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Medical policies for providers

See the latest updates to our medical policies. 

Choose a letter to view policies by first letter.

A B C D E F G H I J K L M N O P Q R S T U V W 



MP204-Nasal and Sinus Surgery
Septoplasty: a surgical revision of the nasal septum performed to improve breathing, relieve nasal obstruction, to reconstruct the septum following extensive surgery or traumatic injury, or to remove benign or malignant tumors. Rhinoplasty: a surgical ...

MP058-Negative Pressure Wound Therapy
Vacuum assisted wound closure is a technique used to promote healing of chronic wounds. It can be used as an adjunct to surgery or as an alternative to surgery for patients who are debilitated or are non-surgical candidates. A special foam dressing wit...

MP001-Neuromuscular Electrical Stimulation (NMES)
Neuromuscular electrical stimulation (NMES) involves the use of a device which transmits an electrical impulse to the skin over selected muscle groups by way of electrodes. Coverage of NMES is limited to the treatment of disuse atrophy where nerve supp...

MP006-Nocturnal Enuresis Alarm
Primary nocturnal enuresis is defined as involuntary loss of urine during sleep in members who have never achieved a sustained period of nighttime continence. Secondary nocturnal enuresis is defined as loss of urine during sleep in a member who has ach...

MP212-Non-contact Low-frequency Ultrasound for Wound Management (MIST Therapy)
The MIST Therapy® System utilizes non-contact, low frequency ultrasound driven atomized mist to produce a non-thermal, mechanical cleansing action thought to create surface tension at the cellular level. Although the mechanism of action of MIST Therapy...

MP241-Non-invasive Measurement of Advanced Glycation Endproducts
Advanced glycation endproducts (AGE) are metabolic byproducts from non-enzymatic glycation of proteins and amino acids. They have been proposed as a biomarker for disease severity and risk prediction. Because AGEs demonstrate autofluorescence when expo...

MP077-Non-invasive Mechanical Treatments for Low Back Pain
Vertebral axial decompression (Vax-D) and MedX lumbar/cervical extension machines are devices designed for the purpose of isokinetic testing and rehabilitation in the treatment of back pain. The Orthotrac Vest is a custom made vest that utilizes pneuma...

MP271-Non-Invasive Testing for Fetal Aneuploidy
Circulating cell-free DNA purified from maternal blood plasma is analyzed to detect aneuploidies at chromosome 21 (Down syndrome), chromosome 18 (Edwards syndrome), and chromosome 13 (Patau syndrome). There are several different tests available for ide...

MP168-Non-invasive Testing for Heart Transplant Rejection
The Heartsbreath test assesses heart transplant rejection by measuring the amount of methylated alkanes, a marker of oxidative stress, in the patient’s breath. Heart transplant rejection seems to be accompanied by oxidative stress which degrades membra...

MP247-Nutritional Supplements
Food Additives: Commercially available products such as fiber, calorie, and/or protein supplements, thickeners, vitamins, minerals, and products to aid in lactose digestion. Grocery Items: Food items available for common consumption, including baby foo...


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