muscle fasciculation and contraction-relaxation cycles that effectively increases blood flow and tissue oxygenation, which would enhance wound healing. According to...

MP193-Microvolt T-wave Alternans
Microvolt T-wave Alternans involve the detection of every-other-beat alternations in T-wave morphology. These alternations are thought to represent abnormalities in intracellular calcium handling that may predispose patients to sudden cardiac death due...

MP263-Minimally Invasive Lumbar Decompression (MILD) and Percutaneous Image-guided Lumbar Decompression (PILD)
Minimally Invasive Lumbar Decompression (MILD) and Percutaneous Image-guided Lumbar Decompression (PILD) utilizes a set of specialized surgical instruments to perform percutaneous lumbar decompressive procedures for the treatment of spinal stenosis. D...


MP303-Molecular Markers to Predict Thyroid FNA (Fine-Needle Aspiration)

Gene expression analysis and mutation analysis has been developed as a means to identify benign nodules when cytopathology of thyroid fine needle aspirate is indeterminate, thereby reducing the number of unnecessary thyroid surgeries.  The testing ...

MP102 -Morphometric Tumor Analysis
Morphometric analysis utilizes a quantitative image analysis system to assess a tissue sample after the diagnosis of malignancy has been established by histopathology. Morphometric analysis is not diagnostic of malignancy, but once the diagnosis is est...

MP166-MR Ultrasound of Uterine Ablations
Uterine fibroids (leiomyomata) are benign tumors commonly found in women in their reproductive years. Magnetic Resonance Focused Ultrasound therapy is a non-invasive treatment that proposes to treat symptomatic fibroids by applying a precise ultrasound...

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