Medical policies for providers
See the latest updates to our medical policies.
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,...
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...
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 ...
MP323-Molecular Profiling of Malignant Tumors to Identify Targeted Therapies
Molecular profiling is a method for identifying multiple biomarkers in the malignant tumors of persons who have cancer. The biomarker information can be used to identify treatment options.
MP314-Molecular Testing – General Guidelines
Molecular tests are specialized laboratory studies that evaluate human DNA, RNA, chromosomes, and/or the presence or absence of proteins whose production is mediated by specific genes.
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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Clinical guidelines offer providers consistent and appropriate guidance for diagnosis and treatment of specific conditions or diseases.
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