Medical policies for providers
See the latest updates to our medical policies.
Morbid obesity is a condition of persistent and uncontrollable weight gain that constitutes a present or potential threat to life. Obesity is most often defined by the body mass index, a mathematical formula that is used to quantitatively evaluate body...
MP201-Obstructive Sleep Apnea
Apnea: Cessation of airflow at the nostrils and mouth lasting at least ten seconds. There are three types of apnea: obstructive, central and mixed. Obstructive apnea is secondary to an upper airway obstruction; central apnea is associated with a ces...
MP234-Occipital Nerve Stimulation
Occipital nerve stimulation has been proposed for the treatment of patients with intractable headache that cannot be managed by alternative treatments. It involves the use of a neurostimulator to deliver low-voltage electrical impulses via ins...
MP238-Ocular Blood Flow Tonometer
Ocular Blood Flow Tonometer measures both the pulsatile ocular blood flow and blood flow velocity both using doppler ultrasonography to monitor activity in specific blood vessels that supply the eye with blood. The device has been proposed to ...
MP003-Ocular Photodynamic Therapy utilizing Verteporfin (Visudyne).
Photodynamic therapy is a treatment for choroidal neovascularization secondary to exudative “wet” age related macular degeneration, presumed ocular histoplasmosis and pathologic myopia. A pharmaceutical (Visudyne) is injected into the bloodstream, whi...
Ocular photoscreening is used to detect risk factors for amblyopia. Ocular photoscreening uses the refractive state of the eye and assesses the pattern of light reflected through the pupil. The images are then analyzed based on the position of the cor...
MP246-Oncotype Dx - Multi-gene Expression Assay for Predicting Recurrence in Colon Cancer
Oncotype DX® Colon Cancer Test is a 12-gene expression test designed to predict the likelihood of disease recurrence for stage II colon cancer patients following surgery. Gene expression is quantified from microdissected fixed paraffin-embedded primary...
This definition of medical necessity will apply to all decisions made under the Health Choices program.• Impacted Wisdom Teeth For insured individuals in which applicable benefit documents include the Impacted Wisdom Tooth rider, the benefit is li...
MP135-Osseointegrated Hearing Device (eg. Bone Anchored hearing Aid (BAHA) Hearing Device)
Osseointegrated hearing devices [eg, BAHA (bone-anchored hearing aid)] are devices which are partially or totally implanted in the skull to replace the function of the middle ear by applying mechanical energy to the cochlea via a mechanical transducer....
MP200-Osteochondral Autograft Transplant
Osteochondral autograft transplant involves the placement of viable hyaline cartilage grafts into a cartilage defect. The grafts are harvested from peripheral non-weight bearing region of the joint and transplanted into a cartilage defect to restore th...
MP080-Outpatient Cardiac Rehabilitation
Cardiac rehabilitation is a program designed to assist insured individuals in dealing with active heart disease. The goal is to recondition the cardiovascular system through exercise, education, counseling and behavioral change.
MP230-Outpatient Pulmonary Rehabilitation
Maintenance Therapy -Maintenance therapy consists of activities that preserve the patient’s present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved or when ...
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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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